The patient as a partner in medical decision-making: Implementation of Shared Decision-

Making in Germany

Angela Buchholz

13.5.2011, Lausanne

Overview

• Shared-Decision Making• Levels of Implementation• Transfer strategies• Research Activities• Examples• Facilitators and Barriers• Discussion

Introduction

Models of medical decision-making

Decision of ...

Physician Patient

Paternalisticmodel

Shared decision-making (SDM)

Information model

=interactive decision-making process

accounted by both patient and physicianunder equal and active participation

based on shared information

Background

Process of SDM

1. Problem definition: Inform that a decision has to be made

2. Equipoise: Express the partners’ (& options’) equality

3. Risk communication: Inform about risks and benefits of options

4. Enabling patients to explore their concerns and queries

5. Decision making

6. Review arrangements

Background

Levels of Implementation

• Macro level: Political decisions with an impact on patientparticipation

• Meso level: Activities of national institutions supportingpatient participation

• Micro level: Implementation of SDM in the medicalencounter

Developments in Germany

• Macro level (Political Decisions)– Federal joint comittee (Gemeinsamer Bundesausschuss) with

advisory rights of patients– Delegate of the Federal government to represent patient interests

(Patientenbeauftragte)

• Meso level (National Institutions)– Institute for Quality and Efficiency in Health Care (IQWiG)– Agency for Quality in Medicine

• Micro level (SDM in the medical encounter)– Several research groups with ongoing research projects on the

topic

Loh et al., 2007

Example: Meso-Level

Transfer strategies (micro level)

• Physicians– Training of (SDM-) communication skills– Expert Systems– Decision Aids / Decision Boards

• Patients– Decision Aids / Boards– Patient education (courses)– Information Material

SDM in Germany: How it all began…

• Research Consortium „The patient as a partner in medical decision-making“

• 2001-2007 Funding by the Federal Ministry of Health

• www.patient-als-partner.de

• Funding of several projects, national and international conferences …

Schizophrenia – München

Fibromyalgia – Heidelberg

Multiple Sclerosis – Hamburg

COPD (Children) – Hannover

Method-Center – FreiburgDepression – Freiburg

Alcohol Abuse – Berlin

Palliative Medicine – Jena

Breast Cancer – München

Peripheral Arterial Disease – Aachen

Hypertension - Erlangen

Projects

Aachen

Saarbrücken

Frankfurt

Heidelberg

Kiel

Mainz

Düsseldorf

Magdeburg

Hannover

Schwerin

Hamburg

JenaDresden

Bremen

Potsdam

Erfurt

Göttingen

Erlangen

FreiburgStuttgart

München

Berlin

Research on SDM in Germany

• 147 Publications from German Researchers from2000 – 2009

• several research groups (health services research, general practice, medical psychology, psychiatry, rehabilitation…)

• majority refers to clinical studies on patients withchronic diseases

• heterogeneous use of SDM-definitions & wording

Rockenbauch & Schildmann, 2011

Current research funding

• Chronic diseases & patient orientation– Funding by the Federal Ministry of Research & Education, the

German statutory pension insurance scheme & the statutoryhealth insurances

– Funding 2008 – 2011, second round this year– several SDM-related projects– http://www.forschung-

patientenorientierung.de/index.php/home.html

• Psychosocial Oncology– Funding by Deutsche Krebshilfe (German Cancer Aid)– since 2007 two funding rounds with SDM-related projects

Research

• Decision Aids (web- or video based, print material)

• Training programs

• Expert systems

• Development / validation of assessment instruments

• Adjustment of the SDM-model to teams of healthprofessionals

Decision Aids: Example Breast Cancer

• Developed by a German statutory healthInsurance scheme(AOK)

• Acceptance by patientsand professionals

• available online & in print format

Schulze-Rath et al., 2009; Vodermaier, 2009

Training: SDM – training for physicians

• PowerPoint Slides• Comprehensive manual

including explanations of the slides & theoreticalbackground

• Tutorials• Instructional videos

Bieber et al., 2007

Training: SDM – training for physicians

• Development and evaluation of a SDM training for generalpractitioners and specialists

• Effects:– Patients: enhanced patient participation, higher satisfaction

with decision, improvement of doctor-patient interaction, better adherence

– Physicians: satisfaction with the training, enhanced self-efficacy and knowledge regarding SDM competences, improvement of the doctor-patient interaction (self-evaluation)

Loh et al., 2007; Bieber et al., 2007; Bieber et al., 2009

Implementation of the training

Physician trainings• 34 workshops• 510 physicians

Train-the-trainer workshops• 7 workshops• 106 facilitators/lecturers

Patient education• 31 trainer• 164 patients

Saarbrücken

Frankfurt

Heidelberg

Kiel

Mainz

Düsseldorf

Magdeburg

Schwerin

Dresden

Bremen

Potsdam

Erfurt

Stuttgart

Hamburg

Jena/Würzburg

Freiburg

Further steps

• Adaptations, development & evaluation of SDM-training for – oncologists treating patients with primary breast cancer

and colon cancer– primary care physicians in hypertension– primary care physicians in advance directives

• 3 ongoing cluster-randomized trials

Expert System: Arriba

• www.arriba-hausarzt.de• expert system for General Practitioners

– useful for SDM in the context of cardiovaskular riskreduction (hypertension, health behavior)

– calculates the cardiovaskular risk– guides the GP through the SDM process– evaluated in several scientific studies– free of charge for GPs widely-used among GPs

Krones et al., 2008; Sadowski et al. 2005

Barriers & Facilitators

Physicians• Barriers

– Time constraints– Lack of applicability due to patient characteristics– Lack of applicability due to the clinical situation

• Facilitators– Provider motivation– Positive impact on the clinical process– Positive impact on patient outcomes

Patients– health literacy– patient activation

Légaré et. al., 2008;Dirmaier & Härter, 2010

Personal Experiences as a researcher

• Structure of decision-making process in clinics (Hierarchy)

• Interferences with existing procedures (tumor board)

• Misunderstanding / Prejudices

• Lack of Interest

• Lack of „novelty“ / innovative character

• „guideline thinking“

References

• Bieber, C., Loh, A., Ringel, N., Eich, W., & Härter, M. ( 2007). Patientenbeteiligung bei medizini-schen Entscheidungen. Manual zur Partizipativen Entscheidungsfindung (Shared Decision-making). Heidelberg: Selbstverlag.

• Bieber, C., Nicolai, J., Hartmann, M., Blumenstiel, K., Ringel, N., Schneider, A., et al. (2009). Training physicians in shared decision-making - Who can be reached and what is achieved? Patient Education and Counseling, In Press.

• Dirmaier, J. & Härter, M. (2011). Stärkung der Selbstbeteiligung in der Rehabilitation. Bundesgesundheitsblatt 54:411–419.

• Krones T, Keller H, Sönnichsen A, Sadowski EM, Baum E, Wegscheider K, Rochon J, Donner-Banzhoff N. Absolute cardiovascular disease risk and shared decision making in primary care: a randomized controlled trial. Ann Fam Med 2008; 6:218-27.

• Legare, F., Ratte, S., Gravel, K., & Graham, I. D. (2008). Barriers and facilitators to implementingshared decision-making in clinical practice: update of a systematic review of health professionals' perceptions. Patient Educ Couns, 73(3), 526-535.

• Loh, A., Simon, D., Bieber, C., Eich, W., & Härter, M. (2007). Patient and citizen participation in German health care--current state and future perspectives. Z Ärztl Fortbild Qualitätssich, 101(4), 229-235.

• Loh, A., Simon, D., Wills, C. E., Kriston, L., Niebling, W., & H„rter, M. (2007). The effects of a shearddecision-making intervention in primary care of depression: A cluster randomized controlled trial. Patient Education and Counseling, 67(324), 332.

• Sadowski EM, Eimer C, Keller H, Krones T, Sönnichsen AC, Baum E, Donner-Banzhoff N. Evaluation komplexer Interventionen: Implementierung von ARRIBA-Herz, einer Beratungsstrategie für die Herz-Kreislaufprävention. Z Allg Med 2005; 81: 429-434.

• Schulze-Rath, R., Husmann, G., Kaiser, M., Kolpatzik, K., Münster, E., Nübling, M., et al. (2009). Einsatz und Bewertung einer Entscheidungshilfe für Patientinnen mit Brustkrebs im T1-Stadium. Geburtsh Frauenheilk, 69(05), 406,412.

• Vodermaier, A., Caspari, C., Koehm, J., Kahlert, S., Ditsch, N., & Untch, M. (2009). Contextualfactors in shared decison making: a randomised controlled trial in women with a strong suspicion of breast cancer. British Journal of Cancer, 100, 590-597.

Thanks for your attention!

www.patient-als-partner.de

Angela Buchholz, PhD

angela.buchholz@uniklinik-freiburg.deDepartment of General Practice

University Medical Centre Freiburg