Policy support for patient-centered care: The need for measurable improvements in decision quality

Health Affairs

Volumn 23, Issue SUPPL., 2004, Pages

  Sepucha, Karen R ^a   Fowler Jr , Floyd J ^b   Mulley Jr , Albert G ^a  

^a MASSACHUSETTS GENERAL HOSPITAL   (United States)

^b Found Informed Med Decis Making   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

HEALTH CARE DELIVERY; HEALTH CARE NEED; HEALTH CARE POLICY; HEALTH CARE QUALITY; HUMAN; MEDICAL DECISION MAKING; MEDICAL PRACTICE; PATIENT CARE; PRACTICE GUIDELINE; QUALITY OF LIFE; REVIEW; ARTICLE; ATTITUDE TO HEALTH; CLINICAL PRACTICE; DECISION MAKING; UNITED STATES;

DECISION MAKING; HEALTH KNOWLEDGE, ATTITUDES, PRACTICE; HEALTH POLICY; HUMANS; PATIENT-CENTERED CARE; PHYSICIAN'S PRACTICE PATTERNS; QUALITY OF HEALTH CARE; UNITED STATES;

EID: 8844241563     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.var.54     Document Type: Review

References (34)

1. K. McPherson et al., "Small-Area Variations in the Use of Common Surgical Procedures: An International Comparison of New England, England, and Norway," New England Journal of Medicine 307, no. 21 (1982): 1310-1314.
2. See J.N. Weinstein et al., "Trends and Geographic Variations in Major Surgery for Degenerative Diseases of the Hip, Knee, and Spine," Health Affairs, 7 October 2004, content.healthaffairs.org/cgi/content/abstract/ hlthaff.var.81.
3. There is some evidence that higher costs may be associated with poorer quality. See E.S. Fisher et al., "The Implications of Regional Variations in Medicare Spending, Part 1: The Content, Quality, and Accessibility of Care," Annals of Internal Medicine 138, no. 4 (2003): 273-287, and "The Implications of Regional Variations in Medicare Spending, Part 2: Health Outcomes and Satisfaction with Care," Annals of Internal Medicine 138, no. 4 (2003): 288-298.
4. There is some evidence that higher costs may be associated with poorer quality. See E.S. Fisher et al., "The Implications of Regional Variations in Medicare Spending, Part 1: The Content, Quality, and Accessibility of Care," Annals of Internal Medicine 138, no. 4 (2003): 273-287, and "The Implications of Regional Variations in Medicare Spending, Part 2: Health Outcomes and Satisfaction with Care," Annals of Internal Medicine 138, no. 4 (2003): 288-298.
5. The RAND-UCLA Health Services Utilization Study (HSUS) was the most ambitious effort to develop appropriateness criteria. See R.E. Park et al., "Physician Ratings of Appropriate Indications for Six Medical and Surgical Procedures," American Journal of Public Health 76, no. 7 (1986): 766-772; N.J. Merrick et al., "Derivation of Clinical Indications for Carotid Endarterectomy by Expert Panel," American Journal of Public Health 77, no. 2 (1987): 187-190; M.R. Chassin et al., "How Coronary Angiography Is Used: Clinical Determinants of Appropriateness," Journal of the American Medical Association 258, no. 18 (1987): 2543-2547; and C.M. Winslow et al., "The Appropriateness of Performing Coronary Artery Bypass Surgery," Journal of the American Medical Association 260, no. 4 (1988): 505-509.
6. The RAND-UCLA Health Services Utilization Study (HSUS) was the most ambitious effort to develop appropriateness criteria. See R.E. Park et al., "Physician Ratings of Appropriate Indications for Six Medical and Surgical Procedures," American Journal of Public Health 76, no. 7 (1986): 766-772; N.J. Merrick et al., "Derivation of Clinical Indications for Carotid Endarterectomy by Expert Panel," American Journal of Public Health 77, no. 2 (1987): 187-190; M.R. Chassin et al., "How Coronary Angiography Is Used: Clinical Determinants of Appropriateness," Journal of the American Medical Association 258, no. 18 (1987): 2543-2547; and C.M. Winslow et al., "The Appropriateness of Performing Coronary Artery Bypass Surgery," Journal of the American Medical Association 260, no. 4 (1988): 505-509.
7. The RAND-UCLA Health Services Utilization Study (HSUS) was the most ambitious effort to develop appropriateness criteria. See R.E. Park et al., "Physician Ratings of Appropriate Indications for Six Medical and Surgical Procedures," American Journal of Public Health 76, no. 7 (1986): 766-772; N.J. Merrick et al., "Derivation of Clinical Indications for Carotid Endarterectomy by Expert Panel," American Journal of Public Health 77, no. 2 (1987): 187-190; M.R. Chassin et al., "How Coronary Angiography Is Used: Clinical Determinants of Appropriateness," Journal of the American Medical Association 258, no. 18 (1987): 2543-2547; and C.M. Winslow et al., "The Appropriateness of Performing Coronary Artery Bypass Surgery," Journal of the American Medical Association 260, no. 4 (1988): 505-509.
8. The RAND-UCLA Health Services Utilization Study (HSUS) was the most ambitious effort to develop appropriateness criteria. See R.E. Park et al., "Physician Ratings of Appropriate Indications for Six Medical and Surgical Procedures," American Journal of Public Health 76, no. 7 (1986): 766-772; N.J. Merrick et al., "Derivation of Clinical Indications for Carotid Endarterectomy by Expert Panel," American Journal of Public Health 77, no. 2 (1987): 187-190; M.R. Chassin et al., "How Coronary Angiography Is Used: Clinical Determinants of Appropriateness," Journal of the American Medical Association 258, no. 18 (1987): 2543-2547; and C.M. Winslow et al., "The Appropriateness of Performing Coronary Artery Bypass Surgery," Journal of the American Medical Association 260, no. 4 (1988): 505-509.
9. M.R. Chassin et al., "Does Inappropriate Use Explain Geographic Variations in the Use of Health Care Services? A Study of Three Procedures," Journal of the American Medical Association 258, no. 18 (1987): 2533-2537; and L.L. Leape et al., "Does Inappropriate Use Explain Geographic Variations in the Use of Health Care Services?" Journal of the American Medical Association 263, no. 5 (1990): 669-672.
10. M.R. Chassin et al., "Does Inappropriate Use Explain Geographic Variations in the Use of Health Care Services? A Study of Three Procedures," Journal of the American Medical Association 258, no. 18 (1987): 2533-2537; and L.L. Leape et al., "Does Inappropriate Use Explain Geographic Variations in the Use of Health Care Services?" Journal of the American Medical Association 263, no. 5 (1990): 669-672.
11. For example, the efforts of back surgeons who disagreed with guidelines based on the work of the Patient Outcome Research Team (PORT) funded by the Agency for Health Care Policy and Research (AHCPR) contributed to AHCPRs near demise in 1995. See B.H. Gray et al., "AHCPR and the Changing Politics of Health Services Research," Health Affairs, 25 June 2003, content.healthaffairs.org/cgi/content/abstract/ hlthaff.w3.283 (29 July 2004).
12. A.G. Mulley Jr. and K.A. Eagle, "What Is Inappropriate Care?" Journal of the American Medical Association 260, no. 4 (1988): 540-541; and P.G. Shekelle et al., "The Reproducibility of a Method to Identify the Overuse and Underuse of Medical Procedures," New England Journal of Medicine 338, no. 26 (1998): 1896-1904.
13. A.G. Mulley Jr. and K.A. Eagle, "What Is Inappropriate Care?" Journal of the American Medical Association 260, no. 4 (1988): 540-541; and P.G. Shekelle et al., "The Reproducibility of a Method to Identify the Overuse and Underuse of Medical Procedures," New England Journal of Medicine 338, no. 26 (1998): 1896-1904.
14. M.J. Barry et al., "Watchful Waiting versus Immediate Transurethral Resection for Symptomatic Prostatism: The Importance of Patients' Preferences," Journal of the American Medical Association 259, no. 20 (1988): 3010-3017; F.J. Fowler Jr. et al., "Symptom Status and Quality of Life following Prostatectomy," Journal of the American Medical Association 259, no. 20 (1988): 3018-3022; and J.E. Wennberg et al., "An Assessment of Prostatectomy for Benign Urinary Tract Obstruction: Geographic Variations and the Evaluation of Medical Care Outcomes," Journal of the American Medical Association 259, no. 20 (1988): 3027-3030.
15. M.J. Barry et al., "Watchful Waiting versus Immediate Transurethral Resection for Symptomatic Prostatism: The Importance of Patients' Preferences," Journal of the American Medical Association 259, no. 20 (1988): 3010-3017; F.J. Fowler Jr. et al., "Symptom Status and Quality of Life following Prostatectomy," Journal of the American Medical Association 259, no. 20 (1988): 3018-3022; and J.E. Wennberg et al., "An Assessment of Prostatectomy for Benign Urinary Tract Obstruction: Geographic Variations and the Evaluation of Medical Care Outcomes," Journal of the American Medical Association 259, no. 20 (1988): 3027-3030.
16. M.J. Barry et al., "Watchful Waiting versus Immediate Transurethral Resection for Symptomatic Prostatism: The Importance of Patients' Preferences," Journal of the American Medical Association 259, no. 20 (1988): 3010-3017; F.J. Fowler Jr. et al., "Symptom Status and Quality of Life following Prostatectomy," Journal of the American Medical Association 259, no. 20 (1988): 3018-3022; and J.E. Wennberg et al., "An Assessment of Prostatectomy for Benign Urinary Tract Obstruction: Geographic Variations and the Evaluation of Medical Care Outcomes," Journal of the American Medical Association 259, no. 20 (1988): 3027-3030.
17. There are difficult technical problems in measuring utilities (preferences), and they are subject to change with patients' knowledge and experience. See A.G. Mulley Jr., "Assessing Patients' Utilities: Can the Ends Justify the Means?" Medical Care 27, no. 3 Supp. (1989): S269-S281.
18. For example, the 1990 National Institutes of Health (NIH) Consensus Conference on the treatment of early-stage breast cancer concluded that lumpectomy plus radiation "is preferable because it provides survival equivalent to total mastectomy...while preserving the breast." This guideline, however, ignored outcomes of importance to patients as indicated in the following letter written to the editor of the New York Times, 20 October 2002: "The decision about treatment for breast cancer remains an intensely personal one. The mastectomy I choose...felt a lot less invasive than the prospect of six weeks of daily radiation, not to mention the 14% risk of local recurrence." In more recent versions of guidelines for breast cancer as well as other conditions, this shortfall has been addressed with specific language highlighting the need to in form patients of benefits and risks and to incorporate patients' preferences in the choice of treatments.
19. Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington: National Academies Press, 2001).
20. A. Kennedy, "On What Basis Should the Effectiveness of Decision Aids Be Judged?" Health Expectations 6, no. 3 (2003): 255-268.
21. P. Cleary, "Satisfaction May Not Suffice! A Commentary on A Patient's Perspective,'" International Journal of Technology Assessment in Health Care 14, no. 1 (1998): 35-37.
22. A.M. O'Connor, "Validation of a Decisional Conflict Scale," Medical Decision Making 15, no. 4 (1995): 25-30.
23. Kennedy, "On What Basis?"
24. E.H. Wagner et al., "The Effect of a Shared Decision-Making Program on Rates of Surgery for Benign Prostatic Hyperplasia," Medical Care 33, no. 8 (1995): 765-770.
25. J. Hammond et al., Smart Choices: A Guide to Making Better Decisions (Cambridge, Mass.: Harvard Business School Press, 1998); A. Ratliff et al., "What Is a Good Decision?" Effective Clinical Practice 2, no. 4 (1999): 185-197; M. Barry, "Involving Patients in Medical Decisions: How Can Physicians Do Better?" Journal of the American Medical Association 282, no. 24 (1999): 2356-2357; H. Llewellyn-Thomas, "Patients' Health-Care Decision Making: A Framework for Descriptive and Experimental Investigations," Medical Decision Maleing 15, no. 2 (1995): 101-106; and Kennedy, "On What Basis?"
26. J. Hammond et al., Smart Choices: A Guide to Making Better Decisions (Cambridge, Mass.: Harvard Business School Press, 1998); A. Ratliff et al., "What Is a Good Decision?" Effective Clinical Practice 2, no. 4 (1999): 185-197; M. Barry, "Involving Patients in Medical Decisions: How Can Physicians Do Better?" Journal of the American Medical Association 282, no. 24 (1999): 2356-2357; H. Llewellyn-Thomas, "Patients' Health-Care Decision Making: A Framework for Descriptive and Experimental Investigations," Medical Decision Maleing 15, no. 2 (1995): 101-106; and Kennedy, "On What Basis?"
27. J. Hammond et al., Smart Choices: A Guide to Making Better Decisions (Cambridge, Mass.: Harvard Business School Press, 1998); A. Ratliff et al., "What Is a Good Decision?" Effective Clinical Practice 2, no. 4 (1999): 185-197; M. Barry, "Involving Patients in Medical Decisions: How Can Physicians Do Better?" Journal of the American Medical Association 282, no. 24 (1999): 2356-2357; H. Llewellyn-Thomas, "Patients' Health-Care Decision Making: A Framework for Descriptive and Experimental Investigations," Medical Decision Maleing 15, no. 2 (1995): 101-106; and Kennedy, "On What Basis?"
28. J. Hammond et al., Smart Choices: A Guide to Making Better Decisions (Cambridge, Mass.: Harvard Business School Press, 1998); A. Ratliff et al., "What Is a Good Decision?" Effective Clinical Practice 2, no. 4 (1999): 185-197; M. Barry, "Involving Patients in Medical Decisions: How Can Physicians Do Better?" Journal of the American Medical Association 282, no. 24 (1999): 2356-2357; H. Llewellyn-Thomas, "Patients' Health-Care Decision Making: A Framework for Descriptive and Experimental Investigations," Medical Decision Maleing 15, no. 2 (1995): 101-106; and Kennedy, "On What Basis?"
29. J. Hammond et al., Smart Choices: A Guide to Making Better Decisions (Cambridge, Mass.: Harvard Business School Press, 1998); A. Ratliff et al., "What Is a Good Decision?" Effective Clinical Practice 2, no. 4 (1999): 185-197; M. Barry, "Involving Patients in Medical Decisions: How Can Physicians Do Better?" Journal of the American Medical Association 282, no. 24 (1999): 2356-2357; H. Llewellyn-Thomas, "Patients' Health-Care Decision Making: A Framework for Descriptive and Experimental Investigations," Medical Decision Maleing 15, no. 2 (1995): 101-106; and Kennedy, "On What Basis?"
30. The authors conducted interviews with more than 500 men with BPH, participated in extended collaboration with urologists, and used the application of formal decision analysis. See Note 8.
31. M.J. Barry et al., "Patient Reactions to a Program Designed to Facilitate Patient Participation in Treatment Decisions for Benign Prostatic Hyperplasia," Medical Care 33, no. 8 (1995): 771-782.
32. J.N. Weinstein et al., "Designing an Ambulatory Clinical Practice for Outcomes Improvement: From Vision to Reality - The Spine Center at Dartmouth-Hitchcock, Year One," Quality Management in Health Care 8, no. 2 (2000): 1-20.
33. Whether the benefits of implementing decision-quality measures would justify the costs remains a question in need of further research. Widespread implementation of these measures will likely highlight important gaps in patients' knowledge and a lack of connection between patients' preferences and the care they receive. However, even more revealing would be studies that randomize decision-support interventions and decision-quality measures in high-use and low-use areas. This type of trial may help determine whether attention to decision quality can help support warranted sources of variation in care, while minimizing unwarranted sources.
34. P. Plsek, "Redesigning Health Care with Insights from Science of Complex Adaptive Systems," in IOM, Crossing the Quality Chasm, 309-322.