JAMA Internal Medicine Publishes Several Articles on Shared Decision Making Between Physicians and Patients

Communication Between Physicians and Patients Important for Expectations

Seriously ill patients undergoing hemodialysis are more optimistic about their prognosis and prospects for transplants than their nephrologists, according to a study published online by JAMA Internal Medicine. The study also found that nephrologists rarely had discussed estimates of life-expectancy with their patients.

Melissa W. Wachterman, M.D., M.P.H., from Veterans Affairs Boston Health Care System and colleagues compared patients’ and physicians’ expectations about one- and five-year survival rates and transplant candidacy among 207 patients undergoing hemodialysis through medical record reviews and interviews.  “Among the 62 interviewed patients, no patients reported that their nephrologist had discussed an estimated life expectancy with them, and the nephrologists reported that they had done so for only two interviewed patients,” the authors found.    The nephrologists reported that “…for 60 percent of patients, they would not provide any estimate of prognosis even if their patient insisted.”     The authors note that patients’ expectations about one-year survival rates are fairly accurate, but that patients over-estimate their long-term survival rates.

“As our ability to accurately prognosticate for seriously ill patients continues to advance, developing interventions to help providers communicate effectively with patients about prognosis will become increasingly important,” the authors conclude.

(JAMA Intern Med. Published online May 27, 2013. doi:10.1001/jamainternmed.2013.6036. 

Patient Participation in Decision Making Associated With Increased Costs, Services

A survey of almost 22,000 admitted patients at the University of Chicago Medical Center found patient preference to participate in decision making concerning their care was associated with a longer length of stay and higher total hospitalization costs, according to a report published online by JAMA Internal Medicine.

Hyo Jung Tak, Ph.D., and colleagues examined the relationship between patient preferences for participation in medical decision making and health care utilization among patients hospitalized between July 1, 2003 and August 31, 2011 by asking patients to complete a survey.  The survey data were then linked with administrative data, including length of stay and total hospitalization costs.  Nearly all of the patients indicated they wanted information about their illnesses and treatment options, but just over 70 percent preferred to leave the medical decisions to their physician.  “Preference to participate in medical decision making increased with educational level and with private health insurance,” the authors note.   “…patients who preferred to participate in decision making concerning their care had a 0.26-day longer length of stay and $865 higher total hospitalization costs.”

In conclusion the authors write: “That patient preference for participation is associated with increased resource use contrasts with some perspectives on shared decision making that emphasize reductions of inappropriate use. However, in the presence of physician incentives to decrease use, such as exist for hospitalized patients and are likely to increase under health reform, increased resource use may occur.  Future studies related to patient participation in decision making should examine effects on both outcomes and costs.”

(JAMA Intern Med. Published online May 27, 2013. doi: 10.1001/jamainternmed.2013.6048. 

How Patient Centered are Medical Decisions?

A national survey sample of adults who had discussions with their physicians in the preceding two years about common medical tests, medications and procedures often did not reflect a high level of shared decision making, according to an article published online by JAMA Internal Medicine.

Floyd J. Fowler, Jr., Ph.D., from the Informed Medical Decisions Foundation and the University of Massachusetts, Boston, conducted a 2011 survey of a cross section of U.S. adults 40 years or older and asked them to indicate whether they reported making one of 10 medical decisions and to describe their interactions with their physicians concerning those decisions.   The decisions included: medication for hypertension, elevated cholesterol, or depression; screening for breast, prostate or colon cancer; knee or hip replacement for osteoarthritis, or surgery for cataract or low back pain.

“…we saw great variation in the extent to which patients reported efforts to inform them about and involve them in 10 common decisions,” the authors write in their conclusion.  “Although there was variation within decision types, decisions concerning four surgical procedures were much more shared than decisions about cancer screening and two very common long-term medications for cardiac risk reduction.  If share decision making is to be one defining characteristic of primary care as delivered in medical homes, primary care physicians and other health care providers will need to balance their discussions of pros and cons to a greater degree and ask patients for their input more consistently.”

(JAMA Intern Med. Published online May 27, 2013. doi:10.1001/jamainternmed.2013.6172.

Decision Making Preferences Among Patients with Heart Attacks

In a research letter, Harlan M. Krumholz, M.D., S.M., from Yale University School of Medicine and colleagues, “sought to investigate preferences for participation in the decision-making process among individuals hospitalized with an acute myocardial infarction ([AMI] or heart attack).”   The researchers combined data from two similar AMI registries (TRIUMPH and PREMIER) which resulted in 6,636 patients in the study sample who were asked about who should make decisions on treatment options.

“More than two-thirds of patients with AMI indicated a preference to play an active role in the decision-making process, and of those, about a quarter preferred that the decision be theirs alone rather than shared with their physician,” the authors found.   “Our findings indicate that physicians who aspire to provide patient-centered care should assess patients’ decision-making preferences by directly asking each patient.”

“Our challenge now is to develop systems that fully respect these preferences and ensure that patients who prefer an active role are given that opportunity,” the authors conclude.

(JAMA Intern Med.  Published online May 27, 2013.  doi:10.1001/jamainternmed.2013.6057.

Commentary:  Shared Decision Making

In an invited commentary, Mack Lipkin, M.D., from NYU Langone School of Medicine, New York City, reviews several of the studies being published online by JAMA Internal Medicine on this topic. Lipkin writes that “shared decision making in the modern era began as informed decision making, a reverse reification of informed consent promulgated in President Reagan’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.”

“I believe a series of prospective studies is needed, starting with taped interviews, to validate current notions of what embodies SDM (shared decision-making), to establish how framing and contextual features alter recollections, and to relate accurately and validly measured strong and weak SDM to the evolution of recalled views about the decisional process.  Such results could then be related to health outcomes.”

(JAMA Intern Med. Published online May 27, 2013. Doi:10.1001/jamainternmedi.2013.6248.