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Shared Decision Making with Older Adults: Evidence and Policy

Shared Decision Making with Older Adults: Evidence and Policy. Dan Matlock, MD, MPH Associate Professor of Medicine University of Colorado School of Medicine. Conflicts of Interest/Acknowledgments. No conflicts to disclose Acknowledgments: NIH (NIA, NHLBI)

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Shared Decision Making with Older Adults: Evidence and Policy

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  1. Shared Decision Making with Older Adults: Evidence and Policy Dan Matlock, MD, MPH Associate Professor of Medicine University of Colorado School of Medicine

  2. Conflicts of Interest/Acknowledgments • No conflicts to disclose • Acknowledgments: • NIH (NIA, NHLBI) • The Patient Centered Outcomes Research Institute (PCORI) • The John A. Hartford Foundation/American Federation for Aging Research

  3. There is a 30% chance of rain tomorrow

  4. 30% chance of rain 750 people on the street were asked what does this mean • It will rain tomorrow in 30% of the region • It will rain tomorrow for 30% of the time • It will rain on 30% of the days like tomorrow Gigerenzer, Psychologic Science and the Public Interest, 2008

  5. 30% chance of rain 750 people on the street were asked what does this mean • It will rain tomorrow in 30% of the region • It will rain tomorrow for 30% of the time • It will rain on 30% of the days like tomorrow Gigerenzer, Psychologic Science and the Public Interest, 2008

  6. People on the street “3 out of 10 meteorologists believe it will rain.” “Thirty percent means that if you look up to the sky and see 100 clouds, then 30 of them are black.” “It’s not about time, it indicates the amount of rain that will fall” “If we had 100 lives, it would rain in 30 of these tomorrow” Gigerenzer, Psychologic Science and the Public Interest, 2008

  7. Overview • The Problem: Poor decision quality • A Solution: Better Shared Decision Making • Challenges: We’re all human

  8. Overview • The Problem: Poor decision quality • A Solution: Better Shared Decision Making • Challenges: We’re all human

  9. Decision Quality: Definitions ‘the extent to which a decision reflects the considered preferences of a well-informed patient, and is implemented’ • Sepucha, Health Affairs, 2004

  10. Decision Quality: Knowledge • 1995, the UK Committee on Safety of Medicines issues a warning: “oral contraception pills increase the risk of potentially life-threatening blood clots by 100%”

  11. Pill Scare in England Abortions

  12. Pill Scare in England • Actual increase: 1/7000 -> 2/7000 • Relative Risk of 100%; Absolute Risk 0.014% • 1996 • 13,000 additional abortions • 13,000 additional births (Risk of blood clots with pregnancy and abortions 10 fold higher than with OCPs)

  13. Relative vs. Absolute Risk Reduction

  14. Relative vs. Absolute Risk Reduction What’s wrong? • Denominator Neglect: Humans think that relative risks are absolute risks • Framing: • Benefits – relative risks • Harms – absolute risks

  15. Example: Implantable Defibrillators Bardy, NEJM 2005

  16. Survey of 295 people with ICDs Matlock, AHA QCOR Abstract, 2012

  17. Overview • The Problem: Poor decision quality • A Solution: Better Shared Decision Making • Challenges: We’re all human

  18. Shared Decision Making “A meeting between experts” Tuckett , 1985 Paternalism Consumerism (abandonment)

  19. Implantable Defibrillators

  20. Potential Harms of ICDs • Procedural risks (Infection, Bleeding, etc.) Additionally: • Increased Heart Failure admissions (Goldenberg I, Circulation. 2006) • Anxiety/Depression/PTSD/QOL (Sears SF, Heart. 2002, Noyes K, Medical Care. 2007) • Inappropriate shocks (Sears SF, Am. J of Card. 2006) • Device malfunction (Washizuka T, Int. Heart J. 2005) • Potential suffering at the end-of-life (Goldstein NE, Annals Int. Med. 2004)

  21. Type of Death Lunney, JAMA. 2003

  22. Type of Death Lunney, JAMA. 2003

  23. Type of Death Lunney, JAMA. 2003

  24. Physician Survey (n=1210, response rate 12%) Caverly, Matlock, Archives of Internal Medicine, 2012

  25. Beneficence (Paternalism) • “I think my biggest concern is if I convey the risks to them too strongly, that they will choose or make an unwise decision and not proceed with therapy.” Matlock, PACE, 2011

  26. Physicians and ICDs (n=11) • “…I have the EP doctors actually explain it to them in much more detail.” – General Cardiologist • “…and most of them have already made up their mind by the time they come to see me.” – Electrophysiologist Matlock, PACE, 2011

  27. Example: Implantable Defibrillators Bardy, NEJM 2005

  28. Overview • The Problem: Poor decision quality • A Solution: Better Shared Decision Making • Challenges: We’re all human

  29. The Dual Process Theory of Decision Making

  30. Multi-option, Multi-attribute decisions • 24 Jams • 60% stopped to look • 3% purchased • 6 Jams • 40% stopped to look • 30% purchased • Greater satisfaction if options were limited Iyengar, Journal of Personality and Social Psychology 2000

  31. Cognitive Effort Physicians were asked: • A 67-year-old farmer with hip osteoarthritis. • You have tried several NSAIDs…and stopped them because they didn’t work. • You decide to refer him to orthopedics to consider a hip replacement Redelmeier et al., JAMA 1995

  32. Before sending him away, however, you check the drug formulary and find that there: • …are two NSAIDs that this patient has not tried (ibuprofen and piroxicam). What do you do? • A. refer and start ibuprofen • B. refer and start piroxicam • C. refer and do not start any new medication • …is one NSAID that this patient has not tried (ibuprofen). What do you do? • A. refer and start ibuprofen • B. refer and do not start any new medication Redelmeier et al., JAMA 1995

  33. Before sending him away, however, you check the drug formulary and find that there: • …are two NSAIDs that this patient has not tried (ibuprofen and piroxicam). What do you do? • A. refer and start ibuprofen • B. refer and start piroxicam • C. refer and do not start any new medication (72% p<0.005) • …is one NSAID that this patient has not tried (ibuprofen). What do you do? • A. refer and start ibuprofen • B. refer and do not start any new medication (53%) Redelmeier et al., JAMA 1995

  34. Framing "imagine that the U.S. is preparing for the outbreak of an unusual Asian disease, which is expected to kill 600 people…” Tversky and Kahneman, Science, 1981 (Nobel Prize, 2002)

  35. Framing "imagine that the U.S. is preparing for the outbreak of an unusual Asian disease, which is expected to kill 600 people…" Tversky and Kahneman, Science, 1981 (Nobel Prize, 2002)

  36. Medicare • Requirements for Shared Decision Making • Lung Cancer Screening • Left Atrial Appendage Closure Devices • Implantable Cardioverter-Defibrillators

  37. Thank You • Core Team: • Bryan Wallace • Jocelyn Thompson • Channing Tate • Colleen McIlvennan • Carmen Lewis • Jean Kutner • Chris Knoepke • Russ Glasgow • Pilar Ingle • Gracie Finnigan-Fox • Larry Allen daniel.matlock@ucdenver.edu www.patientdecisionaid.org

  38. daniel.matlock@ucdenver.edu www.patientdecisionaid.org

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