Published on March 12, 2014
Victor M. Montori, MD, MSc Mayo Clinic Shared Decision Making Toward Evidence-based Patient-centered care firstname.lastname@example.org @vmontori
Glasziou and Haynes ACP JC 2005
The body of evidence Systematic review of 115 RCTs Compared to usual care, decision aids: Increase patient involvement by 34% (+++-) Increase patient knowledge of options by 13% (++++) Increase consultation time by ~2.6 minutes Reduce decisional conflict by ~7% Reduce % undecided by 40% No consistent effect on choice, adherence, health outcomes or costs Stacey D et al. Cochrane review 2014
Examples Decision aid Evaluation Risk communication tools Statin Choice (primary care) Feasible, effective Independently validated Multicenter trial completed Implemented in EHR Chest pain Choice (emergency) Feasible, effective (Emergency) Multicenter trial seeking funding Aspirin Choice (primary care) Implemented in EHR without evaluation Osteoporosis Choice (primary care) Feasible, effective EHR implementation ongoing PCI Choice (cardiology) Ongoing AMI Choice (hospital) Feasible, effective (hospital) Issue cards DM2 Med Choice Feasible, effective Multicenter trial ongoing Implemented in EHR Depression Choice Ongoing
Weymiller et al. Arch Intern Med 2007 Statin Choice Web
Compared to usual care, patients using the decision aid were 22 times more likely to have an accurate sense of their baseline risk and risk reduction with statins. Weymiller et al. Arch Intern Med 2007
Osteoporosis Choice Montori et al, AJM 2011
Chest Pain Choice Hess et al. Circ 2012
Mullan et al, Arch Intern Med 2009 Diabetes Medication Choice Video / Web
Depression Medication Choice LeBlanc 2012
Summary of Mayo experience Age: 40-92 (avg 65) Primary care, ED, hospital, specialty care 74-90% clinicians want to use tools again Adds ~3 minutes to consultation 60% fidelity without training 20% improvement in patient knowledge 17% improvement in patient involvement Variable clinical outcomes
• Clinician decides how & when to use - and may elect not to use • “Considerations” and “What You Should Know” cards are not given to patient as part of the comparison process Clinician and patient discuss the “What You Should Know” card. Patient selects a second card and compares the two. Clinician asks, “What issues concerning a medication to treat depression symptoms would you like to discuss firs t ?” Patient selects firs t card. Medication options are discussed. Patient and clinician review this card. Medication choice is made– brochure given to patient to take home. a clinician guide to: Using the Depression Medication Choice Decision Aid (DA) with Patients
Statin Decision Aid
Web-based tool http://statindecisionaid.mayoclinic.org
Empathic decision making Partnership Dance across models Support deliberation
Incorporate research evidence and clinician’s expertise into patient decisions
Conclusions • It is feasible to promote evidence-based conversations during the clinical encounters with patients with chronic conditions. • Decision aids designed for this purpose are efficient and effective in promoting shared decision making. • Tools tested in randomized trials and proven effective are available for free. • Partners to get to routine use in practice.
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