1. Engaging Patients Through
Evidence-Based Medicine
Margaret Holmes-Rovner, PhD
MSU College of Human Medicine
CMIO Conference, Chicago, Oct 3-4

2. What works? What doesn’t?
 Engagement in decision making
– Encouraging decision making just before the
encounter: question asking and coaching?
– Patient access to electronic medical records?
– Shared decision making with decision aids?
– Patient centered interviewing?
 Engagement in chronic disease self-
management
Kinnersley BMJ 2008; Delbanco Ann Intern Med 2012; Stacy
Cochrane 2011; Dwamena Cochrane forthcoming

3. What is Shared Decision
Making?
 Ensuring patient involvement in decisions
– Provide evidence about the condition, options, long
term and short term outcomes (Decision Aids help)
– Clarify patients‟ values for the outcomes that matter
to them (Engage with evidence)
– Guide patients so the clinical choice matches their
informed values.
– Meaningful dialog rather than uni-directional
disclosure (provider led, patient engaged)
O’Connor et al, Health Affairs, 2007

4. Road to Berwick’s triple aim
 Enhance the patient‟s experience (satisfaction
increases)
 Improve the health of the population through
patient engagement (adherence with
negotiated plans)
 Decrease costs generated by over-use of tests
and procedures
Stacy D, Cochrane, 2011
Arterburn DE, Health Affairs, 2012

5. Roots in Decision Analysis
OpDeath
UDead
pOpDeath
SURGERY NoSurv3
UDead
pNoSurv3
Survive SymL1
USymL1
# pSymL1
Surv3 SymL2
USymL2
CABG Medical or Surgical Rx # pSymL2
SymL3
USymL3
#
MNoSurv3
UDead
pMNoSurv3
MEDICAL MS ymL1
USymL1
pMSymL1
MS urv3 MS ymL2
USymL2
# pMSymL2
MS ymL3
USymL3
#

6. Preference-sensitive decisions?
 No one right answer for everyone
 Requires time for real informing/deciding
 Examples: -Lumpectomy vs mastectomy for early
stage breast CA; -Active surveillance vs surgery vs
radiation for early stage prostate cancer CA; -Stable
CAD (today‟s example)
 “Sensitive” here means responsive to patients‟
goals for outcomes AND concerns about side
effects.

7. Applied health literacy in DAs

10. Choosing Wisely?
 Toss-ups: marginal added benefit to more
aggressive therapies
 Therapeutic Misconception is widespread
– Patients frequently think surgery means they can
skip medical therapy, chronic disease self-
management
 Patients may choose options providers are not
happy about, to date, most often no treatment
Smith, BMJ, 2010

11. PCI Example
PCI + Meds vs Meds alone in stable CAD
 No diff in risk of death or MI
 Function/quality of life improved in first 2 yrs. where chest
pain not controlled by meds
 PCI should be an adjunct to meds in stable CAD
 Decreasing PCIs when not appropriate would:
– Improve the quality of care for many patients
– substantial healthcare savings
Boden, COURAGE trial, NEJM, 2007; Trikalinos, Lancet, 2009.

12. PCI Rates by Medicare Hosp.
Referral Regions, 2005

13. BCBSM PCI Utilization, 2008,
by HRR

14. Where in the diagnostic
therapeutic cascade?
 Cardiology pre-cath?
– Most pressing, proximal to decision
– Data suggest patients don‟t change their
expectation of preventing heart attacks.
– Even “enhanced informed consent” via video in a
recent unpublished study doesn‟t change
expectations or utilization
 Stress test?
 Primary care counseling in stable CAD
patients for “anticipatory SDM”
14

20. Intervention is Not just a DA
 Initiated in primary care when a stress test is ordered
 Cardiology changed their results report to:
1. Normal
2. Abnormal with no high risk features
3. Abnormal with high risk features
 # 1,2 go back to primary care for decision
 “After visit summary sheet” in primary care
 Care manager may do chronic disease self-
management in cardiology or in primary care

21. Good Decision Aids exist?
 Science is strong
– IPDAS update of background
– Quality ratings of DAs: www.IPDAS.ohri.ca
 Public domain is growing (though limited)
 Private companies produce sets of DAs
 Recent Mass legislation will strengthen the
public domain

22. What’s missing? Leadership
 Make it easy: DAs in the hands of providers
and patients
 Make it delegatable by providers? (No)
– Providers need brief training
 Improve care coordination? (Yes)
– Primary care – Specialist
– Providers - Care managers
Holmes-Rovner, PEC, 2010

23. References
 Arterburn D, et al. Introducing decision aids at Group Health
linked to sharply lower hip and knee surgery rates and costs.
Health Aff. 2012;31:9,2094-2104.
 Boden, et al, COURAGE trial, NEJM. 2007; 2007 Apr
12;356(15):1503
 Delbanco et al, Inviting patients to read their doctors‟ notes, Ann
Intern Med, 157: 461-470.
 Holmes-Rovner M, et al, Shared Decision Making Guidance
Reminders In Practice Pat Ed & Coun, 2011 Nov;85(2):219-24.
 Kinnersley P, Interventions before consultations to help patients
address their information needs by encouraging question asking.
BMJ. 2008 Jul 16;337:a485.

24.  O'Connor AM, et al. Toward the „tipping point‟: decision aids and
informed patient choice, Health Affairs, 2007 May-Jun;26(3):716-
25.
 Smith SK, et al, A decision aid to support informed choices about
bowel cancer screening among adults with low education:
randomised controlled trial. BMJ, 2010;341.
 Stacey D, et al, Dec Aids for people faciing health treatment or
screening decisions. Cochrane Database System Reviews 2011,
Issue 10.
 Trikalinos, PCI for non-acute CAD: quantitat 20-year synopsis
and network meta-analysis. Lancet 2009. 2010;341.

25. How to do it? :
 Initiate conversation around shared decision-making
– Set the stage for the visit
– Set an agenda for the visit
– Get the patient‟s story
 Relate to the patient by
– Eliciting emotions
– Expressing empathy
 Educate the patient about his/her unique situation with
disease-specific information (Expanded in SDM.)
 Help patient to commit to engaging in the care of his/her
stable CAD
 Negotiate an action plan (long-term and short-term) with
the patient (SDM: 2-way discussion of options, patient
goals, how best to accomplish them)
 Referral and documentation

26. More examples
PROSTATE CANCER
SCREENING