shared decision making: what? why? how? when? · sdm and health inequalides: a systemac review sdm...

SharedDecisionMaking:What?Why?How?When?

AngelaCoulter,PhDCentreforSharedDecisionMakingUniversityofSouthernDenmark

@acpaDent

Overview

•  PaDentsaredecisionmakerstoo•  MostpaDentswanttobeinformedandinvolvedandcanbenefitfromit

•  Shareddecisionmakingisaskilledtask,notyetwidelypracDsed

•  SDMcanbefiHedintoclinicalrouDnesgivencarefulplanning,well-trainedstaffandavailabilityofdecisionaids

WHATISSHAREDDECISIONMAKING?

WhatitIsandWhatitIsn’t

•  SDMismorethantreaDngpaDentskindly,thoughthat’simportanttoo

•  SDMiscentraltoperson-centredcare,butitisdisDnctfromco-producDonofservices,healthcoachingandpaDentfeedback

•  SDMisaboutpaDents’involvementinkeydecisionsabouttheirownhealth

SharedDecisionMaking–adefiniDon

CliniciansandpaDentsworkingtogethertoselecttests,treatments,managementorsupportopDonsbasedonclinicalevidenceandthepaDent’sinformedpreferences.

KeyComponents

1.  InformaDonReliable,balanced,evidence-basedinformaDonoutliningprevenDon,treatment,ormanagementopDons,outcomesanduncertainDes

2.  DeliberaDonDecisionsupportwithclinicianorhealthcoachtoclarifyopDons,preferences,goalsandacDonplan(personalisedcareplanning)

3.  ImplementaDonSystemforrecording,communicaDngandimplemenDngpaDent’spreferences

Clinicians’Concerns

WHYISITIMPORTANT?

PaDents’ExpectaDons

•  OneinthreepaDentsfeeluninformedabouttheirtreatment

•  Abouthalfwantmoreinvolvementindecisionsabouttheircare

PaDentInformaDonForum2015

PaDents’KnowledgeofTreatmentOutcomes

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BP Chol BrCascr+ PSAscr+ Knee/hip Back Cat

%meanaccuracyamongpeoplewhohadmadetreatmentchoicesinprevious2years

FagerlinAetal.MedDecMak2010;30:35S-52S

ProstatectomyratesintheUSAProstatectomyforbenignprostaDchyperplasia(BPH)

DartmouthAtlasofHealthCarehHp://www.dartmouthatlas.org/

PracDceVariaDons

•  VariableaccesstoresourcesandexperDse

•  Insufficientevidence•  IneffecDvedisseminaDon•  FaultyinterpretaDon•  Parochialspecialty

perspecDves•  Unfoundedenthusiasm•  PoorcommunicaDon

•  ClinicaldifferencesamongpaDents

•  VariableaOtudestorisk•  VariablevaluesaQachedto

healthoutcomes•  Variablewillingnesstomake

Dmetrade-offs•  Variablecopingstyles

Unwarranted Warranted

Knowledge-Based Patient-Centered

Poordecisionquality

Patients:unawareoftreatment

ormanagementoptionsandoutcomes

Clinicians:unawareofpatients’circumstancesand

preferences

TheSilentMisdiagnosis

Mulley et al, King’s Fund, 2012

MisdiagnosisofPaDents’Preferences

71

96

80

07

59

33 33

0

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100

Keepbreast Liveaslongaspossible Looknaturalwithoutclothes Avoidusingprosthesis

Topthreegoalsandconcernsforbreastcancerdecisions

Providers PaDents

LeeCNetal.AnnPlastSurg2010;64(5):563-6

WhatisGoodMedicalCare?

•  Itisnotjustaboutdoingthingsright•  Itisalsoaboutdoingtherightthing

Preference-sensitivecare:Formany,perhapsmost,medicalproblemsthereismorethanonereasonableoption–patients’preferencesmatter

HOWISITDONE?

Clinician•  Diagnosis•  DiseaseaeDology•  Prognosis•  TreatmentopDons•  OutcomeprobabiliDes

PaDent•  Experienceofillness•  Socialcircumstances•  Ajtudetorisk•  Goals,values,preferences

SharingExperDse

DecisionMakingProcess

ChoiceTalk

OpDonTalk

DecisionTalk

Decisionsupport

IniDalpreferences

Informedpreferences

Decision

ElwynetalJGenIntMed2012;27(10):1361-7

DELIBERATION

ChoiceTalk

•  Stepback•  Offerchoice•  JusDfychoice

–  individualgoals–  preferencesmaHer–  uncertainDes

•  CheckreacDon•  Deferclosure

OpDonTalk

•  Checkknowledge•  ListopDons•  DescribeopDons

–explorepreferences

•  Harmsandbenefits–  riskcommunicaDon

•  Providedecisionsupport(PtDAs)

•  Summarize

DecisionTalk

•  Focusonpreferences•  Elicitpreferences•  Movetoadecision•  Offerreview

AppraisingOpDonsandTrade-Offs

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lifestylechanges

medicaDons devices surgery

Improvementinsymptoms

AskThreeQuesDons

Harms minimized

Benefits exaggerated

HealthInformaDonisOnenUnbalanced

PaDentDecisionAidscanHelp

•  Toolstohelppeopleparticipateindecision-making

•  Provideinformationonoptions

•  Helppatientsclarifyandcommunicatetheirvaluesandpreferences

TypesofDecisionSupport

ClinicalGuidelines•  Assumesdoctormakesthe

decisions•  Primarilyfordoctor•  Evidence-based•  Describeslikelihoodof

variousoutcomes•  OutlinesuncertainDes•  RecommendaDonsbasedon

valuesofclinicalexperts

PaDentDecisionAids•  Assumesshareddecision

making•  PrimarilyforpaDent•  Evidence-based•  Describeslikelihoodof

variousoutcomes•  OutlinesuncertainDes•  Doesnotmake

recommendaDons

Pictograph to explain reduction in cardiovascular risk from taking statins in people with a moderate risk of a cardiovascular event (20%

over 10 years).

Ahmed H et al. BMJ 2012;344:bmj.e3996

©2012 by British Medical Journal Publishing Group

Breast Cancer Decision Explorer (BresDex; www.bresdex.com).

Ahmed H et al. BMJ 2012;344:bmj.e3996

©2012 by British Medical Journal Publishing Group

BresDex

iPhoneandAndroidApps

PaDentDecisionAids:theEvidence

•  In115trialsinvolving34,444

parDcipants,usehasledto:

– Greaterknowledge

– MoreaccurateriskpercepDons

– Greatercomfortwithdecisions

– GreaterparDcipaDonindecision-making

– Fewerpeopleremainingundecided

– FewerpaDentschoosingmajorsurgery

Staceyetal.CochraneDatabaseofSystemaDcReviews,2014

PaDentDecisionAidsReduceRatesofElecDveSurgeryby20%:CochraneReview

SharedDecisionMakingReducesUseofAnDbioDcsforRespiratoryTractInfecDonby40%:CochraneReview

CoxeterP,DelMarCB,McGregorL,BellerEM,HoffmannTC.IntervenDonstofacilitateshareddecisionmakingtoaddressanDbioDcuseforacuterespiratoryinfecDonsinprimarycare.CochraneDatabaseofSystemaDcReviews2015,Issue11.Art.No.:CD010907.DOI:10.1002/14651858.CD010907.pub2.

SharedDecisionMakinginPersonalisedCarePlanning

forLong-termCondiDons

•  In19trialsinvolving10,856parDcipants,personalisedcareplanningledto:

•  BeHerphysicalhealth(bloodglucose,bloodpressure)

•  BeHeremoDonalhealth(depression)

•  BeHercapabiliDesforself-management(self-efficacy)

Coulteretal.Personalisedcareplanningforadultswithchronicorlong-termhealthcondiDons.CochraneDatabaseofSystemaDcReviews,2015

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SharedDecisionMakinginOrthopaedics

•  Hip:820intervenDonvs968control•  Knee:3,510intervenDonvs4,217control

•  26%fewerhipreplacements•  38%fewerkneereplacements•  EsDmatedcostreducDonof12-21%oversixmonths

Arterburnetal.HealthAffairs2012

HowtoFindPaDentDecisionAids

InformaDonisnotenough,SDMinvolvesconversaDons

WHENISITRELEVANT?

SelecDngTestsorTreatments

WellnessandHealth

PromoDon

ManagingLong-TermCondiDons

SharedDecisionMaking

DecisionRolePreferencesbyDemographicGroup

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31

24

25

31

27

30

21

28

73

65

71

71

65

70

65

74

68

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5

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4

0 20 40 60 80 100

Female

Male

HSorless

Somecollege

4ycollege+

65+

50-64

<50

Overall

You Bothequally YourHCP n

p<.001*

Age

EducaD

on

Gen

der

p<.001*

628

2,013

1,385

4,027

1,721

1,013

1,154

2,265

1,678p<.001*

IncludesallvaliddemonstrationsitesurveysinIllumedatabasedistributedinaprimarycaresettingasof8/1/12(unweighted)*Statisticallysignificant(p≤0.05)(Chisquaretest)

SDMandHealthInequaliDes:asystemaDcreview

SDMfordisadvantagedgroups(19studies):•  Knowledgeincreased•  ParDcipaDonandinformedchoiceincreased•  Decisionself-efficacyimproved•  Peoplefromdisadvantagedgroupsgainedmorethanthosewithhigherliteracy,educaDonandsocioeconomicstatus

Durandetal.PLOSOne2014

MapPathways,IdenDfyDecisionPoints

PolicyContextforSDM

•  Researchevidence•  Medicalleadership•  DemandfrompaDents•  IncenDves–ethical,financialprofessional

•  Trainingforclinicalteams

•  PaDentdecisionaids•  IntegraDonofPtDAsintoEMRsystems

•  InsDtuDonalsupport•  CerDficaDonscheme•  Decisionqualitymeasures

CoulterAetal.IntJPerson-CentredMedicine2015;5:9-15

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