Shared decision making is designed for gray areas in medical care, otherwise known as "preference-sensitive" decisions. These are cases where there is more than one way to treat a condition, with each having its own risks and benefits. This includes many conditions involving surgery, such as joint replacements, breast cancer and prostate cancer, but even simple treatments like taking aspirin to prevent heart attacks. Dartmouth researchers report that more than half of all Medicare spending falls in such gray areas.
When informed patients make decisions aligned with their values, it also brings down costs. The Health Affairs study found that costs dropped between 12 percent and 21 percent for those like Howell who opted not to have surgery. "Shared decision making is completely agnostic as to what to choose," says Dr. David Arterburn, a researcher at Group Health Research Institute and lead author of the Health Affairs study.
In spite of the evidence behind decision aids and shared decision making, University of California, San Francisco researcher Grace Lin found that efforts to put the practice into place in five California medical groups hit several hurdles, including time constraints and reluctance by some doctors to give up traditional decision-making roles.
"The fee-for-service system is probably our biggest barrier," notes Megan Bowen, implementation manager at the Informed Medical Decisions Foundation, which works to advance evidence-based shared decision. "Doctors are not paid for this, but patients want this."
Under fee for service, the health system is set up to "race patients through the mill of treatment," says Arterburn. "Patients are very much making major medical decisions without knowing their different treatment options, and the risks and benefits" of those options. "Patients are making ill-informed decisions on their medical care. It's the same as a medical error."
For example, significant disagreement remains about which patients are most likely to benefit from elective knee or hip surgeries, Arterburn says. More than more than 900,000 such surgeries were done in the U.S. during 2010, at an estimated price tag of $15.6 billion. There are risks, such as infections and lengthy recuperation, as well as benefits, including relief of symptoms and functional improvement. "Surgery is no small thing," says Howell, who decided against it for her knee.
Since 2009, Group Health has distributed more than 35,000 decision aids for more than 20 conditions, ranging from back pain and depression to prostate cancer. Much of the focus of shared decision making at Group Health is at the specialty-care level.
While Group Health patients can go online, check out a DVD and read booklets, a handful of other organizations around the nation have different models. Patients of Stillwater (Minn.) Medical Group who are diagnosed with certain "preference-sensitive" conditions are given reading materials and a DVD about their condition, and paired with a health coach. "She's great," Nancy Carmichael, 75, of Stillwater, Minn., says of the medical group's health coach. The coach, a registered nurse, works closely with breast cancer patients, helping them decipher their conditions and treatment options.
"I can call her at 6:30 a.m., and she'll call be back in five minutes," says Carmichael, an avid biker and skier, who opted to have a mastectomy rather than a lumpectomy of her right breast. Her doctors first instituted shared decision making in 2006 for uterine fibroids and expanded the practice to several other conditions.
"Patients feel heard," says Dr. Larry Morrissey, a pediatrician who championed shared decision making at the Stillwater clinic. "It's been a great thing."
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