February 4, 2013
Efforts to increase patient involvement in decisions about their medical care face barriers such as overworked physicians, insufficient provider training and deficient medical information systems, according to a new RAND Corporation study.
In order to make medical care more patient-centered, Medicare has encouraged health care providers to implement “shared decision making” in which patients and doctors together choose the treatment that is best for each patient.
However, to make shared decision making a reality, RAND researchers say doctors and other health workers need more instruction on how to engage patients and better information systems to make sure patients know their options and receive individualized care.
RAND researchers examined the experiences of eight primary care practices participating in a demonstration project intended to expand shared decision making that was funded and coordinated by the Informed Medical Decisions Foundation, a nonprofit organization focused on expanding patient involvement in health care decisions. The results are published in the February edition of the journal Health Affairs.
“Even primary care practices that received extra resources to implement shared decision making ran into sizeable real-world obstacles,” said Dr. Mark W. Friedberg, the study's lead author and a natural scientist at RAND, a nonprofit research organization. “Currently, the health care system works against providers who want to make patients full partners in the medical decision-making process. Giving patients truly personalized care will require a long-term commitment to redesigning the system.”
In shared decision making, providers help patients understand medical evidence about the decisions they face, and patients help providers understand their needs, values and preferences concerning health decisions. In theory, shared decision making leads to personalized health care decisions rather than “one-size-fits-all” care.
Experts say shared decision making may be an especially promising way to improve quality while avoiding unwanted and costly medical interventions. One example of such decisions is whether to screen men for prostate cancer.
Such screening (done by checking the level of prostate-specific antigen in the blood) may reduce the risk of dying from prostate cancer, but the screening has its own risks. For example, screening may detect slow-growing cancers that might never harm a patient if left untreated. But once these cancers are detected, the discovery can lead to a cascade of treatments with major and potentially harmful side effects.
Advocates say shared decision making encourages a full discussion of the pros and cons of such tests and treatments, before doctors and patients make a shared decision about which course to follow.
“Despite its importance, shared decision making is still infrequent in American medicine,” Friedberg said. “Introducing shared decision making won't be easy, but we found that providers who have plans for overcoming the barriers will have the best chances of success.”
The RAND study analyzes the experiences of eight primary care sites at the mid-point of a three-year effort to expand shared decision making. The sites used “decision aids,” which are videos and booklets to help patients evaluate their options for medical issues such as low back pain, cancer screenings, care for chronic conditions and orthopedic procedures.
Researchers suggest that using staff other than overworked physicians to distribute decision aids could help more patients learn about the medical decisions they are facing. Addressing deficiencies in electronic medical records could also help. In the demonstration practices, the researchers found that electronic medical records lacked ways to store patient-reported values and preferences and to make sure that patients get personalized care.
“With financial incentives encouraging shared decision making, provider organizations will invest in needed staff, tools and infrastructure, and providers will focus on improving their shared decision making skills,” said Dr. Richard Wexler, a study co-author and chief medical officer at the Informed Medical Decisions Foundation.
The sites taking part in the demonstration included the Dartmouth-Hitchcock Medical Center in New Hampshire; MaineHealth; Massachusetts General Hospital; Mercy Clinics in Iowa; the Oregon Rural Practice-Based Research Network; the Palo Alto Medical Foundation in California; the Stillwater Medical Group in Minnesota; and the University of North Carolina at Chapel Hill.
Support for the study was provided by the Informed Medical Decisions Foundation. Other authors of the study are Kristin Van Busum and Dr. Eric Schneider of RAND, and Megan Bowen of the Informed Medical Decisions Foundation.
RAND Health, a division of the RAND Corporation, is the nation's largest independent health policy research program, with a broad research portfolio that focuses on health care costs, quality and public health preparedness, among other topics.