PubMed · 15829530
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Elie Wiesel. 2005-04-14. Without conscience.. https://doi.org/10.1056/nejmp058069
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BACKGROUND: Decision aids (DA) to assist patients in evaluating treatment options and sharing in decision making have proliferated in recent years. Most require high literacy and do not use plain language principles. We describe one of the first attempts to design a decision aid using principles from reading research and document design. The plain language DA prototype addressed treatment decisions for localized prostate cancer. Evaluation assessed impact on knowledge, decisions, and discussions with doctors in men newly diagnosed with prostate cancer. METHODS: Document development steps included preparing an evidence-based DA in standard medical parlance, iteratively translating it to emphasize shared decision making and plain language in three formats (booklet, Internet, and audio-tape). Scientific review of medical content was integrated with expert health literacy review of document structure and design. Formative evaluation methods included focus groups (n = 4) and survey of a new sample of men newly diagnosed with prostate cancer (n = 60), compared with historical controls (n = 184). RESULTS: A transparent description of the development process and design elements is reported. Formative evaluation among newly diagnosed prostate cancer patients found the DA to be clear and useful in reaching a decision. Newly diagnosed patients reported more discussions with doctors about treatment options, and showed increases in knowledge of side effects of radiation therapy. CONCLUSION: The plain language DA presenting medical evidence in text and numerical formats appears acceptable and useful in decision-making about localized prostate cancer treatment. Further testing should evaluate the impact of all three media on decisions made and quality of life in the survivorship period, especially among very low literacy men.
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Health care provision is almost universally characterised by third party purchasing in which the provider of health services is reimbursed by an agency (public or private insurer), rather than the patient. We show how a purchaser can manage the incentives that patient choice gives rise to by its own choice of monitoring arrangement. Even though patients are ignorant about their exact medical conditions and insulated from the costs of health care, they can help alleviate incentive problems due to asymmetric information through the choices that they make about whether to be treated. We show that if patients are responsive to variations in treatment, it can be worthwhile to base payment on the health outcome achieved rather than upon the treatment delivered. Outcomes-based payments may also be preferable where services are supplied by not-for-profit agencies who are intrinsically concerned with patient welfare.