Shared Decision Making and Perfected Informed Consent Department of Family Medicine Grand Rounds Georgetown University School of Medicine September 2, 2011 Shannon Brownlee, MS Instructor, The Dartmouth Institute for Health Policy and Clinical Practice Acting Director, New America Foundation Health Policy Program DARTMOUTH DATA Named the most influential health policy researcher of the past 25 years by Health Affairs in 2007 2 jw John Wennberg, MD, MPH., Founder, Center for Evaluative Clinical Sciences at Dartmouth Medical School The 3 Categories of Care That Show Unwarranted Variation Effective Care: Evidence-based care that all with need should receive Supply-Sensitive Care: Discretionary hospitalizations, visits, and procedures Preference-Sensitive Care: Elective procedures and tests whose use should depend upon the patient’s choice Preference-Sensitive Care Involves tradeoffs -- more than one treatment exists; not getting treated is often an option; and the outcomes are different Decisions should be based on the patient’s preferences . . . But provider opinion/preference often determines which treatment is delivered Preference-sensitive conditions CONDITION TREATMENT OPTIONS Silent gall stones Surgery vs watchful waiting Stable Angina PCI vs CABG vs. med manage Joint arthritis Joint replacement vs. pain meds Carotid stenosis Surgery vs. medical manage Herniated disc Back surgery vs. other Early prostate cancer Surgery vs. rad vs. watching Middle-aged male PSA test versus no test Source: 2011 Dartmouth Atlas Back surgery per 1,000 Medicare beneficiaries (2003-07) Screen shot 2011-09-02 at 6.58.37 AM.png Screen shot 2011-09-02 at 6.58.10 AM.png Screen shot 2011-01-19 at 7.02.10 AM.png Screen shot 2011-01-23 at 9.05.55 AM.png Screen shot 2011-01-23 at 9.06.35 AM.png Screen shot 2011-01-23 at 8.36.09 AM.png Screen shot 2011-08-23 at 11.04.20 AM.png Source: CHCF PCI per 100,000 among Calif. HSAs Screen shot 2011-08-23 at 10.55.47 AM.png Source: CHCF (Adjusted for age, sex, race, income, prevalence of CAD) Rate of elective angiography compared to state rate in HSAs in 1 Calif. HRR Well Bob, it looks like a paper cut, but just to be sure, let’s do lots of tests. catheterizations. Screen shot 2011-09-02 at 7.07.27 AM.png 1.0 3.0 5.0 7.0 9.0 11.0 1992-93 2000-01 Red dot = U.S. average: 4.03 5.64 40% increase Knee replacement per 1,000 Medicare enrollees Determining the Need for Hip and Knee Arthroplasty: The Role of Clinical Severity and Patients’ Preferences “ Among those with severe arthritis, no more than 15% were definitely willing to undergo (joint replacement), emphasizing the importance of considering both patients’ preference and surgical indications in evaluating need and appropriateness of rates of surgery.” Bottom Line Implications: 1. Clinical appropriateness should be based on sound evaluation of treatment options (comparative effectiveness and outcomes research) 2. Medical necessity should be based on Informed Patient Choice among clinically appropriate options -- high quality shared decision-making SOURCE: U. of Mich. DECISION Survey Surgery: ~ 65% of recommendations: “do it” Screening: ~ 95% of recommendations: “do it” Medications: ~ over 90% of recommendations: “do it” http://1.bp.blogspot.com/_xSyx2BsBV9o/Scuv-jGFElI/AAAAAAAAADE/Sw3c_Ecm5y4/s320/nike.bmp DECISION Survey: Were Patients Asked for their Opinions? For surgery: About 1/2 the time for the orthopedic surgeries; 1/3 of the time for cataracts For screening: Less than 1/5 of the time for decisions about cancer screening For medications: About 1/3 of the time IS INFORMED CONSENT WORKING? Clinical experts identified 4-5 facts a person should know: e.g. common side effects. Respondents were asked the knowledge questions related to their decision. For 8 out of the 10 decisions, fewer than half of respondents could get more than one of the knowledge questions right. Screen shot 2011-08-24 at 11.15.19 AM.png 1/3 of men who were given a PSA test were never asked if they wanted it. Of men who are asked, 2/3 say their doctor failed to mention possible downsides that result from treatment that can follow screening. McFall SL. US men discussing prostate-specific antigen tests with a physician. Annals of family medicine 2006;4(5):433-6. INFORMED PATIENTS? Screen shot 2011-09-02 at 6.57.18 AM.png Screen shot 2011-09-02 at 6.57.49 AM.png Well Bob, it looks like a paper cut, but just to be sure, let’s do lots of tests. I like to do lots of PSA tests. Screen shot 2010-09-20 at 11.35.13 AM.png Screen shot 2010-09-19 at 4.55.03 AM.png Cochrane Collaboration: The Case for Shared Decision Making Improve understanding; More realistic about benefits and harms; More satisfied and less conflicted; More active role; Less likely to remain undecided; Better agreement between patient’s values and choice. Stacey D, Bennett C, Barry M, Col N, Eden K, Holmes-Rovner M, et al. Cochrane Database Syst Rev. 2011. A new way of thinking about informed consent and medical error? Major, potentially dangerous events in a patient’s lives Potential for wrong-patient error Is it ethical to offer elective tests (e.g. PSA) or surgery outside the context of shared decision making? Screen shot 2011-09-02 at 7.56.32 AM.png Screen shot 2011-09-02 at 7.56.15 AM.png JAMA 2004 Screen shot 2011-09-02 at 3.56.55 AM.png POLICY IMPLICATIONS: Clinical effectiveness research won’t be enough to bend the cost curve. Patient centered care: Even when we know what works, patients still need to choose. Unnecessary (or unwanted) treatment poses risk. Ensuring informed patient choice should be a goal of both public policy and clinical practice. Progress on Shared Decision Making WA. State legislation PPACA 2010 provisions DECISION Study Dartmouth Atlas 2011 CHCF Calif. atlas FIMDM demonstration projects NAF-FIMDM certification of patient decision aids Top Five Reasons to Implement Shared Decision Making (with patient decision aids) Prevent harm to patients Perfect informed consent (it’s broken) Bridge health disparities Control health spending It’s the right thing to do