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Clinical Decisionmaking

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Less than 10 percent of medical decisions are made with participation of a fully informed patient

Physicians are being encouraged to involve their patients in decisions about medical tests and procedures. However, many of them have not embraced the concept in day-to-day office practice, according to a study supported in part by the Agency for Healthcare Research and Quality (HS07289). It found that less than 10 percent of medical decisions were actually made with the participation of a fully informed patient (i.e., doctors provided patients with the pros and cons of the test, procedure, or medication regimen; informed them of their options and any side effects; and helped them reach an individualized decision about the right course to take).

Lead author, Clarence H. Braddock III, M.D., M.P.H., of the University of Washington, and his colleagues analyzed audiotapes of 1,057 encounters between patients and 59 primary care physicians (PCPs) and 65 surgeons in two States. Criteria for patient involvement in basic decisions included discussion of the nature of the decision and asking the patient to voice a preference. More complex decisions had more stringent criteria for patient involvement. Results showed that basic decisions (for example, about laboratory tests) were most often completely informed (17.2 percent). No intermediate decisions (for example, changing the dose of a medication or changing to a new medication) and only 0.5 percent of complex decisions (such as prostate cancer screening) were completely informed.

Among the elements of informed decisionmaking, discussion of the nature of the intervention occurred most frequently (71 percent of cases), but alternatives (5.5 to 29.5 percent) and uncertainties (1.1 to 16.6 percent) associated with the decision were seldom discussed. Assessment of patient understanding was done least frequently (1.5 percent). Length of visit and relationship with the doctor were not significantly associated with the degree of informed decisionmaking. These findings raise quality-of-care concerns, since there is mounting evidence that inadequate patient involvement may interfere with patient acceptance of treatment and adherence to medical regimens, notes principal investigator Wendy Levinson, M.D., of the University of Chicago.

See "Informed decision making in outpatient practice: Time to get back to basics," by Dr. Braddock, Kelly A. Edwards, M.A., Nicole M. Hasenberg, M.P.H., and others, in the December 22, 1999, Journal of the American Medical Association 282(24), pp. 2313-2320.

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