The words, “because I said so” were like nails on a chalkboard for many children. I was lucky enough to rarely hear those words. I was blessed with parents that took the time to explain why they were taking the decision they were and as I got older willing to discuss decisions further, allowing me to make my case for important things like why I needed a hundred dollar pair of jeans (I never got them!). This is probably why my skin crawls today when my doctor tries to mandate a course of action to me rather than take the time to explain his reasoning or discuss alternative options. The decision is made for me, not with me. Who died and made him king, especially when it comes to my health?
According to a recent research study in the US, 70% of patients preferred making medical decisions with their doctors. Interestingly, of those, only one in seven would disagree with their doctor over treatment, some saying it would not be socially acceptable or would damage their relationship with the doctor1. What is that about? If the US healthcare system is ever going to increase quality of care while reducing costs, the mentality needs to shift from doctor is the all mighty king to patient is key.
What is Shared Decision Making?
Patient-centered care is one effort to rectify this power imbalance between physician and patient. The Institute of Medicine (IOM) defines patient-centered care as: “Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.2”
A key component of providing patient-centered care is shared decision making (SDM). SDM is a collaborative process where patients are provided with evidence-based information on treatment choices and are encouraged to use this information to have an informed dialogue with their physicians to help them make the healthcare decisions that best align with their values, preferences and lifestyle3. “SDM honors both the provider’s expert knowledge and the patient’s right to be fully informed of all care options and the potential harms and benefits. This process provides patients with the support they need to make the best individualized care decisions, while allowing providers to feel confident in the care they prescribe.4”
SDM’s Impact on Quality of Care and Cost
SDM encourages patient engagement and has the potential to improve quality in care. One study found that 78.5 percent of patients wanted to be involved in the decision-making process, and many researchers have concluded “patient centered decision-making is an important component to quality of care and is closely linked to patient satisfaction5.” SDM can improve patient care by:
- Allowing patients to be more engaged6-Most patients are dissatisfied with their level of involvement in health care decisions and would like to take a more active role. People tend to seek an active role when they feel knowledgeable and confident in their ability to understand, manage, and communicate health concerns.
- Improving patient satisfaction and healthcare outcomes7– When decision making is shared, there is more comfort and satisfaction by the patient with the treatment decisions. This can lead to a greater acceptance of responsibility and engagement in developing and executing long-term treatment plans, which can lead to improved long-term health outcomes.
- Reduces health disparities6– SDM helps patients establish trust in their provider, and it helps doctors engage and communicate better with their patients. Trust and communication are two areas in which health disparities still exist in our health system. Some doctors may unknowingly hold biases toward patients who they feel are not able to understand complex medical information. Similarly, many patients do not trust or feel comfortable discussing health concerns with doctors who they cannot relate to on a personal level. SDM creates a process to ensure that all patients feel empowered to express their preferences, values, and concerns, and that all providers engage their patients in a meaningful way.
- Promotes evidence–based care– In SDM, doctors or nurses often share the best medical evidence with their patients through decision tools, such as patient decision aids6. Patient decision aids are written materials, videos, or interactive electronic presentations designed to inform patients and their families about care options, each option’s outcomes, including benefits and possible side effects, the health care team’s skills, and costs8. The decision tools help patients answer important questions, better understand their treatment options, and decide which treatment option best aligns with their preferences and values9. SDM ensures that doctors stay up-to-date on best practices.
SDM can also generate great cost savings. Studies illustrate the potential for wider adoption of SDM to reduce costs. Consistently, as many as 20% of patients who participate in SDM choose less invasive surgical options and more conservative treatment than do patients who do not use decision aids8. In 2008, the Lewin Group estimated that implementing SDM for just 11 procedures would yield more than $9 billion in savings nationally over 10 years. In addition, a 2012 study by Group Health, a not-for-profit healthcare system based in Seattle, adopted SDM enterprise-wide and achieved significant improvement in patient-decision quality and also increased patient and provider satisfaction9. They provided decision aids to patients eligible for hip and knee replacements, which substantially reduced both surgery rates and costs — with up to 38% fewer surgeries and savings of 12 to 21% over 6 months9.
Though positive cost impact has been presented, it is important to note that some would argue that there could be a potential increase in cost given the fact that there are costs associated with developing and distributing decision aids as well as additional time being spent with each patient on the increased consultations. More research needs to be conducted on the true impact of cost, both positive and negative, in regard to SDM but its positive impact on patient-centered care is unarguable.
Challenges to Implement
As with everything, SDM does not come without its challenges to acceptance. According to The Final Report-The Practice and Impact of Shared Decision Making5, the following challenges have been cited:
- Timing-A lack of time for prolonged clinical interactions with patients is a primary concern when trying to integrate SDM into clinical practice.
- Provider Training-SDM is a new concept for providers and has not been modeled in practices or medical schools. Physicians need training in the use of decision aids and guidance in how to initiate the process.
- Reimbursement-With more time and resources required, providers understandably look for increased compensation when implementing SDM in their practices. Nationally, there is no system of reimbursement in place. There are no standard or local codes specific to SDM but that codes for evaluation and management may be applicable. Time-based evaluation and management codes can be used if more than half of the visit is spent in counseling and/or coordination of care. To code based on time, there must be documentation of the total time spent with the patient, the amount of time spent in counseling/coordination of care, and a detailed description of what was discussed. However, there is a perception among some that SDM simply represents good practice and should not receive differential payment.
- Patient and Physician-The benefits of SDM are enhanced when there is a decision support component – staff members whose job includes responsibility for helping patients and families to access information about their medical conditions and to help them consider their choices in the context of their values and preferences. Clinicians must be sensitive to the emotional, physical and intellectual capacity of their patients and match the level of decision-making involvement to the individual patient. While recognizing that patients have a right to shared decision-making, the process of involvement, unfortunately, often relies on the comfort level of physicians in tailoring a process to the needs of a patient. This variable process may deter clinicians from engaging in SDM.
What do you think? Do you think SDM is a necessity or an optional value-add in care delivery?
Resources cited in this blog: