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      Undetermined impact of patient decision support interventions on healthcare costs and savings: systematic review

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          Abstract

          Objective To perform a systematic review of studies that assessed the potential of patient decision support interventions (decision aids) to generate savings.

          Design Systematic review.

          Data sources After registration with PROSPERO, we searched 12 databases, from inception to 15 March 2013, using relevant MeSH terms and text words. Included studies were assessed with Cochrane’s risk of bias method and Drummond’s quality checklist for economic studies. Per patient costs and projected savings associated with introducing patient decision support interventions were calculated, as well as absolute changes in treatment rates after implementation.

          Eligibility criteria Studies were included if they contained quantitative economic data, including savings, spending, costs, cost effectiveness analysis, cost benefit analysis, or resource utilization. We excluded studies that lacked quantitative data on savings, costs, monetary value, and/or resource utilization.

          Results After reviewing 1508 citations, we included seven studies with eight analyses. Of these seven studies, four analyses predicted system-wide savings, with two analyses from the same study. The predicted savings range from $8 (£5, €6) to $3068 (£1868, €2243) per patient. Larger savings accompanied reductions in treatment utilization rates. The impact on utilization rates was mixed. Authors used heterogeneous methods to allocate costs and calculate savings. Quality scores were low to moderate (median 4.5, range 0-8 out of 10), and risk of bias across the studies was moderate to high (3.5, range 3-6 out of 6), with studies predicting the most savings having the highest risk of bias. The range of issues identified in the studies included the relative absence of sensitivity analyses, the absence of incremental cost effectiveness ratios, and short time periods.

          Conclusion Although there is evidence to show that patients choose more conservative approaches when they become better informed, there is insufficient evidence, as yet, to be confident that the implementation of patient decision support interventions leads to system-wide savings. Further work—with sensitivity analyses, longer time horizons, and more contexts—is required to avoid premature or unrealistic expectations that could jeopardize implementation and lead to the loss of already proved benefits.

          Registration PROSPERO registration CRD42012003421.

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          Most cited references12

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          Decision aids for people facing health treatment or screening decisions.

          Decision aids prepare people to participate in decisions that involve weighing benefits, harms, and scientific uncertainty. To evaluate the effectiveness of decision aids for people facing treatment or screening decisions. For this update, we searched from January 2006 to December 2009 in MEDLINE (Ovid); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, issue 4 2009); CINAHL (Ovid) (to September 2008 only); EMBASE (Ovid); PsycINFO (Ovid); and grey literature. Cumulatively, we have searched each database since its start date. We included published randomised controlled trials (RCTs) of decision aids, which are interventions designed to support patients' decision making by providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies in which participants were not making an active treatment or screening decision. Two review authors independently screened abstracts for inclusion, extracted data, and assessed potential risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards, were:A) decision attributes;B) decision making process attributes.Secondary outcomes were behavioral, health, and health system effects. We pooled results of RCTs using mean differences (MD) and relative risks (RR), applying a random effects model. Of 34,316 unique citations, 86 studies involving 20,209 participants met the eligibility criteria and were included. Thirty-one of these studies are new in this update. Twenty-nine trials are ongoing. There was variability in potential risk of bias across studies. The two criteria that were most problematic were lack of blinding and the potential for selective outcome reporting, given that most of the earlier trials were not registered.Of 86 included studies, 63 (73%) used at least one measure that mapped onto an IPDAS effectiveness criterion: A) criteria involving decision attributes: knowledge scores (51 studies); accurate risk perceptions (16 studies); and informed value-based choice (12 studies); and B) criteria involving decision process attributes: feeling informed (30 studies) and feeling clear about values (18 studies).A) Criteria involving decision attributes:Decision aids performed better than usual care interventions by increasing knowledge (MD 13.77 out of 100; 95% confidence interval (CI) 11.40 to 16.15; n = 26). When more detailed decision aids were compared to simpler decision aids, the relative improvement in knowledge was significant (MD 4.97 out of 100; 95% CI 3.22 to 6.72; n = 15). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.74; 95% CI 1.46 to 2.08; n = 14). The effect was stronger when probabilities were expressed in numbers (RR 1.93; 95% CI 1.58 to 2.37; n = 11) rather than words (RR 1.27; 95% CI 1.09 to 1.48; n = 3). Exposure to a decision aid with explicit values clarification compared to those without explicit values clarification resulted in a higher proportion of patients achieving decisions that were informed and consistent with their values (RR 1.25; 95% CI 1.03 to 1.52; n = 8).B) Criteria involving decision process attributes:Decision aids compared to usual care interventions resulted in: a) lower decisional conflict related to feeling uninformed (MD -6.43 of 100; 95% CI -9.16 to -3.70; n = 17); b) lower decisional conflict related to feeling unclear about personal values (MD -4.81; 95% CI -7.23 to -2.40; n = 14); c) reduced the proportions of people who were passive in decision making (RR 0.61; 95% CI 0.49 to 0.77; n = 11); and d) reduced proportions of people who remained undecided post-intervention (RR 0.57; 95% CI 0.44 to 0.74; n = 9). Decision aids appear to have a positive effect on patient-practitioner communication in the four studies that measured this outcome. For satisfaction with the decision (n = 12) and/or the decision making process (n = 12), those exposed to a decision aid were either more satisfied or there was no difference between the decision aid versus comparison interventions. There were no studies evaluating the decision process attributes relating to helping patients to recognize that a decision needs to be made or understand that values affect the choice.C) Secondary outcomesExposure to decision aids compared to usual care continued to demonstrate reduced choice of: major elective invasive surgery in favour of conservative options (RR 0.80; 95% CI 0.64 to 1.00; n = 11). Exposure to decision aids compared to usual care also resulted in reduced choice of PSA screening (RR 0.85; 95% CI 0.74 to 0.98; n = 7). When detailed compared to simple decision aids were used, there was reduced choice of menopausal hormones (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 to +23 minutes (median 2.5 minutes). Decision aids do not appear to be different from comparisons in terms of anxiety (n = 20), and general health outcomes (n = 7), and condition specific health outcomes (n = 9). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive. New for this updated review is evidence that: decision aids with explicit values clarification exercises improve informed values-based choices; decision aids appear to have a positive effect on patient-practitioner communication; and decision aids have a variable effect on length of consultation.Consistent with findings from the previous review, which had included studies up to 2006: decision aids increase people's involvement, and improve knowledge and realistic perception of outcomes; however, the size of the effect varies across studies. Decision aids have a variable effect on choices. They reduce the choice of discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, patient-practitioner communication, cost-effectiveness, and use with developing and/or lower literacy populations need further evaluation. Little is known about the degree of detail that decision aids need in order to have positive effects on attributes of the decision or decision-making process.
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            Importance of the lay press in the transmission of medical knowledge to the scientific community.

            Efficient, undistorted communication of the results of medical research is important to physicians, the scientific community, and the public. Information that first appears in the scientific literature is frequently retransmitted in the popular press. Does popular coverage of medical research in turn amplify the effects of that research on the scientific community? To test the hypothesis that researchers are more likely to cite papers that have been publicized in the popular press, we compared the number of references in the Science Citation Index to articles in the New England Journal of Medicine that were covered by The New York Times with the number of references to similar articles that were not covered by the Times. We also performed the comparison during a three-month period when the Times was on strike but continued to prepare an "edition of record" that was not distributed; doing so enabled us to address the possibility that coverage in the Times was simply a marker of the most important articles, which would therefore be cited more frequently, even without coverage in the popular press. Articles in the Journal that were covered by the Times received a disproportionate number of scientific citations in each of the 10 years after the Journal articles appeared. The effect was strongest in the first year after publication, when Journal articles publicized by the Times received 72.8 percent more scientific citations than control articles. This effect was not present for articles published during the strike; articles covered by the Times during this period were no more likely to be cited than those not covered. Coverage of medical research in the popular press amplifies the transmission of medical information from the scientific literature to the research community.
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              A randomized trial of a telephone care-management strategy.

              Studies have shown that telephone interventions designed to promote patients' self-management skills and improve patient-physician communication can increase patients' satisfaction and their use of preventive services. The effect of such a strategy on health care costs remains controversial. We conducted a stratified, randomized study of 174,120 subjects to assess the effect of a telephone-based care-management strategy on medical costs and resource utilization. Health coaches contacted subjects with selected medical conditions and predicted high health care costs to instruct them about shared decision making, self-care, and behavioral change. The subjects were randomly assigned to either a usual-support group or an enhanced-support group. Although the same telephone intervention was delivered to the two groups, a greater number of subjects in the enhanced-support group were made eligible for coaching through the lowering of cutoff points for predicted future costs and expansion of the number of qualifying health conditions. Primary outcome measures at 1 year were total medical costs and number of hospital admissions. At baseline, medical costs and resource utilization were similar in the two groups. After 12 months, 10.4% of the enhanced-support group and 3.7% of the usual-support group received the telephone intervention. The average monthly medical and pharmacy costs per person in the enhanced-support group were 3.6% ($7.96) lower than those in the usual-support group ($213.82 vs. $221.78, P=0.05); a 10.1% reduction in annual hospital admissions (P<0.001) accounted for the majority of savings. The cost of this intervention program was less than $2.00 per person per month. A targeted telephone care-management program was successful in reducing medical costs and hospitalizations in this population-based study. (Funded by Health Dialog Services; ClinicalTrials.gov number, NCT00793260.)
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                Author and article information

                Contributors
                Role: postdoctoral fellow
                Role: postdoctoral fellow
                Role: postdoctoral fellow
                Role: associate professor
                Role: professor
                Role: professor
                Journal
                BMJ
                BMJ
                bmj
                BMJ : British Medical Journal
                BMJ Publishing Group Ltd.
                0959-8138
                1756-1833
                2014
                2014
                23 January 2014
                : 348
                : g188
                Affiliations
                [1 ]Dartmouth Center for Health Care Delivery Science, Dartmouth College, 37 Dewey Field Road, Hanover, NH 03755, USA
                [2 ]Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, 35 Centerra Parkway, Lebanon, NH 03766, USA
                [3 ]School of Business and Economics, National University of Ireland, Galway, Ireland
                Author notes
                Correspondence to: G Elwyn glynelwyn@ 123456gmail.com
                Article
                walt015332
                10.1136/bmj.g188
                3900320
                24458654
                b0e48602-9def-47d0-8f0d-d703b42ec6a6
                © Walsh et al 2014

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/.

                History
                : 08 January 2014
                Categories
                Research
                1779

                Medicine
                Medicine

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