Blog | Tuesday, March 6, 2012

QD: News Every Day--Two studies reinforce medical management over stents


Medical management of chest pain works comparably to stents, but doctors need to do a better job of communicating that, because patients rarely recall that options were presented to them.

Comparable benefits for angina can be achieved in most patients with good medical management and lifestyle changes, according to a study published in Archives of Internal Medicine.

Researchers performed a meta-analysis of all randomized clinical trials comparing initial coronary stent implantation with medical therapy to determine the effect on death, nonfatal myocardial infarction, unplanned revascularization and persistent angina.

The meta-analysis found eight trials enrolling 7,229 people. The respective event rates for death with stent implantation and medical therapy were 8.9% and 9.1% (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.84 to 1.16); for nonfatal MI, 8.9% and 8.1% (OR, 1.12; 95% CI, 0.93 to 1.34); for unplanned revascularization, 21.4% and 30.7% (OR, 0.78; 95% CI, 0.57 to 1.06); and for persistent angina, 29% and 33% (OR, 0.80; 95% CI, 0.60 to 1.05).

So, therapy works, but do patients ever find out about it? Nine out of 10 Medicare patients who received a stent responded on a survey that they didn't recall their physicians offering a non-invasive alternative.

"We wanted to see if patients knew about their options and, if not, find out where the process of becoming fully informed was breaking down from the patient perspective," Julie P.W. Bynum, MD, MPH, ACP Member, one of the co-authors of the study, said in a press release.

Researchers conducted a survey by mail among 1,600 Medicare beneficiaries 66 years or who had undergone surgery for prostate cancer or elective coronary artery stenting in 2008. The goal was to compare discussions about prostate cancer and stents, both of which involve either a major surgical intervention or conservative, non-invasive therapies.

Patients were asked if the physicians presented options to them for serious consideration, the amount of time spent discussing the pros and cons of the procedures, and if they were asked about their preferences. Results appeared in the Journal of General Internal Medicine.

Of the respondents, (64%) of prostate cancer surgery patients reported at least one alternative to surgery was presented to them as a serious option. A third said no immediate active treatment was presented as an option. Almost all (94%) said they discussed the pros of the surgery with their doctors, while 63% said they discussed the cons of surgery "a lot" or "some." Most (76%) said they were asked about their treatment preferences.

Of the patients receiving coronary artery stents, 10% said they were presented with options to seriously consider. Most (77%) said they talked with doctors "a lot" or "some" about the reasons for the stents, but few (19%) reported talking about the cons of the procedure. Only 16% were asked about their treatment preferences.

The authors said one possible reason for limited discussion is that many stent procedures are done at the same time as the angiogram, limiting the opportunities for discussion. However, they continued, primary care physicians should be more involved in such decisions as well, and the patient-centered medical home model might bring them into the loop.

"Fewer than three percent of respondents said their primary care provider played a major role in their decisions," the authors wrote. "Because primary care providers are likely to be less predisposed to a specific treatment than specialists, they may provide more balanced information and may increase the likelihood that conservative options are considered."