PCMH Preparedness for Medical Decision-Making: Patients and Clinicians Using Shared Decision Making Tools John G. King, MD, MPH November 6, 2009

AGENDA  Small group role play of usual care.  Rationale: Why is shared decision making important and gaining traction?  Literature: What do we know about shared decision making and decision making aids?  Small group role play use of a Decision Aid.  Feedback on your experience.

Role Play usual care Case 1: 45 year old female with BMI of 35 and two recent fasting blood sugars of 110 and 112 whom you ask to come it to discuss the prediabetes range blood sugars. Case 2: A 20 year old college student with a history of asthma presents with 2 days of cough and fever. H1N1 influenza A is active in you community. You are considering a 5 day course of oseltamivir. Case 3: A 65 year old male smoker with HTN, DM (x10 years), and hyperlipidemia (TC-240, TG-200, HDL-40, LDL 160) has not been treated previously for the latter. You decide to start him on simvastatin. Case 4: A 24 year old in her first trimester of pregnancy is smoking 1 PPD. Counsel her to quit smoking.

Rationale for Shared Decision Making  Our culture values patient autonomy and free choice.  Physician opinion driven decision making leads to a striking geographic variations in preference and supply sensitive-care not explained by illness, medical evidence, or patient preferences.

 Mammography Rates Among Female Medicare Enrollees Age 65-69,  Health Care Today | Variations in Care Map legend 70% to 74% (6) 65% to < 70% (14) 60 % to < 65% (21) 56% to < 60% (9) Percent of female Medicare enrollees age having at least one mammogram during two-year period, Fisher ES, Goodman DC, Chandra A. Disparities in Health and Health Care among Medicare Beneficiaries: A Brief Report of the Dartmouth Atlas Project. Princeton, NJ: Robert Wood Johnson Foundation, 2008.

 Unnecessary—and Possibly Harmful—Services  Fisher ES, Goodman DC, Chandra A. Disparities in Health and Health Care among Medicare Beneficiaries: A Brief Report of the Dartmouth Atlas Project. Princeton, NJ: Robert Wood Johnson Foundation,  Health Care Today | Overuse

Rationale for Shared Decision Making  Patients want to be listened to and involved in many decisions.  Physicians have an ethical obligation to consider patients concerns and values over their own interests.

Why is Shared Decision Making Important?  Many clinical decisions involve value judgments.  Interventions have different benefits/risks that patients value differently.  There is no single right answer for everyone.  Ethical, legal and cultural principles of patient autonomy and informed consent.

Institute of Medicine 2001 “Crossing the Quality Chasm”  Shared decision making is reflected in 4 of the 10 “simple rules” for redesign of Healthcare: – –Patient-Centered Care – –Customization based on patients needs and values – –Shared knowledge and free flow of information – –Evidence based decision making

Shared Decision Making competencies  Shared decision making involvement to the level that is practical and desired by the patient.  Identify problem(s).  Presents options.  Equipoise statements (benefits and harms equally represented).  Provide high-quality information informed by the best evidence in patient-preferred format.  Check understanding and reactions.  Make, discuss, or defer decisions.  Scheduled follow up. Elwyn et al., BJGP, 2000.

Why Decision Making Aids  Patients and their doctors often lack the evidence based information they need at the point of care.  A visual representation of health benefits and harms might improve shared decision making.

International Decision Aids Standards Collaboration Does the patient decision aid:  Provide information about options in sufficient detail for decision-making?  Present probabilities of outcomes in a unbiased and understandable way?  Include methods for clarifying and expressing patients’ values?  Include structured guidance in deliberation and communication?

International Decision Aids Standards Collaboration Development Process:  Presents information in a balanced manner.  Systematic development process.  Up-to-date scientific evidence cited.  Disclose conflicts of interest.  Use plain language.

International Decision Aids Standards Collaboration Effectiveness:  Ensure decision-making is informed and value based.  Improved the match between the chosen option and features that matter most to informed patients.

Does addressing patient information needs work? Based on RCT’s:  Increased patient question asking (6/17 trials).  Variable affect on patient anxiety (2, 6 =).  Increased knowledge (2/5 trials).  Increased patient satisfaction (5/23).  Increased consultation length (3/17). Kinnersley et al. Cochrane review, 2007,2008.

Decision Making Aids: Cochrane review of 55 RCT’s  Improve patient knowledge  Reduced decisional conflict about being uninformed and being unclear of values.  Reduced portion who are undecided.  Reduced portion who where passive.  Simpler aids (compared to more detailed) lead to improved knowledge and greater agreement between values and choice. O’Connor, Cochrane Collaboration, 2009 O’Connor, Cochrane Collaboration, 2009

Decision Making Aids: Cochrane review 2009  Use of quantitative probabilities lead to more accurate risk perceptions.  Reduced elective invasive surgery, post- menopausal hormone therapy and PSA screening.  No effect on satisfaction with decision making, anxiety or health outcomes.  Effect on continuance with chosen option, resource use, consultation length, and patient-clinician communication are inconclusive.

Decision Making Aids: Effects inconclusive and need further study:  Continuance with decision  Patient-practitioner communication  Consultation length  Resource use/cost-effectiveness O’Connor, Cochrane Collaboration, 2009 O’Connor, Cochrane Collaboration, 2009

Role Play with DMA Case 1: 45 year old female with BMI of 35 and two recent fasting blood sugars of 110 and 112 whom you ask to come it to discuss the prediabetes range blood sugars. Counsel the patient on appropriate life style changes. Case 2: A 20 year old college student with a history of asthma presents with 2 days of cough and fever. H1N1 influenza A is active in you community. You are considering a 5 day course of oseltamivir. Counsel the patient on use of this medication. Case 3: A 65 year old male smoker with HTN, DM (x10 years), and Hyperlipidemia (TC-240, TG-200, HDL-40, LDL 160) has not been treated previously for the latter. You decide to start him on simvastatin. Counsel the patient on the use of this drug. Case 4: A 24 year old in her first trimester of pregnancy is smoking 1 PPD. Counsel her to quit smoking.

AGENDA  Small group role play of usual care.  Rationale: Why is shared decision making important and gaining traction?  Literature: What do we know about shared decision making and decision making aids?  Small group role play use of a Decision Aid.  Feedback on your experience.

Comments or Questions?

Decision Aid Resources International Patient Decision Aids Collaboration: Ottawa Patient Decision Aids: Dartmouth Center for Decision Making: aking.cfm aking.cfm aking.cfm Mayo Clinic Wiser Choice Program: earch/ker_unit/decision-aids.cfm earch/ker_unit/decision-aids.cfm earch/ker_unit/decision-aids.cfm