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Promoting Shared Decision Making Jack Fowler Informed Medical Decisions Foundation
Promoting Shared Decision Making
Jack FowlerInformed Medical Decisions
Foundation
Shared decision making means
• 1. Patients are told about all reasonable options
• 2. Patients are told about pros and cons of options
• 3. Patients share goals, concerns and preferences with providers
4 Reasons Not to Increase Efforts to Do Shared Decision Making
• 1. We already do it
• 2. Patients don’t want it
• 3. Patients can’t understand
• 4. Doctors should make decisions
We already do it?
National Survey of Medical Decisions
• Cancer screening tests:– Colorectal Cancer– Breast Cancer (mammography)– Prostate Cancer (PSA testing)
• Prescription medication decisions:– Hypertension– High Cholesterol– Depression
• Surgical interventions:– Knee/hip replacement– Cataracts– Lower back pain
Mean Proportion of Knowledge Items Answered Correctly
69%
49%
34%
43%
37%
17%
32%
49%
25%
0% 50% 100%
High blood pressure
High cholesterol
Depression
Colon cancer
Breast cancer (women)
Prostate cancer (men)
Knee/hip replacement
Cararact
Lower back pain
Medication Initiation:
Cancer screening:
Elective surgery:
Discussion of Pros and Cons- “some” OR “A lot”
82%
83%
79%
73%
75%
69%
90%
76%
72%
31%
34%
39%
14%
13%
16%
49%
33%
62%
0% 50% 100%
High blood pressure
High cholesterol
Depression
Colon cancer
Breast cancer (women)
Prostate cancer (men)
Knee/hip replacement
Cararact
Lower back pain
% Discussed Pros % Discussd Cons
Medication Initiation:
Screened for Cancer:
Underwent surgery:
Did HCP Offer an Opinion and Ask for Patient’s Own Opinion?
84%
85%
78%
84%
80%
80%
85%
78%
82%
41%
45%
74%
34%
38%
46%
77%
61%
76%
0% 50% 100%
High blood pressure
High cholesterol
Depression
Colon cancer
Breast cancer (women)
Prostate cancer (men)
Knee/hip replacement
Cararact
Lower back pain
HCP offered opinion Asked pt. opinion
Medication Initiation:
Screened for Cancer:
Underwent surgery:
PATIENTS DON’T WANT IT?
Testing our First 30-Minute BPH Program
How would you rate the amount of information?
One Universal Truth
• Every time we ask, people (particularly physicians) underestimate how much patients value getting information about their medical conditions and being involved in decisions.
At Dartmouth-Hitchcock
• Patients routinely see decision aids for at least 11 different decisions
• They are surveyed after they see them
Who Should Make Decisions?
Dartmouth patient data collected between July 2005 and July 2009
Would You Recommend DA for Others
Dartmouth patient data collected between July 2005 and July 2009
Patients can’t understand?
Findings with Respect to Literacy
• Compared understanding of risk reduction for samples of college students and senior citizens recruited from community centers
• Both groups were stratified by score on a numeracy test
Percent of Respondents Who Understood Risk Reduction by Numeracy Level and Quality of Data Presentation
Percent of Respondents Who Understood Risk Reduction by Numeracy Level and Quality of Data Presentation
Doctors should make decisions?
Top Three Goals and Concerns for Breast Cancer/Herniated Disc Decisions
Condition: Goal Patient Provider p
Surgery:Keep your breast?
Chemotherapy:Live as long as possible?
Reconstruction:Look natural without clothes
Reconstruction:Avoid using prosthesis
7%
59%
P<0.01
33%
71%
96%
80%
0%
33%
P=0.01
P=0.05
P<0.01
We are not doing it now
Patients do want it
• But many perceive their doctors do not welcome questions and patient participation in decision making
Patients can absorb complex information
• However, it has to be presented well
Decisions should not be delegated to physicians
• Because most medical decisions involve trade offs and quality of life issues
• Providers will not know what patients care about unless they ask
• At the moment, they do not routinely ask
• SO THAT IS WHY WE ALL NEED TO WORK TO PROMOTE THE IDEA THAT PATIENTS ROUTINELY
• SHOULD BE INFORMED ABOUT THEIR OPTIONS AND THEIR PROS AND CONS
• HAVE A VOICE IN MEDICAL DECISIONS
THANK YOU.
