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Making Choice an Option

information about the risks and benefits of surgery and the postop recovery time. After considering the tradeoffs, only 18%chose surgery. "Some said they had learned to live with the pain. Others said it wasn't bad enough yet," Wennberg says.

Study after study has revealed that surgeons are more enthusiastic about surgery than patients are. In clinical trials, Wennberg says, it's typical for somewhere between 21% and 44% of patients to decide against a discretionary procedure after they have gone through the shared decision-making process.

This should come as no surprise. Good surgeons are proud of their craft and of their ability to help people. It is patients, however, who experience the pain, the risks, and the inconvenience of surgery; understandably, they may be more hesitant about an operation than the doctor proposing it.

Furthermore, in this country's fee-for-service payment system, the economic incentives are aligned to reward doctors who do more procedures and provide more treatments. But patients, studies show, often don't want more. When it comes to chemotherapy, for example, too many oncologists encourage patients to undergo "another round," says Dr. Peter Eisenberg, an oncologist in Marin County, California. "From where I sit, the problem is clearly one of perverse incentives which reward guys like me for giving folks lots of chemo—whether or not it will likely help them and whether or not they really understand the implications of their decision to have it.

"As a board member of the American Society of Clinical Oncologists, I have tried to get our professional organization to be more active in this area," Eisenberg adds. "Unfortunately, they are a trade organization and have not yet been very active. So I'm speaking for 'Pete,' not for the board."

In his own practice, Eisenberg says he does not urge patients to continue chemo

The decision made, Spencer and her son head home.

"Decision support only goes as far as the patient wants to go—without imposing on him or her. We don't have the right to run roughshod over patients," emphasizes decision-making researcher Hilary Llewellyn-Thomas.

unless he is quite sure it will help them. "Most oncologists don't talk about the important stuff," he says. "They just say, 'In six to eight months, if this doesn't work, we'll try Plan B.' . . . I ask my patients: 'How do you want to spend the rest of your foreshortened life? Do you want to spend it hanging out with me and my staff—or do you have something else that you want to do? I know I can make you sick. I'm not at all sure I can make you better.'"

So if some patients endure treatments that are unnecessary or futile, could that be contributing to the nation's bloated healthcare budget? And could shared decision-making help rein in runaway

costs? Advocates of the concept are quick to say that saving money is not their primary goal. The cost of overtreatment, they emphasize, is measured first in terms of human suffering.

Financial side-effects
Nevertheless, there is good reason to believe that decision support like that offered at Dartmouth could reduce the number of unwanted treatments, tests, and elective surgeries in the many gray areas of medicine where it's not certain whether the advantages of a procedure outweigh its disadvantages for many patients. If so, the financial savings that could follow from widespread use of shared decision-making would be a very welcome byproduct.

In fact, DHMC is participating in a $5-million demonstration project, funded by the Centers for Medicare and Medicaid Services, that's designed to explore whether shared decision-making might save the federal government money by reducing the number of unwanted and unneeded procedures. Research has shown that 40% of Medicare inpatient spending on surgery is concentrated on just 10 conditions involving invasive procedures. If patients had a chance to make an informed choice, current evidence suggests that the number of surgeries for these 10 conditionsmight fall by at least 20%, resulting in annual savings to Medicare of roughly $3.5 billion. Even a much more modest decline would result in substantial savings: $860 million if surgery drops by only 5%, and $1.7 billion if the decline is 10%.

Make no mistake: the ultimate goal of shared decision-making is not to save money but tomove toward amore efficient, higher-quality health-care system that provides the right care to the right patient at the right time. In the many cases where there's no single "best" treatment, an informed patient's preferences should come into play when determining if he or she is indeed the right patient for that treatment at that time.

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Mahar is currently a fellow at the Century Foundation, where she writes and blogs about health care. She is the author of the book Money-Driven Medicine: The Real Reason Health Care Costs So Much, published in 2006 by HarperCollins, and has worked for the New York Times, Barron's, and Bloomberg. She wrote a feature for Dartmouth Medicine's Spring 2007 issue about the impact of the Dartmouth Atlas of Health Care on the national health-policy debate.

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