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Over One-Third of Surgical Patients Report Inadequate Shared Decision-Making: Opportunities for Improvement from the ACS NSQIP PROMs Demonstration Project
*Jason B. Liu
1, *
Anoosha Moturu2, Larissa K. Temple
3, Zara Cooper
1, Bruce L. Hall
4, Clifford Y. Ko
2, Andrea L. Pusic
11Surgery, Brigham and Women's Hospital, Boston, MA; 2American College of Surgeons, Chicago, IL; 3Surgery, University of Rochester Medical Center, Rochester, NY; 4University of California Davis Health, Sacramento, CA
Objective: Shared decision-making (SDM) that incorporates patients’ preferences, values, and goals is integral to setting expectations and delivering high-quality patient-centered surgical care. We sought to identify opportunities to enhance SDM in surgical care using data from the ACS NSQIP PROMs Demonstration Project (ACS PROMs DP).
Methods: As part of the ACS PROMs DP, the 3-item CollaboRATE measure was administered. CollaboRATE is a patient-reported measure that evaluates the SDM process, specifically the perception of being informed and then involved in decision-making steps. It is validated for use in clinical care and endorsed by the National Quality Forum as a quality measure. CollaboRATE uses top-box scoring: those with perfect scores, indicating excellent SDM, versus all others, indicating inadequate SDM.
Results: Among 30957 patients from 65 hospitals and 2921 surgeons, 11226 (36.3%) reported inadequate SDM. In univariable analysis, those who reported inadequate SDM were older (
p<0.001) with Medicare vs. commercial insurance (38.3% vs. 34.3%,
p<0.001) and more often male vs. female (40.9% vs. 33.3%,
p<0.001), Asian vs. White (40.2% vs. 36.7%,
p<0.001), and non-Hispanic (36.4% vs. 33.4%,
p=0.02). Patients who had operations at teaching vs. non-teaching hospitals more often reported inadequate SDM (36.5% vs. 33.3%,
p=0.001). Surprisingly, preoperative risk for complications based on NSQIP Risk Calculator estimates was not associated with SDM, but variability by procedure was evident (
Figure). Overall, 81.0% underwent ambulatory procedures, and 30-day morbidity, reoperation, and readmission occurred in 4.7%, 1.8%, and 3.7%, respectively. Patients reported inadequate SDM more often if they had complications, including morbidity (42.2% vs 36.0%,
p<0.001), reoperation (43.8% vs. 36.1%,
p<0.001), or readmission (45.3% vs. 35.9%,
p<0.001). In multivariable analysis, inadequate SDM was significantly associated with presence of complications (OR 1.3, 95% CI 1.2-1.5), being male (1.2, 1.2-1.3), Asian (1.3, 1.1-1.5), having Medicare insurance (1.1, 1.01-1.2), and having non-ambulatory procedures (1.1, 1.03-1.2). Further, patients were also more likely to report inadequate SDM if their surgeons were male (1.1, 1.02-1.2) with more years in practice (1.2, 1.1-1.3) and, relative to General Surgery, in Cardiothoracic Surgery (1.4, 1.2-1.8), Neurosurgery (1.2, 1.03-1.3), Orthopedic Surgery (1.4, 1.3-1.5), Urology (1.3, 1.2-1.5), or Vascular Surgery (1.4, 1.2-1.6) disciplines. Preoperative risk remained unassociated with SDM in multivariable analysis.
Conclusions: SDM is essential to patient-centered quality in surgery. We identified several structural and process factors associated with inadequate SDM. Attention paid to improving SDM is critical as SDM is not only a priority for patients and families, but also may soon become a national quality performance standard.
Figure. The percentage of patients reporting excellent (i.e., top box) SDM across (A) quintiles of increasing preoperative surgical risk based on the NSQIP Surgical Risk Calculator and (B) select procedure groups.
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