Patient Engagement and Decision-Making

Ideally, all patients would be very well-informed about their health, about treatment options and the costs of those options, and would make decisions that reflect their personal values.  A recent issue of Health Affairs contained several studies on how to advance patient engagement and decision-making.    One article looks at the effect of filling in default choices on a form regarding choices for end-of-life care.  Overall, out of 132 patients with serious illnesses, most would prefer comfort oriented care to life-extending care.  But giving patients a form that had comfort care checked as the default option increased the number of people actually selecting that option, as opposed to either no default choice or life-extending care as the default.  (HA Article)  In another study, the effect of providing enhanced support for shared decision-making in regard to preference sensitive conditions was examined.  Those patients that received additional “coaching” for their decision-making had 12.5% fewer hospitalizations and 5.3% overall lower medical costs than patients without such support.  No information on comparative quality outcomes was reported.  It is hard not to suspect that these programs are consciously or sub-consciously encouraging patients not to chose certain health services, because the people running the program think those services offer low value.  If that is the case, it is hardly consistent with respecting patients’ preferences in a neutral decision-making context.  (HA Study)  Another commentary in the issue is more overt about the advisability of “nudging” patients to make the “right” choice, the one that some expert thinks they should make.  The authors suggest three situations that justify use of decision aids that highlight or direct a patient to a particular treatment option.  One is when the option is often not considered by doctors or patients even though research shows it is a viable option, one is when research evidence shows that a particular option is very high value in terms of outcome and cost, and the third is when the patient’s values would suggest a particular option be used.  At least these authors are honest about trying to influence patient decisions.    (HA Commentary)  There is often a conflict between the goals of encouraging the most cost-effective treatment and honoring patient values and choices.  Manipulating patients in any way is never justified and people engaged in assisting in patient decision-making should just be upfront about what their goals and tactics are.