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Patients' and Cardiologists' Perceptions of the Benefits of Percutaneous Coronary Intervention for Stable Coronary Disease

Michael B. Rothberg, MD, MPH; Senthil K. Sivalingam, MD; Javed Ashraf, MD, MPH; Paul Visintainer, PhD; John Joelson, MD; Reva Kleppel, MSW, MPH; Neelima Vallurupalli, MD; and Marc J. Schweiger, MD
[+] Article and Author Information

From Baystate Medical Center, Springfield, and Tufts University School of Medicine, Boston, Massachusetts.


Acknowledgment: The authors thank Raul Octaviani, MD, for help with creating an earlier version of the patient and cardiologist surveys.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-0042.

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Rothberg (e-mail, Michael.Rothberg@bhs.org). Data set: Not available.

Requests for Single Reprints: Michael B. Rothberg, MD, MPH, Divisions of General Medicine and Geriatrics, Department of Medicine, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199; e-mail, Michael.Rothberg@bhs.org.

Current Author Addresses: Dr. Rothberg: Divisions of General Medicine and Geriatrics, Department of Medicine, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199.

Dr. Sivalingam and Ms. Kleppel: Division of General Medicine, Department of Medicine, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199.

Drs. Ashraf, Joelson, Vallurupalli, and Schweiger: Division of Cardiology, Department of Medicine, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199.

Dr. Visintainer: Department of Statistics and Epidemiology, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199.

Author Contributions: Conception and design: M.B. Rothberg, S.K. Sivalingam, J. Ashraf, J. Joelson, M.J. Schweiger.

Analysis and interpretation of the data: M.B. Rothberg, J. Ashraf, P. Visintainer, M.J. Schweiger.

Drafting of the article: M.B. Rothberg, S.K. Sivalingam, J. Ashraf.

Critical revision of the article for important intellectual content: S.K. Sivalingam, J. Ashraf, P. Visintainer, J. Joelson.

Final approval of the article: M.B. Rothberg, S.K. Sivalingam, J. Ashraf, P. Visintainer, J. Joelson, M.J. Schweiger.

Provision of study materials or patients: J. Joelson.

Statistical expertise: P. Visintainer.

Administrative, technical, or logistic support: J. Ashraf, J. Joelson, R. Kleppel, M.J. Schweiger.

Collection and assembly of data: M.B. Rothberg, S.K. Sivalingam, J. Ashraf, J. Joelson, R. Kleppel, N. Vallurupalli.


Ann Intern Med. 2010;153(5):307-313. doi:10.7326/0003-4819-153-5-201009070-00005
Text Size: A A A

Background: It is unclear whether patients understand that percutaneous coronary intervention (PCI) reduces only chronic stable angina and not myocardial infarction (MI) or associated mortality.

Objective: To compare cardiologists' and patients' beliefs about PCI.

Design: Survey.

Setting: Academic center.

Participants: 153 patients who consented to elective coronary catheterization and possible PCI, 10 interventional cardiologists, and 17 referring cardiologists.

Measurements: Patients' and cardiologists' beliefs about benefits of PCI. All cardiologists reported beliefs about PCI for patients in hypothetical scenarios. Interventional cardiologists also reported beliefs for study patients who underwent PCI.

Results: Of 153 patients, 68% had any angina, 42% had activity-limiting angina, 77% had a positive stress test result, and 29% had had previous MI. The 53 patients who underwent PCI were more likely than those who did not to have a positive stress test result, but angina was similar in both groups. Almost three quarters of patients thought that without PCI, they would probably have MI within 5 years, and 88% believed that PCI would reduce risk for MI. Patients were more likely than physicians to believe that PCI would prevent MI (prevalence ratio, 4.25 [95% CI, 2.31 to 7.79]) or fatal MI (prevalence ratio, 4.83 [CI, 2.23 to 10.46]). Patients were less likely than their physicians to report pre-PCI angina (prevalence ratio, 0.79 [CI, 0.67 to 0.92]). For the scenarios, 63% of cardiologists believed that the benefits of PCI were limited to symptom relief. Of cardiologists who identified no benefit of PCI in 2 scenarios, 43% indicated that they would still proceed with PCI in these cases.

Limitation: The study was small and conducted at 1 center, and information about precatheterization counseling was limited.

Conclusion: Cardiologists' beliefs about PCI reflect trial results, but patients' beliefs do not. Discussions with patients before PCI should better explain anticipated benefits.

Primary Funding Source: None.

Figures

Grahic Jump Location
Figure.
Reasons for performing and beliefs about PCI.

Error bars represent 95% CIs. LV = left ventricular; MI = myocardial infarction; OMT = optimal medical therapy; PCI = percutaneous coronary intervention. Top. Cardiologists' reasons for performing PCI in 52 patients. Middle. Expectations of patients who had PCI compared with those of their cardiologists. Bottom. Patients' beliefs about the benefits of the PCI that they underwent compared with cardiologists' beliefs about the benefits of PCI in patient scenarios.

Grahic Jump Location

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Comments

Submit a Comment
Cardiac cath: Is it important to educate patients?
Posted on September 8, 2010
Osama SM Amin
Sulaimaniya General Teaching Hospital
Conflict of Interest: None Declared

In this September's issue of Annals, Rothberg and colleagues [1], highlighted a very important subject of cardiac cath; what do our patients think of this invasive intervention and its benefits? Fernandez's editorial article [2] should also be read.

I have understood from our patients (in my area) that cardiac cath is a "life-saving" procedure which "fixes a broken heart." All, not most, of them do not know what is the meaning of symptom relief. Why, simply, because those interventionists don't discuss with their patients the pros and cons of coronary intervention honestly and thoroughly.

Here is an example of what an cardiac interventionist tells a patient with a coronary artery disease (in my area, which is not in the United States):

You need cardiac cath, I have no time to do it in our teaching hospital and therefore my trainees will do the procedure, the waiting list is long and perhaps after 2-3 months you will reach the op room' I will do it tomorrow in this or that private hospital if you can afford, I will do it by myself, stents type and costs are these, and don't ask about the risks!!!

Most of my work is in the field of vascular neurology. Stroke patients (or their families) always ask if there is any intervention that may improve their neurological function and how to prevent another stroke; again, none of them asks about the long-term mortality!

No one admits; it is all about money! The potential for misuse and abuse is very large, unfortunately.

All the very best!

Osama SM Amin MD,MRCPI,MRCPS(Glasg),FCCP,FACP

References:

1. Rothberg MB, Sivalingam SK, Ashraf J, Visintainer P, Joelson J, Kleppel R, et al. Patients' and cardiologists' perceptions of the benefits of percutaneous coronary intervention for stable coronary disease. Ann Intern Med 2010;153:307-13.

2. Fernandez A. Improving the Quality of Informed Consent: It Is Not All About the Risks. Ann Intern Med 2010;153:342-43.

Conflict of Interest:

None declared

Re:Cardiac cath: Is it just patients that think stents prevent heart attacks?
Posted on September 14, 2010
Heather L. Horton
Christiana Care
Conflict of Interest: None Declared

I was not surprised by the results of Rothberg, et al.(1), but as a former interventionalist, I doubt the interventional cardiologists are responsible for the patient's misinformation. I think it would be very interesting to do the same study among primary care physician, emergency room physicians, telemetry nurses, EMT's, cath lab staff, hospital administrators, public relations staff and medical reporters. I strongly suspect all of these groups think coronary stents prevent heart attacks in stable patients (which they don't). It's a losing battle for a busy interventionalist to try to correct all the misinformation that is out there. It would be great to see a follow-up study to see if education directed at those groups of people might be of value.

References

1.Michael B. Rothberg, Senthil K. Sivalingam, Javed Ashraf, Paul Visintainer, John Joelson, Reva Kleppel, Neelima Vallurupalli, and Marc J. Schweiger Ann Intern Med 2010 153:307-313; doi:10.1059/0003-4819-153-5-201009070- 00005 Patients' and Cardiologists' Perceptions of the Benefits of Percutaneous Coronary Intervention for Stable Coronary Disease

Conflict of Interest:

None declared

Additional Considerations in the Effort to Improve Informed Consent
Posted on September 20, 2010
Yael Schenker, MD, MAS
University of Pittsburgh
Conflict of Interest: None Declared

The results of the study by Rothberg et al (1) mirror the findings of previous research in different settings and widespread clinical experience: patient comprehension of informed consent is often poor. While such observations have led some to conclude that expectations for patient understanding and involvement in medical decision making are unreasonable, we agree with Fernandez that improving the quality of informed consent is an attainable and important goal. (2, 3) In the discussion of how to translate the findings of Rothberg and others into practice changes, three additional points bear consideration.

First, more is not always better. Additional information on consent forms does not guarantee that this information will be read or understood, and may in fact have the opposite effect (as anyone who has signed a form without reading the fine print can attest). Similarly, longer discussions with a knowledgeable cardiologist do not translate into improved patient understanding of the benefits of PCI. (1) Efforts to improve informed consent must focus not simply on what information is given, but on how such information is delivered and received. Teach back, a technique in which patients repeat key elements of a discussion to demonstrate understanding, can help to focus patients (and providers) on what is important. (4)

Second, timing is everything. Often in clinical practice, the consent process occurs immediately before the procedure (ie, after the decision to undergo the procedure has been made, and the time for weighing risks and benefits has passed). Additional information is unlikely to be of value at this point, because patients are psychologically committed to undergoing the procedure. If we expect patients to engage in informed consent as a meaningful process of shared decision making, we must give them time for contemplation before having to decide.

Third, we need strategies to improve informed consent that do not involve physicians. While the traditional model of informed consent involves a discussion with the physician performing the procedure, in reality such discussions are often ill-timed or ineffective. Given the constraints of clinical practice, this is not surprising. A busy gastroenterologist, for example, may perform 15 colonoscopies (accompanied by 15 informed consent discussions) in one day. Is it any wonder that informed consent often amounts to little more than a signature on a form? While physicians must establish trust and answer questions, interactive, computer-based programs may be more suitable and practical vehicles for improving patient understanding. (5)

References

1. Rothberg MB, Sivalingam SK, Ashraf J, et al. Patients' and cardiologists' perceptions of the benefits of percutaneous coronary intervention for stable coronary disease. Ann Intern Med;153(5):307-13.

2. Fernandez A. Improving the quality of informed consent: it is not all about the risks. Ann Intern Med;153(5):342-3.

3. Schenker Y, Fernandez A, Sudore R, Schillinger D. Interventions to Improve Patient Comprehension in Informed Consent for Medical and Surgical Procedures: A Systematic Review. Med Decis Making. 2010 Mar 31. [Epub ahead of print]

4. Fink AS, Prochazka AV, Henderson WG, et al. Enhancement of surgical informed consent by addition of repeat back: a multicenter, randomized controlled clinical trial. Ann Surg;252(1):27-36.

5. Tait AR, Voepel-Lewis T, Moscucci M, Brennan-Martinez CM, Levine R. Patient comprehension of an interactive, computer-based information program for cardiac catheterization: a comparison with standard information. Arch Intern Med. 2009;169(20):1907-14.

Conflict of Interest:

None declared

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Summary for Patients

Patients' and Cardiologists' Beliefs About a Common Heart Procedure

The summary below is from the full report titled “Patients' and Cardiologists' Perceptions of the Benefits of Percutaneous Coronary Intervention for Stable Coronary Disease.” It is in the 7 September 2010 issue of Annals of Internal Medicine (volume 153, pages 307-313). The authors are M.B. Rothberg, S.K. Sivalingam, J. Ashraf, P. Visintainer, J. Joelson, R. Kleppel, N. Vallurupalli, and M.J. Schweiger.

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