Is this a study of shared decision making?

At first, it seemed like the study by Hyo Jung Tak, Gregory Ruhnke, and David Meltzer challenged the idea that shared decision making (SDM) is associated with lower health care resource use.

Importance  Patient participation in medical decision making has been associated with improved patient satisfaction and health outcomes. However, there is little evidence concerning its effects on resource utilization. Patient participation in medical decision making has been hypothesized to decrease excess utilization but might be expected to increase utilization when other decision makers have incentives to reduce utilization, as under prospective payment systems for hospital care.

Objective  To examine the relationship between patient preferences for participation in medical decision making and health care utilization among hospitalized patients.

Design and Setting  Survey study in an academic research setting.

Participants  A survey that included questions about preferences to receive medical information and to participate in medical decision making was administered to all patients admitted to the University of Chicago Medical Center general internal medicine service between July 1, 2003, and August 31, 2011, and completed by 21 754 (69.6%) of admitted patients.

Main Outcomes and Measures  The survey data were linked with administrative data, including length of stay and total hospitalization costs. We used generalized linear models to measure the association of patient preference for participation in decision making with length of stay and costs.

Results  The mean length of stay was 5.34 days, and the mean hospitalization costs were $14 576. While 96.3% of patients expressed a desire to receive information about their illnesses and treatment options, 71.1% of patients preferred to leave medical decision making to their physician. Preference to participate in decision making increased with educational level and with private health insurance. Compared with patients who had a strong desire to delegate decisions to their physician, patients who preferred to participate in decision making concerning their care had a 0.26-day (95% CI, 0.06-0.47 day) longer length of stay (P = .01) and $865 (95% CI, $155-$1575) higher total hospitalization costs (P = .02).

Conclusions and Relevance  Patient preference to participate in decision making concerning their care may be associated with increased resource utilization among hospitalized patients. Variation in patient preference to participate in medical decision making and its effects on costs and outcomes in the presence of varying physician incentives deserve further examination.

It’s important to recognize that the results on length of stay and hospital costs are associated with the response to a single question at time of admission: “I prefer to leave decisions about my medical care up to my doctor.” There was neither any random assignment nor any test of an SDM intervention. Indeed, we don’t even know if patients who expressed greater interest in participating in decision making actually did so, or, if so, to what extent. Perhaps in an environment without an SDM protocol, patients who seek to guide their own care end up making poor decisions, leading to longer stays and higher costs.

This leaves open the possibility that SDM could reduce health care utilization among patients who self-identify as having a lower preference for leaving medical decisions up to their doctors, among others. Moreover, by its nature it would do so in a way consistent with patients’ values.

Of course, if it led to higher utilization, that would be consistent with patient values too. In this study, we have one measure of patients’ values and measures of resource use and cost, but no confidence that the latter are really connected to more fully informed and articulated versions of the former, as might be obtained in an SDM process.


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