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Shared decision making has value but providers need more support

Publish date: MAY 01, 2011



Getty Images / Tom Grill
ADVOCATES FOR SHARED decision making say that patients have neither the information nor the opportunities necessary to participate fully in clinical decisions. The University of Michigan's Institute for Social Research found among other things that physicians do not always discuss the risks involved in a medical decision and tend focus on the benefits.

The survey of 3,000 U.S. adults focused on nine common medical decisions and found that patients don't have sufficient information to make the best healthcare choices. For example, only 20% of patients considering breast cancer screening and 49% of patients considering blood pressure medications reported receiving information about drawbacks.

"Decisions are pretty much made top-down with physicians making recommendations," says Lyn Paget, director of policy and outreach at the Foundation for Informed Medical Decision Making (FIMDM) in Boston. "They're just telling us to do it without providing a balanced representation of risk. Therefore, our knowledge when we make these decisions is quite poor."

Paget says the preferences and values of the individual patient must be considered. Shared decision making supported by appropriate tools is one way to ensure that patients have a voice.

ONE STEP TO ACCOUNTABLE CARE

With leaders increasingly focused on patient-centered care, shared decision making is gaining traction. Healthcare reform not only encourages patient-centered care through accountable care organizations (ACOs), it also specifically calls for the creation of Shared Decision Making Resource Centers and standards for decision aids. The Department of Health and Human Services will provide grants to fund the centers and will coordinate efforts with the Agency for Healthcare Research and Quality.

In addition, shared decision making falls in line with consumer-directed healthcare and value-based purchasing that plan sponsors are exploring to reduce costs.

"With shared decision making, you have an educated and informed consumer who is making choices and also has some financial stake in what's going on," says Helen Darling, president of the National Business Group on Health. "But the key is to understand that the individual patient, and not the doctor, is the capstone of the healthcare team."

Among the rationale for shared decision making is that patients are more likely to choose lower risk interventions and that, in turn, will lead to lower use of unwarranted services.

"If a health plan is interested in making sure patients are not overtreated or undertreated, the solution is to provide patient with full information when they are in the window of time for making medical decisions," says Paget.

There are several studies showing the impact shared decision making can indeed have on patient care, outcomes and costs.

A 2010 study of 174,120 patients conducted by Health Dialog Services found that patients using telephone-based support, including shared decision making, averaged monthly medical and pharmacy costs per person 3.6% lower than patients without that level of support. The patients with enhanced support also saw a 10.1% reduction in hospital admissions.

A 2009 review of 55 randomized controlled trials conducted by the Cochrane Collaboration found patients exposed to decision making aids are more likely to forgo elective invasive surgery in favor of more conservative treatment options, less likely to use menopausal hormones and more likely to forgo prostate-specific antigen (PSA) screening.

"The healthcare system is not ready for large-scale implementation but the soil is getting very fertile," says David Wennberg, chief science and products officer with Health Dialog in Boston.


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