A Care Experience with Shared Decision Making

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Presentation given at the Foundation's Jan. 26 Research and Policy Forum by Richard Wexler, MD, director of Patient Support Strategies for the Foundation.

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  • But it’s worth pausing for a moment to consider what we mean by “proof”
  • Add ACOs
  • To start with, we hoped to find organizations that had a high likelihood of succeeding We also wanted to establish a shared schematic or conceptual framework for the implementation efforts
  • Not meant to be strictly linear Two items I will present with a little more detail
  • We are also working on distribution rates rather than distribution numbers as well as viewing rates So, onto our approach to implementation strategy ….
  • Today I’d like to provide : If all goes according to plan – we should have 10 or 15 minutes for Q and A
  • Other significant differences: Screening ------------------------------------ None  Most (58%  84%) Some  All (70%  87%) Most  All (84%  87%) Preference-Sensitive ------------------------------------ None  Most (35%  57%) Some  All (49%  62%)
  • A Care Experience with Shared Decision Making

    1. 1. Richard Wexler, MD Director, Patient Support Strategies Shared Decision Making in Primary Care Moving From Concept to Reality
    2. 2. Presentation Outline <ul><li>Provide a brief overview of our Foundation’s demonstration site program </li></ul><ul><li>Share a few findings from the sites </li></ul><ul><li>Offer a context for the presentations and video which follow </li></ul>
    3. 3. Overview – Program Objective <ul><li>To demonstrate that the use of patient decision aids (DAs) and the process of shared decision making (SDM) can become part of routine care </li></ul>
    4. 4. Overview – Program Objective <ul><li>We are establishing proof of concept </li></ul><ul><li>Practical question: how strong does the case have to be? </li></ul><ul><li>Considerations </li></ul><ul><ul><li>Level of proof required by target audience </li></ul></ul><ul><ul><li>Potential harm of intervention </li></ul></ul><ul><ul><li>Potential benefit of intervention </li></ul></ul><ul><ul><ul><li>Is there an ethical imperative </li></ul></ul></ul><ul><ul><li>Financial cost of intervention </li></ul></ul><ul><ul><li>Time required to attain “proof” </li></ul></ul><ul><ul><li>Leveling the playing field </li></ul></ul>
    5. 5. Overview – The “Sites” Funded Demonstration Sites Primary Care Specialty Care Massachusetts General Hospital X University of North Carolina X Maine Health X Mercy Clinics Inc. X Stillwater Medical Group X Oregon Rural Practice Based Research Network X Palo Alto Medical Research Foundation X Group Health Cooperative X X University of Washington X X Allegheny General Hospital - Breast Center X University of California San Francisco - Breast Center X Dartmouth Hitchcock Medical Center (DHMC) - Breast Center X DHMC - Urology X DHMC - Orthopedics X DHMC - Spine Center X DHMC - Cardiology X
    6. 6. Overview - Support <ul><li>Sponsorship includes </li></ul><ul><ul><li>Financial support </li></ul></ul><ul><ul><li>Technical support </li></ul></ul><ul><ul><li>Participation in a learning community </li></ul></ul><ul><ul><li>Data aggregation and analysis </li></ul></ul><ul><li>Sponsorship duration – one to five years </li></ul>
    7. 7. Overview – Strategy <ul><li>Focus on Primary Care </li></ul><ul><ul><li>Primary care as a source of unbiased information </li></ul></ul><ul><ul><li>Use of patient decision aids prior to referral for elective surgery for preference sensitive care </li></ul></ul><ul><ul><li>Align with “Patient Centered” Medical Home and ACO movements </li></ul></ul>
    8. 8. Overview – Strategy <ul><li>Recruit for success </li></ul><ul><ul><li>Cultural commitment to quality improvement </li></ul></ul><ul><ul><li>Strong leadership support for SDM </li></ul></ul><ul><ul><li>Supporting infrastructure </li></ul></ul><ul><ul><li>Track record of success </li></ul></ul><ul><li>Establish clear objectives up front </li></ul>
    9. 9. Overview - Strategy <ul><li>Establish Conceptual Framework </li></ul>©Copyright 2010 Foundation for Informed Medical Decision Making All Rights Reserved
    10. 10. Overview - Strategy <ul><li>Measurement strategy </li></ul><ul><ul><li>Patient questionnaires </li></ul></ul><ul><ul><li>Data aggregation and analysis </li></ul></ul><ul><ul><li>Provider and staff satisfaction surveys </li></ul></ul><ul><ul><li>Focus group guides </li></ul></ul><ul><ul><li>Implementation tracking sheets </li></ul></ul>
    11. 11. Presentation Outline <ul><li>Provide a brief overview of our Foundation’s demonstration site program </li></ul><ul><li>Share a few findings from their work </li></ul><ul><li>Offer a context for the presentations and video which follow </li></ul>
    12. 12. Demonstration Sites – Returned Questionnaires July 2009 to January 2011 <ul><li>Acute Low Back Pain </li></ul><ul><li>Adjuvant Breast Cancer Therapy </li></ul><ul><li>Breast Reconstruction </li></ul><ul><li>Breast Cancer Surgery </li></ul><ul><li>Benign Prostatic Hyperplasia </li></ul><ul><li>Abnormal Uterine Bleeding </li></ul><ul><li>Uterine Fibroids </li></ul><ul><li>Coronary Artery Disease </li></ul><ul><li>Ductal Carcinoma in Situ </li></ul><ul><li>Depression </li></ul><ul><li>Herniated Disc </li></ul><ul><li>Hip Osteoarthritis </li></ul><ul><li>Knee Osteoarthritis </li></ul><ul><li>Menopause </li></ul><ul><li>Prostate Cancer </li></ul><ul><li>Spinal Stenosis </li></ul><ul><li>Weight Loss Surgery </li></ul>Preference-Sensitive n=1661 <ul><li>Colorectal Cancer Screening </li></ul><ul><li>PSA Testing </li></ul>Screening n=539
    13. 13. Patient Responses After Viewing DA: Overall how would you rate the program? Data submitted to Illume data warehouse as of 4-January-2011 n=1571 n=458
    14. 14. Patient Responses After Viewing DA: How important for clinicians to give DAs to patients? Data submitted to Illume data warehouse as of 4-January-2011 n=780 n=264
    15. 15. Patient Responses After Receiving DA: How much of the video did you watch? Data submitted to Illume data warehouse as of 4-January-2011 n=1582 n=472
    16. 16. Percentage of Correctly Answered Knowledge Questions By Amount of Video Watched Data submitted to Illume data warehouse as of 4-January-2011 n=546 n=144 NOTE: Does not include patients who read ALL of booklet * Scores for patients who watched NONE or ALL of the video are statistically significantly different at the p<.05 level
    17. 17. Patient Responses Before & After Viewing DA: How far along are you with this decision? Before DA After DA Preference-Sensitive Before DA After DA Screening Decided/ Close to deciding Not thought about it/ Considering options Data submitted to Illume data warehouse as of 4-January-2011 * NOTE: All before/after comparisons are statistically significantly different at the p<.05 level
    18. 18. Patient Responses Before & After Viewing DA: What are you leaning toward doing? Before DA After DA Before DA After DA Before DA After DA CRC Screening Surgery PSA Screening Data submitted to Illume data warehouse as of 4-January-2011 n=914 n=162 n=332
    19. 19. Thank You
    20. 21. Change that Works

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