In the last few years, there has been a real push to involve patients more in their care. Some refer to this as “shared decision making”. The term refers to cases when multiple treatment options are available, and it specifically involves making patients more active participants in their care. Another way to describe this new initiative is to refer to “patient preferences”. This type of focus can be seen across the research spectrum, including the newly formed Patient Centered Outcomes Research Institute (PCORI). There are a lot of reasons to like this type of care. Some have charged that research has, for too long, ignored the outcomes that matter to patients, focusing instead on things that matter to physicians or the health care system. Others believe that ignoring the will of patients can lead to physician or health care provider biases driving up health care utilization and expenditures. In other words, it’s possible that shared decision making could lower the cost of care. This hypothesis was recently tested in a manuscript published in JAMA Internal Medicine, “Association of Patient Preferences for Participation in Decision Making With Length of Stay and Costs Among Hospitalized Patients”:
Importance: Patient participation in medical decision making has been associated with improved patient satisfaction and health outcomes. However, there is little evidence concerning its effects on resource utilization. Patient participation in medical decision making has been hypothesized to decrease excess utilization but might be expected to increase utilization when other decision makers have incentives to reduce utilization, as under prospective payment systems for hospital care. Objective: To examine the relationship between patient preferences for participation in medical decision making and health care utilization among hospitalized patients. Design and Setting: Survey study in an academic research setting. Participants: A survey that included questions about preferences to receive medical information and to participate in medical decision making was administered to all patients admitted to the University of Chicago Medical Center general internal medicine service between July 1, 2003, and August 31, 2011, and completed by 21 754 (69.6%) of admitted patients. Main Outcomes and Measures: The survey data were linked with administrative data, including length of stay and total hospitalization costs. We used generalized linear models to measure the association of patient preference for participation in decision making with length of stay and costs.Basically, this study surveyed almost 22,000 patients admitted to a hospital in Chicago over an eight year period. They asked patients whether they would like to receive more information and have a more active role in decisions made about their care. Then they looked at how those answers corresponded to how long people were hospitalized and how much their care cost. The researchers found that nearly all (96%) of patients wanted to receive more information about their care. Most, however, (71%) said that they would rather leave their care to their physician. To be honest, I was a bit surprised by this result. I’ve been taught repeatedly that patients generally rebel against paternalistic medicine. But the finding that’s making news all over the country is that patient who preferred to participate more in their care had a longer hospital stay, by a quarter of a day, and a higher cost to their hospitalization of $865. Many are reading this as evidence that shared decision making may increase health care costs. Such news is rarely welcome. But, for a number of reasons, I think people are reading too much into these results. For one thing, this study measured whether patients would prefer to be more involved, not whether they were. It’s entirely possible that the patients who expressed a preference to be more involved were the patients who felt marginalized; therefore involving them more might reduce spending in reality. Second, it’s generally assumed that spending might come down in areas of supply sensitive care. There’s little variation in that in one hospital, likely. Finally, since this is an inpatient population, it’s likely that physicians might already be incentivized to spend as little as possible. If reimbursement is DRG-based, then this might not be representative of how physicians might act in other settings. But that’s almost beside the point. I have always believed that the point of patient centered outcomes and shared decision making was to make health care better for patients. It’s supposed to improve quality. As I’ve discussed repeatedly, improved quality sometimes actually costs more. We’ve got to get away from the idea that better should always mean cheaper. Sometimes good things cost money. P.S. Austin's thought's on this study can be found here. --Aaron Carroll