intro to shared decision making
TRANSCRIPT
Introduction to Shared Decision Making and Patient Decision Aids
Richard Wexler, MDChief Medical Officer
February, 2012
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What is Shared Decision Making?
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Shared Decision Making (SDM)
“the process of interacting with patients who wish to be involved in arriving at an informed, values-based choice among two or more medically reasonable alternatives”¹
Informed• There is a choice• The options• The benefits and harms
of the options
Values-Based• What’s important to the patient
The ClinicianInformation
The Patient
¹A.M. O'Connor et al, “Modifying Unwarranted Variations In Health Care: Shared Decision Making Using Patient Decision Aids” Health Affairs, 7 October, 2004
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A Word on Taxonomy
Effective Care• Strong evidence base
supports care• Benefit-to-harm ratio high• All with need should receive
Preference-Sensitive Care• Evidence supports more
than one approach• Treatment/testing options
involve significant trade offs
• Personal values, preferences and life circumstances should drive decisions
SDM Sweet Spot
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A Schematic of Shared Decision Making
Decision to Make
A
C
Benefits
Risks
Benefits
Risks
Benefits
Risks
Patient LensBenefits
Risks
BenefitsRisks
Benefits
Risks
B Deliberate Decision
Goals and Concerns
Unique Life Circumstances
Options
© Informed Medical Decisions Foundation. All Rights Reserved. 2012
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1. Invite patient to participate2. Present options3. Provide information on benefits and risks4. Assist patient in evaluating options based on
their goals and concerns5. Facilitate deliberation and decision making6. Assist with implementation
Invite Options Benefits and Risks
Patient Preferences
Deliberate and Decide Implementation
Six Steps to SDM
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Patient Decision Aids: Tools to Facilitate SDM
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Decision to Make
A
C
Benefits
Risks
Benefits
Risks
Benefits
Risks
Patient LensBenefits
Risks
BenefitsRisks
Benefits
Risks
B Deliberate Decision
Goals and Concerns
Unique Life Circumstances
Options
Supported by Patient Decision Aids
© Informed Medical Decisions Foundation. All Rights Reserved. 2012
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Patient Decision Aids
• Information about a specific condition
• Evidence organized around specific decisions
• Accessible—charts, graphs
• Balanced
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Patient Decision Aids
• Encourage patients to interpret evidence in context of their own goals and concerns
• Include patient stories
• Encourage patients to make decisions with physician
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Patient Decision Aids: Development Process
• Literature review• Patient interviews and focus groups help identify:• issues most important to patients• common misconceptions• Provider interviews and focus groups help identify:• decision points and treatment options
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Patient Decision Aids: Development Process
• An evidence summary is produced by Foundation research associates, working with medical editors•Medical editors are generalists and free from industry conflicts• Summary is reviewed by clinical advisors, who are specialists• Editor has final control
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Patient Decision Aids: Development Process
From evidence summary, a decision aid is produced which includes text, graphics, and often video.
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Patient Decision Aids: Evaluation Process
What• Clinical accuracy• Balance• Viewer
acceptability
Who• Patients• Medical editors• Clinical advisors• Foundation and
Health Dialog staff
• Clinical reviewers
When• Draft scripts,
interview material, graphical presentations
• Rough cut• “Final” version
incorporates feedback from evaluation process
• Reviewed at 6 months for clinical accuracy
• Evaluated every 2 years for accuracy, balance and relevance
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Why Bother with SDM?
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Why Bother with SDM?
•No fateful decision in the face of avoidable ignorance
•Doctors aren’t very good at diagnosing patient preferences
• If doctors get it wrong, patients will still listen
• It’s a patient safety issue
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No Fateful Decision in the Face of Avoidable Ignorance
The DECISIONS Study
Nationwide telephone surveyConducted by University of MichiganThe Decisions Study. Medical Decision Making 2010; 30 supplement 1
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DECISIONS Study Findings
• Patients often not knowledgeable about the basic benefits and risks of their treatment• Patients usually not asked for their preferences about treatment• Providers discuss pros of treatments more than cons• Providers advise “do it” 65-95% of the time
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Doctors Aren’t Very Good at Diagnosing Patient Preferences
Karen Sepucha• Identified key facts and goals for 14
decisions• Surveyed providers and patients
• How important was each item• Identify the 3 most important items
Sepucha KR, et al. Pt Education and Counseling. 2008;73:504-10.
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Top Three Goals and Concerns for Breast Cancer Decisions
Condition: Goal Pat Prov p
Keep your breast? 7% 71% P<0.01
Live as long as possible? 59% 96% P=0.01
Look natural without clothes 33% 80% P=0.05
Avoid using prosthesis 33% 0% P<0.01
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If Doctors Get It Wrong,
Patients Will Still Listen
Sepucha KR, et al. Pt Education and Counseling. 2008;73:504-10.
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Is Doing What the Doctor Thinks Best a Top Priority?
Decision Pat Prov p
BCA surgery 86% 14% P<0.01
Hip replacement 84% 40% P<0.01
Knee replacement 78% 35% P<0.01
Menopause 60% 21% P=0.02
PSA 59% 21% P=0.03
Spinal Stenosis 46% 5% P<0.01
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It’s a Patient Safety Issue
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Patient Safety
Wrong Site Surgery
Wrong Patient Surgery
How do we describe operating on a patient who would say NO to surgery if alternatives, risks and benefits were well understood?
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Is SDM Effective?
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Cochrane Review
Review of 86 randomized trials evaluating patient decision aids• Increase patient knowledge• Increase patient involvement in decision making• Increase the proportion of patients with accurate risk perceptions (patients have more realistic expectations)
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Cochrane Review
• Increase the consistency between patient decisions and patient values• Reduce decisional conflict related to feeling uninformed or unclear about personal values• Reduce the proportion of patients who remain undecided• Reduce the choice of major elective surgery in favor of more conservative options
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Thank you!