Intro to Shared Decision Making
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This document provides an introduction to shared decision making (SDM) and patient decision aids. It defines SDM as a process where patients are involved in making an informed, values-based choice between medically reasonable options. The document outlines the six steps to SDM and explains how patient decision aids can support the process by providing balanced information about conditions, treatments, and patient stories. It also reviews evidence that SDM increases patient knowledge and involvement in decisions, improves risk perception, and reduces decisional conflict and uncertainty.
Intro to Shared Decision Making
- 1. Introduction to Shared Decision Making and Patient Decision Aids Richard Wexler, MD Chief Medical Officer February, 2012
- 2. What is Shared Decision Making? 2
- 3. Shared Decision Making (SDM) “the process of interacting with patients who wish to be involved in arriving at an informed, values-based choice among two or more medically reasonable alternatives”¹ Informed Values-Based • There is a choice • What’s important to the patient • The options • The benefits and harms of the options Information The Clinician The Patient ¹A.M. O'Connor et al, “Modifying Unwarranted Variations In Health Care: Shared Decision Making Using Patient Decision Aids” Health Affairs, 7 October, 3 2004
- 4. A Word on Taxonomy Preference-Sensitive Effective Care • Strong evidence base Care supports care • Evidence supports more • Benefit-to-harm ratio high than one approach • All with need should receive • Treatment/testing options involve significant trade offs • Personal values, preferences and life circumstances should drive decisions SDM Sweet Spot 4
- 5. A Schematic of Shared Decision Making Options Patient Lens Goals and Concerns Benefits Benefits Risks Risks A Decision B Benefits Benefits Deliberate Decision to Make Risks Risks C Benefits Benefits Unique Life Risks Circumstances Risks © Informed Medical Decisions Foundation. All Rights Reserved. 2012 5
- 6. Six Steps to SDM 1. Invite patient to participate 2. Present options 3. Provide information on benefits and risks 4. Assist patient in evaluating options based on their goals and concerns 5. Facilitate deliberation and decision making 6. Assist with implementation Benefits and Patient Deliberate and Invite Options Implementation Risks Preferences Decide 6
- 7. Patient Decision Aids: Tools to Facilitate SDM 7
- 8. Supported by Patient Decision Aids Options Patient Lens Goals and Concerns Benefits Benefits Risks Risks A Decision B Benefits Benefits Deliberate Decision to Make Risks Risks C Benefits Benefits Unique Life Risks Circumstances Risks © Informed Medical Decisions Foundation. All Rights Reserved. 2012 8
- 9. Patient Decision Aids • Information about a specific condition • Evidence organized around specific decisions • Accessible—charts, graphs • Balanced 9
- 10. Patient Decision Aids • Encourage patients to interpret evidence in context of their own goals and concerns • Include patient stories • Encourage patients to make decisions with physician 10
- 11. Patient Decision Aids: Development Process • Literature review • Patient interviews and focus groups help identify: • issues most important to patients • common misconceptions • Provider interviews and focus groups help identify: • decision points and treatment options 11
- 12. Patient Decision Aids: Development Process • An evidence summary is produced by Foundation research associates, working with medical editors • Medical editors are generalists and free from industry conflicts • Summary is reviewed by clinical advisors, who are specialists • Editor has final control 12
- 13. Patient Decision Aids: Development Process From evidence summary, a decision aid is produced which includes text, graphics, and often video. 13
- 14. Patient Decision Aids: Evaluation Process What Who When • Clinical accuracy • Patients • Draft scripts, interview • Balance • Medical editors material, graphical presentations • Viewer acceptability • Clinical advisors • Rough cut • Foundation and Health • “Final” version Dialog staff incorporates feedback • Clinical reviewers from evaluation process • Reviewed at 6 months for clinical accuracy • Evaluated every 2 years for accuracy, balance and relevance 14
- 15. Why Bother with SDM? 15
- 16. Why Bother with SDM? • No fateful decision in the face of avoidable ignorance • Doctors aren’t very good at diagnosing patient preferences • If doctors get it wrong, patients will still listen • It’s a patient safety issue 16
- 17. No Fateful Decision in the Face of Avoidable Ignorance The DECISIONS Study Nationwide telephone survey Conducted by University of Michigan The Decisions Study. Medical Decision Making 2010; 30 supplement 1 17
- 18. DECISIONS Study Findings • Patients often not knowledgeable about the basic benefits and risks of their treatment • Patients usually not asked for their preferences about treatment • Providers discuss pros of treatments more than cons • Providers advise “do it” 65-95% of the time 18
- 19. Doctors Aren’t Very Good at Diagnosing Patient Preferences Karen Sepucha • Identified key facts and goals for 14 decisions • Surveyed providers and patients • How important was each item • Identify the 3 most important items Sepucha KR, et al. Pt Education and 19 Counseling. 2008;73:504-10.
- 20. Top Three Goals and Concerns for Breast Cancer Decisions Condition: Goal Pat Prov p Keep your breast? 7% 71% P<0.01 Live as long as possible? 59% 96% P=0.01 Look natural without clothes 33% 80% P=0.05 Avoid using prosthesis 33% 0% P<0.01 20
- 21. If Doctors Get It Wrong, Patients Will Still Listen Sepucha KR, et al. Pt Education and 21 Counseling. 2008;73:504-10.
- 22. Is Doing What the Doctor Thinks Best a Top Priority? Decision Pat Prov p BCA surgery 86% 14% P<0.01 Hip replacement 84% 40% P<0.01 Knee replacement 78% 35% P<0.01 Menopause 60% 21% P=0.02 PSA 59% 21% P=0.03 Spinal Stenosis 46% 5% P<0.01 22
- 23. It’s a Patient Safety Issue 23
- 24. Patient Safety How do we describe operating on a patient who would say NO to surgery if Wrong Site Surgery alternatives, risks and benefits were well understood? Wrong Patient Surgery 24
- 25. Is SDM Effective? 25
- 26. Cochrane Review Review of 86 randomized trials evaluating patient decision aids • Increase patient knowledge • Increase patient involvement in decision making • Increase the proportion of patients with accurate risk perceptions (patients have more realistic expectations) 26
- 27. Cochrane Review • Increase the consistency between patient decisions and patient values • Reduce decisional conflict related to feeling uninformed or unclear about personal values • Reduce the proportion of patients who remain undecided • Reduce the choice of major elective surgery in favor of more conservative options 27
- 28. Thank you! 28