shared decision making · systematic reviews •reviewed by medical editor •regularly updated...
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Shared Decision Making
Rebekah E. Gee MD, MPH, MS, FACOG Medicaid Medical Director, Louisiana
Assistant Professor LSU Schools of Medicine and Public Health
ACOG and Informed Consent
As an ethical doctrine, informed consent is a process of communication whereby a patient is enabled to make an informed and voluntary decision about accepting or declining medical care.
ACOG Committee Opinion 439 august 2009*Reaffirmed 2012
Informed Consent Reality
• Inadequate time
• Lack of financial incentives
• Low health literacy/numeracy
• Clinician and patient miscommunication
• Focus liability protection, not on the needs and rights of patients
Informed consent as a
piece of paper, not a
process
photo credit: http://www.flickr.com/photos/denisemattox/4413044798/
Listening to Mothers
Evidence of Inadequate Informed Consent
• Majority unable to correctly answer basic
questions about adverse effects of induction
and cesarean section.
• “Not sure” was most common response
• When mothers did respond they were as
likely to be incorrect as correct
• Having had the intervention did not increase
proportion of correct answers
Listening to Mothers III Survey, 2013
Evidence of Inadequate Informed Consent
• Mothers felt pressure from a health
professional to have induction (25%)
and cesarean (25%)
• 82% of women having episiotomies did
not give consent
Listening to Mothers III Survey, 2013
Summary of Problems with Informed Consent
• Inadequate standards for informed consent
• Inadequate processes for informed consent
• Clear evidence that most health care decisions remain uninformed
• Caregiver attitudes, preferences, and incentives strongly impact use of interventions
Mothers’ Ratings of Trustworthiness of Possible Sources of Pregnancy and Childbirth Information
Solution: Shared Decision Making
www.informedmedicaldecisions.org
Trevor
Trevor Play video
Broad Consensus About SDM
Affordable Care Act
State Legislation
National Quality Strategy
Policy and clinical reports
Shared Decision Making
• Facilitates decision making when:
– multiple reasonable options
– insufficient outcomes data, leading to clinical uncertainty among options
– trade-offs among benefits and harms
These are known as “preference-sensitive” decisions
Six Steps to Shared Decision Making
1. Invite the patient to participate - she may not realize she is making a decision
2. Present options - including the option of doing nothing
3. Provide information on benefits and risks - quantify if possible
4. Assist patients in evaluating options based on their goals/concerns - no one choice is right for all women
5. Facilitate deliberation and decision making - deal with lingering concerns or questions
6. Assist with implementation - plan next steps
http://informedmedicaldecisions.org/
Decision Aids
• Tools or technologies designed to facilitate SDM
– DVD
– Web
– Patient portal of EHR
– Mobile app
• Developed and evaluated according to international standards.
Cochrane Review of DAs
• Improved knowledge – better when more detailed
• More accurate expectations of possible benefits and harms – better with quantified probabilities
• Choices that are more consistent with patients’ informed values – better with explicit values clarification
• Increased participation in decision making • Less decisional conflict • Lower likelihood of choosing interventions
Existing Maternity DAs
• Prenatal testing – Routine early ultrasound
– Amniocentesis
– Chorionic Villus Sampling
– Triple/quad screen
• Treatments for pregnancy-related conditions – Antidepressant use in pregnancy
– Multiple pregnancy - fetal reduction
– Treatment options for incomplete miscarriage
• Labor/Birth – VBAC vs. ERCS
– VBAC vs. ERCS
– Epidural
– Elective Induction
• Postpartum/Newborn – Breastfeeding
– Banking umbilical cord blood
– Male circumcision
Existing Maternity DAs
Is SDM Feasible?
Commonly cited barriers to SDM:
• Take too much time
• Patients do not want to participate in decisions
• Patients will not understand clinical information
• Decision aids not relevant to individual circumstances
None borne out by the evidence.
• First national maternity SDM initiative funded by the Informed Medical Decisions Foundation
• Web-based, open access decision aids and other decision support tools for major maternity decisions
• Support tools to carry out informed decisions
• Partnering with stakeholders to test implementation models
transform.childbirthconnection.org
Pregnant Me
• Multi-media decision aids and decision support content for women at 6th grade health literacy level (user-testing in CA and LA) available in early 2014, including:
• Induction of labor for suspected macrosomia
• Induction of labor at 40-41 weeks
• Elective repeat cesarean vs. planned vaginal birth
• Choosing a caregiver and birth setting
• Gestational diabetes screening and treatment
Evidence-based
• literature on preferences, attitudes, and knowledge
• clinical studies including well-designed systematic reviews
• reviewed by Medical Editor
• regularly updated
Woman-centered
• Based on surveys of women to elicit high priority knowledge and concerns
• focus group testing s
• user-centered design / usability testing
• featuring women’s perspectives throughout
• explicit values clarification
Clinically Appropriate
• survey to elicit high priority knowledge and concerns
• reviewed by Clinical Advisors
• featuring variety of clinicians’ perspectives throughout
Rigorous Content & Development Standards
www.transform.childbirthconnection.org | www.childbirthconnection.org
read the full report at: http://bit.ly/LTM-III
twitter: #LTM3
“I switched to a doctor
who was more willing to
give me the care I wanted
in a much friendlier and
supportive environment. - Listening to MothersSMIII: New Mothers Speak Out
survey participant
References
• Angood, P. B., Armstrong, E. M., Ashton, D., Burstin, H., Corry, M. P., Delbanco, S. F., et al. (2010). Blueprint for action: Steps toward a high-quality, high-value maternity care system. Women's Health Issues, 20(1, Supplement 1), S18-S49.
• Coulter, A., & Collins, A. (2011). Making shared decision-making a reality: No decision about me, without me. London, U.K.: The King's Fund.
• Declercq, E. R., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to mothers II: Report of the second national U.S. survey of women’s childbearing experiences. New York: Childbirth Connection.
• Frosch, D.L., Moulton, B.W., Wexler, R.M., Holmes-Rovner, M., Volk, R.J., & Levin, C.A. (2011) Shared decision making in the United States: policy and implementation activity on multiple fronts. Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen (ZEFQ) 105, 305–312.
• Goldenberg, R. L., McClure, E. M., Bhattacharya, A., Groat, T. D., & Stahl, P. J. (2009). Women's perceptions regarding the safety of births at various gestational ages. Obstetrics and Gynecology,114(6), 1254-1258. doi:10.1097/AOG.0b013e3181c2d6a0
• O'Malley, A. S., Carrier, E. R., Docteur, E., Shmerling, A. C., & Rich, E. C. (2011). Policy options to encourage patient-physician shared decision making No. 5). Washington, DC: National Institute of Health Care Reform.
• Sakala, C., & Corry, M. P. (2008). Evidence-based maternity care: What it is and what it can achieve. New York: Milbank Memorial Fund.
• 19. Yong, P. L., Saunders, R. S., & Olsen, L. (2011). The healthcare imperative: Lowering costs and improving outcomes. Washington, DC: National Academies Press.
• Stacey, D., Bennett, C. L., Barry, M. J., Col, N. F., Eden, K. B., Holmes-Rovner, M., et al. (2011). Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews (Online), 10, CD001431. doi:10.1002/14651858.CD001431.pub3
• Say R, Robson S, Thomson R. Helping pregnant women make better decisions: a systematic review of the benefits of patient decision aids in obstetrics. BMJ Open 2010;1:e000261.
• Simpson, K. R., Newman, G., & Chirino, O. R. (2010). Patient education to reduce elective labor inductions. MCN, The American Journal of Maternal Child Nursing, 35(4), 188-94.