1. 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)
2. 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
3. Why we came to shared decision making
Patient centered high value healthcare
Evidence based medicine
Makes explicit the uncertainty of the evidence
Gives a voice to patients (values/ preferences)
Reduce unwarranted variations
Right thing to do
4. 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
6. Patient and clinician begin consultation
Patient and clinician discuss medications.
Patient leaves with a prescription.
Current state of decision making
Patient makes decision about medication.
7. Anatomy of a Decision (MD)
• Medical knowledge
• Years of education
• Practice experience
• Clinician preferences
8. Anatomy of a Decision (PT)
• Expert on their life
• Personal health view
• Lifestyle preferences
• Own/ther experiences
9. Anatomy of a Decision (Environment)
• History
• Ritual
• Tools
10. Patient and clinician begin consultation
Patient and clinician discuss medications.
Patient leaves with a prescription.
Shared decision making
Patient makes decision about medication.
12. Our Decision Aids are focused
on facilitating a conversation between
health professionals and patients
and thus
designed as tools intended for use
during the clinical encounter
13.
14. “What do we need to know to make this
decision together ”
15. Observations
Evidence synthesis clinical encounters
Initial prototype
Designers
Field Study team Modified
testing Patient advisory groups prototype
Clinicians
Stakeholders
Final Decision Aid
Evaluation
Practice-based Randomized Controlled Trials
Real life encounters
17. Glucose control in T2 diabetes
No clear evidence for a goal HbA1c
Comparative effectiveness data of safety
9 types of agents (+ lifestyle modification)
Many attributes per agent
21. More helpful
Improved knowledge
More involvement in making decisions
6-mo perfect medication use
Better adherence
Persistence
No significant impact on HbA1c levels
22. 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
25. Depression
Can be improved by
Lifestyle changes, self-care practices
psychotherapy, pharmacotherapy
But of different
efficacy, safety, cost, burden to the patient
29. Cluster RCT in Rural & urban PC practices
(10 practices WI MN, 106 clinicians, 200/300 patients)
30. “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”
33. 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
39. 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)
40. 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
41. Patients involvement
70
N=398
60
Mean Total OPTION Score (%)
50
p=0.001
Adjusted Mean OPTION Score
40
Adjusted
37.6
30
20
20.4
10
0
All Chest Pain Diabetes Osteo I Osteo II Statin
Usual care Decision aid
42. Summary of experience
Age: 40-92 (avg 65)
74-90% clinicians want to tools again
Adds ~3 minutes to consultation
60% fidelity without training
20% improvement in patient knowledge
17% improvement in patient involvement
Variable effect on clinical outcomes and cost
43. Summary of experience
• 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
44. Evidence synthesis
Translation of evidence into action
Creating a conversation
Design of care Patient important research
around the needs of the patient
Shared decision making
Improve value of healthcare to the patient
Minimally disruptive medicine
FIT
medical knowledge practice experience clinician preferences
personal health view lifestyle preferences own/others experience
HistoryRitualTools
HistoryRitualTools
Focusing on creating a conversation between patients and clinicians provides a way to deal with conflict which is an inevitable part of the healthcare delivery system.Tools structure the conversation and skill both the patient and the clinician.
