SMARTCare Shared Decision Making Webinar Tom Lewandowski, MD, FACC, Project Director SMARTCare Steering Committee With contributions by Mary Norine Walsh, MD, FACC Chair, Patient Centered Care Committee & Katherine Doermann Byrd Associate Director, Clinician and Patient Pathways American College of Cardiology

The project described was supported by Grant Number 1C1CMS331322 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the US Department of Health and Human Services or any of its agencies.

Shared Decision-Making (SDM) Active engagement of patients when health care decisions must be made Relevant decisions occur when diverging paths have different and important consequences with lasting implications. Examples include: major surgery medications that must be taken for the rest of one's life, screening and diagnostic tests that can trigger cascades of serious and stressful interventions. Barry MJ, Edgman-Levitan, S.N Engl J Med2012;366:780781. March 1, 2012

The reality is that most decisions are not black and white. Subdural Hematoma after MVA Botox Mostly Physician Driven Mostly Patient Driven

“…clinicians…need to relinquish their role as the single, paternalistic authority and TRAIN to become more effective coaches or partners — learning, in other words, how to ask, ‘What matters to you?’ as well as ‘What is the matter?’ ” Barry & Edgman-Levitan NEJM 366;9 (March 1, 2012)

Shared Decision Making to Improve Care and Reduce Costs ~20% of patients who participate in shared decision making choose less invasive surgical options and more conservative treatment than do patients who do not use decision aids. Estimate show that implementing shared decision making for just 11 procedures would yield more than $9 billion in savings nationally over 10 years A 2012 study by Group Health in Washington State showed that providing decision aids to patients eligible for hip and knee replacements substantially reduced both surgery rates and costs — with up to 38% fewer surgeries and savings of 12 to 21% over 6 months. 1. Stacey D, Bennett CL, Barry MJ, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2011;10:CD001431-CD001431 2. Arterburn D, Wellman R, Westbrook E, et al. Introducing decision aids at Group Health was linked to sharply lower hip and knee surgery rates and costs. Health Aff (Millwood) 2012;31:2094-2104

Shared Decision Making to Improve Care and Reduce Costs Section 3506 of the ACA aims to facilitate shared decision making by encouraging greater use of shared decision making in health care. However, more than 2 years after enactment of the ACA, little has been done to promote shared decision making. We believe that the Centers for Medicare and Medicaid Services (CMS) should begin certifying and implementing patient decision aids, aiming to achieve three important goals: -promote an ideal approach to clinician–patient decision making -improve the quality of medical decisions -reduce costs In our view, it seems most critical to begin with the 20 most frequently performed procedures and to require the use of decision aids in those cases. Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D. New Eng J Med Jan 3, 2013

SHARE Approach: Quick Steps for SDM Step 1: Seek your patient's participation. Step 2: Help your patient explore and compare treatment options, risks and benefits. Step 3: Assess your patient's values and preferences. Step 4: Reach a decision with your patient. Step 5: Evaluate your patient's decision. AHRQ Share Approach: http://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/tools/tool-1/index.html

SHARE Step 1: Seek patient's participation. If referring patient for stress test, introduce SMARTCare (see flier), and explain its importance: Improve the care your doctor gives you? Understand better your medical options and choices? Decrease health care costs? AHRQ Share Approach: http://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/tools/tool-1/index.html

SHARE Step 2: Help your patient compare treatment options If stress test comes back positive, inform patients there are benefits and harms to their options – their preferences matter. Refer them to decision aid, be it print or online. AHRQ Share Approach: http://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/tools/tool-1/index.html

SHARE Step 3: Assess your patient's values and preferences. Encourage your patient to talk about what matter most to them. Ask open-ended questions. Listen actively to your patient. Acknowledge the values and preferences that matter to your patient. Agree on what is important to your patient. Allow patient to delegate decision to someone else (i.e. family member, caregiver). AHRQ Share Approach: http://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/tools/tool-1/index.html

SHARE Step 4: Reach a Decision With Patient (After Review of the Decision Aid) Encourage patient to ask questions based on decision aid. Review what matters most to the patient. Ask if patient is ready to make a decision. If yes, discuss it. If no, ask if additional materials are needed. Confirm decision. Schedule follow-up/treatment.

SHARE Step 5: Evaluate Your Patient’s Decision Revisit decision at a follow-up appointment. Deploy final decision quality survey at 6 months.

The project described was supported by Grant Number 1C1CMS331322 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the US Department of Health and Human Services or any of its agencies.