Effective Patient Care

Patient Care and Clinical Testing and Treatment

FAQ’s

1. What is shared decision making?

Shared decision making (SDM) is a collaborative process whereby patients and doctors make health-care treatment decisions together, taking into account the best scientific evidence available as well as patients’ values and preferences. SDM supports an informed, values-based choice of interventions when there are two or more medically reasonable alternatives likely to produce similar outcomes.

Patient decision aids (DA) support SDM and include written materials, video and web tools that offer balanced, evidence-based information about clinical conditions and related options and trade offs. DAs help patients personalize choices by showing them how the options can be considered in the context of an individual’s own values, preferences and life circumstances. These DAs support patients and physicians in making health-care choices together.

SDM honors patients’ fundamental right to be fully informed of all options, risks and benefits and to actively participate with their physicians in decisions based on the best scientific evidence available. In addition to its application in cases of preference sensitive conditions, SDM can also support more effective self management of chronic conditions and choices among screening options.

When SDM happens, patients:

  • are fully informed of the best scientific evidence available including options, risks and benefits;
  • take into account their values, preferences and circumstances; and
  • actively participate with their physicians in decisions.

2. What are the benefits of shared decision making?

There have been over 50 randomized controlled trials of SDM. SDM offers significant benefits for patients, physicians, and the health-care system in general.

  • Patients who use decision aids are empowered to choose the treatment option that best fits their values and circumstances. These patients report less decisional conflict and greater satisfaction.
  • The Cochrane Collaboration found that patients who participate in SDM are 25% more likely to choose a less invasive option where evidence shows that more than one option would provide equally effective outcomes. These less invasive interventions are often less costly and avoid risks of harmful complications.
  • SDM results in greater patient compliance with chronic care management plans.
  • SDM reduces overall costs in the health-care system. In a 2009 report prepared for the Commonwealth Fund, the Lewin Group estimates that savings associated with implementing shared decision making in the Medicare population for 11 conditions alone would be more than $15 billion over 5 years.
  • After HealthNet implemented shared decision making in California, surgery rates for back pain, hip replacement and cardiac revascularization declined by 18 to 20%.

The Cochrane Collaboration looked at studies measuring the impact of shared decision making on such diverse clinical situations as prenatal screening, colon cancer screening, genetic testing, Hepatitis B vaccination and screening, prostate cancer screening, hormone replacement, Ischemic heart disease, male newborn circumcision, breast cancer surgery and chemotherapy, treatment for abnormal uterine bleeding, cardiovascular risk management, osteoporosis treatment, and pre-operative autologous blood donation. These studies assessed varying claims around SDM and found, among other things, that SDM creates better informed patients who are more satisfied with their treatment choices, experience less decisional conflict, and tend to choose less invasive and less expensive treatment options. The Cochrane Collaboration’s review reports that use of shared decision making is associated with a 25% reduction in preference-sensitive surgical treatment.

3. Isn’t shared decision making already happening?

Recent patient and provider survey research shows that:

  • while providers frequently offer their opinion, they much less frequently ask the patient her opinion;
  • providers discuss the advantages of the treatment options much more frequently than the disadvantages;
  • typically, patients are limited in their grasp of knowledge essential to understanding their condition and their treatment options; and
  • key differences exist between the focus of providers and that of patients both in terms of what they believe key information is and what patients care about most.

4. How do we know that patients really want to be involved in decision making?

As decisions become more complicated and more treatment options become available it is increasingly important that patients become involved in making decisions about their health care so that choices reflect their values and preferences. A 2009 poll of California voters commissioned by the Campaign for Effective Patient Care illustrates the high level of interest people have in understanding the evidence base underlying their health care:

  • 92% of respondents would require doctors to tell them about strong scientific evidence supporting a specific best treatment option; and
  • 90% want to know when there is no such evidence.

5. What How do physicians view shared decision making?

Doctors know that patients have a fundamental right to be fully informed of options, risks and benefits and to actively participate in decisions that affect health and well being. A 2009 Lake Research Partners poll of primary care physicians found agreement among physicians: 93% thought the principle of shared decision making was positive, and 52% felt that it sounded like a “very” positive process. In a survey of HealthNet providers, 88% reported improved communications with their patients after implementing shared decision-making processes. Physicians’ biggest concern with SDM was the time it would take in their already busy practices.

6. How How can we address physician concerns about time?

Patients who use decision aids are often much better informed than patients who come into their doctors’ office with questions based on information from TV ads or less reliable internet sites. To the extent that already busy physicians are concerned about additional time required by SDM, we must experiment with payment and reimbursement systems to address this. SDM processes often include the use of trained coaches to work with patients in using decision aids and preparing questions for a visit with their doctor.

7. So What happens when patient preferences and values are not taken into account?

The case for shared decision making is most compelling in situations where there is more than one valid treatment choice available. Currently treatment for such preference sensitive conditions varies significantly based primarily on geographical variations in physician practices. For example, there are almost twice as many hip replacements per capita in Palo Alto as there are only 35 miles away in San Francisco. A considerable portion of such variations is unwarranted, fails to take into account patients’ values and preferences, may result in more invasive interventions, and can unnecessarily drive up the overall cost of health care.

8. Can we afford the cost of SDM?

In a 2009 report prepared for the Commonwealth Fund, the Lewin Group estimates that implementing shared decision making in Medicare for just 11 conditions would save the country more than $15 billion dollars in health care spending over five years. Lewin looked at the following conditions: lumbar procedures for lower back pain, coronary artery bypass graft procedure, mastectomy for early breast cancer, prostatectomy, stroke prevention, hypertension, dementia and tube feeding, colon cancer screening, prostate cancer, and menorrhagia.

While some additional costs would be associated with developing decision making tools, training practitioners, and incorporating additional provider time into collaboration with patients, these costs are greatly outweighed when compared to the savings that accrue when better informed patients choose treatments aligned with their values. Evidence suggests that fully informed patients are 25% more likely to opt for less invasive, less costly interventions resulting in reduced exposure to harmful complications. Also, patients who participate in SDM are more likely to follow up with recommended treatment including chronic care management.

9. How does the federal reform legislation address shared decision making?

The national health reform law creates a new shared decision-making program and calls for:

  • establishing a process to certify decision aids;
  • awarding funding to produce and update aids;
  • creating Shared Decision Making Resource Centers; and
  • providing grants to heath care providers for development, use and assessment of shared decision making using certified decision aids.

The new law provides support for new metrics to assess shared decision-making tools, and, under a new Center for Medicare and Medicaid Innovation provides support to test innovations that assist individuals in making informed health-care choices.

10. What are other states doing about SDM policies?

State policy makers can play an important role in advancing shared decision making. A number of states are considering SDM bills. Washington state passed a demonstration project bill in 2007 to gauge the effect of shared decision making on preference-sensitive care, including whether the process can lower costs associated with certain elective medical procedures: treatment for osteoarthritis of the knee; low back pain; stable angina; early-stage breast cancer; and breast reconstruction after mastectomy.

It will be wise for states to establish well-designed pilot projects to measure the benefits of shared decision making processes and perhaps to experiment with incentives that will allow overburdened practitioners to invest the attention that shared decision making requires.

Research

Comparative Effectiveness Research and the Learning Health Care System

The Institute of Medicine (IOM) Roundtable on Value & Science-Driven Health Care, formerly IOM Roundtable on Evidence-Based Medicine, focuses on both the near-term need for evidence on the comparative effectiveness of diagnostic and treatment options, and the long-term effort of marshaling emerging technology and expertise to create a health care system in which patient care reflects the best available evidence while accumulating new knowledge.

Hospital Safety

Preventable errors cause as many as 98,000 deaths a year. The IOM report To Err is Human: Building A Safer Health System lays out a comprehensive strategy by which government, health care providers, industry, and consumers can reduce preventable medical errors, concluding that the know-how already exists to prevent many of these mistakes.

According to a Consumers Union report, Preventable Harm, medical errors kill as many as 10,000 Californians each year and injure 140,000. These errors include a class of adverse events known as “never-events” because they can always be prevented and should never happen.

 

Preventing Medication Errors

Medication errors cause an estimated 7,000 deaths a year. The IOM report Preventing Medication Errors finds that medication errors are surprisingly common and costly to the nation, and outlines a comprehensive approach to decreasing the prevalence of these errors. This approach will require changes from doctors, nurses, pharmacists, and others in the health care industry, from the Food and Drug Administration (FDA) and other government agencies, from hospitals and other health-care organizations, and from patients.

Geography as Destiny

 

For more than 20 years, the Dartmouth Atlas Project has documented dramatic variations in how medical resources are distributed and used in the United States. Where Medicare patients live and who delivers care has a profound effect on what medical care is delivered. For example, according to the Dartmouth Atlas:

  • patients in Napa were three and a half times more likely to undergo aortic or mitral valve replacement than patients in Alameda;
  • patients in Palm Springs were twice as likely to have back surgery as patients in San Francisco;
  • patients in Ventura were five times more likely to have a transurethral resection of the prostate (TURP) as patients in Salinas; and
  • patients in Redding were twice as likely to have knee replacement surgery as patients in San Jose.

A 2008 Dartmouth Atlas White Paper, An Agenda for Change: Improving Quality and Curbing Health Care Spending, provides a brief but compelling overview of supply-sensitive care and preference-sensitive care and the impact these can have on overuse, underuse and misuse. The paper includes a comprehensive set of policy solutions.

Underuse of Preventive and Acute Care

 

In a national study, The Quality of Health Care Delivered to Adults in the United States, that examined the medical charts of over four thousand patients, the RAND Corporation determined that patients received only 55% of the preventive care and 54% of the acute care that evidence-based guidelines would recommend.

The National Healthcare Quality Report measures trends in effectiveness of care, patient safety, timeliness of care, patient centeredness, and efficiency of care. In 2006, only about 40 percent of adults over age 40 with diagnosed diabetes receive all three recommended services for diabetics. Such services are intended to detect complications that can cause blindness or lead to amputations. There was no significant change in these rates between 2002 and 2006.

 

Overuse

As counterintuitive as it may sound, more care isn’t always better care. Unnecessary care can expose people to infections and medical errors. “Overuse” refers to patients receiving care that is known not to be helpful and may even be harmful.

For example, between 1993 and 2003, spending for lumbar spinal fusion rose 500 percent, despite lack of evidence supporting the effectiveness of back surgeries. Indeed, studies currently show that a combination of physical therapy and anti-inflammatory medication is often the most effective treatment, and that many patients with low-back pain will see their symptoms fade on their own within three months.

Preference-Sensitive Care, Shared Decision Making and Misuse

Shared decision making (SDM) is a collaborative process whereby patients and doctors make health-care treatment decisions together, taking into account the best scientific evidence available as well as patients’ values and preferences. SDM supports an informed, values-based choice of interventions in the case of “preference-sensitive care,” i.e. when there are two or more medically reasonable alternatives likely to produce similar outcomes. SDM helps avoid the misuse of care that happens when a patient receives a treatment they would not have wanted, had they been fully informed.

In a JAMA study that analyzed over 1,000 audiotapes of patients’ visits with physicians, it was found that few decisions met criteria for informed patient decision making.

Patients’ Perspective

A Health Affairs article examined research into employees’ attitudes about evidence-based medicine. They found that few consumers understood terms such as “medical evidence“ or “quality guidelines.”

The Campaign for Effective Patient Care (CEPC) believes the practice of medicine should be based on solid science and that when health care is divorced from evidence, patient outcomes are likely to suffer. In the summer of 2009, the Campaign for Effective Patient Care commissioned nationally recognized pollster Celinda Lake to survey California voters about their views on the use of science in the delivery of health care.

  • 92% of respondents would require doctors to tell them about strong scientific evidence supporting a specific best treatment option; and
  • 90% want to know when there is no such evidence.

Results are published in a CEPC report, Perception vs. Reality: Evidence-Based Medicine, California Voters, and the Implications for Health Care Reform.