Angela Coulter: Getting the best value for patients

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Dr Angela Coulter, Director of Global Initiatives, Foundation for Informed Medical Decision Making, spoke at The King's Fund's 'Reducing unwarranted variations in health care' conference, giving her expert opinion on how to give the best value for patients: with the right intervention, in the right place, at the right time with the right level of involvement.

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Angela Coulter: Getting the best value for patients

  1. 1. 1<br />Best Value for Patients<br />Angela Coulter, PhD<br />Director of Global Initiatives<br />Foundation for Informed Medical Decision Making<br />acoulter@fimdm.org<br />www.informedmedicaldecisions.org<br />
  2. 2. 2<br />Overview<br />Shared decision-making<br />in acute conditions<br />in long-term conditions<br />Implementation challenges<br />
  3. 3. The clinical decision problem<br />Patients: <br />making decisions in the <br />face of avoidable ignorance<br />Clinicians: <br />poorly ‘diagnosing’ patients’ preferences leading to underuse, overuse and waste<br />Poor decision quality<br />
  4. 4. What we have learnt<br />Paternalistic or directive practice styles...<br />Create dependency<br />Discourage self-care<br />Ignore preferences<br />Undermine confidence<br />Do not encourage healthy behaviours<br />4<br />
  5. 5. Shared decision-making<br />A process in which clinicians and patients work together to select tests, treatments, management or support packages, based on clinical evidence and the patient’s informed preferences.<br />
  6. 6. 6<br />Sharing expertise<br />Clinician<br />Diagnosis<br />Disease aetiology<br />Prognosis<br />Treatment options<br />Outcome probabilities<br />Patient<br />Experience of illness<br />Social circumstances<br />Attitude to risk<br />Values<br />Preferences<br />
  7. 7. Key components of shared decision-making<br />Reliable, balanced, evidence-based information outlining treatment options, outcomes and uncertainties.<br />Decision support counselling with clinician or health coach to clarify options and preferences.<br />System for recording, communicating and implementing patient’s preferences.<br />
  8. 8. When is it appropriate?<br />When people face major health care decisions where there is more than one feasible option.<br />When people with chronic conditions want to be involved in planning their care, adopting healthier lifestyles, and enhancing their ability to self-manage.<br />
  9. 9. 9<br />What patients need to know<br />Is there more than one way to treat my condition?<br />Will treatment relieve the symptoms?<br />Benefits and harms?<br />Is treatment essential?<br />Recovery time?<br />Impact on quality of life?<br />What can I do to help myself?<br />
  10. 10. Patient decision aids<br />Information on…..<br />condition<br />treatment options<br />outcomes with and without treatment<br />uncertainties<br />values clarification<br />balanced<br />evidence-based<br />
  11. 11. Variations in hysterectomy rates in England<br />Hysterectomy is (usually) discretionary<br />Population-based hysterectomy rates vary more than 3x between local areas<br />Patients’ values and preferences should influence decisions<br />11<br />
  12. 12. 12<br />Decision aid + decision support<br />Helped patients form preferences<br />Reduced hysterectomy rates<br />Increased long-term satisfaction<br />Information + preference elicitation was cost-effective<br />Kennedy et al. JAMA 2002; 288: 2701-8<br />
  13. 13. 13<br />Decision aid + coaching in gynaecology<br />
  14. 14. Decision aids: the evidence<br />In 55 trials addressing 23 different screening or treatment decisions, use has led to:<br /><ul><li>greater knowledge
  15. 15. more accurate risk perceptions
  16. 16. greater comfort with decisions
  17. 17. greater participation in decision-making
  18. 18. fewer people remaining undecided
  19. 19. fewer patients choosing major surgery</li></ul>O’Connor et al. Cochrane Database of Systematic Reviews, 2009<br />
  20. 20. Chronic care model<br />HEALTH SYSTEM<br />COMMUNITY<br />Health Care Organisation<br />Resources and Policies<br /> ClinicalInformationSystems<br />Self-Management Support<br />DeliverySystem<br />Design<br />Decision<br />Support <br />Prepared,<br />Proactive<br />Practice Team<br />Informed,<br />Activated<br />Patient<br />Productive<br />Interactions<br />Improved outcomes<br />
  21. 21. Collaborative care planning in diabetes<br />
  22. 22. The clinic experience<br />Access & communication<br />Named contact<br />Registration, recall, review, and follow up<br />IT templates<br />Organisational processes<br />Professional<br />’<br />s <br />Professional<br />’<br />s <br />Professional<br />’<br />s <br />Individual<br />’<br />s story<br />Individual<br />’<br />s story<br />Individual<br />’<br />s story<br />story<br />story<br />story<br />Awareness of process & options<br />Knowledge <br />Knowledge <br />Knowledge <br />Awareness of approach to self-management<br />Emotional<br />Emotional<br />Emotional<br />Social<br />Clinical<br />Social<br />Social<br />Clinical<br />Clinical<br />Behavioural<br />Behavioural<br />Behavioural<br />and health <br />and health <br />and health <br />beliefs<br />beliefs<br />beliefs<br />HCP committed to partnership working<br />Engaged,<br /> informed patient<br />Share and discuss information<br />Share and discuss information<br />Share and discuss information<br />Structured education/ Information<br />Consultation skills / competencies<br />Goal Setting <br />Goal Setting <br />Goal Setting <br />Access to own records<br />Action<br />Action<br />Action<br />Action<br />Action<br />Action<br />Action<br />Action<br />Action<br />Action<br />Action<br />Action<br />Multi-disciplinary team working<br />Pre-consultation results<br />Knowledge of local options<br />Emotional & psychological support<br />Clinical expertise<br />Commissioning<br />- The foundation<br />
  23. 23. Informed, empowered patients <br />Have the knowledge, skills and confidence to manage their own health and healthcare,<br />And they…<br />make healthy lifestyle choices<br />tend to adhere to medication regimes <br />make informed and personally relevant decisions about their treatment and care<br />use less health care<br />Mosen et al 2007<br />
  24. 24. Changing the culture of care<br />Help patients understand their options<br />Give information about risks, benefits, consequences and uncertainties<br />Support patients to articulate their values and preferences<br />Reach a mutually agreed decision on the most appropriate course of action<br />19<br />
  25. 25. What are the barriers?<br />Time/resources<br />Inflexible systems<br />Clinical culture<br />
  26. 26. What could help?<br />Clinical leadership, training and skills<br />Social marketing<br />Identifying decision points and integrating decision support into clinical pathways<br />System for recording and acting on patients’ preferences<br />Monitoring and feedback<br />Incentives for clinicians<br />Strong social networks and community support<br />Supportive public policy<br />
  27. 27. What are the rewards?<br /><ul><li>Better consultations
  28. 28. Clearer risk communication
  29. 29. Improved health literacy
  30. 30. More appropriate decisions
  31. 31. Fewer unwanted treatments
  32. 32. Improved confidence and self-efficacy
  33. 33. Improved health behaviours
  34. 34. Safer care
  35. 35. Greater compliance with ethical standards
  36. 36. Reduced costs
  37. 37. Less litigation
  38. 38. Better health outcomes</li></li></ul><li>For more information………<br />www.informedmedicaldecisions.org<br />23<br />

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