• Some more thoughts on shared decision making

    Nice JAMA Viewpoint on shared decision making:

    The growing emphasis on patient-centered care is increasing the demand on physicians’ time and effort to more fully engage patients and their families in treatment decision making. Thus, it is important to understand the potential effects of shared decision making (SDM) with patients on the outcomes of clinical encounters. Shared decision making is being strongly promoted for several reasons. First, it is the ethical responsibility of clinicians to facilitate patient involvement in treatment decision making because patients and their families are ultimately subjected to the outcomes of these decisions. Second, there is evidence that more engaged patients are more informed, more likely to fully deliberate about the risks and benefits between different treatment options, and ultimately more satisfied with the clinical encounter. The objectives of SDM are to fully inform patients and their families about treatment options, including the trade-offs between risk and benefits, and to incorporate patient values and preferences into treatment decisions.

    I have no argument with the first point. Informing patients fully is just right, full stop.I don’t doubt the second, either. Makes total sense that informed patients are more satisfied with their decisions. It’s the next thing I have an issue with:

    More recently, SDM has also been promoted as a strategy to reduce overtreatment and costs, a rationale grounded in the belief that better-informed patients may be less likely to choose a treatment strategy more extensive than that recommended by their clinicians. The increasing expectations about the role of SDM in clinical and health policy warrant closer scrutiny of the evidence.

    There’s really no evidence for this. I don’t know where people came up with the belief that “better informed” equals “cheaper”. That would assume that the system leans towards efficiency, but patients are pushing us – ignorantly – towards spending more. Does anyone believe that to be the case? I’ve been arguing for some time that patient knowledge isn’t the biggest problem in the system.

    This is part of our ongoing inability to separate out access, cost, and quality. Some interventions are designed to increase access. Some are designed to reduce spending. Shared decision making is about improving quality. I think there’s a growing amount of evidence that it might work, specifically when we consider patient-centered outcomes. But just because it improves quality doesn’t mean that it will reduce spending. It might do just the opposite.

    Sometimes good things cost money.


    • The practice of medicine is largely uninformed by decades of research in management science, included well-documented findings in human performance.

      Properly-structured involvement in decisions almost always leads to greater commitment to the decision outcome. This runs counter to the tradition of physician-centered medicine.

      The question in Shared Decision Making is how to properly structure the decision such that the best clinical knowledge is brought to treatment and, more and more frequently, how committed the patient is to the treatment regime.

      It is silly to think that, in the normal case, patients are better able than physicians to make clinical determinations. That said, it is equally silly to think that the best quality care at the lowest cost can be achieved if patients are not committed to the best course.

      When patients are more committed to better courses of treatment across the system, the health of the population will rise and costs will fall.

    • I agree that decision aids will not reduce costs because of the wide diffusion and saturation of another type of decision aid: direct to consumer marketing (anyone ever seen a Viagra commercial?)

      I work in a specialty which has taken up a very expensive technology and, in my region, marketed it heavily in every form of media. Even when patients are presented with other alternatives for treatment with, so far, equivalent efficacy and side effects data (some data even suggest worse side effects), they choose the newer, more expensive, and heavily marketed option (which must be paid for with volume since capital costs were high to install said technology).

    • 1) You really do need more (some?) evidence to make the claim it will save money. If you spend more time with patients and answer all of their questions, they begin to trust you more. It makes it much easier to sell them on your preferred treatment plan, if that is your goal. It may make it more likely that a hyper-informed, internet savvy (usually younger) patient may decide to defer expensive care. However, this may well be offset by the less well informed deciding to opt for marginal care since they now trust the nice doctor who was willing to spend so much time with them.

      2) On the issue of costs my real thought was who pays for all of this doctor talking time? If a surgeon needs to see X number of patients to generate Y number of cases, what happens when he sees 1/2X patients since he takes twice as long with each one?


    • There is some evidence that use of decision aids makes patients less likely to choose elective surgery (hip and knee replacment, in this case). http://content.healthaffairs.org/content/31/9/2094.abstract

      Another recent study in Health Affairs found that giving patients enhanced support with health coaches had fewer hospital admissions (by 12.5%) and preference-sensitive surgeries (nearly 10% fewer).

      If you buy these results, then SDM may have some ability to reduce spending in certain contexts. It’s probably not a panacea for fixing the US’s problem with rising health care spending, but it could make a small difference, or at very least, improve the value of care provided (defined as quality/cost).

    • I saw this a while ago and thought of this thread. Hope it provides some light without heat.

      “In this article we examine the relationship between patient activation levels and billed care costs. In an analysis of 33,163 patients of Fairview Health Services, a large health care delivery system in Minnesota, we found that patients with the lowest activation levels had predicted average costs that were 8 percent higher in the base year and 21 percent higher in the first half of the next year than the costs of patients with the highest activation levels, both significant differences. What’s more, patient activation was a significant predictor of cost even after adjustment for a commonly used “risk score” specifically designed to predict future costs. As health care delivery systems move toward assuming greater accountability for costs and outcomes for defined patient populations, knowing patients’ ability and willingness to manage their health will be a relevant piece of information integral to health care providers’ ability to improve outcomes and lower costs.”


    • The author’s claim about no evidence for savings through SDM just isn’t true. One year ago, several Seattle clinicians and researchers published a landmark article in Health Affairs on savings from just hip and knee replacement surgery:


      I’m an interested party, because I was interviewing those folks (from the Group Health Cooperative) for a Dartmouth case study, The authors admit some limitations to their work, of course. But don’t say baldly there’s “no evidence.”

    • There is evidence that using decision aids, often used with doctors, can lead patients to forego treatment or opt for more conservative choices, or not being screened, such as not having adjuvant chemotherapy or certain surgery or prostate screening.

      See this Cochrane review: http://www.ncbi.nlm.nih.gov/pubmed/21975733

      Shared or rather patient-centred communication can also help avoid futile treatments at end of life.

      • Read the JAMA Viewpoint. The Cochrane review is discussed.

        • I believe there is evidence beyond what’s cited in Cochrane that better informed patients make more conservative ( and less costly ) choices for treatment at the end of life. Alas, as I’m retired, I no longer have ready access to citations, but someone must.

        • It’s gated so I can’t read it but I agree that those findings are only secondary. The main aim of SDM has been to at least involve patients in treatment choices such as breast conserving surgery vs mastectomy, as patients often are expecting the doc to say there’s only one way to go.

          I think it makes sense though that if you explain and share the risk/benefit of say adjuvant chemo fewer people will take the treatment that if it is just offered, especially in groups where the gain is quite small.

    • According to a July 2010 NIH news release on a study of Physician Orders for Life Sustaining Treatment (POLST), nursing home “residents who used a POLST form to indicate their preference for comfort care only were 59 percent less likely to receive life-sustaining medical interventions that were not requested, when compared to residents with DNR orders, suggesting that POLST promotes closer adherence to documented treatment preferences than DNR orders. Similarly, residents with POLST orders for comfort care only were 67 percent less likely to receive life-sustaining treatments than those with POLST orders for full treatment. Overall, residents with POLST forms were also more likely to have treatment preferences documented as medical orders than those without POLST forms.”

      Hickman SE, Nelson CA, Perrin NA, Moss AH, Hammes BJ, Tolle SW. The Journal of the American Geriatrics Society. 2010; 58:1241-1248

    • Aaron, if you just listen to doctors, you’ll understand overuse, underuse an misuse.

      Overuse is caused by greedy lawyers and pushy patients, who doctors are powerless to resist. Also, those drug reps who influence OTHER doctors. And sometimes guys in other specialties who make way more money than they should.

      Underuse is caused by insurance companies, or sometimes by patients who don’t follow their doctors’ orders.

      Misuse (errors) isn’t very important, but just seems that way because of the lawyers and the sensationalist media.

      Shared decision making is simply part of the process known as “consenting” the patient.

      All clear?

    • “I don’t know where people came up with the belief that “better informed” equals “cheaper”.”

      from the godfather of “less care is more care!” himself, jack wennberg. wennberg is semi-famous for founding the dartmouth atlas “research” group, but he’s also a founder of the informed medical decisions foundation. fun fact: the imdf has trademarked the phrase “shared decision-making” btw.

      here’s a dartmouth atlas white paper from dec 2008 on controlling rising health care costs (apologies, you’ll have to search the document for “shared decisions making’): http://www.dartmouthatlas.org/downloads/reports/agenda_for_change.pdf

      here’s a white paper from the informed medical decisions foundation from 2010: http://informedmedicaldecisions.org/wp-content/uploads/2010/10/Perspectives_SDM-Cost_v2.pdf

      at least by 2010 they had gotten around to mentioning patients’ rights to information ahead of diving into detail about how shared decision making lowers costs.