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MAGIC
MAking Good decisions In Collaboration
Shared decision making the norm
Multi-centre, large scale implementation programme
How can we embed in mainstream health services ?
Shared Decision Making…
What’s it all about ?
Why do we do it ?
When do we use it ?
How can we do more ?
So where do you stand? Individually choose one of these
three statements:1. Healthcare professionals are responsible for supporting
patients to make decisions that the patient feels are best for them, even if the professional disagrees
2. Patients should only be involved in decisions about alternative treatments when the alternatives are equally effective.
3. Some patients prefer the clinician to make the decision for them, and in this case that is what should happen.
Give your statement a score between 1 and 10
0 = completely DISAGREE with the statement
10 = completely AGREE
.
What’s it all about ?
Poor decision qualityPoor decision quality
Patients: unaware of treatment
or management options and outcomes
Clinicians: unaware of patients’ circumstances and
preferences
The Clinical Decision Problem
Slide from Foundation for Informed Medical Decision MakingWith thanks to Angela Coulter
7
Sharing Expertise
Clinician• Diagnosis• Disease aetiology• Prognosis• Treatment options• Outcome probabilities
Patient• Experience of illness• Social circumstances• Attitude to risk• Values• Preferences
Slide from Foundation for Informed Medical Decision MakingWith thanks to Angela Coulter
Models of clinical decision making in the consultation
Paternalistic Informed ChoiceShared Decision Making
Models of clinical decision making in the consultation
Paternalistic Informed ChoiceShared Decision Making
“When we want your opinion, we’ll give it to you”
Models of clinical decision making in the consultation
Paternalistic Informed ChoiceShared Decision Making
“I’m sorry doctor, but again I have to disagree”
Models of clinical decision making in the consultation
Paternalistic Informed ChoiceShared Decision Making
I think I prefer this option…
Paternalistic Informed ChoiceShared Decision Making
Patient well informed (Knowledge)
Knows what’s important to them (Values elicited)
Decision consistent with values
SDM is an approach where clinicians and patients make decisions together using the best available evidence. (Elwyn et al. BMJ 2010)
“Shall I have a knee
replacement?”
“Shall I have a prostate
operation?”
“Shall I take a statin tablet for the
rest of my life?”
“Should I use insulin or an alternative?”
“I would like to lose weight”
“I would like to eat/smoke/drink
less”
Spectrum of SDM to SMS
TO
OL
S
SK
ILL
S
Shared Decision Making….
Are you doing it?
Answer
Yes – but not as much as people want
Why do we do it ?
ARE PATIENTS INVOLVED?
%
Wanted more involvement in treatment decisions
Source: NHS inpatient surveys
SDM – Why do we do it ?Evidence: Cochrane Review of Patient Decision Aids(O’Connor et al 2011):
Improve knowledge More accurate risk perceptions Feeling better informed and clear about values More active involvement Fewer undecided after PDA More patients achieving decisions that were informed and consistent with their
values Reduced rates of: major elective invasive surgery in favour of conservative
options; PSA screening; menopausal hormones
Improves adherence to medication (Joosten, 2008)
Better outcomes in long term care
“No decisions in the face of avoidable ignorance”
Reduce unwarranted variation
Decision Aids reduce rates of discretionary surgery
RR=0.76 (0.6, 0.9)
O’Connor et al., Cochrane Library, 2009
0% 25% 50% 75%
CA-Prostatectomy
CAOrchiectomy*
coronary bypass*
coronary bypass
hysterectomy
hysterectomy*
mastectomy
back surgery
mastectomy*
bphprostatectomy
bphprostatectomy
Standard Care
D-Aid
.
Primary Knee Replacement - AgeSexNeeds standardised cost per 1000 population for PCTs
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
1 11 21 31 41 51 61 71 81 91 101 111 121 131 141 151
PCT
Ag
eSex
Nee
ds
stan
dar
dis
ed c
ost
(£
per
100
0 p
op
ula
tion
)
Musculoskeletal programme- variation in knee replacement
activity
Extra slide
Shared decision making about treatments:
Patients who don’t have decision support:• Are 59 times more likely to change their
mind• Are 23 times more likely to delay their
decision• Are five times more likely to regret their
decision• Blame their practitioner for bad outcomes
19% more often
Thanks to Alf Collings
Decision aid and coaching in gynaecology
2751
2026
1566
0
500
1000
1500
2000
2500
3000
Usual care Decision aid Decision aid + coaching
Treatment costs ($) over 2 years
Extra slide
When do we use it ?
SDM – When is it appropriate?
• SDM not right for all decisions (but is still useful in some surprising situations)
• Genuine choices sensitive to patient preferences– Early breast cancer - mastectomy or breast
conserving surgery– LUTS – watchful waiting, medication, surgery– CVD risk reduction – statins or diet/exercise– Hyperacute stroke?
Core skills in SDM
Core Skills in SDM
PreferenceTalk
Deliberation
Patient Decision Support materials
DecisionChoice
TalkOptionTalk
SDM Consultation skills
Choice talkIntroduce preference sensitive decision. Respond to patient’s reaction,
Introduce preference talk
Option talkIntroduce options, detail pros and cons, check understanding, introduce
decision support, continue preference talk when appropriate
DeliberationHelp patient to deliberate about options, could be supported by decision
specific / generic decision support tool
Preference/decision talkIn light of options clarify ‘what matters to me’ – the values and preferences of
the patientDecision Immediate or delayed
SDM consultation skills
Brief exercise
What do you need to do SDM?
• Willingness to do SDM – clinicians and patients
• Key SDM Skills
• Support tools
• Organisational system to support SDM
Decision aids:their role and their pitfalls
Decision Support Interventions
•Generic tools•Decision specific tools
»BDAs»Option Grids»NHS
•Variety of formats»Websites»Interactive tools»Leaflets & booklets»DVDs
Shared decision making – support for HCPs and patients
•10 Brief Decision Aids (BDAs) available now on patient.co.uk
•Around 15 more in development
•Inform patients (and clinicians!)
•In consultation/take home
•On-line Patient Decision Aids•http://sdm.rightcare.nhs.uk/pda/
Lumpectomy with
Radiotherapy
Mastectomy
Which surgery is best for long term survival?
There is no difference between surgery options.
There is no difference between surgery options.
What are the chances of cancer coming back?
Breast cancer will come back in the breast in
about 10 in 100 women in the 10 years after a
lumpectomy.
Breast cancer will come back in the area of the scar
in about 5 in 100 women in the 10 years
after a mastectomy.
What is removed?The cancer lump is
removed with a margin of tissue.
The whole breast is removed.
Will I need more than one operation
Possibly, if cancer cells remain in the breast after the lumpectomy. This can
occur in up to 5 in 100 women.
No, unless you choose breast reconstruction.
How long will it take to recover?
Most women are home 24 hours after surgery
Most women spend a few nights in hospital.
Will I need radiotherapy? Yes, for up to 6 weeks after surgery.
Unlikely, radiotherapy is not routine after
mastectomy.
Will I need to have my lymph glands removed?
Some or all of the lymph glands in the armpit are
usually removed.
Some or all of the lymph glands in the armpit are
usually removed.
Will I need chemotherapy?
Yes, you may be offered chemotherapy as well,
usually given after surgery and before radiotherapy.
Yes, you may be offered chemotherapy as well,
usually given after surgery and before radiotherapy.
Will I lose my hair? Hair loss is common after chemotherapy. Hair loss is common after chemotherapy.
Option Grid
Patients’ knowledge post diagnostic consultation
Measuring impact of change in clinical practice (Option Grid)
Patient Decision Aids – key messages
• Have much value, but need to be accessible at the right time and designed for purpose
• We will never have enough PDAs for all decisions
• PDAs are an adjunct to good clinical practice
• BMJ recently made clear that…. you can have PDAs available, and clinicians trained to use them but this does not necessarily change patient experience – the challenge of the ‘black box’
• PDAs are helpful, skills are even more helpful but….
Attitudes trump all!
Decision Support Interventions
• Facilitate patient involvement in SDM
• Provide information about options
• Help patients think about:
– how they would feel about possible outcomes
– think about what’s important to them
Key Reading
Elwyn G, Laitner S, Coulter A, Walker E, Watson P, Thomson R. Implementing shared decision making in the NHS. BMJ 2010;341:c5146 http://www.bmj.com/content/341/bmj.c5146 Coulter A Do patients want a choice and does it work? BMJ 2010;341:c4989 http://www.bmj.com/content/341/bmj.c4989 Shared Decision-Making in Health Care: Achieving evidence-based patient choice Second Edition A Edwards, G Elwyn 2009 Oxford University Press, Oxford Al Mulley King’s Fund Report. Patients’ preferences matter: Stop the silent misdiagnosis http://www.kingsfund.org.uk/publications/patients%E2%80%99-preferences-matter King’s Fund report on Delivering better services for people with long-term conditions: Building the house of care http://www.kingsfund.org.uk/publications/delivering-better-services-people-long-term-conditions Gigerenzer G. Reckoning with Risk: Learning to Live with Uncertainty. Penguin, 2002. http://www.amazon.co.uk/Reckoning-Risk-Learning-Live-Uncertainty/dp/0140297863 Gigerenzer, G. (2007). Gut feelings. London, Penguin. http://www.amazon.co.uk/Gut-Feelings-Better-Decision-Making/dp/0141015918
