Download A New Culture of Health Care: Who Chooses

A New Culture of Health Care:
Who Chooses What…and Why?
Tom Bartol, Nurse Practitioner
Richmond Area Health Center
[email protected]
Twitter: @tombartol
Think Outside the Box
Think beyond
– the way everybody is doing things
– the way we have been paid to do things
A culture (way of thinking, behaving, or working)
change
– not on minimizing cost of each intervention
– maximizing the value over the entire care cycle
Rather than treat the symptoms (rash, blood
pressure, blood sugar, anxiety) engage patients
to treat the cause (stress, low self-esteem, fear)
Disclosures
The presenter has no financial affiliations with
pharmaceutical companies or the health care
industry
The presenter works in a primary care clinic and
has increased his appointment times to 30
minutes each
Objectives
Describe 3 key concepts in the relationship
between patient and health care clinician when
making decisions
State a working definition for “value” of care
Utilize some effective tolls for shared decision
making
“What we really need is not a doctor
who delivers more care but one who
seems to care more—and has the
time to make sure we understand
what we need in order to be well.”
Shannon Brownlee in “Overtreated”
Brownlee, S. Overtreated: Why too much medicine is making us sicker and poorer. 2007
Who Makes Health Care Choices?
Clinician: based on authority, what is “needed”
Patient:
– By recommendation (from clinician)
– Rational decision making (considering pros, cons,
alternatives, cost, and value)
Payer: Only certain things are covered
Clinical Guidelines: Population based
recommendations that define “quality care”
Evidence: Does evidenced based mean it is best?
How do we do Shared Decision
Making outside of Health Care?
Buying a car
The auto mechanic
Choosing a college
Financial investments
…Are health care choices made like any of these?
Quality Care vs Value Care
Quality:
– Degree of excellence
– Degree of being very good
Value:
– Usefulness
– Importance
VALUE =
Outcomes that Matter to the Patient
Cost Per Patient
A Tale of Two Patients:
Who is Heathier?
55 y/o Patient A with diabetes
A1c 6.8% on 3 oral agents and
basal insulin, up from 6.4%
B/P 118/80 on 3 b/p
medications
LDL-C 98 on simvastatin 40mg
Asked about smoking and
gave Rx for Chantix
Weight measured: BMI 43, up
from 39 six months ago
55 y/o Patient B with diabetes
A1c 7.4, no meds, down
from 8.1%
B/P 142/88, no meds, down
from 160/100
LDL 108 on no meds, down
from 157
Quit smoking 2 weeks ago
cold turkey
Weight measured BMI 33, down
from 40 a year ago
It’s not just getting to the goals but HOW they get there
that makes a difference!
Engaging Patients
Ask, “What matters to you?” as well as “What is
the matter?”
Helping people find connection, purpose and
hope in life.
Ascertaining the patients needs, values and
goals at that point in time.
Building Self Esteem
Affirm the patient and find something positive
Celebrate the positive
Listen
Put positive, affirming notes in lab letters
Questions that Engage
What could be better?
What’s the hardest thing for you right now in
dealing with your (diabetes or any condition)?
If you could change one thing in your life right
now, what would you change?
Are you interested in working on your weight?
How was your childhood?
Empathy Associated with Better
Outcomes in Diabetes
Correlational study in 891 patients with DM
Physicians rated as high, moderate or low on
Jefferson Scale of Empathy
29% more patients had A1c <7.0% in the high
empathy group vs. low empathy (p<0.001)
25% more patients had LDL-cholesterol <100 in
high vs. low empathy group (p<0.001)
Highly empathetic physicians saw fewer patients
Hojat et. al. Acad. Med. 2011;86:359-64
Shared Decision Making
Stratify Risk
Share information
– Risks of problem/condition being checked or treated
– Risks of intervention
– Benefits of intervention
– Costs
Let patients make choices
But this takes more time
Assess Baseline Risk
Family History (genetics)
Lifestyle
– Exercise
– Dietary Intake
– Habits (smoking, ETOH, etc)
Other risk factors/or medical history
Socioeconomic Status/Satisfaction/purpose in
life (or “Are you happy?”)
BASELINE RISK
Woloshin S et al. JNCI J Natl Cancer Inst 2008;100:845-853
Relative Risk Reduction
% Reduction from Baseline Risk
50% off coupon
– Save $0.50 on a $1.00 item
– Saves $500.00 on a $1000.00 item
Higher baseline risk, higher the absolute reduction
Baseline risk is important in using Relative Risk
Reduction
AFCAPS/TexCAPS:
Results
3304 Lovastatin
Number with
Primary Endpoint
Relative Risk Ratio
Relative Risk
Reduction
Absolute Risk
Reduction (ARR)
3301 Placebo
116/3304 (3.5%) 183/3301 (5.5%)
3.5÷5.5= 0.63
5.5-3.5/5.5 = .37 or 37%
5.5-3.5= 2%
JAMA 1998;279:1615-1622
Framing:
The Way the Data is Presented
37% reduction in 1st major coronary events
3304 patients treated with lovastatin for 5 years:
– prevent 67 1st major coronary events
– Has no preventive effect on 3118 patients (3301 in
placebo – 183 events in placebo = 3118)
Taking lovastatin for ~5 years can reduce risk of
1st major coronary event from 5.5 in 100 to
3.5 in 100
Risk of NOT having 1st major coronary event
– 94.5 out of 100 without taking simvastatin
– 96.5 out of 100 with taking simvastatin
JAMA 1998;279:1615-1622
False Positive Results
Test is positive, but condition is not really
present
Often leads to worry, more testing, and
unnecessary treatment
The lower the baseline risk of a condition, the
higher the false positive test results
Low-dose CT screening for Lung Cancer: 96%
of people who screen positive don’t have lung
cancer
https://www.harding-center.mpg.de/en/health-information/facts-boxes/mammography, accessed 12/5/14
Additional ways to reduce risk:
“Physically active women have a lower
risk of developing breast cancer than
inactive women…risk reduction varies
(between 20-80%).
http://www.cancer.gov/cancertopics/factsheet/prevention/physicalactivity
Number Needed to Treat (NNT)
A tool to help give a perspective on a treatment
risk vs benefit
Number of people who must be treated for given
time period to prevent 1 event
Number Needed to Harm (NNH): Number needed
to treat to get one harm event
Statin Drug Given for 5 Years for
Heart Disease Prevention
(Without known heart disease)
Thennt.com
http://www.thennt.com/nnt/statins-for-heart-disease-prevention-without-prior-heart-disease/,
accessed 2/22/15
Low-Dose CT Screening
for Lung Cancer
http://www.thennt.com/nnt/ct-scans-to-screen-for-lung-cancer/, accessed 2/28/15
Coronary Stenting for Non-Acute
CAD Compared to Medical Therapy
http://www.thennt.com/nnt/coronary-stenting-for-non-acute-coronarydisease-compared-to-medical-therapy/, accessed 2/28/15
Strength and Balance Training Programs for
Preventing Falls in the Elderly
Thennt.com
http://www.thennt.com/nnt/strength-and-balance-programs-for-elderly-falls/, accessed 2/22/15
Results of Shared Decision Making
My Practice
All Providers
% Change
Rx per User
3.47
5.57
-48%
Diagnostic Tests
User
0.13
0.50
-74%
Consult Referrals
per User
0.26
0.62
-58%
Rx per Encounter
1.15
1.60
-28%
Diagnostic Tests
per Encounter
0.04
0.14
-61%
Referrals per
Encounter
0.08
0.18
-66%
Data on file with speaker
Questions to Ask
How good is the evidence that this test (or drug)
will reduce my risk of dying or having an event?
Is the test itself dangerous?
Could the test lead to my being treated
unnecessarily?
Does the treatment I might face have side
effects?
Can I make changes in my eating habits and
lifestyle to reduce the risk of getting the disease?
Brownlee, S. Overtreated: Why too much medicine is making us sicker and poorer. 2007
http://consumerhealthchoices.org/campaigns/choosing-wisely/ accessed 1/23/14
“People don’t care how much we
know unless they know how
much we care.”
Phil Noe, NP
Tools and Resources
Baseline Risk Chart
Woloshin S, Schwartz LM, & Welch HG. The risk of death by
age, sex, and smoking status in the United States: Putting
health risk in context. J Natl Cancer Inst 2008;100:845-853
Harding Center for Risk Literacy Fact Boxes
https://www.harding-center.mpg.de/en/health-information/factsboxes
Number Needed to Treat (NNT)
http://www.thennt.com/home-nnt/
National Cancer Institute Physician Data Query (PDQ)
http://www.cancer.gov/cancertopics/pdq#summaries