Better Shared Decision Making in Practice Charlie Brackett, MD, MPH Blair Brooks, MD Nan Cochran, MD (France Légaré, MD) 2007 Dartmouth-Hitchcock Medical Center White River Jct. Veterans Administration Hospital Dartmouth Medical School Research and Workshop Sponsored by FIMDM
Workshop Goals • Increase interest in SDM • Share our experience and address challenges • Demonstrate ways to facilitate SDM • Practice communication skills • Decision Aids • Explore broader implementation of SDM in primary care
There is unwarranted variation in the practice of medicine and the use of medical resources
The 3 Categories of Care • Effective care: underused • Evidence-based care that all with need should receive • Preference-sensitive care: misused • Treatment choices with multiple options; involves tradeoffs, scientific evidence re: outcomes is variable • Supply-sensitive care: overused • Visits, hospitalizations, ICU admissions and other services where utilization is associated with supply of resources
Hip Fracture (CV=13.8) Knee Replacement (CV= 55.0) 4x Hip Replacement (CV= 67.2) Back Surgery (CV= 93.6) 7x Incidence of surgery: hip fracture repair, knee and hip replacement and back surgery: 306 hospital regions (2000-01)( Preference-sensitive care is typified by elective surgery)
Preference-Sensitive Care • Involves tradeoffs -- more than one treatment exists and the outcomes are different • Scientific evidence re: outcomes sometimes good, sometimes not • Decisions should be based on the patient’s own preferences and values • But Provider Opinion Often Determines Which Treatment is Used
Shared Decision making – a definition Decisions that are shared by doctors and patients, informed by the best evidence available and weighted according to the specific characteristics and values of the patient. Légaré et al. Patient Education and Counseling. 2006
Knowledge of relevant treatmentoptions and outcomes Concordance between patientvalues and care received Which rate is right? Impact of improved decision quality on surgery rates: BPH 40% reduction in TURP after DA
IOM “Crossing the Quality Chasm” Shared decision making is reflected in 4 of the 10 “simple rules” for redesign of HC: • Customization based on patients’ needs and values • Patient as source of control • Shared knowledge and free flow of information • Evidence based decision making
SDM has not been adopted by health professionals. Why not? What are the barriers?
TIME • Time Required to Deliver All Highly Recommended 7.4 hrs/day Preventive Services: • Time Required to Deliver All Highly Recommended 10.6 hrs/day Chronic Care Services: Yarnall, AJPH, 2003 Yarnell, Ann Fam Med, 2005
Barriers to practicing SDM • Clinicians • Challenge to physician autonomy • Don’t recognize preference sensitive decisions • Evidence difficult to extract, interpret, communicate • Practice • Logistics • Lack of time • Lack of reimbursement • Patients • “Patients don’t want to participate” • Variation in role preference • Literacy, Numeracy
Patient Decision Aids • Evidence based tools designed to facilitate SDM. • Many formats: print, audio, video, internet • Adjunct to counseling
Impact of Decision Aids:Cochrane review of 51 RCTs • Increase patient involvement • Improve patient knowledge • Clarify patient values • Improve concordance between values and choices • Reduce patient decisional conflict, regret • Improve realistic expectations • Decrease number who are undecided O’Connor, Cochrane Collaboration, 2006
BPH PSA Screning Prostate Cancer Coronary Artery Disease CHF Advanced Directives Uterine Fibroids Ovarian Cancer Depression Weight loss surgery Breast Cancer DCIS Breast Reconstruction Abnormal Uterine Bleeding LBP: Herniated Disc LBP: Spinal Stenosis Chronic LBP Knee OA Diabetes (Type II) The Informed HC Consumer FIMDM Video DAs Foundation for Informed Medical Decision Making
Resources to Support Decision Making • Ottawa Health Research Institute • http://decisionaid.ohri.ca/index.html • FIMDM • http://www.fimdm.org • WebMD • http://www.webmd.com/ • Mayo Clinic • http://www.mayoclinic.com • DHMC Center for Shared Decision Making • http://www.hitchcock.org/dept/csdm
Ottawa Decision Aids • Ottawa Personal Decision Guide • A to Z Global Inventory of Patient Decision Aids • Cochrane Systematic Review: Efficacy of Patient Decision Aids • Training in Decision Support • Evaluation Measures • Resources www.ohri.ca/decisionaid
DHMC experience with SDM • Spine Center • Comprehensive Breast Program • Center for Shared Decision Making • Primary Care: • Implementation of PSA Decision Aids study
PSA DA Study: GOALS Assess: • Feasibility of routine use of decision aids in Primary Care • Impact of video decision aid on decision choice and quality • Patient and provider satisfaction
RESULTSPSA Video Distribution * Ongoing
RESULTSPatient Choice * P < .01
RESULTSVideo Impact on Choice AfterVideo
RESULTS Decision Quality Patient Knowledge of key PSA facts
Decision Quality: Patient Values Patients who feel it is more important to “Know if you have cancer” are MORE likely to choose PSA screening (OR 1.9 (95% CI 1.6-2.4)). Patients who feel it is more important to “Avoid worry from false alarm” are LESS likely to choose PSA screening (OR 0.7 (95% CI 0.6-0.8)).
CONCLUSIONS • Systematic use of a PSA DA in primary care is feasible. • Viewing the PSA DA resulted in fewer patients being unsure of their decision and more patients choosing no screening. • Viewing the PSA DA helped patients make a higher quality screening decision. • Patients and clinicians found the PSA DA helpful and time efficient.
Next steps: DHMC DA Research Introduce Chronic Condition DAs into routine use in GIM practices Expand DAs to community based sites Assess impact of DAs on decision quality, choice and resource utilization.
SDM Communication Skills • Define/explain problem • Discuss patient’s desired role • Present options • Discuss pros/cons • Explore patient values, preferences • Assess patient self-efficacy • Present doctor recommendations • Clarify understanding • Make or explicitly defer decision Adapted from Makoul G. An Integrative Model of Shared Decision Making in Medical Encounters. Pt Educ and Counseling 2006
Which skills do clinicians most need to improve? • Ask about patients’ preferred role in decisions • Assess patients’ values • Screen for decisional conflict • Assess support or undue pressure on patient • Increase patients’ involvement in decision making Légaré, Canadian Family Physician, 2006
Decisional Conflict Decisional conflict is defined as a state of uncertainty about which course of action to take when the choice among competing actions involves risk, loss, regret, or a challenge to personal life values. Legare et al, Canadian Family Physician 4/06
S.A.V. E. Sure of your decision Adequate information Values Encouragement • Are you sure which choice you want to make? • Do you feel you have adequate information about the options, risks and benefits? • Do you know what matters most to you, the risks or the benefits? • Do you have enough support or are you feeling undue pressure from others?
Trigger tape #1 Making a Prostate Cancer Screening Decision: Usual Care
Trigger Tape #2 Making a Prostate Cancer Screening Decision: Information Based Shared Decision Making
Trigger Tape #3 Making a Prostate Cancer Screening Decision: Shared Decision Making after Decision Aid
Supporting patients facing difficult health decisions Most important changes participants intended to make in their practice: To ask about patient’s preferred role in decision making To assess patient values To screen for decisional conflict To assess support or undue pressure on patients To increase patients involvement in decision making Legare, et al. Canadian Family Physician 4/06
Practice communication skills • The scenario • 60 year old at primary care visit • Considering PSA screening • Concerned about possibility of erectile dysfunction • The task: (~7 min/role play) • Engage in shared decision making discussion w/ pt. • Assess patient values • Identify decisional conflict • Observer(s) provide feedback
Practice communication skills The scenario 50 year old at primary care visit Considering treatment options for HNP Concerned about current limitations despite optimal NSAID’s; fearful of complications of surgery The task: (~7 min/role play) Engage in shared decision making discussion w/ pt. Assess patient values Identify decisional conflict Observer(s) provide feedback
Debrief What surprised you? What confused you? What went well? What would you change?