Shared decision making: Some benefits, many limitations

Despite the push toward patient-centered care and shared decision making, two physicians argued in an editorial published Oct. 16 in JAMA that there is insufficient evidence to suggest shared decision making can lower costs and reduce overtreatment.

Research does support some benefits of shared decision making, wrote Steven J. Katz, MD, MPH, and Sarah Hawley, PhD, of the University of Michigan in Ann Arbor. However, in some of those same studies, physician-level factors may have played a bigger role in influencing patient decisions.

For example, Katz and Hawley highlighted one meta-analysis that found that the use of decision aids among patients led them to choose major elective surgery less often than other patients who had no decision aids. However, the editorialists pointed out that only five of 14 studies found fewer patients chose more extensive treatments and also that it was difficult to “disentangle patient- vs. clinician-level effects of the intervention on utilization.”

In addition to the challenges of separating out patient and physician factors, the authors argued that determining patient preferences is a complex undertaking that involves understanding the interaction between intuition and careful thought processes. What patients value and prefer in terms of treatment are not fully understood.

There is no evidence that patients would actually prefer less intensive treatments over what their physicians recommend and in fact, some research has hinted that patients may actually prefer more extensive treatments.

The authors also concluded that interactions with providers may be overly simplified.

“Blanket assumptions about which health conditions or treatments are more or less sensitive to patient preferences (often called ‘preference-sensitive conditions’) do not fully consider the wide variability in the context of the clinical management,” they wrote.

Breast cancer surgery, they explained, is considered a preference-sensitive condition, but many women may not be medically able to have breast-conserving surgery, which is why they undergo mastectomy.

These limitations of shared decision making will hopefully lead to more research, the authors wrote, but they also “underscore that too little is known about SDM [shared decision making] and its outcomes to support its role in addressing the increasing concern about overtreatment and medical cost inflation.”