A survey of Medicare patients who had major elective surgery found that although most participated in the decision regarding the hospital at which they would undergo their procedures, physicians served as the main decision-makers one-third of the time, according to an article in the March issue of Archives of Surgery, one of the JAMA/Archives journals.

Public and private agencies are encouraging hospitals to distribute data on quality and performance to patients, according to background information in the article. “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,” the authors write. “Not surprisingly, Medicare policymakers have become interested in disseminating surgeon and hospital volume (or mortality) data to help patients choose where to have surgery.” These efforts assume that patients take an active role in deciding where to have surgery, but little is known about how such choices are made and whether patients are involved at all.

Chad T. Wilson, M.D., then of the Department of Veterans Affairs Medical Center, White River Junction, Vt., and Dartmouth Medical School, Hanover, N.H., and now at Massachusetts General Hospital in Boston, and colleagues surveyed 500 Medicare patients in 2004 who had undergone one of five elective high-risk operations about three years prior. The average age of the patients was 78 years and 68 percent were men; 103 underwent abdominal aneurysm repair, 96 had a heart valve replacement and the rest had procedures involving tumor removal: 119 for bladder cancer, 128 for lung cancer and 64 for stomach cancer.

Among the patients, 42 percent said they decided equally with their physician where they would have surgery; 31 percent said the physician was the main decision-maker; 22 percent of patients said they primarily made the decision themselves; and 5 percent said a family member played a leading role. Men were more likely to report that the physician was the main decision-maker (34 percent vs. 24 percent for women) and so were patients in worse health (37 percent of those with poor to fair health vs. 28 percent of those with good to excellent health). Physicians were more likely to lead the decision for cardiovascular procedures (39 percent) than for cancer operations (26 percent).

“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,” the authors conclude. “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.”
(Arch Surg. 2007;142:242-246. Available to the media pre-embargo at www.jamamedia.org).

Editor's Note: Co-authors Dr. Woloshin and Dr. 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 a grant from the Agency for Health Care Research and Quality. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

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