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Shared Decision Making: A Path to
High-Value Care
2016 CTC-RI Annual Learning Collaborative
Advancing Primary Care: Practicing with Value
October 20,2016
Karen Sepucha, PhD
Leigh Simmons, MD
MGH Health Decision Sciences Center
www.massgeneral.org/decisionsciences/
Mr. M’s Story
Mr. M’s Story
• 71yo man referred to orthopedic surgeon, worsening
right hip pain, x-rays confirm severe degenerative
changes
• Mr. M met the clinical appropriateness criteria for
total joint replacement
• Orthopedic surgeon’s note: “I went over in some
detail different treatment options. He very much
wishes to proceed with right total hip replacement.”
For discussion
For Mr. M’s decision to have surgery:
• Is this an example of “shared decision
making”? Why or why not?
• Was this a good decision?
Mr. M’s Story - continued
• 3 months until surgery
• Mr. M discussed surgery with family and friends
• Continued physical activity which helped relieve
pain, particularly night time hip pain
• Saw primary care physician for pre-op visit, and
Mr. M raised some concerns
• Primary care physician sent patient decision aid
(DVD and booklet) to review
Mr. M’s Letter
For discussion:
For Mr. M’s decision to cancel the surgery:
• Is this an example of “shared decision
making”? Why or why not?
• Was this a good decision?
The rest of the story
• 2 years later Mr. M.’s night time hip pain
came back
• He scheduled surgery with the same
orthopedist
• He had good relief of pain, no regrets
about timing
Discussion
• Was this a good outcome?
• Are there ways to improve systems of care
to enhance decision making at every step?
By the end of this session,
you will…
• Define shared decision making and its role in routine
care
• List the steps of shared decision making
• Assess two video clinical decision making
interactions for elements of shared decision making
• Introduce tools to facilitate shared decision making in
the Foundational Continuity Clinic
• Practice a decision coaching exercise
Introductions from You
• Raise your hand
– Heard of shared decision
making?
– Observed a conversation
about a significant health
decision?
– Seen a decision aid
used to help with making
a decision?
Shared Decision Making
• 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
• Another definition
– A collaborative process that recognizes the expertise
of patients and family as well as the expertise of
clinicians
– C, Soc Sci Med 1997; 44:681; Mulley A. Med Care 1989)
(Charles
Challenging Conversations
• Here’s what we find hard:
–
–
–
–
Rapidly changing guidelines in many areas
New cancer screening guidelines
Updated cardiovascular health recommendations
Growing concerns about the potential harms of
medications (statins, calcium supplements,
bisphosphonates)
• What conversations do you think may be hard in
primary care?
SDM in Clinical Guidelines
• Chemoprevention for breast cancer:
“Clinicians should inform patients of the
potential benefits and harms of
chemoprevention.”
• Screening for osteoporosis: “… clinicians
also should consider each patient's values
and preferences and use clinical judgment
when discussing screening with
women...”
SDM in Clinical Guidelines
• Coronary revascularization: “Shared
patient/physician decision making for many
scenarios would be expected and may result in
the patient deferring coronary revascularization
while maintaining medical therapy.”
• ADA/EASD 2012 Management of Hyperglycemia
in Type 2 Diabetes: A Patient-Centered Approach:
“Choice is based on patient and drug characteristics,
with the over-riding goal of improving glycemic control
while minimizing side effects. Shared decision
making with the patient may help in the selection
of therapeutic options.”
A word on taxonomy
• Effective care
– Strong evidence base supports care
– Benefit to harm ratio high
– All with need should receive it
SDM
Sweet Spot
• Preference sensitive care
– Evidence supports more than one approach
– Treatment/testing options involve significant trade-offs
– Personal values, preferences and life circumstances should
drive decisions
– Many of our treatment decisions do fall into this category
Credit: Dr. Richard Wexler, FIMDM
How often does this really apply?
• Classifying interventions:
• Beneficial
• Likely to be beneficial
• Trade-off between benefits and harms
• Unlikely to be beneficial
• Likely to be ineffective or harmful
• Unknown effectiveness
• How effective are our interventions?
17
Unknown
effectiveness
50%
11%
Beneficial
Effectiveness of 3,000 treatments as studied in RCTs, as collected by BMJ’s Clinical
Effectiveness (2012)
18
Practice variation and clinical
decision making
• Lack of scientific basis for much medical care
• Care depends more on where you live and
which doctor you see than on who you are and
what you care about!
• But…not all variation is bad
• Shared decision making can help us get to the
“right rate”
What’s the Goal? Decision Quality
To provide evidence that:
• The patient understands key
facts.
• The treatment received is
consistent with the patient’s
personal goals.
• The patient was meaningfully
involved in decision making
Sepucha et al. 2004 Health Affairs
How to get doctors and
patients to do this?
22
A common sentiment among healthcare providers
regarding shared decision making:
“We already do that
all the time.”
23
What do patients think?
Who made the decision about treatment of your breast cancer?
 Mainly the doctor

X Both equally
 Mainly you
“they didn’t say to me, “Well, we could
remove the breast, we could do this,
we could do that.” They just said, “This
is what we’re going to do.” And that
was it—I wasn’t in on the decision.”
“She was compassionate, … [and] gave
me the data that I needed ... We talked
statistics and sizes and measurements
and things that helped me..with my
decision.”
“I made the decision. I’m very happy with the
lumpectomy because that’s what I wanted to
do from the beginning. They [my doctors]
didn’t disagree. They didn’t agree. They just
said, “Okay.” They understood.”
Six Steps to SDM
1.
2.
3.
4.
5.
6.
Invite
Invite patient to participate
Present options (+/- using a decision aid)
Provide information on benefits and risks
Elicit patient preferences
Facilitate deliberation and decision making
Assist with implementation
Options
Benefits and
Risks
Patient
Preferences
Credits: R. Wexler, FIMDM, and K. Clay, Center for Shared Decision
Making, Dartmouth-Hitchcock Medical Center
Deliberate
and Decide
Implementation
Do We Know SDM When
We See It?
• Two videos of discussions around
management of high cholesterol
• Handout: please rate the extent to which
each aspect of shared decision making
was present in the conversation
SDM in the visit
• Clip 1
• Clip 2
Reality check
• Study of 1057 audio-taped clinical encounters,
containing 3552 decisions.
• What proportions of decisions met most basic
definition of fully informed decisions?
• Nature of decision
• Patient role in decision making
• Explanation of pros and cons
• Discussion of patient preferences
• 9%
Braddock, et al. JAMA, 1999
28
Reality check
29
Reality check
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Would ask questions
Would discuss
preferences
Would disagree
30
Reality check
100.0%
93.1%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Would ask questions
Would discuss
preferences
Would disagree
31
Reality check
100.0%
93.1%
94.0%
Would ask questions
Would discuss
preferences
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Would disagree
32
Reality check
Most people don’t feel comfortable disagreeing with a
physician’s recommendation
100.0%
94.0%
93.1%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
14.0%
20.0%
10.0%
0.0%
Would ask questions
Would discuss
preferences
N=1340, p<.0001
Would disagree
33
Reality check
Because they fear being labeled a “difficult patient”
Will lead me to being viewed as
a difficult patient
50.0%
47.6%
45.0%
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
11.5%
14.1%
10.0%
5.0%
0.0%
Asking questions
N=1340, p<.0001
Discussing
preferences
Adams et al, 2012, Archives of Internal Medicine
Disagreeing
34
Summary, so far
• Many (most) situations have more than
one medically appropriate option
– Best decision depends on patients’ goals and
preferences
• Patients are not routinely engaged in
decisions about their care
– But most want to be…
How to do it?
• Skill set required to communicate and
execute shared decision making
effectively
• Tools called decision aids can help
Decision Aids
• 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
Evidence Base: Decision Aids
2014 Cochrane Systematic Review contains 115 RCTs:
Decision aids increase decision quality:
 increase in knowledge
 increase in realistic expectations
 increase in value-choice concordance
Decision aids engage patients
 less passive (RR 0.66)
 Fewer who remain undecided (RR 0.59)
 Patients more satisfied with the decision and the
decision making process
Decision aids address over- and under- use
 reduction in major invasive elective surgery (RR 0.79)
 reduction in PSA testing (RR 0.87)
 reduction in HRT use (0.73)
Stacey et al. Cochrane Database of Systematic Reviews, 2014
Six Steps to SDM
1.
2.
3.
4.
5.
6.
Invite
Invite patient to participate
Present options (+/- using a decision aid)
Provide information on benefits and risks
Elicit patient preferences
Facilitate deliberation and decision making
Assist with implementation
Options
Benefits and
Risks
Patient
Preferences
Credits: R. Wexler, FIMDM, and K. Clay, Center for Shared Decision
Making, Dartmouth-Hitchcock Medical Center
Deliberate
and Decide
Implementation
Shared Decision Making Program
at Mass General
• Clinicians and office staff
can order decision aids
(DA’s) through the
patient’s electronic
medical record
• Informed Medical
Decisions Foundationproduced DAs
• 40 programs available;
variety of conditions
relevant to adult primary
care
Practice Your Skills!
•
•
•
•
Use the enclosed Ottawa Decision Guide
Select a decision for discussion
One student serves as coach
Swap after 15 minutes
Discussion
• Reflections on using a decision guide
• As the one making a decision?
• As the coach?
Summary
• High quality, patient-centered care requires that we
inform patients, involve them in decisions and tailor
treatments to their goals and preferences
• Tools and workflows exist to facilitate shared decision
making in the primary care setting
• Implementing shared decision making in the primary
care setting may require a culture shift, and requires
leadership support
Goal of Shared Decision Making
Every patient facing a significant
medical decision is well
informed, meaningfully involved
and receives treatment that
matches their goals.
Changing healthcare…
Changing healthcare is the process
of moving from the complex to the
obvious in time consuming and
expensive steps.
George Bennett, former CEO Health Dialog