Using Shared Decision Making to Improve Erik's Hospital Stay. Part 4: Protocols
This week JAMA published a study that surveyed doctors and medical residents at a major medical center to ascertain their understanding of the risks and benefits of medical interventions. The results mirrored similar findings of other studies: that most doctors are unaware of actual risks and benefits. In this study, that happened to be conducted in the very institution where Erik was treated for his heart attack, 80% of doctors over-estimated the benefit of common interventions (see BRCT). Physicians consistently under-estimated how often interventions had no effect, and most lacked confidence in their responses. Stated the authors: “Poor ability to estimate frequency of benefit likely relates to medical education focusing only on treatments that are recommended, with a heavy emphasis on P values alone, rarely using more accurate assessments of treatment effect size or frequency with absolute risk reduction or number needed to treat.”
This and other studies found that most doctors do not understand the concept of actual risks and benefits, and they rarely engage in meaningful shared decision making. Other studies found that patients also over-estimate the benefit of interventions, and they rely on their doctors to provide them with accurate information with which they can make informed decisions. As was the case in Erik’s hospitalization, doctors can sometimes tell a patient what to do without a true understanding of what they are advocating. This is the very antithesis of shared decision making. As we saw in the case of warfarin for afib, revascularization of a single blocked artery, and the use of high dose statins, Erik’s doctors provided him with information that was not accurate, and then they insisted that he follow their advice without asking any questions. They did not wish to discuss these decisions with Erik, nor did they listen to him when he tried to present an alternative point of view. What occurred to Erik during his major medical crisis mirrors what is transpiring in all of health care today: doctors and patients lacking actual medical knowledge and not discussing issues in an accurate way. This results in over-treatment, adverse outcomes, poor patient satisfaction, and a higher cost of care.
In Erik’s case he was told that he had to be on a handful of medicines for the rest of his life, and he was given no explanation as to why. We have shown how some of these medicines could have been harmful to him had he complied blindly with the advice. His doctors also insisted that he take several other medicines, including Beta-blockers and ACE inhibitors. In fact, the use of these medicines are mainstays of clinical practice guidelines. Did Erik need beta blockers and ACE inhibitors after his heart attack? Some protocols suggest that he did, and it is “common knowledge” that both medicines help prevent poor outcomes after a heart attack. But what are the facts?
A 2012 article in Current Cardiology Reviews, that we cited in our JAMA article, suggests that whatever benefit beta blockers confer to patients after a heart attack are negated by their sometimes lethal risk. At best, a 4/1000 benefit was found short term, but many studies showed no benefit, especially when patients have normal heart function, as was the case with Erik. A more recent study (Bangalore, American Journal of Medicine, 2014) shows that the use of beta blockers do not lead to improved life span (0/1000 benefit), but do cause significant side effects that lead to drug withdrawal. There is a reduced chance of having another heart attack (4.7/1000 benefit) which is counter-balanced by an increased chance of developing congestive heart failure (12.6/1000 risk, see BRCT). Thus, especially in Erik’s case, the risk of these drugs may well exceed the benefit.
ACE inhibitors are similarly less effective in people with normal heart function. In that group, there is a survival benefit of approximately 5 out of 1000 people treated, but most of that benefit is in younger people with impaired heart function. In people like Erik who are over 75 and who have normal heart function, such benefit is not seen, and there is a higher risk of dangerous drops in blood pressure and kidney dysfunction. Like with beta blockers, the use of ACE inhibitors post-MI are enshrined in clinical guidelines, but the evidence shows that they are not effective for everyone, including Erik.
To Erik, the maximum benefit of taking an ACE inhibitor was not enough to justify its use (by the best estimate, 995/1000 people do not benefit), and in fact, given Erik’s age and normal heart function, his actual benefit is close to 0/1000, which mirrors his benefit with beta blockers, as shown on the BRCT. In addition, Erik has low blood pressure, and both medicines are known to cause harm when the baseline blood pressure is low. When Erik left the hospital with these medicines, which he was told was necessary, his blood pressure was very low, he was weak and tired, and he nearly passed out. We stopped the medicines, and he almost instantly improved. By all reliable data, Erik is not at any more risk of dying from being off both of these drugs, but his quality of life is markedly better. What the doctors felt to be essential for Erik was actually detrimental. Had his doctors used actual data rather than protocols, had they treated Erik as a 75yo individual with low blood pressure and normal heart function rather than as a generic patient, had they discussed risks and benefits with Erik, then he would have left the hospital healthier and happier.
Shared decision making is crucial both for doctors and patients to improve outcome. The basic building block of such patient-centered care is the acquisition of accurate medical data, which is then individualized to a specific patient’s medical condition, symptoms, and expectations. We believe that BRCTs can facilitate the very care that was absent during Erik’s hospitalization. Had BRCTs been used by Erik’s doctors and individualized to his particular situation, then Erik's experience would have been much improved. If Erik had access to BRCTs, then he could have been a more active participant in his care. It is our goal to convince doctors, medical schools, insurance companies, and patient advocacy groups to embrace facile tools like BRCTs to enhance shared decision making in all medical settings. As Erik’s case demonstrates, the dangers of allowing the status quo to continue are real and impactful. With BRCTs, those dangers will be minimized, and a true patient-centered experience can result, leading to better outcomes, lower cost, and much happier and healthier patients.