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BHCAG Summit Minneapolis, MN February 23, 2012 Shannon Brownlee, MS

BHCAG Summit Minneapolis, MN February 23, 2012 Shannon Brownlee, MS Instructor, The Dartmouth Institute Acting Director, New America Foundation Health Policy. Clinicians, patients and preference-sensitive (elective) care. What do patients know about tradeoffs? What do they need to know?

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BHCAG Summit Minneapolis, MN February 23, 2012 Shannon Brownlee, MS

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  1. BHCAG Summit Minneapolis, MN February 23, 2012 Shannon Brownlee, MS Instructor, The Dartmouth Institute Acting Director, New America Foundation Health Policy

  2. Clinicians, patients and preference-sensitive (elective) care • What do patients know about tradeoffs? • What do they need to know? • What do clinicians know about patient preferences? • How does knowledge change behavior?

  3. Al Mulley Michael Barry Jack Fowler Jack Wennberg

  4. Involves tradeoffs -- more than one treatment exists; not getting treated is often an option; and the outcomes are different • Decisions should be based on the patient’s preferences . . . • But provider opinion/preference often determines which treatment is delivered

  5. PCI per 1,000 Enrollees (2003 – 2007)

  6. “Yes, medical therapy is as effective as PCI, but when I see a lesion, the bottom line is that the oculostenotic reflex always wins out.” • “[The patient] is not going to get out of the cath lab without a stent.” Grace A. Lin, et al ARCH INTERN MED/VOL 167 (NO. 15), AUG 13/27, 2007

  7. WHAT DO PATIENTS KNOW (1990s)? • 75% believed PCI would help prevent an MI • 71% believed PCI would help them live longer • Less than half could name even one possible complication of PCI • 85% were “consented” just before the procedure (by a fellow or an NP) From a survey of consecutive patients scheduled for an elective coronary revascularization procedure at Yale New Haven Hospital in 1997-1998. (Holmboe ES. JGIM 2000; 15:632)

  8. What patients know (2010) . . . • 88% believed PCI would help prevent an MI • 76% believed PCI would help them live longer (Baystate Medical Center in 2007-2008 Rothberg MB. Annals Intern Med 2010; 153:307)

  9. Only 31% had activity limiting chest pain • Cardiologists’ perception of the patient’s angina was often greater than the patient’s MB Rothberg Ann Intern Med. 2010 Sep 7;153(5):307-1

  10. What drives utilization? Well Bob, it looks like a paper cut, but just to be sure, I like to do lots of catheterizations.

  11. Relationship Between Procedure Indications and Outcomes of Percutaneous Coronary Interventions by American College of Cardiology/American Heart Association Task Force Guidelines H. Vernon Anderson et al Circulation 2005;112;2786-2791

  12. CABG in Minnesota

  13. What do clinicians know about what their patients prefer? U. Mich Decision Survey

  14. What do Clinicians Know? Sepucha K, et al. PatientEducation and Counseling 2008 and Lee et al. 30th Annual Society for Medical Decision Making Conference, Philadelphia, 2008.

  15. DECISION Survey: How can you know if you don’t ask? • Surgery: • About 1/2 the time for the orthopedic surgeries; 1/3 for cataracts • Screening: • Less than 1/5 of the time for decisions about cancer screening • Medications: • About 1/3 of the time SOURCE: U. of Mich. DECISION Survey

  16. What do patients know? • Clinical experts identified 4-5 facts, e.g. common side effects • Respondents were asked the knowledge questions related to their decision. • For 8 out of the 10 decisions, less than half of respondents could get more than 1 of the knowledge questions right. U. Mich Decision Survey

  17. Clinicians, patients and preference-sensitive care • What do patients know about tradeoffs? Not much • What do they need to know? A lot more • What do clinicians know about patient preferences? Not much • How does knowledge change behavior?

  18. Behavior GREATER KNOWLEDGE LEADS TO DIFFERENT CHOICES Behavior Changes with Knowledge * P < .01 Source: N. Cochran, MD, WRJ V.A.

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