Evidence‐based Patient Choice by A. Edwards and G. Elwyn

Edited by Adrian Edwards and Glyn Elwyn. Oxford University Press, 2001, PB £19.95, 329 pp, ISBN 0-19-263194-2. Two recent prominent trends in health-care include evidence based health-care – the increased emphasis on informing clinical decisions with the research evidence – and the move to involve patients more centrally in the delivery of health-care, at a planning and a personal level where more choice would be offered over the type, timing and location of health-care; sometimes called patient-centred care. This impressive edited book brings together these two currents and provides a comprehensive survey of the state of knowledge about approaches to patient involvement in clinical decision making (but not service planning), written by international thinkers from a wide variety of disciplines. It covers most of the important conceptual issues and debates (although the section on economics is rather unimaginative). It also has several chapters dealing with some of the more practical issues of evidence-based patient choice such as developing appropriate clinical methods, use of decision aids to help structure patient involvement and the training needs of professionals. The challenge posed is how to put both the evidence and the patient centre stage. The combination can be an uneasy one and raises several questions. What happens if patients choose options that are not supported as effective by the evidence? How does one reconcile the concept of patient empowerment with centralised rationing of health technologies? How can one ensure that patients have access to good quality research evidence and are able to filter out the data, often biased, put out by lobby groups, product suppliers and other vested interests? Finally, what mechanisms or aids can be used to support such informed decision-making and what is the likely impact on professional–client relationships? This book is truly excellent in the way these and other issues are handled. It does not take evidence-based patient choice as an automatic good, ignore the difficulties of conceptualizing or implementing it, or take the easy way out by assuming that all will be solved by the ‘information revolution’. Thus it is a useful antidote to the rather simplistic mantras over the last few years about patient involvement and partnerships peddled by policy makers who might have good intentions but who would benefit greatly from a deeper analysis of what this really means contained in this book. Patient involvement in clinical decision- making and informing this with research evidence is not simple or straightforward. Patients vary in their preferences, in their desire for information and control and in their valuation of different health states. It is not clear how patients will interrogate, interpret and use research evidence in making decisions – the response to the recent results of the RCT of hormone replacement therapy showing raised cancer risks is a good example. Research evidence can act as a limit to autonomy and constrain choices and so may not be seen as an ally. The book is also realistic about the barriers to informed choice such as the time, funds, skills and continuity of relationships needed to sustain such an aim on top of the complexity of dealing with research findings and the gaps in knowledge. An important chapter also highlights the adverse impact increased emphasis on evidence-based patient choice can have as a result of variability in health literacy. This may result in inequalities being reinforced not only within the English-speaking countries but also between them and countries which cannot access the research evidence easily because of language barriers. It is slightly marred by the editor's argument in the introduction that the protagonists of evidence-based health-care have had a blind spot about patients and have ignored their potential role in favour of an exclusive focus on clinicians. I think this is a straw man thrown up to make the book seem more innovative. People involved in Cochrane Collaboration, for example, have for some time championed the involvement of patients in reviews, research and its implementation. Evidence-based advocates (in as much as one can talk about them as a whole) have challenged the hegemony of the professional expert and, by being explicit in reviewing and weighing the evidence, have provided the basis for more democratic and open discussion of the effectiveness of treatments. What has been missing, and this is where the book is so important and authoritative, is the research and deeper thinking on how this could be done; how we can promote evidence-informed patient choice or an informed partnership and what would be the effects? This book is essential reading for all those interested in patient involvement and evidence-based health-care. I look forward to future editions marking our progress in taking this important project forward and evaluating its results.