Studies examine the patient's role in healthcare decision-making
One study finds doctors reluctant to discuss long-term life expectancy with dialysis patients
Sunday, June 2, 2013
In any discussion of healthcare, there's always a lot of emphasis on empowering patients, making patients active participants in their care and keeping patients fully informed of their situation.
But the reality often doesn't live up to these idealistic notions, as demonstrated in a couple of recent studies. One study looked at seriously ill patients undergoing dialysis treatment because of kidney failure and another examined whether patient participation drives up costs.
The dialysis study found that seriously ill dialysis patients were more optimistic about their prognosis and their prospects for transplants than were their nephrologists. Further, the study published online by JAMA Internal Medicine found that the nephrologists had rarely discussed estimates of life expectancy with their patients.
Melissa W. Wachterman, M.D., M.P.H., from Veterans Affairs Boston Health Care System and her colleagues compared patients’ and physicians’ expectations about one- and five-year survival rates and transplant candidacy among 207 patients undergoing hemodialysis, using medical record reviews in some cases and interviews in others.
“Among the 62 interviewed patients, no patients reported that their nephrologist had discussed an estimated life expectancy with them, and the nephrologists reported that they had done so for only two interviewed patients,” the authors found.
The nephrologists reported that “…for 60 percent of patients, they would not provide any estimate of prognosis even if their patient insisted.”
The authors said that patients’ expectations about one-year survival rates are fairly accurate, but that patients over-estimate their long-term survival rates.
Patient participation drives up costs
While patient participation in decision-making may be desirable, another study found it may drive up costs.
The survey of almost 22,000 admitted patients at the University of Chicago Medical Center found patient preference to participate in decision-making concerning their care was associated with a longer length of stay and higher total hospitalization costs, according to a report published online by JAMA Internal Medicine.
Nearly all of the patients indicated they wanted information about their illnesses and treatment options, but just over 70 percent preferred to leave the medical decisions to their physician.
“Preference to participate in medical decision making increased with educational level and with private health insurance,” the authors note. “…patients who preferred to participate in decision making concerning their care had a 0.26-day longer length of stay and $865 higher total hospitalization costs.”
Hyo Jung Tak, Ph.D., and colleagues studied patients hospitalized between July 1, 2003 and August 31, 2011 by asking patients to complete a survey. The survey data were then linked with administrative data, including length of stay and total hospitalization costs.
Heart attack patients
Yet another study found that two-thirds of heart attack patients wanted to play an active role in making decisions about their care.
In a research letter, Harlan M. Krumholz, M.D., S.M., from Yale University School of Medicine and colleagues combined data from two studies of 6,636 patients who were asked about who should make decisions on treatment options.
“More than two-thirds of patients with AMI (acute myocardial infaraction, or heart attack) indicated a preference to play an active role in the decision-making process, and of those, about a quarter preferred that the decision be theirs alone rather than shared with their physician,” the authors found.
“Our findings indicate that physicians who aspire to provide patient-centered care should assess patients’ decision-making preferences by directly asking each patient.”
“Our challenge now is to develop systems that fully respect these preferences and ensure that patients who prefer an active role are given that opportunity,” the authors conclude in their study, published online in JAMA Internal Medicine.
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