EBM12: Decision aid can improve patient engagement
CHICAGO—“We need shared decision making but it’s got to be led by clinicians,” said Margaret Holmes-Rovner, PhD, professor at the Health Services Research Center for Ethics and Humanities in the Life Sciences at Michigan State University College of Human Medicine in East Lansing, speaking Oct. 4 at the CMIO Leadership Forum: Transforming Healthcare through Evidence-Based Medicine.
Studies have found that coaching patients to ask questions of their clinicians does not engage patients with the evidence and doesn’t improve the number of questions they ask. Access to medical records improves patients’ knowledge and is “almost universally popular with patients" and “tolerable to physicians, which is really critical,” she said.
Shared decision-making with decision aids, however, has been shown to improve knowledge and improve patients’ comfort with making decisions. “To affect outcomes, we have to have some form of concrete patient information,” even just a simple handout. “Getting patients comfortable through good clinical skills is not enough. They want real evidence.”
When patients use decision aids either before or during their clinician encounter they have greater satisfaction with their encounter and it improves adherence with the negotiated plans that come about through a healthy debate about the evidence, Holmes-Rovner reported.
She discussed a study on the differences between surgery and medical therapy in patients with one- and two-vessel cardiac disease. Researchers found that patient values for the outcomes change the decision because the treatment and outcome is a preference-sensitive decision. There is no one right answer when it comes to the best course of treatment, especially when it comes to such decisions as lumpectomy and chemotherapy vs. mastectomy, and active surveillance vs. surgery and radiation for early stage prostate cancer.
Patients reported a handout for prostate cancer patients that listed specific outcome numbers and side effects for each treatment was most valuable, Holmes-Rovner said. “It allowed patients, in real numbers, to compare each treatment. Talking about absolute numbers is really important to patients.”
In this new Choosing Wisely movement, she said that values matter so clinicians need to talk to their patients. “Many preference-sensitive decisions are the ones where there is marginal benefit to aggressive therapy.” There wouldn’t be a debate about treatment if that wasn’t the case. “Patients frequently think surgery means they can skip medical therapy and chronic self-management,” she said. “Even when you offer all of the viable options to patients, patients make decisions you’re not happy about. That’s something we have to live with.”
Homes-Rovner discussed a study about improving shared decision-making in the treatment of coronary artery disease (CAD). Percutaneous coronary intervention (PCI) and appropriate medical therapy is no better than medical therapy alone in stable CAD. The rate of deaths and myocardial infarction stayed the same. A pilot study conducted in Michigan tried to determine where in the diagnostic therapeutic cascade it would be best to discuss cardiac pre-catheterization. “When the patient is on the way to the cath lab is not the time,” she said. “We decided to back it up to the point of the stress test order.” Based on the results of the stress test, the patient may or may not be invited to do angiography with or without a stent.
While patients like having decision aids in their hands they tend not to look at them during an encounter. One goal of the pilot study was to overcome primary care providers’ initial reaction that if the patient has heart disease, then someone else should be responsible for the care. The pilot leaders worked with cardiologists to provide something other than narrative results of stress tests because there is some abnormality on almost every test. The cardiologists ultimately came up with a check box in the EHR for normal, abnormal with no high risk features or abnormal with high risk features. Those in the first two categories can go back to their primary care provider for a discussion about more testing and secondary prevention.
After the visit, “a summary sheet is another piece of the toolkit we added,” which serves multiple documentation needs. That includes recording the results of this negotiated encounter, such as what the patient has agreed to do and who is primarily responsible for managing the stable CAD, and how often the patient will get a stress test in the future and under what conditions.
Rather than just handing decision aids to patients, “we found we needed to add other pieces to the chain of events to make it viable,” Holmes-Rovner said. “Presently, it is viable at least for the early adopters. It’s not being done 100 percent of the time by any means but we’re ready to move forward and work with CMIOs to get it routinely implemented.”
What’s missing is leadership, Holmes-Rover said. Make it easy by putting decision aids in the hands of providers and patients. Providers need brief training to understand that this kind of counseling won't significantly extend encounters. The information can be “gone through very quickly particularly if the patient had the opportunity to look at the information ahead of time.” Clinicians can then check to see how much the patient understands and move on to negotiating a care plan. This is a way to improve care coordination, she said.
Studies have found that coaching patients to ask questions of their clinicians does not engage patients with the evidence and doesn’t improve the number of questions they ask. Access to medical records improves patients’ knowledge and is “almost universally popular with patients" and “tolerable to physicians, which is really critical,” she said.
Shared decision-making with decision aids, however, has been shown to improve knowledge and improve patients’ comfort with making decisions. “To affect outcomes, we have to have some form of concrete patient information,” even just a simple handout. “Getting patients comfortable through good clinical skills is not enough. They want real evidence.”
When patients use decision aids either before or during their clinician encounter they have greater satisfaction with their encounter and it improves adherence with the negotiated plans that come about through a healthy debate about the evidence, Holmes-Rovner reported.
She discussed a study on the differences between surgery and medical therapy in patients with one- and two-vessel cardiac disease. Researchers found that patient values for the outcomes change the decision because the treatment and outcome is a preference-sensitive decision. There is no one right answer when it comes to the best course of treatment, especially when it comes to such decisions as lumpectomy and chemotherapy vs. mastectomy, and active surveillance vs. surgery and radiation for early stage prostate cancer.
Patients reported a handout for prostate cancer patients that listed specific outcome numbers and side effects for each treatment was most valuable, Holmes-Rovner said. “It allowed patients, in real numbers, to compare each treatment. Talking about absolute numbers is really important to patients.”
In this new Choosing Wisely movement, she said that values matter so clinicians need to talk to their patients. “Many preference-sensitive decisions are the ones where there is marginal benefit to aggressive therapy.” There wouldn’t be a debate about treatment if that wasn’t the case. “Patients frequently think surgery means they can skip medical therapy and chronic self-management,” she said. “Even when you offer all of the viable options to patients, patients make decisions you’re not happy about. That’s something we have to live with.”
Homes-Rovner discussed a study about improving shared decision-making in the treatment of coronary artery disease (CAD). Percutaneous coronary intervention (PCI) and appropriate medical therapy is no better than medical therapy alone in stable CAD. The rate of deaths and myocardial infarction stayed the same. A pilot study conducted in Michigan tried to determine where in the diagnostic therapeutic cascade it would be best to discuss cardiac pre-catheterization. “When the patient is on the way to the cath lab is not the time,” she said. “We decided to back it up to the point of the stress test order.” Based on the results of the stress test, the patient may or may not be invited to do angiography with or without a stent.
While patients like having decision aids in their hands they tend not to look at them during an encounter. One goal of the pilot study was to overcome primary care providers’ initial reaction that if the patient has heart disease, then someone else should be responsible for the care. The pilot leaders worked with cardiologists to provide something other than narrative results of stress tests because there is some abnormality on almost every test. The cardiologists ultimately came up with a check box in the EHR for normal, abnormal with no high risk features or abnormal with high risk features. Those in the first two categories can go back to their primary care provider for a discussion about more testing and secondary prevention.
After the visit, “a summary sheet is another piece of the toolkit we added,” which serves multiple documentation needs. That includes recording the results of this negotiated encounter, such as what the patient has agreed to do and who is primarily responsible for managing the stable CAD, and how often the patient will get a stress test in the future and under what conditions.
Rather than just handing decision aids to patients, “we found we needed to add other pieces to the chain of events to make it viable,” Holmes-Rovner said. “Presently, it is viable at least for the early adopters. It’s not being done 100 percent of the time by any means but we’re ready to move forward and work with CMIOs to get it routinely implemented.”
What’s missing is leadership, Holmes-Rover said. Make it easy by putting decision aids in the hands of providers and patients. Providers need brief training to understand that this kind of counseling won't significantly extend encounters. The information can be “gone through very quickly particularly if the patient had the opportunity to look at the information ahead of time.” Clinicians can then check to see how much the patient understands and move on to negotiating a care plan. This is a way to improve care coordination, she said.
Beth Walsh, Editor
Editor Beth earned a bachelor’s degree in journalism and master’s in health communication. She has worked in hospital, academic and publishing settings over the past 20 years. Beth joined TriMed in 2005, as editor of CMIO and Clinical Innovation + Technology. When not covering all things related to health IT, she spends time with her husband and three children.