Executive Summary: Medical Discussion Guides: Less Confusion, Better Decisions for Patients

Hearing the words, “you have cancer,” flood a patient with anxiety and fear. As much as a doctor may want to help a patient, that moment is not the right time for a patient to make a major decision about a course of medical treatment. That is why doctors at the Dartmouth Hitchcock Medical Center give patients with breast cancer and other dreaded diseases a "pre-visit" medical discussion guide (also known as a decision aid) to review before they meet with a surgeon about treatment options. The guide includes a DVD that shows how women with breast cancer have faced the disease and how they determined the best treatment option for them.

The guide, which draws on scientific evidence to avoid any biases, explains the difference between a mastectomy and a lumpectomy, which have similar success rates in beating cancer. It allows women to consider this tough choice at a time of their choosing. When given the opportunity to make an informed decision, women generally chose the more conservative lumpectomy. Afterwards, patient surveys show they also feel the care they received was better compared to those who did not use the discussion guides. If doctors and patients widely used medical discussion guides for common but complicated health problems, patients would be more satisfied with their care. They would also save money—trimming $11.4 billion from Medicare over ten years for four common ailments.

This idea brief is one of a series of Third Way proposals that cuts waste in health care by removing obstacles to quality patient care. This approach directly improves the patient experience—when patients stay healthy, or get better quicker, they need less care. Our proposals come from innovative ideas pioneered by health care professionals and organizations, and show how to scale successful pilots from red and blue states. Together, they make cutting waste a policy agenda instead of a mere slogan.

What is Stopping Patients from Getting Quality Care?

With a major disease or injury, people sometimes feel they do not get a clear explanation of the problem or the options to treat it. In fact, many health problems do not have one obvious course of treatment but, instead, several options with various possible outcomes. Patients facing chronic back pain or deciding on screening for early-stage breast or prostate cancer have options ranging from supportive care with no active treatment to intensive treatment interventions. Patients and doctors need to communicate clearly so patients get the care that is right for them.

Where are Innovations Happening?

Innovative efforts across the United States are helping patients make good health care decisions. One of these innovative efforts is the introduction of medical discussion guides and shared decision-making. Discussion guides are tools that patients can utilize to educate themselves about options for their care and likely outcomes. Patients can navigate through a range of modalities, including online, on paper, using a telephone, or watching a DVD.

• In 2007, the Washington State legislature passed a law expanding legal protection for health professionals using shared decision-making and discussion guides.
• A study of the Group Health results focused on patients with knee and hip arthritis. A year and a half after introducing the discussion guides, Group Health found that rates of hip replacements for patients with knee and hip arthritis fell by over 25% and rates of knee replacements went down 38%.

How Can We Bring Solutions to Scale?

The use of discussion guides should be standard medical practice. This can be accomplished in five ways:

• Create a verification process where health plans report on whether patients were offered discussion guides in their decision-making process.
• Establish federal standards for discussion guides.
• Provide incentives for health professionals to offer discussion guides to patients as a routine step in receiving Medicare payment.
• Engage health professionals in the shared decision-making process and use of discussion guides through continuing medical education and medical school curriculum.
• Reform state informed consent laws to reflect that shared decision-making and the use of discussion guides is the standard for valid informed consent for certain conditions.

Potential Savings

The federal budgetary savings from this proposal is $11.4 billion dollars over ten years.