Preconceived Ideas Don’t Always Lead to What We Expect

By | May 13, 2020

A commonly held premise of shared decision-making is that the healthcare profession neither adequately gives specific treatment options nor discusses the trade-offs of surgical intervention. Predominantly, the thought is that if more in-depth conversations were to occur concerning the trade-offs, and there is more appropriate management of expectations, the chosen solution would be the more conservative approach.

With an industry hope of decreasing utilization, one such major area of focus for this type of intervention concerns hip and knee surgery. The hope is that if I increase the usage of decision aids to inform patients about treatments, benefits and potential risks before surgery, shared-decision making can occur, resulting in fewer operations.  However, recently a study in Health Affairs by Hurley et al. found no difference between groups that utilized shared-decision making tools and those that did not.

Once again, we face a situation where our hypothesis that shared-decisions making would lead to less surgeries was proven incorrect. What do we do with such results? Moreover, is shared-decision making harmful, or are the results just simply different than the endpoint studied? For example, perhaps overall patient satisfaction increased on account of the intervention, there were less follow up costs, or redo surgeries were fewer. Another possible scenario is one in which the decision tree occurred at a point in the process where the patient had already made up their mind; therefore, even when posed with additional information, her inherent bias overrides any presented new data points.

Therefore, as we continue to focus on value-based care, it’s essential to continue implementing a scientific approach in addressing whether or not the solutions are impactful, and even more so, how to pivot our thinking and those interventions. Let us continue on our journey, and remember, although we may not see the results, that does not necessarily convey the response is not beneficial. Hence, it may merely suggest we change how we define success. As the study above indicated, “These findings suggest that health care systems adopting decision aids developed for use in shared-decision making and use in conjunctions with hip and knee osteoarthritis consultations, should not expect reduced surgical utilization.” Thus, the researchers are not stipulating that it is inappropriate to intercede, or that other benefits may not occur, only that this situation did not show what others would expect.

With this knowledge, let us move on to analyzing the potential benefits of intervening. Maybe it is more beneficial to move decisions aids to a different point in the decision-making process, and if the desired result in a particular situation requires a different methodology. The key to the scientific approach is to remember each outcome leads to more questions.