Patient Decision Support Tools
Patients must make decisions each time they encounter the health care system. For example, an outpatient visit for low-back pain may involve decisions about whether to perform an imaging study, refer to a specialist physician or physical therapy, or use spinal injections or pain medications. Within each of these decisions are additional challenges, such as balancing side effects, mitigating risks, and meeting patients’ needs. Patients and clinicians confronted with these types of decisions in the course of a 20-minute clinic visit often feel overwhelmed. Most decisions in health care, from choices about health maintenance and screening to advanced treatments and end-of-life care, are made in a complex milieu of clinical evidence, professional expertise, and an individual patient’s values and preferences.
Understanding and supporting patients’ values and preferences for health care options is an important part of patient care. Patient decision support tools have been created to help patients and clinicians address these decisions at the point of care. Evidence has shown that use of these tools results in improved patient knowledge, greater likelihood of decisions congruent with patient values, and overall increased patient satisfaction. Increasingly, public and private health care quality standards include the use of patient decision support tools for certain conditions and treatments.
This toolkit was created to provide insights and offer resources for patients, clinicians, insurers, and health policymakers interested in encouraging the adoption and use of patient decision support tools.
Like patients and practitioners, insurers also have an interest in promoting health care decisions are well-informed and based on the best available evidence combined with the values and preferences of those whom they cover. Thus, some public and private payers have expressed an interest in promoting the use of decision support tools through their coverage and benefit design.
Defining Patient Decision Support Tools
When the various interventions may entail different burdens or balances of benefits and harms, individual values and preferences are central to decision making. For example, an individual over age 50 with an average risk of colon cancer must decide whether to have screening for colon cancer, which screening test to choose from, and whether to take daily aspirin to reduce the risk of colon cancer. The individual’s values and preferences related to care, quality of life, and acceptable risks will be critical in the decision about the course of care.
Not all medical conditions or health care situations are as sensitive to preference. The decision to administer aspirin to a patient having a heart attack is not generally regarded as preference sensitive because of the acuity and seriousness of the illness, the need to avoid delay in treatment, and the low variability of patient preferences in this situation. Thus, conditions and their treatments exist along a spectrum of preference sensitivity. Conceptually, some the features that determine the degree of preference sensitivity include the acuity and severity of an illness, patient and clinician knowledge about the condition, the certainty of evidence for competing choices, and the level of trust in the professional relationship (Thompson, 2006). Thus, the distinction between preference sensitive and non-preference sensitive decisions is likely to be fluid.
Decision aids have been developed for hundreds of conditions and treatments. Decision aids can be presented in a variety of formats and have been designed for independent use by patients or in collaboration with the health care team, including those trained as decision coaches. Different types of decision aids and models for their use are discussed later in this toolkit.
The use of validated, high-quality patient decision aids is a central feature of shared decision making. The Informed Medical Decisions Foundation (2016) defines shared decision making as “a collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences.”
Novel models of care have elaborated on the use of shared decision making. One such approach, minimally disruptive medicine, has been extolled by researchers at the Mayo Clinic Shared Decision Making National Research Center. Minimally disruptive medicine “seeks to advance patient goals for health, health care, and life, using effective care programs designed and implemented in a manner that respects the capacity of patients and caregivers and minimizes the burden of treatment – the healthcare footprint – the care program imposes on their lives.” (Minimally Disruptive Medicine).