The cost of implementing shared decision-making in medication adherence: evidence from the IMA- RCT study
This study quantifies the implementation costs of the IMA shared decision-making intervention across 12 primary care centers in Spain, finding that while costs are highest during the initial pre-implementation phase and driven primarily by human resources, the overall intervention is affordable and effective planning is crucial for successful adoption.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
In the daily rhythm of modern healthcare, a persistent challenge lies not in prescribing the right medicine, but in ensuring patients actually take it. This gap between a doctor's order and a patient's action is known as medication non-adherence, a problem that can lead to worsening conditions for those with chronic illnesses like heart disease or diabetes. To bridge this gap, medical experts have turned to a concept called shared decision-making. This approach shifts the dynamic from a simple instruction to a genuine conversation, where the doctor and patient discuss options together, weighing the benefits and risks to reach a mutual agreement on treatment. While this method sounds ideal, health systems often hesitate to adopt it broadly. The hesitation rarely stems from a lack of belief in the idea, but rather from a fog of uncertainty regarding the practical costs. Leaders need to know not just if an intervention works, but exactly what it costs to set it up, who needs to spend their time on it, and whether those costs remain manageable as the program grows. Without this financial clarity, even the most promising strategies can stall before they ever reach the patients who need them.
A team of researchers in Catalonia, Spain, decided to clear away this fog by conducting a detailed financial map of a specific shared decision-making program called the Initial Medication Adherence, or IMA, intervention. They did not just guess at the expenses; they tracked every hour of work and every material used as the program was rolled out in twelve primary care centers between 2021 and 2022. The study followed the program through three distinct periods: the preparation phase before any patients were involved, the active launch phase where training and tools were distributed, and a long-term sustainability phase projected over five years to see what it would take to keep the program running. The researchers meticulously recorded the time spent by everyone involved, from hospital managers and doctors to nurses and specialized technicians, and converted these hours into monetary values based on local salary data. They also tracked material costs, such as the printing of informational leaflets and the maintenance of a website designed to help patients and doctors make decisions together.
The results of this accounting exercise revealed a clear and surprisingly manageable financial picture. The total cost to implement and sustain the IMA intervention across the twelve centers for a five-year period was just under forty-eight thousand euros. When the researchers looked at the breakdown of where that money went, they found that the most expensive part of the process was not the actual delivery of care, but the preparation. The initial phase, where the team planned the strategy, designed the training materials, and set up the systems, accounted for the largest share of the total cost. During this early stage, specialized technicians and implementation staff did the heavy lifting, investing the most time to ensure the foundation was solid. Once the program was up and running, the nature of the costs shifted. In the later years, when the focus moved to keeping the program alive, the doctors and nurses became the primary drivers of the expense, as their ongoing time and engagement were essential to maintaining the new way of working.
The study also looked ahead to see what would happen if this program were expanded from twelve centers to one hundred, a scenario that many health systems might consider. The researchers found that while the total price tag would rise to roughly one hundred and thirty-two thousand euros, the cost per center would actually drop significantly. This is because many of the initial expenses, such as designing the training curriculum and building the website, are one-time investments that do not need to be repeated for every new location. As more centers join, these fixed costs are spread out, making the program more efficient. The data showed that the first year of any rollout is always the most expensive, requiring a heavy upfront investment of time and resources. However, the costs in subsequent years settle down, with a notable peak in the fourth year driven by the need for refresher training and material updates, before stabilizing at a much lower level.
Despite the detailed tracking, the researchers were careful to note that their numbers represent a conservative estimate. They deliberately chose to count the full time of the staff involved to avoid underestimating the resources needed for a real-world rollout, even though some of that time in the study was part of a research project that might not exist in a standard hospital setting. They also acknowledged that they could not perfectly measure the extra minutes a doctor might spend with a patient during a consultation to practice shared decision-making, assuming instead that this time would be absorbed into the normal flow of work. The study suggests that for a program that requires very few physical materials, the key to success lies in the quality of the planning and the willingness of the organization to invest in the initial setup. The findings indicate that implementing shared decision-making to improve how patients manage their medications is financially feasible, offering a clear path for health systems to move from uncertainty to action.
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