Hospital stays may cost a bit more when patients help to make decisions about their care, a new study suggests. The study focused on inpatients at one hospital during an 8-year period. More than 22,000 people filled out surveys. About 38% said they strongly favored leaving decision-making about their care to their doctors. Another 34% agreed somewhat. The remaining 29% said they did not want doctors to make all decisions. The patient population was not typical of the United States as a whole. About three-quarters were African-American. More than three-quarters were on Medicaid or Medicare. Half had a high school education or less. Researchers looked at the costs of care for people in each group. They adjusted their numbers for patients' age, education, race and other factors. People who did not want doctors to make all decisions stayed in the hospital 5% longer than those who definitely wanted their doctors to make decisions. That was equal to about one-quarter of a day. Costs for people who wanted to share in decisions were about 6% higher, or $865. The journal JAMA Internal Medicine published the study. HealthDay News wrote about it May 28.
By Howard LeWine, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
The daily decisions about what to do for your health don't require much thought or conversation. For example, you know that you should take the stairs instead of the elevator all the time. But when rushed or tired, you may rationalize that skipping the stairs today won't make a big difference in your health.
Medical decisions are often another matter. Is my knee arthritis bad enough or bothering me enough to have surgery? Even less dramatic medical decisions are often difficult, as well. For example, do I really need to take a statin for my high cholesterol or can I just try harder with my diet?
Not that long ago, doctors instructed patients with little or no discussion about the pros and cons of the advice. Doctors didn't ask what patients preferred. And patients rarely spoke up.
In the old days, the doctor would say: "You have a blocked artery in your heart that's causing chest pain. Here is what you need to do."
Today the doctor is more likely to say: "You have a blocked artery in one or more blood vessels that supply oxygen to your heart. When you exercise or get stressed, the heart pumps faster and harder. It needs more oxygen to do this. The blocked artery comes from a build-up of fat inside. Now, let's talk about your options."
This is known as shared decision making. It's also called informed decision making. These terms refer to a thoughtful, informed conversation between you and your doctor aimed at making a decision that's right for you.
Shared decision making has gained acceptance as a best practice. Most studies suggest patients who share in decision making:
- Have better health outcomes
- Are more likely to take their medicines and follow doctors' instructions
- Feel more satisfied with their care
But it may come at higher financial costs. This new study found that people in the hospital who said they wanted to take part in medical decisions stayed in the hospital longer. This translated to $865 in extra costs compared with patients who preferred to just follow their doctors' advice.
I actually don't think shared decision making is what caused the higher cost. I can't dismiss the findings, since controlling health care costs is a must. However, the patients requesting shared decision making had a higher level of education than others. They were more likely to have private health insurance. And they were financially more secure.
People with higher education, private insurance and more financial stability are known to have higher health care costs in general. So the shared decision making process probably isn't the reason for the higher hospital costs seen in this study.
What Changes Can I Make Now?
You may be taken aback by your doctor asking "What do you want to do?" You might be thinking, "You're the doctor. Shouldn't you be telling me what to do?"
Your doctor is not actually asking you to make the final medical decision. He or she can describe different treatments and tell you how effective they are. The doctor also can lay out the negative side effects and their odds of happening.
But your doctor can't know what you want out of treatment, what you fear or how the treatment might affect your ability to do things you now enjoy and value. Your preferences play an important part in the decision-making process.
Say your doctor recommends warfarin (Coumadin) for life to prevent a stroke. But what if you loved riding motorcycles, lived to ski or did other activities that could cause an injury? People who take warfarin are urged to avoid such activities because the drug makes it hard to stop bleeding after an injury.
Other options exist, such as aspirin. They are not as good as warfarin, but the risk of bleeding is much less. Some people would choose to start warfarin and stop their risky activity. But you might choose the aspirin rather than giving up your passion. You have made an informed and shared decision with your doctor.
Some people have trouble honestly expressing their fears and desires to their doctors. Some doctors have trouble listening to their patients. If the conversation feels like a struggle, try something like this. "Doctor, this sounds like the best treatment. But are there reasonable alternatives? Might one of them fit better with my life and what I like to do?"
What Can I Expect Looking to the Future?
How do you know if you have made the right decision? Or at least a good decision? It should be based on solid information and your own feelings about benefits and risks.
And always keep in mind that you are not making the decision alone. It is a shared decision with your doctor.
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