Decision Quality

Decision Situation

The decision situation plays a big role in determining the quality of a medical decision. There are [Page 297]situations in medicine where a treatment or approach has considerable evidence of a significant benefit with considerable evidence of minimal harm. Most clinical guideline committees, such as the U.S. Preventive Services Task Force (USPSTF), set out explicit criteria for grading the clinical evidence for the benefits and harms of different tests and treatments. When the benefits are determined to outweigh the harms, there is a “right” answer that can be termed effective care. For example, the use of beta blockers following a heart attack fit the criteria for effective care. Most patients have a strong desire to reduce the risk of repeat heart attacks and death, and most feel the modest side effects of the medicines are worth the benefit. As a result, high-quality decisions in these situations are about efficiently delivering proven, effective care to all those who may benefit. Decision quality can be inferred by the percentage of eligible patients who receive the proved treatment, or the percentage of care that is “consistent” with the guidelines.

Not all situations in medicine are examples of effective care. In fact, a surprising number of decisions do not have sufficient evidence of benefit for one option over another, or have evidence of equivalence of two or more options, or have evidence of substantial harm that accompanies the benefit. In these situations, often called preference-sensitive decisions, there is not a clearly superior approach, and the preferences of individual patients are critical to selecting the “best” choice. Simply examining treatment rates will not provide enough information to determine the quality of decisions—a more sophisticated approach is needed.

Many different stakeholders have recognized this complexity and have called for attention to this challenge. The Institute of Medicine has defined patient-centered care as “healthcare that establishes a partnership among practitioners, patients and their families (when appropriate) to ensure that decisions reflect patients' wants, needs and preferences and that patients have the education and support they need to make decisions and participate in their own care” (p. 7). Researchers in the field of medical decision making have also focused on two themes that are in this definition— that patients are informed and that choices for tests and treatments reflect patients' goals and preferences. In an international consensus process, researchers, providers, policy makers, and patients overwhelmingly supported a definition of decision quality as the extent to which a decision reflects the considered preferences of a well-informed patient, and is implemented.

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