A six-fold variation in the use of cardiac procedures by U.S. geographic region suggests that medical decisions are neither approached in a standard fashion, nor informed by medical evidence. The decision between a patient and their physician is key to efforts aimed at understanding this variation, and at translating medical evidence into clinical practice. In considering the factors that lead to treatment decisions, both patient and physician must be examined together. Lacking knowledge and experience, patients presented with treatment decisions must rely on their physicians to act as their advocate. How physicians frame information will strongly influence the patient's decision process. The objective of this research will be to examine the patient and physician factors involved in the selection of diagnostic and therapeutic procedures in the management of coronary artery disease, and to compare procedural strategies related to patient and physician influences to strategies suggested by clinical trials. The study will encompass two main approaches. The first approach will be to directly examine the patient decision process by administering the Shared Decision Program (SDP) to patients facing treatment decisions following cardiac catheterization. The SDP is a computer based interactive video device that provides patients with easily understood information about their disease and potential therapeutic options in a neutrally framed format. The program also provides viewers with individualized comparisons of survival according for angioplasty, bypass surgery, and medical therapy. If patients are given sufficient information about their disease process and treatment options, they have a greater potential to actively participate in decisions about procedures, possibly selecting those therapies most consistent with medical evidence. The second approach will involve an examination of the physician factors related to differences in cardiac procedure use following acute myocardial infarction. For this approach, we will take advantage of the data available at Duke to develop a longitudinal description of myocardial infarction care from hospital admission through long term follow up, including detailed patient descriptors, inpatient and outpatient cardiac procedures, daily records of physician care, rehospitalizations, and survival status. Using this information, we will examine procedural variation according to the characteristics of the admitting physician. We will also examine """"""""which rate is right?"""""""" by comparing adjusted outcomes (mortality, resource use, and costs), and by comparing procedure use to approaches based on medical evidence.
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