Health Policy$ense

Will Decision Aids Save Money?

Where you end up may depend on where you start. That’s the perspective taken by LDI Senior Fellow Said Ibrahim in the New England Journal of Medicine, as he discusses how shared decision-making tools and increased patient knowledge affect treatment choice. Specifically, Ibrahim looks at elective joint replacement, and examines how increased use of decision aids affects the choice to pursue either conservative management or total joint replacement.


Said A. Ibrahim, MD, MPH, MBA is a Professor of Medicine at Penn's Perelman School of Medicine and Director of the Philadelphia VA Center of Excellence for Health Equity Research & Promotion (CHERP).

Ibrahim argues that the effect of decision aids may depend on the patient’s baseline treatment preference. Patients with a higher baseline preference for surgery might adopt a more conservative approach, and those with a lower baseline preference might be more likely to opt for surgery.  In either case, he suggests, decision aids can improve patient-provider communication, and help clarify a population’s true demand for preference-sensitive treatments such as joint replacement.  Whether greater use of decision aids will save money is an open question.

Previous studies have shown that the use of shared decision-making aids is linked to lower rates of invasive procedures, such as joint replacement. However, Ibrahim notes, these studies involved predominantly white participants, who are more likely than black patients to prefer joint replacement. In fact, Ibrahim’s more recent research has shown that an educational video increased the rate of total knee replacement among black patients in a randomized clinical trial.

In December 2016, the Centers for Medicare and Medicaid Services (CMS) announced a national pilot of shared-decision-making tools that target treatments based on patient preference. Hip and knee replacement make strong targets for a number of reasons. First, osteoarthritis in the hip and knee is one of the most prevalent chronic conditions in the United States, particularly in Medicare beneficiaries. Additionally, marked racial differences in utilization of joint replacement exist, as black Americans are nearly half as likely than white Americans to undergo the procedure. Lastly, joint replacement procedures involve patient discretion, as the balance of benefits and risks differ between individuals. As such, the decision to undergo hip or knee replacement may be influenced by how conversations between the patient and provider are framed.

The initiative is designed to increase patient engagement and improve the quality of decisions, not to save money.  But Ibrahim says that an implicit assumption is that well-informed patients might choose less invasive treatments, thereby reducing costs. He concludes, “…whether they [decision aids] will result in cost savings for CMS will depend on their net effect on utilization in various patient groups.”