1. Statin Choice Decision Aid Share-Decision Making
SCIP

2. Shared Decision Making
*Evidence-based practice considers two principals. The first principal is that the stronger the evidence, the more confident the decision maker will be. Most people think that this is the only principal in evidence best practice. But there is a second one and that is that the evidence alone is never sufficient to fully inform a decision, the one has to consider the patient’s values and preferences and the patient’s context in order to make a fully informed decision.
*In order to make a fully informed decision we will require: patient values and preferences, context, and research evidence.

3. Shared Decision Making
*A second justification for SDM comes from the considering the path that evidence follows into the practice. To the left of this slide you see an inverted triangle that at the base represents most of clinical research but at the steep you will find the best evidence that is ready to become actionable (Systematic reviews and meta analysis). To act on this evidence clinicians have to become aware of it, have to accept it, have to find it applicable to their practice and then have to have the tools to be able to apply it and to detect the situations in which that evidence is actionable.
*But notice the right side of this box, and that is in order for evidence to be applied it is important that patients would agree to the course of action and adhere to it, making it critically important for SDM to be a part of the path of translating evidence into practice of improving the value of healthcare.
Glasziou and Haynes ACP JC 2005

4. What is Shared Decision Making?
Promote a process where patients and clinicians make a choice together.
Clinicians are the expert on evidence-based medicine and guidelines
Patients are the expert on his or her preferences, values, and personal context.
SDM acknowledges that both perspectives contribute equal weight to decision making.
*The body of evidence from clinical research indicates that there are
Ting HH, Brito JP, Montori VM. Shared decision making: science and action. Circ Cardiovasc Qual Outcomes. 2014;7:323–7.

5. The body of evidence
Systematic review  115 RCTs of shared-decision making interventions.
The results (decision aids compare to usual care) show that :
Increase patient involvement by 34% (+++-)
Increase patient knowledge of options by 13% (++++)
Increase consultation time by ~2.6 minutes
Reduce decisional conflict by ~7%
Reduce % undecided by 40%
No consistent effect on the choice patients make, adherence, health outcomes or costs.
*The body of evidence from clinical research indicates that there is over a hundred RCTs (Randomized controlled trials) of SDM interventions. The results are fairly consistent in showing that patients can become more involved in decision making thanks to these interventions, that they become more knowledgeable about the options and more comfortable about the decisions they make with less uncertainty. This comes of a cost of about 3 minutes of the consultation. Also important is that the current evidence does not show a consistent effect of SDM on the nature of choices patients make, on the adherence to therapy, on the health outcomes a patient experience and on the cost and utilization of health services.
Stacey D et al. Cochrane review 2014

6. Decision Aids
* At mayo clinic the approach has focused on decisions that patients and clinicians make in the office about medicines, and we noticed that many of those decisions that patients have to continue after they leave the consultation are made by patient after they leave the consultation. Perhaps at that point they realize the side effects of the medicine or their cost, and as a result they make decisions without access to the experience and expertise of the clinician. To solve that problem we thought to bring together the patient’s values, preferences and goals as well as the best available research evidence with the clinician’s experience and expertise within the exam room by using the decision aid.

7. Decision Aids - Examples
Evaluation
Risk communication tools
Statin Choice (primary care)
Feasible, effective
Independently validated
Multicenter trial completed
Implemented in EHR
Chest pain Choice (emergency)
Feasible, effective (Emergency)
Multicenter trial seeking funding
Aspirin Choice (primary care)
Implemented in EHR without evaluation
Osteoporosis Choice (primary care)
EHR implementation ongoing
PCI Choice (cardiology)
Ongoing
AMI Choice (hospital)
Feasible, effective (hospital)
Issue cards
DM2 Med Choice
Multicenter trial ongoing
Depression Choice
This slide some of the decisions aid available. The range go from preventive to treatment, from primary care to specialty care, from the emergency department to the ambulatory care clinic. And it involves physical and mental health.

8. Statin Choice Decision Aid
This decision aid is for patients who are trying to prevent a heat attack by taking statin medicine.

9. Statin Choice Decision Aid
In this particular case this is a risk communication tool (show the risk calculator)/

10. Statin Choice Decision Aid
In the left side there are 100 people just like the patient with the same risk factors of the patient, and shows that in the next 10 years this 100 people just like the patient, 92 will not have a heart attack (green) and 8 will (those 8 in yellow). It also shows that if you were to give statins to all 100 people, the 92 that were not destined to have a heart attack will take medicine with no benefit. 6 of the 8 who are destined to have a heart attack will still experience the heart attack despite taking the medicine, and 2 in blue who are destined to have a heart attack will avoid that destiny by taking statins. The patient can then have the discussion with the clinician as to whether

11. Statin Choice Decision Aid
The patient can then have the discussion with the clinician as to whether this size of the benefit is worth taking a pill everyday.
At the bottom left of the slide there is a link, following the link will show you the latest version of statin choice which is now designed for use in the electronic environment linked to your electronic medical record.

12. patients using the decision aid were
Mayo Experience
Compared to usual care,
patients using the decision aid were
22 times more likely
to have an accurate sense of their baseline risk and risk reduction with statins.
In the clinical trial published in 2007, it was shown that the use of this tool improves the sense of risk and risk reduction with statins that patients had by 22 times
Weymiller et al. Arch Intern Med 2007

13. Mayo Experience
Age: (avg 65) Primary care, ED, hospital, specialty care 74-90% clinicians want to use tools again Adds ~3 minutes to consultation 60% fidelity without training 20% improvement in patient knowledge 17% improvement in patient involvement
Accordin to Mayo Experience, SDM can improve the experience of patients in a whole range of ages across a range of settings. Clinicians find that this tools are helpful and improve their practice despite adding about on average 3 minutes to their consultation, that many can use them as intended without further training, that they can improve patient knowledge and patient involvement in decision making. And they may have variable clinical outcomes, for instance the depression decision aid created by Mayo is associated with improve outcomes in terms of depression symptoms.

14. Decision Aid
One more difficult domain to measure is how it affects the quality of the interaction on the consultation. In this slide we show the same doctor in the same office with different patients, the patient to the right is using the statin choice decision aid. If I were showing you this as a movie you will see a high level of interaction and dialogue between the patient and the clinician, interaction and dialogue that did not take place when the discussion was focused on laboratory parameters displayed on a computer screen as shown on the left side.

15. Decision Aid
The decision aids tool were made so that they can take place with minimal training.

16. Why to do it?
It is about the patient
It is the right thing to do.

17. Statin Choice Decision Aid
This statin choice decision aid that can be linked from any electronic medical record and display the levels of risk for any specific patient seen in the consultation. This also has the added advantage now to be completely consistent with the 2014 cholesterol guidelines released by the American college of cardiology and the American Heart Association emphasizing focus on statin therapy to reduce the 10-year heart disease risk. Instead of focusing on
Instead of focusing on a threshold of risk to initiate statins such as 7.5% as indicated in the guideline, the use of a decision aid allows for the personalization of the decision making moment such that the threshold necessary to initiate therapy is decided throughout a conversation between the patient and the clinician.
Last but not least, the 2015 Secondary Prevention Lipid Performance Measures of the American College of Cardiology and American Heart Association encourages the use of Statin choice decision aid and considers its use a performance measurement.

18. Implementation into the EMR
We have also done efforts to implement this tools in the EMR with different degrees of success. Here is the statin choice decision which is finally available to be implement at the medical record of your health center.

19. Empathic decision making
Decision Aid
The need for an empathic process in which patients and clinicians develop a partnership and then dance across participatory models of decision making. In some cases the clinician may give a recommendation after closely listening to the patient, in others the patient might drive the conversation as they may have both understood the information from the evidence and have a clear sense of what their values and preferences are.
In many cases however it would be more like a dance, and the patient and the clinician would take turns in taking responsibility for decision making to the extent that the patient is comfortable and desires some degree of control over that choice.
We need to recognize that many decisions are purely technical and here we are not talking about such decisions, we are focusing on decisions in which the options available are equally available to the patient and that their prons and cons differ in ways that matter to the patient such that their participation is important. We also find that it is important to support the deliberation that this process of showing the pros and cons of the available options is a process that will allow us to understand better what are the values and preferences of the patients.
Empathic decision making
Partnership
Dance across models
Support deliberation

20. Decision Aid
At the end of the day particularly in relation to patients with chronic conditions our goals is to incorporate the research evidence that we have accumulated over the years as well as our own expertise, clinician expertise, into the decisions that patients would make after they leave the consultation.
Incorporate research evidence and clinician’s expertise into patient decisions

21. Conclusions
It is feasible to promote evidence-based conversations during the clinical encounters with patients with chronic conditions.
Decision aids designed for this purpose are efficient and effective in promoting shared decision making.
Tools tested in randomized trials and proven effective are available for free.
Partners to get to routine use in practice
In conclusion