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Understanding the Impact of Gender in the Decision-Making Process to Undergo Certain Surgeries Compared to Uncertain Surgeries
Abstract
Purpose Procedures can be categorized as certain surgeries based on their necessity and outcomes while others are classified as uncertain surgeries based on these areas. To account for this variance, policies such as the Affordable Care Act (ACA) call for health care providers to engage in shared decision making (SDM) with patients to ensure they are informed of treatment options and asked their preferences. Yet, gender may influence the decision-making process. Thus, this project examines the decision process and how gender impacts patients’ participation in decisions to undergo certain surgeries compared to uncertain surgeries.
Methodology/approach This research project analyzed data from the National Survey of Medical Decisions 2006–2007 which surveyed the medical decisions of US residents 40 and older.
Findings First, the data reveals that women felt more informed having uncertain surgeries compared to men. Second, patients were less likely asked their preference for surgery when undergoing certain surgeries compared to uncertain surgeries. Third, compared to men, women having uncertain surgeries were less likely to make the final decision to have surgery, compared to sharing the final decision with health care providers.
Limitations Due to the sample size, this project could not perform three-way interactions between gender, race, and surgery type.
Originality/value Gender influences the level patients feel informed having uncertain surgeries. Though policy calls for SDM, health care providers are less likely to ask patients their preference for surgery regarding certain surgeries, relative to uncertain surgeries. Gender impacts the final decision-making process regarding whether patients should have uncertain surgeries.
... Few studies have examined whether psoriasis patients' demographic factors affect their participation in SDM. However, studies in the general medical setting have found that male patients demonstrate decreased participation in SDM as compared to female patients [11]. In addition, elderly US patients report physicians' non-responsiveness to their concerns as the leading factor discouraging them from seeking medical care [12]. ...
... In part, these results may be explained by findings from studies that have reported male patients to be significantly less likely to participate in shared decision-making with their providers [11], feel informed about their care [11], and prefer an active role in their health decision-making [17] compared to female patients. As male patients have been found to demonstrate lower engagement in their healthcare, a reciprocal dynamic may exist in which they perceive their clinicians to be less engaged with them. ...
... In part, these results may be explained by findings from studies that have reported male patients to be significantly less likely to participate in shared decision-making with their providers [11], feel informed about their care [11], and prefer an active role in their health decision-making [17] compared to female patients. As male patients have been found to demonstrate lower engagement in their healthcare, a reciprocal dynamic may exist in which they perceive their clinicians to be less engaged with them. ...
Background
Shared decision-making (SDM) refers to a collaborative process in which clinicians assist patients in making medically informed, evidence-based decisions that align with their values and preferences. There is a paucity of literature on SDM in dermatology.
Objective
We aim to assess whether male and female psoriasis patients evaluate their clinicians’ engagement in SDM differently across different age groups.
Methods
Cross-sectional study using data from the 2014–2017 and 2019 Medical Expenditure Panel Surveys (MEPS).
Results
A weighted total of 7,795,608 psoriasis patients were identified. SDM Scores ranged from 1 to 4, with 4 representing the most favorable patient evaluation of their clinicians’ engagement in SDM. We conducted multivariate linear regression to compare mean SDM Scores in male psoriasis patients versus female psoriasis patients across different patient age groups. Female patients ages 60–69 perceived significantly greater clinician engagement in SDM compared to age-matched male patients (female patient perception of SDM 3.65 [95%CI:3.61–3.69] vs. male patient perception of SDM 3.50 [95%CI:3.43–3.58], p<0.005). The same trend of older female patients evaluating their clinicians’ engagement in SDM significantly higher than their age-matched male counterparts exists for the age group >70 (p<0.005). No significant differences between male and female patients’ evaluations of their clinicians’ engagement in SDM were demonstrated in subjects younger than 60. All calculations were adjusted for demographic and clinical factors.
Conclusions
Compared to older male psoriasis patients, older female psoriasis patients evaluated their clinicians to be more engaged in shared decision-making.
... Kruskal-Wallis test (mean rank, P significance) desire for orthodontic treatment; however, there were no gender sub-group analysis details. [23] A US national health survey found that males may value professional credentials more when choosing orthodontic options, viewing the decision as an investment that requires proven expertise. [35] In contrast, gender differences in dentist advice and negligence fear were the opposite. Women were twice as likely to use a dentist's advice as motivation. ...
OBJECTIVES
To investigate the socio-economic and personal factors that impact parental decisions regarding orthodontic treatment for their children in Madinah, Saudi Arabia.
MATERIALS AND METHODS
A digital self-administered questionnaire was employed to collect data from 414 parents, focusing on their motivations and barriers that influence their decision-making process regarding orthodontic treatment.
RESULTS
Income level was the most significant factor in orthodontic decisions. Parents with higher incomes were twice as likely to choose orthodontic treatment for esthetic reasons compared to parents with middle incomes. The main incentive for seeking treatment was getting advice from dental professionals, with 60% of participants rating it as the most important factor. 34.5% of respondents identified cost as the main barrier, with middle-income parents being 151% more inclined to perceive it as a significant barrier compared to high-income parents. Gender dynamics revealed that mothers exhibited 48.9% greater concern regarding treatment costs compared to fathers, whereas fathers placed 2.105 times more importance on the orthodontist’s reputation than mothers.
CONCLUSION
Income levels, along with other socio-economic factors and gender dynamics, have a significant influence on parental decisions regarding orthodontic care. Personalized consultations that address these variations are crucial for improving communication between patients and practitioners and increasing the accessibility of treatment.
Background: What is the quantitative relationship between repeated surgical intervention and unemployment in the spine surgery population? And, does the literature pay sufficient attention to this important aspect of spine surgery out-come? Methods: This was a retrospective review of 905 patients of working age undergoing one of three types of spine surgery. The index surgery at the time of the study was either on the cervical or lumbar spine. We retrospectively col-lected data on patients' employment status and history of prior spine surgery. In this study, history of prior spine sur-gery was coded using two nominal (categorical) variables: The number of previous spine surgeries (0, 1, 2, ≥3) and the variability of location of previous spine surgeries (cervical, lumbar). We also looked into scientific publications re-lated to spine surgery and probed "employment" and "reoperation" awareness in randomized controlled trials (RCTs). In addition, we queried some common factors that are known to play an important role in exacerbating the unemploy-ment problem, such as opioid (ab)use and depression. Results: The unemployment rate was 19.4% among males and 34.8% among females. Unemployment rate correlated with the number of previous spine surgery (r = 0.077, p = 0.020), opioid use (r = 0.080, p = 0.017) and being on antidepressants (r = 0.119, p = 0.000). The unemployment rate was sta-tistically different (χ2 = 10.656, p = 0.014) among patients with different numbers of previous spine surgeries: 25.6% of de novo patients versus 28.1% of patients with one previous spine surgery, 32.7% of patients with two previous spine surgeries and 48.7% of patients with three or more previous spine surgeries. Females had significantly higher unem-ployment rate if they had three or more previous spine surgeries in their past (31.4%, 34.4%, 46.2% versus 83.3%, χ2 = 21.841, p = 0.000). Unemployment rate was as high as 90% in female patients with ≥3 surgeries on different regions of the spine and receiving antidepressants. Among randomized controlled trials addressing spine surgery in humans and published in English, 10.4% of reported studies mentioned opioids in their text, 4.1% (23/566) mentioned reoperation, 1.4% (8/566) mentioned employment, and none mentioned antidepressants. Conclusion: Females' employment status is more sensitive to repeated surgical intervention, regardless of the part of the spine being targeted, reaching close to ten times the general population's unemployment rate (83.3% versus 8%). On the other hand, a small percentage of ran-domized controlled trials pertaining to spine surgery deals with employment issues and reoperation rate in their out-come analysis.
The principles of shared decision making are well documented but there is a lack of guidance about how to accomplish the approach in routine clinical practice. Our aim here is to translate existing conceptual descriptions into a three-step model that is practical, easy to remember, and can act as a guide to skill development. Achieving shared decision making depends on building a good relationship in the clinical encounter so that information is shared and patients are supported to deliberate and express their preferences and views during the decision making process. To accomplish these tasks, we propose a model of how to do shared decision making that is based on choice, option and decision talk. The model has three steps: a) introducing choice, b) describing options, often by integrating the use of patient decision support, and c) helping patients explore preferences and make decisions. This model rests on supporting a process of deliberation, and on understanding that decisions should be influenced by exploring and respecting "what matters most" to patients as individuals, and that this exploration in turn depends on them developing informed preferences.
Creation of a platform of tools to provide information to doctors and patients should be the first step in giving patients choice about their treatment, say Glyn Elwyn and colleagues.
This article reviews an aspect of daily clinical practice which is of critical importance in virtually every clinical consultation, but which is seldom formally considered. Non-clinical influences on clinical decision-making profoundly affect medical decisions. These influences include patient-related factors such as socioeconomic status, quality of life and patient's expectations and wishes, physician-related factors such as personal characteristics and interaction with their professional community, and features of clinical practice such as private versus public practice as well as local management policies. This review brings together the different strands of knowledge concerning non-clinical influences on clinical decision-making. This aspect of decision-making may be the biggest obstacle to the reality of practising evidence-based medicine. It needs to be understood in order to develop clinical strategies that will facilitate the practice of evidence-based medicine.
Total hip replacement is one of the most successful and cost effective interventions in medicine.1 2 It offers reliable relief of pain and considerable improvement in function in patients suffering with osteoarthritis or inflammatory arthritis of the hip.3-7 Currently about 50 000 hip replacements are performed in the United Kingdom annually while worldwide the number is over 300 000. Two thirds of these are performed in patients over 65 years of age.8 Ninety to ninety five per cent of patients can expect to have their total hip replacement functioning at 10 years,8 and in 85% they will still be functioning at 20 years.9
Although 85% of patients undergoing total hip replacement have a diagnosis of osteoarthritis,8 inflammatory arthritis, both seropositive and seronegative, is an important indication for total hip replacement and can offer tremendous improvements in quality of life even in the very young.10 In rheumatoid arthritis it has been estimated that the cost to the community of total hip replacement will be recuperated within an average 1.5 years because of savings made on medical and social care.2
Quality of life after surgery approximates that of a healthy reference population.4 Improvements in pain, energy levels, sleep, social, and sexual function are all observed.4 7 Oxygen demands on activity are decreased and walking ability improves.5 11 Most of these improvements are seen within three months of surgery.5 These gains in quality of life allow large numbers of patients to retain their independence and function more actively in society.
### PAIN
Pain is the principal indication for hip replacement and is reliably relieved as early as one week after surgery.12 Pain from an arthritic hip is classically located in the groin and buttock. Radiation into the thigh may occur and at times pain …
Epidemiologic studies have reported differences in the use of cardiovascular procedures according to the race and sex of the patient. Whether the differences stem from differences in the recommendations of physicians remains uncertain.
We developed a computerized survey instrument to assess physicians' recommendations for managing chest pain. Actors portrayed patients with particular characteristics in scripted interviews about their symptoms. A total of 720 physicians at two national meetings of organizations of primary care physicians participated in the survey. Each physician viewed a recorded interview and was given other data about a hypothetical patient. He or she then made recommendations about that patient's care. We used multivariate logistic-regression analysis to assess the effects of the race and sex of the patients on treatment recommendations, while controlling for the physicians' assessment of the probability of coronary artery disease as well as for the age of the patient, the level of coronary risk, the type of chest pain, and the results of an exercise stress test.
The physicians' mean (+/-SD) estimates of the probability of coronary artery disease were lower for women (probability, 64.1+/-19.3 percent, vs. 69.2+/-18.2 percent for men; P<0.001), younger patients (63.8+/-19.5 percent for patients who were 55 years old, vs. 69.5+/-17.9 percent for patients who were 70 years old; P<0.001), and patients with nonanginal pain (58.3+/-19.0 percent, vs. 64.4+/-18.3 percent for patients with possible angina and 77.1+/-14.0 percent for those with definite angina; P=0.001). Logistic-regression analysis indicated that women (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) and blacks (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) were less likely to be referred for cardiac catheterization than men and whites, respectively. Analysis of race-sex interactions showed that black women were significantly less likely to be referred for catheterization than white men (odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.7; P=0.004).
Our findings suggest that the race and sex of a patient independently influence how physicians manage chest pain.
Previous studies suggest that, for some conditions, women receive fewer health care interventions than men. We estimated the potential need for arthroplasty and the willingness to undergo the procedure in both men and women and examined whether there were differences between the sexes.
All 48,218 persons 55 years of age or older in two areas of Ontario, Canada, were surveyed by mail and telephone to identify those with hip or knee problems. In these subjects, we assessed the severity of arthritis and the presence of coexisting conditions by questionnaire, documented arthritis by examination and radiography, and conducted interviews to evaluate the subjects' willingness to undergo arthroplasty. The potential need for arthroplasty was defined by the presence of severe symptoms and disability, the absence of any absolute contraindications to surgery, and clinical and radiographic evidence of arthritis. The estimates of need were then adjusted for the subjects' willingness to undergo arthroplasty.
The overall response rates were at least 72 percent for the questionnaires and interviews. As compared with men, women had a higher prevalence of arthritis of the hip or knee (age-adjusted odds ratio, 1.76; P<0.001) and had worse symptoms and greater disability, but women were less likely to have undergone arthroplasty (adjusted odds ratio, 0.78; P<0.001). Despite their equal willingness to have the surgery, fewer women than men had discussed the possibility of arthroplasty with a physician (adjusted odds ratio, 0.63). The numbers of people with a potential need for hip or knee arthroplasty were 44.9 per 1000 among women and 20.8 per 1000 among men. After adjustment for willingness to undergo the procedure, the numbers were 5.3 per 1000 for women and 1.6 per 1000 for men.
There is underuse of arthroplasty for severe arthritis in both sexes, but the degree of underuse is more than three times as great in women as in men.
There are large variations in the use of knee arthroplasty among Medicare enrollees according to race or ethnic group and sex. Are racial and ethnic disparities more pronounced in some regions than in others, and if so, why?
We used all Medicare fee-for-service claims data for 1998 through 2000 to determine the incidence of knee arthroplasty according to Hospital Referral Region, sex, and race or ethnic group. A total of 430,726 knee arthroplasties were performed during the three-year study period.
At the national level, the annual rate of knee arthroplasty was higher for non-Hispanic white women (5.97 procedures per 1000) than for Hispanic women (5.37 per 1000) and black women (4.84 per 1000). The rate for non-Hispanic white men (4.82 procedures per 1000) was higher than that for Hispanic men (3.46 per 1000) and more than double that for black men (1.84 per 1000). The rates were significantly lower for black men than for non-Hispanic white men in nearly every region of the country (P<0.05). For the Hispanic population and for black women, racial or ethnic disparities at the national level were due in part to geographic differences rather than to differences in the rates for different racial and ethnic groups within geographic areas. Residential segregation and low income levels contributed to racial and ethnic disparities in arthroplasty rates.
In the Medicare population, the rate of surgical treatment for osteoarthritis of the knee varies dramatically according to sex, race or ethnic group, and region. These variations underscore the importance of geography and sex in determining racial or ethnic barriers to health care.
Gender disparities in the treatment of coronary artery disease (CAD) have been extensively documented in studies from the United States. However, they have been less well studied in other countries and, to our knowledge, have not been investigated at the more disaggregated spatial level of cities.
This study tests the hypothesis that there is a common international pattern of gender disparity in the treatment of CAD in persons aged > or =65 years by analyzing data from the United States, France, and England and from their largest cities-New York City and its outer boroughs, Paris and its First Ring, and Greater London.
This was an ecological study based on a retrospective analysis of comparable administrative data from government health databases for the 9 spatial units of analysis: the 3 countries, their 3 largest cities, and the urban cores of these 3 cities. A simple index was used to assess the relationship between treatment rates and a measure of CAD prevalence by gender among age-adjusted cohorts of patients. Differences in rates were examined by univariate analysis using the Student t test for statistical differences in mean values.
Despite differences in health system characteristics, including health insurance coverage, availability of medical resources, and medical culture, we found consistent gender differences in rates of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting across the 9 spatial units. The rate of interventional treatment in women with CAD was less than half that in men. This difference persisted after adjustment for the prevalence of heart disease.
A consistent pattern of gender disparity in the interventional treatment of CAD was seen across 3 national health systems with known differences in patterns of medical practice. This finding is consistent with the results of clinical studies suggesting that gender disparities in the treatment of CAD are due at least in part to the underdiagnosis of CAD in women.
Aquatic physical therapy is frequently used in the management of patients with hip and knee osteoarthritis (OA), yet there is little research establishing its efficacy for this population. The purpose of this study was to evaluate the effects of aquatic physical therapy on hip or knee OA.
A total of 71 volunteers with symptomatic hip OA or knee OA participated in this study.
The study was designed as a randomized controlled trial in which participants randomly received 6 weeks of aquatic physical therapy or no aquatic physical therapy. Outcome measures included pain, physical function, physical activity levels, quality of life, and muscle strength.
The intervention resulted in less pain and joint stiffness and greater physical function, quality of life, and hip muscle strength. Totals of 72% and 75% of participants reported improvements in pain and function, respectively, compared with only 17% (each) of control participants. Benefits were maintained 6 weeks after the completion of physical therapy, with 84% of participants continuing independently.
Compared with no intervention, a 6-week program of aquatic physical therapy resulted in significantly less pain and improved physical function, strength, and quality of life. It is unclear whether the benefits were attributable to intervention effects or a placebo response.
Although evidence suggests that shared decision-making (SDM) can improve patient outcomes, uptake to date has been sparse. The purpose of this review was to determine the reported opinions of physicians regarding the use of SDM in clinical practice and to identify strategies to promote uptake.
We conducted a systematic review, including papers published between 2007 and 2014.
The electronic search yielded 11,761 results. Following abstract review, 123 papers were selected for full text review, and 43 papers were included for analysis. Fourteen of the included studies considered SDM within the context of primary care, 25 in secondary care, and 4 in both.
Physicians express positive attitudes toward SDM in clinical practice, although the level of support varies by clinical scenario, treatment decision and patient characteristics.
Physician support for SDM is a necessary, if not sufficient, condition to facilitate meaningful SDM. In order to garner support for SDM, additional empirical evidence regarding the clinical and patient important outcomes must be established. Based on the results of this review, the authors suggest assessing the impact of SDM within the context of chronic disease management where multiple therapeutic options exist, and outcomes may be measured long-term.
Copyright © 2015. Published by Elsevier Ireland Ltd.
Electronic health records (EHRs) are expected to bring a variety of health benefits, including reducing disparities in health-care access, but only if they are valued by all patient populations. We used the 2007 Health Information and National Trends Survey to characterize which health-care users report that electronic access to their health records is important for themselves and their providers. Respondents from populations that generally experience health-care disparities (Blacks, Latina/os, and patients with psychological distress) were among the most likely to report that the EHR was very important for themselves. Women were less likely than men to deem the EHR very important for their providers. Findings remained consistent after controlling for respondents’ socioeconomic status, health status, and health care. By identifying the characteristics of current health-care users who see electronic access to records as important for themselves and providers, we can better understand potential barriers as well as motivators to adoption that could contribute to equitable usage across groups or a digital divide.
Objective.
—This study examines the differences in the rates of coronary artery bypass grafting (CABG) between white and black Medicare patients.Design.
—This is a cross-sectional study with data from the 1986 Health Care Financing Administration hospital claims records on all Medicare patients, the 1988 update of the Bureau of Health Professions area resource file, and the 1985 Census Bureau's county population estimates file.Setting.
—Data are from all Medicare patients in the United States in 1986.Main Outcome Measures.
—Sex- and age-adjusted CABG rates for whites and blacks over the age of 65 years were computed for each of 50 states and 305 Standard Metropolitan Statistical Areas (SMSAs).Results.
—Nationally the CABG rate was 27.1 per 10000 for whites (40.4 for white men and 16.2 for white women), but only 7.6 for blacks (9.3 for black men and 6.4 for black women). Racial differences were greater in the Southeast, particularly in nonmetropolitan areas, than in other regions. Neither white nor black SMSA rates were associated with the rate of admission for acute myocardial infarction (an indication of the amount of coronary artery disease). White rates, but not black rates, were associated with the number of thoracic surgeons per 100 000 people.Conclusions.
—For patients insured by Medicare, race is strongly associated with CABG rates, and this association is greater for men than for women and greater in the Southeast than in other parts of the country. Physician supply may relate to the CABG rates for whites.(JAMA. 1992;267:1473-1477)
Background: Few investigations include both subjective and objective measurements of the effectiveness of treatments for osteoarthritis of the knee. Beneficial interventions may decrease the disability associated with osteoarthritis and the need for more invasive treatments. Objective: To evaluate the effectiveness of physical therapy for osteoarthritis of the knee, applied by experienced physical therapists with formal training in manual therapy. Design: Randomized, controlled clinical trial. Setting: Outpatient physical therapy department of a large military medical center. Patients: 83 patients with osteoarthritis of the knee who were randomly assigned to receive treatment (n = 42; 15 men and 27 women [mean age, 60 ± 11 years]) or placebo (n = 41; 19 men and 22 women [mean age, 62 ± 10 years]). Intervention: The treatment group received manual therapy, applied to the knee as well as to the lumbar spine, hip, and ankle as required, and performed a standardized knee exercise program in the clinic and at home. The placebo group had subtherapeutic ultrasound to the knee at an intensity of 0.1 W/cm 2 with a 10% pulsed mode. Both groups were treated at the clinic twice weekly for 4 weeks. Measurements: Distance walked in 6 minutes and sum of the function, pain, and stiffness subscores of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A tester who was blinded to group assignment made group comparisons at the initial visit (before initiation of treatment), 4 weeks, 8 weeks, and 1 year. Results: Clinically and statistically significant improvements in 6-minute walk distance and WOMAC score at 4 weeks and 8 weeks were seen in the treatment group but not the placebo group. By 8 weeks, average 6-minute walk distances had improved by 13.1 % and WOMAC scores had improved by 55.8% over baseline values in the treatment group (P < 0.05). After controlling for potential confounding variables, the average distance walked in 6 minutes at 8 weeks among patients in the treatment group was 170 m (95% Cl, 71 to 270 m) more than that in the placebo group and the average WOMAC scores were 599 mm higher (95% Cl, 197 to 1002 mm). At 1 year, patients in the treatment group had clinically and statistically significant gains over baseline WOMAC scores and walking distance; 20% of patients in the placebo group and 5% of patients in the treatment group had undergone knee arthroplasty. Conclusions: A combination of manual physical therapy and supervised exercise yields functional benefits for patients with osteoarthritis of the knee and may delay or prevent the need for surgical intervention.
Self-reports of fear from 100 patients (25 men and 75 women 71 to 76 years old) having two cataract operations were investigated. 33% of the patients reported having fear and 32% felt tension about the operation performed on the first eye. Women feared the operation significantly more than men. Fears were significantly associated with hypochondriasis, hysteria, and hypomania (unadjusted) as indicated by correlations with scores on the Mini-Mult MMPI. The cataract operation restored sufficient visual acuity for reading (minimum E-test value 0.40 or 1.8-cm high letters at a distance of 6 meters) to 79% of the subjects. The experience of a good operation result on the first eye significantly reduced the fear of the cataract operation on the second eye and at the same time the fear of becoming blind. Other factors reducing fear included positive experiences of a safe and painless cataract operation.
Reducing overuse of low-value health care services could theoretically improve quality while slowing spending growth. But we need to determine whether current policy tools, which were designed to address underuse, will work to reduce overuse.
Using the United States Nationwide Inpatient Sample, we identified national trends in revision spinal fusion along with a comprehensive comparison of comorbidities, inpatient complications and surgical factors of revision spinal fusion compared to primary spinal fusion.
In 2009, there were 410 158 primary spinal fusion discharges and 22 128 revision spinal fusion discharges. Between 2002 and 2009, primary fusion increased at a higher rate compared with revision fusion (56.4% vs 51.0%; p < 0.001). In 2009, the mean length of stay and hospital charges were higher for revision fusion discharges than for primary fusion discharges (4.2 days vs 3.8 days, p < 0.001; USD 87 161, p < 0.001). In 2009, recombinant human bone morphogenetic protein (BMP) was used more in revision fusion than in primary fusion (39.6% vs 27.6%, p < 0.001), whereas interbody devices were used less in revision fusion (41.8% vs 56.6%, p < 0.001).
In the multivariable logistic regression model for all spinal fusions, depression (odds ratio (OR) 1.53, p < 0.001), psychotic disorders (OR 1.49, p < 0.001), deficiency anaemias (OR 1.35, p < 0.001) and smoking (OR 1.10, p = 0.006) had a greater chance of occurrence in revision spinal fusion discharges than in primary fusion discharges, adjusting for other variables. In terms of complications, after adjusting for all significant comorbidities, this study found that dural tears (OR 1.41; p < 0.001) and surgical site infections (OR 3.40; p < 0.001) had a greater chance of occurrence in revision spinal fusion discharges than in primary fusion discharges (p < 0.001). A p-value < 0.01 was considered significant in all final analyses.
Cite this article: Bone Joint J 2014;96-B:807–16.
To assess the 2012 cost utility of cataract surgery in the United States and to compare 2012 cost-utility data with those from 2000.
Value-Based Medicine (Flourtown, PA), patient preference-based, comparative effectiveness analysis and cost-utility analysis using 2012 real United States dollars.
Previously published Patient Outcomes Research Team Study data and time tradeoff utilities obtained from patients with vision loss. Visual acuity measurements from patients wtih untreated cataract were used as controls.
Thirteen-year, average, first-eye and second-eye cataract surgery cost-utility analysis using the societal and third-party insurer cost perspectives.
Patient value gain in quality-adjusted life years (QALYs) and percent gain in quality of life as well as the cost-utility ratio using the dollars expended per QALY gained. Patient and financial value outcomes were discounted at 3% annually with net present value analysis.
First-eye cataract surgery conferred 1.6212 QALYs over the 13-year model, a 20.8% quality-of-life gain. Bilateral cataract surgery conferred 2.8152 QALYs over 13 years, a 36.2% improvement in quality of life. The direct ophthalmic medical cost for unilateral cataract surgery in 2012 United States nominal dollars was 121 198, a 4567% gain. The third-party insurer cost perspective average cost-utility ratio was 1636/QALY for unilateral cataract surgery, whereas the societal cost perspective average cost-utility ratio was -74 759/QALY. The net 13-year 36.4 billion; Medicaid, 9.6 billion; patients, 25.4 billion.
Cataract surgery in 2012 greatly improved quality of life and was highly cost effective. It was 34.4% less expensive than in 2000 and 85% less expensive than in 1985. Initial cataract surgery yielded an extraordinary 4567% financial ROI to society over the 13-year model.
Proprietary or commercial disclosure may be found after the references.
Importance
Ischemic heart disease is the leading cause of death globally. Coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) are the revascularization options for ischemic heart disease. However, the choice of the most appropriate revascularization modality is controversial in some patient subgroups.
Objective
To summarize the current evidence comparing the effectiveness of CABG surgery and PCI in patients with unprotected left main disease (ULMD, in which there is >50% left main coronary stenosis without protective bypass grafts), multivessel coronary artery disease (CAD), diabetes, or left ventricular dysfunction (LVD).
Evidence Review
A search of OvidSP MEDLINE, EMBASE, and Cochrane databases between January 2007 and June 2013, limited to randomized clinical trials (RCTs) and meta-analysis of trials and/or observational studies comparing CABG surgery with PCI was performed. Bibliographies of relevant studies were also searched. Mortality and major adverse cardiac and cerebrovascular events (MACCE, defined as all-cause mortality, myocardial infarction, stroke, and repeat revascularization) were reported wherever possible.
Findings
Thirteen RCTs and 5 meta-analyses were included. CABG surgery should be recommended in patients with ULMD, multivessel CAD, or LVD, if the severity of coronary disease is deemed to be complex (SYNTAX >22) due to lower cardiac events associated with CABG surgery. In cases in which coronary disease is less complex (SYNTAX ≤22) and/or the patient is a higher surgical risk, PCI should be considered. For patients with diabetes and multivessel CAD, CABG surgery should be recommended as standard therapy irrespective of the severity of coronary anatomy, given improved long-term survival and lower cardiac events (5-year MACCE, 18.7% for CABG surgery vs 26.6% for PCI; P = .005). Overall, the incidence of repeat revascularization is higher after PCI, whereas stroke is higher after CABG surgery. Current literature emphasizes the importance of a heart-team approach that should consider coronary anatomy, patient characteristics, and local expertise in revascularization options. Literature pertaining to revascularization options in LVD is scarce predominantly due to LVD being an exclusion factor in most studies.
Conclusions and Relevance
Both CABG surgery and PCI are reasonable options for patients with advanced CAD. Patients with diabetes generally have better outcomes with CABG surgery than PCI. In cases of ULMD, multivessel CAD, or LVD, CABG surgery should be favored in patients with complex coronary lesions and anatomy and PCI in less complicated coronary disease or deemed a high surgical risk. A heart-team approach should evaluate coronary disease complexity, patient comorbidities, patient preferences, and local expertise.
To estimate the incidence of cataract surgery in a defined population and to determine longitudinal cataract surgery patterns.
Mayo Clinic, Rochester, Minnesota, USA.
Cohort study.
Rochester Epidemiology Project (REP) databases were used to identify all incident cataract surgeries in Olmsted County, Minnesota, between January 1, 2005, and December 31, 2011. Age-specific and sex-specific incidence rates were calculated and adjusted to the 2010 United States white population. Data were merged with previous REP data (1980 to 2004) to assess temporal trends in cataract surgery. Change in the incidence over time was assessed by fitting generalized linear models assuming a Poisson error structure. The probability of second-eye cataract surgery was calculated using the Kaplan-Meier method.
Included were 8012 cataract surgeries from 2005 through 2011. During this time, incident cataract surgery significantly increased (P<.001), peaking in 2011 with a rate of 1100 per 100 000 (95% confidence interval, 1050-1160). The probability of second-eye surgery 3, 12, and 24 months after first-eye surgery was 60%, 76%, and 86%, respectively, a significant increase compared with the same intervals in the previous 7 years (1998 to 2004) (P<.001). When merged with 1980 to 2004 REP data, incident cataract surgery steadily increased over the past 3 decades (P<.001).
Incident cataract surgery steadily increased over the past 32 years and has not leveled off, as reported in Swedish population-based series. Second-eye surgery was performed sooner and more frequently, with 60% of residents having second-eye surgery within 3 months of first-eye surgery.
No author has a financial or proprietary interest in any material or method mentioned.
Section 3506 of the Affordable Care Act encourages use of shared decision making in health care, but progress on this front has been slow. The first step is for the Centers for Medicare and Medicaid Services to begin certifying and implementing patient decision aids.
Purpose of review: Based on current projections, the American Academy of Orthopedic Surgeons estimates that approximately 750 000 joint-replacement procedures will be performed annually. Total-hip-replacement surgery has been shown to be one of the safest and most effective interventions in medicine, decreasing pain and restoring mobility and function in people with long-term hip disease, or injury.
Recent findings: With the reported increases in life expectancy, a large segment of the population will be entering their fifties and sixties over the next decade. Many of these so-called baby-boomers have been physically active through their life and have a strong desire to maintain their current active lifestyles. Demand on these joint-replacement procedures will increase significantly. Between one-third and one-half of all joint-replacement procedures performed in the USA are hip replacements.
Summary: It is estimated that over $15 billion per year are spent on hip-replacement surgery in the USA alone. These large outlays of dollars have made this procedure the focus of cost-containment efforts by the government and private payers.
Purpose:
To present descriptive epidemiology of cataract surgery among Medicare recipients in the United States.
Setting:
Cataract surgery performed on Medicare beneficiaries in 2003 and 2004.
Methods:
Medicare claims data were used to identify all cataract surgery claims for procedures performed in the United States in 2003-2004. Standard assumptions were used to limit the claims to actual cataract surgery procedures performed. Summary statistics were created to determine the number of procedures performed for each outcome of interest: cataract surgery rates by age, sex, race and state; surgical volume by facility type and surgeon characteristics; time interval between first- and second-eye cataract surgery.
Results:
The national cataract surgery rate for 2003-2004 was 61.8 per 1000 Medicare beneficiary person-years. The rate was significantly higher for females and for those aged 75-84 years. After adjustment for age and sex, blacks had approximately a 30% lower rate of surgery than whites. While only 5% of cataract surgeons performed more than 500 cataract surgeries annually, these surgeons performed 26% of the total cataract surgeries. Increasing surgical volume was found to be highly correlated with use of ambulatory surgical centers and reduced time interval between first- and second-eye surgery in the same patient.
Conclusions:
The epidemiology of cataract surgery in the United States Medicare population documents substantial variation in surgical rates by race, sex, age, and by certain provider characteristics.
The need is urgent to bring US health care costs into a sustainable range for both public and private payers. Commonly, programs to contain costs use cuts, such as reductions in payment levels, benefit structures, and eligibility. A less harmful strategy would reduce waste, not value-added care. The opportunity is immense. In just 6 categories of waste--overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, and fraud and abuse--the sum of the lowest available estimates exceeds 20% of total health care expenditures. The actual total may be far greater. The savings potentially achievable from systematic, comprehensive, and cooperative pursuit of even a fractional reduction in waste are far higher than from more direct and blunter cuts in care and coverage. The potential economic dislocations, however, are severe and require mitigation through careful transition strategies.
To make informed decisions, patients must have adequate knowledge of key decision-relevant facts.
To determine adults' knowledge about information relevant to common types of medication, screening, or surgery decisions they recently made.
National sample of US adults identified by random-digit dialing.
Cross-sectional survey conducted between November 2006 and May 2007.
A total of 2575 English-speaking adults aged 40 y or older who reported having discussed the following medical decisions with a health care provider within the previous 2 y: prescription medications for hypertension, hypercholesterolemia, or depression; screening tests for colorectal, breast, or prostate cancer; or surgeries for knee/hip replacement, cataracts, or lower back pain.
Participants answered knowledge questions and rated the importance of their health care provider, family/friends, and the media as sources of information.
Accuracy rates varied widely across questions and decision contexts. For example, patients considering cataract surgery were more likely to correctly estimate recovery time than those patients considering lower back pain or knee/hip replacement (78% v. 29% and 39%, P < 0.001). Similarly, participants were more knowledgeable of facts about colorectal cancer screening than those who were asked about breast or prostate cancer. Finally, respondents were consistently more knowledgeable on comparable questions about blood pressure medication than cholesterol medication or antidepressants. The impact of demographic characteristics and sources of information also varied substantially. For example, blacks had lower knowledge than whites about cancer screening decisions (odds ratio [OR] = 0.57; 95% confidence interval [CI] = 0.43, 0.75; P = 0.001) and medication (OR = 0.77; 95% CI = 0.60, 0.97; P = 0.03) even after we controlled for other demographic factors. The same was not true for surgical decisions.
The questions did not measure all knowledge relevant to informed decision making, were subject to recall biases, and may have assessed numeracy more than knowledge.
Patient knowledge of key facts relevant to recently made medical decisions is often poor and varies systematically by decision type and patient characteristics. Improving patient knowledge about risks, benefits, and characteristics of medical procedures is essential to support informed decision making.
Many clinicians have called for an increased emphasis on the patient's role in clinical decision making. However, little is known about the extent to which physicians foster patient involvement in decision making, particularly in routine office practice.
To characterize the nature and completeness of informed decision making in routine office visits of both primary care physicians and surgeons.
Cross-sectional descriptive evaluation of audiotaped office visits during 1993.
A total of 1057 encounters among 59 primary care physicians (general internists and family practitioners) and 65 general and orthopedic surgeons; 2 to 12 patients were recruited from each physician's community-based private office.
Analysis of audiotaped patient-physician discussions for elements of informed decision making, using criteria that varied with the level of decision complexity: basic (eg, laboratory test), intermediate (eg, new medication), or complex (eg, procedure). Criteria for basic decisions included discussion of the nature of the decision and asking the patient to voice a preference; other categories had criteria that were progressively more stringent.
The 1057 audiotaped encounters contained 3552 clinical decisions. Overall, 9.0% of decisions met our definition of completeness for informed decision making. Basic decisions were most often completely informed (17.2%), while no intermediate decisions were completely informed, and only 1 (0.5%) complex decision was completely informed. Among the elements of informed decision making, discussion of the nature of the intervention occurred most frequently (71 %) and assessment of patient understanding least frequently (1.5%).
Informed decision making among this group of primary care physicians and surgeons was often incomplete. This deficit was present even when criteria for informed decision making were tailored to expect less extensive discussion for decisions of lower complexity. These findings signal the need for efforts to encourage informed decision making in clinical practice.
Empirical literature on patient decision role preferences regarding treatment and screening was reviewed to summarize patients' role preferences across measures, time and patient population.
Five databases were searched from January 1980 to December 2007 (1980-2007 Ovid MEDLINE, Cochrane Database of Systematic Reviews, PsychInfo, Web of Science and PubMed (2005-2007)). Eligible studies measured patient decision role preferences, described measures, presented findings as percentages or mean scores and were published in English from any country. Studies were compared by patient population, time of publication, and measure.
115 studies were eligible. The majority of patients preferred sharing decisions with physicians in 63% of the studies. A time trend appeared. The majority of respondents preferred sharing decision roles in 71% of the studies from 2000 and later, compared to 50% of studies before 2000. Measures themselves, in addition to patient population, influenced the preferred decision roles reported.
Findings appear to vary with the measure of preferred decision making used, time of the publication and characteristics of the population.
The role preference measure itself must be considered when interpreting patient responses to a measure or question about a patient's preference for decision roles.
Shared decision-making is increasingly advocated as an ideal model of treatment decision-making in the medical encounter. To date, the concept has been rather poorly and loosely defined. This paper attempts to provide greater conceptual clarity about shared treatment decision-making, identify some key characteristics of this model, and discuss measurement issues. The particular decision-making context that we focus on is potentially life threatening illnesses, where there are important decisions to be made at key points in the disease process, and several treatment options exist with different possible outcomes and substantial uncertainty. We suggest as key characteristics of shared decision-making (1) that at least two participants--physician and patient be involved; (2) that both parties share information; (3) that both parties take steps to build a consensus about the preferred treatment; and (4) that an agreement is reached on the treatment to implement. Some challenges to measuring shared decision-making are discussed as well as potential benefits of a shared decision-making model for both physicians and patients.
Patient involvement is required before patients' preferences can be reflected in the medical care they receive. Furthermore, patients are a vital link between physicians' assessments of patients' needs and actual implementation of appropriate care. Yet no study has specifically examined how and when a representative sample of patients considered, discussed, and made medical decisions.
To identify decision prevalence and decision-making processes regarding 1) initiation of prescription medications for hypertension, hypercholesterolemia, or depression; 2) screening tests for colorectal, breast, or prostate cancer; and 3) surgeries for knee or hip replacement, cataracts, or lower back pain.
Computer-assisted telephone interview survey.
Nationally representative sample of US adults in households with telephones.
3010 English-speaking adults age 40 and older identified using a stratified random sample of telephone numbers.
Estimated prevalence of medical decisions, defined as the patient having initiated medications, been screened, or had surgery within the past 2 years or having discussed these actions with a health care provider during the same interval, as well as decision-specific data regarding patient knowledge, attitudes and patient-provider interactions.
82.2% of the target population reported making at least 1 medical decision in the preceding 2 years. The proportion of decisions resulting in patient action varied dramatically both across decision type (medications [61%] v. screening [83%] v. surgery [44%]; P < 0.001), and within each category (e.g., blood pressure medications [76%] v. cholesterol medications [55%] vs. depression medications [48%]; P < 0.001). Respondents reported making more decisions if they had a primary care provider or poorer health status and fewer decisions if they had lower education, were male, or were under age 50. Limitations. Retrospective self-reports may incorporate recall biases.
Medical decisions with significant life-saving, quality of life, and cost implications are a pervasive part of life for most US adults. The DECISIONS dataset provides a rich research environment for exploring factors influencing when and how patients make common medical decisions.
Lumbar spinal stenosis (LSS) is a prevalent degenerative condition in the elderly that can be managed medically or with surgical treatments. Recent studies have shown an increase in the utilization of surgery in the United States and great regional variations. An understanding of treatment patterns and costs in a population-based setting will help identify subgroup differences to help inform strategies for optimal care in patients with LSS.
This study sought to examine surgical treatment rate and types, time to treatment, and patient characteristics that affect treatment patterns for newly diagnosed LSS in the US Medicare population.
A retrospective longitudinal study of administrative claims was performed on a 5% randomly selected sample of Medicare beneficiaries.
Six thousand two hundred sixty-five Medicare beneficiaries newly diagnosed with LSS in the first quarter of 2003 were identified and followed until the end of 2005.
Rate of LSS surgery, type and timing of LSS surgery, and Medicare costs.
A "de novo" LSS patient cohort was defined as those with claims with a primary diagnosis of LSS during the period of January to March 2003, excluding those with a LSS diagnosis in 2002. These patients were stratified into surgery and nonsurgery cohorts based on the presence of procedure codes for LSS surgery. The surgery cohort was further divided into three subgroups: laminectomy or laminotomy only; fusion only; and fusion with laminectomy or laminotomy. All Medicare claims for these patients were extracted and reviewed through December 2005. Descriptive statistics were carried out for demographic characteristics, comorbidities, treatment rates, and Medicare costs.
This study indicated that 21% of LSS patients underwent surgery within 3 years of initial diagnosis. Surgery skews toward the healthier and younger patients. Overall, 78% of LSS surgeries were performed in the year of diagnosis, 13% in the second, and 9% in the third. Although laminectomies and laminotomies were the most frequently performed procedures across all years, a higher percentage of fusions were performed in addition to laminectomy or laminotomy in the second or third years after diagnosis than in the first year. The 3-year Medicare payments were 36,691 in the nonsurgery cohort. Patients who underwent a laminectomy/laminotomy alone incurred significantly lower Medicare payments (57,171) or laminectomy/laminotomy plus fusion ($63,555).
The surgical management of LSS varies with respect to timing and type of surgery provided. Such variation needs to be explained beyond demographic and comorbid factors.
To compare the long-term effectiveness of surgical and non-surgical treatment in patients with chronic low back pain.
Two merged randomised clinical trials compared instrumented transpedicular fusion with cognitive intervention and exercises in 124 patients with disc degeneration and at least 1 year of symptoms after or without previous surgery for disc herniation. The main outcome measure was the Oswestry disability index.
At 4 years 14 (24%) patients randomly assigned to cognitive intervention and exercises had also undergone surgery. 15 (23%) patients assigned fusion had undergone re-surgery. The mean treatment effect for the primary outcome was 1.1; 95% CI -5.9 to 8.2, according to the intention-to-treat analysis and -1.6; 95% CI -8.9 to 5.6 in the as-treated analysis. There was no difference in return to work.
Long-term improvement was not better after instrumented transpedicular fusion compared with cognitive intervention and exercises.
Systematic review.
To systematically assess benefits and harms of surgery for nonradicular back pain with common degenerative changes, radiculopathy with herniated lumbar disc, and symptomatic spinal stenosis.
Although back surgery rates continue to increase, there is uncertainty or controversy about utility of back surgery for various conditions.
Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of the above therapies. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force.
For nonradicular low back pain with common degenerative changes, we found fair evidence that fusion is no better than intensive rehabilitation with a cognitive-behavioral emphasis for improvement in pain or function, but slightly to moderately superior to standard (nonintensive) nonsurgical therapy. Less than half of patients experience optimal outcomes (defined as no more than sporadic pain, slight restriction of function, and occasional analgesics) following fusion. Clinical benefits of instrumented versus noninstrumented fusion are unclear. For radiculopathy with herniated lumbar disc, we found good evidence that standard open discectomy and microdiscectomy are moderately superior to nonsurgical therapy for improvement in pain and function through 2 to 3 months. For symptomatic spinal stenosis with or without degenerative spondylolisthesis, we found good evidence that decompressive surgery is moderately superior to nonsurgical therapy through 1 to 2 years. For both conditions, patients on average experience improvement either with or without surgery, and benefits associated with surgery decrease with long-term follow-up in some trials. Although there is fair evidence that artificial disc replacement is similarly effective compared to fusion for single level degenerative disc disease and that an interspinous spacer device is superior to nonsurgical therapy for 1- or 2-level spinal stenosis with symptoms relieved with forward flexion, insufficient evidence exists to judge long-term benefits or harms.
Surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to nonsurgical therapy, though benefits diminish with long-term follow-up in some trials. For nonradicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation, but associated with small to moderate benefits compared to standard nonsurgical therapy.
Despite the fact that coronary artery disease is the leading cause of death among women, previous studies have suggested that physicians are less likely to pursue an aggressive approach to coronary artery disease in women than in men. To define this issue further, we compared the care previously received by men and women who were enrolled in a large postinfarction intervention trial.
We assessed the nature and severity of anginal symptoms and the use of antianginal and antiischemic interventions before enrollment in the 1842 men and 389 women with left ventricular ejection fractions less than or equal to 40 percent after an acute myocardial infarction who were randomized in the Survival and Ventricular Enlargement trial.
Before their index infarction, women were as likely as men to have had angina and to have been treated with antianginal drugs. However, despite reports by women of symptoms consistent with greater functional disability from angina, fewer women had undergone cardiac catheterization (15.4 percent of women vs. 27.3 percent of men, P less than 0.001) or coronary bypass surgery (5.9 percent of women vs. 12.7 percent of men, P less than 0.001). When these differences were adjusted for important covariates, men were still twice as likely to undergo an invasive cardiac procedure as women, but bypass surgery was performed with equal frequency among the men and women who did undergo cardiac catheterization.
Physicians pursue a less aggressive management approach to coronary disease in women than in men, despite greater cardiac disability in women.
Previous studies at individual hospitals have reported differences in the use of major diagnostic and therapeutic procedures for women and men with coronary heart disease. To assess whether these differences can be generalized, we performed retrospective analyses of coronary angiography and revascularization (coronary-artery bypass surgery or percutaneous transluminal coronary angioplasty) in women and men hospitalized for coronary heart disease in 1987, using abstract data on 49,623 discharges in Massachusetts and 33,159 discharges in Maryland. We used multiple logistic regression to estimate the adjusted odds of the use of a procedure, controlling for principal diagnosis, age, secondary diagnosis of congestive heart failure or diabetes mellitus, race, and insurance status.
The adjusted odds of undergoing angiography were 28 percent and 15 percent higher for men than for women in Massachusetts and Maryland, respectively (95 percent confidence intervals for the odds ratios, 1.22 to 1.35 and 1.08 to 1.22). The respective adjusted odds of undergoing revascularization were 45 percent and 27 percent higher for men than for women (95 percent confidence intervals, 1.35 to 1.55 and 1.16 to 1.40). Because these differences could be related to differing thresholds for hospital admission, we performed a second analysis limited to patients with diagnosed acute myocardial infarction (11,865 discharges in Massachusetts and 6894 discharges in Maryland), a group in which all patients would be expected to receive hospital care. The male-to-female odds ratios in both states remained similar in magnitude and were statistically significant for angiography and revascularization.
These findings demonstrate that women who are hospitalized for coronary heart disease undergo fewer major diagnostic and therapeutic procedures than men. These differences may represent appropriate levels of care for men and women, but it is also possible that they reflect underuse in women or overuse in men. Further study should assess the cause of these differences and their effect on patients' outcomes.
The relative impact of a patient's sex and expressivity (expression of a personal problem) on attitudes of physicians toward patients was assessed using case simulations and questionnaires. Eight simulated cases were used that varied by presenting complaint, patient sex, and inclusion or exclusion of a personal problem. Two non-identical cases were read by each of 253 primary-care physicians, yielding 506 questionnaires for analysis. Of the physicians, 25 per cent believed women were likely to make excessive demands on physician time, although only 14 per cent believed this likely of men (p less than 0.01); women's complaints were judged more likely to be influenced by emotional factors (65 per cent versus 51 per cent in men, p less than 0.01), and were identified as psychosomatic more frequently than were men's (21 per cent versus 9 per cent, p less than 0.01). No sex differences were observed for tranquilizer prescriptions. Sex differences persisted when complaint and expressiveness were controlled; however, physicians' reactions to expressivity were strong enough to equalize male-female differences in some items. Although non-expressive women were more likely to receive a psychosomatic diagnosis than non-expressive men (14 per cent versus 2 per cent, p less than 0.01), expressive men and women were almost equally likely to receive psychosomatic diagnoses. Thus, differences in labeling occurred as a function of the patient's sex and expressivity. The effects of these differences on quality of care remain to be determined.
Cataract surgery is the most frequently performed surgical procedure on Medicare beneficiaries, with an annual cost to the Medicare program of more than 15,000. Neither analysis detected a statistically significant association between the concentration of ophthalmologists per 1,000 Medicare beneficiaries and the regional rate of, or an individual's likelihood of, cataract surgery. Compared with the geographic variation in provision of other surgical procedures, the variation in cataract surgery across large geographic areas observed in this analysis was relatively low.(ABSTRACT TRUNCATED AT 400 WORDS)
To study gender-specific preferences regarding timing of elective total joint replacement (TJR) surgery in patients with moderately severe osteoarthritis (OA) of the hip or knee.
Focus group discussions regarding TJR surgery were conducted among 18 women and among 12 men with moderately severe OA of the hip or knee. Discussions were tape recorded, transcribed, coded for themes, and evaluated semiquantitatively and qualitatively for gender differences.
In general, men were more likely to choose surgery earlier in the disease than women and had higher expectations for surgical success. Women were more fearful of surgery. Women preferred to suffer arthritis pain rather than risk surgery, and indicated they would delay surgery to await better technology and to avoid disrupting caregiving roles for dependent spouses and others.
Men and women differ in their willingness to accept continued functional decline, risks of surgery, and disruption of usual role. Gender differences may influence decisions regarding utilization of TJR.
Content:
Shared medical decision making is a process by which patients and providers consider outcome probabilities and patient preferences and reach a health care decision based on mutual agreement. Shared decision making is best used for problems involving medical uncertainty. During the process the provider-patient dyad considers treatment options and consequences and explores the fit of expected benefits and consequences of treatment with patient preferences for various outcomes. This paper reviews the literature on shared medical decision making. Several questions are considered. Although several studies suggest that patients do not want to be involved in decision making, these studies typically fail to separate decisions about technical aspects of treatment from preferences for outcomes. There is considerable evidence that patients want to be consulted about the impact of treatment. Studies on the acceptability of shared decision making for physicians have produced inconsistent results. Shared decision making is more acceptable to younger and better-educated patients. It remains unclear whether shared decision making requires expensive video presentations or whether the same results can be obtained with simpler methods, such as the decision board. We conclude that shared medical decision making is an important development in health care. More research is necessary to identify the effects of shared decision making on patient satisfaction and health outcomes. Further, more research is necessary in order to evaluate the most effective methods for engaging patients in decisions about their own health care.
The aim was to identify factors that are related to fear among patients who need to undergo cataract surgery. The data were collected by focus group interviews (n=27). The doctor-patient relationship, patient education, the wait, hospital organization, social support, sensations, previous experience, outcome of surgery, and coping strategies were identified as the main factors that contribute to feelings of fear related to cataract surgery. Five stages of fear were identified: at home after diagnosis, during preparation for surgery at the hospital, the day of surgery, the post-operative visits, and the period after these follow-up visits at home. A model regarding the factors related to fear in patients awaiting cataract surgery was developed, which emphasizes the importance of a good doctor-patient relationship, and the need for patient education that is tailored to the individual patients.
This article proposes a model of medical decisions based on 2 fundamental characteristics of each decision--importance and certainty. Importance reflects a combination of objective and subjective factors; certainty is present if 1 intervention is superior and absent if 2 or more interventions are approximately equal. The proposed model uses these characteristics to predict who will have decisional priority for any given decision and shows how one class of decisions lends itself particularly well to shared decision making. Three other types of decisions are less well suited to a collaborative decision: 1) For major choices that have low certainty, patients should be encouraged to be the primary decision makers, with physician assistance as needed. 2) Most minor decisions that have high certainty are expected to be made by physicians. 3) Major decisions that have high certainty are likely to cause serious conflict when patients and physicians disagree.
The risk of cardiovascular mortality is higher among black women than white women, and the reasons for this disparity are largely unexplored. We sought to evaluate differences in medical care and clinical outcomes among black and white women with established coronary artery disease.
Among the 2699 women enrolled in the Heart and Estrogen/progestin Replacement Study (HERS), we used Cox proportional hazards models to determine the association of race with risk of coronary heart disease (CHD) events independent of major cardiovascular risk factors or medical therapies. During an average of 4.1 years of follow-up, CHD events were twice as likely in black compared with white women (6.4 versus 3.1 per 100 person-years, hazard ratio, 2.1; 95% confidence interval, 1.5 to 2.8; P<0.001). Black women had higher rates of hypertension, diabetes, and hypercholesterolemia, yet were less likely to receive aspirin or statins. Black women less often had optimal blood pressure (56% versus 63%; P=0.01) and LDL cholesterol (30% versus 38%; P=0.04) control at baseline and during follow-up. After adjusting for these and other differences, black women still had >50% higher CHD event risk (hazard ratio, 1.52; 95% confidence interval, 1.1 to 2.1; P=0.03).
In a large cohort of women with heart disease, black women less often received appropriate preventive therapy and adequate risk factor control despite a greater CHD event risk. Interventions to improve appropriate therapy and risk factor control in all women, and especially black women, are needed.
It is easy to march behind the banner of shared medical decision making.
Sharing with a patient who faces tough choices when he or she is ill is one
of the true gifts of being in the medical profession. The patient-physician
relationship is the sacrosanct epitome of professionalism with the goals of
ensuring that patients receive the treatment best for them (science) and that
the best treatment is carried out in the most efficient and compassionate
manner (quality and safety).
The Institute of Medicine calls for physicians to engage patients in making clinical decisions, but not every patient may want the same level of participation.
1) To assess public preferences for participation in decision making in a representative sample of the U.S. population. 2) To understand how demographic variables and health status influence people's preferences for participation in decision making.
A population-based survey of a fully representative sample of English-speaking adults was conducted in concert with the 2002 General Social Survey (N= 2,765). Respondents expressed preferences ranging from patient-directed to physician-directed styles on each of 3 aspects of decision making (seeking information, discussing options, making the final decision). Logistic regression was used to assess the relationships of demographic variables and health status to preferences.
Nearly all respondents (96%) preferred to be offered choices and to be asked their opinions. In contrast, half of the respondents (52%) preferred to leave final decisions to their physicians and 44% preferred to rely on physicians for medical knowledge rather than seeking out information themselves. Women, more educated, and healthier people were more likely to prefer an active role in decision making. African-American and Hispanic respondents were more likely to prefer that physicians make the decisions. Preferences for an active role increased with age up to 45 years, but then declined.
This population-based study demonstrates that people vary substantially in their preferences for participation in decision making. Physicians and health care organizations should not assume that patients wish to participate in clinical decision making, but must assess individual patient preferences and tailor care accordingly.
Unlabelled:
The popularity of total knee arthroplasty combined with the aging US population indicates a dramatic increase in revision TKA procedures. Our objective was to project revision surgery costs in the United States, and to estimate the financial burden for hospitals historically under-reimbursed for these complex surgical procedures. Inflation adjusted charge data derived from a series of knee revision surgeries performed by a single surgeon practice (CJL) (n = 100) were applied to population projections of the number of revision surgeries expected for the Medicare population from 2005-2030. The average charge of TKA revision surgery was 73,696 dollars, (Cost was 36,848 dollars) with substantially higher costs for patients undergoing surgery because of deep joint infection, patients receiving a three component exchange, and patients receiving hinged or constrained condylar knee implants. The number of revision procedures is expected to increase from 37,544 in 2005 to 56,918 in 2030. Projected hospital costs for these procedures may exceed 2 billion dollars by 2030. The number of revision knee surgeries may increase by 66% in the next 25 years. Reimbursement rates will not cover hospital costs for this procedure despite recent increases in Medicare payments for revision arthroplasty.
Level of evidence:
Economic analysis study, level III. See the Guidelines for Authors for a complete description of levels of evidence.