Effectively engaging patients in everyday health-care decisions

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Applied Evidence

Effectively engaging patients in everyday health-care decisions

J Fam Pract. 2017 October;66(10):E1-E6

By

David J. Satin, MD

Sarah A. Swenson, DPhil

Steven D. Stovitz, MD, MS

You can improve health outcomes and patient satisfaction—without increasing the length of the patient visit—by employing the tenets of shared decision-making.

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PRACTICE RECOMMENDATIONS

› Provide patients with information in terms of absolute and baseline risks, ideally using pictograph decision aids. A

› Elicit the patient’s values and priorities by categorizing decisions and asking broad open-ended questions. C

› Offer patients a professional (not a personal) recommendation, including your rationale. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

References

1. Medalie JH. Family Medicine: Principles and Applications. Baltimore, MD: Williams and Wilkins; 1978.

2. Philips RL Jr, Brundgardt S, Lesko SE, et al. The future role of the family physician in the United States: a rigorous exercise in definition. Ann Fam Med. 2014;12:250-255.

3. Berwick DM. Era 3 for medicine and health care. JAMA. 2016;315:1329-1330.

4. Edwards A, Elwyn G. Shared decision making in health care: achieving evidence-based patient choice. 2nd ed. Oxford, United Kingdom: Oxford University Press; 2009.

5. American Medical Association. Shared decision making H-373.997. Available at: https://policysearch.ama-assn.org/policyfinder/detail/H-373.997%20?uri=%2FAMADoc%2FHOD.xml-0-3162.xml. Accessed September 6, 2017.

6. Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health Aff (Millwood). 2013;32:207-214.

7. Parchman ML, Zeber JE, Palmer RF. Participatory decision making, patient activation, medication adherence, and intermediate clinical outcomes in type 2 diabetes: a STARNet study. Ann Fam Med. 2010;8:410-417.

8. Fowler FJ Jr, Gerstein BS, Barry MJ. How patient centered are medical decisions? Results of a national survey. JAMA Intern Med. 2013;173:1215-1221.

9. Spatz ES, Krumhoiz HM, Moulton BW. The new era of informed consent: getting to a reasonable-patient standard through shared decision making. JAMA. 2016;315:2063-2064.

10. Faden RR, Becker C, Lewis C, et al. Disclosure of information to patients in medical care. Med Care. 1981;19:718-733.

11. Zipkin DA, Umscheid CA, Keating NL, et al. Evidence-based risk communication: a systematic review. Ann Intern Med. 2014;161:270-280.

12. Fagerlin A, Zikmund-Fisher BJ, Ubel PA. Helping patients decide: ten steps to better risk communication. J Natl Cancer Inst. 2011;103:1436-1443.

13. Stovitz SD, Shrier I. Medical decision making and the importance of baseline risk. Br J Gen Pract. 2013;63:e795-e797.

14. Lipkus IM, Samsa G, Rimer BK. General performance on a numeracy scale among highly educated samples. Med Decis Making. 2001;21:37-44.

15. Stacey D, Bennett CL, Barry MJ, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2011:CD001431.

16. Mayo Clinic. Statin choice decision aid. Available at: https://statindecisionaid.mayoclinic.org/index.php/statin/index. Accessed September 6, 2017.

17. Risk Science Center and Center for Bioethics and Social Sciences in Medicine, University of Michigan. Icon Array. Available at: http://www.iconarray.com/. Accessed September 6, 2017.

18. Price M, Cameron R, Butow P. Communicating risk information: the influence of graphical display format on quantitative information perception–accuracy, comprehension and preferences. Patient Educ Couns. 2007;69:121-128.

19. Kon AA. The shared decision making continuum. JAMA. 2010;304:903-904.

20. Légaré F1, Ratté S, Gravel K, et al. Barriers and facilitators to implementing shared decision making in clinical practice: update of a systematic review of health professionals’ perceptions. Patient Educ Couns. 2008;73:526-535.

21. Haidet P, Paterniti DA. “Building” a history rather than “taking” one: a perspective on information sharing during the medical interview. Arch Intern Med. 2003;163:1134-1140.

22. Frankel RM, Stein R. Getting the most out of the clinical encounter: the four habits model. J Med Pract Manage. 2001;16:184-194.

23. Delbanco TL. Enriching the doctor-patient relationship by inviting the patient’s perspective. Ann Intern Med. 1992;116:414-418.

24. Doukas DJ, McCullough LB. The values history: the evaluation of the patient’s values and advance directives. J Fam Pract. 1991;32:145-153.

25. Stiggelbout AM, Van der Weijden T, De Wit MP, et al. Shared decision making: really putting patients at the centre of healthcare. BMJ. 2012;344:e256.

26. Bernacki RE, Block SD, American College of Physicians High Value Care Task Force. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014;174:1994-2003.

27. Katz J. The Silent World of Doctor and Patient. Baltimore, MD, and London, England: The Johns Hopkins University Press; 1984.

28. Baylis F, Downie J. Professional recommendations: disclosing facts and values. J Med Ethics. 2001;27:20-24.

29. Sackett DL, Rosenburg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71-72.

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31. Mora S, Ames JM, Manson JE. Low-dose aspirin in the primary prevention of cardiovascular disease: shared decision making in clinical practice. JAMA. 2016;316:709-710.

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The discipline of family medicine is committed to providing patient-centered care through recommendations that are grounded both in evidence and in patients’ personal values.^1,2 The current health care environment, however, often demands heavy reliance on outcome-based performance metrics that can be insensitive to patient preferences.³ This tension necessitates models of decision-making that maximize reliance on measured performance, yet fulfill the clinician’s fiduciary responsibility to prioritize patients’ interests. The philosophy and practice of shared decision-making (SDM) can facilitate these aims.

The 3 elements of shared decision-making

SDM provides a framework for offering everyday medical advice and facilitating informed consent.⁴ Its 3 elements are:

discussing with patients relevant information about their health conditions, possible treatments, and likely outcomes,
clarifying and understanding a patient’s unique values and priorities and how they relate to the treatment options, and
enabling a patient to select a care plan that is in keeping with his or her personal goals.⁵

This model is significant not only from a theoretical perspective, but also from a practical one. Studies have shown that both health outcomes and patient satisfaction improve when patients participate more actively in health care decision-making.^6,7

Unfortunately, there is evidence that some decision-making practices in primary care settings remain inadequate. For example, unlike the standard disclosure of procedure risks in surgical settings, the burdens of cancer screening are frequently omitted from primary care discussions.⁸ Moreover, agreement about what should be disclosed, as well as how to disclose it, is still not sufficient. The following 3 recommendations, one for each element of SDM, aim to help clinicians effectively engage patients in everyday decision-making.

1. Provide patients with relevant information

The first element of SDM requires discussing the health-related information that is relevant to the patient’s decision-making process. The literature about informed consent supports explaining the risks that are common, as well as those that are particularly dangerous, and the likely benefits of recommended treatment, nontreatment, and alternative treatments.⁹ Moreover, adequate informed consent requires identifying what a reasonable person in a particular patient’s position would want to know.¹⁰

Studies have shown that both health outcomes and patient satisfaction improve when patients participate more actively in health care decision-making.

Accounting for “a patient’s position” is significant because it signals that personal factors (eg, the individual’s beliefs, goals, and familial responsibilities) are as important as the patient’s external clinical situation and what can be known by reviewing medical evidence. Incorporating a patient’s particular circumstances distinguishes patient-centered care from the mechanical application of generic best practices. This is the standard for what information should be provided.

When evidence is lacking. Clinicians facilitating decisions for which data is lacking should convey the best available evidence, including the inherent uncertainties. Like evidence-based medicine (EBM), the principles of SDM should be at work in most clinical encounters. The extent to which one engages in SDM depends upon the seriousness of the proposed interventions, the degree to which the decision is preference-sensitive, and the availability of evidence.

Statistics: Explain absolute and baseline risk

It is generally better to provide absolute risk rather than relative risk, because people perceive absolute risk reductions more accurately.¹¹ Presentation of risks, in terms of relative risk or relative risk reduction, typically exaggerates the benefits of treatment, especially when the risk is small. This exaggeration makes it more likely that patients will accept interventions they might otherwise have rejected after reviewing the data more fully. Furthermore, relative risk statistics can impact clinicians’ perceptions, leading them to recommend an intervention more often than they might when absolute risk statistics are discussed.¹²

But even absolute risk, if presented on its own, can be misleading. A reasonable person trying to determine the value of an intervention needs to know his or her baseline risk of an event, in addition to his or her absolute risk with the intervention. For example, a hypothetical absolute risk reduction associated with a breast cancer treatment of 10% has different meanings, depending upon whether the baseline risk is 10% or 80%. A reduction from 10% to 0% would be a miraculous cure, while going from 80% to 70% may be viewed as only a slight improvement. Try as we might to present a single neat statistic, presenting both baseline risk and absolute risk with intervention is often necessary.¹³

How to effectively communicate medical information

Many patients struggle with processing information that is expressed as a probability.¹⁴ Patients process frequencies (eg, 10 in 100) better than probabilities (eg, 10%), and there is evidence that they understand best when decision aids are used.¹⁵ Decision aids, such as pictographs (FIGURE¹⁶), are supplementary, evidence-based tools for effectively communicating with patients and their families in a way that facilitates comparison between available options. Such aids are readily available online for many conditions or can be created using various software tools.^16,17