There is growing interest by patients, policymakers, and clinicians in shared decision-making as a means to include patients in health decisions and translate patient evidence into clinical practice. Conceptually, sharing of information seems like a natural interplay between doctors and their patients. However, while studies indicate that most patients want more dialogue, many clinicians don’t feel adequately trained to implement shared decision-making in their oncology practice. At the recent ASCO Quality Care Symposium in San Diego, Steven J. Katz, MD, MPH, examined this important issue.
Show Me the Data
“There’s compelling evidence that’s been summarized in several editions of a Cochrane Review that addresses the impact of patient decision aids suggesting that sharing makes decisions more effective,” said Dr. Katz. “Patients are more informed and more deliberative. And although the evidence also suggests that patients are more satisfied, there is little evidence that shared decision-making changes behavior.”
Dr. Katz noted that over the past 3 years we’ve seen an additional rationale emerge in the literature for increasing shared decision-making. “Some have argued that incorporating patient preferences into treatment decision-making could reduce overtreatment and overall costs,” he said, pointing to recent commentaries and studies that suggest that informed patient choice via the use of decision aids may decrease the demand for invasive surgical procedures and reduce costs.
He enumerated three main limitations to the argument that more shared decision-making between patients and clinicians could reduce overtreatment and medical costs: The literature fails to distinguish clinician vs patient influences on treatment decisions, there is insufficient consideration of the complexity of how patients construct and express treatment preferences, and the studies project an oversimplistic view of the doctor/patient clinical encounter.
What Do Patients Value?
“Ultimately, the question is, what do patients value? There are really only three things. The first two are quantity of life and quality of life, as far as their physical, social, and emotional well-being. But the third value is something we as doctors under-recognize, and that is the treatment decision-making process itself, “ said Dr. Katz.
“When we’re in the exam room, there is an interplay between the three basics of making a decision: rational deliberation, intuition, and of course the clinical rules that guide physicians. For the patient, it is all new and pretty scary. There are a number of interdependent treatment options, and the evaluative information is very complex. This creates a challenging environment for shared decision-making, which is often done at a pressured pace,” he continued.
Dr. Katz concluded, “Shared decision-making improves the patients experience with the clinical encounter and makes decisions more effective—patients are more informed and more engaged. However, there is no compelling evidence that more shared decision-making with patients will reduce overtreatment and medical cost inflation. So this is a strong call for more research about the consequences of shared treatment decision-making between patients and their clinicians.” ■
Disclosure: Dr. Katz reported no potential conflicts of interest.