Creating Meaningful Conversations


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  • medical knowledge practice experience clinician preferences
  • personal health view lifestyle preferences own/others experience
  • HistoryRitualTools
  • HistoryRitualTools
  • Focusing on creating a conversation between patients and clinicians provides a way to deal with conflict which is an inevitable part of the healthcare delivery system.Tools structure the conversation and skill both the patient and the clinician.
  • Creating Meaningful Conversations

    1. 1. Creating Meaningful ConversationsInsights from Shared Decision Making at the point of care Annie LeBlanc PhD Knowledge and Evaluation Research (KER) Unit Mayo Clinic, Rochester, MN (USA)
    2. 2. Disclosure No financial conflict of interestKER Unit houses the processes of design & evaluation of decision aids, decides on topics, pursues funding, and conducts evaluation trialsKER unit does not receive funding from any for-profit pharmaceutical/manufacturer, nor do they receive any royalties / monetary benefits, directly or indirectly, from the use of the decision aids All decision aids are available free of charge
    3. 3. Why we came to shared decision making Patient centered high value healthcare Evidence based medicine Makes explicit the uncertainty of the evidence Gives a voice to patients (values/ preferences) Reduce unwarranted variations Right thing to do
    4. 4. Shared decision makingPlethora of trials demonstrating efficacy of tools Uptake still minimal in practices Barriers & facilitators How to achieve greater integration of SDM within clinical encounters How to facilitate its translation into practice
    5. 5. Current State
    6. 6. Patient and clinician begin consultationPatient and clinician discuss medications.Patient leaves with a prescription. Current state of decision makingPatient makes decision about medication.
    7. 7. Anatomy of a Decision (MD) • Medical knowledge • Years of education • Practice experience • Clinician preferences
    8. 8. Anatomy of a Decision (PT)• Expert on their life• Personal health view• Lifestyle preferences• Own/ther experiences
    9. 9. Anatomy of a Decision (Environment) • History • Ritual • Tools
    10. 10. Patient and clinician begin consultationPatient and clinician discuss medications.Patient leaves with a prescription. Shared decision makingPatient makes decision about medication.
    11. 11. Shared decision makingResearch Decision Patient Values andEvidence Aid Preferences Within an exam room
    12. 12. Our Decision Aids are focusedon facilitating a conversation between health professionals and patients and thus designed as tools intended for use during the clinical encounter
    13. 13. “What do we need to know to make this decision together ”
    14. 14. Observations Evidence synthesis clinical encounters Initial prototype Designers Field Study team Modified testing Patient advisory groups prototype Clinicians Stakeholders Final Decision Aid EvaluationPractice-based Randomized Controlled Trials Real life encounters
    15. 15. The case of diabetes medication
    16. 16. Glucose control in T2 diabetes No clear evidence for a goal HbA1c Comparative effectiveness data of safety9 types of agents (+ lifestyle modification) Many attributes per agent
    17. 17. Mullan et al. 2009
    18. 18. Web-based Decision aids
    19. 19. Online tutorial
    20. 20. More helpful Improved knowledgeMore involvement in making decisions 6-mo perfect medication use Better adherence PersistenceNo significant impact on HbA1c levels
    21. 21. Additional benefits observed• Patients gravitate towards weight change and daily routine cards• Physical form encourages patients to own decision• Noticeable positive change in body language• Card use prompts questions and encourages discussion but cards alone are not enough to give patients confidence• Gives permission to patients and clinicians to acknowledge cost as a factor in decision making• Lack of ability to provide a specific answer isn’t viewed negatively
    22. 22. The story of our 92 y old patient
    23. 23. The case of Depression Care
    24. 24. Depression Can be improved by Lifestyle changes, self-care practices psychotherapy, pharmacotherapy But of differentefficacy, safety, cost, burden to the patient
    25. 25. LeBlanc 2012
    26. 26. Cluster RCT in Rural & urban PC practices(10 practices WI MN, 106 clinicians, 200/300 patients)
    27. 27. “Actually used the depression medication decision cards with the patient, which she seemed to enjoy. Patient would like at this time to start on an SNRI. Shehad taken an SSRI before and felt that this did not help.I am comfortable with this decision. Together we chose to start” “Use the cards without patient being enrolled in the study” “Patient admits sexual side effects are important to her; as such, we chose”
    28. 28. Other Wiser Choices Decision Aids Chronic and acute care
    29. 29. Statin Choice Weymiller et al. Arch Intern Med 2007
    30. 30. Compared to usual care, patients using the decision aid were 22 times more likelyto have an accurate sense of their baseline risk and risk reduction with statins. Weymiller et al. Arch Intern Med 2007
    31. 31. Web-based tool http//
    32. 32. Osteoporosis Choice Montori et al, AJM 2011
    33. 33. AMI Choice
    34. 34. Chest Pain Choice Hess et al. Circ 2012
    35. 35. Head CT for Children
    36. 36. Work Setting Phase of developmentIndividualized medicineGenomic Choice IM clinic Design phase (electronic)Perioperative medicineSmoking choice Primary care Ongoing clinical trialCardiovascular medicineICD Choice Specialty care Design phaseHypertension e-primary care Design phaseMen’s healthProstate cancer screening and early treatment General (tablet) Design phase (scholar project; electronic)Women’s healthMammography < 40 Primary care Design phase (scholar project)Menopause symptoms Primary care Design phase (scholar project)Contraception Primary care Design phase (medical student project)Graves disease - treatment Specialty care Design phase (scholar project)OtherNonpharmacological treatment of depression Primary care Protocol phase (submitted to PCORI)Head CT for children with mild head trauma Emergency care Protocol phase (submitted to PCORI)Imaging wisely campaign Radiology/primary care Protocol phase (submitted to PCORI)
    37. 37. Wiser Choices Program ~20 decision aids for the clinical encounter11 practice-based randomized controlled trials >50 practices >300 clinicians >1000 patients >500 videos Patients & clinicians = key role No for-profit funding
    38. 38. Patients involvement 70 N=398 60Mean Total OPTION Score (%) 50 p=0.001 Adjusted Mean OPTION Score 40 Adjusted 37.6 30 20 20.4 10 0 All Chest Pain Diabetes Osteo I Osteo II Statin Usual care Decision aid
    39. 39. Summary of experience Age: 40-92 (avg 65) 74-90% clinicians want to tools again Adds ~3 minutes to consultation 60% fidelity without training 20% improvement in patient knowledge 17% improvement in patient involvementVariable effect on clinical outcomes and cost
    40. 40. Summary of experience• Creating a conversation between patients and clinicians: –Provides a way to deal with conflict which is an inevitable part of the healthcare delivery system –Gives permission to patients and clinicians to acknowledge factors in decision making• Lack of ability to provide a specific answer isn’t viewed negatively• Tools structure the conversation and skill of both the patient and the clinician
    41. 41. Evidence synthesisTranslation of evidence into action Creating a conversationDesign of care Patient important researcharound the needs of the patient Shared decision making Improve value of healthcare to the patientMinimally disruptive medicine FIT
    42. 42. Can we do thisMonday morning ?
    43. 43. Brief tools with minimal footprint (IPDAS)User-centered design, evidence-based content For use during consultation Free
    44. 44. 7th International SDM Conference Lima, Perú - June 16-19 2013 Globalizing SDMentes @ centre of healthcare
    45. 45. @annie_leblanc