1. Better Shared Decision Making in Practice
Charlie Brackett, MD, MPH
Blair Brooks, MD
Nan Cochran, MD
(France Légaré, MD)
2007
Dartmouth-Hitchcock Medical Center
White River Jct. Veterans Administration Hospital
Dartmouth Medical School
Research and Workshop
Sponsored by FIMDM

2. Workshop Goals Increase interest in SDM
Share our experience and address challenges
Demonstrate ways to facilitate SDM
Practice communication skills
Decision Aids
Explore broader implementation of SDM in primary care

3. There is unwarranted variation in the practice of medicine and the use of medical resources
Variability due to different practice patterns. Preference sens care has historically been the doctor’s preference- but should be the patient’s preference based on the pt’s values together with a well informed consideration of the pros and cons.
Supply sens- no time

4. The 3 Categories of Care Effective care: underused
Evidence-based care that all with need should receive
Preference-sensitive care: misused
Treatment choices with multiple options; involves tradeoffs, scientific evidence re: outcomes is variable
Supply-sensitive care: overused
Visits, hospitalizations, ICU admissions and other services where utilization is associated with supply of resources

5. Incidence of surgery: hip fracture repair, knee and hip replacement and back surgery: 306 hospital regions ( ) ( Preference-sensitive care is typified by elective surgery)
Hip
Fracture
(CV=13.8)
Knee
Replacement
(CV= 55.0) 4x
(CV= 67.2)
Back
Surgery
(CV= 93.6) 7x
…………….how can we explain this variation?

6. Preference-Sensitive Care
Involves tradeoffs -- more than one treatment exists and the outcomes are different
Scientific evidence re: outcomes sometimes good, sometimes not
Decisions should be based on the patient’s own preferences and values
But Provider Opinion Often Determines Which Treatment is Used

7. Shared Decision making – a definition
Decisions that are shared by doctors and patients, informed by the best evidence available and weighted according to the specific characteristics and values of the patient.
Légaré et al. Patient Education and Counseling. 2006

8. Which rate is right? Impact of improved decision quality on surgery rates: BPH
Knowledge of relevant treatment options and outcomes
Concordance between patient values and care received
Under the normative assumption that the “right rate” for a given procedure should be based on the choices made by informed patients (free of undue influence by the practice style preferences of their physicians or other unwarranted influences), the systematic implementation of decision aids among patient populations would offer the opportunity to obtain valid benchmarks for the “true” demand for a given treatment option. Such an opportunity presented itself to our research group in the early 1990’s when a decision aid we had designed to help patients decide between watchful waiting and surgery for their enlarge prostate was introduced in the urologic clinics in 2 pre-paid group practices, Kaiser-Permanente in Denver and Group Health Cooperative in Seattle. After the implementation of shared decision making, the population based rates for prostatectomy fell 40% , providing a benchmark for demand under shared decision making. (Rates in the control group, Group Health Cooperative’s Tacoma site, did not change.) giving us a benchmark for demand under shared decision making. When we compared this benchmark to the rates among the 306 region (blue dots in the above figure)s, it was of interest that the shared benchmark was at the extreme low end of the national distribution, suggesting that the rates of surgery in most US regions exceeded the amount that informed patients want.
40% reduction in TURP after DA

9. IOM “Crossing the Quality Chasm”
Shared decision making is reflected in 4 of the 10 “simple rules” for redesign of HC:
Customization based on patients’ needs and values
Patient as source of control
Shared knowledge and free flow of information
Evidence based decision making

10. SDM has not been adopted by health professionals.
Why not?
What are the barriers?

11. TIME Time Required to Deliver All Highly Recommended 7.4 hrs/day
Preventive Services:
Time Required to Deliver All
Highly Recommended hrs/day
Chronic Care Services:
Yarnall, AJPH, 2003
Yarnell, Ann Fam Med, 2005

12. Barriers to practicing SDM
Clinicians
Challenge to physician autonomy
Don’t recognize preference sensitive decisions
Evidence difficult to extract, interpret, communicate
Practice
Logistics
Lack of time
Lack of reimbursement
Patients
“Patients don’t want to participate”
Variation in role preference
Literacy, Numeracy
Communication skills and decision aids are key strategies that address many of these barriers.

13. Patient Decision Aids Evidence based tools designed to facilitate SDM.
Many formats: print, audio, video, internet
Adjunct to counseling

14. Impact of Decision Aids: Cochrane review of 51 RCTs
Increase patient involvement
Improve patient knowledge
Clarify patient values
Improve concordance between values and choices
Reduce patient decisional conflict, regret
Improve realistic expectations
Decrease number who are undecided
balance, accuracy, consistency of information
O’Connor, Cochrane Collaboration, 2006

15. FIMDM Video DAs Breast Cancer BPH DCIS PSA Screning
Breast Reconstruction
Abnormal Uterine Bleeding
LBP: Herniated Disc
LBP: Spinal Stenosis
Chronic LBP
Knee OA
Diabetes (Type II)
The Informed HC Consumer
BPH
PSA Screning
Prostate Cancer
Coronary Artery Disease
CHF
Advanced Directives
Uterine Fibroids
Ovarian Cancer
Depression
Weight loss surgery
Foundation for Informed Medical Decision Making

16. Resources to Support Decision Making
Ottawa Health Research Institute
FIMDM
WebMD
Mayo Clinic
DHMC Center for Shared Decision Making

17. www.ohri.ca/decisionaid Ottawa Decision Aids
Ottawa Personal Decision Guide
A to Z Global Inventory of Patient Decision Aids
Cochrane Systematic Review: Efficacy of Patient Decision Aids
Training in Decision Support
Evaluation Measures
Resources

18. Decision Aid Example: Information

19. Decision Aid Example: Patient Values

20. DHMC experience with SDM
Spine Center
Comprehensive Breast Program
Center for Shared Decision Making
Primary Care:
Implementation of PSA Decision Aids study

21. PSA DA Study: GOALS Assess:
Feasibility of routine use of decision aids in Primary Care
Impact of video decision aid on decision choice and quality
Patient and provider satisfaction
Video mailed to men age before preventive medicine or routine visit at dhmc and va
DQ = knowledge and concordance between values and choice.

22. RESULTS PSA Video Distribution
DHMC
WRJ VA
Distributed
1166
549
Returned video*
845
313
Enrolled in study (completed questionnaire)
394
252
Over 1000 videos at DHMC, and 500 at VA
Most people return video
Between 50 – 80 % complete a questionnaire
Conclusion – feasible to distribute DAs to patients
* Ongoing

23. RESULTS Patient Choice
Before vs After
Video
Unsure
30%
16% *
No PSA screening
23%
42% *
PSA Screening
47%
CHANGED THEIR MINDS
30%*
After viewing the video: fewer patients are “Unsure” (p < .001)
After viewing DA: more patients choose “No screening” (p <0.01)
30% of patients change their minds after viewing DA
* P < .01

24. RESULTS Video Impact on Choice
After Video
Before Video
No PSA Screen
Unsure
PSA Screen
No PSA Screen
126 7 5
Unsure 84 71 23
PSA Screen 38 24
220
Before the video: 138 people chose no PSA screening,
After the video: 126 stayed with no PSA screen
7 were unsure
5 switched to PSA screening
30% of patients change decision after viewing DA
More patients are leaning toward No PSA screening after the video (p < 0.01)

25. RESULTS Decision Quality
Patient Knowledge of key PSA facts
Average test score
(% correct)
DHMC (n = 369)
93%
WRJ VA (n=230)
89%
Total (n = 599)
91%
Knowledge items – (2 slides)
Both the PSA test and prostate biopsy may miss a prostate cancer 81% 74%
How many men will die of prostate ca 99% 97%
Does having an elevated PSA always mean you have prostate cancer? 97% 96%
Many men with prostate cancers found by PSA screening will die of something else… 98% 98%
PSA tests may not help a man live, may find slow growing cancer 88% 84%
Value items –
Patients who feel it is more important to Know if you have cancer are more likely to choose PSA screening
Patients who feel it is more important to “Avoid worry from false alarm” are LESS likely to choose PSA screening

26. Decision Quality: Patient Values
Patients who feel it is more important to “Know if you have cancer” are MORE likely to choose PSA screening (OR 1.9 (95% CI )).
Patients who feel it is more important to “Avoid worry from false alarm” are LESS likely to choose PSA screening (OR 0.7 (95% CI )).
Value items –
Patients who feel it is more important to Know if you have cancer are more likely to choose PSA screening
Patients who feel it is more important to “Avoid worry from false alarm” are LESS likely to choose PSA screening

27. DAs increase patients’ agreement between values and choice
Before vs After
Video
(% match)
No PSA screening
76%
81% *
PSA Screening
80%
92% *
Subtotal
79%
87% *
Using patient value scores, we calculated a predicted choice and compare it to their reported choice (% match)
Patients are switching to the screening option that is in-line with their value scores
* P < .01

28. Patient and Provider Satisfaction
Patients feel DA is:
(%)
Very/somewhat helpful 87
Definitely/probably recommend 96
Clinicians feel DA:
Helps patients choose what matters most to them
Improves communication and efficiency during visit
Patients found the video helpful and would recommend it to others facing the same decision

29. CONCLUSIONS Systematic use of a PSA DA in primary care is feasible.
Viewing the PSA DA resulted in fewer patients being unsure of their decision and more patients choosing no screening.
Viewing the PSA DA helped patients make a higher quality screening decision.
Patients and clinicians found the PSA DA helpful and time efficient.

30. Next steps: DHMC DA Research
Introduce Chronic Condition DAs into routine use in GIM practices
Expand DAs to community based sites
Assess impact of DAs on decision quality, choice and resource utilization.

31. SDM Communication Skills
Define/explain problem
Discuss patient’s desired role
Present options
Discuss pros/cons
Explore patient values, preferences
Assess patient self-efficacy
Present doctor recommendations
Clarify understanding
Make or explicitly defer decision
Adapted from Makoul G. An Integrative Model of Shared Decision Making in Medical Encounters. Pt Educ and Counseling 2006

32. Which skills do clinicians most need to improve?
Ask about patients’ preferred role in decisions
Assess patients’ values
Screen for decisional conflict
Assess support or undue pressure on patient
Increase patients’ involvement in decision making
Légaré, Canadian Family Physician, 2006

33. Decisional Conflict
Decisional conflict is defined as a state of uncertainty about which course of action to take when the choice among competing actions involves risk, loss, regret, or a challenge to personal life values.
Legare et al, Canadian Family Physician 4/06

34. S.A.V. E. Sure of your decision Adequate information Values
Encouragement
Are you sure which choice you want to make?
Do you feel you have adequate information about the options, risks and benefits?
Do you know what matters most to you, the risks or the benefits?
Do you have enough support or are you feeling undue pressure from others?
Voici l’échelle de conflit décisionnel version clinique proposée par la dre O’Connor afin d’établir si l’individu au centre de la décision est bel et bien confortable avec la décision ( soit la mesure de résultats principale)

35. Making a Prostate Cancer Screening Decision: Usual Care
Trigger tape #1
Making a Prostate Cancer Screening Decision: Usual Care

36. Trigger Tape #2
Making a Prostate Cancer Screening Decision: Information Based Shared Decision Making

37. Trigger Tape #3
Making a Prostate Cancer Screening Decision: Shared Decision Making after Decision Aid

38. Supporting patients facing difficult health decisions
Most important changes participants intended to make in their practice:
To ask about patient’s preferred role in decision making
To assess patient values
To screen for decisional conflict
To assess support or undue pressure on patients
To increase patients involvement in decision making
Legare, et al. Canadian Family Physician 4/06

39. Practice communication skills
The scenario
60 year old at primary care visit
Considering PSA screening
Concerned about possibility of erectile dysfunction
The task: (~7 min/role play)
Engage in shared decision making discussion w/ pt.
Assess patient values
Identify decisional conflict
Observer(s) provide feedback

40. Practice communication skills
The scenario
50 year old at primary care visit
Considering treatment options for HNP
Concerned about current limitations despite optimal NSAID’s; fearful of complications of surgery
The task: (~7 min/role play)
Engage in shared decision making discussion w/ pt.
Assess patient values
Identify decisional conflict
Observer(s) provide feedback 40

41. Debrief What surprised you? What confused you? What went well?
What would you change?