Creating Meaningful Conversations Insights from Shared Decision Making at the point of care Annie LeBlanc PhD Knowledge and Evaluation Research (KER) Unit Mayo Clinic, Rochester, MN (USA)
Creating Meaningful ConversationsInsights from Shared Decision Making at the point of care
Annie LeBlanc PhDKnowledge and Evaluation Research (KER) Unit
Mayo Clinic, Rochester, MN (USA)
Disclosure
No financial conflict of interest
KER Unit houses the processes of design & evaluation of decision aids, decides on topics, pursues funding,
and conducts evaluation trials
KER unit does not receive funding from any for-profit pharmaceutical/manufacturer, nor do they receive
any royalties / monetary benefits, directly or indirectly, from the use of the decision aids
All decision aids are available free of charge
Why we came to shared decision making
Patient centered high value healthcareEvidence based medicine
Makes explicit the uncertainty of the evidenceGives a voice to patients (values/ preferences)
Reduce unwarranted variationsRight thing to do
Shared decision making
Plethora of trials demonstrating efficacy of tools Uptake still minimal in practices
Barriers & facilitators
How to achieve greater integration of SDM within clinical encounters
How to facilitate its translation into practice
Current State
Current state of decision makingPa
tient
and
clin
icia
n be
gin
cons
ulta
tion
Patie
nt a
nd c
linic
ian
disc
uss
med
icati
ons.
Patie
nt le
aves
with
a p
resc
riptio
n.
Patie
nt m
akes
dec
isio
n ab
out m
edic
ation
.
Anatomy of a Decision (MD)
• Medical knowledge• Years of education• Practice experience• Clinician preferences
Anatomy of a Decision (PT)
• Expert on their life• Personal health view• Lifestyle preferences• Own/ther experiences
Anatomy of a Decision (Environment)
• History• Ritual• Tools
Shared decision makingPa
tient
and
clin
icia
n be
gin
cons
ulta
tion
Patie
nt a
nd c
linic
ian
disc
uss
med
icati
ons.
Patie
nt le
aves
with
a p
resc
riptio
n.
Patie
nt m
akes
dec
isio
n ab
out m
edic
ation
.
Shared decision making
Research Evidence
Patient Values and Preferences
Decision Aid
Within an exam room
Our Decision Aids are focused on facilitating a conversation between
health professionals and patientsand thus
designed as tools intended for use during the clinical encounter
“What do we need to know to make this decision together ”
Evidence synthesisObservations
clinical encounters
DesignersStudy team
Patient advisory groupsClinicians
Stakeholders
Initial prototype
Field testing
Modified prototype
Final Decision Aid
EvaluationPractice-based Randomized Controlled Trials
Real life encounters
The case of diabetes medication
Glucose control in T2 diabetes
No clear evidence for a goal HbA1cComparative effectiveness data of safety
9 types of agents (+ lifestyle modification)Many attributes per agent
Mullan et al. 2009
Web-based Decision aidshttp://diabetesdecisionaid.mayoclinic.org/
Online tutorial
More helpful Improved knowledge
More involvement in making decisions 6-mo perfect medication use
Better adherence Persistence
No significant impact on HbA1c levels
Additional benefits observed• Patients gravitate towards weight change and daily
routine cards• Physical form encourages patients to own decision• Noticeable positive change in body language• Card use prompts questions and encourages
discussion but cards alone are not enough to give patients confidence
• Gives permission to patients and clinicians to acknowledge cost as a factor in decision making
• Lack of ability to provide a specific answer isn’t viewed negatively
The story of our 92 y old patient
The case of Depression Care
Can be improved byLifestyle changes, self-care practices psychotherapy, pharmacotherapy
But of different efficacy, safety, cost, burden to the patient
Depression
LeBlanc 2012
Cluster RCT in Rural & urban PC practices(10 practices WI MN, 106 clinicians, 200/300 patients)
“Actually used the depression medication decision cards with the patient, which she seemed to enjoy.
Patient would like at this time to start on an SNRI. She had taken an SSRI before and felt that this did not help. I am comfortable with this decision. Together we chose
to start”
“Use the cards without patient being enrolled in the study”
“Patient admits sexual side effects are important to her; as such, we chose”
Other Wiser Choices Decision AidsChronic and acute care
Weymiller et al. Arch Intern Med 2007
Statin Choice
Compared to usual care,
patients using the decision aid were
22 times more likely to have an accurate sense of their baseline
risk and risk reduction with statins.
Weymiller et al. Arch Intern Med 2007
Web-based tool
http//:statinchoice.e-bm.info
Osteoporosis Choice
Montori et al, AJM 2011
AMI Choice
Chest Pain Choice
Hess et al. Circ 2012
Head CT for Children
Work Setting Phase of development
Individualized medicine
Genomic Choice IM clinic Design phase (electronic)
Perioperative medicine
Smoking choice Primary care Ongoing clinical trial
Cardiovascular medicine
ICD Choice Specialty care Design phase
Hypertension e-primary care Design phase
Men’s health
Prostate cancer screening and early treatment
General (tablet) Design phase (scholar project; electronic)
Women’s health
Mammography < 40 Primary care Design phase (scholar project)
Menopause symptoms Primary care Design phase (scholar project)
Contraception Primary care Design phase (medical student project)
Graves disease - treatment Specialty care Design phase (scholar project)
Other
Nonpharmacological treatment of depression Primary care Protocol phase (submitted to PCORI)
Head CT for children with mild head trauma Emergency care Protocol phase (submitted to PCORI)
Imaging wisely campaign Radiology/primary care Protocol phase (submitted to PCORI)
Wiser Choices Program~20 decision aids for the clinical encounter
11 practice-based randomized controlled trials
>50 practices>300 clinicians>1000 patients
>500 videos
Patients & clinicians = key role No for-profit funding
Patients involvement
Usual care Decision aid
Mea
n To
tal O
PT
ION
Sco
re (
%)
Adj
ust
ed
All Chest Pain Diabetes Osteo I Osteo II Statin0
10
20
30
40
50
60
Ad
just
ed M
ean
OP
TIO
N S
core
N=398
p=0.001
20.4
37.6
Summary of experienceAge: 40-92 (avg 65)
74-90% clinicians want to tools againAdds ~3 minutes to consultation
60% fidelity without training20% improvement in patient knowledge
17% improvement in patient involvement Variable effect on clinical outcomes and cost
• Creating a conversation between patients and clinicians:–Provides a way to deal with conflict which is an
inevitable part of the healthcare delivery system–Gives permission to patients and clinicians to
acknowledge factors in decision making• Lack of ability to provide a specific answer
isn’t viewed negatively• Tools structure the conversation and skill of
both the patient and the clinician
Summary of experience
Creating a conversation
Evidence synthesisTranslation of evidence into action
Patient important researchDesign of carearound the needs of the patient
Improve value of healthcare to the patientMinimally disruptive
medicineFIT
Shared decision making
Can we do this Monday morning ?
http://shareddecisions.mayoclinic.org
Brief tools with minimal footprint (IPDAS)User-centered design, evidence-based content
For use during consultationFree
Lima, Perú - June 16-19 2013
Globalizing SDMPacientes @ centre of healthcare
www.isdm2013.org
7th International SDM Conference
[email protected]@annie_leblanc
http://kerunit.e-bm.orghttp://kercards.e-bm.info/
http://shareddecisions.mayoclinic.org/www.isdm2013.org