Intro to Shared Decision Making


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An introduction to shared decision making and patient decision aids for health care providers.

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Intro to Shared Decision Making

  1. 1. Introduction to Shared DecisionMaking and Patient Decision Aids Richard Wexler, MD Chief Medical Officer February, 2012
  2. 2. What is Shared Decision Making? 2
  3. 3. Shared Decision Making (SDM) “the process of interacting with patients who wish to be involved in arriving at an informed, values-based choice among two or more medically reasonable alternatives”¹ Informed Values-Based • There is a choice • What’s important to the patient • The options • The benefits and harms of the options Information The Clinician The Patient¹A.M. OConnor et al, “ModifyingUnwarranted Variations In Health Care:Shared Decision Making Using PatientDecision Aids” Health Affairs, 7 October, 32004
  4. 4. A Word on Taxonomy Preference-SensitiveEffective Care• Strong evidence base Care supports care • Evidence supports more• Benefit-to-harm ratio high than one approach• All with need should receive • Treatment/testing options involve significant trade offs • Personal values, preferences and life circumstances should drive decisions SDM Sweet Spot 4
  5. 5. A Schematic of Shared Decision Making Options Patient Lens Goals and Concerns Benefits Benefits Risks Risks ADecision B Benefits Benefits Deliberate Decisionto Make Risks Risks C Benefits Benefits Unique Life Risks Circumstances Risks © Informed Medical Decisions Foundation. All Rights Reserved. 2012 5
  6. 6. Six Steps to SDM1. Invite patient to participate2. Present options3. Provide information on benefits and risks4. Assist patient in evaluating options based on their goals and concerns5. Facilitate deliberation and decision making6. Assist with implementation Benefits and Patient Deliberate and Invite Options Implementation Risks Preferences Decide 6
  7. 7. Patient Decision Aids: Tools to Facilitate SDM 7
  8. 8. Supported by Patient Decision Aids Options Patient Lens Goals and Concerns Benefits Benefits Risks Risks ADecision B Benefits Benefits Deliberate Decisionto Make Risks Risks C Benefits Benefits Unique Life Risks Circumstances Risks © Informed Medical Decisions Foundation. All Rights Reserved. 2012 8
  9. 9. Patient Decision Aids• Information about a specific condition• Evidence organized around specific decisions• Accessible—charts, graphs• Balanced 9
  10. 10. Patient Decision Aids• Encourage patients to interpret evidence in context of their own goals and concerns• Include patient stories• Encourage patients to make decisions with physician 10
  11. 11. Patient Decision Aids: Development Process• Literature review• Patient interviews and focus groups help identify: • issues most important to patients • common misconceptions• Provider interviews and focus groups help identify: • decision points and treatment options 11
  12. 12. Patient Decision Aids: Development Process• An evidence summary is produced by Foundation research associates, working with medical editors• Medical editors are generalists and free from industry conflicts• Summary is reviewed by clinical advisors, who are specialists• Editor has final control 12
  13. 13. Patient Decision Aids: Development ProcessFrom evidencesummary, a decision aidis produced whichincludestext, graphics, and oftenvideo. 13
  14. 14. Patient Decision Aids: Evaluation Process What Who When• Clinical accuracy • Patients • Draft scripts, interview• Balance • Medical editors material, graphical presentations• Viewer acceptability • Clinical advisors • Rough cut • Foundation and Health • “Final” version Dialog staff incorporates feedback • Clinical reviewers from evaluation process • Reviewed at 6 months for clinical accuracy • Evaluated every 2 years for accuracy, balance and relevance 14
  15. 15. Why Bother with SDM? 15
  16. 16. Why Bother with SDM?• No fateful decision in the face of avoidable ignorance• Doctors aren’t very good at diagnosing patient preferences• If doctors get it wrong, patients will still listen• It’s a patient safety issue 16
  17. 17. No Fateful Decision in the Face of Avoidable IgnoranceThe DECISIONS StudyNationwide telephone surveyConducted by University of MichiganThe Decisions Study. Medical Decision Making 2010; 30 supplement 1 17
  18. 18. DECISIONS Study Findings• Patients often not knowledgeable about the basic benefits and risks of their treatment• Patients usually not asked for their preferences about treatment• Providers discuss pros of treatments more than cons• Providers advise “do it” 65-95% of the time 18
  19. 19. Doctors Aren’t Very Good at Diagnosing Patient PreferencesKaren Sepucha• Identified key facts and goals for 14 decisions• Surveyed providers and patients • How important was each item • Identify the 3 most important itemsSepucha KR, et al. Pt Education and 19Counseling. 2008;73:504-10.
  20. 20. Top Three Goals and Concerns for Breast Cancer Decisions Condition: Goal Pat Prov pKeep your breast? 7% 71% P<0.01Live as long as possible? 59% 96% P=0.01Look natural without clothes 33% 80% P=0.05Avoid using prosthesis 33% 0% P<0.01 20
  21. 21. If Doctors Get It Wrong, Patients Will Still ListenSepucha KR, et al. Pt Education and 21Counseling. 2008;73:504-10.
  22. 22. Is Doing What the Doctor Thinks Best a Top Priority? Decision Pat Prov pBCA surgery 86% 14% P<0.01Hip replacement 84% 40% P<0.01Knee replacement 78% 35% P<0.01Menopause 60% 21% P=0.02PSA 59% 21% P=0.03Spinal Stenosis 46% 5% P<0.01 22
  23. 23. It’s a Patient Safety Issue 23
  24. 24. Patient Safety How do we describe operating on a patient who would say NO to surgery ifWrong Site Surgery alternatives, risks and benefits were well understood? Wrong Patient Surgery 24
  25. 25. Is SDM Effective? 25
  26. 26. Cochrane ReviewReview of 86 randomized trials evaluatingpatient decision aids • Increase patient knowledge • Increase patient involvement in decision making • Increase the proportion of patients with accurate risk perceptions (patients have more realistic expectations) 26
  27. 27. Cochrane Review• Increase the consistency between patient decisions and patient values• Reduce decisional conflict related to feeling uninformed or unclear about personal values• Reduce the proportion of patients who remain undecided• Reduce the choice of major elective surgery in favor of more conservative options 27
  28. 28. Thank you! 28