Thursday, August 25, 2011

A really informative consent

I started reading Safe Patients, Smart Hospitalson the plane back to Boston yesterday until my battery died.  I'm still not done, so I'll save the review to a later post.  The author, Peter Provenost quotes statistics that I found rather disturbing.

One study concluded that there were 1.7 errors per patient day in America's ICUs.  Of these errors, 29 percent could have caused significant harm or death.

He points out that the average stay is about 3 days.  That means just over 5 errors.  The chance of leaving the ICU without suffering from such an error means that you need need to succeed on five rolls on a pair of dice without rolling a 2, 3, 4 or 5.  You'll manage that less than 1 time in five (about 18% of the time).

Many of us have seen informed consent forms.  They list the significant risks of a surgical or diagnostic procedure.  But what they don't do is list the actual chances associated with that risk.

What if, on being asked to consent to a procedure you were told:

There is a significant risk of ____.  In similar procedures performed (by your surgeon/at this institition), patients were X% likely to incur this risk.  This is [significantly][above|below] the national average of Y% in similar institutions and procedures.

Even better yet, it could use one of those pictures like Energy Star uses.

Wouldn't that actually say something relevant to patients and incent institutions and providers to do better?


  1. It's a fascinating idea. But don't you have to tell the other side of the risk story too? That is - if you elect not to undergo this procedure (that your provider presumably feels is medically necessary) you are facing this *different* set of outcomes, with their own respective probabilities?

    And given how poorly most people are able to interpret information about probability, and to assess risk, how do you end up affecting people's health by starting to provide this information in this way?

  2. If the people are not able to interpret information about probability then we should teach them what really means, not hide it on the corner hoping they don't misinterpret the probabilities

  3. Tom,

    The point of Dr. Provenost's book is that some of these risks are avoidable. At John's Hopkins, they nearly eliminated Central Line infections in the ICU, and then they did it for the entire state of Michigan. It was the SECOND central line infection in the same stay that killed my step-father a couple of years ago.

    Using something like the Energy Guide label shows how well the facility does with regard to that risk. Patients can readily determine if it is the best care they can get, or if they could get better care elsewhere. If we could compare risks, would mom and he have picked a DIFFERENT hospital? While I know now how to locate this information, most patients don't.

    If the risks were published, would that hospital have paid more attention to eliminating them?

  4. I see what you're saying, Keith. You're thinking about people using the information to compare facilities and providers; where I'm thinking about people using it to decide whether to have procedures done (at all). I think you're right that requiring facilities and providers to give this information to patients, in a very clear form, would motivate them to do better.

    I am just wondering if it could also have unintended consequences. For instance, what if it turned out that when presented with risk information in this way, people had a tendency to avoid early interventions, only to end up accepting later, riskier ones (under the motivation of pain, risk of death, etc.)?