You’ve heard it said that, “Talk is cheap.” Well that turns out to be particularly true in the realm of health care spending. Studies show that if you communicate clearly with patients and their families, there’s a fair chance that they’re not going to want to spend all the money that you feel compelled to spend.
A new study at Johns Hopkins University is looking to corroborate other studies that show that patients, if properly informed, will opt for lower cost health care options. The study, called the Critical Care Collaboration & Communication Project (The C4 Project) could explode some of the myths about the cost of health care. The project is lead by Sammy Zakaria, MD, MPH of the Department of Medicine, but involves people from virtually every department of the hospital, from medicine and surgery to pastoral care, gerontology and social work. In setting the stage for the importance of the study, Dr. Zakaria noted that the ICU accounts for 4.1% of the national health care expenditures and amounts to over $106.6 billion per year. Since most insurance, even the best policies, does not cover the entire bill, an ICU stay can be financially crushing for a family. And if the patient doesn’t recover to full health – or expires – the family is left wondering if it was all worth it.
Further confusing matters during these difficult decisions are two important factors. First, doctors, nurses and staff responsible for spending the patients health care dollars often don’t share the same socioeconomic, racial, or ethnic perspectives of their patients and their families. Second, a lack of proper training for these difficult, life-and-death conversations, leaves physicians and nurses feeling stressed and unprepared. This stress creates disincentives to communicate at the moment when that communication is most needed.
However, despite it being almost axiomatic that increasing communication results in lower health care expenditures and increased patient satisfaction, Dr. Zakaria notes that formal multidisciplinary family communication takes place only 4% of the time and seldom happens in a timely or reliable manner. Often, complete communication only occurs when all aggressive treatment options have been exhausted and the end of life is imminent.
Zakaria’s study is not just about giving the patient more information, however. As more physicians, nurses, caregivers, and consultants get involved in the patient’s care, the patients and their families can easily get overwhelmed with information. They may need help sorting out all of the options that are available to them. To relieve the physician team leader of this responsibility and to make sure there is one consistent person to whom the patient and family can turn, The C4 Project hopes to be able to assign every patient a ‘navigator’.
The Hopkins study, while still in its earliest stages, plans to enroll 1000 patients the first year and as many as 6000 the second year, if more funding can be found. Dr. Zakaria anticipates spending about the cost of one day in the ICU to train staff and educate patients and families, but hopes to achieve savings equal to six days. He projects that a program of formalized staff education, patient navigators, and changes in provider fees could save the country $4 billion per year. More importantly, patients and their families would achieve greater satisfaction and control of their lives. But as another axiom states, “you have to spend money to make money,” and Dr. Zakaria is still looking for more grant money to prove his theory of the value of communication.
It’s somewhat ironic that one of the world’s foremost medical institutions is conducting such a study when similar studies have shown for years that for every dollar spent in patient education, $3 to $4 dollars were saved (Bartlett, 1995). One study by Brownson, et al. (2009) found that $2,823 dollars were saved by one hour of nurse education of patients being discharged with the diagnosis of Type II diabetes. In this case, decreased utilization came as the result of empowering patients and their families with the ability to decide what services they needed and when. But that study, and others similar to it, focused on keeping people out of the ED by better educating them. What about patients who are in the ED. Can emergency physicians trim costs with better communication? Maybe so.
Some family practitioners in Canada looked at whether fewer people would choose to get antibiotics in acute respiratory infections – a common problem seen in the fast track of the ED – if the issues were communicated to them more clearly. The study, called DECISIONS+2, compared a control group of physicians to a group that had undergone a 2-hour interactive seminar about shared decision-making. This group spent more time helping the patient come to an informed decision about the need for antibiotics, or lack thereof. The primary outcome was the proportion of patients who decided to use antibiotics. Two weeks after the consultation each person was re-contacted to check on whether they thought they would have done better with the antibiotics and whether they had gotten well. The “shared decision-making” group chose to use antibiotics half the time the patients in the control group did and demonstrated no significant decisional regret or change in quality of outcomes. No surprise?
What about a decision that could possibly be thought of as life and death, like the decision to stay in the hospital for cardiac stress testing after an episode of chest pain? You might think that fear would drive most people in that setting to opt for hospitalization. But that’s not what Hess et al found when they studied patient choice in this setting. These researchers looked at patients making just such a decision when the physician was assisted by a pictorial decision aid that illustrated pretest probabilities of acute coronary syndrome and the available management options. First, they found that patients were paying attention, which is no surprise. Second, they demonstrated a significantly higher level of understanding of their potential disease process, as tested in a post education survey. But most importantly, given the information on their real risk of disease, more patients opted out of hospitalization – almost 20% less.
The economic implications for potential reductions in the cost of health care by a thorough discussion of the options is simply staggering. But there is just one problem remaining: the legal burden. Allowing patients to participate in the decision making process would certainly suggest that when a rare bad outcome occurs, they might be less likely to sue the physician. And numerous studies have shown this to be true. Entering statements into the record that the patient was informed of the risk and chose a certain pathway might make us feel more secure. But the truth is that no court has ever barred a plaintiff in a medical malpractice suit on the doctrine of assumption of the risk. The courts have opined repeatedly that while it is the doctors’ responsibility to advise the patient, he or she ultimately bears the responsibility for the outcome, because only the physician has the experience and knowledge to make that decision.
So the truth is that while better education of patients and more involvement in the decision making will certainly decrease costs without hurting quality, we are still flying without a net as long as there is no significant fundamental reform in our medical tort system. We must do our part, but we should not believe that we can do it alone.
- Bartlett, E. E. (1995). Cost-benefit analysis of patient education. Patient Education and Counseling, 26, 87-91.
- Brownson, C. A., Hoerger, T. J., Fisher, E. B., & Kilpatrick, K. E. (2009). Cost-effectiveness of diabetes self-management programs in community primary care settings. Diabetes Educ, 35(5), 761-769
- Erik P. Hess, MD, Meghan A Knoedler, RN; Nilay D. Shah, PhD; Jeffery A. Kline, MD; Maggie Brslin, MDes; Megan E. Branda, Ms; Laurie J Pencille, RN; Brent R. Asplin, MD, MPH; David Nestler, MD; Annie T Sadosty, MD; Ian G Stiell, MD; Henry H Ting, MD, MBA; Victor M Montori, MD, (2012). The Chest Pain Choice Decision Aid. Circ Cardiovasc Qual Outcomes, May 2012, 251-259