Nananda F. Col, MD, MPP, MPH, FACP Director, Center for Outcomes Research and Evaluation Maine Medical Center Dept of M

1. Implementing Shared Decision Making: Improving Efficiency and Quality of Care Nananda F. Col, MD, MPP, MPH, FACP Director, Center for Outcomes Research and Evaluation Maine Medical Center Dept of Medicine Coln@MMC.org

2. INTRODUCTION • Most patients want to be more involved in decisions about their health • Shared decisions have better outcomes • Despite repeated calls for shared decision making, it remains uncommon

3. What is Shared Decision Making?

4. What is Shared Decision Making (SDM)? • A recent systematic review identified 161 different conceptual definitions • “A decision-making process jointly shared by patients and their health care provider”

5. QUESTION • How often do you engage in informed decision making with your patients? • Most visits • Occasionally • Seldom • Never

6. Elements of Informed Decision Making • Discuss: • clinical issue and nature of the decision to be made • alternatives • pros and cons of the alternatives • uncertainties associated with the decision • Assess patient’s understanding • Ask patient to express preferences Braddock CH, JGIM 1997

7. QUESTION 2. How often do you discuss the uncertainty about risks and benefits of treatment? • Most visits that involve a treatment decision • Occasionally • Seldom • Never

8. How common is shared decision making? Analysis of 1057 clinical encounters by PCPs and surgeons • 16-18% of discussions met minimum criteria for an informed decision • 1% discussed the uncertainty about risks and benefits of treatment Braddock, JAMA 1999

9. QUESTION State of Knowledge 3. What percent of all treatments for clinical prevention or treatment are of unknown effectiveness? • 95% • 75% • 50% • <10% Clinical Evidence, BMJ

10. Answer: A recent comprehensive summary of the state of medical knowledge • 47%: unknown efficacy • 7%: uncertain tradeoff between benefits and harms

11. The Challenge • More and more people realize that they are the best judges of their values when deliberating over a health care decision

12. Patient barriers to shared decision making • Cognitive: complex risk information • Affective: anxiety, fear • Self-efficacy: medical decision making • Social/environmental influences • Locus of control for decision making

13. The Problem • 52% of pts were dissatisfied with the information given (in all aspects) and reported a desire for more information • The better the match between the information that was desired and the information received, the better patient outcomes

14. Role of Decision Support Tools Patient • Educate about risks, treatments, and how to incorporate preferences into the treatment decision PCP’s • collect relevant pt data (risk factors, medical history) • understand patient preferences for outcomes and treatments • Integrate/synthesize risks and preferences to make informed decisions

15. Patient Decision Aids Adjuncts to counselling • Inform 2. Clarify values 3. Support

16. 1. Inform Provide facts Condition, options, benefits, harms Communicate probabilities

17. 2. Clarify values Patient experience Ask which benefits/harms matters most Facilitate communication

18. 3. Support Guide in steps of deliberation, communication Worksheets, list of questions

19. What’s wrong with the status quo? • Standard counseling is inadequate • Clinicians are poor judges of pts’ values • Leads to overuse of treatments that patients do not value • Preference sensitive surgeries (hip replacements, prostatectomy, mastectomy, discectomy, CABG) vary 2-5 fold • Informing pts about these procedures ↓ use 25% • No adverse impact on pt satisfaction or health outcomes

20. Compared to standard care, decision aids… • Reduce decisional conflict (9 points) • Help undecided to decide (50%) • Patients 40% less passive in decisions • Reduce over-use • ↓25% surgery; ↓ 20% PSA; ↓29% HRT • Potential to reduce under-use • Improve decision quality • 15% higher knowledge scores • 70% more realistic expectations (probabilities) • better match between values & choices O’Connor et al., Cochrane Library, 2007

21. Are they cost-effective? • A randomized controlled trial measured economic impact of using pt decision aids • Hysterectomy for heavy menstrual bleeding:

22. Kennedy et al. JAMA 2002; 288: 2701-2708

23. Growth in trials and PtDAs Registered in Cochrane Collaboration’s Inventory

24. How are decision aids available? • Paper (pamphlet) • Game boards • Touch screen monitors • Videos • CD ROMs • Internet

25. Delivery Models • Internet [8 million in 2006] • Call Center • Practice Centers or Shared DM Center

26. Range of Decision Support Tools • Information: • diagnostictests: • Where to order • Costs Clinical trials Information: cancer, risk factors, diagnostic tests ?? personal health journal MD-pt interaction PATIENT DOCTOR Risk self-assessment Tools to assess risk Patient portals: Tricare disease tracking & management tools Patient electronic medical record (EMR)

28. Foundation for Informed Decision Making • The Informed Health Care Consumer • Treatment Choices for Benign Prostatic Hyperplasia • Treatment Choices for Prostate Cancer • Is a PSA Test Right for You? • Treatment Choices for Abnormal Uterine Bleeding • Treatment Choices for Uterine Fibroids • Ovarian Cancer: Reducing Your Risks • Early Breast Cancer: Hormone Therapy and Chemotherapy • Early Stage Breast Cancer: Choosing Your Surgery • Breast Reconstruction: Is It Right For You? • Living with Metastatic Breast Cancer • Ductal Carcinoma In Situ: Choosing Your Treatment • Managing Menopause: Choosing Treatments for Menopause Symptoms

29. Ottawa Health Research Institute: www.ohri.ca

30. Fox Chase Cancer Center: http://www.fccc.edu

32. Decision Aid Personal Decision Form

33. GP/Physio screens for surgical eligibility Decision Aid Assess patients’ informed preference Patient decision aid Decision quality

34. Dear Dr. Thank you for the referral. Your patient, ___________________, was assessed at the Orthopaedic Intake Clinic at the Riverside campus of the Ottawa Hospital. We used the following standardized assessment: A. Clinical Assessment of Surgical Eligibility Your patient completed an osteoarthritis specific quality of life measure, the validated WOMAC (Western Ontario McMaster Osteoarthritis Index). Higher scores indicate worse quality of life (threshold for consideration of joint replacement > 39). A physician completed joint replacement assessment tool, HKPT (Hip & Knee Priority Tool) developed and validated for the Western Canada Wait List Project and includes aspects of history, physical examination and X-ray interpretation. Higher scores indicate higher need for joint replacement Your patient self-reported a WOMAC osteoarthritis score of ____/120 and was assigned a HKPT screening score of _______/80. Both forms are attached for your information. Based on this global assessment, your patient meets the criteria for further assessment by an orthopaedic surgeon. B. Assessment of Patients’ Informed Preferences Your patient watched an evidence-based, validated video/DVD patient decision aid on total knee replacement surgery. It describes the options, benefits, risks, and their associated probabilities. It also helps them to clarify the personal importance of benefits versus risks. Your patient completed a decision quality measure eliciting: a) their knowledge of options, benefits, and harms; b) the personal importance they place on benefits versus risks; and c) unresolved decisional needs. The form is appended. After viewing a patient decision aid on total knee replacement surgery, your patient prefers non-operative alternatives at this time and did not want to consider surgery. Other non-operative alternatives to consider include: physiotherapy, bracing_______________; intra-articular cortisone injection; viscosupplementation injections; weight loss Information on these alternatives can be found at www.aaos.org/Research/documents/oainfo_knee.asp The Ottawa Hospital Orthopaedic Intake Clinic staff would be happy to reassess your patient in 6 months if the condition changes and your patient re-considers having surgery.

37. Challenges in Counseling Women about Menopause HT: complex benefits versus risks Many other treatments available Long-term vs short-term effects Importance of individual risk Uncertainty/probabilities Women often harbor other concerns Quality of menopausal counseling poor

38. An Interactive Website • Patient-specific decision model translates RCT findings to individual patients • Applies RR from WHI to individual baseline risks • Links decision model to comprehensive database of treatments • Considers major outcomes affected by HT, including relief from menopausal symptoms Col et al: JAMA, AIM, MDM

39. Women’s Interactive System for Decisions on Menopause • Purpose: • Empower women to make better decisions about menopause • Help clinicians counsel menopausal patients • Designed by multidisciplinary team • Funding: AHRQ R01

40. Screen Shots from WISDOM

41. Treatment Options Chart

42. Alternative Treatments

43. Drilling Down to Tailor Amount of Information to Information Needs

45. Drilling Down: References

46. Risk Assessment

47. Personalized Risk Report

49. Clinician Summary

50. Clinician Summary (cont)