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Original Article |

Choosing Where to Have Major Surgery:  Who Makes the Decision? FREE

Chad T. Wilson, MD; Steven Woloshin, MD, MS; Lisa M. Schwartz, MD, MS
[+] Author Affiliations

Author Affiliations: Department of Veterans Affairs Medical Center, VA Outcomes Group, White River Junction, Vt (Drs Wilson, Woloshin, and Schwartz); the Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, NH (Drs Wilson, Woloshin, and Schwartz); and Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH (Drs Woloshin and Schwartz). Dr Wilson is now with Massachusetts General Hospital, Boston.


Arch Surg. 2007;142(3):242-246. doi:10.1001/archsurg.142.3.242.
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Hypothesis  Efforts are under way to distribute hospital performance data directly to patients to inform their decisions about where to go for major surgery, but patients are not always involved in making the decision of where they will have surgery.

Design  Telephone interviews.

Participants  Five hundred ten randomly selected Medicare patients who had undergone 1 of 5 elective high-risk operations approximately 3 years earlier: abdominal aneurysm repair (n = 103), heart valve replacement surgery (n = 96), or resections for bladder (n = 119), lung (n = 128), or stomach (n = 64) cancer.

Main Outcome Measure  Proportion of patients who responded that their physician was the main decision maker of where they would have surgery.

Results  Thirty-one percent of patients said their physician was the main decision maker about where the patient would have surgery (42% said they decided equally with their physician, 22% said they were the main decision maker, and 5% said their family helped make the decision for them). This proportion was similar across patient age, income, and educational attainment. Men were more likely to say the physician was the main decision maker (34% vs 24%; P = .02), as were patients in poor to fair health compared with those in good to excellent health (37% vs 28%; P = .05). The physician was significantly more likely to be the main decision maker for cardiovascular operations compared with cancer operations (39% vs 26%; P = .001).

Conclusion  Although most patients participated in the decision of where they would have major surgery, one third said the decision was made mainly by their physician.

Figures in this Article

There are growing efforts from federal governmental agencies, US state departments of public health, proprietary health quality–rating firms, patient advocacy groups, and purchaser coalitions to distribute hospital performance data directly to patients to help them select the best hospitals to use.15 These efforts are especially relevant to patients who need major elective surgery, which has a substantial risk of morbidity and mortality, and who have time to make a considered decision. Not surprisingly, Medicare policymakers have become interested in disseminating surgeon and hospital volume (or mortality) data to help patients choose where to have major surgery.6

These efforts, however, assume that patients are actively involved in choosing where to have surgery. In fact, little is known about the patient's role in such decisions; it is possible that many patients may not participate at all. Theoretically, there is a spectrum of involvement. At one extreme, the referring physician (eg, primary care physician or cardiologist) may simply choose a surgeon or hospital without any input from the patient. At the other extreme, the patient might take on a very active role in the decision-making process, perhaps looking for information to compare different hospitals.

We conducted a national survey to find out how involved Medicare patients and their families felt they were in deciding where to have major surgery. This population is important because Medicare covers more than half of all patients undergoing these major surgical procedures in the United States.7 We also describe the characteristics of patients who reported limited involvement in the decision-making process.

SURVEY DEVELOPMENT

The data presented herein were collected as part of a larger survey conducted in 2004 designed to learn how patients choose where to go for major surgery.8 We developed a draft survey based on a review of the literature, a previously published survey of patients who underwent coronary artery bypass surgery in Pennsylvania,9 and the results of 2 focus groups (the participants of which were individuals who had recently undergone major surgery) conducted by professional interviewers from the Center for Survey Research, a professional survey research firm affiliated with the University of Massachusetts. The survey—a telephone interview script—underwent pilot testing (with 25 elderly patients who had undergone major surgery) and was revised based on the pretest results.

The final survey consisted of 3 major sections covering experiences with major surgery—how they decided where to have surgery, what factors influenced this choice, and their perceptions of the hospital and the surgeon—knowledge, and reaction to surgical performance data, and responses to 2 scenarios—how they would advise a friend who needed major surgery and their reactions to Medicare publishing a list of best hospitals for different operations. The present analysis focuses on the patient's perceptions of who was the main decision maker of where they would have surgery. This project was approved by the institutional review boards at Dartmouth Medical School, the University of Massachusetts, and the Center for Medicaid and Medicare Services.

SAMPLE SELECTION

We designed the survey to focus on elective procedures because, theoretically, choice of hospital or surgeon was possible. We interviewed a random sample of Medicare beneficiaries who had undergone 1 of the following 5 major elective operations: abdominal aneurysm repair, heart valve replacement, or resections for bladder, lung, or stomach cancer. Figure 1 details the steps of the sampling procedure.

Place holder to copy figure label and caption
Figure 1.

Sample selection process. *Interview responses were classified as no answer after 6 attempts at different times of day were made, and at least 3 additional attempts were made 2 weeks later.

Graphic Jump Location

Our goal was to get 100 interviews for each operation. To do so we had to vary the sampling fraction for each procedure (ie, the proportion of patients sampled from all Medicare patients undergoing the operation). Thus, rare procedures had to have higher sampling fractions than more common ones (eg, cystectomy compared with valve replacement, respectively). Sampling fractions had to be higher for procedures with lower survival (eg, gastrectomy), because we were interviewing patients 3 years after their surgery. The resulting sampling fraction for each operation was the following: lung resection, 4.2%; gastrectomy, 10.8%; cystectomy, 14.5%; abdominal aneurysm repair, 1.7%; and valve replacement, 1.1%.

ADMINISTRATION

In December 2003, potentially eligible respondents were sent a prenotification letter (as required by the Center for Medicaid and Medicare Services); 2 weeks later they received a second letter stating that the Center for Survey Research would be calling. Interviews were conducted by professional interviewers at the Center for Survey Research's telephone facility from January through February of 2004. All interviewers received special training on the purposes and procedures of this particular study, and all underwent monitoring for quality control and feedback from a supervisor. The interviews took an average of 21 minutes (range, 12-46 minutes). Answers to the survey were directly entered into the computer-assisted telephone interviewing system by the interviewers.

A total of 500 individuals without cognitive impairment completed the telephone interview and answered the question, “Who made the decision to go to your hospital—mainly your doctor, mainly you, both you and the doctor equally, or someone else.” We calculated response rates using the 2 methods recommended by the American Association of Public Opinion Research.10 Using the denominator of all eligible survivors, the response rate for the present analysis was 47% (500 of 1055 participants). Using the denominator of those who had the ability to participate (those with accurate contact information and no cognitive impairment), the corresponding response rate was 67% (500 of 751 participants). Response rates varied little and did not differ statistically across the 5 operations.

ANALYSIS

We created weights to account for the different probabilities of selection into our sample (ie, the differing sampling fractions) and to account for nonresponse. The weighted results were nearly identical to the unweighted results (they only differed by 1% or 2%). Because the weighted results assume that nonrespondents would answer questions similarly to respondents, we chose to present the unweighted results. All analyses were performed using STATA statistical software (Version 8.2; Stata Corp, College Station, Texas).

MAIN DECISION MAKER

The mean age of the respondents was 78 years (range, 67-104 years); 68% were men and 90% were white (Table). Forty-two percent of patients said they decided equally with their physician about where to have surgery; 22% of patients said they were the main decision maker; and 5% indicated that the role belonged to a family member. The remaining 31% of patients said the physician was the main decision maker of where they would have surgery.

Table Graphic Jump LocationTable. Characteristics of Survey Respondents*
DECISION-MAKING FACTORS

The following characteristics were associated with surgical decision making:

  • Patient characteristics: the proportion of patients who said the physician was the main decision maker about where to have surgery did not vary by age (Figure 2). Nor were the small differences across income and educational attainment statistically significant. Men were more likely to report that the physician was the main decision maker (34% for men vs 24% for women; P = .02), as were patients with worse health status (37% for poor to fair health vs 28% for good to excellent health; P = .049).

  • Type of surgery: patients reported less involvement in decisions about cardiovascular operations. The physician was the main decision maker in 39% of cardiovascular operations vs 26% of cancer operations (P = .001).

  • Hospital location: patients who drove less than an hour were more likely than those driving an hour or more to say that the physician was the main decision maker (34% vs 24%, respectively; P = .03) (Figure 3). Similarly, patients who said hospital location was of little or no importance to their decision about where to have surgery were more likely than those reporting that location was very or extremely important to say that the physician was the main decision maker (35% vs 26%, respectively; P = .02).

  • Patient perception of the hospital: patients who did not rate the hospital highly were more likely to say that the physician was the main decision maker. Patients who did not know how their hospital was rated were most likely to say that the physician was the main decision maker, followed by those patients who said their hospital rated the same or worse than most and those who said it rated better than most (54%, 37%, and 27%, respectively; P = .009). Similarly, patients whose family or friends did not recommend the hospital were more likely to say that the physician was the main decision maker (37% vs 20%; P<.001).

  • Consumer behavior: patients who expressed less interest in an active consumer role were more likely to say that the physician was the main decision maker. Patients who did not try to find hospital information comparing hospitals were more likely to say that the physician was the main decision maker (33% vs 17% of those who did try to find information; P = .01). When asked how they would like to get hospital quality information, patients who preferred to get hospital information from their physician only were more likely than those who preferred other sources to say that the physician was the main decision maker (39% vs 26%, respectively; P = .003).

Place holder to copy figure label and caption
Figure 2.

Percentage of patients who said that their physician was the main decision maker of where they would have major surgery, according to patient characteristics. The vertical line represents the percentage of patients overall who said the physician was the main decision maker (31%). *P<.05.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Percentage of patients who said the physician was the main decision maker of where to have major surgery according to informed survey responses. The vertical line represents the percentage of patients overall who said the physician was the main decision maker (31%). *P<.05. †P<.01.

Graphic Jump Location

We know of no prior study that examines patient involvement in choosing where to have major surgery, a decision that potentially affects mortality. In our nationally representative study of Medicare patients who had undergone major surgery, most said that they participated in the decision; still, one third said the decision was made mainly by their physician. Our findings regarding involvement in this specific decision are consistent with other work exploring general decision-making styles: men, individuals in poorer health, and more acutely ill patients tend to adopt a more passive decision-making role.11

Our findings should be interpreted in light of several limitations. First, given our target population—Medicare beneficiaries who survived 3 years since having a major elective operation—achieving a good response was extremely challenging. We deliberately chose this population because Medicare covers most patients undergoing major surgery in the United States.7 Our response rate was good (47% among eligible survivors and 67% among those with the ability to participate); nevertheless, systematic bias between respondents and nonrespondents is still possible. This concern is lessened by the fact that participants' demographics closely approximated those of all Medicare patients undergoing the 5 procedures (including those who did not survive the 3 years). How well our findings generalize to younger patients is unknown. Next, some may be concerned about how well elderly participants were able to recall the details of a decision-making process that occurred 3 years earlier. We tried to ensure that participants were cognitively able; participants were limited to those living in a community dwelling who did not have cognitive impairment that was obvious to the trained interviewers. Item nonresponse rates were extremely low for all questions, and results did not differ importantly by respondent age. Finally, we took care to include patients who had undergone a variety of operations. Nonetheless, extrapolating from our respondents to patients undergoing other elective surgeries should be done cautiously.

Our study has 2 important implications for policymakers interested in guiding patients to the best surgeons and hospitals. First, the fact that two thirds of our respondents said they were involved in deciding where to have surgery helps validate a key assumption underlying the public dissemination of performance data, namely, that patients will adopt an active decision-making role. Access to performance data may be very useful for these patients.

The second implication relates to the substantial proportion of patients who said that the physician was the main decision maker. The role of performance data for these patients is less clear and hinges on a question our data do not directly address: are these patients as involved in the decision-making process as they would like to be? Some patients may not want an active role in selecting a surgeon or hospital. They may feel that such decision making is better left to the referring physician, assuming, of course, that the referring physician knows how to choose wisely; whether this is generally the case is unknown and merits study. In fact, we found that patients with less involvement in the decision-making process reported less consumeristic behavior; they were less likely to look for comparative information about hospitals and preferred to receive information from the physician exclusively (as opposed to having access to information on their own). But it is also possible that these patients may have wanted a greater role in the decision-making process but were unable to participate more, either because a paternalistic physician (or health care system) imposed a decision on them or because the patients could not find the information they needed to participate meaningfully.

The process by which patients who need major surgery get directed to surgeons and hospitals is poorly understood, and the role of the patient in this process has received little attention. While many patients participate in the decision-making process and may desire objective information to inform their decisions, a substantial proportion of patients are not involved at all. Research is needed to help us understand whether patients would like a greater role in deciding where to have major surgery and, if so, how to facilitate such involvement.

Correspondence: Chad T. Wilson, MD, Division of General Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114 (ctwilson@partners.org).

Accepted for Publication: January 14, 2006.

Author Contributions: Dr Wilson had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Woloshin and Schwartz. Analysis and interpretation of data: Wilson. Drafting of the manuscript: Wilson. Critical revision of the manuscript for important intellectual content: Woloshin and Schwartz. Statistical analysis: Wilson. Obtained funding: Woloshin and Schwartz. Administrative, technical, and material support: Woloshin and Schwartz.

Financial Disclosure: None reported.

Funding/Support: Drs. Woloshin and Schwartz were supported by Veterans Affairs Advanced Research Career Development Awards in Health Services Research and Development, and Robert Wood Johnson Generalist Faculty Scholar Awards. This study was supported by grant R03HS1304901 from the Agency for Health Care Research and Quality.

Disclaimer: The views expressed herein do not necessarily represent the views of the Department of Veterans Affairs or the United States government.

Acknowledgment: The authors would like to thank Emily Finlayson, MD, for her work on the pilot survey at the beginning of the project; John D. Birkmeyer, MD, for his help with the conception and design of the survey; and H. Gilbert Welch, MD, MPH, for his helpful comments on this manuscript.

Davies  HTMarshall  MN Public disclosure of performance data: does the public get what the public wants? Lancet 1999;3531639- 1640
PubMed Link to Article
Epstein  AM Public release of performance data: a progress report from the front. JAMA 2000;2831884- 1886
PubMed Link to Article
Marshall  MNShekelle  PGLeatherman  SBrook  RH The public release of performance data: what do we expect to gain? a review of the evidence. JAMA 2000;2831866- 1874
PubMed Link to Article
Milstein  AGalvin  RSDelbanco  SFSalber  PBuck  CR  Jr Improving the safety of health care: the leapfrog initiative. Eff Clin Pract 2000;3313- 316[erratum appears in Eff Clin Pract. 2001;4:94]
PubMed
Galvin  RMilstein  A Large employers' new strategies in health care. N Engl J Med 2002;347939- 942
PubMed Link to Article
Birkmeyer  JDGoodney  PPSiewers  ASStukel  TALucas  FL Policy implications of public reporting of hospital volume with selected procedures and recommendations: a white paper for the Center for Medicare and Medicaid Services. 2002;
Finlayson  EVBirkmeyer  JD Operative mortality with elective surgery in older adults. Eff Clin Pract 2001;4172- 177[erratum appears in Eff Clin Pract. 2001;4:235]
PubMed
Schwartz  LMWoloshin  SBirkmeyer  JD How do elderly patients decide where to go for major surgery? telephone interview survey. BMJ 2005;331821
PubMed Link to Article
Schneider  ECEpstein  AM Use of public performance reports: a survey of patients undergoing cardiac surgery. JAMA 1998;2791638- 1642
PubMed Link to Article
 Standard Definitions: Final Disposition of Case Codes and Outcome Rates for Surveys.  American Association for Public Opinion Researchhttp://aapor.org. Accessed February 7, 2003
Stiggelbout  AMKiebert  GM A role for the sick role: patient preferences regarding information and participation in clinical decision-making. CMAJ 1997;157383- 389
PubMed

Figures

Place holder to copy figure label and caption
Figure 1.

Sample selection process. *Interview responses were classified as no answer after 6 attempts at different times of day were made, and at least 3 additional attempts were made 2 weeks later.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Percentage of patients who said that their physician was the main decision maker of where they would have major surgery, according to patient characteristics. The vertical line represents the percentage of patients overall who said the physician was the main decision maker (31%). *P<.05.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Percentage of patients who said the physician was the main decision maker of where to have major surgery according to informed survey responses. The vertical line represents the percentage of patients overall who said the physician was the main decision maker (31%). *P<.05. †P<.01.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable. Characteristics of Survey Respondents*

References

Davies  HTMarshall  MN Public disclosure of performance data: does the public get what the public wants? Lancet 1999;3531639- 1640
PubMed Link to Article
Epstein  AM Public release of performance data: a progress report from the front. JAMA 2000;2831884- 1886
PubMed Link to Article
Marshall  MNShekelle  PGLeatherman  SBrook  RH The public release of performance data: what do we expect to gain? a review of the evidence. JAMA 2000;2831866- 1874
PubMed Link to Article
Milstein  AGalvin  RSDelbanco  SFSalber  PBuck  CR  Jr Improving the safety of health care: the leapfrog initiative. Eff Clin Pract 2000;3313- 316[erratum appears in Eff Clin Pract. 2001;4:94]
PubMed
Galvin  RMilstein  A Large employers' new strategies in health care. N Engl J Med 2002;347939- 942
PubMed Link to Article
Birkmeyer  JDGoodney  PPSiewers  ASStukel  TALucas  FL Policy implications of public reporting of hospital volume with selected procedures and recommendations: a white paper for the Center for Medicare and Medicaid Services. 2002;
Finlayson  EVBirkmeyer  JD Operative mortality with elective surgery in older adults. Eff Clin Pract 2001;4172- 177[erratum appears in Eff Clin Pract. 2001;4:235]
PubMed
Schwartz  LMWoloshin  SBirkmeyer  JD How do elderly patients decide where to go for major surgery? telephone interview survey. BMJ 2005;331821
PubMed Link to Article
Schneider  ECEpstein  AM Use of public performance reports: a survey of patients undergoing cardiac surgery. JAMA 1998;2791638- 1642
PubMed Link to Article
 Standard Definitions: Final Disposition of Case Codes and Outcome Rates for Surveys.  American Association for Public Opinion Researchhttp://aapor.org. Accessed February 7, 2003
Stiggelbout  AMKiebert  GM A role for the sick role: patient preferences regarding information and participation in clinical decision-making. CMAJ 1997;157383- 389
PubMed

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