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Benefits of Knowing Your Risks: A Step Toward Shared Surgical Decision-Making and High-Value Care.

April 2019 • Volume 128 • Number 4 www.anesthesia-analgesia.org 607 DOI: 10.1213/ANE.0000000000003978 Informed consent is a core component of ethical medical practice, but its relevance to the pursuit of high-value surgical care is poorly understood. As anesthesiologists, we know what informed consent is, but we understand relatively little about how best to obtain it, how to measure it, and most importantly, how high-quality informed consent is essential to the goal of promoting value in health care. The Centers for Medicare and Medicaid Services dictate that an informed consent process should include, among other components, discussion of “material risks and benefits for the patient related to the surgery and anesthesia, including the likelihood of each, based on the available clinical evidence, as informed by the responsible practitioner’s clinical judgment.” In this issue of Anesthesia & Analgesia, Raymond et al1 explore use of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator in the process of obtaining informed consent for surgery. The authors assessed patients’ estimation of personal perioperative risk, reviewed their American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator results with them, and elicited perceptions about its use. While many patients overestimated their risk for specific complications, subgroup analysis suggested that “high-risk” patients were more likely to underestimate their risk of adverse outcomes, including serious complications, discharge to a nursing or rehabilitation facility, and death. Patient perceptions of the calculator were favorable, with 93% endorsing improved understanding of their risks and 81% expressing that they would have wanted to know their calculated risks before consenting to surgery. Disclosure of risk decreased or did not change levels of anxiety in 91% of participants. No patients delayed or withdrew consent for their surgery after reviewing their risk predictions, and 70% stated that they would consider participating in a “prehabilitation” program to decrease their risk for complications. The investigation of the National Surgical Quality Improvement Program for use in communicating risk to patients by Raymond et al1 is part of a broader agenda: advancing from an “informed decision making model” to one of shared decision-making. The informed decisionmaking model involves physicians providing relevant technical information to patients including risks and benefits of a proposed procedure, and then allowing patients reach a decision based on their own preferences. Shared decisionmaking entails not only communication of risks and benefits but also eliciting patients’ goals, values, and concerns, and assisting them with how to conceptualize risks and benefits and how to approach the decision.2 Empirical evidence suggests a strong connection between shared decision-making and high-value care (defined as care that yields a favorable ratio of quality to cost).3 Patients who participate in a robust decision-making process focused on their goals and values are more likely to choose conservative management options with associated reductions in health care expenditures. In the following paragraphs, we will consider the contribution by Raymond et al1 within this larger context of efforts not only to inform patients but also to engage them in a process that will ultimately result in appropriate, highvalue care. The American College of Surgeons National Surgical Quality Improvement Program Calculator is designed to provide evidence-based information about patientand procedure-specific risks, with the goal of guiding surgical decision-making and informed consent. Using 20 patient predictors and the planned procedure, the calculator generates predictions of the likelihood of 15 different outcomes occurring within the first 30 days after surgery. In the study by Raymond et al1, the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator appeared to be effective as a tool for communication; although the authors did not formally assess patients’ comprehension or retention of the information delivered, the majority of participants reported that disclosure of their calculator results improved their understanding of their risks. However, when it comes to shared decision-making, informing patients of their risks is only part of the challenge. Although useful, the calculator results may not address patients’ broader concerns (eg, whether undergoing a procedure might help a patient achieve a certain level Benefits of Knowing Your Risks: A Step Toward Shared Surgical Decision-Making and High-Value Care