Shared decision making requires focusing on outcomes, not procedures

By | April 10, 2018
Physical therapy

As we continue to discuss areas of healthcare savings, we need to focus on the lack of patient education, specifically how to have different discussions between patients and their physicians. Presently, we are asking our providers to share information with their patients, thereby allowing for informed, shared decision making. But is the information complete and delivered in a way that is best for those on the receiving end?

Even though providers are the subject matter experts, being shouldered with the entire burden of delivering all information may not lead to optimal results. For example, as our population ages hip and knee replacements will increase. Per the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project, in 2014, there were 505,000 hip replacements and 723,000 knee replacements done at a cost greater than $20 billion. Different algorithms have projected that 34% of such procedures might be considered inappropriate based on the level of mobility limitations. Being a society of high expectations, many will undergo these elective procedures with distinct ideas about their outcomes, yet the actual result will not meet their pre-surgery expectations. In reality, the final result could be deemed a success by the physician but a failure by the patient. Having a conversation about all the potential outcomes within the expectations of the patient is imperative. How should that conversation occur? As a provider of such a service, how do I have such a discussion?

Historically, we share the risks of procedures, but do we frame them within the context of possible potential harm to that individual? Framing the decision to proceed as the ratio of potential improvement to a certain level compared to the impairment that could occur is an optimal way to present options to the patient. The pre-surgery patient educational material focuses on the details and risks of the procedure itself, not the possible range of outcomes.

An additional area not extensively discussed is alternative treatments. As a specialist, my focus is on the procedure offered, and I might not be the best person to have such a conversation regarding all the available treatment options. Stacey D. et al. in their 2016 publication concerning the impact of decision aids for knee and hip arthroplasty found that when visual decision aids were implemented concerning the above, 73.2% of patients underwent hip or knee replacement surgery compared to 80.5% in a matched control group.

As we continue to contemplate what is of greater value to those we serve, we will need to address not only shared decision making, but also how do we present the different levels of information most suitably. Human learning and educational models will encompass a greater focus if we are to manage the expectations better and elevate the conversations that will be required. Shifting from a factual, risk of possible side effects model of education to one that is based on alternatives and outcomes within the context of the individual’s life, will be required for true shared decision making.