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Creating Meaningful Conversations
- 1. Creating Meaningful Conversations Insightsfrom Shared Decision Making at the point of care Annie LeBlanc PhD Knowledge and Evaluation Research (KER) Unit Mayo Clinic, Rochester, MN (USA)
- 2. Disclosure No financial conflict of interest KER Unit houses the processes of design & evaluation of decision aids, decides on topics, pursues funding, and conducts evaluation trials KER 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. Why we cameto 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. Shared decision making Plethoraof 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.
- 6. Patient and clinicianbegin consultation Patient and clinician discuss medications. Patient leaves with a prescription. Current state of decision making Patient makes decision about medication.
- 7. Anatomy of aDecision (MD) • Medical knowledge • Years of education • Practice experience • Clinician preferences
- 8. Anatomy of aDecision (PT) • Expert on their life • Personal health view • Lifestyle preferences • Own/ther experiences
- 9. Anatomy of aDecision (Environment) • History • Ritual • Tools
- 10. Patient and clinicianbegin consultation Patient and clinician discuss medications. Patient leaves with a prescription. Shared decision making Patient makes decision about medication.
- 11. Shared decision making Research Decision Patient Values and Evidence Aid Preferences Within an exam room
- 12. Our Decision Aidsare focused on facilitating a conversation between health professionals and patients and thus designed as tools intended for use during the clinical encounter
- 14. “What do weneed to know to make this decision together ”
- 15. Observations Evidence synthesis clinical encounters Initial prototype Designers Field Study team Modified testing Patient advisory groups prototype Clinicians Stakeholders Final Decision Aid Evaluation Practice-based Randomized Controlled Trials Real life encounters
- 16. The case ofdiabetes medication
- 17. Glucose control inT2 diabetes No clear evidence for a goal HbA1c Comparative effectiveness data of safety 9 types of agents (+ lifestyle modification) Many attributes per agent
- 18. Mullan et al.2009
- 19.
- 20.
- 21. More helpful Improved knowledge More involvement in making decisions 6-mo perfect medication use Better adherence Persistence No significant impact on HbA1c levels
- 22. 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
- 23. The story ofour 92 y old patient
- 24. The case ofDepression Care
- 25. Depression Can be improved by Lifestyle changes, self-care practices psychotherapy, pharmacotherapy But of different efficacy, safety, cost, burden to the patient
- 28.
- 29. Cluster RCT inRural & urban PC practices (10 practices WI MN, 106 clinicians, 200/300 patients)
- 30. “Actually used thedepression medication decision cards with the patient, which she seemed to enjoy. Patient would like at this time to start on an SNRI. She had 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”
- 31. Other Wiser ChoicesDecision Aids Chronic and acute care
- 32. Statin Choice Weymiller et al. Arch Intern Med 2007
- 33. Compared to usualcare, patients using the decision aid were 22 times more likely to have an accurate sense of their baseline risk and risk reduction with statins. Weymiller et al. Arch Intern Med 2007
- 34. Web-based tool http//:statinchoice.e-bm.info
- 35. Osteoporosis Choice Montori et al, AJM 2011
- 36.
- 37. Chest Pain Choice Hess et al. Circ 2012
- 38. Head CT forChildren
- 39. Work Setting Phase of development Individualized medicine Genomic Choice IM clinic Design phase (electronic) Perioperative medicine Smoking choice Primary care Ongoing clinical trial Cardiovascular medicine ICD Choice Specialty care Design phase Hypertension e-primary care Design phase Men’s health Prostate cancer screening and early treatment General (tablet) Design phase (scholar project; electronic) Women’s health Mammography < 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) Other Nonpharmacological 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)
- 40. Wiser Choices Program ~20 decision aids for the clinical encounter 11 practice-based randomized controlled trials >50 practices >300 clinicians >1000 patients >500 videos Patients & clinicians = key role No for-profit funding
- 41. Patients involvement 70 N=398 60 Mean 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
- 42. 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 involvement Variable effect on clinical outcomes and cost
- 43. 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
- 44. Evidence synthesis Translation ofevidence into action Creating a conversation Design of care Patient important research around the needs of the patient Shared decision making Improve value of healthcare to the patient Minimally disruptive medicine FIT
- 45. Can we dothis Monday morning ?
- 46. http://shareddecisions.mayoclinic.org Brieftools with minimal footprint (IPDAS) User-centered design, evidence-based content For use during consultation Free
- 47. 7th International SDMConference Lima, Perú - June 16-19 2013 Globalizing SDM entes @ centre of healthcare www.isdm2013.org
- 48. leblanc.annie@mayo.edu @annie_leblanc http://kerunit.e-bm.org http://kercards.e-bm.info/ http://shareddecisions.mayoclinic.org/ www.isdm2013.org
Editor's Notes
- #8 medical knowledge practice experience clinician preferences
- #9 personal health view lifestyle preferences own/others experience
- #10 HistoryRitualTools
- #12 HistoryRitualTools
- #44 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.