Publicity surrounding the implementation of patient decision support interventions (DESIs) traditionally focuses on two areas of improvement: helping patients make better decisions AND lowering health care spending. The use of patient decision support interventions as a means to generate health care savings has been widely advocated, but the extent and quality of evidence is unclear.
A systematic review found that the evidence for savings was not as broad or deep as suspected. In addition, an examination of the quality of the economic analyses in the studies was performed. Not surprisingly for a young field, the quality has room for improvement. An assessment of the risk of bias in each study found a moderate to high risk across the studies that found savings.
Led by Thom Walsh, a post-doctoral fellow at the Dartmouth Center for Health Care Delivery Science, the team included Paul James Barr and Rachel Thompson, also postdoctoral fellows at the Dartmouth Center for Health Care Delivery Science, Elissa Ozanne, associate professor at the Dartmouth Institute for Health Policy & Clinical Practice, Ciaran O'Neill, professor at the School of Business and Economics, National University of Ireland, and Glyn Elwyn, professor at both the Dartmouth Center for Health Care Delivery Science and the Dartmouth Institute for Health Policy & Clinical Practice.
Their objective was to perform a detailed systematic review of a wide range of studies to assess DESIs' potential to generate savings, given a concern that premature or unrealistic expectations could jeopardize wider implementation and lead to the loss of the already proven benefits. The ethical imperative to inform patients is, in the authors' views, paramount. Although there is good evidence to show that patients tend to choose more conservative approaches when they become better informed, there is insufficient evidence, as yet, to be confident that the implementation of patient decision support interventions leads to system-wide savings.
After reviewing 1,508 citations, seven studies with eight analyses were included in the analysis. Of these seven studies, four analyses predict system-wide savings, with two analyses from the same study. The predicted savings range from US $8 to $3,068 per patient. Larger savings accompanied reductions in treatment utilization rates. The impact on utilization rates, overall though, was mixed. Authors used heterogeneous methods to allocate costs and calculate savings.
Dr. Walsh said, "Our review tells us the ability for decision support to lead to savings is still undetermined. There are many other reasons for the use of decision support. We are concerned the benefits could be lost if promises of savings are unfulfilled."
- T. Walsh, P. J. Barr, R. Thompson, E. Ozanne, C. O'Neill, G. Elwyn. Undetermined impact of patient decision support interventions on healthcare costs and savings: systematic review. BMJ, 2014; 348 (jan23 2): g188 DOI: 10.1136/bmj.g188
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