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Shared Decision-Making

By December 4, 2017Commentary

Shared decision-making in health care is predicated on a patient’s interest in and ability to participate in decisions about his or her health and health care.  There are a lot of stumbling blocks to its widespread use in routine clinical practice.  A recent piece of research published at the Annals of Family Medicine examines the extent of use of shared decision-making and changes in that use.   (Ann. Fam. Med. Article)   The researchers used data from the annual Medical Expenditure Panel Survey for 2002 to 2014.  They compared responses to seven questions on that survey for 2002 to the same responses in 2014.  In my opinion, the questions aren’t necessarily clear indicators regarding use of shared decision-making, but the authors had to make do with what they had.  Over the study time period, the respondents became older, less Caucasian, more Hispanic and more educated, while they less often had private insurance and a usual source of care.  The responses to the shared decision-making questions showed a marked increase in positive responses over this time, for example the number saying that their physician always helped them make decisions went from 52% in 2002 to 63% in 2014.  Greater use of shared decision-making was correlated with having a same-race or ethnicity usual source of care and being African-American.  Lower use of SDM was associated with an Asian ethnicity, being uninsured and being in poor health.

While it appears that physicians and patients are conducting decision-making in a manner more consistent with the tenets of SDM, you have to wonder how much of an impact this has on overall health spending or on health outcomes.  There is little research on this topic.  As the results of this study suggest, those with the highest health needs, those in poor health, are less likely to be engaged in shared decision-making.  This likely includes many patients who have cognitive or other deficits which make them incapable of making decisions.  The topic of surrogate decision-making deserves as much or more attention.  These people are often less willing to forego care for the person on whose behalf they are making decisions.  And obviously, good, detailed advance directives can be helpful in this regard.  The people most likely to be engaged in their health are generally those who have few medical needs.  Shared decision-making is a good idea, and should be pursued for its own virtue, but it seems unlikely to really impact our cost and quality issues.

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