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Shared Decision-Making: Bringing Patients into their Healthcare Loop
Suresh R. Mulukutla, MD FACC Director, Interventional Cardiology &
HVI Center for Quality, Outcome, and Clinical Research
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Complexity of Everyday Decisions
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Normal Decision-Making Apparatus
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Traditional Decision-Making Model: Paternalism at Its Peak
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• 10-fold variation in tonsillectomy
• 8-fold risk of death with surgery
• “… tendency for the operation to be performed for no particular reason and no particular result.”
• “…sad to reflect that many of the anesthetic deaths… were due to unnecessary operations.”
Variation in Medical Practice
1938: J Allison Glover
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• 17-fold variation in tonsillectomy
• 6-fold variation in hysterectomy
• 4-fold variation in prostatectomy
• “Need for assessing outcome of
common medical practices”
• “Professional uncertainty and
problem of supplier-induced demand”
Variation in Medical Practice…It Still Exists!
John E. Wennberg, 1973
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Variation in Discharges following Orthopedic Surgery
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8
Variability in Coronary Revascularization
Ratio of Rates of PCI (Stent Procedures) to US Average
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Variability in Cardiovascular Decision Making
Hannan EL, Racz MJ, Gold J, Cozzens K, Stamato NJ, Powell T, Hibberd M, Walford G. Adherence of catheterization laboratory cardiologists to American College of Cardiology/American Heart Association guidelines for percutaneous coronary interventions and coronary artery bypass graft surgery: what happens in actual practice? Circulation. 2010; 121: 267–275.
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• Shared Decision-Making: Engage patients in decision and allow for decisions to be driven based on their understanding and their own preferences
• Adjust supply of healthcare (clinicians, beds, etc)
• Change financial incentives for healthcare providers
Strategies to Reducing Variation
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Traditional Healthcare Decision-Making: An Unequal Partnership
Physician
Patient
Physician-Driven
Healthcare Decision
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Shared decision making is a process in which clinicians and patients work together to clarify treatment, management or self management support goals, sharing information about options and preferred outcomes with the aim of reaching mutual agreement on the best course of action.
Shared-Decision Making - Definition
(Shared Decision Making. Coulter, Collins. Kings Fund, July 2011)
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Shared Decision Making
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Forging a New Partnership
Activated, engaged patients Trained Healthcare Professionals
Patient-Centered Outcomes
Partnership Sharing Information Setting Expectations
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Creating a New Paradigm in the Redesign of Health Care
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Barriers to Shared Decision Making
We do it already!
Will it work?
My patients don’t want it
What if they don’t do what I think they should do?
I don’t have the time!
I don’t know how to do it!
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Healthcare providers • Challenge to autonomy
• Don’t want to recognize preference sensitive decisions
• Difficulty in communicating nuanced data to non-medical individuals
Practice • Lack of time
• Lack of reimbursement
• Logistics are not conducive to practicing SDM
Patients • Patients want to give up autonomy
• Literacy challenges
Lack of Decision Aids
Barriers to SDM are Not Easily Overcome
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What’s the Barrier?
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• Ethical imperative (patients want to be involved, and clinicians think they’re doing it by they are not)
• Legal imperative (medicolegal requirement to discuss options, risks, and consequences)
• Evidence based care (patients are more knowledgeable than we give them credit for)
• Appropriate allocation of resources (patients get ‘the care they need and no less, the care they want and no more’)
Why Should We Incorporate SDM?
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Misalignment of Physician-Patient Perceptions
• 85% of physicians believe that they share decisions about treatments with physicians… 50% of patients believe this to be true
• Only 65% of patients feel that they had enough information for a recent decision
• Patients are more willing to use decision aids than providers perceive
• Patients willing to discuss decisions with other members of healthcare team more than physicians perceive 20
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Activating Patients Empowers Them
21
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Activating Patients Empowers Them
22
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Patient Activation Measure
• Activated patients with the knowledge and skills to manage their own health and healthcare…
• …Working in partnership with prepared and trained clinical teams in scheduled appointments in a supportive system…
• …To proactively manage health and to anticipate and plan for times of need (care planning and anticipatory care planning)
23
Hibbard JH et al. Health Services Research. 2004.
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Patient Activation is a Journey
24
Compared with people at low levels of activation, people at high levels of
activation tend to enjoy a higher quality of life, have better clinical outcomes
and make more informed decisions about accessing medical services.
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Levels of Activation: A Tailored Approach
ACTIVATION PREDICTS OUTCOMES
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Shared decision making about treatments:
Patients who don’t have decision support:
• Are 59 times more likely to change their mind
• Are 23 times more likely to delay their decision
• Are five times for likely to regret their decision
• Blame their practitioner for bad outcomes 19% more often
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Shared decision making about treatments:
• Reduces unwarranted variation due to practitioner preferences
• Improves satisfaction
• Reduces wish to proceed to invasive treatments
• Reduces negligence claims
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Benefits of Patient Activation
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Decision aid and coaching in gynaecology
2751
2026
1566
0
500
1000
1500
2000
2500
3000
Usual care Decision aid Decision aid + coaching
Treatment costs ($) over 2 years
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Decision Aids reduce rates of discretionary surgery
RR=0.76 (0.6, 0.9)
O’Connor et al., Cochrane Library, 2009
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Self management of warfarin and INR. Cochrane review Heneghan et al April 2010
1. Clinician management of warfarin and INR
2. Self monitoring of INR and clinician advice re:
warfarin dose
3. Self management of INR and warfarin
Compared to groups 1 and 2, group 3 have • same risk of bleeding • 50% fewer thrombotic episodes • 36% lower mortality
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32
Bloodletting Plague
Pneumonia
Inflammation
Acne Herpes
Stroke
Leprosy
Pretty much anything
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Patient Activation Through Decision Aids
…People are supported to make informed and personally relevant decisions about managing their own health and healthcare
Should I take that pill today?
Am I going to stick to that
exercise regime? Do I really want that
heart operation?
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Types of Decision Aids
Format • Paper and pencil • Boards • Audio booklets • Videos • Computer interactive
– CDs – Web-based
• http://www.optiongrid.org/ • http://decisionaid.ohri.ca/ • www.hitchcock.org/dept/csdm • http://decisionaid.ohri.ca • www.fimdm.org
To be used
• Alone
• With family members
• With practitioner
• With health educator
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Gossey T & Volk R
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Baylor College of Medicine
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46
24.2
18.1
8.6
0
5
10
15
20
25
30
Medical Tx PCI CABG
7.2 7.5 6.8
0
5
10
15
20
25
30
Medical Tx PCI CABG
Angina
Death/MI
Event rate (%)
Event rate (%)
13.211.8
6.4
0
5
10
15
20
25
30
Medical Tx PCI CABG
23.1
17.8
5.9
0
5
10
15
20
25
30
Medical Tx PCI CABG
ACS-Hospitalization
Subsequent Revascularization
Event rate (%)
Event rate (%)
Coronary Revascularization Aid
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Other New Decision Aids in Cardiology
47
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3 key stages
Decision talk
Option talk
Choice talk
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2 key enablers
Support deliberation
Provide decision aid/option grid
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D e l i b e r a t i o n
Choice talk Option talk Decision talk
D e c I s I o n s u p p o r t
Prior preference Informed preference
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Choice talk
1. Establish diagnosis or explanation
2. Step back. Check there is agreement on nature of the problem.
‘we agree that there is a problem with arthritis in your knee….pause’
3. Choice exists. Be explicit- many patients expect to be told what to do.
‘There are a number of things we can discuss’
‘I’d like to share some information with you about your options- is that OK?’
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Choice talk
4. Justify choice and clarify partnership/support ‘We need to think about what’s important for you’ ‘ I am here to help you think this through’ 5. Check reaction. Patient engagement may be evident- however
if not: ‘Before we think this through in more detail, I just want to
check that you are comfortable with us thinking this through together’
6. Defer closure and emphasize partnership. Some patients want you to decide; however this will lead to a decision that is not informed by ‘what matters to them’
I really want us to come to a decision that’s right for you. To help us do that, why don’t we look at a little more information. Is that OK?
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Clinical scenario
• Mrs Jones is 68
• She is overweight and complaining of knee pain
• An Xray confirms arthritis
• You have just told her she has arthritis
• The options she faces include getting more active, losing weight, taking analgesics or seeing a surgeon with a view to an injection or possible surgery
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2. Option talk. Introduce option grid
Step 1. ‘Here is an option grid’
• Tell them that this is a summary of the reasonable options
Step 2. ‘Please take a look at it’
• Check they are happy to read it for themselves
Step 3. ‘Highlight the bits that matter most to you’
• Supports them to guide the conversation
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2. Option talk.
Step 4. ‘Do you have any questions?’
• Focusses conversation on what matters for them
Step 5. ‘It’s yours to keep’
• Reinforces that the information is theirs
• Remind them to look for other sources of information
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3. Preference talk, decision talk
Step 6. ‘In terms of what you know about your options, what’s most important for you?
• An open question which invites patients to express their preferences; they may be most interested in risk, predictability, outcome, recovery etc etc
Step 7. ‘To come to a decision that’s right for you, what else do you need to know?’
• Ask if patients have knowledge gaps as a result of expressing their preferences
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3. Decision talk
Step 8. ‘Are we ready to make a decision about what’s right for you”
• An open question that invites reflection
• May be followed by ‘what else do you need to know’
• Or:’ it’s natural to feel uncertain. Take your time.’
Step 9. Patient articulates decision. Affirm decision, reinforce partnership.
• ‘We agree that we’ll go ahead and…..’
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4. Confidence talk
Step 10. Check for confidence
‘ On a scale of 0-10, how confident are you that this is the right decision for you?’
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Patient-Driven
Healthcare Decision
Healthcare Consumer
Stakeholders
Healthcare Provider Stakeholders
Patient Advocate Stakeholder
Healthcare Finance Stakeholders
Feasibility of Shared Decision Making Model
Patient-Centered Outcomes & Satisfaction
Quality of Life Survey
Patient Experience Survey
Informed Consent Assessment
Survey Tools to Evaluate Correlation of Patient
and Physician Understanding of
Decision’s Risks/Benefits
Financial Assessment
Healthcare resource utilization
Decreased Practice variation
Shared Decision Making in Healthcare
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Act Plan
Study Do
Adapted from Brent James, Intermountain Health
What hunches do we have? What can we learn as we go along?
What have others done?
Measuring processes and outcomes
Understanding the problem. Knowing what you’re trying to do - clear and desirable aims and objectives
What change can we make that will result in improvement?
How will we know that a
change is an improvement?
accomplish? What are we trying to
Model for Improvement
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Shared Decision Making: An Obligation to Patients
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Healthcare professional = 4 hrs/year Self care = 8760 hrs/year
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Beckwith Institute Grants: Making Shared Decision Making a Reality
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