Preference-sensitive care comprises treatments for conditions where legitimate treatment options exist -- options involving significant tradeoffs among different possible outcomes of each treatment (some people will prefer to accept a small risk of death to improve their function; others won’t). Decisions about these interventions -- whether to have them or not, and which ones to have -- should thus reflect patients’ personal values and preferences, and should be made only after patients have enough information to make an informed choice, in partnership with the physician. There are two principal causes of variations in rates of preference-sensitive care.
First, there is the often poor state of clinical science; for many conditions for which major surgery is an option, the alternative treatments have not been adequately evaluated through rigorous scientific studies. Thus, when surgeons recommend surgery, they often do so on the basis of subjective opinion, personal experience, anecdote, or an untested clinical theory that might or might not prove true were it subjected to some actual science.
The second problem lies in how many medical decisions are made. Even when evidence exists as to outcomes, surgery rates can vary dramatically from place to place. This is the case in early stage breast cancer. Studies show that mastectomy and lumpectomy achieve similar long-term survival, but women generally differ sharply in their attitudes toward these treatments. Yet in an early Dartmouth Atlas study, we found regions in which virtually no Medicare women underwent lumpectomy, while in another, nearly half did. We see dramatic variations in rates of surgical treatment for other conditions where multiple treatment options are possible, such as chronic angina (coronary bypass or angioplasty), low back pain (disc surgery or spinal fusion), arthritis of the knee or hip (joint replacement), and early stage cancer of the prostate (prostatectomy). Such extreme variation arises because patients commonly delegate decision-making to physicians, under the assumption that doctors can accurately understand patients’ values and recommend the correct treatment for them. Yet studies show that when patients are fully informed about their options, they often choose very differently from their physicians.
Reducing unwarranted variation in preference-sensitive care and establishing the right rate of demand for discretionary treatments require improvements in clinical science and fundamental changes in the ethical standards that govern the way patients are informed. Delegated decision-making should be replaced by shared decision-making, and the doctrine of informed patient consent replaced by informed patient choice.