Patient preference

Modern health care is recognising, albeit with difficulty, that it is a service industry and has to pay more attention to those who use it. It may have unique features—in that it deals with high stake issues—but in common with other knowledge intensive services, it has to balance the expert skills with the expectations and experiential expertise of users. Service industries have learnt that sustained profitability stems from meaningful customer focus, collaboratively designed products and services, and positive interpersonal exchanges that management science calls "moments of truth." Healthcare organisations are now keen to take patients' perspectives seriously, but it's not as simple as it may sound.

Reviews of patient priorities are consistent. Summarised, they state that patients assume technical competence at both professional and organisational levels. Patients admit difficulty in judging whether these assumptions are met, although they further assume that systems are in place to ensure that basic standards are maintained and that all aspects of care are safe. They expect, however, to have good access to care and be respected. Patients also report high expectations about the experience of receiving and, often co-producing, health care—that it should be timely and that their views and preferences will be considered at least equally important as those of health professionals.

Patients' preferences do not exactly overlap with good quality care; meeting their priorities is necessary but not sufficient. Indeed, some of their wishes, particularly when uninformed or ill informed, can be detrimental. In many circumstances, rapid access to health care is necessary and important—for example, fast treatment is essential in thrombolysis and early identification and treatment of cervical neoplasia improves prognosis. However, given that access will inevitably be limited in a resource bounded system, it is unrealistic to have a service without limits.

Surveys by the Picker Institute Europe show the UK has a more paternalistic approach than other countries. Patients report comparatively good levels of doctor-patient communication and provider continuity but low scores for choice, involvement, and information.

We know enough about contractual frameworks that set goals to predict that paying doctors according to patients' scores will result in behaviour changes to maximise financial rewards. We remain convinced, however, that over the next decade medicine will give patients' perspective more attention. Firstly, we need to respect subjective experiences, both evaluations and reports; secondly, we need to measure them, and then manage them–aiming for improvements.

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Screening for prostate cancer in younger men

Current policies on screening for prostate cancer vary worldwide. This discrepancy can be explained in part by the lack of clear evidence to support or refute such screening. Evidence is lacking for the diagnostic accuracy of current screening tests (digital rectal examination and prostate specific antigen testing) and whether screening ultimately improves survival and quality of life. In their recent study in the BMJ, Lane and colleagues present results from the prostate testing for cancer and treatment study, which assesses the feasibility of testing for prostate cancer in younger men (45-49 years).

A recent systematic review identified two randomised controlled trials (RCTs) assessing the effectiveness of screening for prostate cancer. Both trials had several methodological weaknesses. Reanalysis of these trials using an intention to treat analysis showed no significant reduction in mortality between men randomised to screening and men in control groups (relative risk 1.01). The review concluded that these trials found insufficient evidence to support or refute screening for prostate cancer.

In the presence of such uncertainty further evidence from methodologically robust studies is needed to determine the effect of screening for prostate cancer on prostate cancer specific mortality, quality of life, potential harms, and costs. The results of several ongoing trials are awaited.

Clinicians and consumers currently stumble through the darkness that pervades the debate on screening for prostate cancer. Until the results of ongoing RCTs can shed light on this important clinical and policy decision, we recommend informed discussion between clinicians and patients about the benefits, potential harms, and limitations of screening. Greater uptake of patient education and decision aids, and incorporation of the clinician's experience and expertise, may help overcome the barriers to discussion and facilitate an informed decision.

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