Monday, April 21
Grant Miller: Managerial Incentives in Public Service Delivery
Zikmund-Fisher, Brian J., Mick P. Couper, Eleanor Singer, Peter A. Ubel, Sonja Ziniel, Floyd J. Fowler, and Angela Fagerlin. 2010. "Deficits and Variations in Patients' Experience with Making 9 Common Medical Decisions: The DECISIONS Survey." Medical Decision Making, 30(Suppl. 5): 85S-95S.
Background. Although many researchers have examined patient involvement and patient-provider interactions within specific clinical environments, no nationally representative data exist to characterize patient perceptions of decision making and patient-provider communications across multiple common medical decisions. Objective. To identify deficits and variations in the patient experience of making common medical decisions about initiation of prescription medications for hypertension, hypercholesterolemia, or depression; screening tests for colorectal, breast, or prostate cancer; and surgeries for knee or hip replacement, cataracts, or lower back pain, as well as to identify factors associated with patient confidence in the decisions. Setting. National sample of US adults identified by random-digit dialing. Design. Cross-sectional survey conducted from November 2006 to May 2007. Participants. Included 2473 English-speaking adults age 40 and older who reported undertaking 1 or more of the above 9 medical actions or discussing doing so with a health care provider within the past 2 years. Measurements. Patients reported who initiated discussions and made the final decisions, how much discussion of pros and cons occurred, whether they were asked about their preferences, and their confidence that the decision "was the right one." Results. The proportion of patient-driven decisions varied significantly across decisions (range: blood pressure: 16% to knee/hip replacement: 48%). Most patients (78%-85%) reported that providers made a recommendation, and such recommendations generally favored taking medical action. Fewer patients reported that providers asked them about their preferences (range: colon cancer screening: 34% to knee/hip replacement: 80%) or discussed reasons not to take action (range: breast cancer screening: 20% to lower back surgery: 80%). Decision confidence was higher among patients who reported primarily making the decision themselves (odds ratio [OR] = 14.6, P < 0.001) or having been asked for their preference (OR = 1.32, P < 0.01) and was lower among patients whose patient-provider discussions included cons (OR = 0.74, P = 0.008). Limitations. Recall biases may affect patients' memories of their decision-making processes. Conclusions. DECISIONS participants reported wide variations in the proportion of discussions that included a conversation about reasons not to take action or a conversation about patients' preferences about what they would like to do. These factors appear directly related to patients' confidence that the decision was "right."
Country of focus: United States.