OHP Quality and Health Outcomes Committee 14 April 2014 L.J. Fagnan, MD Oregon Rural Practice-based Research Network Oregon Health & Science University

 Defining Shared Decision Making (SDM)  Describe why SDM is a “hot” topic  List conditions where SDM is likely to be of use  Learn where to find SDM resources/tools  Describe models of implementing SDM o “From the trenches” report—the ORPRN Rural Study  Describe patient and practice SDM outcomes

 Moving from individual patient care to population- based care  Moving from physician-based care to team-based care  Using the Shared Decision Making concept to create an informed activated patient

A Multidimensional Framework for Patient and Family Engagement in Health and Health Care Carman K L et al. Health Aff 2013;32: ©2013 by Project HOPE - The People-to-People Health Foundation, Inc.

 Shared Decision Making to Improve Care and Reduce Costs. NEJM, January 3, 2013 — “A sleeper provision of the Affordable Care Act encourages SDM…”  CAHPS PCMH Survey includes self-management support and shared decision making as a domain of care  Oregon PCPCH Standards’ Core Attribute of Person and Family-Centered Care  Milestone #7 of the CMS Comprehensive Primary Care Initiative  Makes the “Triple Aim” Possible—Better Population Health; Improved Experience of Care, Lower Per Capita Cost  Bottom Line: SDM is a standard of practice

 Integrative process between patient and clinician :  Engages the patient in decision-making  Provides patient with information about alternative treatments  Facilitates the incorporation of patient preferences and values into the medical plan (Charles C, Soc Sci Med 1997; 44:681) Slide from Michael Barry, MD, IMDF President

BHM Healthcare Solutions Better Patient Outcomes from Shared Decision Making “No Decision About Me Without Me”

 A central tenet of medicine and our approaches to treatment and diagnosis is its uncertainty  “Many doctors aspire to excellence in diagnosing disease. Far fewer, unfortunately, aspire to the same standards of excellence in diagnosing what patients want.” Mulley A, Trimble C, Elwyn G. Patients’ preferences matter: stop the silent misdiagnosis. 367 London: King’s Fund, 2012

Poor Decision Quality Unwanted Practice Variation Patients: Making Decisions in the Face of Avoidable Ignorance Clinicians: Less than optimal “Diagnosis” of Patients’ Preferences Slide from M. Barry. Informed Medical Decision Foundation

Tools that help patients make informed medical choices, consistent with their values and preferences Three key elements: Present balanced information about treatment or testing options, specifying probabilities of outcomes Help people interpret the options in the context of what is important to them Encourage patients to collaborate with their clinicians when making decisions

 Improve decision quality  14% higher level of knowledge  74% more realistic expectations  25% better match of values and choices  Patients 39% less passive in decisions  Reduce over-use of surgery-20%  PSA testing-15%  HRT-27% Stacey et al Cochrane Review Patient Decision Aids

 Introduced PDAs for hip/knee arthroplasty candidates in 2009  Reached 28% of eligible knee (N=3510)and 41% of hip patients (N=820)  Over 6 months:  38% fewer knee replacements  26% fewer hip replacements  12-21% lower costs Arterburn D, et al. Health Affairs 2012; 31(9)

 59 times more likely to change mind (e.g. not showing up for colonoscopy)  23 times more likely to delay decision  5 times more likely to have regret  3 times more likely to fail knowledge test (e.g. informed consent)  19% more likely to blame clinician for bad outcomes Sun, Q. (MSc thesis). University of Ottawa. 2005; Gattelari & Ward J Med Screen 2004; 11:

 SDM is the “Pinnacle of Care”  NEJM, March 1, 2012  “No care about me without me”  Patients exposed to SDM DAs are big fans and want this level of care  The care team will develop an appreciation for the value of SDM to enhance patient- centered care

SDM is Difficult To Do  SDM implementation as the Triple Axel of patient- centered care  Push back from clinicians, staff, and patients

Objective: to demonstrate that the use of patient decision aids and the process of shared decision making can effectively and efficiently become part of day-to-day care © Informed Medical Decisions Foundation 2013

 Four year study  Funded by Informed Medical Decision Making Foundation (IMDF)  Facilitated by ORPRN  Implemented SDM in six sites in rural Oregon The mission of ORPRN is to improve the health of rural populations in Oregon through conducting and promoting health research in partnerships with the communities and practitioners we serve.

Bayshore Family Medicine Winding Waters Clinic Pioneer Memorial Clinic Lincoln City Medical Center

Engage Providers and Staff Target Individuals or Populations Identify Distribute Encourage Viewing Provide Support Measure Impact Provide Feedback Practice Facilitation

Six Steps of Shared Decision Making 1. Invite patient to participate 2. Present Options 3. Provide information on benefits and risk 4. Assist patient in evaluation options based on their goals and concerns 5. Facilitate deliberation and decision making 6. Assist with implementation

Invite Patient to Participate  “There’s a decision to make about your treatment (or testing) and I’d like to make it with you. Knowing what’s important to you will help us make a better decision.” OR  “Sometimes things in medicine aren’t as clear as most people think. Let’s work together so we can come up with the decision that’s right for you.”

ABCD Living with Diabetes Living with Diabetes Acute Low Back Pain Managing Menopause Managing Menopause Chronic Pain Management Managing Menopause PSA Testing Coronary Artery Disease PSA Testing Colorectal Cancer Screening Knee Osteoarthritis Growing OlderTo be determined… Peace of Mind

Topic (response rate*)

How important for providers to give DAs to patients? Data submitted to Illume data warehouse as of 17-Mar IMDF Demonstration Sites. N=194 N=1382 Patient Responses after Viewing DA:

Question: “How useful was the program in helping you prepare to talk to your healthcare provider?” [not at all / somewhat / very / extremely]

▶ Established highly functional SDM team  Clinic staff (front desk, MA, office manager)  Clinicians ▶ High performing practice facilitator (PERC)  Develop implementation protocols  Provide at the elbow support  Respond to clinic requests

▶ Developing team based distribution strategies ▶ Creating system level protocols ▶ Clinician champion and identifying a staff data liaison ▶ Identify DAs for “common” conditions Clinic stability essential to DA implementation

▶ Patient buy-in for DAs ▶ Sharing patient feedback (i.e., Patient Advisory Council) ▶ External support through practice facilitation (ORPRN PERCs)  Implementation protocols  Distribution process  Interpretation of clinic level data reports Script pad designed by Winding Waters Patient Advisory Council

 DA implementation guide  Using Decision Aids (DAs) to facilitate SDM in routine care  Step-by-step guide based on lessons learned from our practices  Feedback from clinicians and staff  Ready-to-use resources

Merci beaucoup! LJ Fagnan ORPRN