The neglected topic: presentation of cost information in patient decision AIDS.
TL;DR: The findings suggest that presentation of cost information in decision aids is highly variable and evidence-based guidelines should be developed by the International Patient Decision Aid Standards (IPDAS) Collaboration.
Abstract: Costs are an important component of patients' decision making, but a comparatively underemphasized aspect of formal shared decision making. We hypothesized that decision aids also avoid discussion of costs, despite their being tools designed to facilitate shared decision making about patient-centered outcomes. We sought to define the frequency of cost-related information and identify the common modes of presenting cost and cost-related information in the 290 decision aids catalogued in the Ottawa Hospital Research Institute's Decision Aid Library Inventory (DALI) system. We found that 56% (n = 161) of the decision aids mentioned cost in some way, but only 13% (n = 37) gave a specific price or range of prices. We identified 9 different ways in which cost was mentioned. The most common approach was as a "pro" of one of the treatment options (e.g., "you avoid the cost of medication"). Of the 37 decision aids that gave specific prices or ranges of prices for treatment options, only 2 were about surgery decisions despite the fact that surgery decision aids were the most common. Our findings suggest that presentation of cost information in decision aids is highly variable. Evidence-based guidelines should be developed by the International Patient Decision Aid Standards (IPDAS) Collaboration.
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TL;DR: Patient preferences for communication about costs with physicians are high, and medical debt and delay in care-seeking are prevalent, and Delay in Care-seeking independently predicts cost communication preferences.
Abstract: Context Health care costs have increasingly shifted to patients, and financial distress caused by medical care has increased Patients may wish to discuss costs with their clinicians Objective Describe patient preferences for communication about cost in the clinical setting Design Cross-sectional, self-administered survey of a stratified random sample of the population insured in an integrated health care system in Washington State Our sampling frame was the entire membership aged 21 years or older Sampling was stratified by sex and group practice enrollment Main outcome measures Preference for discussing health care costs with one's physician We conducted regression analyses to determine predictors of communication preference; potential predictors included demographic characteristics, financial burden, delay in seeking care because of cost, and socioeconomic variables Survey responses were weighted to adjust for nonresponse and sampling Results Of 7200 invitations sent, 2200 survey responses were returned Ninety-two percent wished to know their out-of-pocket costs before beginning treatment Most respondents preferred their physician talk with them about out-of-pocket costs (814%) and expressed comfort with discussing costs with their physician (756%) Overall, 437% reported any delay in seeking care in the previous 12 months One in 5 respondents (216%) reported family medical debt Delay in seeking care was positively and independently associated with preferring to discuss costs with one's physician; current medical financial burden was not Conclusion Patient preferences for communication about costs with physicians are high, and medical debt and delay in care-seeking are prevalent Delay in care-seeking independently predicts cost communication preferences
31 citations
TL;DR: Appreciating the variability in information preferences across topics and patients may aid efforts to meet patients' information needs and improve outcomes.
Abstract: Objective: Patient-centered decision making requires cancer patients be actively involved and feel sufficiently informed about their care, but patients' preferences for information are often unrecognized or unmet by their oncologist, particularly for more distressing topics. This study examined cancer patients' preferences for information about three care-related topics: (1) diagnostic information, (2) treatment costs, and (3) prognosis. We tested whether factors known to influence information preferences (psychological distress, control preferences, and financial distress) were differently associated with information preferences for each topic. Methods: Cancer patients (N = 176) receiving ongoing treatment completed a questionnaire that assessed their out-of-pocket treatment costs, psychological distress, preferences for control over their medical decisions, and the amount of information they desired and received from their oncologists about the three topics. Results: Patients' preferences were l...
27 citations
TL;DR: Developing a decision support intervention based on the findings can improve levels of SDM and provide clinicians and consumers with a tool to address the existing misalignment in information priorities.
Abstract: Objective To identify information priorities for consumers and clinicians making depression treatment decisions and assess shared decision-making (SDM) in routine depression care. Design 20 questions related to common features of depression treatments were provided. Participants were initially asked to select which features were important, and in a second stage they were asked to rank their top 5 ‘important features’ in order of importance. Clinicians were asked to provide rankings according to both consumer and clinician perspectives. Consumers completed CollaboRATE, a measure of SDM. Multiple logistic regression analysis identified consumer characteristics associated with CollaboRATE scores. Setting Online cross-sectional surveys fielded in September to December 2014. Participants We administered surveys to convenience samples of US adults with depression and clinicians who treat depression. Consumer sampling was targeted to reflect age, gender and educational attainment of adults with depression in the USA. Primary outcome measures Information priority rankings; CollaboRATE, a 3-item consumer-reported measure of SDM. Results 972 consumers and 244 clinicians completed the surveys. The highest ranked question for both consumers and clinicians was ‘Will the treatment work?’ Clinicians were aware of consumers’ priorities, yet did not always prioritise that information themselves, particularly insurance coverage and cost of treatment. Only 18% of consumers reported high levels of SDM. Working with a psychiatrist (OR 1.87; 95% CI 1.07 to 3.26) and female gender (OR 2.04; 95% CI 1.25 to 3.34) were associated with top CollaboRATE scores. Conclusions While clinicians know what information is important to consumers making depression treatment decisions, they do not always address these concerns. This mismatch, coupled with low SDM, adversely affects the quality of depression care. Development of a decision support intervention based on our findings can improve levels of SDM and provide clinicians and consumers with a tool to address the existing misalignment in information priorities.
25 citations
TL;DR: The results show underestimation by oncologists regarding the subjective financial burden on a patient, and poor patient-physician concordance in cost communication.
Abstract: We assessed cost communication between cancer patients, caregivers, and oncologists and identified factors associated with communication concordance. A national, multicenter, cross-sectional survey of patient-caregiver-oncologist triads was performed, and 725 patient-caregiver pairs, recruited by 134 oncologists in 13 cancer centers, were studied. Discordance in preferences and experiences regarding cost communication between patients, caregivers, and oncologists were assessed. Hierarchical generalized linear models were used to identify predictors of concordance and to identity the possible association of concordance with patient satisfaction and degree of trust in the physician. Although the oncologists thought that patients would be affected by the cost of care, only half of them were aware of the subjective burden experienced by their patients, and the degree of concordance for this parameter was very low (weighted kappa coefficient = 0.06). Caregivers consistently showed similar preferences to those of the patients. After controlling for covariates, the education level of patients [adjusted odds ratio (aOR) for > 12 vs. < 9 years, 2.92; 95% confidence interval (CI), 1.87–4.56], actual out-of-pocket costs [aOR for ≥ 8 million vs. < 2 million Korean Won, 0.56; 95% CI, 0.34–0.89], and physician age (aOR for ≥ 55 vs. < 45 years, 1.83; 95% CI, 1.04–3.21) were significant. The results show underestimation by oncologists regarding the subjective financial burden on a patient, and poor patient-physician concordance in cost communication. Oncologists should be more cognizant of patient OOP costs that are not indexed by objective criteria, but instead involve individual patient perceptions.
18 citations
Cites background or result from "The neglected topic: presentation o..."
...Consistent with previous studies [1, 14, 17, 27, 32], the main reason cited by patients for not discussing OOP costs was difficulty in speaking openly about their concerns, or suspicion that the clinician would disapprove of their decision....
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...Costs may st i l l be a compara t ive ly underemphasized aspect of the formal shared decisionmaking process, even though they are an important component of patient decisions [14]....
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...However, among patients who reported one or more instances of cost-related underuse of their prescription medications, one third had never provided this information to their physician [14]....
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TL;DR: The DA was acceptable to women, including the format, content and proposed implementation strategies, and practical and financial issues are important to women in considering treatment options.
17 citations
References
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Book•
01 Jan 1974TL;DR: The authors described three heuristics that are employed in making judgements under uncertainty: representativeness, availability of instances or scenarios, and adjustment from an anchor, which is usually employed in numerical prediction when a relevant value is available.
Abstract: This article described three heuristics that are employed in making judgements under uncertainty: (i) representativeness, which is usually employed when people are asked to judge the probability that an object or event A belongs to class or process B; (ii) availability of instances or scenarios, which is often employed when people are asked to assess the frequency of a class or the plausibility of a particular development; and (iii) adjustment from an anchor, which is usually employed in numerical prediction when a relevant value is available. These heuristics are highly economical and usually effective, but they lead to systematic and predictable errors. A better understanding of these heuristics and of the biases to which they lead could improve judgements and decisions in situations of uncertainty.
31,082 citations
Book•
08 Apr 2008TL;DR: In Nudge as discussed by the authors, Thaler and Sunstein argue that human beings are susceptible to various biases that can lead us to blunder and make bad decisions involving education, personal finance, health care, mortgages and credit cards, the family, and even the planet itself.
Abstract: A groundbreaking discussion of how we can apply the new science of choice architecture to nudge people toward decisions that will improve their lives by making them healthier, wealthier, and more free Every day, we make decisions on topics ranging from personal investments to schools for our children to the meals we eat to the causes we champion. Unfortunately, we often choose poorly. Nobel laureate Richard Thaler and legal scholar and bestselling author Cass Sunstein explain in this important exploration of choice architecture that, being human, we all are susceptible to various biases that can lead us to blunder. Our mistakes make us poorer and less healthy; we often make bad decisions involving education, personal finance, health care, mortgages and credit cards, the family, and even the planet itself. In Nudge, Thaler and Sunstein invite us to enter an alternative world, one that takes our humanness as a given. They show that by knowing how people think, we can design choice environments that make it easier for people to choose what is best for themselves, their families, and their society. Using colorful examples from the most important aspects of life, Thaler and Sunstein demonstrate how thoughtful "choice architecture" can be established to nudge us in beneficial directions without restricting freedom of choice. Nudge offers a unique new take-from neither the left nor the right-on many hot-button issues, for individuals and governments alike. This is one of the most engaging and provocative books to come along in many years.
7,772 citations
TL;DR: Three heuristics that are employed in making judgements under uncertainty are described: representativeness, availability of instances or scenarios, which is often employed when people are asked to assess the frequency of a class or the plausibility of a particular development.
5,935 citations
"The neglected topic: presentation o..." refers methods in this paper
...We were guided by behavioral economics influence theory in our distinguishing ‘‘positive frame (pro)’’ and ‘‘negative frame (con)’’ categories of how cost was mentioned.(12) These categories were not mutually exclusive; a decision aid could mention cost in more than one way....
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TL;DR: Decision aids reduced the proportion of undecided participants and appeared to have a positive effect on patient-clinician communication, and those exposed to a decision aid were either equally or more satisfied with their decision, the decision-making process, and the preparation for decision making compared to usual care.
Abstract: Background
Decision aids are intended to help people participate in decisions that involve weighing the benefits and harms of treatment options often with scientific uncertainty.
Objectives
To assess the effects of decision aids for people facing treatment or screening decisions.
Search methods
For this update, we searched from 2009 to June 2012 in MEDLINE; CENTRAL; EMBASE; PsycINFO; and grey literature. Cumulatively, we have searched each database since its start date including CINAHL (to September 2008).
Selection criteria
We included published randomized controlled trials of decision aids, which are interventions designed to support patients' decision making by making explicit the decision, providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies of participants making hypothetical decisions.
Data collection and analysis
Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were:
A) 'choice made' attributes;
B) 'decision-making process' attributes.
Secondary outcomes were behavioral, health, and health-system effects. We pooled results using mean differences (MD) and relative risks (RR), applying a random-effects model.
Main results
This update includes 33 new studies for a total of 115 studies involving 34,444 participants. For risk of bias, selective outcome reporting and blinding of participants and personnel were mostly rated as unclear due to inadequate reporting. Based on 7 items, 8 of 115 studies had high risk of bias for 1 or 2 items each.
Of 115 included studies, 88 (76.5%) used at least one of the IPDAS effectiveness criteria: A) 'choice made' attributes criteria: knowledge scores (76 studies); accurate risk perceptions (25 studies); and informed value-based choice (20 studies); and B) 'decision-making process' attributes criteria: feeling informed (34 studies) and feeling clear about values (29 studies).
A) Criteria involving 'choice made' attributes:
Compared to usual care, decision aids increased knowledge (MD 13.34 out of 100; 95% confidence interval (CI) 11.17 to 15.51; n = 42). When more detailed decision aids were compared to simple decision aids, the relative improvement in knowledge was significant (MD 5.52 out of 100; 95% CI 3.90 to 7.15; n = 19). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.82; 95% CI 1.52 to 2.16; n = 19). Exposure to a decision aid with explicit values clarification resulted in a higher proportion of patients choosing an option congruent with their values (RR 1.51; 95% CI 1.17 to 1.96; n = 13).
B) Criteria involving 'decision-making process' attributes:
Decision aids compared to usual care interventions resulted in:
a) lower decisional conflict related to feeling uninformed (MD -7.26 of 100; 95% CI -9.73 to -4.78; n = 22) and feeling unclear about personal values (MD -6.09; 95% CI -8.50 to -3.67; n = 18);
b) reduced proportions of people who were passive in decision making (RR 0.66; 95% CI 0.53 to 0.81; n = 14); and
c) reduced proportions of people who remained undecided post-intervention (RR 0.59; 95% CI 0.47 to 0.72; n = 18).
Decision aids appeared to have a positive effect on patient-practitioner communication in all nine studies that measured this outcome. For satisfaction with the decision (n = 20), decision-making process (n = 17), and/or preparation for decision making (n = 3), those exposed to a decision aid were either more satisfied, or there was no difference between the decision aid versus comparison interventions. No studies evaluated decision-making process attributes for helping patients to recognize that a decision needs to be made, or understanding that values affect the choice.
C) Secondary outcomes
Exposure to decision aids compared to usual care reduced the number of people of choosing major elective invasive surgery in favour of more conservative options (RR 0.79; 95% CI 0.68 to 0.93; n = 15). Exposure to decision aids compared to usual care reduced the number of people choosing to have prostate-specific antigen screening (RR 0.87; 95% CI 0.77 to 0.98; n = 9). When detailed compared to simple decision aids were used, fewer people chose menopausal hormone therapy (RR 0.73; 95% CI 0.55 to 0.98; n = 3). For other decisions, the effect on choices was variable.
The effect of decision aids on length of consultation varied from 8 minutes shorter to 23 minutes longer (median 2.55 minutes longer) with 2 studies indicating statistically-significantly longer, 1 study shorter, and 6 studies reporting no difference in consultation length. Groups of patients receiving decision aids do not appear to differ from comparison groups in terms of anxiety (n = 30), general health outcomes (n = 11), and condition-specific health outcomes (n = 11). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive.
Authors' conclusions
There is high-quality evidence that decision aids compared to usual care improve people's knowledge regarding options, and reduce their decisional conflict related to feeling uninformed and unclear about their personal values. There is moderate-quality evidence that decision aids compared to usual care stimulate people to take a more active role in decision making, and improve accurate risk perceptions when probabilities are included in decision aids, compared to not being included. There is low-quality evidence that decision aids improve congruence between the chosen option and the patient's values.
New for this updated review is further evidence indicating more informed, values-based choices, and improved patient-practitioner communication. There is a variable effect of decision aids on length of consultation. Consistent with findings from the previous review, decision aids have a variable effect on choices. They reduce the number of people choosing discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, cost-effectiveness, use with lower literacy populations, and level of detail needed in decision aids need further evaluation. Little is known about the degree of detail that decision aids need in order to have a positive effect on attributes of the choice made, or the decision-making process.
5,042 citations
"The neglected topic: presentation o..." refers background in this paper
...Patient decision aids assist patients in making health care decisions where an optimal course is uncertain and patients’ individual preferences are central to decision making.(1,2) They take a variety of forms (e....
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...A recent Cochrane Systematic Review concluded that decision aids increase knowledge, decrease decisional conflict, increase accurate risk perceptions, and increase match between values and choice.(1,2) Costs are an important component of patients’ decision making but a comparatively underemphasized aspect of formal shared decision making....
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