Tessa Richards: Patients as cost savers?

Tessa RichardsMight patients hold the key to putting the brake on spiralling healthcare costs?  If you had asked me that question a few days ago I’d have said no. We all know about the problem of spiralling demand for healthcare and rising patients’ expectations. But after participating in the Salzburg  Global Seminar,  where the  thesis that” better decision making by patients will result in better and cheaper healthcare” was debated,  my views have shifted.
All participants agreed that health professionals  have an ethical duty to support patients to make informed  “shared”  decisions, and  that they should explore patients’ values and preferences for treatment, although  choice is not a luxury that all countries enjoy,  as Biao Xu, an epidemiologist from Shanghai underlined in her blog.

But in well resourced countries, patients do have options, and evidence presented at the meeting, including the work on choice of treatment for  prostate cancer  suggests that when they are fully and accurately informed about the benefits and harms of interventions, they opt for fewer treatments. Hence  the  potential for cost savings.

Several  participants  dissected the choices and decisions made about their own medical care, and  half way I found myself silently interrogating one of mine.  Five years ago I opted to have postoperative abdominal  radiotherapy, despite the absence  of evidence it would reduce  recurrence of a rare cancer. The consultant was clear about this but suggested that it made empirical sense.  Towards the end of treatment ,  when I had boned up on all the risks of undergoing  high dose radiotherapy I became alarmed about the trade-off and skipped the last sessions. A good example of a bad and expensive decision?

Many factors influence patients’ choice about treatment, foremost among which is the ability and readiness  of doctors to offer it.  But this varies from region to region and unit to unit and needs to be confronted and unpicked (read BMJ article by Jack Wennberg).  “Supplier induced demand” is a reality,  that doctors and patients need to be much more aware of.  One way to counter this is to ensure that decisions on management are fully shared and informed, the  “nothing about me without me ”agenda. Patients need  comprehensive accurate and up to date information about the benefits and harms of treatment (and  high quality decision aids help) and their preferences and values taken into account  (read BMJ article by Albert G Mulley), not least on decisions about end of life care. These messages came over loud and clear from the  authors of these two seminal BMJ papers , Jack Wennberg and Al Mulley, who cofounded the Foundation for Informed Medical Decision Making, which supported the symposium.

Doctors’ enthusiasm to offer treatment to patients is  fuelled by the publication of papers that are optimistic about its value.  Medical journals clearly have a pivotal role here. I shrank in my seat as I listened to a  barrage of criticism about the  way journals propagate misinformation, and fan the daily tsunami  of hype ridden  health stories in the media.  Editors need to get much better at tackling publication bias (towards studies with positive results),  misleading communication of risk (read BMJ article by Gerd Gigerenzer et al), letting authors get away with spin, and reproducing this in press releases.

This was my main take home message, and in the linked blogs below you can read what other  participants took away from Salzburg, where snow doesn’t  disrupt  services and the Sound of Music is everywhere,  and  the vision of realising best practice can be seen.

Tessa Richards is analysis editor, BMJ.