DISCUSSION
cancer, multiple sclerosis
CANCER, RECRUITMENT, SECONDARY, MULTIPLE SCLEROSIS, HEART FAILURE
Results of this secondary analysis of a large multicenter trial investigating differences in medical knowledge and perceived quality of care during hospitalization in patients according to their DCP are threefold. First, we found that most patients (i.e., 3 in 4 patients) prefer to participate in medical decision-making actively or collaboratively and only a minority has a passive DCP. Second, DCP is not associated with patients’ subjective and objective knowledge regarding their medical care. Third, although knowledge was similar between groups, patients with an active DCP were significantly more critical regarding their medical care with lower trust in the healthcare team and lower satisfaction with their overall hospital stay. Several points of this ancillary project are worth mentioning.Results of our main trial indicated that patients have similar subjective and objective knowledge regardless of patient case presentations being conducted at the bedside or outside the room.While DCP has been investigated in different specific patient populations (e.g., patients with cancer), there has been little evidence in unselected medical inpatients. Herein, our analysis provides important new insights in a large sample of patients with different main diagnoses. There are few studies looking specifically at associations between patients’ control preference and their medical knowledge. An older study from Germany found a weak correlation between preferences and knowledge in a cohort of patients with multiple sclerosis (MS).Also, in line with previous research, we found that DCP appears to be closely related to patients’ perception regarding their care received. In our analysis, patients with an active DCP were significantly less satisfied with their hospital stay than patients with a passive DCP. Further, we found that patients with an active as well with a collaborative DCP had significantly less trust in the physician and nursing team compared to patients with a passive DCP. A recent study from Thailand, which recruited patients with heart failure, reported similar findings and participants with a collaborative DCP were more dissatisfied with their care compared to patients with a passive DCP.Although we cannot estimate the effect of our findings and the differences in trust and satisfaction appear to be small, we believe our findings are clinically relevant.There might be different explanations for these associations. Ruhnke et al. suggested that patients with a stronger desire to participate in decision-making might have higher expectations of care and communication or that patients have had previous suboptimal interactions which could possibly impact patients’ DCP and perceived quality of care.The significant differences in trust in the healthcare team and satisfaction in our study might appear to be small. However, literature has shown that ratings of patient-related experience measures often show ceiling effects with little or no difference.Regardless of the mechanism, patient satisfaction is increasingly seen as a critical quality indicator in healthcare and patient-related experience measurements influence hospital reimbursements for care provided.Further, our results suggest that patients with a passive DCP appear to be less involved in their medical care than patients with a collaborative and active DCP. Ward rounds in patients with a passive DCP were significantly shorter, and sensitive topics were less frequently addressed. At a first glance, this might be in accordance with patients’ preferred role in medical decision-making. However, an Australian trial investigating strategies to adequately respond to patients with different DCPs found that most physicians responded to passive patients by talking most of the time, after outlining their own agendas.This study has some limitations. First, this trial took place exclusively in Swiss hospitals, which limits the generalizability of our findings to other countries and cultures. Second, we assessed patients’ knowledge and perceptions regarding the quality of care using a survey developed for this study, which has not been externally validated. Third, as the purpose of the original trial was to assess the effect of bedside and outside-the-room patient case presentation during ward rounds on patient knowledge and other patient-relevant outcomes, we only assessed patients’ preference for participation but not actual participation. Fourth, in our main trial, we did not assess the duration of patients’ hospitalization upon recruitment. However, all participants were only recruited within their first week of hospitalization. Finally, DCP is a self-measure. We may have little knowledge about if patients’ self-declared preference for involvement reflects their real preference and whether patients declaring themselves as “passive” are more satisfied in courses of health care with little involvement than in courses with greater involvement.