Patient-centered Translation of Evidence Into Practice
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1 Patient-centered Translation of Evidence Into Practice Nilay Shah Division of Health Care Policy and Research Center for the Science of Health Care Delivery Mayo Clinic
2 Disclosures Funding provided by: AHRQ: R18 HS019214; R18 HS NIDDK: R34 DK84009 Foundation for Informed Medical Decision Making (FIMDM) American Diabetes Association (ADA) Mayo Clinic Foundation for Medical Education and Research Mayo Clinic CCaTS
3 EBM KT Glasziou and Haynes ACP JC 2005
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5 There are now 75 trials and 11 systematic reviews of trials, per day Bastian et. al, 2010 PLoS Medicine
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7 Source: IOM, Best Care at Lower Costs
8 A survey of 627 US primary care clinicians 50% of my patients get too much care 50% of primary care docs are too aggressive 60% of specialists are too aggressive 35% practice much more aggressively than what they would like Sirovich BE et al. Arch Intern Med 2011
9 Treatment of Low Grade Prostate Cancer Urologists: AS* 3.5% 13.2% 79.7% Radiation Oncologists: AS* 3.9% 11.3% 80.0% Urologists: BT* 37.1% 42.1% 15.0% Radiation Oncologiss: BT* 17.8% 36.3% 43.4% Urologists: RT* 48.2% 46.7% 3.5% Radiation Oncologists: RT* 32.4% 45.4% 20.6% Urologists: RP 45.6% 48.8% 4.4% Radition Oncologists: RP 70.3% 23.5% 2.8% 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% Overused Right rate Underused Kim SP et al. Prostate Cancer Prostatic Dis 2014
10 Rates of Mammography Screening Among Younger Women Wang AT et al. PLOS One 2014
11 CER Translation Gap Study Results Practice Translation ALLHAT Thiazide diuretics were superior in preventing cardiovascular disease events ACE-inhibitors No change CATIE Conventional antipsychotics were as effective as atypical antipsychotics for schizophrenia Atypical Antipsychotics No change COMPANION Compared to optimal medical therapy, both cardiac resynchronization therapy (CRT) and CRT plus defibrillator use improved survival, reduced hospitalization rates, and improved functional status in patients with moderate to severe heart failure Medical therapy Minimal change COURAGE Optimal medical therapy combined with percutaneous coronary intervention (PCI) had similar survival benefit and angina relief, compared to optimal medical therapy alone PCI Minimal/No change SPORT Surgery for lumbar spinal stenosis had better outcomes than nonsurgical treatment, according to the cohort study results Surgical Treatment No change Source: Timbie 2012
12 Why? Misalignment of financial incentives Complexity of research Biases in interpretation of results Applicability of the evidence Limited use of decision support Source: Timbie 2012; Morrato 2013
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15 Key problem: Do not follow advice Wasted or misallocated healthcare resources: US$ 290b (100b in avoidable hospitalizations) Poor health despite cost and side effects Complicated patient-clinician relationship Cutler and Everett NEJM /NEJMp
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17 Encounter Research
18 Evidence synthesis Observations clinical encounter Initial prototype Field testing Designers Study team Patients advisory groups Clinicians Modified prototype Final Decision aid Evaluation
19 Diabetes Cards Nature of diabetes medication discussions Summarizing the research evidence Iterative process Choice Architecture
20 Baseball Cards
21 Narrative Cards
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23 More helpful Improved knowledge Increased patient involvement No difference in adherence (perfect adherence in control gr) No significant impact on HbA1c levels Mullan RJ et al. Archives of Internal Medicine 2009
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25 Risk-Treatment Paradox Ko, Mamdani and Alter JAMA 2004
26 ACC/AHA Cholesterol Guidelines
27 ACC/AHA Cholesterol Guidelines Ioannidis JP. JAMA 2014
28 ACC/AHA Cholesterol Guidelines Pencina MJ. NEJM. 2014; March 19 online.
29
30 Improved Knowledge Risk estimation Comfort with the decision Total trust Action (70% fewer Rx in low risk patients) Short-term adherence Weymiller et al. Arch Intern Med 2007
31 Web Statin Choice
32 Web Statin Choice
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34 Adherence after Initiating Bisphosphonates Source: Rabenda et. al Osteoporosis 2008
35 Association Between Adherence and Risk of Fracture
36 Osteoporosis Choice >75% MDs found helpful + 1 min to consultation time Improved knowledge & risk estimate No change in comfort or trust Increased patient involvement Montori VM et al. Am J Med 2011
37 Decision to Start Bisphosphonate
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39 Recommended Medication Bundle after an AMI Shah ND, et al. Am J Med 2009
40 Structural Intervention Remove copay on recommended medications 60.0% 50.0% 40.0% 30.0% 20.0% 49.3% 41.9% Full Coverage Usual Coverage 10.0% 24.3% 19.3% 0.0% Choudhry N et. al. NEJM 2011 Statins All Medications
41 Knowledge Transfer 4-5 min to consultation time Improved knowledge & risk estimate No change in comfort or trust High-levels of patient involvement Increased satisfaction
42 Knowledge of Risks and Benefits
43 Adherence to Medications 100% 90% 80% Decision Aid Usual Care 70% 60% 50% 40% 30% 79% 78% 72% 73% 20% 10% 0% Statins All Medications
44 A Case Study A 63 y.o. woman presents to the ED with pain in the neck going to her left arm. Intermittent sharp twinges of pain in her chest. No ischemic changes on ECG; serial cardiac troponins were negative PMH: Hypertension, Migraines, Breast cancer Former smoker Overall risk of ACS in the next 45-days: <3% What would you want to do if you were her?
45 Hospital or ED Observation Unit Admission
46 Hess et. al Circ CQO 2012
47 Summary of Findings: Chest Pain Improved knowledge Choice Comfort with the decision Greater level of engagement High levels of satisfaction
48 Management Decisions
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50 Comparative effectiveness research synthesis of evidence that compare benefits & harms of options Patient centered translation into action design of care around the needs of the patient Decision aid helps involve patients in making deliberate choices based on pros/cons of options Shared decision making path to high quality healthcare
51
52 Evidence Synthesis
53 Stakeholders meetings 24 participants /12 organizations (Health systems, patients, clinicians, buyers) Clinical observations 2 primary care practices (Patients, family physicians, care managers) Focus groups/ Discussion Family physicians, care managers Patients Advisory Groups
54
55 Comfortable Knowledgeable Satisfied (feel better) Free Minimal resource needed Comfortable Satisfied Use tool/like it Engaged in decision making process
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57 PCI Choice
58 Head CT Choice
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61 Experience Work Setting Evaluation Statin Choice Primary + specialty care Feasible, effective, implemented in EHR, web-based, multicenter trial DM2 Med Choice Primary care Feasible, effective, multicenter trial, web-based Aspirin Choice Primary care (group) Not evaluated Depression Choice Primary care Ongoing trial Genomic Choice Experimental Design phase Osteoporosis Choice Primary care Feasible, effective, EHR ICD Choice Specialty care Design phase Smoking choice Primary care Feasible, effective, single center trial Chest Pain Choice Emergency Feasible, effective, multicenter trial AMI Choice Hospital ward Feasible, effective, multicenter trial Hypertension e-primary care Design phase Rosiglitazone General Not evaluated Prostate cancer screening and early treatment General (tablet) Design phase PCI vs. medical therapy Specialty care Feasible, effective, multicenter trial Mammography < 40 Primary care Design phase Pediatric Head CT Emergency Department Trial
62 Lessons learnt User-centered design happens in the field, takes multiple iterations and expertise Challenges with evidence synthesis and changing evidence Testing decision aids in usual clinical settings is tough: decision moments are unpredictable Repeated use for chronic decisions has been difficult to study in efficacy trials
63 Lessons learnt Decision aids have increased knowledge and patient involvement in the decision consistently The impact on improving adherence to medications is mixed Clinicians and patients have reported high-levels of satisfaction (in trial settings); however culture is important
64
Shared Decision Making in Diabetes: What, Why, and How? Nilay D. Shah Mayo Clinic Rochester, Minnesota, USA
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