Interdependence of Evidence-based Practice & Shared Decision Making Implications for Quality

Transcription

1 New York Academy of Medicine August 6, 2015 Interdependence of Evidence-based Practice & Shared Decision Making Implications for Quality Henry H. Ting, MD, MBA Senior Vice President & Chief Quality Officer, New York-Presbyterian Hospital

2 Disclosures A. No relationships with industry B. Research grants: AHRQ (PI); NHLBI (Co-PI) C. Foundations, Boards, & Professional Societies: NQF, ABIM, AHA, ACC

3 Objectives 1. What is shared decision making (SDM)? 2. Why do it? 3. How to do it?

4 Objectives 1. What is shared decision making (SDM)? 2. Why do it? 3. How to do it?

5 Evidence-based medicine 1. Make decisions based on all the relevant research evidence

6 Confidence in estimates of benefit & risk 1. Bias design 2. Imprecision 3. Inconsistency 4. Indirectness 5. Biased reporting

7 Cumulative Year RCTs Pts Fibrinolytic Therapy Routine Textbook/Review Recommendations Specific Rare/Never Experimental Not Mentioned P< P<.001 P< Odds Ratio (Log Scale) M M M M M Favors Treatment Favors Control Lau J. NEJM 1992; 327:

8 Evidence-based medicine 1. Make decisions based on all the relevant research evidence 2. Make decisions with more confidence when the evidence is better

9 What would you do? year old mother of two and otherwise healthy develops pneumococcal pneumonia year old man, demented, incontinent, and mute, without family or friends and in apparent discomfort. He develops pneumococcal pneumonia. 3. Woman with terminal cancer and chronic pain has come to terms with her condition, has issues in order, said her goodbyes. She wishes to receive palliative care. She develops pneumococcal pneumonia.

10 What would you do? Atrial Fibrillation without treatment: In 2 years, 100 patients will have: 10 strokes (5 major, 5 minor) 2 serious upper GI bleeds Atrial Fibrillation with anticoagulation: In 2 years, 100 patients will have: 2 strokes (8 fewer strokes) How many more serious GI bleeds would you accept in 100 patients and still be willing to use anticoagulation?

11 Devereaux PJ et al. BMJ 2001;323:1218

12 Is this real? 530 Physicians 3120 patients with atrial fibrillation + warfarin bleed 90 days 1 afib patient at high risk of stroke days 1 afib patient at high risk of stroke

13 Likelihood of warfarin prescription Days relative to bleed 90 d prior 0-90 d post d post d post d post Odds ratio (95% CI) ( ) 0.60 ( ) 0.61 ( ) 0.72 ( ) 1.0 Less warfarin after bleeding

14 Evidence-based medicine 1. Make decisions based on all the relevant research evidence 2. Make decisions with more confidence when the evidence is better 3. Evidence based medicine alone is never sufficient to make a decision

15 Patient values and preferences Context Research evidence

16 Patient values, preferences, & context

17 Decision making models Parental Clinician-asperfect agent Shared decision-making Informed Choice talk Implicit Clinician Team Patient Option talk Informed consent Clinician Patient Deliberation Clinician Clinician Joint Patient Decision talk Clinician orders Clinician recommends Consensus Patient requests Consistent with EBM principles No Yes Yes Yes Modified from Charles C et al

18 Objectives 1. What is shared decision making? 2. Why do it? 3. How to do it?

19 CEO checklist for high-value health care IOM Roundtable, June 2012 Delos Cosgrove Cleveland Clinic Micheal Fischer Cincinnati Children s Patricia Gabow Denver Health Gary Gottlieb Partners HealthCare George Halvorson Kaiser Brent James Intermountain Gary Kaplan Virginia Mason Jonathan Perlin HCA Robert Petzel Dept Veterans Affairs Glenn Steele Geisinger John Toussaint ThedaCare

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22 Shared decision making Why do it? 1. Payment and policy 2. Efficiency time, cost, utilization 3. Patient Safety 4. Patient Engagement 5. Patient Experience 6. Ethics

23 Objectives 1. What is shared decision making? 2. Why do it? 3. How to do it?

24 ACC/AHA cholesterol guidelines Stone NJ. Circulation. 2014;129(25 Suppl 2):S1-45.

25 ACC/AHA cholesterol guidelines 1. Four high risk groups Secondary prevention in patients with prior ACS, revascularization, stroke/tia, PAD Primary prevention for LDL 190 Primary prevention for diabetes (age 40-75) and LDL Primary prevention if 10-year risk 7.5% 2. Treat to risk, not treat to target LDL 3. Use of statins Stone NJ. Circulation. 2014;129(25 Suppl 2):S1-45.

26 ACC/AHA cholesterol guidelines Pencina MJ. NEJM. 2014; 370(15):

27 ACC/AHA Cholesterol Guidelines Ionannidis JAMA. 2014; 311:

28 Glasziou and Haynes ACP JC 2005

29 % Patients taking statins as prescribed Patients taking statins (%) Acute coronary syndrome Coronary artery disease Primary prevention Follow-up (yr) Jackevicius CA. JAMA 2002; 288:462.

30 Employees & dependents with insurance Beta blockers % Statins ACE-I/ARB Months since incident MI Shah ND, Ting HH. Am J Med 2009;122:961

31 ACC/AHA cholesterol guidelines Montori VM, Ting HH. JAMA. 2014; 311:

32 Participatory research Coylewright M, Ting HH. PLoS One 2012; 7(11):e49827

33 Web Statin choice

34 Web Statin choice

35 Video / Web Diabetes Medication Choice

36 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

37 SDM and SES Coylewright MC, Ting HH. Circulation CQO 2014; 7:

38 Opportunities for SDM in practice 1. When pros and cons are closely balanced 2. When pros>cons only if patients adhere 3. When pros and cons are not well known

39 Contact (212)