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Promise and perils of patient decision aids for reducing low-value care
  1. Rachel Thompson1,
  2. Danielle M Muscat1,
  3. Jesse Jansen2,
  4. Darlene Cox3,
  5. Joshua R Zadro1,
  6. Adrian C Traeger1,
  7. Kirsten McCaffery1
  1. 1 School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
  2. 2 Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
  3. 3 Health Care Consumers’ Association, Hackett, Australian Capital Territory, Australia
  1. Correspondence to Dr Rachel Thompson, School of Public Health, The University of Sydney, Sydney, NSW 2006, Australia; rachel.thompson{at}sydney.edu.au

https://doi.org/10.1136/bmjqs-2020-012312

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    Recognition of excessive waste and harm in health systems has prompted efforts to reduce low-value care, which has been defined as ‘use of an intervention where evidence suggests it confers no or very little benefit on patients, or risk of harm exceeds likely benefit, or, more broadly, the added costs of the intervention do not provide proportional added benefits’.1 The development and distribution of patient decision aids (and the related practice of shared decision-making) has been advocated as a promising strategy for reducing low-value care. However, this idea has not been scrutinised in the scientific literature nor hypothesised mechanisms of effect fully elucidated. To address this, we offer an analysis of observed and possible effects of patient decision aids that aim to reduce low-value care, conclude that there is not yet compelling evidence that patient decision aids will reduce low-value care and make recommendations that may mitigate potential unintended consequences.

    Patient decision aids and low-value care

    Patient decision aids are ‘evidence-based tools designed to help patients make specific and deliberated choices among healthcare options’.2 3 They can be implemented in a host of different ways and may be designed for self-directed use by patients outside of the healthcare visit or for use by the patient–clinician dyad during the visit.4 According to the International Patient Decision Aid Standards Collaboration, decision aids should provide detailed information on the positive and negative features of options and assist patients to clarify the personal value of each of these features.5 By definition, and unlike many other patient-directed interventions, decision aids were not intended to encourage or discourage a particular option but rather to facilitate a choice based on a patient’s individual values and goals.6 In keeping with this, demonstrating the effectiveness of a decision aid requires showing that it improves both (1) the quality of the …

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    Footnotes

    • Twitter @rachelthomp, @Dmuscat92, @JesseJansen_, @darlenecox, @zadro_josh, @adrian_traeger, @KirstenMcCaffer

    • Contributors This analysis was conceptualised by RT, DMM and KM. RT drafted the manuscript. DMM, JJ, DC, JRZ, ACT and KM reviewed the manuscript and provided suggestions and insights that further developed and refined the argument and recommendations. The final analysis benefited from the authors’ collective expertise in patient decision aids and decision aid research, health communication, healthcare decision-making, low-value care, behaviour change, and the lived patient experience, and from their varied perspectives on the notion of developing and distributing patient decision aids to reduce low-value care. All authors take responsibility for the contents of this analysis and have approved the final version of the manuscript. RT is the guarantor of the study.

    • Funding The following funding sources supported the authors’ time contributing to this analysis: National Health and Medical Research Council (NHMRC) Program Grant 1113532 (RT, JRZ), Western Sydney Local Health District Westmead Fellowship (DMM), NHMRC Career Development Fellowship 1162149 (JJ), Health Care Consumers’ Association (DC), NHMRC Early Career Fellowship 1144026 (ACT) and NHMRC Principal Research Fellowship 1121110 (KM).

    • Competing interests RT and KM are unpaid members of the International Patient Decision Aid Standards (IPDAS) Collaboration Steering Committee, which develops and maintains voluntary standards for patient decision aid development and evaluation. KM is a collaborator on the evaluation of the arthroscopic surgery patient decision aid described in this analysis. JRZ received a research grant from Arthritis Australia to The University of Sydney to develop the subacromial decompression patient decision aid described in this analysis. RT and KM are collaborators on the development of the subacromial decompression patient decision aid described in this analysis. RT, JJ, DC, JRZ, ACT and KM are members of or affiliated with Wiser Healthcare, a research collaboration for reducing overdiagnosis and overtreatment.

    • Patient and public involvement statement The idea for this analysis emerged from an initial discussion among patient representatives, researchers and clinicians at a national meeting of the Wiser Healthcare research collaboration. In preparing the analysis, we sought input from coauthor DC, an eminent health consumer advocate who contributed unique and crucial insights to this work based on her expertise in the lived patient experience.

    • Provenance and peer review Not commissioned; externally peer reviewed.