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TRAINING PEDIATRICS RESIDENTSAND FELLOWS IN THE PRACTICE OF

SHARED DECISION-MAKINGLaurenM.Hubner,MDMPH1

RebeccaL.Blankenburg,MDMPH1

KimB.Hoang,MD1

IanChua,MD2

LynneC.Huffman,MD11StanfordUniversitySchoolofMedicine

2Children’sNationalMedicalCenter

March21,2018

LearningObjectivesAfterattendingthisworkshop,participantswillbeableto� DescribeSharedDecision-Making(SDM)asaclinicalskillimportantinthepracticeof

pediatrics,bothinpatientandoutpatient◦ RecognizethatSDMcanbetaughttoresidents/fellowsonanyrotationwhere

patients’familiesarefacedwithmultiplediagnosticwork-uportreatmentoptions� PracticeseveraltrainingstrategiesthatcanbeusedtoteachSDM

Strategy#1.DidacticPresentationStrategy#2.On-lineclinicalcases,withproblem-basedlearningStrategy#3.Observationofsimulatedclinicalencounter,withbehaviorcodingStrategy#4.SDMonfamily-centeredrounds

� IdentifySDMtoolsthattheycanusetoteachSDMtopediatricsresidentsandfellowsintheirhomeinstitutions

ICE BREAKER TRAINING STRATEGY 1:DIDACTIC PRESENTATION

• DefinitionofSDM• SignificanceofSDM• CoreComponents/BarriersandFacilitators

• Outpatient• Inpatient

Decision-Making

Thedecision-makingprocessinvolvinghealthcareprovidersandpatientsisthoughttoexistalongacontinuum◦ Autonomous◦ Paternalistic

Autonomous Paternalistic

WhatisSharedDecision-Making(SDM)?

“theactiveparticipationofbothcliniciansandfamiliesintreatmentdecisions,theexchangeofinformation,discussionofpreferences,andajointdeterminationofthetreatmentplan”

(- Fiks etal.2010)

Autonomous Paternalistic

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SignificanceofSDM

� GrowingemphasisonSDM(InstituteofMedicine,AccountableCareAct)

� Recognizedasanimportantdimensionofhighqualityhealthcare◦ Improvementsinpatientoutcomes

� Helpfulinmedicalcomplexity� Well-describedintheadultmedicineliterature;lessstudiedinpediatrics

CoreComponentsofSDM- Outpatient

� Describeneedforatreatmentdecision� Reviewtreatmentoptions� Explorepatientvalues� Determinepreferences� Negotiatecourseofaction� Makeplansforfollow-up

- Volketal.,2014

SDMBarriersandFacilitators- Outpatient� Barriers◦ Patient(family)characteristics◦ Differencesbetweenfamilyandclinician� Culture/language� Perceivedpower◦ Lackofclinicianknowledgeortools◦ Healthsystemconstraints(e.g.,limitedtime,lackofcontinuity)

� Facilitators◦ Clinicianmotivation◦ Positiveeffectonclinicalprocessandoutcomes

- Adamsetal.2017

CoreComponentsofSDM- Inpatient

- Rennke etal.2017

SDMBarriersandFacilitators- Inpatient

� Barriers◦ Busyserviceandtimeconstraints◦ Severityandacuityofillness◦ Highparentalstressandanxiety◦ Lackofanestablishedrelationshipwithproviders

� Facilitators◦ Sufficienttimeperpatientencounters◦ Longerhospitalizationstay - Rennke etal.2017

- Blankenburg etal.2018

TRAINING STRATEGY 2:ON-LINE PROBLEM-BASED LEARNING USINGCLINICAL CASES

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StanfordMedicalEducationResearch:TheEffectivenessofOn-lineSDMTraining� Objective:Toinvestigateeffectsof2differenton-lineinteractivelearningexperiencesonself-ratedSDMinDBPfellows

� Design:RCT,with97DBPfellowsenrolledfromacrossUS◦ RandomassignmenttoInterventionorComparisongroups◦ DatagatheredelectronicallyatPre-Interventionand4weeksPost-Intervention

StanfordMedicalEducationResearch:TheEffectivenessofOn-lineSDMTraining� Method:On-linelearningexperiences,withclinicalcases,facultyresponses,linkstoadditionalscientificevidence◦ InterventionCase- ongoingcareofchildwithASD,highlightedtreatmentdecisionwithdirectteachingaboutSDMprocesses◦ ComparisonCase- useofrisperidoneinchildwithASD,highlightedpracticeguidelinesconcerningatypicalantipsychoticswithdirectteachingaboutmedicationprosandcons

StanfordMedicalEducationResearch:TheEffectivenessofOn-lineSDMTraining� Results◦ Pre-intervention,groupsweresimilarre:fellowtraininglevel,gender,andprogramlocation◦ At4weekspost-intervention(aftertheeducationalintervention),bothgroups showedsignificantlyincreasedSDM(measuredwithaself-reportscale,SDM-9-Doc)

� Conclusions◦ SDMcanbeenhancedbyanonlinecase-basedtrainingthatisfocusedon

evidence-basedpracticeor focusedonSDMprinciples◦ ConsistentandmeasurableSDMeducationcanbeprovidedtotrainees,

irrespectiveoftrainingsitelocation

TRAINING STRATEGY 3:OBSERVATION OF A CLINICIAN-PARENT INTERACTION

• Watchvideoofasimulatedclinician-parentinteraction• UsingtheOPTION5(Modified)Scale,astructuredinstrumentthat

assessesextentofSDM,ratebehaviorinsimulatedinteraction• UsePollEverywhereandtextmessagingtoanonymouslysubmitratings• DiscussOPTION5ratings

ObserverOPTION5Modified(Barretal.,2015)

Item 1: Affirm need for a decisionFor the health issue being discussed, the clinician draws attention to or re-affirms that alternate treatment or management options exist or that the need for a decision exists.

If the patient rather than the clinician draws attention to the availability of options, the clinician responds by agreeing that the options need deliberation.

Item 2: Support education and deliberation processThe clinician reassures the patient, or re-affirms, that the clinician will support the patient to become informed and to deliberate about the options.

If the patient states that they have sought or obtained information prior to the encounter, the clinician supports such a deliberation process.

Item 3: Describe options, exchange viewsThe clinician gives information, or checks understanding, about the pros and cons of the options that are considered reasonable (including taking ‘no action’), to support the patient in comparing the alternatives.

If the patient requests clarification, explores options, or compares options, the clinician supports the process. Item 4: Elicit preferencesThe clinician makes an effort to elicit the patient’s preferences in response to the options that have been described.

If the patient declares their preference(s), the clinician is receptive/supportive. Item 5: Integrate preferences and decisionsThe clinician makes an effort to integrate the patient’s preferences as decisions are made.

If the patient indicates how best to integrate their preferences as decisions are made, the clinician is supportive.

OPTION5- Scoring

Score Description

0 = No effort Nothing observed or heard.

1 = Minimal effort Short phrases used that indicate the ideas/issue is being raised.

2 = Moderate effort Substantive (basic/reasonable) phrases/sentences used to convey the ideas and issues.

3 = Skilled effort Substantive phrases/sentences used to convey the ideas and issues, with checks on understanding.

4 = Exemplary effort Excellent, careful attention to communication around the ideas and issues, with checks on understanding.

Foreachitem,chooseascoreof0to4

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PollEverywhere

� Nowwe’regoingtoaskyoutousePollEverywhereandtheOPTION5torateSDMinasimulatedclinicalinteraction.

ClinicalScenario– Jimmy(5.5yearoldboywithrecentdiagnosisofADHDand↑ing difficultiesinkindergarten)

Video– SharedDecision-Making ThoughtsAbouttheClinicalInteraction?

• WhatcomponentsofSDMwerepresentinthisscenario?• WhatcomponentsofSDMweremissing?• Anypossiblebarriers?

TRAINING STRATEGY 4:INPATIENT SDMON FAMILY-CENTERED ROUNDS

� Setting:◦ August2014– March2015◦ Hospitalistservicesinpediatricsandinternalmedicine◦ Twolargeuniversity-basedhospitals◦ Team-levelSDMmeasured

� RepeatedCross-sectionalStudyDesign:◦ Uniquepatientsandmatchedhospitalistsinthepre- andpost-

interventionperiods

Pre-InterventionAssessments(12weeks)

Post-InterventionAssessments(12weeks)

Intervention(8weeks)

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5.25.7

2.9

5.7

4.6

5.7

4.2

6.2

4

5.8

0

1

2

3

4

5

6

7

8

9

Pre-Intervention Post-Intervention

RPAD

Score

MedAPeds APeds B

AllServices

MedB

MeanRPADChange+1.8(range:0.5to2.8),p =0.05

Results– PeerAssessments Results– HighScoringRPADItems

Results– LowScoringRPADItems Packet

� ToolsthatcanbeusedtofacilitateSDM• PatientDecisionAids(e.g.OttawaHospitalResearch

Institute,A-Zinventory)• Optiongrid/DecisionBox(e.g.Complexbehaviorproblemsin

childrenandyouth- OptionGrid– Dartmouth,OSA-CincinnatiChildren’sHospitalMedicalCenter)

• MedicationCards/Booklet(e.g.ADHD- CincinnatiChildren’sHospitalMedicalCenter)

Reflection

� PlansforincorporatingSDMtraininginyourhomeinstitution FinalIdeasorQuestions?

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Thankyou!

SelectedReferences� AdamsRC,LevySE,CouncilonChildrenwithDisabilities.Shareddecision-makingandchildrenwithdisabilities:Pathwaysto

consensus.Pediatrics,2017,Jun:139(6)e20170956.� BarrPJ,O’MalleyAJ,TsulukidzeM,GionfriddoMR,MontoriV,ElwynG.ThepsychometricpropertiesofObserverOPTION5,an

observermeasureofshareddecisionmaking.PatientEduc Counseling,2015,Aug:98(8):970-6.

� Blankenburg,R.,J.F.Hilton,P.Yuan,S.Rennke,B.Monash,S.M.Harman,D.S.Sakai,P.Hosamani,A.Khan,I.Chua,E.Huynh,L.ShiehandL.Xie.SharedDecision-MakingDuringInpatientRounds:OpportunitiesforImprovementinPatientEngagementandCommunication.J.Hosp.Med.PublishedonlinefirstFebruary5,2018.

� Design-A-Case(DAC)UTMBHealth.http://www.designacase.org

� Fiks,A.G.,A.R.Localio,E.A.Alessandrini,D.A.AschandJ.P.Guevara(2010)."Shareddecision-makinginpediatrics:anationalperspective."Pediatrics126(2):306-314.

� Rennke,S.,P.Yuan,B.Monash,R.Blankenburg,I.Chua,S.Harman,D.S.Sakai,A.Khan,J.F.Hilton,L.ShiehandJ.Satterfield.TheSDM3CircleModel:ALiteratureSynthesisandAdaptationforSharedDecisionMakingintheHospital. J.Hosp.Med. 2017;12;1001-1008.

� SmalleyLP,KennyMK,DenbobaD,StricklandB.Familyperceptionsofshareddecision-makingwithhealthcareproviders:ResultsoftheNationalSurveyofChildrenwithSpecialHealthCareNeeds,2009-12010.MaternChildHealthJ,2014,Aug:18(6):1316-27.

� VolkRJ,Shokar NK,LealVB,Bulik RJ,LinderSK,MullenPD,WexlerRM,Shokar GS.Developmentandpilottestingofanonlinecase-basedapproachtoshareddecisionmakingskillstrainingforclinicians.BMCMedInformDecis Mak,2014,Nov1;14:95.doi:10.1186/1472-6947-14-95

SelectedWebsites� https://decisionaid.ohri.ca/� http://optiongrid.org� https://www.cincinnatichildrens.org/service/j/anderson-center/evidence-based-care/decision-aids� http://www.decisionbox.ulaval.ca/index.php?id=810&L=2