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D e c i s i o n Q u a l i t y M e a s u r e m e n t
Aligning Incentives for Patient
Engagement
May 23, 2013
Measuring and Improving
Decision Quality
Karen Sepucha, PhD
Health Decision Science Center
Massachusetts General Hospital
...
Measuring Decision Quality in
Clinical Practice
Dale Collins Vidal, MD
Section Chief, Plastic Surgery, DHMC
Professor of S...
36 years old female
Presented with sore on right breast
Referred for biopsy
Diagnosis:
Invasive Breast Cancer
Meet Amy
Typical Journey
Amy’s Journey
Amy’s Journey
• Sometimes, there is no “right” choice
• When there is a single best option,
doctors may not be aware of it
• Or worse, t...
Comprehensive
Breast Program
Surg. Oncology
Med. Oncology
Radiation Onc.
Radiology
Pathology
Plastic Surgery
Familial Canc...
Health Care Delivery
is Complicated
Health Care Delivery
Is Complicated
Health Care Decisions are
More Complicated
Categories of Care
Effective
Care
Preference
Sensitive
Supply
Sensitive
Health Care
Shared Decision Making
Preference
Sensitive
SDM
Discussion
• In 1993, an NIH consensus panel
recommended that breast
conservation would be the preferred
treatment for mos...
Discussion
• In situations where there is no single
best option and/or the evidence is
uncertain, how should we inform
pat...
Slides courtesy of Nan Cochran
“The risk of a side effect
from this medication is…”
Qualitative
Term
Your Estimate of the
...
High Quality Decision require
Adequate Knowledge
Values clarification
Values-Choice
Concordance
Sepucha, Fowler, Mulley.
P...
Former Intake Process for Patients Newly
Diagnosed with Breast Cancer
Biopsy
reveals
invasive
cancer
Patient
proceeds to
a...
Biopsy
reveals
invasive
cancer
Patient view
DA prior to
appt. with
surgeon
Radiologist
informs patient
of diagnosis
Coordi...
Evidence Based
Decision Aids:
Norms
dex*
1/7
es
Leaning toward : Mastectomy
Sure about choice : No
Knowledge :
Understands :
survival rates
recurrence rates
Question
Post
Video
Post
Consult
1. Survival Rate 100% 96%
2. Recurrence Rate 84% 93%
3. Recurrence Likelihood 98% 94%
4. ...
2.3
2.5
2.2
2.2
4.3
4.2
3.9
4.6
1-A Little
Important
2 3 4 5-Very
Important
Reasons to choose Lumpectomy
Breast is saved
N...
Logistic regression of value scores as
predictors of surgical treatment choice.
Collins E D et al. JCO 2009;27:519-525
70
75
80
85
90
95
100
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
PercentBCS
Which rate is right? 70%? Or 95%?
Rates...
Discussion
• Which rate is right?
Health Care Decisions
are Complicated
…and decision quality is an important
dimension of care if we want to insure
that pa...
Value Proposition for SDM
The clinical encounter may be further
complicated by the emotional distress
associated with a recent diagnosis or
underlyi...
Discussion
• How can shared decision making
optimize the value equation?
Value = Quality/Cost
36 years old female
Presented with sore on right breast
Referred for biopsy
36 year single special educator
Invasive Breas...
Take Aways
• Why is health care delivery so
complicated?
• What is it about health care decisions
that make them so compli...
Thank You!
• Jack Wennberg
• Jim Kim, Jim Weinstein
• Al Mulley, K. Sepucha
• Hilary Llewellyn-Thomas
• Annette O’Connor
• Allison Ha...
Agenda
 What is a good decision?
 How to measure “decision quality”?
 Knowledge
 Matching treatment to goals
 How mig...
Case study: Mr. M’s Story
 71yo man referred to orthopedics, worsening
right hip pain over past 2 years, x-rays confirm
d...
Mr. M’s Letter
38
High quality, patient-centered care
NQFNational Quality Forum
Core Themes:
 fully informed
 treatments reflect
patients’...
Agenda
 What is a good decision?
 How to measure “decision quality”?
 Knowledge
 Matching treatment to goals
 How mig...
Measuring Decision Quality
To provide evidence that
- The patient understands key
facts.
-The treatment received is
consis...
“they didn’t say to me, “Well, we could
remove the breast, we could do
this, we could do that.” They just
said, “This is w...
Survey development process
ITEM GENERATION
 Literature review
 Focus groups and
interviews
 Candidate facts and
goals
...
Field tests for many decisions
 Surgical decisions (n=1,221)
 Breast cancer surgery (n=237, n=445) and Reconstruction (n...
Measuring
knowledge
 Key facts
 Mix of gist and
quantitative
 Strong
psychometrics
Measuring
goals
 Straightforward
task
 Key
consequences
good and bad
 Challenge of
timing
assessment
Do patients get treatments that match their
goals?
Had
Surgery
Had non surgical
treatment
Goals suggest
Surgery
Goals sugg...
Do patients get treatments that match their
goals? (n=383)
Had
Surgery
Had non surgical
treatment
Goals suggest
Surgery
50...
Is there a “Decision Quality” score?
 Informed and receive treatments that match their
goals
 31% of respondents met cut...
Agenda
 What is a good decision?
 How to measure “decision quality”?
 Knowledge
 Matching treatment to goals
 How mig...
What’s the purpose of measurement?
Research
BasicTranslClinical
Accountability
Performance
measured and
compared
Clinica...
Partners ACO: care improvement tactics
52
Longitudinal Care Episodic Care
Primary Care Specialty Care Hospital Care
Access...
PrOE – Procedure Decision Support
53
Carotid
Endarterectomy
Carotid
Stent
Mr. M’s story, continued
 2 years later, pain worsened and night time
pain came back
 Went back to surgeon and had repla...
Summary
 Well-tested decision quality survey instruments
exist for common topics
 Download from
(www.massgeneral.org/dec...
Decision Quality Measurement
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Decision Quality Measurement

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Published on

Aligning Incentives for Patient Engagement: Enabling Widespread Implementation of Shared Decision Making
May 23, 2013

Karen Sepucha, Massachusetts General Hospital
Dale Collins Vidal, The Dartmouth Institute for Health Policy & Clinical Practice

Published in: Health & Medicine
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Decision Quality Measurement

  1. 1. D e c i s i o n Q u a l i t y M e a s u r e m e n t Aligning Incentives for Patient Engagement May 23, 2013
  2. 2. Measuring and Improving Decision Quality Karen Sepucha, PhD Health Decision Science Center Massachusetts General Hospital ksepucha@partners.org http://www.massgeneral.org/decisionsciences/
  3. 3. Measuring Decision Quality in Clinical Practice Dale Collins Vidal, MD Section Chief, Plastic Surgery, DHMC Professor of Surgery, Dartmouth Medical School Director of the Center for Informed Choice, TDI
  4. 4. 36 years old female Presented with sore on right breast Referred for biopsy Diagnosis: Invasive Breast Cancer Meet Amy
  5. 5. Typical Journey
  6. 6. Amy’s Journey
  7. 7. Amy’s Journey
  8. 8. • Sometimes, there is no “right” choice • When there is a single best option, doctors may not be aware of it • Or worse, they may know the best choice, but fail to act on it Fragmented care of the past…
  9. 9. Comprehensive Breast Program Surg. Oncology Med. Oncology Radiation Onc. Radiology Pathology Plastic Surgery Familial Cancer Program Physical Therapy Clinical Trials Palliative Care …replaced by coordinated care
  10. 10. Health Care Delivery is Complicated
  11. 11. Health Care Delivery Is Complicated Health Care Decisions are More Complicated
  12. 12. Categories of Care Effective Care Preference Sensitive Supply Sensitive Health Care
  13. 13. Shared Decision Making Preference Sensitive SDM
  14. 14. Discussion • In 1993, an NIH consensus panel recommended that breast conservation would be the preferred treatment for most women with early breast cancer • What is the right rate for breast conserving surgery in the setting of early stage breast cancer?
  15. 15. Discussion • In situations where there is no single best option and/or the evidence is uncertain, how should we inform patients about their options?
  16. 16. Slides courtesy of Nan Cochran “The risk of a side effect from this medication is…” Qualitative Term Your Estimate of the probability Rare Unlikely Probable Very Likely
  17. 17. High Quality Decision require Adequate Knowledge Values clarification Values-Choice Concordance Sepucha, Fowler, Mulley. Policy Support For Patient- Centered Care: The Need For Measurable Improvements In Decision Quality, Health Affairs 2004
  18. 18. Former Intake Process for Patients Newly Diagnosed with Breast Cancer Biopsy reveals invasive cancer Patient proceeds to appt. with surgical oncologist Radiologist informs patient of diagnosis Coordinator schedules appt. with surgical oncologist
  19. 19. Biopsy reveals invasive cancer Patient view DA prior to appt. with surgeon Radiologist informs patient of diagnosis Coordinator schedules 2 appts: CSDM & surgery Current Intake Process for Patients Newly Diagnosed with Breast Cancer
  20. 20. Evidence Based Decision Aids: Norms
  21. 21. dex* 1/7 es Leaning toward : Mastectomy Sure about choice : No Knowledge : Understands : survival rates recurrence rates
  22. 22. Question Post Video Post Consult 1. Survival Rate 100% 96% 2. Recurrence Rate 84% 93% 3. Recurrence Likelihood 98% 94% 4. Urgency of decision 94% 98% Total (Average) 94% 95% Patient Knowledge N=115 Collins et al. Can Women With Early-Stage Breast Cancer Make an Informed Decision for Mastectomy? J Clin Oncol 27:519-525. © 2008
  23. 23. 2.3 2.5 2.2 2.2 4.3 4.2 3.9 4.6 1-A Little Important 2 3 4 5-Very Important Reasons to choose Lumpectomy Breast is saved No prosthesis Recurrence rate Summary score Reasons to choose Mastectomy May take less time Peace of mind Recurrence rate Summary score 2.7 2.9 3.2 2.9 3.8 4.2 4.5 4.2 1-A Little Important 2 3 4 5-Very Important Reasons to choose Lumpectomy Breast is saved No prosthesis Recurrence rate Summary score Reasons to choose Mastectomy May take less time Peace of mind Recurrence rate Summary score Lumpectomy Choice Mastectomy Choice Values for Possible Outcomes Compared to Treatment Choice 65% 35%
  24. 24. Logistic regression of value scores as predictors of surgical treatment choice. Collins E D et al. JCO 2009;27:519-525
  25. 25. 70 75 80 85 90 95 100 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 PercentBCS Which rate is right? 70%? Or 95%? Rates of Breast Conservation at a major academic medical center
  26. 26. Discussion • Which rate is right?
  27. 27. Health Care Decisions are Complicated …and decision quality is an important dimension of care if we want to insure that patients are getting the care they need and would choose when fully informed.
  28. 28. Value Proposition for SDM
  29. 29. The clinical encounter may be further complicated by the emotional distress associated with a recent diagnosis or underlying disease The push for increased clinical efficiency and clinical documentation is driving shorter and shorter interactions…. At the same time, we must evaluate and inform patients about increasingly complex options – often in situations where the evidence may lacking or inadequate. Clinical Barriers
  30. 30. Discussion • How can shared decision making optimize the value equation? Value = Quality/Cost
  31. 31. 36 years old female Presented with sore on right breast Referred for biopsy 36 year single special educator Invasive Breast Cancer Remember Amy?
  32. 32. Take Aways • Why is health care delivery so complicated? • What is it about health care decisions that make them so complicated? • What does it take to redesign delivery systems to support high value, patient centered care? • How can we embed change into practice?
  33. 33. Thank You!
  34. 34. • Jack Wennberg • Jim Kim, Jim Weinstein • Al Mulley, K. Sepucha • Hilary Llewellyn-Thomas • Annette O’Connor • Allison Hawke, Caroline Moore, Kate Clay, Stephen Kearing, • Sue Berg, Ashley Harris, Sherry Thornburg • Lisa Weiss, DCS • FIMDM, Health Dialog Acknowledgments
  35. 35. Agenda  What is a good decision?  How to measure “decision quality”?  Knowledge  Matching treatment to goals  How might the survey be used?
  36. 36. Case study: Mr. M’s Story  71yo man referred to orthopedics, worsening right hip pain over past 2 years, x-rays confirm damage  Orthopedic surgeon’s note: “I went over in some detail different treatment options. He very much wishes to proceed with right total hip replacement.”  Talked with family and friends, saw PCP for pre- op evaluation 37
  37. 37. Mr. M’s Letter 38
  38. 38. High quality, patient-centered care NQFNational Quality Forum Core Themes:  fully informed  treatments reflect patients’ want, needs and preferences  play a key role in making healthcare decisions
  39. 39. Agenda  What is a good decision?  How to measure “decision quality”?  Knowledge  Matching treatment to goals  How might the survey be used?
  40. 40. Measuring Decision Quality To provide evidence that - The patient understands key facts. -The treatment received is consistent with the patient’s personal goals. -The patient was meaningfully involved in decision making Sepucha et al. 2004 Health Affairs; Elwyn BMJ 2006
  41. 41. “they didn’t say to me, “Well, we could remove the breast, we could do this, we could do that.” They just said, “This is what we’re going to do.” And that was it—I wasn’t in on the decision.” “I made the decision. I’m very happy with the lumpectomy because that’s what I wanted to do from the beginning. They [my doctors] didn’t disagree. They didn’t agree. They just said, “Okay.” They understood.” “She[the doc] was compassionate, … [and] gave me the data that I needed ... We talked statistics and sizes and measurements and things that helped me..with my decision.” Who made the decision about treatment of your breast cancer? Mainly the doctor Both equally Mainly you X
  42. 42. Survey development process ITEM GENERATION  Literature review  Focus groups and interviews  Candidate facts and goals  Patient and provider importance ratings (~n=20) DRAFT INSTRUMENT • Draft items • Cognitive interviews (~n=5) • Medical and literacy review • Field testing FINAL INSTRUMENT • Formal evaluation, large, diverse samples • Benchmarks and standards for reporting
  43. 43. Field tests for many decisions  Surgical decisions (n=1,221)  Breast cancer surgery (n=237, n=445) and Reconstruction (n=84)  Knee and hip osteoarthritis (n=382; n=127)  Herniated disc (n=183)  Cancer screening (n=338)  Colon cancer screening (n=338)  Medication decisions (n=1,243)  Menopause (n=401)  Depression (n=404)  Breast cancer systemic therapy (n=358)  Underserved populations (n=289)  Colon cancer screening, African American (n=191)  Breast surgery Spanish language, Hispanic (n=98)
  44. 44. Measuring knowledge  Key facts  Mix of gist and quantitative  Strong psychometrics
  45. 45. Measuring goals  Straightforward task  Key consequences good and bad  Challenge of timing assessment
  46. 46. Do patients get treatments that match their goals? Had Surgery Had non surgical treatment Goals suggest Surgery Goals suggest Non surgical 47Source: Sepucha K et al. Decision quality instrument for treatment of hip and knee osteoarthritis: a psychometric evaluation. BMC Musculoskelet Disord 2011 Jul 5;12(1):149. Overuse Underuse
  47. 47. Do patients get treatments that match their goals? (n=383) Had Surgery Had non surgical treatment Goals suggest Surgery 50% 25% Goals suggest Non surgical 12% 14% 48Source: Sepucha K et al. Decision quality instrument for treatment of hip and knee osteoarthritis: a psychometric evaluation. BMC Musculoskelet Disord 2011 Jul 5;12(1):149.
  48. 48. Is there a “Decision Quality” score?  Informed and receive treatments that match their goals  31% of respondents met cutoff for knowledge and had treatment that matched their goals  Site (using decision aids), involvement score, and having had surgery were associated with higher DQ  Linked to less regret and more confidence
  49. 49. Agenda  What is a good decision?  How to measure “decision quality”?  Knowledge  Matching treatment to goals  How might the survey be used?
  50. 50. What’s the purpose of measurement? Research BasicTranslClinical Accountability Performance measured and compared Clinical practice Care is implemented in various settings Benchmarks Cost/Feasible Risk adjustment Actionable Feasible Acceptable Detailed Theory Controlled
  51. 51. Partners ACO: care improvement tactics 52 Longitudinal Care Episodic Care Primary Care Specialty Care Hospital Care Access to care Patient portal/physician portal Access program Extended hours/same day appointments Reduced low acuity admissions Expand virtual visit options Design of care Defined process standards in priority conditions (multidisciplinary teams) High risk care management Shared decision making Re-admissions Hospital Acquired Conditions 100% preventive services Appropriateness Hand-off and continuity programs Chronic condition management EHR with decision support and order entry Measurement Incentive programs Variance reporting/performance dashboards Quality metrics: clinical outcomes, satisfaction Costs/population Costs/episode Milford, CE, Ferris TG (2012 Aug). A modified “golden rule” for health care organizations. Mayo Clin Proc. 87(8):717-720.
  52. 52. PrOE – Procedure Decision Support 53 Carotid Endarterectomy Carotid Stent
  53. 53. Mr. M’s story, continued  2 years later, pain worsened and night time pain came back  Went back to surgeon and had replacement surgery  Good relief of pain, good function, no regrets
  54. 54. Summary  Well-tested decision quality survey instruments exist for common topics  Download from (www.massgeneral.org/decisionsciences/ )  Provide accountability that we have reached right patient, right treatment, right time

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