Population and Patient Perspectives on Shared Decision-Making: Acknowledging the Controversies

Transcription

1 Population and Patient Perspectives on Shared Decision-Making: Acknowledging the Controversies Christine Dehlendorf, MD, MAS Patty Cason RN, MS, FNP-BC Sonya Borrero, MD, MS Michaela Gonzalez BA

2 Disclosures Patty Cason, MS, FNP-BC Commercial Interest Role Status Allergan Consultant, Advisory Board, trainer, speaker Resolved Amphora Advisory Board Resolved Bayer Consultant Resolved ContraMed Consultant, trainer, advisory Board Resolved Medicines 360 Consultant, advisory board Resolved Merck Advisory board, speaker, trainer Resolved Teva Consultant Resolved

3 Disclosures Continued Sonya Borrero, MD, MS Commercial Interest Role Status Nothing to disclose Christine Dehlendorf, MD, MAS Commercial Interest Role Status Nothing to disclose Michaela Gonzalez, BA Commercial Interest Role Status Nothing to disclose

4 Objectives Delineate the potential tension between clientcenteredness and public health goals in family planning care Discuss the role of reproductive life planning in a client-centered family planning encounter Recognize personal triggers and/or biases that can interfere with the provision of client-centered counseling Discuss women's perspectives and experiences of reproductive and sexual health counseling. Review the relationship of performance measures to client-centered family planning care

5 Client-Centered Care in Family Planning: Acknowledging the Complexity Christine Dehlendorf, MD MAS Associate Professor Department of Family and Community Medicine and Obstetrics, Gynecology and Reproductive Sciences

6 Approaches to family planning care Conventional Model All women should have a clearly defined reproductive life plan Proposed client-centered Model Providers should recognize that not all women want to plan pregnancies, and that this is not catastrophic Contraceptive effectiveness should be emphasized in family planning care Choice of a less effective method often related to poor quality care Women s preferences should be emphasized in family planning care Quality care is measured by the degree to which women are supported and their needs met

7 It is not always simple Potential conflict between public health goals and client-centered care Potential conflict between guidelines and clientcentered care Potential conflict between our own instincts and client-centered care

8 Elucidating the tensions Reproductive life planning Care of women with social or medical issues Women s own perspective on these tensions Performance measures

9 Reproductive Life planning: Acknowledging the Complexity Patty Cason MS, FNP-BC Assistant Clinical Professor UCLA School of Nursing

10 What is the goal of a family planning encounter? 1. To decrease rates of unintended pregnancy? 2. To increase LARC use? 3. To optimize inter-pregnancy intervals? 4. To help your client avoid unintended pregnancy? To help clients clarify what they want and help them get it?

11 Reproductive Life Plan Pregnancy Intention or Acceptability

12 Reproductive Plan in Context A self-assessment of life priorities and goals Education Work/Career Family Relationships We assist or guide as needed

13 Purpose Help client clarify for themselves what is important to her or him. So she or he can: Obtain necessary information. Make choices. Fulfill their own goals.

14 Agency Control over one s own reproduction Support agency by: demonstrating client-centered communication examining bias continually

15 Three Questions 1. Do you think you would like to have (more) children some day? 2. When do you think that might be? 3. How important is it to you to prevent pregnancy (until then)?

16 How does it help? Clarifies motivation and degree of acceptability regarding pregnancy so we discuss interventions +/- Contraception +/- Preconception Care Basic Infertility Services

17 Preconception care Since would you like to discuss ways to prepare for a healthy pregnancy? Since you have said if it happens, it happens Since many women using this method of contraception get pregnant

18 Alternate questions: How would it be for you (or how would you feel) if you were to become pregnant over the next few months? If you were to have a child now how would it affect your: work, education, romantic relationship(s), family relationships, finances?

19 Challenging Cases: Identifying Triggers that can Interfere with Client-Centered Counseling Sonya Borrero, MD, MS Associate Professor of Medicine Director, CWHRI University of Pittsburgh

20 Case 1 An adolescent presents to the office for an annual well-visit. She is sexually active and currently uses condoms and withdrawal for contraception. She is satisfied with this method of contraception. How would you counsel this client?

21 Case 1: Responses A. Assume that she does not know about IUDs or implants but once you educate her about these methods, she will want one of these methods B. Tell her that condoms and withdrawal put her at high risk for pregnancy and warn her that a pregnancy right now would derail her future prospects C. Elicit her preferences for a contraceptive method and her thoughts about potential trade-offs

22 Case 1: Learning points Establishing rapport is the most important first step! Tendency to be more directive with adolescents Can elicit negative reactions Need to find balance between concerns about teens decision making ability and respecting autonomy Can choice of condoms and withdrawal represent an informed choice?

23 Case 1: Learning points Elicit the clients preferences surrounding method characteristics, including effectiveness Evaluate if her contraceptive choice aligns with her goals Provide education about relative effectiveness of methods Ensure that preferences are informed Promote continued use of condoms to prevent STI transmission Screen for reproductive coercion and/or abuse

24 Case 2 A client of yours is on Lisinopril. She has had a copper IUD in for the past 2 years but now wants it removed because of cramping and heavy bleeding with her periods. She is not interested in starting any new birth control and says she will just use condoms for the time being. How would you manage this client?

25 Case 2: Responses A. Tell her you will not prescribe her Lisinopril anymore unless she uses a LARC method A. Inform her about the risks of pregnancy on Lisinopril and tailor your counseling based on her responses B. Tell her she shouldn t get pregnant and continue prescribing the Lisinopril

26 Case 2 A client of yours is on Lisinopril. She has had a copper IUD in for the past 2 years but now wants it removed because of cramping and heavy bleeding with her periods. She is not interested in starting any new birth control and says she will just use condoms for the time being. How would you manage this client? How might your response differ if she was on: - Isotretinoin? - Methotrexate?

27 Case 2 A client of yours is on Lisinopril. She has had a copper IUD in for the past 2 years but now wants it removed because of cramping and heavy bleeding with her periods. She is not interested in starting any new birth control and says she will just use condoms for the time being. How would you manage this client? How might your response differ if she started OCPs?

28 Case 2: Learning points Reproductive autonomy requires that each woman receives information about risks and can make her own decision Some cases will create tension between desire to respect client autonomy and concerns about effect on the fetus Elicit attitudes towards and access to abortion for an individual woman

29 Case 2: Learning points Choice between withholding medication versus being directive about using highly effective contraception Acronym to help with teratogenic counseling: TARCC T: Identify Teratogen A: Consider Alternative medication R: Counsel client on teratogenic Risk C: Provide Contraceptive counseling C: Chart discussion

30 Case 3 A 23 year old presents for an abortion, her 6th. During the counseling session, when you ask her if she would like to discuss birth control at this visit she replies, No and makes it clear she does not wish to discuss this further. How would you proceed with this counseling session?

31 Case 3: Responses A. Ask her if there is anything more you can do to help her today and remind her that you are here if she decides that she needs anything else B. Try to elicit what the problem is, since nobody wants to have an abortion, let alone 6 C. Tell her that multiple abortions can impact her chances for future fertility so she really needs to avoid another one

32 Case 3: Learning points May have a desire to encourage contraceptive use now in this client, but this may conflict with a focus on providing the care that is consistent with her preferences Many women do not wish to discuss contraception at time of an abortion May reflect previous negative experiences with family planning providers Recognize that clients may prefer to risk pregnancy (and undergo abortion) rather than use a method that is not acceptable to them Matulich: Contraception, 2014

33 Case 3: Learning points Key is to listen to clients needs and concerns and provide non-judgmental counseling and support Be aware of your own biases that may not apply to your clients (e.g., stigma around relying on abortion as a method of birth control or having multiple abortions) Keeping the door open for future conversations and continuity with client may be best means of helping her meet her family planning needs

34 Case 4: Learning points Understand both absolute and relative risks Balance risks of CHCs against the counterfactual: pregnancy Might be tricky to balance client preferences and established guidelines (and thus liability) Documentation is key

35 Client Centered-Reproductive Care: A Women s Perspective Michaela Gonzalez B.A. Patient Partner

36 Two Stories

37 Why does this matter? We are the experts of our bodies and our lives. We need a community to rely on when it comes to navigating our reproductive and sexual health needs. Providers are valued members of this community that help us unravel the medical information we need.

38 Women s Perspective: Doctor Knows Best Power dynamic in the Patient- Doctor relationship puts providers in control. We re naturally designed to be powerless patients, stopping us from advocating for ourselves. We have come to believe that the time during our appointment is not ours.

39 Women s Perspective: Our Feelings Discouraged Intimidated Judged Lack of trust Not being heard Fear Ashamed Disempowered

40 Advice to Providers Acknowledge your privilege and position of power; make space for women s voices. Invest in meaningful relationship building Take responsibility for initiating the change of the Doctor-Patient Culture Engage with your clients - ask for our feedback and listen to us. Create opportunities for advocacy and empowerment - patient advisory councils

41 Performance Measures in Family Planning Care Christine Dehlendorf, MD MAS Associate Professor Department of Family and Community Medicine and Obstetrics, Gynecology and Reproductive Sciences

42 Performance measures matter Incentivize behavior change Influence policy makers and health systems to focus on specific aspects of care Can have unintended negative impacts on care

43 Performance measures in family planning National Quality Forum endorsement sought for four family planning related measures: Use of highly or moderately effective methods among 1) women of reproductive age and 2) post-partum women Use of LARC methods among 1) women of reproductive age and 2) post-partum women What impact could these measures have on clientcentered care?

44 Access is client-centered Goal of measures are to ensure women have access and are given information about all methods LARC-based measure is explicitly a floor measure, designed to ensure methods are at least available MORE IS NOT BETTER!!! But there is potential for incentivizing non-client centered counseling

45 Safeguarding against negative effects Need to ensure LARC measure is appropriately understood Need to recognize that barrier methods are appropriate for some people Goal on moderately/highly effective measure is not 100% OPA in the process of developing a performance measure of client-centered counseling as counterbalance

46 Performance measures: Coming soon to you Claims-based performance measures are a blunt tool Be aware of potential to negatively influence care Be sure your clinical site is correctly interpreting LARC based measure Continue to work to promote access and eliminate barriers to contraceptive access