shared decision making: what? why? how? when? · sdm and health inequalides: a systemac review sdm...
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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
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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
Billedet kan ikke vises. Computeren har muligvis ikke hukommelse nok til at åbne billedet, eller billedet er muligvis blevet beskadiget. Genstart computeren, og åbn derefter filen igen. Hvis det røde x stadig vises, skal du muligvis slette billedet og indsætte det igen.
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
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21
28
73
65
71
71
65
70
65
74
68
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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
Nothingaboutmewithoutme!