States Explore Shared Decision Making

Health officials in Washington State are probing whether more actively involving patients in decision making will help improve patient care and satisfaction and perhaps lower costs associated with certain elective medical procedures.

In 2007, the state passed legislation that officially recognized shared decision making as a high standard of informed consent. The law also required a demonstration project, which is now under way, to gauge the effects of this model of informed consent for treating patients with “preference-sensitive conditions” that have multiple options for care. The project includes such conditions as osteoarthritis of the knee or hip, low back pain, abnormal uterine bleeding, fibroids, benign prostatic hyperplasia, chronic stable angina, early-stage breast cancer, and breast reconstruction after mastectomy.

Four other states are considering legislation that would mandate a pilot study of shared decision making. A federal bill proposing such an experiment in the Medicare program is also under consideration in the US Congress. The proposals come as state and federal governments grapple with how best to improve the quality of health care and reduce unnecessary costs.

Some of the proposals build on evidence that the cost and delivery of health care vary substantially between different geographic regions. Specifically, researchers have found that although physicians in both high-spending and low-spending regions were equally likely to follow clinical guidelines for care, when there are multiple acceptable options for treating a particular medical condition, physicians in higher-spending regions are more likely to recommend more expensive interventions, while physicians in lower-spending regions are more likely to recommend more conservative options (Sirovich B et al. Health Aff [Millwood]. 2008;27[3]:813-823).

Officials at Group Health Cooperative, a nonprofit health insurer and medical system that covers 580 000 individuals in Washington State, analyzed state-level data to determine whether such geographic differences were also occurring locally. They found important differences in care for a variety of conditions. For example, men with benign prostatic hyperplasia in Wenatchee, Wash, are 5 times more likely to undergo transurethral resection of the prostate than men in Seattle, according to 2005 data on Medicare enrollees. They also noted that patients in some regions were about twice as likely to have knee replacement than those in other areas.

However, it was not clear why such variations were occurring, explained David Arterburn, MD, an assistant investigator at Group Health Cooperative's Center for Health Studies. “We don't think that knees are different [in these areas]; it might be differences in the way care is provided,” he said.

Ideally, when multiple options for care are available, patients should be fully aware of their options and physicians should know which option the patient would prefer. However, physicians often do not share with their patients the information needed to make an informed decision. In fact, in a study of more than 1057 recorded patient encounters involving 3552 clinical decisions, only 9% of the decisions met criteria for informed decision making (Braddock CH et al. JAMA. 1999;282[24]:2313-2320). In a more recent study of 51 conferences between physicians and families regarding major end-of-life decisions, only 2% met all the criteria for shared decision making (White DB et al. Arch Intern Med. 2007;167[5]:461-467).

To address this information gap and promote shared decision making, some individuals and groups are advocating the use of decision aids—often Web-based videos—to walk patients through information about their treatment options and to encourage them to incorporate their own values and preferences in the decision-making process.

A Cochrane Collaboration review of 55 randomized controlled trials of shared decision making found that patients who used such decision aids had greater knowledge about their treatment options, were more actively involved in the process of deciding on a treatment, and were more satisfied with their decision and the process (O’Connor AM et al. Cochrane Database Syst Rev. 2003;[1]:CD00143). Aids that provided greater detail were more effective than aids that were less thorough. Additionally, patients who used decision aids were about 20% less likely to chose invasive surgical options over more conservative ones, without a negative effect on outcomes.

Washington State's shared decision-making law does not require that physicians use shared decision making instead of a more standard informed consent procedure, Arterburn explained. But using shared decision making may provide a greater level of liability protection because the state has recognized it as a higher standard, according to Arterburn.

In January, the state's 2-year demonstration project began. Participants include the Washington State Health Care Authority (which oversees the effort) and several organizations, including the Group Health Cooperative; the Everett Clinic (a multispecialty medical group); the Virginia Mason Medical Center, in Seattle; the Puget Sound Health Alliance (a Seattle-based health care quality improvement organization representing employers, patients, health plans, and hospitals); the Carol Millard Breast Cancer Center in Tacoma; and the Multicore Medical Center (a nonprofit health care organization based in Tacoma that includes hospitals, clinics, and multispecialty centers). The University of Washington secured a grant from the Foundation for Informed Medical Decision Making (http://www.informedmedicaldecisions.org/), a nonprofit group that promotes shared decision making and makes decision aids to help fund the project.

Lawmakers in Connecticut and Vermont are also considering similar laws and demonstration projects, according to the Foundation for Informed Medical Decision Making. Minnesota is contemplating legislation that would require clinicians treating state-insured employees or recipients of state medical assistance to use shared decision making in order to be reimbursed for certain procedures, including abnormal uterine bleeding, benign prostatic hyperplasia, chronic back pain, early stage breast cancer, urinary incontinence, and gastroesophageal reflux disease. Maine is considering legislation that would require health insurers and the state insurance program to implement shared decision making. On the federal level, US Senator Ron Wyden of (D, Ore) has proposed federal legislation that would require a pilot study of shared decision making for Medicare beneficiaries.

Karen Merrikin, JD, executive director of public policy at the Group Health Cooperative, said many lawmakers find shared decision making appealing because it has been shown to reduce the number of surgeries when some patients opt for more conservative, and likely less costly, interventions.

“Lawmakers are interested in an approach that could address the sweet spot of good outcomes and better value in health care,” Merrikin said.

Although physicians generally support the idea of making patients more involved in the decision-making process, a variety of factors often stand in the way of following this standard of care in their practice, said Clarence H. Braddock III, MD, MPH, of Stanford University School of Medicine. For example, physicians often say they do not have sufficient time or that their patients do not really want to be presented with options. Some may worry that shared decision making takes the decision completely out of their hands.

“What a lot of physicians hear, mistakenly so, is that the goal [of shared decision making] is to give patients information and let them decide what is the best treatment for them,” Braddock said. But the goal, he said, is to first give a patient sufficient information to allow his or her personal values and preferences inform the decision and then the patient and the physician work together to arrive at the best option for that patient.

As part of this process to ensure that the decision the physician and patient reach together is consistent with the patient's values, Arterburn explained, after a patient has viewed a decision aid, the physician may ask the patient how they feel about the risks and benefits associated with each option and how various options might affect the patient's life. For example, for those women with breast cancer who may place a high value on preserving their breast, lumpectomy with radiation might better fit this value than mastectomy.

Some physicians may also take issue with the content of the decision aids, but may become more comfortable with such aids as more of them become available and studies are conducted to assess and compare them, said Arterburn. In the meantime, the International Patient Decision Aid Standards Collaboration is creating a set of criteria that can be used to judge whether decision aids are evidence-based and free of bias or conflict.

Although no data are yet available, the Group Health Cooperative has been using decision aids produced by the Foundation for Informed Medical Decision Making (which are reportedly based on systematic reviews of the evidence and focus groups and interviews about patient preferences) and has received some positive anecdotal feedback, Merrikin said. For example, some orthopedic surgeons have commented that patients are better prepared to discuss the options, are more knowledgeable, and ask more sophisticated questions—factors that have helped reduce the amount of time necessary for such discussions. There also is evidence in the literature that patients who go through the shared decision-making process are more likely to adhere to the selected therapy, Braddock said.

However, there may be financial disincentives that might discourage physicians from taking time for shared decision making. For example, Braddock said, physicians are reimbursed more for performing procedures than for consultations. Some of the state bills do require reimbursement for shared decision making, however, which may help address this potential barrier.

Whether adopting shared decision making will actually cut costs remains to be seen. Patients faced with various options that produce a similar outcome may not necessarily choose the less expensive one. In any case, Braddock and Arterburn said, physicians have an ethical obligation to ensure that their patients are fully informed and given a say in what happens to their bodies.

“It's the right thing to do,” Braddock said.