Shared Decision Making in Clinical Practice
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1 Shared Decision Making in Clinical Practice November 20, 2017 Karen Sepucha, PhD; Leigh Simmons, MD; Lauren Leavitt, MA; Felisha Marques, MPH MGH Health Decision Sciences Center
2 Support conversations that draw on expertise of patients and families, care team, and clinical evidence to ensure informed, patient-centered decisions
3 Shared Decision Making in 6 Steps
4 Introductions from You Tell us about you Your role in health care Heard of shared decision making? Observed a conversation about a significant health decision? Seen a decision aid used to help with making a decision?
5 Some challenging decisions for patients (and families) When should I start having a mammogram? Should I have an MRI to evaluate my acute low back pain? Should I try medication or counseling for my depression? Is it time to get my knee replaced? Should I join a clinical trial for cancer therapy or have standard care? Would my loved one want to have a feeding tube?
6 And for providers How far should I push this older patient with diabetes, but also many other illnesses, to lower their A1c? Should this patient with chest pain be admitted for observation or can they go home and f/u with specialist in a few days? I disagree with this patient s preferred treatment (e.g. contralateral mastectomy), should I just do it anyway?
7 Shared Decision Making (SDM) Interactive process between patient (and family) and clinician(s): Engages patient in decision making Gives accurate information about options and outcomes Tailors treatments to patient s goals and concerns SDM is means to ensuring informed decisions that reflect patients goals (Charles C, Soc Sci Med 1997; 44:681; Mulley A. Med Care 1989)
8 Six Steps to SDM 1. Invite patient to participate 2. Present options (+/- using a decision aid) 3. Provide information on benefits and risks 4. Elicit patient preferences 5. Facilitate deliberation and decision making 6. Assist with implementation Invite Options Benefits and Risks Patient Preferences Deliberate and Decide Implementation Credits: R. Wexler, FIMDM, and K. Clay, Center for Shared Decision Making, Dartmouth-Hitchcock Medical Center
9 What can help? Patient Decision Aids
10 Tools designed to help people participate in decision-making Available in different media (online, DVD, booklets) Provide information on the options Help patients clarify and communicate their goals and treatment preferences Decision Aids
11 Evidence for Decision Aids 2017 Cochrane Systematic Review contains 105 RCTs: Decision aids increase decision quality: increase in knowledge increase accuracy of risk perceptions increase in value-choice concordance Decision aids engage patients less passive (RR 0.68) fewer who remain undecided Reduced decisional conflict due to feeling uninformed (MD -9.28/100) and indecision about personal values (MD -8.81/100) Decision aids address over- and under- use reduction in major invasive elective surgery (RR 0.86) reduction in PSA testing (RR 0.88) increase in medication use for diabetes (RR1.65) Stacey et al. Cochrane Database of Systematic Reviews, 2017
12 # of Decisionm aids Overview of decision aid use Cumulative Volume of Decision Aids By the numbers: ~10,000 distributed annually ~75% of orders from primary care (vs. 25% specialty) >1000 unique clinicians and staff have prescribed programs Top Titles: 1. Insomnia 2. Anxiety 3. Chronic Low Back Pain 4. Knee Osteoarthritis 5. PSA Testing
13 Some limitations of decision aids Limited number of clinical topics available Decisions may come up that need to be dealt with in the visit
14 What can help? Decision Coaching
15 What is coaching? Non directive Structured elicitation of needs, elicitation of preferences, preparation for communication, and facilitation of deliberation Trained health professionals or lay people
16 Ottawa Personal Decision Guide Generic tool 4 steps Clinicians or trained students
17 Step 1: Clarify the Decision Should I have hormone replacement? Hot flashes and night sweats are really impacting life Not sure, but would like to get some help soon X X I am nervous about hormone therapy
18 Step 2: Explore your decision Hormone therapy Relieve hot flashes Help sleep **** ***** Breast cancer Blood clots **** *** Antidepressants Avoid hormones Relieve hot flashes *** **** Difficulty sleeping? *** Lifestyle changes Avoid medicines Don t seem to work
19 Step 2: Explore your decision Husband anything that stops night sweats X he can t sleep when I am up each night so impacting both of us X Health care team
20 Step 3: Identify decision making needs X X X X
21 Step 4: Plan next steps
22 Using the Decision Guide 1. Form groups of two Client making a difficult decision Practitioner interview/coach 2. Client choose a real decision (career, education, move, buy a car) 3. Practitioner interviews patient & documents on the Ottawa Guide 4. Discussion Any Decision ~10 min
23 Discussion Reflections on using a decision guide As the patient making a decision? As the coach?
24 Developing new decision aids
25 Summary SDM is important part of clinical care, skills can be learned High quality, patient-centered care requires that we inform patients, involve them in decisions and tailor treatments to their goals and preferences
26 Contact us Visit our website: Contact us: Karen Sepucha, PhD, Director HDSC Leigh Simmons, MD, Medical Director HDSC Lauren Leavitt, MA, Project Manager HDSC Felisha Marques, MPH, Sr. Research Coordinator
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