appd sdm workshop - 03122018 online2 · 2020. 6. 11. · 3/12/18 1 training pediatrics residents...
TRANSCRIPT
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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