Creating Meaningful Conversations

Creating Meaningful ConversationsInsights from Shared Decision Making at the point of care

Annie LeBlanc PhDKnowledge and Evaluation Research (KER) Unit

Mayo Clinic, Rochester, MN (USA)

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

Why we came to shared decision making

Patient centered high value healthcareEvidence based medicine

Makes explicit the uncertainty of the evidenceGives a voice to patients (values/ preferences)

Reduce unwarranted variationsRight thing to do

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

Current State

Current state of decision makingPa

tient

and

clin

icia

n be

gin

cons

ulta

tion

Patie

nt a

nd c

linic

ian

disc

uss

med

icati

ons.

Patie

nt le

aves

with

a p

resc

riptio

n.

Patie

nt m

akes

dec

isio

n ab

out m

edic

ation

.

Anatomy of a Decision (MD)

• Medical knowledge• Years of education• Practice experience• Clinician preferences

Anatomy of a Decision (PT)

• Expert on their life• Personal health view• Lifestyle preferences• Own/ther experiences

Anatomy of a Decision (Environment)

• History• Ritual• Tools

Shared decision makingPa

tient

and

clin

icia

n be

gin

cons

ulta

tion

Patie

nt a

nd c

linic

ian

disc

uss

med

icati

ons.

Patie

nt le

aves

with

a p

resc

riptio

n.

Patie

nt m

akes

dec

isio

n ab

out m

edic

ation

.

Shared decision making

Research Evidence

Patient Values and Preferences

Decision Aid

Within an exam room

Our Decision Aids are focused on facilitating a conversation between

health professionals and patientsand thus

designed as tools intended for use during the clinical encounter

“What do we need to know to make this decision together ”

Evidence synthesisObservations

clinical encounters

DesignersStudy team

Patient advisory groupsClinicians

Stakeholders

Initial prototype

Field testing

Modified prototype

Final Decision Aid

EvaluationPractice-based Randomized Controlled Trials

Real life encounters

The case of diabetes medication

Glucose control in T2 diabetes

No clear evidence for a goal HbA1cComparative effectiveness data of safety

9 types of agents (+ lifestyle modification)Many attributes per agent

Mullan et al. 2009

Web-based Decision aidshttp://diabetesdecisionaid.mayoclinic.org/

Online tutorial

More helpful Improved knowledge

More involvement in making decisions 6-mo perfect medication use

Better adherence Persistence

No significant impact on HbA1c levels

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

The story of our 92 y old patient

The case of Depression Care

Can be improved byLifestyle changes, self-care practices psychotherapy, pharmacotherapy

But of different efficacy, safety, cost, burden to the patient

Depression

LeBlanc 2012

Cluster RCT in Rural & urban PC practices(10 practices WI MN, 106 clinicians, 200/300 patients)

“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”

Other Wiser Choices Decision AidsChronic and acute care

Weymiller et al. Arch Intern Med 2007

Statin Choice

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

Web-based tool

http//:statinchoice.e-bm.info

Osteoporosis Choice

Montori et al, AJM 2011

AMI Choice

Chest Pain Choice

Hess et al. Circ 2012

Head CT for Children

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)

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

Patients involvement

Usual care Decision aid

Mea

n To

tal O

PT

ION

Sco

re (

%)

Adj

ust

ed

All Chest Pain Diabetes Osteo I Osteo II Statin0

10

20

30

40

50

60

Ad

just

ed M

ean

OP

TIO

N S

core

N=398

p=0.001

20.4

37.6

Summary of experienceAge: 40-92 (avg 65)

74-90% clinicians want to tools againAdds ~3 minutes to consultation

60% fidelity without training20% improvement in patient knowledge

17% improvement in patient involvement Variable effect on clinical outcomes and cost

• 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

Summary of experience

Creating a conversation

Evidence synthesisTranslation of evidence into action

Patient important researchDesign of carearound the needs of the patient

Improve value of healthcare to the patientMinimally disruptive

medicineFIT

Shared decision making

Can we do this Monday morning ?

http://shareddecisions.mayoclinic.org

Brief tools with minimal footprint (IPDAS)User-centered design, evidence-based content

For use during consultationFree

Lima, Perú - June 16-19 2013

Globalizing SDMPacientes @ centre of healthcare

www.isdm2013.org

7th International SDM Conference

leblanc.annie@mayo.edu@annie_leblanc

http://kerunit.e-bm.orghttp://kercards.e-bm.info/

http://shareddecisions.mayoclinic.org/www.isdm2013.org