Adherence to scientific principles underscores the performance of health professionals but patient preference is equally important.
Many decisions can be solved using the “Goldilocks and Three Bears” method. Whether choosing which bowl of porridge, or which treatment, there is one that is “just right”. Too much (blood pressure, oxygen, blood) is likely to be harmful. Not enough is likely to be ineffective. Finding the treatment and intensity that is “just right” will lead to the best outcome for the patient. This analogy about appropriate treatment, can be extended throughout medicine [Fig 1].
A patient receiving appropriate care is treated based on the best current evidence, and according to their needs and preferences. If you focus on just treating according to the current evidence (and not patient preferences), work from the United States suggests patients receive recommended care 55% of the time. A study in Australia showed that 57% of patients received guideline concordant care for 22 common conditions – those inappropriately treated could be getting nothing, too much (unnecessary), harmful, incorrect or outdated treatments.
When you add in patient preferences it becomes even more complicated. Shared decision making involves taking the time to elicit patient wishes and values and combining these with treatment options.
Appropriate treatments are important. Unnecessary treatments place patients at undue risk (no healthcare intervention is risk-free) and waste limited healthcare resources. Value in healthcare is the balance between the outcomes (benefit) and the costs. To improve value, we start by examining the appropriateness of the treatments provided. [Porter ME. What is value in Health Care? NEJM 2010;363:2477-2481]
The Choosing Wisely Australia initiative through the specialty colleges that have signed on has started identifying treatments and investigations of low value to patients. Low value treatments can cause harm, are unlikely to benefit the patient, and incur a financial cost [www.choosingwisely.org.au] One example is the many “routine” or “repeat” tests now common in medical practice, ordered for convenience or “just in case”. By re-designing work practices and expectations, it is possible to reduce these unnecessary tests.
Patients who do not receive appropriate care can also block equitable access to health care for others. The Australian Commission on Safety and Quality in Health Care has created an interactive atlas identifying areas of variation in healthcare use. [www.safetyandquality.gov.au/atlas] Obviously, variation may be due to factors out of control of the doctor, such as disease burden or patient preferences but there are many examples of large differences in the treatments offered to patients with the same condition. It does not seem fair that treatments should be affected by where you live and the doctor you see.
Science is advancing and we are about to enter the era of personalised medicine where treatments will be tailored to the genetic profile of the patient. An advance that could have even greater impact would be to ensure that all patients receive guideline-concordant and preference-appropriate treatments.
References available on request