Better Shared Better Shared Decision Making in Decision Making in

PracticePracticeCharlie Brackett, MD, MPH Charlie Brackett, MD, MPH

Blair Brooks, MDBlair Brooks, MDNan Cochran, MDNan Cochran, MD

(France Légaré, MD)(France Légaré, MD)20072007

Dartmouth-Hitchcock Medical CenterDartmouth-Hitchcock Medical CenterWhite River Jct. Veterans Administration HospitalWhite River Jct. Veterans Administration Hospital

Dartmouth Medical SchoolDartmouth Medical School

Research and Workshop Research and Workshop Sponsored by FIMDMSponsored by FIMDM

Workshop GoalsWorkshop Goals Increase interest in SDMIncrease interest in SDM

Share our experience and address challengesShare our experience and address challenges

Demonstrate ways to facilitate SDMDemonstrate ways to facilitate SDM Practice communication skillsPractice communication skills Decision AidsDecision Aids

Explore broader implementation of SDM in Explore broader implementation of SDM in primary careprimary care

There is unwarranted variation There is unwarranted variation in the practice of medicine and the

use of medical resources

The 3 Categories of CareThe 3 Categories of Care Effective care: underusedEffective care: underused

Evidence-based care that all with need should Evidence-based care that all with need should receivereceive

Preference-sensitive care: misusedPreference-sensitive care: misused Treatment choices with multiple options; involves Treatment choices with multiple options; involves

tradeoffs, scientific evidence re: outcomes is tradeoffs, scientific evidence re: outcomes is variablevariable

Supply-sensitive care: overusedSupply-sensitive care: overused Visits, hospitalizations, ICU admissions and other Visits, hospitalizations, ICU admissions and other

services where utilization is associated with supply services where utilization is associated with supply of resourcesof resources

Incidence of surgery: hip fracture repair, knee and hip Incidence of surgery: hip fracture repair, knee and hip replacement and back surgery: 306 hospital regions (2000-01)replacement and back surgery: 306 hospital regions (2000-01)

( Preference-sensitive care is typified by elective surgery)( Preference-sensitive care is typified by elective surgery)

0.2

1.0

4.0

HipHipFractureFracture

(CV=13.8)(CV=13.8)

KneeKneeReplacementReplacement

(CV= 55.0)(CV= 55.0)4x4x

HipHipReplacementReplacement

(CV= 67.2)(CV= 67.2)

BackBackSurgerySurgery

(CV= 93.6)(CV= 93.6)7x7x

Preference-Sensitive Care

Involves tradeoffs -- more than one treatment exists and the outcomes are different

Scientific evidence re: outcomes sometimes good, sometimes not

Decisions should be based on the patient’s own preferences and values

But Provider Opinion Often Determines Which Treatment is Used

Shared Decision Shared Decision making – making –

a definitiona definition

Decisions that are shared by Decisions that are shared by doctors and patients, doctors and patients, informed by the best evidence informed by the best evidence available and weighted available and weighted according to the specific according to the specific characteristics and values of characteristics and values of the patient.the patient.

Légaré et al. Patient Education and Counseling. 2006Légaré et al. Patient Education and Counseling. 2006

Which rate is right? Impact of Which rate is right? Impact of improved improved decision qualitydecision quality on on

surgery rates: BPHsurgery rates: BPH

Knowledge of relevant treatment options and outcomes

Concordance between patient values

and care received

40% reduction in TURP after DA

IOM “Crossing the Quality IOM “Crossing the Quality Chasm”Chasm”

Shared decision making is reflected Shared decision making is reflected in 4 of the 10 “simple rules” for in 4 of the 10 “simple rules” for redesign of HC:redesign of HC:

Customization based on patients’ needs and Customization based on patients’ needs and valuesvalues

Patient as source of controlPatient as source of control Shared knowledge and free flow of Shared knowledge and free flow of

informationinformation Evidence based decision makingEvidence based decision making

SDM has not been SDM has not been adopted by health adopted by health

professionals.professionals.Why not?Why not?

What are the barriers?What are the barriers?

TIMETIME Time Required to Deliver Time Required to Deliver

All Highly Recommended All Highly Recommended 7.4 hrs/day7.4 hrs/day

Preventive ServicesPreventive Services: :

Time Required to Deliver All Time Required to Deliver All

Highly Recommended Highly Recommended 10.6 10.6 hrs/dayhrs/dayChronic Care Services:Chronic Care Services:

Yarnall, AJPH, 2003 Yarnell, Ann Fam Med, 2005

Barriers to practicing Barriers to practicing SDMSDM

CliniciansClinicians Challenge to physician autonomyChallenge to physician autonomy Don’t recognize preference sensitive decisionsDon’t recognize preference sensitive decisions Evidence difficult to extract, interpret, Evidence difficult to extract, interpret,

communicatecommunicate

PracticePractice LogisticsLogistics Lack of timeLack of time Lack of reimbursementLack of reimbursement

PatientsPatients “ “Patients don’t want to participate” Patients don’t want to participate” Variation in role preference Variation in role preference Literacy, NumeracyLiteracy, Numeracy

Patient Decision Aids

Evidence based tools designed to facilitate SDM.

Many formats: print, audio, video, internet

Adjunct to counseling

Impact of Decision Aids:Impact of Decision Aids:Cochrane review of 51 RCTsCochrane review of 51 RCTs

Increase Increase patient involvementpatient involvement Improve Improve patient knowledgepatient knowledge Clarify Clarify patient valuespatient values

Improve concordance between values Improve concordance between values and choices and choices

Reduce Reduce patient decisional conflict, patient decisional conflict, regretregret Improve realistic expectationsImprove realistic expectations Decrease number who are undecidedDecrease number who are undecided

O’Connor, Cochrane Collaboration, 2006O’Connor, Cochrane Collaboration, 2006

FIMDM Video DAsFIMDM Video DAs

BPHBPH PSA ScreningPSA Screning Prostate CancerProstate Cancer Coronary Artery DiseaseCoronary Artery Disease CHFCHF Advanced DirectivesAdvanced Directives Uterine FibroidsUterine Fibroids Ovarian CancerOvarian Cancer DepressionDepression Weight loss surgeryWeight loss surgery

Breast CancerBreast Cancer DCISDCIS Breast ReconstructionBreast Reconstruction Abnormal Uterine Abnormal Uterine

BleedingBleeding LBP: Herniated DiscLBP: Herniated Disc LBP: Spinal StenosisLBP: Spinal Stenosis Chronic LBPChronic LBP Knee OAKnee OA Diabetes (Type II)Diabetes (Type II) The Informed HC The Informed HC

ConsumerConsumer

Foundation for Informed Medical Decision Making

Resources to Support Decision Resources to Support Decision MakingMaking

Ottawa Health Research InstituteOttawa Health Research Institute http://decisionaid.ohri.ca/index.html

FIMDMFIMDM http://www.fimdm.org

WebMDWebMD http://www.webmd.com/

Mayo ClinicMayo Clinic http://www.mayoclinic.com

DHMC Center for Shared Decision MakingDHMC Center for Shared Decision Making http://www.hitchcock.org/dept/csdm

• Ottawa Decision Aids

• Ottawa Personal Decision Guide

• A to Z Global Inventory of Patient Decision Aids

• Cochrane Systematic Review: Efficacy of Patient Decision Aids

• Training in Decision Support

• Evaluation Measures

• Resources

www.ohri.ca/decisionaid

Decision Aid Example: Decision Aid Example: InformationInformation

Decision Aid Example: Decision Aid Example: Patient ValuesPatient Values

DHMC experience with DHMC experience with SDMSDM

Spine CenterSpine Center Comprehensive Breast ProgramComprehensive Breast Program Center for Shared Decision MakingCenter for Shared Decision Making

Primary Care: Primary Care: Implementation of PSA Decision Aids Implementation of PSA Decision Aids

studystudy

PSA DA Study: GOALSPSA DA Study: GOALS

Assess:Assess:

1.1. Feasibility of routine use of Feasibility of routine use of decision aids in Primary Caredecision aids in Primary Care

2.2. Impact of video decision aid Impact of video decision aid on decision choice and qualityon decision choice and quality

3.3. Patient and provider Patient and provider satisfactionsatisfaction

RESULTSRESULTSPSA Video DistributionPSA Video Distribution

DHMCDHMC WRJ VAWRJ VA

DistributedDistributed 11661166 549549

Returned video*Returned video* 845 845 313 313

Enrolled in study Enrolled in study (completed questionnaire)(completed questionnaire)

394394 252 252

* Ongoing

RESULTSRESULTSPatient ChoicePatient Choice

Choice Before vs AfterVideo

Unsure 30% 16% *

No PSA screening 23% 42% *

PSA Screening 47% 42% *

CHANGED THEIR MINDS

30%*

* P < .01

RESULTSRESULTSVideo Impact on ChoiceVideo Impact on Choice

Before VideoBefore Video

No No PSA PSA

ScreenScreen

UnsureUnsure PSA PSA ScreenScreen

No PSA Screen No PSA Screen

138138126126 77 55

Unsure Unsure

1781788484 7171 2323

PSA Screen PSA Screen

2822823838 2424 220220

AfterAfter VideoVideo

RESULTS RESULTS Decision Quality Decision Quality

Average test scoreAverage test score (% correct)(% correct)

DHMC DHMC (n = 369)(n = 369) 93%93%WRJ VA WRJ VA (n=230)(n=230) 89%89%

Total Total (n = 599)(n = 599) 91%91%

Patient Knowledge of key PSA factsPatient Knowledge of key PSA facts

Decision Quality: Patient Decision Quality: Patient Values Values

Patients who feel it is more important Patients who feel it is more important to to “Know if you have cancer”“Know if you have cancer” are are MOREMORE likely to choose PSA likely to choose PSA screening (OR 1.9 (95% CI 1.6-2.4)).screening (OR 1.9 (95% CI 1.6-2.4)).

Patients who feel it is more important Patients who feel it is more important to to “Avoid worry from false alarm” “Avoid worry from false alarm” areare LESS LESS likely to choose PSA likely to choose PSA screening (OR 0.7 (95% CI 0.6-0.8)).screening (OR 0.7 (95% CI 0.6-0.8)).

DAs increase patients’ DAs increase patients’ agreement between values agreement between values

and choiceand choice

ChoiceBefore vs After

Video (% match)

No PSA screening 76% 81% *

PSA Screening 80% 92% *

Subtotal 79% 87% *

* P < .01

Patient and Provider Patient and Provider SatisfactionSatisfaction

Patients feel DA is:Patients feel DA is: (%)(%)

Very/somewhat helpfulVery/somewhat helpful 8787

Definitely/probably Definitely/probably recommendrecommend

9696

Clinicians feel DA:Clinicians feel DA:

Helps patients choose what Helps patients choose what matters most to themmatters most to them

Improves communication and Improves communication and efficiency during visitefficiency during visit

CONCLUSIONSCONCLUSIONS

1)1) Systematic use of a PSA DA in Systematic use of a PSA DA in primary care is feasible.primary care is feasible.

2)2) Viewing the PSA DA resulted in Viewing the PSA DA resulted in fewer patients being unsure of fewer patients being unsure of their decision and more patients their decision and more patients choosing no screening.choosing no screening.

3)3) Viewing the PSA DA helped Viewing the PSA DA helped patients make a higher quality patients make a higher quality screening decision.screening decision.

4)4) Patients and clinicians found the Patients and clinicians found the PSA DA helpful and time efficient.PSA DA helpful and time efficient.

Next steps: DHMC DA Next steps: DHMC DA ResearchResearch

Introduce Chronic Condition DAs into Introduce Chronic Condition DAs into routine use in GIM practicesroutine use in GIM practices

Expand DAs to community based sitesExpand DAs to community based sites

Assess impact of DAs on decision Assess impact of DAs on decision quality, choice and resource quality, choice and resource utilization. utilization.

SDM Communication SkillsSDM Communication Skills

Define/explain problemDefine/explain problem Discuss patient’s desired roleDiscuss patient’s desired role Present optionsPresent options Discuss pros/consDiscuss pros/cons Explore patient values, preferencesExplore patient values, preferences Assess patient self-efficacyAssess patient self-efficacy Present doctor recommendationsPresent doctor recommendations Clarify understandingClarify understanding Make or explicitly defer decisionMake or explicitly defer decision

Adapted from Makoul G. An Integrative Model of Shared Decision Making in Medical Encounters. Pt Adapted from Makoul G. An Integrative Model of Shared Decision Making in Medical Encounters. Pt Educ and Counseling 2006Educ and Counseling 2006

Which skills do clinicians Which skills do clinicians most need to improve?most need to improve?

Ask about patients’ preferred role in decisions Ask about patients’ preferred role in decisions Assess patients’ valuesAssess patients’ values Screen for decisional conflictScreen for decisional conflict Assess support or undue pressure on patientAssess support or undue pressure on patient Increase patients’ involvement in decision Increase patients’ involvement in decision

makingmaking

Légaré, Canadian Family Physician, 2006Légaré, Canadian Family Physician, 2006

Decisional ConflictDecisional Conflict

Decisional conflict is defined as a state Decisional conflict is defined as a state of uncertainty about which course of of uncertainty about which course of action to take when the choice action to take when the choice among competing actions involves among competing actions involves risk, loss, regret, or a challenge to risk, loss, regret, or a challenge to personal life values.personal life values.

Legare et al, Canadian Family Legare et al, Canadian Family Physician 4/06Physician 4/06

S.A.V. E.

Sure of your decision

Adequate information Values

Encouragement

Are you sure which choice you want to make?

Do you feel you have adequate information about the options, risks and benefits?

Do you know what matters most to you, the risks or the benefits?

Do you have enough support or are you feeling undue pressure from others?

Trigger tape #1Trigger tape #1

Making a Prostate Cancer Screening Making a Prostate Cancer Screening

Decision: Decision: Usual CareUsual Care

Trigger Tape #2Trigger Tape #2

Making a Prostate Cancer Screening Making a Prostate Cancer Screening

Decision: Decision: Information Information Based Shared Decision Based Shared Decision

MakingMaking

Trigger Tape #3Trigger Tape #3

Making a Prostate Cancer Making a Prostate Cancer

Screening Decision: Screening Decision: Shared Shared Decision Making after Decision Making after

Decision AidDecision Aid

Supporting patients facing Supporting patients facing difficult health decisionsdifficult health decisions

Most important changes Most important changes participants intended to make participants intended to make in their practice:in their practice:

1.1. To ask about patient’s preferred role in decision makingTo ask about patient’s preferred role in decision making

2.2. To assess patient valuesTo assess patient values

3.3. To screen for decisional conflictTo screen for decisional conflict

4.4. To assess support or undue pressure on patientsTo assess support or undue pressure on patients

5.5. To increase patients involvement in decision makingTo increase patients involvement in decision making

Legare, et al. Canadian Family Legare, et al. Canadian Family Physician 4/06Physician 4/06

Practice communication Practice communication skillsskills

The scenarioThe scenario 60 year old at primary care visit60 year old at primary care visit Considering PSA screening Considering PSA screening Concerned about possibility of erectile Concerned about possibility of erectile

dysfunctiondysfunction The task: (~7 min/role play)The task: (~7 min/role play)

Engage in shared decision making Engage in shared decision making discussion w/ pt. discussion w/ pt.

Assess patient valuesAssess patient values Identify decisional conflictIdentify decisional conflict

Observer(s) provide feedbackObserver(s) provide feedback

Practice communication Practice communication skillsskills

The scenarioThe scenario 50 year old at primary care visit50 year old at primary care visit Considering treatment options for HNP Considering treatment options for HNP Concerned about current limitations despite Concerned about current limitations despite

optimal NSAID’s; fearful of complications of optimal NSAID’s; fearful of complications of surgerysurgery

The task: (~7 min/role play)The task: (~7 min/role play) Engage in shared decision making discussion w/ Engage in shared decision making discussion w/

pt. pt. Assess patient valuesAssess patient values Identify decisional conflictIdentify decisional conflict

Observer(s) provide feedbackObserver(s) provide feedback

DebriefDebrief

1.1. What surprised you?What surprised you?

2.2. What confused you?What confused you?

3.3. What went well?What went well?

4.4. What would you What would you change?change?