Creating Meaningful Conversations

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  • 1. Creating Meaningful ConversationsInsights 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 interestKER Unit houses the processes of design & evaluation of decision aids, decides on topics, pursues funding, and conducts evaluation trialsKER 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 makingPlethora 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
  • 5. Current State
  • 6. Patient and clinician begin consultationPatient and clinician discuss medications.Patient leaves with a prescription. Current state of decision makingPatient 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 consultationPatient and clinician discuss medications.Patient leaves with a prescription. Shared decision makingPatient makes decision about medication.
  • 11. Shared decision makingResearch Decision Patient Values andEvidence Aid Preferences Within an exam room
  • 12. Our Decision Aids are focusedon facilitating a conversation between health professionals and patients and thus designed as tools intended for use during the clinical encounter
  • 13. What do we need to know to make this decision together
  • 14. Observations Evidence synthesis clinical encounters Initial prototype Designers Field Study team Modified testing Patient advisory groups prototype Clinicians Stakeholders Final Decision Aid EvaluationPractice-based Randomized Controlled Trials Real life encounters
  • 15. The case of diabetes medication
  • 16. Glucose control in T2 diabetes No clear evidence for a goal HbA1c Comparative effectiveness data of safety9 types of agents (+ lifestyle modification) Many attributes per agent
  • 17. Mullan et al. 2009
  • 18. Web-based Decision aidshttp://diabetesdecisionaid.mayoclinic.org/
  • 19. Online tutorial
  • 20. More helpful Improved knowledgeMore involvement in making decisions 6-mo perfect medication use Better adherence PersistenceNo significant impact on HbA1c levels
  • 21. 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 isnt viewed negatively
  • 22. The story of our 92 y old patient
  • 23. The case of Depression Care
  • 24. Depression Can be improved by Lifestyle changes, self-care practices psychotherapy, pharmacotherapy But of differentefficacy, safety, cost, burden to the patient
  • 25. LeBlanc 2012
  • 26. Cluster RCT in Rural & urban PC practices(10 practices WI MN, 106 clinicians, 200/300 patients)
  • 27. 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. Shehad 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
  • 28. Other Wiser Choices Decision Aids Chronic and acute care
  • 29. Statin Choice Weymiller et al. Arch Intern Med 2007
  • 30. Compared to usual care, patients using the decision aid were 22 times more likelyto have an accurate sense of their baseline risk and risk reduction with statins. Weymiller et al. Arch Intern Med 2007
  • 31. Web-based tool http//:statinchoice.e-bm.info
  • 32. Osteoporosis Choice Montori et al, AJM 2011
  • 33. AMI Choice
  • 34. Chest Pain Choice Hess et al. Circ 2012
  • 35. Head CT for Children
  • 36. Work Setting Phase of developmentIndividualized medicineGenomic Choice IM clinic Design phase (electronic)Perioperative medicineSmoking choice Primary care Ongoing clinical trialCardiovascular medicineICD Choice Specialty care Design phaseHypertension e-primary care Design phaseMens healthProstate cancer screening and early treatment General (tablet) Design phase (scholar project; electronic)Womens healthMammography < 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)OtherNonpharmacological treatment of depression Primary care Protocol phase (submitted to PCORI)Head CT for children with mild head trauma Emergen