In this feature, Kimberly Westrich (National Pharmaceutical Council, DC, USA) and Theresa Schmidt (Discern Health, MD, USA) present a ‘peek inside the panel debate’ at the International Society for Pharmacoeconomics and Outcomes Research’s (ISPOR) 2020 Virtual Annual Meeting (18–20 May): is shared decision-making (SDM) worth it?
Shared decision-making (SDM) has been referred to as the ‘pinnacle of patient-centered care’ and has been demonstrated to increase patient satisfaction, reduce decisional conflict and improve care outcomes. However, less is known about the impacts of SDM on healthcare costs and utilization, as well as the unintended consequences of SDM. Does SDM reduce low-value care or is it, in and of itself, low-value care?
On May 19 2020, an issue panel held at Virtual ISPOR 2020 debated this question and other controversies around SDM.
The panel was moderated by Kimberly Westrich (National Pharmaceutical Council, DC, USA) and featured Theresa Schmidt (Discern Health, MD, USA), Karen Fields (Moffitt Cancer Center, FL, USA) and Alan Balch (Patient Advocate Foundation, VA, USA) as panelists, who offered researcher, provider and patient advocate perspectives on SDM respectively.
During the panel presentation, Westrich and Schmidt described preliminary findings from systematic reviews currently being conducted by the National Pharmaceutical Council and Discern Health to evaluate the impact of SDM and patient decision aids (PtDAs) on healthcare costs and utilization. They noted that many types of interventions are described as ‘SDM’ in the literature and used the National Quality Forum (DC, USA) definition as a starting point to differentiate between SDM and related interventions such as PtDAs. According to this definition, SDM is “a process of communication in which clinicians and patients work together to make optimal health care decisions.”
“No matter the impact on cost and utilization, SDM is a way to build meaningful relationships between providers and patients and drive treatment decisions based on patient goals and preferences.”
Building on the National Quality Forum definition, Balch listed three dimensions of SDM that the Patient Advocate Foundation’s research has determined to be the most important to patients: “feeling respected, feeling listened to and feeling like care is personalized to them.” No matter the impact on cost and utilization, SDM is a way to build meaningful relationships between providers and patients and drive treatment decisions based on patient goals and preferences.
SDM is also not a one-time event, as Fields observed, but should be a multidisciplinary process that occurs throughout each patient’s care continuum as their experiences, goals and preferences change.
Impact of COVID-19 on SDM
The panel reflected on the impact of the COVID-19 pandemic on SDM conversations. The pandemic has highlighted the importance of advance care planning to increase care concordance with patient goals and reduce crisis-care utilization. Documentation of patient goals and preferences in medical records is also more critical than ever before for patients with cancer or other chronic diseases; these patients may have relationships with providers they trust for ongoing treatment but may encounter other providers during an acute incident.
“The pandemic has highlighted the importance of advance care planning to increase care concordance with patient goals and reduce crisis-care utilization.”
COVID-19 also has implications for SDM around elective procedures, as patients have added health and financial risks to consider prior to utilizing care. Finally, expanded use of telehealth may create more opportunities for engaging patients in SDM.
The gap between the ideal and reality of SDM
Though SDM has potential benefits, especially during the current pandemic, the panelists recognized differences between the ideal of SDM and the reality. According to Schmidt: “The key feature of SDM is the communication and collaboration between the clinician and the patient.” However, some of the ‘SDM’ interventions uncovered during the systematic review, presented during the panel, did not meet this criterion. For example, PtDAs that patients use by themselves to help think through decisions may support future conversations with clinicians but are not substitutes for collaborative SDM.
As Fields outlined, even when collaboration occurs, providers often do not optimize SDM delivery. Clinicians do not always have the communication skills to convey complex information like medical evidence, prognosis and cost in ways that are useful and meaningful to patients. More training and proper tools for implementation can help improve providers’ SDM abilities. Moreover, medical knowledge is increasing at an exponential rate; this also increases providers’ difficulty in conveying to patients the vast amount of information needed to support decision-making.
As a patient advocate, Balch described the need for a systematic and evidence-based way of delivering SDM. Standardizing SDM does not mean that individual SDM conversations would be identical. Rather, the domains that make up SDM must be clearly defined for interventions to be effectively delivered. SDM should also be supported by processes, tools and technology to ensure that both clinicians and patients are prepared to a make an evidence-based decision that maximizes the chances of finding the optimal balance between risks, benefits, and costs for each patient. If this does not occur, SDM may not deliver value to patients.
Impact of SDM on cost and utilization
An audience member asked whether evidence exists regarding the value of SDM, prompting Westrich to return to the research question at the core of the National Pharmaceutical Council’s and Discern Health’s study: what is the impact of SDM on healthcare cost and utilization?
Sharing results from the systematic review, Schmidt described how SDM has been associated with decreases in costs and some utilization, such as unwanted crisis care. However, studies also link SDM to greater utilization resulting from an increase in recommended behavior – such as cancer screening or medication adherence. This could result in higher spending in the short term, however, may provide greater value by lowering cost and utilization outcomes in the long term.
“One common hypothesis that we hear in policy discussions,” observed Westrich, “is that SDM can decrease costs because informed patients will be more likely to choose the less costly option.” This did not resonate with Fields’ experience as a physician: Fields attested that patients are not necessarily focusing on cost until they encounter non-coverage issues or out-of-pocket costs that are excessive. Physicians face many challenges in communicating cost information to patients and often place greater focus on presenting information about expected outcomes.
“…even when collaboration occurs, providers often do not optimize SDM delivery.”
Balch asserted that patients want to factor costs into their decisions, but how such cost conversations will impact the final decision will vary depending upon multiple factors. Patients are very capable of participating in conversations about cost when they know how cost information is relevant to them. For patients, costs may include factors such as transportation, missed work and financial impacts on caregivers. These and other costs must be balanced against the likelihood that a given treatment will be effective, which is an equation that may change during the course of care.
Unintended consequences of SDM
The value of SDM may be undermined by the possibility of unintended consequences. Fields mentioned that targeted therapies and personalized medicine are changing outcomes but are associated with rapidly rising costs of care, suggesting that SDM may encourage more patients to choose these options.
Balch explained that without any standardization in the processes used to deliver SDM, it may be very difficult to evaluate the effectiveness of SDM. Conversely, too much standardization could result in developing a rigid ‘check-box’ process for delivering SDM. Schmidt agreed, emphasizing that in a value-based payment context, quality measures should capture more than simply whether SDM occurred and incentives should promote high-value SDM.
Is SDM worth It?
Despite the discrepancies between an ideal scenario and reality, mixed evidence and the potential for unintended consequences, the panelists all agreed that SDM is ultimately ‘worth it’.
As Balch expressed: “The quintessential goal of healthcare should be to get the right care to the right patient at the right time. SDM is the intervention and the process to maximize the likelihood of that outcome.”
Kimberly Westrich is an employee of the National Pharmaceutical Council, an industry funded health policy research group that is not involved in lobbying or advocacy.
Theresa Schmidt is an employee of Discern Health, a consulting firm with many clients including government, life sciences, non‐profit and provider organizations. No life sciences companies provided direct funding for or were directly involved in this research.
Karen Fields and Alan Balch do not have any conflicts of interest to declare with regards to this topic.
The opinions expressed in this feature are those of the interviewees/authors and do not necessarily reflect the views of The Evidence Base® or Future Science Group.