1 / 30

Shared Decision Making Defined

Shared Decision Making: 2011 Overview and Role in Depression Care November 3, 2011 Ruby Spicer, MPH, RN. Shared Decision Making Defined. A Shared Decision Making (SDM) process results in medical decisions that are: Shared by doctors and patients

tanaya
Download Presentation

Shared Decision Making Defined

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Shared Decision Making: 2011 Overview and Role in Depression CareNovember 3, 2011Ruby Spicer, MPH, RN

  2. Shared Decision Making Defined A Shared Decision Making (SDM) process results in medical decisions that are: • Shared by doctors and patients • Informed by the best evidence available about alternative treatments • Weighted according to the specific needs, preferences and values of the patient (Légaré et al., 2006)

  3. SDM Defined, cont. • Appropriate when there is more than one evidence-based option, or when evidence isn’t clear about the best option • Preference-sensitive conditions: knee replacement, BPH, early breast cancer, depression • Cancer screening • Chronic conditions (decisions about self-care) • Advance care planning

  4. SDM Background: Dartmouth • Jack Wennberg, MD: Unwarranted variations • Effective care • Supply sensitive care • Preference sensitive care

  5. Dartmouth Atlas: “Geography is destiny” Percent enrolled in hospice during last six months of life, 2003-2007

  6. Dartmouth Atlas, cont. How often did hospital staff explain medications to patients? 2003-2007

  7. SDM: A means of reducing unwarranted variation • “The right rate” is the rate at which well-informed patients choose any procedure, test, etc. • Jack Wennberg co-founds Foundation for Informed Medical Decision Making, 1988 • First decision aids from FIMDM • inform patients about known benefits and harms of specific procedures • elicit patient values and preferences

  8. 2008: Growing National Interest in SDM • SDM research: clearly “the right thing to do,” and potential cost-saver • 2007 Cochrane review: avg. 24% reduction in choice of elective surgery after SDM (BPH, knee replacement, spine, etc.) • Better patient-provider communication; focused visits; more participation and “decision comfort” • MAY lead to better care plan adherence, better outcomes; mixed and limited evidence • From research to practice • 2007: WA demonstration requires DAs before hip, knee replacement; legal protection for physicians

  9. So…What is SDMin practice? • In 2011, there is disagreement • Experts agree that SDM ideally involves: • Decision aid (print, video, online), used outside or during clinical encounter • Does more than provide information! • Decision support to help patient “process” decision aid, move closer to decision • Staff type may vary • Closing the loop with primary care provider

  10. Decision Aids • Patient-based types: Healthwise, FIMDM • Health literacy, patient motivation may be issues

  11. Decision aids, cont. • Encounter-based types (e.g., Mayo Clinic diabetes cards) combine clinical information with decision support • More resource-intensive, especially when used by providers

  12. Origins of SDM at MaineHealth • 1998-2008: • Learning Resource Center had offered a range of decision aids, but never used systematically • Physician researchers just beginning to study specific decision aids (breast CA, prostate CA, menopause) • 2009: Grant from Foundation for Informed Medical Decision Making funds demonstration projects introducing DAs into routine primary care

  13. MaineHealth: SDM in Primary Care, 2009-present • Five primary care, two employee health sites offering FIMDM DAs by Sept. 2010 • DA selection varies • Most chose diabetes, colorectal CA screening, PSA screening, depression, acute or chronic low back pain • Clinical workflows differ • Some mail DAs before visits; some give or mail after visits; some give between • Varying degrees of follow-up

  14. Patient satisfaction data, Jan. 2010-Sept. 2011

  15. Patient data, cont. • Depression: • 6 out of 70 surveys returned • 17 out of 440 decision aids given • Why so few? • Many practices interested in depression DA due to work with PHQ-9, mental health integration • Unsure how to integrate DA into workflow

  16. Depression and SDM • A preference-sensitive condition • Choice of medication, psychotherapy, self-care, or combination • If not severe, watchful waiting • Improved patient engagement likely to improve treatment adherence and outcomes (and other health outcomes?) • Two prominent decision aids • Healthwise: electronic format • FIMDM: DVD-based; features patient stories

  17. Healthwise: Should I take an antidepressant? http://www.mainehealth.com/healthinformation.cfm?xyzpdqabc=0&id=2872&action=detail&AEProductID=HW_Knowledgebase&AEArticleID=ty6745#zx3770 • Get the Facts; Compare Options • Your Feelings • Your Decision • Quiz  Summary • Can be printed for review with clinician • In the future, may become part of patient record

  18. Healthwise: Should I take an antidepressant? Discussion • What did you like, and not like? • What are opportunities, challenges for use in practice?

  19. FIMDM: Coping with symptoms of depression Introduction(Chapter 3 to 4:45)

  20. FIMDM: Coping with symptoms of depression Discussion: • What did you like, and not like?

  21. FIMDM: Coping with symptoms of depression • How do I feel better?(10:42; 2.5 mins.) • Self help/watchful waiting (13:47-17:15; 3.5 mins.) • Antidepressant medications (17:16-19:33; 2.25 mins.) • Counseling (22:30-26:00; 3.5 mins.) • Looking forward(28:50-32:20; 3.5 mins.)

  22. FIMDM: Coping with symptoms of depression Discussion: • What did you like, and not like? • What are opportunities, challenges for use in practice?

  23. MaineHealth: Depression DA workflow questions • Which patients should receive DAs? • If based on PHQ-9 score, which range? • Should patients currently using antidepressants revisit decisions? • Automatic distribution, vs. “hand picking” of patients? • What will trigger distribution, and who will offer the DA? (provider, behavioralist, RN care manager?) • What will follow-up look like?

  24. Depression workflow: Practice #1 • Eligibility: new or current patient with depression dx with PHQ-9 score 10-19 • Medication and psychotherapy equally effective • 10-14 score includes watchful waiting option • 20+ not appropriate; Rx is indicated • Patient flagged prior to appt.; DA placed in box outside exam room • Follow-up unclear • Patient may leave office without treatment plan • No fixed interval until next visit or contact

  25. Lessons learned: Practice #1 • Providers offer DAs only to “right patients” • Providers report high rates of patient decline • Providers are concerned about team approach; difficulty involving care managers, health educator • Practice decided to select new decision aids rather than address perceived barriers; why?

  26. Depression workflow: Practice #2 • International, vulnerable patient population • MD resident makes EHR referral to health educator at Learning Resource Center • Educator and patient make appt. for DA viewing, decision support; may involve interpreter • Patient surveys indicate high level of satisfaction with DA, decision support • Only a few DAs prescribed in one year after two resident training sessions; why?

  27. Despite challenges, SDM should be part of depression care • Current practice often leads to people not following through with treatment • Adherence to treatment likely to be improved when patient participates in choice of treatment • Better adherence leads to improved outcomes

  28. 2011: More interest in SDM than ever • Maine, 2009 • Act to mandate SDM for certain conditions covered by public payers; became Resolve to study • Affordable Care Act, 2010 • $ to develop standards, certification for decision aids • $ to establish SDM Resource Centers • $ to providers for implementation • AMA report on SDM, 2010 • Encourages physicians to adopt SDM processes, but opposes payer mandates, cautioning against cost reduction as primary goal (though not yet proven to save $$)

  29. SDM at MaineHealth: 2012 and beyond • SDM role in strategic initiatives • Role in targeted health improvement goals: chronic conditions, end of life care, colorectal CA screening • Patient-centered care: Patient-Centered Medical Home, Accountable Care • Above all, the right thing to do

  30. Questions/discussion Ruby Spicer, RN, MPH spicer2@mainehealth.org Many thanks to: Neil Korsen, MD, MS Kathleen Fairfield, MD, DrPH Foundation for Informed Medical Decision Making

More Related