UPDATE: Costs of Care and Shared Decision Making: The Value of Knowing

In the original post, I discussed the case of a 57 year old man with what sounded like very mild angina. He had modest risk factors for coronary artery disease with a 10-year ASCVD risk of 7-9%. I discussed that I had recommended he have a second stress test after the first was equivocal, and then I discussed how we all learned a lot about health care economics from that decision. I explained that I learned from my patient and from the superstar patient care coordinator in my office that this was going to cost him a significant amount of money and likely would not change our management. Learning this led me to choose a different, more cost-effective test. I also believe the new test could be better. That test was a coronary artery calcium scan (CAC).

So he has now had that test. The test cost him $300 out of pocket. Don't get me started about why insurance won't reimburse for these. Going in, I said this:

"At that point, I suggested that we could do a coronary calcium scan (CAC) and that if the score were 0 or close, we could probably feel comfortable that this is not angina and that he would not benefit from a statin."

We discussed it for a while and he agreed this seemed like a reasonable and cheaper option and we both agreed it might even provide us with more information (assuming the CAC was low)."

Well, what did it show? So, in a perfect world, this test would have had a binary result:
  1. CAC=0 which would have led us to conclude that the symptoms he was having were likely not angina and he could safely skip his statin.
  2. CAC>300 or >75th percentile for age which would have led us to conclude he likely has CAD and would clearly benefit from a statin. 
Sadly, medicine is not often binary. The result here was CAC of 88 which was 55th percentile for age meaning that 45% of men his age have lower CAC scores. 

My first reaction was: "UGH!" 

I hate tests that don't add anything. I want a test result that is clear and concise. I wanted option 1 or 2 above and I got 3. 

So what to do? Well, I think the answer was in what I wrote in the quote above. My clinical judgment was that I thought he had CAD. The first low-risk stress test obviated the need for further possible intervention since his symptoms were not particularly limiting. This whole thing came down to one simple question: statin or no statin. And my default reaction was yes statin. And my patient wanted and thus what I wanted was something that would possibly talk us out of that default decision. And that would have been option 1 above. I did not get that. He already meets guideline-based criteria for using a statin with his ASCVD risk of 7-9% so the CAC was not necessary to move him into the category of where we would consider a statin. Rather, we would only be satisfied with a CAC of 0 or near 0 to give us to comfort to skip it

So after spending 30 minutes chatting about this with my patient, I wrote an electronic prescription for a statin. I told him this is not a lifetime decision. If he has side effects or other trouble tolerating the medicine, we will stop. If we learn in the future that this approach is flawed, we will stop. If a better drug comes along or if we learn we can achieve the same thing with a diet or lifestyle change, we will stop. 

Finally, I will leave you with the question my patient asked me that left me without much in the way of an answer: "How will we know if it is working?"



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