A SYSTEMATIC REVIEW OF THE INFLUENCE OF PATIENT DECISION AIDS ON COST, HEALTH OUTCOMES, AND COST-EFFECTIVENESS

Purpose: A developing literature indicates that the use of shared decision making, and patient decision aids (PtDAs) specifically, is associated with an increase in the quality of health care and cost savings. We sought to determine how the use of PtDAs in clinical practice may influence costs, health outcomes, and cost-effectiveness.

Method: A systematic review of the literature was undertaken. The search included bibliographic databases (Medline, EMBASE, PsycINFO, CINAHL, and Cochrane) using keywords and MeSH terms. Title and abstract screening, full text review and data abstraction was conducted independently and in duplicate by two reviewers, with discrepancies resolved through discussion. The reference lists of included articles were hand-searched to identify additional papers of interest.

Result: The search produced 5,347 references, with 30 included following full-text review. Three key themes where PtDA may influence costs were identified: (1) cost of administration and delivery of PtDAs, (2) short-term, and (3) long-term costs related to treatment decision, adherence, and health outcomes. Evidence to support the claim that PtDA will result in reduced health care costs has been drawn on selectively to date. The best evidence indicates that PtDA increase administration and delivery costs, and may reduce short-term costs by reducing the rate of elective surgery. Little is known about the effect of PtDAs on long-term costs or adherence due to methodological shortcomings (time horizon, confounding, and measurement).  PtDAs have demonstrated a small influence on health outcomes. The direction of effect is inconclusive, yet it is not clear whether this is a suitable outcome given patients may legitimately choose less effective options. Three economic evaluations have been completed, with the lone cost-effectiveness analysis finding lower costs and higher quality adjusted life years in the PtDA arm compared to control.

Conclusion: We find that recent claims of PtDA resulting in better health outcomes while reducing costs to be premature. A greater focus should be placed on investigating the influence of PtDAs on health and quality of life outcomes, in addition to adherence to treatment, as they have the potential to impact short- and long-term costs. PtDA have an important role in the future, and could save costs in certain treatment decisions, and in certain contexts.