Giving patients more say in their medical treatment choices — a health-care innovation called shared decision-making — improves outcomes and saves money, according to an article published online Friday in the Atlantic magazine.
“The habit of assuming the doctor knows best has created a system where huge numbers of patients aren’t getting the treatment they would have chosen if they were fully informed,” write the article’s authors, Shannon Brownlee and Joe Colucci of the New American Foundation. “It also means that hundreds of thousands of patients are going through surgery that wasn’t really worth it, and that they wouldn’t have chosen had they understood their options.”
How exactly does shared decision-making work? Here is Brownlee and Colucci’s explanation:
Shared decision making is a way of dealing with the tough questions posed by “preference-sensitive conditions” — conditions where there are multiple treatment options, and none of those options is clearly better than the others. That includes conditions like arthritis in knees and hips, low back pain, stable angina (chest pain from heart disease), and early-stage prostate and breast cancer. (Obviously, it doesn’t include emergency conditions like heart attacks and hip fractures, or conditions where there is clearly only one treatment.)
Deciding on a treatment for preference-sensitive conditions involves weighing a variety of risks and possible benefits, and different patients will end up making different “right” decisions because they have different values and preferences. The best example here is women with early-stage breast cancer. They can choose lumpectomy (surgery that preserves the breast) or mastectomy (which removes it entirely). The two options are equally good in terms of reducing the risk of dying of breast cancer, but they require different kinds of follow-up and different women prefer one over the other.
Making such decisions means that patients must have the relevant information about all their treatment options, and doctors must understand their individual patients’ preferences — basically, what they want from treatment. But too often, patients only hear about one treatment option, the one the doctor usually uses — and doctors routinely assume they know what their patients want without actually asking them. And in many cases, the doctor is wrong.
‘Patient decision aids’
A common but not essential part of the shared decision-making process, note Brownlee and Colucci, is the use of “patient decision aids” — written materials or videos, which can be accessed either online or off. These aids present all treatment options, including the option to do nothing.
“There have been more than 80 randomized controlled trials on the effects of patient decision aids, and the results are pretty clear,” Brownlee and Colucci write. “According to the Cochrane Collaboration, which reviews groups of studies, using patient decision aids improves the match between patients’ preferences, improves patients’ knowledge of the possible results of treatment, and reduces the number of patients who still don’t know what they want. Here’s the icing on the cake in terms of health care spending: Patients also tend to choose less invasive (and therefore less expensive) treatment options.”
As an example, Brownlee and Colucci point to the results of a study published in the September issue of the journal Health Affairs:
Group Health Cooperative (an integrated insurer and hospital system) gave all 660,000 of their patients access to decision aids when they were considering any of a dozen preference-sensitive treatments. They also made all of the doctors and staff watch the decision aids, and kept physicians informed of how many of their patients were choosing surgery.
The results were striking. [The Health Affairs paper] covers two orthopedic procedures — knee replacement and hip replacement for arthritis of those joints. During the year and a half immediately after they introduced the decision aids, rates of hip replacement fell over 25%; knee replacement went down 38%. Total spending went down 21% on patients with hip osteoarthritis and 12% for knee patients — not just on those patients who skipped surgery, but for the whole study population.
The major stumbling block
Brownlee and Colucci also discuss how our current way of financing health care — the fee-for-service model, where doctors get paid for the number of procedures they perform rather than for outcomes — is the main stumbling block to a wider implementation of shared decision-making.
“Changing that payment system will be tough,” they conclude, “but it needs to be done, because fee-for-service payment isn’t just making us spend more money than we need to for good care — it’s actually making our medical system worse.”
You can read the full article on the Atlantic website. In addition to being acting director of the New American Foundation, Brownlee is author of the 2007 book “Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer.”