Shared decision-making (SDM) is considered essential to involving patients in decisions about their care, and understanding individual patients’ needs and priorities. Previous studies have indicated that SDM can improve quality of care and patient experience by increasing patient satisfaction and knowledge, reducing decisional conflict, and improving medication adherence and other care outcomes. SDM can also advance two of the three goals of the U.S. National Quality Strategy Triple Aim by promoting better care and healthy people/healthy communities. The results from research conducted by the National Pharmaceutical Council (NPC) and Discern Health, part of Real Chemistry, however, found that SDM and patient decision aid (PtDA) interventions do not always lead to the third goal of reduced health care costs or utilization.
A May 12 session at the Pharmacy Quality Alliance (PQA) 2021 Annual Meeting highlighted the recent systematic review conducted by NPC and Discern that evaluated whether SDM and PtDAs lower health care cost, decrease utilization, and increase prevention-related care in the United States. NPC Vice President of Health Services Research Kimberly Westrich and Discern Vice President Theresa Schmidt presented the findings and reflected on the use of SDM and PtDAs in value-based care.
For the systematic review, Discern and NPC analyzed articles related to SDM and PtDAs that were published on PubMed between January 1, 2010 and September 30, 2019 and that reported cost, utilization and prevention-related care outcomes.
The following were key take-aways from the session:
- A majority of articles examined in the systematic review showed favorable changes in cost, utilization, and prevention-related care from SDM or PtDAs. However, many articles had mixed findings, indicating that these interventions may not always lead to health care savings.
The terms “favorable” and “unfavorable” were used to describe outcomes in the context of value-based care: decreases in cost or high-cost utilization are favorable, while increases in prevention-related care are favorable and may lead to longer-term savings. Thirty-one of the 51 included articles reported at least one outcome that was identified as being “favorable” and only five articles reported an “unfavorable” outcome.
While a majority of articles presented favorable results, a greater majority (39 of 51) assessed at least one relevant outcome where no significant difference (p≥ 0.05) was observed. Some articles reported both favorable outcomes and outcomes with no significant differences.
The presenters noted that the variation in findings may be related to the intended goals or methodology of the reviewed articles, including intervention design, setting and patient population.
- SDM and PtDA interventions can increase medication adherence by promoting patient engagement and care concordant with patient preferences.
One of the favorable SDM and PtDA intervention outcomes highlighted in the presentation was increased medication adherence. Nine of the 12 articles that measured adherence had an outcome with favorable increases, while 8 of the 12 articles had an outcome with no significant difference.
“SDM can lead to a greater patient-provider bond,” explained Schmidt, “Informed patients who help choose their treatment will have a better understanding of what to expect and be less surprised by side-effects and more committed to finishing a regimen even after they begin to show improvement.” The increase in medication adherence also has been shown to lead to better treatment outcomes, fewer adverse events, and longer-term savings.
- Value-based care incentives for SDM may produce long-term benefits vs. short-term savings.
The mixed results from the systematic review indicate that implementing SDM and PtDAs will not always lead to reducing costs, in the short term. Thus, tying incentives to shared decision-making by including quality measures in value-based payment programs may not help those programs save money, especially within narrow payment windows.
However, the interventions can still add value to care and generate long-term savings by promoting the first two goals of the Triple Aim: better care and healthy people/healthy communities. Westrich emphasized this in her remarks, noting that “the stated goal of SDM or PtDA interventions is often to help patients share in deciding what they believe is right for their care, whether or not these decisions create savings.”