Is patients' preferred involvement in health decisions related to outcomes for patients with HIV?

BACKGROUND: Previous studies suggest that patients who are more involved in their medical care have better outcomes. OBJECTIVES: We sought to compare health care processes and outcomes for patients with HIV based on their preferred level of involvement in health decisions. DESIGN: Cross-sectional analysis of audio computer-assisted interviews with patients at an urban HIV clinic. PATIENTS: One thousand and twenty-seven patients awaiting an appointment with their primary care provider. MEASURES: Patients were asked how they preferred to be involved in decisions (doctor makes most or all decisions, doctor and patient share decisions, patient makes all decisions). We also asked patients to rate the quality of communication with their HIV provider, and their self-reported receipt of and adherence to HAART. RESULTS: Overall, 23% patients preferred that their doctor make all or most decisions, 63% preferred to share decisions with their doctor, and 13% preferred to make all final decisions alone. Compared to patients who prefer to share decisions with their HIV provider, patients who prefer that their provider make all/most decisions were significantly less likely to adhere to HAART (OR [odds ratio] 0.57, 95% CI 0.38-0.86) and patients who preferred to make decisions alone were significantly less likely to receive HAART or to have undetectable HIV RNA in unadjusted analyses (OR 0.52, 95% CI 0.31-0.87 for receipt of HAART; OR 0.64, 95% CI 0.44-0.95 for undetectable HIV RNA). After controlling for potentially confounding patient characteristics and differences in patient ratings of communication quality, patients who preferred that their provider make all/most decisions remained significantly less likely to adhere to HAART (OR 0.58, 95% CI 0.38-0.89); however, the associations with receipt of HAART and undetectable HIV RNA were no longer significant (OR 0.60, 95% CI 0.34-1.05 for receipt of HAART; OR 0.80, 95% C.I 0.53-1.20 for undetectable HIV RNA). CONCLUSIONS: Although previous research suggests that more patient involvement in health care decisions is better, this benefit may be reduced when the patient wants to make decisions alone. Future research should explore the extent to which this preference is modifiable so as to improve outcomes.