These days, most people support increased patient involvement in clinical decision making because it improves patient knowledge and satisfaction with care.
In recent years, it has become increasingly clear that shared decision making also tends to decrease utilization of interventions that are perceived by patients to be “risky.”
It would be nice to know why this happens, since some “risky” interventions have enormous clinical upside and thus represent a better option for the patient—especially if the actual risk is low.
So why does shared decision making tend to reduce utilization of risky alternatives?
One theory is that patients’ perception of medical risk increases (sometimes illogically) when they are asked to choose for themselves whether to participate in a risk-associated activity as opposed to having a doctor make the decision for them.
Earlier this week, scientists at Yale published a study designed to test this theory.
In the study, Liana Fraenkel and Ellen Peters tested patients’ willingness to accept a risky treatment in 2 hypothetical situations: in the first situation, patient involvement in the decision was minimized; in the second, patients decided on their own.
The scientists asked 216 patients at an arthritis clinic to view one of 2 videos about drug treatments for which they were candidates…either a pain medication or a drug that reduced cardiac risk.
In both videos, a physician said the drug was “very effective” and “generally safe,” and then explained that the drug was associated with a “small risk of a serious side effect.”
The pain medication could, patients were told, be complicated by necrosis of jaw tissue (as with fosamax). The serious side effect associated with the cardiac drug was progressive multifocal leukoencephalopathy, an often fatal brain infection (as with Tysabri)
After watching a video, patients were randomized to receive either of 2 sets of instructions, and then queried about their plans to take, or not take the drug. The first instruction set was intended to minimize patient choice. In a nutshell, “the doctor decides that you should take this medication and she writes you a prescription for it.”
The second was designed to maximize patient choice: “The doctor tells you that it is completely up to you whether or not you take this medication and then asks you to make a decision.”
The scientists found that patients who made the decision themselves were significantly less willing to take the proposed medication (4.2 vs. 5.3 on a 10-point scale, p<0.001), and their concern about the risk of the adverse event was significantly greater (6.1 versus 5.5, P<0.001) than those who were told what to do by their physicians.
Subjects also were asked how responsible they would feel if they developed the complication, and patients told to make their own decision were found to have significantly higher scores (6.6 versus 4.8, P<0.001).
The findings were not affected by age, gender, educational level or health status.
The scientists acknowledged that their scenarios represented extreme examples, and that in practice other factors would come into play. Nonetheless, they concluded that clinicians should be aware that increased participation in decision-making by patients may lead to decreased use of risky interventions.
“The results of this study suggest that the worry and concern that patients experience in contemplating treatment decisions is influenced not only by the actual risks posed by treatments, but by the responsibility they feel for making the decision,” the researchers wrote.
“Clinicians should be aware that promoting increased patient responsibility for decisions involving their health care may be associated with lower uptake of risky procedures or interventions,” advised Dr. Fraenkel.
The write-up appears in Arthritis Care and Research.
Glenn Laffel MD, PhD
Sr. Vice President, Clinical Affairs, Practice Fusion
