Clinical decision-making: Patients’ preferences and experiences

Abstract

Objective

To determine the congruence between patients’ preferred style of clinical decision-making and the style they usually experienced and whether this congruence was associated with socio-economic status and/or the perceived quality of care provided by the respondent's regular doctor.

Methods

Cross-sectional survey of the American public using computer-assisted telephone interviewing.

Results

Three thousand two hundred and nine interviews were completed (completion rate 72%). Sixty-two percent of respondents preferred shared decision-making, 28% preferred consumerism and 9% preferred paternalism. Seventy percent experienced their preferred style of clinical decision-making. Experiencing the preferred style was associated with high income (OR, 1.59; 95% CI, 1.16–2.16) and having a regular doctor who was perceived as providing excellent or very good care (OR, 2.39; 95% CI, 1.83–3.11).

Conclusion

Both socio-economic status and having a regular doctor whom the respondent rated highly are independently associated with patients experiencing their preferred style of clinical decision-making.

Practice implications

Systems which promote continuity of care and the development of an on-going doctor–patient relationship may promote equity in health care, by helping patients experience their preferred style of clinical decision-making.

Introduction

Three styles of decision-making in clinical care have been described: paternalist, shared and consumerist. This typology highlights the importance of information exchange and deliberation about the treatment decision [1], [2], [3] (Box 1). In a paternalist model, doctors make health care decisions based on what they believe to be the best interests of the patient. At the other end of the scale is the consumerist model, where the patient makes the decisions about their own health care. In the middle is shared decision-making, where the physician and the patient deliberate together and discuss how the various treatment options meet the patient's priorities and health utilities. Consumerism can be distinguished from shared decision-making by the lack of joint deliberation and joint affirmation of the treatment decision made.

Shared decision-making has been advocated because it respects patients as persons [4], [5], because it may have a positive impact on health outcomes [6], [7], and because clinical decisions should be consistent with patient values [4]. Research on shared decision-making has focused on definitions and components of shared decision-making [8], [9], [10]; methods of promoting shared decision-making, for example, with decision aids [11], [12], [13] or training programmes [14]; or defining physician competencies needed for this model [15], [16], [17]. There have been a number of surveys of patient preferences for participation in decision-making, but, with the exception of a recent large survey by Levinson et al. [18], these tend to have been limited by restricted populations, e.g. to patients with a diagnosis of cancer [19], [20], [21], [22], [23], [24]. Other studies are limited by small samples or hypothetical scenarios [25], [26], [27].

There are fewer data on patient experiences of clinical decision-making [28], [29], and there has been little attempt to look at the relationship between socio-economic status and patient experiences of clinical decision-making. Yet socio-economic status (SES) is known to be associated with disparities in the process and outcomes of medical care [30], [31]. Hence, it is possible that low SES is also associated with disparities in clinical decision-making. Most authors argue that clinicians should try to explore patient preferences for decision-making, and attempt to accommodate this preference [17], [25], [26]. Doctors do not always find it easy to determine patient preferences [32], and this knowledge may take multiple consultations to acquire. A survey of 653 women in New South Wales, Australia, found that women with a regular doctor were more likely to experience their preferred decision-making role [29]. Hence, we hypothesised that patients who had a regular doctor, whom they perceived as providing high quality care, may be more likely to achieve their preferred role in clinical decision-making.

Patient access to, and understanding of, adequate health information is a pre-requisite for active participation in decision-making [3], [8], [33], [34], [35]. Yet many people report a lack of information [34], [36]. We were therefore also interested in the degree to which respondents perceived they had access to adequate information.