angela coulter: getting the best value for patients
DESCRIPTION
Dr Angela Coulter, Director of Global Initiatives, Foundation for Informed Medical Decision Making, spoke at The King's Fund's 'Reducing unwarranted variations in health care' conference, giving her expert opinion on how to give the best value for patients: with the right intervention, in the right place, at the right time with the right level of involvement.TRANSCRIPT
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Best Value for Patients
Angela Coulter, PhDDirector of Global Initiatives
Foundation for Informed Medical Decision [email protected]
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