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Shared Decision MakingWhen there is more than one right option

“To write prescriptions is easy, but to come to an understanding with people is hard. ”

Franz Kafka , A Country Doctor

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PATIENT- ANDFAMILY-CENTERED CARE

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Picker Principles of Patient-Centered Care

• Respect for patients’ values, preferences and expressed needs

• Coordination and integration of care

• Information, communication and education

• Physical comfort

• Emotional support and alleviation of fear and anxiety

• Involvement of family and friends

• Transition and continuity Picker Institute transitiontopractice.org

CROSSING THE QUALITY CHASM, INSTITUTE OF MEDICINE

Health care should be patient-centered. The individual patient’s culture, social context, and specific needs deserve respect, and the patient should play an active role in making decisions about her own care.

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WHEN THERE IS MORE THAN ONE RIGHT OPTION

“Wait a minute here, Mr. Crumbley…Maybe itisn’t kidney stones after all.”

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“Its goal [shared decision making] is to improve the conversation between an informed patient and an attentive clinician, leading to a better clinical decision in tune with a patient’s preferences as much as with her needs.”

Patient, help heal thyself:A case for letting patients help pick their treatments. The Boston Globe, October 2013, Dr. Glyn Elwyn and Eric Weinberger

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Why and When?

• Increase in medical choices with greater combinations of therapeutic effects and side effects

• Long term therapies and costs

• Secondary consequences of screening or not

• End of life care and advanced directives

• Acute illness versus chronic conditions

• Incentives to systems and providers

COMMUNICATION AND DECISION-MAKING IN SERIOUSLY ILL PATIENTS: FINDINGS OF THE SUPPORT PROJECTCOVINSKY, KE JOURNAL OF THE AMERICAN GERIATRICS SOCIETYVOLUME:48 ISSUE:5 PAGES:S187-S193 PUBLISHED:MAY 2000

Only 41% of Medicare patients believed that their treatment reflected their preference for palliative care over more aggressive interventions.

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INFORMED DECISION MAKING: GETTING BACK TO THE BASICSBRADDOCK CH, JAMA 1999, DEC 22-29

Results: Of over 3500 clinical decisions with 1000 encounters in primary care and surgery outpatient offices, only 9% met the criteria for completeness for shared decision making.

The information regarding the nature of the intervention occurred most frequently (71%) while assessment of the patient understanding occurred the least frequently (1.5 %).

Shared Decision Making

Shared medical decision making is a processby which patients and providers consider outcome probabilities and patient preferences, and reach a health care decision based on mutual agreement.

Shared decision making is best used for problems involving medical uncertainty.

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Shared Decision Making

During the process the provider-patient dyad considers treatment options and consequences, and explores the fit of expected benefits and consequences of treatment with patient preferences for various outcomes.

The Best Practice…

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Date of download: 4/1/2014Copyright © 2014 American Medical

Association. All rights reserved.

From: The Shared Decision-Making Continuum

JAMA. 2010;304(8):903-904. doi:10.1001/jama.2010.1208

Figure Legend:

What is the matter?

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What matters to you?

ACA and SDM

• Section 3506

• Creation of patient decision aides

• Evaluation of these tools

• Center for Medicare and Medicaid Innovation to tests models; approaches that improve quality, safety and reduce costs will be mandated through Medicare

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Costs and SDM

• Remain controversial

• Less treatment vs. more

• Evidence for greater patient engagement leads to positive service surveys

• Choosing Wisely campaign

INTRODUCING DECISION AIDS AT GROUP HEALTH WAS LINKED TO SHARPLY LOWER HIP AND KNEE SURGERY RATES AND COSTSARTERBURN, D, HEALTH AFFAIRS VOLUME:31 ISSUE:9 PAGES:2094-2104, SEPT 2012

Consistent with prior randomized trials, our introduction of decision aids was associated with:

• 26 percent fewer hip replacement surgeries,

• 38 percent fewer knee replacements

• 12-21 percent lower costs over six months

Findings support the concept that patient decision aids for some health conditions, for which treatment decisions are highly sensitive to both patients' and physicians' preferences, may reduce rates of elective surgery and lower costs.

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ENHANCED SUPPORT FOR SHARED DECISION MAKING REDUCED COSTS OF CARE FOR PATIENTS WITH PREFERENCE SENSITIVE HEALTH CONDITIONSDAVID VEROFF, ET AL, HEALTH AFFAIRS, FEBRUARY 3013

Patients who received enhanced support had 5.3 percent lower overall medical costs than patients who received the usual level of support.

The enhanced-support group had 12.5 percent fewer hospital admissions than the usual-support group, and 9.9 percent fewer preference-sensitive surgeries, including 20.9 percent fewer preference-sensitive heart surgeries.

ENHANCED SUPPORT FOR SHARED DECISION MAKING REDUCED COSTS OF CARE FOR PATIENTS WITH PREFERENCE SENSITIVE HEALTH CONDITIONSDAVID VEROFF, ET AL, HEALTH AFFAIRS, FEBRUARY 3013

Findings:

Indicate support for shared decision making can generate savings

Suggest that a “remote” model of support—e.g., combining telephonic coaching with decision aids—may constitute a relatively low-cost and effective intervention that could reach broader populations without the need for the direct involvement of regular medical care team members

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PATIENT INVOLVEMENT IN SURGERY TREATMENT DECISIONS FOR BREAST CANCERSTEVEN J. KATZ ET AL, JOURNAL OF CLINICAL ONCOLOGYAUGUST 14, 2005

Most women reported that they made or shared the decision about surgical treatment. More patient involvement in decision making was associated with greater use of mastectomy.

TOOLS

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Decision Aids

• Improve their knowledge of the options

• Feel more informed and more clear about what matters most to them

• Have more accurate expectations of possible benefits and harms of their options

• Participate more in decision making

Cochrane Summaries, Jan. 2014

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www.http//statindecisionaid.mayoclinic.org/index.php.statin.index

Statindecisionaid.mayoclinic.org/index.php./statin.index

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http://shareddecisions.mayoclinic.org/

Debate

• More Data is needed

• Will time spent in SDM, lead to better treatment adherence, less overtreatment, and improved quality and thus, justify the cost?

• Do Clinical Guidelines subvert patient preferences?

Shared Decision Making: Really putting patients at the center of healthcare,Stigglebout,A BMJ, 2012:322

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THE OPTIMAL PRACTICE OF EVIDENCE-BASED MEDICINE: INCORPORATING PATIENT PREFERENCES IN PRACTICE GUIDELINESVICTOR M. MONTORI, MD, MSC; JUAN PABLO BRITO, MBB; M. HASSAN MURAD, MD, MPH13 JAMA. 2013;310(23):2503-2504. DOI:10.1001/JAMA.2013.281422

“Clinicians should remember that taking care of patients is supposed to be difficult. Although guidelines may simplify this task, when patient preferences and context matter, guidelines must not replace clinicians’ compassionate and mindful engagement of the patient in making decisions together.

This is the optimal practice of evidence-based medicine.”

Shared Decision Making Summary

• A patient centered process

• Embraces the patients values and preferences

• Should be used when there is not a clear choice

• Resource in the ACA

• May reduce costs and interventions

• Research regarding optimal tools continues

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VALERIE BILLINGHAM, THROUGH THE PATIENT'S EYES,SALZBURG SEMINAR SESSION 356, 1998

Nothing about me without me.

Citations Franz Kafka , A Country Doctor Twisted Spoon Press (October 1, 1997)

Picker principles of patient-centered care. Retrieved at http://transitiontopractice.org/files/module2/PCC%20-%20Picker%20Principles.pdf

Crossing the quality chasm, IOM. Retrieved at http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf

FarSide cartoon, Eric Larson

Patient, help heal thyself: A case for letting patients help pick their treatments. The Boston Globe, October 2013, Dr. Glyn Elwyn and Eric Weinberger

Communication and decision-making in seriously ill patients: Findings of the SUPPORT project. Covinsky, KE JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Volume:48 Issue:5 Pages:S187-S193 Published:MAY 2000

Informed Decision Making: Getting back to the basics. Braddock CH, JAMA 1999, Dec 22-29

Shared Decision Making Continuum, JAMA. 2010;304(8):903-904. doi:10.1001/jama.2010.1208

Introducing Decision Aids At Group Health Was Linked To Sharply Lower Hip And Knee Surgery Rates And Costs. Arterburn, D, HEALTH AFFAIRS Volume:31 Issue:9 Pages:2094-2104, Sept 2012

Enhanced Support For Shared Decision Making Reduced Costs Of Care For Patients With Preference Sensitive Health Conditions. David Veroff, et al, Health Affairs, February 3013.

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Citations continued

Patient Involvement in Surgery Treatment Decisions for Breast Cancersteven j. katz et al, Journal of Clinical Oncology. August 14, 2005

Decision aids.Cochrane Summaries, Jan. 2014

Mayo statin tool: www.http//:statindecisionaid.mayoclinic.org/index.php.statin.index

Ottawa personal decision aid retrieved at Ottawapersonaldecisionaid.ohri.ca/docs/das/OPDG.pd

http://patients.dartmouth-hitchcock.org/shared_decision_making.html

http://shareddecisions.mayoclinic.org/

Shared Decision Making: Really putting patients at the center of healthcare, Stigglebout,A BMJ, 2012:322

The Optimal Practice of Evidence-Based Medicine: Incorporating Patient Preferences in Practice GuidelinesVictor M. Montori, MD, MSc; Juan Pablo Brito, MBB; M. Hassan Murad, MD, MPH13 JAMA. 2013;310(23):2503-2504. doi:10.1001/jama.2013.281422

Valerie Billingham, Through the Patient's Eyes, Salzburg Seminar Session 356, 1998