Involving patients in primary care consultations: assessing preferences using discrete choice experiments

BACKGROUND

Shared decision making (SDM) involves patients and doctors contributing as partners to treatment decisions. It is not known whether or to what extent SDM contributes to the welfare arising from a consultation, and how important this contribution is relative to other attributes of a consultation.

AIM

To identify patient preferences for SDM relative to other utility bearing attributes of a consultation.

DESIGN OF STUDY

In parallel with a randomised trial in training GPs in SDM competencies and risk communication skills, a discrete choice experiment exercise was conducted to assess patients' utilities.

SETTING

Twenty general practices in South Wales, UK.

METHOD

Five hundred and eighty-four responders from 747 patients attending the randomised trial (response rate = 78%). All patients had one of four conditions (atrial fibrillation, menorrhagia, menopausal symptoms or prostatism) and attended a consultation with a doctor in their own practice. Patients were randomised to attend a consultation either with a doctor who had received no training in the study or risk communication training alone or SDM training alone, or both combined.

RESULTS

Five key utility bearing attributes of a consultation were identified. All significantly influenced patient's choice of preferred consultation style (P<0.001). Larger increases in utility were associated with changes on "doctor listens" attribute, followed by easily understood information, a shared treatment decision, more information and longer consultation. Utilities were influenced by whether the doctor had received risk communication training alone or SDM training alone, or both combined, prior to the consultations. The randomised trial itself had identified that the communication processes of these consultations changed significantly, with greater patient involvement in decision making, after the training interventions.

CONCLUSION

Shared treatment decisions were valued less than some other attributes of a consultation. However, patient utilities for such involvement appeared responsive to changes in experiences of consultations. This suggests that SDM may gain greater value among patients once they have experienced it.

Can electronic routine data act as a surrogate for patient-assessed outcome measures?

Objectives:There has been a rapid growth in the use of patient-assessed outcomes (PAOs) that are measured in the assessment of health technologies. The process of collection of such measures can be costly, and there may be problems associated with the ability of the patient to complete them. The use of electronically stored routine data may reduce costs and overcome the problems associated with patient completion. The feasibility of using routine data surrogates for the UK Inflammatory Bowel Disease Questionnaire (UKIBDQ) and the Short Form 36 (SF-36) was examined.

Methods:Clinical terms and codes for the UKIBDQ and SF-36 questions were identified, and data from electronic routine sources were sought on patients participating in a randomized controlled trial. The presence or absence of relevant symptoms was used to generate surrogate scores, which were compared with the original scores.

Results:Most questions in the UKIBDQ and SF-36 were codable but only one third of the terms were recorded routinely in electronic form. The surrogate total IBDQ score had reasonable reliability (Kuder–Richardson coefficient = 0.51), but this reliability could not be determined for the SF-36. Intraclass correlations between routine and designed data were poor to weak.

Conclusions:Although electronic routine data sources had the capacity to develop surrogate measures for patient assessed outcomes, there was evidence of wide underutilization of coding systems leading to an underreporting of symptoms. This finding is consistent with previous literature where only poor correlations were illustrated between patient assessed outcomes and surrogate scoring of symptoms.

Resource effects of training general practitioners in risk communication skills and shared decision making competences

RATIONALE, AIMS AND OBJECTIVES

Involving patients more in decisions about their own care requires doctors to be trained in effective ways of communicating information and in developing competences to negotiate levels of patient involvement which are most appropriate for each case. The aim of this study was to determine the cost of such training and identify which service resource variables are subsequently affected.

METHODS

An explanatory cluster randomized crossover trial was carried out which involved training general practitioners (GPs) in the use of risk communication (RC) tools, shared decision making (SDM) competences or both. Continuing care by GPs of patients with one of four chronic conditions (menopausal symptoms, menorrhagia, atrial fibrillation, prostatism) was reviewed before and after training. Cost of training was assessed by prospective monitoring of resources used. Data on prescribing, referrals and investigations were collected via questionnaires to participating practitioners. Data on follow-up GP consultations were extracted from medical records. Three two-level logistic models were performed to investigate the probability of training having an effect on prescribing, referrals and investigations ordered at the review consultation.

RESULTS

Training cost pound 1218 per practitioner which increased the cost of a consultation by pound 2.89. Training in SDM or combined with RC significantly affected the probability of a prescription being issued to women with menopausal symptoms and menorrhagia (although RC on its own had no effect) but did not significantly affect prescribing for patients with prostatism or atrial fibrillation. It did not significantly affect the probability of investigations, referrals or follow-up GP visits for any of the conditions.

CONCLUSION

Unless training has a major influence on consultation length, it is unlikely to have any major impacts on cost.

Estimating the marginal value of 'better' research output: 'designed' versus 'routine' data in randomised controlled trials

We recently completed a study which demonstrated that the costs of health technology assessment (HTA) by randomised controlled trial (RCT) can be reduced by substituting routine datasets for data designed and collected specifically for a trial. This cost reduction, however, had the effect of reducing the quality of the research output. In the present study we attempted to tease out the values attached to the 'better' information provided by designed data RCTs using a mock grants committee. Two valuation techniques, implied values and willingness to pay, were used. Ex ante valuations were determined by comparing alternative research proposals - a more costly version using designed data and a cheaper version using routine data. Ex post valuations were determined by comparing results of both versions. The exercise was performed on four exemplar studies. Overall, the committee expressed a general lack of trust towards routine data both ex ante and ex post and placed high values on the better information from the designed data studies - particularly information on preferences. This suggests that currently available routine datasets are not perceived to be able to provide efficient alternatives to designed data for RCTs.

Can randomised trials rely on existing electronic data? A feasibility study to explore the value of routine data in health technology assessment

OBJECTIVES

To estimate the feasibility, utility and resource implications of electronically captured routine data for health technology assessment by randomised controlled trials (RCTs), and to recommend how routinely collected data could be made more effective for this purpose.

DATA SOURCES

Four health technology assessments that involved patients under care at five district general hospitals in the UK using four conditions from distinct classical specialties: inflammatory bowel disease, obstructive sleep apnoea, female urinary incontinence, and total knee replacement. Patient-identifiable, electronically stored routine data were sought from the administration and clinical database to provide the routine data.

REVIEW METHODS

Four RCTs were replicated using routine data in place of the data already collected for the specific purpose of the assessments. This was done by modelling the research process from conception to final writing up and substituting routine for designed data activities at appropriate points. This allowed a direct comparison to be made of the costs and outcomes of the two approaches to health technology assessment. The trial designs were a two-centre randomised trial of outpatient follow-up; a single-centre randomised trial of two investigation techniques; a three-centre randomised trial of two surgical operations; and a single-centre randomised trial of perioperative anaesthetic intervention.

RESULTS

Generally two-thirds of the research questions posed by health technology assessment through RCTs could be answered using routinely collected data. Where these questions required analysis of NHS resource use, data could usually be identified. Clinical effectiveness could also be judged, using proxy measures for quality of life, provided clinical symptoms and signs were collected in sufficient detail. Patient and professional preferences could not be identified from routine data but could be collected routinely by adapting existing instruments. Routine data were found potentially to be cheaper to extract and analyse than designed data, and they also facilitate recruitment as well as have the potential to identify patient outcomes captured in remote systems that may be missed in designed data collection. The study confirmed previous evidence that the validity of routinely collected data is suspect, particularly in systems that are not under clinical and professional control. Potential difficulties were also found in identifying, accessing and extracting data, as well as in the lack of uniformity in data structures, coding systems and definitions.

CONCLUSIONS

Routine data have the potential to support health technology assessment by RCTs. The cost of data collection and analysis is likely to fall, although further work is required to improve the validity of routine data, particularly in central returns. Better knowledge of the capability of local systems and access to the data held on them is also essential. Routinely captured clinical data have real potential to measure patient outcomes, particularly if the detail and precision of the data could be improved.

ACS general surgeons participate in payment reform activities

As reported in the Bulletin at various times over the past several years, the American College of Surgeons has frequently been called upon by federal agencies and commissions to provide clinical information and advice on issues that are associated with implementation of the Medicare physician payment system reforms mandated by the Omnibus Budget Reconciliation Act of 1989 (OBRA '89). In doing so, the College has often relied on the expertise of Fellows who are deeply committed both to the practice of general surgery and to the College. The purpose of this article is to provide a review of the College's participation in activities related to implementation of the Medicare reforms, as viewed by some of the general surgeons who shared in those efforts.