What Is Shared in Shared Decision Making? Complex Decisions When the Evidence Is Unclear, by Ronald M. Epstein and Robert E. Gramling (Medical Care Research and Review)
Patient involvement in decisions is central to patient-centered care. Yet many important decisions must be made in complex, ambiguous clinical situations in which all possible options cannot be known, evidence is inadequate to inform patients’ preferences fully, and/or patients are unclear about their desired level of involvement. In these situations, preferences are shaped by affect, framing, and “collaborative cognition” among clinicians, patients, and their families; thus, decisions are often relational, dynamic, iterative, provisional, and/or conditional. Clinicians can help patients achieve greater autonomy by engaging both intuitive and deliberative decision-making processes (“whole mind”) and involving others in exploring, clarifying, and co-constructing patients’ preferences (“shared mind”). Clinical and interpersonal relationships can promote effective decision making through developing a shared attentional focus, tailoring information, and identifying conditions under which provisional preferences might change. Information technology and health systems offer untapped potential to deepen the relationships and conversations within which decisions are made.
Supporting Shared Decision Making When Clinical Evidence Is Low, by Clarence H. Braddock III (Medical Care Research and Review)
Shared decision making (SDM) is the process of providing the patient with critical information that can support his or her informed participation in decision making. Shared decision making has become accepted as an important component of quality health care. Influenced by its foundations in law and ethics and by empirical work on its value as a tool to reduce variability in care, a perception has developed that SDM is relevant primarily to clinical situations with high-quality clinical evidence. This raises the question of the role of SDM in situations when clinical evidence is lacking or of low quality. This article posits that SDM is equally relevant and important to low-evidence situations in four ways—SDM fosters shared acceptance of uncertainty, closes the gap in knowledge between patient and physician, promotes patient empowerment, and enhances trust through transparent communication.
Supporting Shared Decisions When Clinical Evidence Is Low, by Mary C. Politi, Carmen L. Lewis and Dominick L. Frosch (Medical Care Research and Review)
There is growing interest in shared decision making (SDM) in the United States and globally, at both the clinical and policy levels. SDM is typically employed during “preference-sensitive” decisions, where there is equipoise between treatment options with equal or similar outcomes from a medical standpoint. In these situations, patients’ preferences for the possible risks, benefits, and trade-offs between options are central to the decision. However, SDM also may be appropriate in clinical situations besides those in which data demonstrate equipoise. In situations of low evidence, where evidence is conflicting, unavailable or not applicable to an individual patient, supporting SDM can present unique challenges, above and beyond the challenges faced during more standard preference-sensitive decisions. This article discusses challenges in supporting shared decisions when clinical evidence is low, describes strategies that can facilitate SDM despite low evidence, and suggests avenues for future research to explore further these proposed strategies.
Public Health Insurance Eligibility and Labor Force Participation of Low-Income Childless Adults, by Gery P. Guy Jr., Adam Atherly and E. Kathleen Adams (Medical Care Research and Review)
The Affordable Care Act aims to substantially increase public health insurance eligibility among low-income childless adults. The literature suggests that public health insurance may have important implications for labor market participation. With data from the March supplement to the Current Population Survey, difference-in-difference multivariable regression modeling is used to examine the association between state-level public health insurance expansions and the likelihood of full-time employment, part-time employment, and not working among eligible childless adults. Results indicate that public health insurance eligibility is associated with a 2.2 percentage point decrease in full-time employment, a 0.8 percentage point increase in the likelihood of part-time employment, and a 1.4 percentage point increase in the likelihood of not working. These associations were greatest among those with worse health and those aged from 50 to 64 years. This analysis provides important insights into the potential labor market repercussions of health insurance expansions under the Affordable Care Act.
The Patient-Centered Medical Home. A Review of Recent Research, by Timothy Hoff, Wendy Weller and Matthew DePuccio (Medical Care Research and Review)
The patient-centered medical home is an important innovation in health care delivery. There is a need to assess the scope and substance of published research on medical homes. This article reviews published evaluations of medical home care for the period 2007 to 2010. Chief findings from these evaluations as a whole include associations between the provision of medical home care and improved quality, in addition to decreased utilization associated with medical home care in high-cost areas such as emergency department use. However, fewer associations were found across evaluations between medical home care and enhanced patient or family experiences. The early medical home research appears to reflect both the wide variation in how medical homes are being designed and implemented in practice and in how researchers are choosing to evaluate patient-centered medical home design and implementation. While some aspects of medical home care show promise, continued evolution of medical home evaluative research is needed.
Many Accountable Care Organizations Are Now Up And Running, If Not Off To The Races, by Harris Meyer (Health Affairs)
From a standing start two years ago, there are now more than 300 ACOs in existence, with some yielding promising early results.
Accountable Care Organizations May Have Difficulty Avoiding The Failures Of Integrated Delivery Networks Of The 1990s, by Lawton R. Burns and Mark V. Pauly (Health Affairs)
Accountable care organizations are intended to improve the quality and lower the cost of health care through several mechanisms, such as disease management programs, care coordination, and aligning financial incentives for hospitals and physicians. Providers employed several of these mechanisms in forming the integrated delivery networks of the 1990s. The networks failed, however, because of heavy financial losses stemming from hospitals’ purchase of physician practices and their inability to align incentives, garner capitated contracts, and develop the infrastructure to manage risk. Although the current mechanisms underlying accountable care organizations continue to evolve, whether and how they will have an impact on quality and costs remains open to question. Care coordination and information technology are proving more complicated and expensive to implement than anticipated, providers may lack the ability to implement these mechanisms, and primary care providers are in short supply. As in the 1990s, success depends on targeting specific populations, such as people with multiple chronic conditions who need and may benefit from coordinated care.
Physicians With The Least Experience Have Higher Cost Profiles Than Do Physicians With The Most Experience, by Ateev Mehrotra, Rachel O. Reid, John L. Adams, Mark W. Friedberg, Elizabeth A. McGlynn and Peter S. Hussey (Health Affairs)
Health plans and Medicare are using cost profiles to identify which physicians account for more health care spending than others. By identifying the costliest physicians, health plans and Medicare hope to craft policy interventions to reduce total health care spending. To identify which physician types, if any, might be costlier than others, we analyzed cost profiles created from health plan claims for physicians in Massachusetts. We found that physicians with fewer than ten years of experience had 13.2 percent higher overall costs than physicians with forty or more years of experience. We found no association between costs and other physician characteristics, such as having had malpractice claims or disciplinary actions, board certification status, and the size of the group in which the physician practices. Although winners and losers are inevitable in any cost-profiling effort, physicians with less experience are more likely to be negatively affected by policies that use cost profiles, unless they change their practice patterns. For example, these physicians could be excluded from high-value networks or receive lower payments under Medicare’s planned value-based payment program. We cannot fully explain the mechanism by which more-experienced physicians have lower costs, but our results suggest that the more costly practice style of newly trained physicians may be a driver of rising health care costs overall.
State Unemployment In Recessions During 1991–2009 Was Linked To Faster Growth In Medicare Spending, by Melissa Powell McInerney and Jennifer M. Mellor (Health Affairs)
During the US recession of 2007–09, overall health care spending growth fell, but Medicare spending growth increased. Using state-level data from the period 1991–2009, we show that these divergent trends were also observed within states. Furthermore, increases in state unemployment rates were associated with higher Medicare spending per capita and increased hospital use by Medicare beneficiaries. For example, a one-percentage-point point rise in the unemployment rate was associated with a $40 (0.7 percent) increase in Medicare spending per capita. Our results suggest that economic downturns contribute to Medicare spending and use. One of many possible explanations may be that health care providers have greater capacity, inclination, and financial incentive to treat Medicare patients during recessions as a result of slackening demand from the non-Medicare population.
Ten Modifiable Health Risk Factors Are Linked To More Than One-Fifth Of Employer-Employee Health Care Spending, by Ron Z. Goetzel, Xiaofei Pei, Maryam J. Tabrizi, Rachel M. Henke, Niranjana Kowlessar, Craig F. Nelson and R. Douglas Metz (Health Affairs)
An underlying premise of the Affordable Care Act provisions that encourage employers to adopt health promotion programs is an association between workers’ modifiable health risks and increased health care costs. Employers, consultants, and vendors have cited risk-cost estimates developed in the 1990s and wondered whether they still hold true. Examining ten of these common health risk factors in a working population, we found that similar relationships between such risks and total medical costs documented in a widely cited study published in 1998 still hold. Based on our sample of 92,486 employees at seven organizations over an average of three years, $82,072,456, or 22.4 percent, of the $366,373,301 spent annually by the seven employers and their employees in the study was attributed to the ten risk factors studied. This amount was similar to almost a quarter of spending linked to risk factors (24.9 percent) in the 1998 study. High risk for depression remained most strongly associated with increased per capita annual medical spending (48 percent, or $2,184, higher). High blood glucose, high blood pressure, and obesity were strongly related to increased health care costs (31.8 percent, 31.6 percent, and 27.4 percent higher, respectively), as were tobacco use, physical inactivity, and high stress. These findings indicate ongoing opportunities for well-designed and properly targeted employer-sponsored health promotion programs to produce substantial savings.
Behavioral Counseling After Screening for Alcohol Misuse in Primary Care: A Systematic Review and Meta-analysis for the U.S. Preventive Services Task Force, by Daniel E. Jonas, James C. Garbutt, Halle R. Amick, Janice M. Brown, Kimberly A. Brownley, Carol L. Council, Anthony J. Viera, Tania M. Wilkins, Cody J. Schwartz, Emily M. Richmond, John Yeatts, Tammeka Swinson Evans, Sally D. Wood and Russell P. Harris (Annals of Internal Medicine)
Background: Alcohol misuse, which includes the full spectrum from risky drinking to alcohol dependence, is a leading cause of preventable death in the United States.
Purpose: To evaluate the benefits and harms of behavioral counseling interventions for adolescents and adults who misuse alcohol.
Data Sources: MEDLINE, EMBASE, the Cochrane Library, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and reference lists of published literature (January 1985 through January 2012, limited to English-language articles).
Study Selection: Controlled trials at least 6 months’ duration that enrolled persons with alcohol misuse identified by screening in primary care settings and evaluated behavioral counseling interventions.
Data Extraction: One reviewer extracted data and a second checked accuracy. Two independent reviewers assigned quality ratings and graded the strength of the evidence.
Data Synthesis: The 23 included trials generally excluded persons with alcohol dependence. The best evidence was for brief (10- to 15-minute) multicontact interventions. Among adults receiving behavioral interventions, consumption decreased by 3.6 drinks per week from baseline (weighted mean difference, 3.6 drinks/wk [95% CI, 2.4 to 4.8 drinks/wk]; 10 trials; 4332 participants), 12% fewer adults reported heavy drinking episodes (risk difference, 0.12 [CI, 0.07 to 0.16]; 7 trials; 2737 participants), and 11% more adults reported drinking less than the recommended limits (risk difference, 0.11 [CI, 0.08 to 0.13]; 9 trials; 5973 participants) over 12 months compared with control participants (moderate strength of evidence). Evidence was insufficient to draw conclusions about accidents, injuries, or alcohol-related liver problems. Trials enrolling young adults or college students showed reduced consumption and fewer heavy drinking episodes (moderate strength of evidence). Little or no evidence of harms was found.
Limitations: Results may be biased to the null because the behavior of control participants could have been affected by alcohol misuse assessments. In addition, evidence is probably inapplicable to persons with alcohol dependence and selective reporting may have occurred.
Conclusion: Behavioral counseling interventions improve behavioral outcomes for adults with risky drinking.
