Shared Decision-making Studies Reveal Trends, Costs and Benefits

Date Posted: June 4, 2013

June 4, 2013 - Could putting a greater emphasis on patient preferences and shared decision making improve the care your organization provides while also reducing costs?

Many experts suggest that including patients in the decision-making process can have great value. For example, the American Medical Association (AMA) has included shared decision making as a key component of quality care. Health reform even encourages the phenomenon, since the Patient Protection and Affordable Care Act (ACA) included a provision to spur greater shared decision making.

However, there seems to be a lengthy road ahead when it comes to making shared decision making a widespread phenomenon.

A January 2013 Perspective column in the New England Journal of Medicine (NEJM) stated, “more than two years after enactment of the ACA, little has been done to promote shared decision making.”  Co-authors Emily Oshima Lee and Ezekiel Emanuel, MD, PhD, wrote that the Centers for Medicare and Medicaid Services (CMS) need to step up: “CMS should begin certifying and implementing patient decision aids, aiming to achieve three important goals:  promote an ideal approach to clinician–patient decision making, improve the quality of medical decisions, and reduce costs.”

A recent study for JAMA Internal Medicine titled “How Patient Centered Are Medical Decisions?” found that when patients were asked to reflect on certain common tests, procedures and medications after the fact, they didn’t report a high level of shared decision making.

Floyd J. Fowler, Jr. hopes shared decision making becomes more routine.
Floyd J. Fowler, Jr., PhD, hopes that the increased interest in shared decision making will lead to material changes that make it more routine.

“I think that dynamic is one that people increasingly are beginning to appreciate, but we’re a long way from there,” said Floyd Fowler Jr., PhD, lead author of the study, which appeared as a part of a series of articles on shared decision making that were published online on May 27.

The study, which was co-authored by Bethany Gerstein and Michael Barry, MD, examined responses from 2,718 patients over age 40. The researchers examined their perceptions about the extent to which pros and cons were discussed with their providers, as well as whether they remembered being told they had choices and if they were asked for their input. They found that pros tended to be discussed with patients more than cons, and certain procedures tended to engender more conversations about choices than others.

While some of the decisions that this research team studied took place in the primary care environment, they emphasized that one cannot assume that primary care providers are less likely to engage in shared decision making than specialists do. It varies from decision to decision, from provider to provider, Fowler said.

But the world is changing, and a growing emphasis on patient satisfaction and patient-centered care seems to be having an effect.

“It’s not the way we’ve been doing it for a long time,” said Fowler. “And it’s going to take some time and effort to make change.”

Patient participation linked with higher costs

But some worry that shared decision making could cost more.

In a policy brief, the AMA notes that the goal of shared decision making isn’t to reduce spending.  “Rather, the aim is to better incorporate patients’ individual goals and preferences into decisions. Health care that better meets patients’ goals provides better value, even if it potentially costs more,” the brief states.

Another study in the recent JAMA Internal Medicine series suggested that including more patient input in the decision-making process could lead to higher costs.

In “Association of Patient Preferences for Participation in Decision Making with Length of Stay and Costs Among Hospitalized Patients,” Hyo Jung Tak, PhD, Gregory Ruhnke, MD, and David Meltzer, MD, PhD, analyzed the responses of a survey administered to nearly 22,000 patients at the University of
Chicago Medical Center between July 2003 and August 2011 and compared it to administrative data from the same period.

The patients who wanted to participate in decision making tend to be hospitalized slightly longer--0.26 of a day on average--and incurred an additional $865 in costs.

The authors wrote that their study suggests that “policies that increase patient engagement in decision making may increase (length of stay) and costs, at least in context in which physicians face incentives to decrease utilization. This contrasts with the expectation that patient participation in care decisions might decrease cost and suggests that it is important to evaluate efforts to increase patient engagement in decision making with respect to their effects on outcomes and costs.”

What do patients really want?

One of the biggest challenges going forward may be determining what patients really want.

Mack Lipkin: shared decision making will vary from patient to patient.
Mack Lipkin, MD, said some patients want to be more actively involved in decision making about their care than others, and their wishes should be respected.

“There is really a big spectrum of how people want to deal with situations,” said Mack Lipkin, MD, who authored a commentary on the shared decision making series for JAMA Internal Medicine.

There are some patients who want to be actively involved in their care and in the decision-making process, he said, but there are others who would prefer to ask the doctor what she or he would recommend.

“I think it’s disrespectful not to respect that and give them what they’re asking for,” said Lipkin.

Tak, et al., wrote that a good issue for future research is the question of “why some patients definitely disagree with leaving decisions up to their physician, despite his or her lack of professional knowledge, while others strongly agree.”

The greater implementation of formal decision-making aids or support tools may also be helpful for providers in including patients in the decision-making process, as well as providing some level of protection for the physician who is reluctant to give up some degree of control.

The AMA notes that these aids and formal processes may “improve the medical liability climate for physicians, which could lead to a reduction in the amount of waste associated with spending on defensive medicine.” According to the AMA, some research suggests the documented use of patient decision aids “may help strengthen a jury’s belief that a physician met the appropriate standard of care.”

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