Impact and importance of patient preference still TBD

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Patient preference is on JAMA's mind. The publication's May issue includes several perspectives on the doctor-informed patient dynamic that provide broad talking points, but show that context beyond beyond statistics is necessary if the healthcare industry is going to be able to make sense of what constitutes valuable care, how much of a long view is necessary to assess value, and just where the patient stands in what is purportedly a dynamic in which patient say-so is a given part of medical care.

For example, a study that focused on hospital stays found that patients who wanted to have a say in their care generally stayed in hospitals longer than their uninvolved peers, which translated into roughly 6% higher hospitalization costs. The researchers also point out that an informed hospital patient does not necessarily mean an involved one—while over 96% of patients wanted to at least know about their illness, just over 71% were happy to defer to their doctors about how their conditions should be handled. Younger, educated patients with private insurance tended to fall into the informed and involved categories. At the same time, the research team, which included Hyo Jung Tak and Gregory Ruhnke, noted that the deferring 71% were disproportionately older, lesser-educated and minority patients with public insurance. This division indicates a disparity of care, and researchers conjecture that shared decision making among this less empowered group could tip use rates and costs in the opposite direction by unwinding discrepancies in care.

Outside of the hospital, a second research team comprised of Floyd Fowler, Bethany Gerstein and Michael Barry found that patient-centric or patient-engaged care is a matter of context. In this case they took on the idea of just how engaged engaged means and to what extent, if any, the doctor's role has changed since the 20th Century (e.g., as leader with orders to be followed, versus professional with info to share). The conclusion: it comes down to what's being discussed. This research team focused on three categories that covered 10 common medical decisions:

  • Medications for blood pressure, cholesterol and depression
  • Screening for colon, breast and prostate cancers
  • Surgery for knee replacement, hip replacement, lower-back and cataracts

The overall takeaway was that the advantage of medications, screenings and surgery were discussed far more often than potential drawbacks, and that for cancer screenings “the discussion of cons was almost non-existent, despite recent concerns raised about the possible downsides of PSA testing and of mammograms.”

Of the surgeries studied, patients showed that possible downsides were discussed far more with knee and back surgeries than hip replacements or cataract removal.

Researchers also found that doctors did not always indicate that alternate treatments existed or asked patients if they had a preference. Among medications, high blood pressure ranked highest in term of options being discussed, while almost 75% of patients said doctors did not discuss cholesterol medication options and almost 77% were similarly mum on depression treatments. Knee replacement ranked higher, with data showing close to 86% of patients saying doctors didn't explain their choices and just under 91% of back surgery candidates had that same response—this despite a lengthier discussion about possible drawbacks. These high rates of undisclosed options corresponded with a reduced sounding out of what patients might prefer: 78% of lower back patients said they weren't asked, almost 73% of knee patients weren't asked, but almost 70% of cataract patients were (around 36% of these patients also said docs ran through other options). Patient preference had a greater hearing in medication and cancer screenings: researchers said almost 62% of patients were asked for their cholesterol medication input or preference, close to 33% were asked if they had a depression remedy preference and around 57% said the same when it came to blood pressure medications.

Yet neither of these studies were able to quantify the impact patient preference had on their overall health, an absence acknowledged by Tak's team, and a critical factor in a world of outcomes-based compensation.
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