angela coulter: getting the best value for patients

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Best Value for Patients

Angela Coulter, PhDDirector of Global Initiatives

Foundation for Informed Medical Decision Makingacoulter@fimdm.org

www.informedmedicaldecisions.org

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Overview

• Shared decision-making– in acute conditions– in long-term conditions

• Implementation challenges

Poor decision quality

Patients: making decisions in

the face of avoidable

ignorance

Clinicians: poorly ‘diagnosing’

patients’ preferences leading to underuse, overuse and waste

The clinical decision problem

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What we have learnt

Paternalistic or directive practice styles...

• Create dependency• Discourage self-care• Ignore preferences• Undermine confidence• Do not encourage healthy behaviours

Shared decision-making

A process in which clinicians and patients work together to select tests, treatments, management or support packages, based on clinical evidence and the patient’s informed preferences.

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Sharing expertise

Clinician• Diagnosis• Disease aetiology• Prognosis• Treatment options• Outcome probabilities

Patient• Experience of illness• Social circumstances• Attitude to risk• Values• Preferences

Key components of shared decision-making

1. Reliable, balanced, evidence-based information outlining treatment options, outcomes and uncertainties.

2. Decision support counselling with clinician or health coach to clarify options and preferences.

3. System for recording, communicating and implementing patient’s preferences.

When is it appropriate?

• When people face major health care decisions where there is more than one feasible option.

• When people with chronic conditions want to be involved in planning their care, adopting healthier lifestyles, and enhancing their ability to self-manage.

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What patients need to know

• Is there more than one way to treat my condition?

• Will treatment relieve the symptoms?

• Benefits and harms?• Is treatment essential?• Recovery time?• Impact on quality of life?• What can I do to help

myself?

Patient decision aids

Information on…..• condition• treatment options• outcomes with and

without treatment• uncertainties• values clarification• balanced• evidence-based

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Variations in hysterectomy rates in England

• Hysterectomy is (usually) discretionary

• Population-based hysterectomy rates vary more than 3x between local areas

• Patients’ values and preferences should influence decisions

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Decision aid + decision support

• Helped patients form preferences• Reduced hysterectomy rates• Increased long-term satisfaction• Information + preference elicitation

was cost-effective

Kennedy et al. JAMA 2002; 288: 2701-8

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Decision aid + coaching in gynaecology

Decision aids: the evidence

• In 55 trials addressing 23 different screening or treatment decisions, use has led to:

• greater knowledge

• more accurate risk perceptions

• greater comfort with decisions

• greater participation in decision-making

• fewer people remaining undecided

• fewer patients choosing major surgery

O’Connor et al. Cochrane Database of Systematic Reviews, 2009

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformationSystems

Self-Management Support

HEALTH SYSTEM

Resources and Policies

COMMUNITY

Health Care Organisation

Chronic care model

Individual ’s story Professional ’s story

Share and discuss information

Goal Setting

Action ActionActionAction

Knowledge and health

beliefs

Emotional Behavioural Social Clinical

Individual ’s story Professional ’s story

Share and discuss information

Goal Setting

Action ActionActionAction

Individual ’s story Professional ’s story

Share and discuss information

Goal Setting

Action ActionActionAction

Knowledge and health

beliefs

Knowledge and health

beliefs

EmotionalEmotional BehaviouralBehavioural SocialSocial ClinicalClinical

Individual ’s story Professional ’s story

Share and discuss information

Goal Setting

Action ActionActionAction

Individual ’s story Professional ’s story

Share and discuss information

Goal Setting

Action ActionActionAction

Knowledge and health

beliefs

Knowledge and health

beliefs

EmotionalEmotional BehaviouralBehavioural SocialSocial ClinicalClinical

Individual ’s story Professional ’s story

Share and discuss information

Goal Setting

Action ActionActionAction

Individual ’s story Professional ’s story

Share and discuss information

Goal Setting

Action ActionActionAction

Knowledge and health

beliefs

Knowledge and health

beliefs

EmotionalEmotional BehaviouralBehavioural SocialSocial ClinicalClinical

Collaborative care planning in diabetes

Engaged,

informed patient

HC

P com

mitted to

partnership working

Organisational processes

Commissioning- The foundation

Individual ’s story Professional ’s story

Share and discuss information

Goal Setting

Action ActionActionAction

Knowledge and health

beliefs

Emotional Behavioural Social Clinical

Individual ’s story Professional ’s story

Share and discuss information

Goal Setting

Action ActionActionAction

Individual ’s story Professional ’s story

Share and discuss information

Goal Setting

Action ActionActionAction

Knowledge and health

beliefs

Knowledge and health

beliefs

EmotionalEmotional BehaviouralBehavioural SocialSocial ClinicalClinical

The clinic experience

Registration, recall, review, and

follow up

Access & communication

Named contact

IT templates

Awareness of approach to self-

management

Consultation skills / competencies

Multi-disciplinary team working

Knowledge of local options

Clinical expertise

Structured education/ Information

Awareness of process & options

Pre-consultation results

Access to own records

Emotional & psychological

support

Informed, empowered patients

Have the knowledge, skills and confidence to manage their own health and healthcare,

And they…

• make healthy lifestyle choices• tend to adhere to medication regimes • make informed and personally relevant decisions

about their treatment and care• use less health care

Mosen et al 2007

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Changing the culture of care• Help patients understand

their options• Give information about risks,

benefits, consequences and uncertainties

• Support patients to articulate their values and preferences

• Reach a mutually agreed decision on the most appropriate course of action

What are the barriers?

• Time/resources• Inflexible

systems• Clinical culture

What could help?

• Clinical leadership, training and skills

• Social marketing• Identifying decision points and

integrating decision support into clinical pathways

• System for recording and acting on patients’ preferences

• Monitoring and feedback• Incentives for clinicians• Strong social networks and

community support• Supportive public policy

What are the rewards?

• Better consultations• Clearer risk communication• Improved health literacy• More appropriate decisions• Fewer unwanted treatments• Improved confidence and self-efficacy• Improved health behaviours• Safer care• Greater compliance with ethical standards• Reduced costs• Less litigation• Better health outcomes

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For more information………

www.informedmedicaldecisions.org