Patient participation in decision making may raise cost of care, study shows

BMJ 2013; 346 doi: (Published 04 June 2013) Cite this as: BMJ 2013;346:f3597
  1. Michael McCarthy
  1. 1Seattle

Increasing the participation of patients in healthcare decision making may prolong the length of stays in hospital and increase the cost of care, a new US study has found. Extrapolating the study’s results to the national scale, the researchers concluded that patient participation could cost an extra $8.7bn (£5.7bn; €6.7bn) a year.

Three other studies published online at the same time by the journal JAMA Internal Medicine showed that, though some patients wanted a bigger role in their treatment decisions, doctors often failed to explain the pros and cons of interventions or to be candid with patients about prognoses.

The first study, that showing the increased cost of decision sharing, gathered data from 21 754 patients admitted to the University of Chicago Medical Center. It found that 71% of patients said that they preferred to leave medical decisions to their physicians.1 Patients with higher educational levels and who had private insurance were more likely to say that they would like to take part in decision making. But after controlling for such factors as age, race or ethnicity, self reported health assessment, comorbidities, and admission diagnoses, the researchers found that patients keen on being involved in healthcare decision making had longer stays in hospital and higher hospital treatment costs.

Compared with the 8181 (38%) patients who had a strong desire to leave decision making in the hands of their doctors, the 6287 (29%) patients who wanted to be involved in decisions about their care stayed in the hospital 0.26 days longer (95% confidence interval 0.06 to 0.47 days; P=0.01) and had a higher average hospitalization cost of $865 ($155 to $1575; P=0.02).

If this increase in hospital stays and costs were applied to patients who were not normally involved in decision making, the researchers said, the additional 0.26 days and $865 per hospitalization would translate nationally to 2.6 million days in hospital and $8.7bn in costs.

In the first of the three other studies, researchers surveyed 2718 patients who in the previous two years had either made a decision about or talked to a healthcare provider about one of 10 common interventions: taking a drug for hypertension, elevated cholesterol, or depression; being screened for breast, prostate, or colon cancer; having a knee or hip replacement for osteoarthritis; or undergoing surgery for cataract or low back pain.2 The researchers found that decisions typically made in the primary care setting tended to be more driven by physicians than were those typically made in the surgical setting.

Floyd J Fowler Jr, of the Informed Medical Decisions Foundation and Center for Survey Research at the University of Massachusetts, and his colleagues found that, in general, any discussions that took place between a doctor and patient tended to focus on the advantages of the intervention rather than its disadvantages. In decisions on drug treatments, for example, about twice as many patients reported that their discussions focused more on why they might want to take the medication rather than on why they might not.

The authors wrote, “For cancer screening, the discussion of cons was almost nonexistent, despite recent concerns raised about the possible downsides of PSA [prostate specific antigen] testing and of mammograms.”

The balance of pros and cons in discussions about surgery for cataract or hip replacement surgery was similar to that seen in discussions about drug treatments, but discussions about knee replacement and back surgery included more discussion of the potential downsides of the interventions, the researchers reported.

The study also found substantial variation in the proportion of participants recalling that they had been asked what they wanted or being told that they had a choice. Of the 1027 patients who were involved in making a decision about taking a drug for hypertension, 674 (66% (95% confidence interval 62% to 70%)) said that the healthcare provider had explained the choices and only 378 (37% (34% to 41%)) said that the provider had asked for the patient’s preference.

For lower back surgery, on the other hand, 140 of 157 patients (90% (82% to 95%)) reported that their healthcare provider had explained the choices.

Among the cancer screening decisions, patients considering mammography were least likely to believe that they had a choice (369 of 683 patients (54% (49% to 59%))), and less than half (268 of 683 (40% (35% to 45%))) reported that they had been asked whether they had a preference.

“These data show that there is still considerable paternalism in medical decision making,” the researchers concluded.

The second study found that seriously ill patients undergoing hemodialysis were considerably more optimistic than were their nephrologists about their chances of survival and of obtaining a transplant.3

Melissa W Wachterman, of the Veterans Affairs Boston Health Care System, and colleagues interviewed 62 hemodialysis patients all of whom had a predicted one year mortality of 20% or more. The authors wrote, “Overall, 81% of patients thought they had at least a 90% chance of being alive in 1 year, whereas nephrologists were this optimistic for only 25% of patients.”

In fact, patients’ one year expectations were more accurate than those of their nephrologists, the researchers found, but patients “dramatically” overestimated their two year survival.

“Only 6% of patients thought they had less than a 50% chance of being alive in 5 years, whereas actual survival at just less than 2 years of follow-up was only 56%,” the authors wrote.

The patients’ optimism might be explained by the finding that no patients reported that their nephrologist had discussed their life expectancy and that the nephrologists reported doing so with only two (3%) of their patients, the authors said.

Patients were also much more optimistic about their chances of receiving a transplant than their doctors were, with 37 (66%) reporting that they thought they had a chance of getting a transplant, whereas the nephrologists’ assessment was that only 24 patients (39%) had a chance.

“Our findings suggest the need for interventions to help providers communicate effectively with patients about prognosis,” the researchers concluded.

The third study found that two thirds of patients with acute myocardial infarction wanted to participate in decisions about their care. Harlan M Krumholz of Yale University School of Medicine, and colleagues looked at patients’ preferences regarding shared decision making as gleaned from data from two large acute myocardial infarction registries.4

Of the 6636 patients in the sample, 4536 (68%) reported that they wanted to be actively engaged.

The authors wrote, “Among those, 2735 (60.3%) indicated that the physician and patient should participate equally, 696 (15.3%) indicated that the patient should predominantly determine the decision, and 1105 (24.4%) said that the patient alone should determine it.”

Although women, white people, and patients with higher education were more likely to prefer to be actively involved in decision making, such demographic characteristics—and clinical characteristics such as severity of myocardial infarction—were not good predictors of patients’ preferences, the researchers reported.

“Our findings indicate that physicians who aspire to provide patient-centered care should assess patients’ decision-making preferences by directly asking each patient,” they concluded.


Cite this as: BMJ 2013;346:f3597