“Variation in patient preferences and expectations concerning engagement may be associated with patient-reported quality metrics, including satisfaction, ratings of care, quality of life, and other measures of health service quality. Because preferences and expectations exhibit geographic variation, such associations could complicate the interpretation of patient-reported outcomes (PROs) as measures of clinician performance. Despite the growing use of such performance metrics, literature on the association of PROs with preferences for participation in decision-making is limited, particularly among urban minority racial/ethnic populations. Because race/ethnicity has important associations with patient trust and satisfaction, studies that include diverse populations are essential to understand preferences among diverse groups and their implications for PROs.
[..] Data were collected on 13,902 hospitalized patients admitted to the general internal medicine service of The University of Chicago Medical Center between July 1, 2004, and September 30, 2012, who answered an inpatient survey administered soon after the time of admission and a 30-day follow-up survey. [..] Trained research assistants obtained written informed consent from all admitted patients immediately after admission for an inpatient survey with 44 questions, including race/ethnicity, educational attainment, general self-assessed health status, and patient preference for medical decision-making. We contacted patients 30 days after discharge to ask 56 follow-up questions, including postdischarge medical care use, health status, and service quality measures during the previous hospitalization.
[..] Among the inpatient survey participants, 13,902 of 22,954 patients (60.6%) completed the 30-day follow-up survey. For the 30-day follow-up survey, nonparticipants were more likely than participants to be male, less educated, and less healthy and were more likely to be publicly insured or uninsured.
[..] The mean (SD) patient age was 56.7 (19.1) years, 60.4% (n = 8397) were women, 39.6% (n = 5505) were men, and 74.2% were African American. Overall, 53.2% had no higher educational attainment, 22.7% were insured by Medicaid, and 51.1% reported a general self-assessed health status of fair or poor. The proportions of respondents who agreed and disagreed with delegating decisions to the responsible physician were 71.1% and 28.9%, respectively. A statistically significantly higher proportion of those who agreed rated their overall care as excellent or very good compared with those who disagreed (68.0% vs 62.5%; P < .001). Similarly, a statistically significantly higher proportion of those who agreed were extremely satisfied with the physician care received (67.8% vs 62.5%; P < .001).
[..] 9.6% evaluated the overall rating of care received as fair or poor, 6.5% expressed dissatisfaction with physician care, and 4.9% did not have confidence and trust in the physicians providing treatment. [..] the characteristics of age younger than 65 years, White race, higher educational attainment, and worse general self-assessed health status were associated with greater degrees of dissatisfaction in the overall rating of care received. White race, higher educational attainment, and worse general self-assessed health status were also associated with greater degrees of dissatisfaction with physician care. The characteristics of age younger than 65 years and worse general self-assessed health status were associated with greater lack of confidence and trust in the physicians providing treatment.
[..] Reduced willingness to defer medical decisions to the physicians providing treatment was associated with greater dissatisfaction in the overall care received, more dissatisfaction with physician care, and reduced confidence and trust in the physicians providing treatment. Compared with patients who definitely preferred to leave medical decisions to their physician, those who definitely disagreed with delegating decisions to their physician were more likely to be dissatisfied in the overall care received (14.2% vs 7.3%), express dissatisfaction with physician care (9.2% vs 4.9%), and lack confidence and trust in the physicians providing treatment (7.9% vs 3.9%) (P < .001 for all).
[..] [multivariable-adjusted association of patient preference for medical decision-making with the 3 service quality measures] Compared with patients who strongly preferred to leave medical decisions to their physician, those who definitely disagreed with delegating decisions were more likely to be dissatisfied in the overall care received (odds ratio [OR], 1.86; 95% CI, 1.54-2.24), express dissatisfaction with physician care (OR, 1.78; 95% CI, 1.42-2.22), and lack confidence and trust in the physicians providing treatment (OR, 2.05; 95% CI, 1.62-2.59). The findings were unchanged when the analysis was restricted to patients without missing data (ie, without imputations).
[..] The medical community’s desire for greater patient participation in decisions arises from a theory based on sociopolitical factors, including cultural predispositions for patient autonomy and changing views regarding the ethical aspects of decision-making. However, there is some evidence for greater satisfaction and improved outcomes as a result of patient participation in decisions. Although definitive research in this area is limited, the discrepancy between prior literature and the present study may be worth exploring. First, much literature has studied healthy volunteers or outpatients. Based on a sample of hospitalized patients, our findings may reflect a vulnerability that modifies the consequences of preferences for participation on care satisfaction and trust.
[..] several previous relevant studies were based on interventions directed at improving satisfaction through shared decision-making. This study differs in that it evaluates the associations between preexisting patient desire to participate in decisions, patient motivation for participation, and satisfaction. We cannot know with certainty the contributions of innate patient characteristics and prior health care experiences in generating patient desire to participate in decisions. However, we believe that greater expectations of care and communication among patients who do not want to delegate decision-making may create increased potential for dissatisfaction and lack of trust. The consistency of associations found across 2 measures (satisfaction with overall service and physician care) of satisfaction and confidence and trust suggests that the connections between patient preferences and outcomes are meaningful. Greater expectations may both give rise to a desire to participate in decisions and create more opportunity for dissatisfaction.
[..] The associations we found suggest that efforts to involve patients in shared decision-making should be sensitive to the heterogeneity of patients’ preferences to participate and encourage only types of involvement concordant with their wishes. This implication supports concerns in the published literature suggesting caution regarding overzealous efforts to involve patients because many do not wish to have active participation. Efforts to involve patients in health care decisions should be individualized and reflect the importance of shared decision-making in maximizing satisfaction for a substantial proportion of patients.
[..] Although many national policies, including the Affordable Care Act, encourage shared decision-making, a substantial proportion of patients do not desire an active role in medical decisions. Institutions with patient populations less willing to defer decisions to physicians may be at risk for poor ratings on publicly reported measures of satisfaction. In addition to other recognized challenges of such reporting, this implication may create substantial difficulty in the interpretability of statistics based on patient surveys.
[..] we did not measure the consequences of participation in decision-making on objective health outcomes. If a preference for participation in medical decisions improves health outcomes, such benefits may outweigh the satisfaction-reducing associations we observed with PROs.”
Full article, Ruhnke GW, Tak HJ and Meltzer DO. JAMA Network Open 2020.10.2