1. Engaging Patients ThroughEvidence-Based Medicine Margaret Holmes-Rovner, PhD MSU College of Human Medicine CMIO Conference, Chicago, Oct 3-4
2. What works? What doesn’t? Engagement in decision making – Encouraging decision making just before the encounter: question asking and coaching? – Patient access to electronic medical records? – Shared decision making with decision aids? – Patient centered interviewing? Engagement in chronic disease self- management Kinnersley BMJ 2008; Delbanco Ann Intern Med 2012; Stacy Cochrane 2011; Dwamena Cochrane forthcoming
3. What is Shared DecisionMaking? Ensuring patient involvement in decisions – Provide evidence about the condition, options, long term and short term outcomes (Decision Aids help) – Clarify patients‟ values for the outcomes that matter to them (Engage with evidence) – Guide patients so the clinical choice matches their informed values. – Meaningful dialog rather than uni-directional disclosure (provider led, patient engaged)O’Connor et al, Health Affairs, 2007
4. Road to Berwick’s triple aim Enhance the patient‟s experience (satisfaction increases) Improve the health of the population through patient engagement (adherence with negotiated plans) Decrease costs generated by over-use of tests and procedures Stacy D, Cochrane, 2011 Arterburn DE, Health Affairs, 2012
5. Roots in Decision Analysis OpDeath UDead pOpDeath SURGERY NoSurv3 UDead pNoSurv3 Survive SymL1 USymL1 # pSymL1 Surv3 SymL2 USymL2 CABG Medical or Surgical Rx # pSymL2 SymL3 USymL3 # MNoSurv3 UDead pMNoSurv3 MEDICAL MS ymL1 USymL1 pMSymL1 MS urv3 MS ymL2 USymL2 # pMSymL2 MS ymL3 USymL3 #
6. Preference-sensitive decisions? No one right answer for everyone Requires time for real informing/deciding Examples: -Lumpectomy vs mastectomy for early stage breast CA; -Active surveillance vs surgery vs radiation for early stage prostate cancer CA; -Stable CAD (today‟s example) “Sensitive” here means responsive to patients‟ goals for outcomes AND concerns about side effects.
7. Applied health literacy in DAs
8. Choosing Wisely? Toss-ups: marginal added benefit to more aggressive therapies Therapeutic Misconception is widespread – Patients frequently think surgery means they can skip medical therapy, chronic disease self- management Patients may choose options providers are not happy about, to date, most often no treatment Smith, BMJ, 2010
9. PCI ExamplePCI + Meds vs Meds alone in stable CAD No diff in risk of death or MI Function/quality of life improved in first 2 yrs. where chest pain not controlled by meds PCI should be an adjunct to meds in stable CAD Decreasing PCIs when not appropriate would: – Improve the quality of care for many patients – substantial healthcare savingsBoden, COURAGE trial, NEJM, 2007; Trikalinos, Lancet, 2009.
10. PCI Rates by Medicare Hosp.Referral Regions, 2005
11. BCBSM PCI Utilization, 2008,by HRR
12. Where in the diagnostictherapeutic cascade? Cardiology pre-cath? – Most pressing, proximal to decision – Data suggest patients don‟t change their expectation of preventing heart attacks. – Even “enhanced informed consent” via video in a recent unpublished study doesn‟t change expectations or utilization Stress test? Primary care counseling in stable CAD patients for “anticipatory SDM” 14
13. Intervention is Not just a DA Initiated in primary care when a stress test is ordered Cardiology changed their results report to: 1. Normal 2. Abnormal with no high risk features 3. Abnormal with high risk features # 1,2 go back to primary care for decision “After visit summary sheet” in primary care Care manager may do chronic disease self- management in cardiology or in primary care
14. Good Decision Aids exist? Science is strong – IPDAS update of background – Quality ratings of DAs: www.IPDAS.ohri.ca Public domain is growing (though limited) Private companies produce sets of DAs Recent Mass legislation will strengthen the public domain
15. What’s missing? Leadership Make it easy: DAs in the hands of providers and patients Make it delegatable by providers? (No) – Providers need brief training Improve care coordination? (Yes) – Primary care – Specialist – Providers - Care managers Holmes-Rovner, PEC, 2010
16. References Arterburn D, et al. Introducing decision aids at Group Health linked to sharply lower hip and knee surgery rates and costs. Health Aff. 2012;31:9,2094-2104. Boden, et al, COURAGE trial, NEJM. 2007; 2007 Apr 12;356(15):1503 Delbanco et al, Inviting patients to read their doctors‟ notes, Ann Intern Med, 157: 461-470. Holmes-Rovner M, et al, Shared Decision Making Guidance Reminders In Practice Pat Ed & Coun, 2011 Nov;85(2):219-24. Kinnersley P, Interventions before consultations to help patients address their information needs by encouraging question asking. BMJ. 2008 Jul 16;337:a485.
17. OConnor AM, et al. Toward the „tipping point‟: decision aids and informed patient choice, Health Affairs, 2007 May-Jun;26(3):716- 25. Smith SK, et al, A decision aid to support informed choices about bowel cancer screening among adults with low education: randomised controlled trial. BMJ, 2010;341. Stacey D, et al, Dec Aids for people faciing health treatment or screening decisions. Cochrane Database System Reviews 2011, Issue 10. Trikalinos, PCI for non-acute CAD: quantitat 20-year synopsis and network meta-analysis. Lancet 2009. 2010;341.
18. How to do it? : Initiate conversation around shared decision-making – Set the stage for the visit – Set an agenda for the visit – Get the patient‟s story Relate to the patient by – Eliciting emotions – Expressing empathy Educate the patient about his/her unique situation with disease-specific information (Expanded in SDM.) Help patient to commit to engaging in the care of his/her stable CAD Negotiate an action plan (long-term and short-term) with the patient (SDM: 2-way discussion of options, patient goals, how best to accomplish them) Referral and documentation