How BRCTs can reduce overtreatment and cost: the case of cardiac stents.
Looking at cardiac revascularization is illustrative of both the nuance inherent in medical decision making as well as the power of the BRCT in helping patients understand their options in a clear and accurate way. Perhaps as significantly, the use of BRCTs in revascularization demonstrates how shared decision making can curb overtreatment and, without much fanfare, make a substantial impact on health care reform.
Revascularization—both cardiac bypass and cardiac stents—costs insurance companies $50 billion annually, so it touches not only the individual patient, but also society in general. Many studies now point to the overuse of cardiac stents and bypass; in fact, Bloomberg Business suggests that unnecessary stents cost at least $2.4 billion a year. We also know that when patients are given accurate information they often choose to eschew stents, but unfortunately meaningful discussions between doctor and patient rarely occur in the setting of revascularization.
It seems sensible to think that opening a blocked artery will improve outcomes by reducing heart attacks and even death. But health care is often counter-intuitive. Most heart attacks occur in heart blood vessels that are not blocked, which is the reason that such a large percentage of patients who have a heart attack would have a normal stress test immediately prior. Thus, opening blocked arteries has a negligible impact on heart attack risk in most patients with either stable heart disease or without any symptoms. There are some heart blood vessels that may benefit from being open, and stents likely improve outcome in people actively having a heart attack, but for most stable patients the results are less promising.
BRCTs show that if 1000 people with stable heart disease have significant blockages opened with stents, none will benefit (in terms of lives saved and fewer heart attacks) compared to 1000 people who are treated with medicines (see BRCT above). However, out of those 1000 people who have blockages opened with stents, an additional 20 will suffer severe complications (including stroke, heart attack, kidney failure, bleeding, or death) compared to 1000 people treated with medicine. (see BRCT on the left) Thus, by using BRCTs, patients can be given an accurate and easily digestible means of assessing the procedure’s utility.
There are caveats to the decision making tree. Both stents and bypass procedures can trigger significant complications that are not life threatening but do cause medical impairment in patients. For instance, bypass surgery is known to lead to mental decline in an uncertain number of patients. Some earlier studies suggest that long term mental decline after bypass can occur in 250 people out of 1000 who have bypass compared to 1000 who do not have bypass. (BRCT on the left) Other studies are less convincing. Many other complications are not measured in studies but need to be discussed with patients nonetheless, including local bleeding and the effects of anesthesia.
In addition, revascularization may be beneficial to certain populations, and thus any discussion needs to be individualized. In people with symptoms of chest pain, stents may improve that pain better than medicines, although the numbers are difficult to gauge. One large study suggests that perhaps 40 more people out of 1000 are free of chest pain with stents compared to 1000 people who get medical treatment. (BRCT on the left) Thus, if a patient is having chest pain, he/she may be willing to accept the risk of stenting in the hope of alleviating that pain. Also, people with congestive heart failure (CHF) may garner some benefit from revascularization, although not necessarily from a stent. A recent small study of cardiac bypass in people with CHF shows there is a possible survival advantage after ten years from revascularization. Both medicine and bypass groups had high mortality after 10 years (59% vs 66%), but out of 1000 people who had bypass compared to 1000 people who were treated with medical therapy, 70 more people were still alive in the bypass group than the medicine group. It is important to note that such benefit has not been demonstrated in people who get stents, and that the 5 year numbers in the bypass study showed no survival advantage. But again, people with CHF may be willing to balance the risk of bypass with the potential benefit.
Therefore, if the option of revascularization is brought up to patients, they can assess their individual risks and benefits by using BRCTs. Rather than simply being told that they have a blocked artery that can be opened up, patients and doctors can discuss the options and come to a shared decision. But how do we know that such patient-centered care will curb overtreatment and the proliferation of unnecessary revascularization? And how often do these discussions actually occur?
In fact, some studies suggest that most cardiologists do not even discuss risks and benefits of stents before telling patients that they need them. It has been found that 75% of cardiologists recommend stents for blocked arteries without talking about the risks and benefits, and that only 3% of cardiologists provide an accurate and complete assessment of risks and benefits to their patients. Of cardiologists who did engage in meaningful shared decision making, virtually none of their patients chose to get stents. Of cardiologists who recommended stents without shared decision making, virtually all of them chose to get stents. Thus, meaningful doctor-patient discourse about this expensive and over-used procedure can clearly curb its use and potentially save the system billions of dollars. We believe that the simplicity of the BRCT model will enable a facile discussion that can be done easily in a doctor’s office.
When we set up focus groups (CLICK HERE to see the focus group results) to analyze the utility of medical decision making tools, we used stents as one of our examples. Most of the participants felt most comfortable with the BRCTs than with other models (such as NNT), and they certainly felt that the information conveyed to them through BRCTs was more revealing and understandable than the typical relative risk/benefit language that is ubiquitous in the press and the medical community. Clearly, having a tool that enables such discussions can save money, increase patient satisfaction, reduce over-treatment, and potentially save lives. Perhaps that should be the primary goal of health care reform.