Unfortunately, there’s a bit of a problem. On the physician side, we probably don’t have good mechanisms through which to translate evidence to individual patients. Most information derived from clinical studies describes outcomes from aggregated cohorts – so, usually, the best we can do is inform our patients how the “average” person performed with a specific treatment.
Then, on the patient side – as this study demonstrates – their risk-taking behavior is heterogenous, irrational, and extreme. These authors report on 234 surveys of patients presenting with low-acuity chest pain in a Veterans Affairs cohort, trying to get a handle on hospitalization preferences given a certain pretest likelihood of disease. Their basic model: hospitalization reduces the risk of bad outcome by 10%. Then, they asked if the patient would like to be hospitalized for base likelihood of poor outcomes ranging from 1 in 2 to 1 in 10,000.
Half the patients wanted to be hospitalized, even when the benefit to hospitalization reduced the event rate from 1 in 10,000 to 1 in 11,000 (an NNT of 110,000). Then, another 10% of patients wanted to be discharged in all circumstances, even when the risk of poor outcome was improved from 1 in 2 to 5 in 11 (an NNT of 22). And, depending on how the risks were communicated, and whether visual or numeric scales were used, also affected how the patients chose.
So, ultimately – yes, we’d like to involve patients in their decisions. But, unfortunately, it looks as though it’s going to be quite the challenging proposition – and we might not like (or have the capacity to abide by) their preferences.
“Measuring Patient Tolerance for Future Adverse Events in Low-Risk Emergency Department Chest Pain Patients”