Decision aids in hospitals may improve patient care, engagement

A recently published Health Affairs study conducted at Massachusetts General Hospital shows how the use of decision aids can benefit both clinicians and patients.

In a 10-year study, conducted from 2005 to 2015, more than 900 clinicians and other hospital staff were trained in decision making, and more than 28,000 orders for one of 40 decision aids were placed. Clearly, there must be a need for this integral part of patient engagement, so why have so few hospitals implemented such programs?

In medical situations without one clear best option for care, needs for decision aids and shared decision making are most important. Shared decision making encourages conversations that combine the expertise of clinicians, the best available medical evidence and patient’s experiences, goals and preferences to select the care they feel is right for them. The problem facing this process is the “follow the doctor’s recommendation” approach to care, which leads to patients becoming unknowledgeable about their own care. The survey of 50,000 patients in 272 hospitals found that 17 to 52 percent of patients reported not having enough say in decisions about their care.

“What we’ve seen is a huge knowledge gap between patients,” said Karen Sepucha, PhD, director of the Health Decision Sciences Center in the General Medicine Division at Massachusetts General Hospital and an assistant professor in medicine at Harvard Medical School. “They believe they are very well informed, but when asked about their care, they could not answer simple questions about the procedure.”

Started in 2005, the program at Massachusetts General Hospital focused on three goals: developing a culture receptive to and healthcare providers skilled in shared decision-making conversations, using patient decision aids to help inform and engage patients, and providing infrastructure and resources to support the implementation of shared decision making in practice.

Using 40 different patient decision aids, covering topics relevant to general primary care, clinicians are able to order patient decision aids through electronic medical records (EMRs). Decision aids are available in many different formats including email messages, DVDs and booklets.

By the end of 2008, the study found about 200 clinicians had ordered at least one patient decision aid, users were twice as likely to have watched one of the patient decision aids compared to nonusers, 75 percent of clinicians believed that using a decision aid would not significantly lengthen the patient visit, and 75 percent of the nonusers agreed that watching a patient decision aid would make it more likely that they would order one.

With these findings, the research team developed a training program for clinicians where the session provided an opportunity to watch a video decision aid, review provider and practice level data on the use of patient decision aids, discuss challenges and concerns with their practice leaders and colleagues, and learn more about the EMR-enabled ordering program. Of the 165 clinicians surveyed, 88 percent said they would make changes in their practices based on the session.

Although feedback was mostly positive, questions such as “education, literacy, cultural disparities for our multicultural, immigrant community will be a barrier to use of the programs” raised concerns about the use of decision aids for troubled populations.

“These are the people who need decision aids the most,” said Sepucha. “Accessibility is a challenge, but with group meeting, led by a nurse, these people are able to gain access to decision aids in their native language and with a discussion period after the video people are able to discuss all their options for care. When analyzed it was shown that undeserved communities gained a huge amount of information from decision aids.”

The study found an interesting result when comparing decision aids ordered by physicians to those ordered by patients. The top three topics ordered by patients included chronic lower back pain, diabetes and anxiety, while the top three topics for aids ordered by physicians were prostate cancer screening, colon cancer screening and advance directives. 

“Not as many patients come into the doctor’s office concerned about cancer,” Sepucha said. "They are more symptom driven and focus on what is important to them in that moment."

The study concludes with noting that although the hospital has made progress there is much more work to do on the implementation of shared decision making into the routine and incorporating it into many more hospitals.

“Leadership need to provide the resources,” said Sepucha. “Leadership needs to be in place to make changes. For example, there needs to be a chief knowledge officer to evaluate the research and show the positive impact shared decision making has on informing patients about their care and making it easier for doctors to treat them.”