Decision-making for Hemophilia Treatment Differs Between US and UK Doctors, Study Finds

U.S. doctors caring for people with hemophilia are more likely to make treatment decisions based on patient preferences than doctors in the U.K., who tend to be more influenced by their colleagues and government policies, according to a study comparing decision-making in both countries.

Additionally, U.S. doctors report that their decisions were sometimes limited by insurance companies, but their appeals to insurance decisions were often successful.

In both countries, physicians agree that standard guidelines are insufficient to guide the management of bleeding disorders, as treatments need to be tailored to each patient.

Doctors also recognize that many patients are becoming highly knowledgeable of their bleeding disorder, giving more weight to their preferences during the decision‐making process.

The study, “UK vs US physician decision‐making in the treatment of haemophilia,” was published in the journal Haemophilia.

Through interviews with hemophilia specialists in the U.S. and U.K., the study compared the uses and applications of shared decision-making between patients and physicians and the influence of healthcare systems on the management of hemophilia in both countries.

Shared decision‐making between patients and doctors has emerged as a positive approach with benefits for the management of chronic diseases.

This process “has been defined as an ‘approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences,’ ” the researchers wrote.

However, little is known about the factors encouraging its use, how effective it may be at improving patient outcomes, or its cost‐effectiveness.

Comparing decision‐making for the treatment of hemophilia — which often requires highly skilled decisions and costly treatments — in the U.S. and the U.K., two countries with very different healthcare systems, “may offer insights into how chronic care can be improved,” the team said.

After analyzing the responses of 12 physicians from each country, the researchers detected both similarities and differences in the way they make decisions.

Treatment guidelines (evidence-based medicine standards) were recognized by both groups, but considered insufficient for effective patient care. They viewed their applicability as limited because there are no universal best options in hemophilia and each decision needs to be adjusted to the individual patient.

Doctors in both countries favored a more intuition-based approach, especially for initial treatment and changes to treatment.

“Participant US#10 stated that there although evidence‐based medicine (EBM)‐based guidelines are available, these alone are insufficient for decision‐making, and one must rely on experience and training for the nuances of care,” the researchers wrote as an example.

U.S. physicians appeared to be more influenced by patient needs than physicians in the U.K.

“The US participants would work closely with a patient to inform them of suggested treatment options while also coordinating with their insurance company,” the researchers wrote.

However, U.S. doctors said that sometimes insurance company policies imposed limits on their decisions. But there were cases where doctors personally appealed to the insurance company, which then accepted the claim.

When asked about being cost-conscious, one U.S. doctor said, “I don’t sit there and try to wonder what’s going to be paid for and what isn’t. On the other hand, if I think one approach is going to cost 75% more than another, I wonder whether I’m going to get push‐back from the insurers and have to write a whole bunch of letters and spend hours of time trying to get approval.”

Doctors in the U.K. were found to be more “disease‐oriented” — influenced by their colleagues and following policies and standards of care more closely.

As a result, U.K. physicians rarely considered other options such as plasma‐derived agents. Additionally, “when a UK physician seeks alternative treatment options for a patient, they must get special approval or risk the hospital incurring the cost of the care,” the researchers said.

Physicians from both countries recognized that many of their patients had become highly knowledgeable of their bleeding disorder, which even allowed some to persuade their doctors to change their decisions.

In general, patient decisions become more relevant concerning adjustments and corrections to treatment after recurring visits when patients are more knowledgeable and aware of their disease and treatment needs.

For nudging patient decisions, where physicians encouraged patients toward a specific treatment route, U.S. doctors more often provided vast information on the physician’s preferred choice. In the U.K., doctors could omit information on alternative options to standard care or those not included in the tendering system. 

Researchers noted that in the U.K., the master list of products available for tender is determined by the United Kingdom Haemophilia Centres Doctors’ Organisation and hematologists throughout the U.K., which ends up placing the physician at the beginning and the end of a decision-nudging process.

“The research suggests that there are different influences on decision‐making between healthcare systems; patients and overarching healthcare systems play a major role in how physicians treat haemophilia,” the researchers wrote.

These results “may also be of interest from a policy perspective in understanding the influences and barriers that physicians experience when making treatment decisions for the management of haemophilia and may be applicable to other disease states with high treatment costs,” they concluded.