The patient as a partner in medical decisionmaking: Implementation of Shared Decision- Making in Germany

Transcription

1 The patient as a partner in medical decisionmaking: Implementation of Shared Decision- Making in Germany Angela Buchholz , Lausanne

2 Overview Shared-Decision Making Levels of Implementation Transfer strategies Research Activities Examples Facilitators and Barriers Discussion Introduction

3 Models of medical decision-making Decision of... Physician Patient Paternalistic model Shared decisionmaking (SDM) Information model = interactive decision-making process accounted by both patient and physician under equal and active participation based on shared information Background

4 Process of SDM 1. Problem definition: Inform that a decision has to be made 2. Equipoise: Express the partners (& options ) equality 3. Risk communication: Inform about risks and benefits of options 4. Enabling patients to explore their concerns and queries 5. Decision making 6. Review arrangements Background

5 Levels of Implementation Macro level: Political decisions with an impact on patient participation Meso level: Activities of national institutions supporting patient participation Micro level: Implementation of SDM in the medical encounter

6 Developments in Germany Macro level (Political Decisions) Federal joint comittee (Gemeinsamer Bundesausschuss) with advisory rights of patients Delegate of the Federal government to represent patient interests (Patientenbeauftragte) Meso level (National Institutions) Institute for Quality and Efficiency in Health Care (IQWiG) Agency for Quality in Medicine Micro level (SDM in the medical encounter) Several research groups with ongoing research projects on the topic Loh et al., 2007

7 Example: Meso-Level

8 Transfer strategies (micro level) Physicians Training of (SDM-) communication skills Expert Systems Decision Aids / Decision Boards Patients Decision Aids / Boards Patient education (courses) Information Material

9 SDM in Germany: How it all began Research Consortium The patient as a partner in medical decision-making Funding by the Federal Ministry of Health Funding of several projects, national and international conferences

10 Projects Kiel Aachen Düsseldorf Frankfurt Mainz Saarbrücken Freiburg Hamburg Bremen Hannover Göttingen Erfurt Jena Schwerin Magdeburg Erlangen Heidelberg Stuttgart München Potsdam Dresden Berlin Alcohol Abuse Berlin Peripheral Arterial Disease Aachen Palliative Medicine Jena Hypertension - Erlangen Breast Cancer München Schizophrenia München Method-Center Freiburg Depression Freiburg Fibromyalgia Heidelberg Multiple Sclerosis Hamburg COPD (Children) Hannover

11 Research on SDM in Germany 147 Publications from German Researchers from several research groups (health services research, general practice, medical psychology, psychiatry, rehabilitation ) majority refers to clinical studies on patients with chronic diseases heterogeneous use of SDM-definitions & wording Rockenbauch & Schildmann, 2011

12 Current research funding Chronic diseases & patient orientation Funding by the Federal Ministry of Research & Education, the German statutory pension insurance scheme & the statutory health insurances Funding , second round this year several SDM-related projects Psychosocial Oncology Funding by Deutsche Krebshilfe (German Cancer Aid) since 2007 two funding rounds with SDM-related projects

13 Research Decision Aids (web- or video based, print material) Training programs Expert systems Development / validation of assessment instruments Adjustment of the SDM-model to teams of health professionals

14 Decision Aids: Example Breast Cancer Developed by a German statutory health Insurance scheme (AOK) Acceptance by patients and professionals available online & in print format Schulze-Rath et al., 2009; Vodermaier, 2009

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17 Training: SDM training for physicians PowerPoint Slides Comprehensive manual including explanations of the slides & theoretical background Tutorials Instructional videos Bieber et al., 2007

18 Training: SDM training for physicians Development and evaluation of a SDM training for general practitioners and specialists Effects: Patients: enhanced patient participation, higher satisfaction with decision, improvement of doctor-patient interaction, better adherence Physicians: satisfaction with the training, enhanced selfefficacy and knowledge regarding SDM competences, improvement of the doctor-patient interaction (selfevaluation) Loh et al., 2007; Bieber et al., 2007; Bieber et al., 2009

19 Implementation of the training Kiel Bremen Schwerin Hamburg Physician trainings 34 workshops 510 physicians Potsdam Düsseldorf Erfurt Magdeburg Dresden Jena/Würzburg Train-the-trainer workshops 7 workshops 106 facilitators/lecturers Saarbrücken Frankfurt Mainz Heidelberg Stuttgart Freiburg Patient education 31 trainer 164 patients

20 Further steps Adaptations, development & evaluation of SDM-training for oncologists treating patients with primary breast cancer and colon cancer primary care physicians in hypertension primary care physicians in advance directives 3 ongoing cluster-randomized trials

21 Expert System: Arriba expert system for General Practitioners useful for SDM in the context of cardiovaskular risk reduction (hypertension, health behavior) calculates the cardiovaskular risk guides the GP through the SDM process evaluated in several scientific studies free of charge for GPs widely-used among GPs Krones et al., 2008; Sadowski et al. 2005

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26 Barriers & Facilitators Physicians Barriers Time constraints Lack of applicability due to patient characteristics Lack of applicability due to the clinical situation Facilitators Provider motivation Positive impact on the clinical process Positive impact on patient outcomes Patients health literacy patient activation Légaré et. al., 2008; Dirmaier & Härter, 2010

27 Personal Experiences as a researcher Structure of decision-making process in clinics (Hierarchy) Interferences with existing procedures (tumor board) Misunderstanding / Prejudices Lack of Interest Lack of novelty / innovative character guideline thinking

28 References Bieber, C., Loh, A., Ringel, N., Eich, W., & Härter, M. ( 2007). Patientenbeteiligung bei medizinischen Entscheidungen. Manual zur Partizipativen Entscheidungsfindung (Shared Decision-making). Heidelberg: Selbstverlag. Bieber, C., Nicolai, J., Hartmann, M., Blumenstiel, K., Ringel, N., Schneider, A., et al. (2009). Training physicians in shared decision-making - Who can be reached and what is achieved? Patient Education and Counseling, In Press. Dirmaier, J. & Härter, M. (2011). Stärkung der Selbstbeteiligung in der Rehabilitation. Bundesgesundheitsblatt 54: Krones T, Keller H, Sönnichsen A, Sadowski EM, Baum E, Wegscheider K, Rochon J, Donner- Banzhoff N. Absolute cardiovascular disease risk and shared decision making in primary care: a randomized controlled trial. Ann Fam Med 2008; 6: Legare, F., Ratte, S., Gravel, K., & Graham, I. D. (2008). Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals' perceptions. Patient Educ Couns, 73(3), Loh, A., Simon, D., Bieber, C., Eich, W., & Härter, M. (2007). Patient and citizen participation in German health care--current state and future perspectives. Z Ärztl Fortbild Qualitätssich, 101(4), Loh, A., Simon, D., Wills, C. E., Kriston, L., Niebling, W., & H rter, M. (2007). The effects of a sheard decision-making intervention in primary care of depression: A cluster randomized controlled trial. Patient Education and Counseling, 67(324), 332. Sadowski EM, Eimer C, Keller H, Krones T, Sönnichsen AC, Baum E, Donner-Banzhoff N. Evaluation komplexer Interventionen: Implementierung von ARRIBA-Herz, einer Beratungsstrategie für die Herz-Kreislaufprävention. Z Allg Med 2005; 81: Schulze-Rath, R., Husmann, G., Kaiser, M., Kolpatzik, K., Münster, E., Nübling, M., et al. (2009). Einsatz und Bewertung einer Entscheidungshilfe für Patientinnen mit Brustkrebs im T1-Stadium. Geburtsh Frauenheilk, 69(05), 406,412. Vodermaier, A., Caspari, C., Koehm, J., Kahlert, S., Ditsch, N., & Untch, M. (2009). Contextual factors in shared decison making: a randomised controlled trial in women with a strong suspicion of breast cancer. British Journal of Cancer, 100,

29 Thanks for your attention! Angela Buchholz, PhD Department of General Practice University Medical Centre Freiburg