Research Brief -- Enhanced Support for Shared Decision Making

There is a growing body of evidence that patients who are more actively involved in their health care have better outcomes and incur lower medical costs. An article by David Veroff, Amy Marr, and David Wennberg in Health Affairs titled, “Enhanced Support for Shared Decision Making Reduced Costs of Care for Patients with Preference-Sensitive Conditions” compares the effects of patients who received a usual level of support for making a medical decision with the effects of having more enhanced support. This study suggests that the amount of care that is desired from some patients under a shared decision-making model might be less than the level currently provided.

The research was based on data from a randomized controlled trial of 174,120 patients that ran for twelve months (July 1, 2006 through June 30, 2007) and was conducted by Health Dialog, a for-profit total population health management and analytics firm, in collaboration with two regional health plans. Veroff and colleagues then created a subset of this year-long trial, focusing only on patients with preference-sensitive conditions, those in which there are multiple treatment options with equivalent health care outcomes. The subset (60,185 patients) included those with one or more of six different preference-sensitive conditions: heart conditions, benign uterine conditions, benign prostatic hyperplasia, hip pain, knee pain, and back pain.

The subset of patients was then randomly divided into two groups, one that would receive enhanced support (experimental group) and the other that would received the usual support (control group). Patients in both groups received basic information about treatment options, preferences, and the importance of communicating with their health care providers, but the experimental group received an enhanced level of support that involved more contact via telephone, mail, e-mail, and Internet. (See table below.)

The researchers measured outcomes by analyzing health insurance claims data. They found that patients who received the “enhanced” support had 5.3 percent lower medical costs overall compared to those receiving the usual level of support. The enhanced group also had 12.5 percent fewer hospital admissions and 9.9 percent fewer preference-sensitive surgeries (including 20.9 percent fewer heart surgeries) than the “usual support” group. The findings suggest that remote models of support via health coaches has the potential to impact medical costs.

Implications and Limitations

It is important to note that the health care coaches in this study contacted approximately three times more people in the enhanced-support/experimental group than did the coaches in the usual-support/control group. Health coaches had telephone contact with 2,267 people in the control group (7.5 percent of those randomly assigned) and 6,828 people in the experimental group (22.8 percent of those randomly assigned). The coaches also sent more educational material, literature, and videos to those in the enhanced/experimental group, as the health coaches in this group were required to use a broader set of criteria for contacting patients and to make more attempts to reach qualifying patients.

The low response rate, small sample sizes, and disproportionate numbers of patients within the enhanced-support/experimental versus the usual-support/control groups may be sources of bias in this study. It is unclear which patients with which conditions were in each group and what factors or contexts may have encouraged or discouraged patient communication with coaches. Additionally, information about average outcomes and costs for people with the conditions in the analysis would be useful in understanding the relative significance of the findings.

This study suggests that alternative models of patient support may be useful for some types of patients. There is a need for more research to understand how patient preferences influence medical decision-making and the kinds of interventions that would improve informed decision making and doctor-patient communication within the varied contexts of patients’ lives.

Source: David Veroff, Amy Marr, and David Wennberg. 2013. ”Enhanced Support for Shared Decision Making Reduced Costs of Care for Patients with Preference-Sensitive Conditions,” Health Affairs [Feb;32(2):285-93].

 

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