It’s awfully hard for patients to participate in decisions about their medical care if they don’t know all their options.
But that’s exactly what seems to be happening, at least with many Medicare patients who received a stent procedure for coronary disease or prostate surgery for cancer, according to a new study.
The research, published online by the Journal of General Internal Medicine, surveyed 685 patients who had prostate-cancer surgery and 472 who had stents for coronary disease about their decision-making process.
While those conditions are “clinically really different, the thing that intrigued us was that completely conservative treatment is a reasonable option for both,” says Floyd J. Fowler Jr., an author of the study and senior research fellow at the Center for Survey Research at the University of Massachusetts Boston. (There’s been growing concern in the last several years that stents are overused, as the WSJ has reported.)
Yet only 10% of the stent patients surveyed recalled discussing an alternative to stenting as a serious option. Prostate-surgery patients had a different experience; 64% recalled discussing alternatives to surgery.
“We’re not saying that they made the wrong choice” by having the surgery or stenting, but “people should know what all the options are,” says Fowler, who is also senior scientific advisor at the Informed medical Decisions Foundation.
Only 19% of stent recipients recalled discussing the cons of the procedure, while 63% of the prostate-surgery patients reported the same. And only 16% of stent recipients recalled being asked their preferences for treatment type, vs. 76% of prostate-surgery patients.
“The core of a good decision-making process is to know what the options are, hear the pros and cons, and that someone should ask you what you think,” says Fowler.
It’s possible the discrepancy between the two types of patients came because stents are often inserted at the same time that a blockage is diagnosed with an angiogram. “Once the catheter is in and they see a blockage, it’s really easy — with the same catheter — to put in a stent,” explains Fowler. “That is the wrong time to have an extended conversation” with a patient.
But if that’s often the case, the discussion should happen before the angiogram, he says.
There are limits to the study — namely, it was based on a patient’s recollection of events. The procedures were done in the latter half of 2008 and interviews were conducted up to a about a year later, says Fowler. In addition, only patients who had the surgery or stent were interviewed. It’s possible that surveying patients who opted for more conservative treatment would have reported differently, or that the decision to go ahead with surgery influenced what the patient remembered after the fact.
But the differences between the prostate-surgery and stent groups would still hold.
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