Practical Use of Decision Aids in Primary Care. Michael Soung, MD, FACP Virginia Mason Medical Center General Internal Medicine

Transcription

1 Practical Use of Decision Aids in Primary Care Michael Soung, MD, FACP Virginia Mason Medical Center General Internal Medicine

2 Question #1 40 yo man with total cholesterol 170, HDL 50, LDL 90. African American, smokes 1/2 PPD, HTN on 2 meds but often forgets to take his pills. BP 160/ year ASCVD risk is 12.5%. Which of the following would NOT be an appropriate next step? A) Recommend a moderate-intensity statin B) Recommend diet / activity changes C) Explore barriers to medication adherence D) Assess motivation & confidence to quit smoking E) They are all appropriate

3 Decisions in Primary Care Shared decision making and Decision aids ACC/AHA CV risk calculator Lots of Mayo decision aids Statin Osteoporosis Depression medications Diabetes medications Some Virginia Mason examples Others as time allows

4 Shared Decision Making (SDM) 3 key elements: 1) Choice: Be clear that a decision is required 2) Options: Understand the best available evidence re: risks and benefits of each option 3) Decision: Make a decision based patient s values and preferences, with provider s guidance Health Affairs 2013;32: J Gen Intern Med 2012;27:1361-7

5 Why SDM? May improve well-being through Helping to get the right treatment for this person Better adherence to treatment Fewer concerns about illness Higher satisfaction with health outcomes 71% of patients expressed a wish to actively participate in treatment decisions And, it s just the right thing to do Autonomy, Beneficence, Non-maleficence, Justice Circ Cardiovasc Qual Outcomes. 2014;7: Circ Cardiovasc Qual Outcomes. 2014;7: BMJ 2013;346:f4147 BMJ 2012;344:e256

6 SDM Challenges Innumeracy Variable interpretations of verbal qualifiers (e.g. what is high risk?) 22% couldn t identify which was highest risk: 1 in 10, 1 in 100, or 1 in % of college-educated adults couldn t identify which is highest: 1%, 5%, 10% Many health professionals lack facility and confidence w/ numbers Circ Cardiovasc Qual Outcomes. 2014;7: Health Affairs 2013;32: Circ Cardiovasc Qual Outcomes. 2014;7: Acad Med 2010;85:

7 SDM expert recommendations Present information using Absolute Risk Risk seems larger when using relative risk Medical treatments are viewed more favorably using relative risk Highlight incremental risks distinctly from baseline risks Use pictographs patients better comprehend risk (regardless of numeracy) Circ Cardiovasc Qual Outcomes. 2014;7:

8 What s a Decision Aid? Tool to aid (shared) decision making Online, print, video, others Should include: Decision to be made Options available Outcomes (benefits, harms, uncertainties) of these options based on current evidence Help for people to think through their values and preferences BMJ 2013;346:f4147

9 Use of decisions aids improves: Knowledge of options, benefits, and harms Clarity regarding own values Informed values-based choices Patient involvement in decision making Patient-practitioner communication Use of global CV risk information: Improves accuracy of risk perception Increases statin Rx s in mod-high risk patients May reduce predicted CV risk over time Cochrane Database of Syst Rev 2014, Issue 1 BMC Health Services Research 2008;8:60-73 Arch Int Med 2010;170:230-9

10 (search ACC AHA risk calculator )

11 Question #2 55 yo man with total cholesterol 220, HDL 40, TGs 150, LDL 150. Caucasian, no significant past medical history, no family history of vascular disease or smoking. His BP is 130/75. His 10-year ASCVD risk is 7.8% What is the most appropriate next step? A) Recommend a statin B) Recommend intensive lifestyle changes C) A and B D) Recheck lipids in 3 months E) Engage in a shared decision making process

12 (search Mayo statin decision aid )

13 Question #3 79 yo caucasian woman with DXA T-score of left femoral neck of cm, 83 kg (BMI 30). No personal or family history of fragility fractures. No smoking. 1 drink of EtOH per evening. FRAX: 10 year risk of hip fracture = 3.4%. 10 year risk of major osteoporotic fracture = 13% What is the most appropriate next step? A) Recommend appropriate calcium and vitamin D B) Recommend regular weight-bearing exercise C) Recommend a bisphosphonate D) Recheck bone density in 2 years E) Engage in a shared decision making process

14 Treatment of osteoporosis 2013 National Osteoporosis Foundation: Postmenopausal women and med age 50+ with: A hip or vertebral fracture T-score < 2.5 at the femoral neck or spine T-score between -1.0 and -2.5 at the femoral neck, PLUS 10-year probability of hip fracture 3%, OR 10- year probability of major osteoporotic fracture 20% Based in part on US-specific cost-effectiveness analysis (i.e. $60,000 per QALY gained) National Osteoporosis Foundation 2013: Clinician's guide to prevention and treatment of osteoporosis Osteoporos Int 2008;19:

15 (search Mayo osteoporosis decision aid )

16 The NY Times has noticed t/can-this-treatment-help-me-theres-astatistic-for-that.html?emc=eta1 t/how-to-measure-a-medical-treatmentspotential-for-harm.html?emc=eta1

17 Clinical Scenario #4 27 yo woman with 6 months of: Depression and anhedonia, no suicidality Insomnia Poor appetite, thin at baseline Has tried other measures and is now interested in starting an antidepressant. No personal or FH antidepressant use

18 (Just search Mayo Depression Decision Aid )

19 Clinical Scenario #5 67 yo man with type 2 DM on max dose metformin Last 2 HbA1c s have both been ~8.5% Has been very adherent to healthy lifestyle He d prefer: Simplest oral regimen Lower cost Weight neutral

20 (Search Mayo diabetes decision aid )

21 Clinical Scenario #6 62 yo man, new to your clinic, scheduled for a preventive health visit. You re running about 15 minutes behind Any reading material you d like him to have while he s waiting for you?

22 VM PSA screening Decision Aid 2014 Virginia Mason Medical Center

23 VM PSA screening Decision Aid 2014 Virginia Mason Medical Center

24 Results: p<0.05 p=0.01 p= Virginia Mason Medical Center

25 VM Mammogram Decision Aid 2014 Virginia Mason Medical Center

26 VM Mammogram Decision Aid 2014 Virginia Mason Medical Center

27 JAMA 2014;312:2585

28 Clinical scenario #7 72yo woman asks about Chest CT to screen for lung cancer. Currently smoking Smoked 1 PPD for 45 years No asbestos exposure

29 (search Lung cancer screening decision tool )

30 (search Lung cancer screening decision tool )

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33 Take home points Shared decision making = right thing to do And it doesn t have to take forever Be clear that a decision is needed And that your patient is the decider Our job is to help diagnose values and preferences as much as it is to diagnose diseases Consider using decision aids to improve communication and decision quality