Shared Decision Making: A Timely Review Courtesy of Health Affairs

"Let's go over your options...."

If you're a lawmaker, policymaker, academic, health executive or other health care expert, you may want to take advantage of this handy review of "shared decision making" (SDM) by Floyd Fowler, Carrie Leven and Karen Sepucha that apears in the April 2011 edition of Health Affairs.  After reading it, you'll be able to confidently use the acronym "SDM" in your meetings, conference calls and presentations, thereby impressing colleagues, partners, collaborators and coalition members with your health policy chops.

And if you're not a lawmaker, policymaker, academic or executive, but run into them from time to time, the DMCB recommends you spring a "SDM" question on them.

For example:

"Of the 65 quality metrics in the current ACO proposed rule, do you see any role for SDM?"

The answer you get may speak volumes about their expertise.  If you get a blank look, you may want to question their credentials and do them a favor by referring them to the DMCB in general and to the Health Affairs article summary below.

Just because "preference sensitive" health care (for example, elective surgery such as a hip replacement for arthritis, or selection among the various treatment options for prostate cancer) is appropriate or safe doesn't mean it's necessary or desired.  To meet those additional dimensions, patients have to be informed and involved (or what the population health and disease management industry refers to as engaged).  That means that the physician-patient conversation over a proposed treatment needs to not only review the evidence but help patients to personally weigh the benefits, risks and personal costs involved - all of which involve trade offs. 

Because patients differ in preferences and values, there is no "right" answer. Since it  the patient who will have to live with the benefits, risks and costs  of a treatment, it should be the patient who should choose among different options.  Yes, patients can choose "wrongly" (which is difficult to define), but it turns out that state-of-the-art patient support makes wacky unreasonableness far less likely than doctors would expect. What's more, there is good science - 55 randomized clinical trials - that shows that patients tend to be remarkably intelligent and conservative in their decision-making.

"Decision aids," which are defined as high quality support materials that assist patient decision-making, have matured to the point where they can be routinely used in mainstream healthcare.  For example, they are used a lot at Dartmouth-Hitchcock Hospital in New Hampshire. State-of-the-art aids have been linked up with EHRs and, even better, don't have to necessarily be individually triggered by busy physicians.  In other words, docs could pre-order thresholds in which the decision aid is automatically delivered to the patient, depending on the diagnosis and other patient factors.

The science of SDM has also developed validated surveys that can assess baseline knowledge, gauge symptom-based "decision windows"  and ascertain what patients want in terms of symptom control or lifestyle. These surveys can help the targeting of decision aids. 

How can SDM be promoted in mainstream clinical practice?  The authors have four recommendations:

1) Accountability:  important surveys such as CAHPS could be modified to assess use of SDM. Other patient surveys are in the works.  Their results can be used to assess clinical performance.

2) Guidelines: if a patient chooses contrary to a clinical guideline recommendation, the physician shouldn't be penalized.

3) Research and CMMI:  If this isn't a topic worthy of CMS' interest in promoting high value innovation, what is?  The ACA has other myriad funding mechanisms that could be deployed.  This may also something worthy of comparative effectiveness research.

4) The Patient Centered Medical Home:  It's time to make SDM a feature of PCMH Ver. 2.0.

The DMCB would note that there is widespread agreement that health insurers are generally justified in limiting coverage of treatments not backed by "evidence."  Perhaps a more enlightened approach is for insurers to not cover treatments that haven't been offered to a patient using SDM.  While that may sound radical, the DMCB wonders if that isn't a better alternative to the controversial 15 member Independent Payment Advisory Board.  If someone has to choose, why not insist that the patient chooses?

The DMCB also finds it curious that the authors didn't mention "disease management," especially given the close association between SDM and companies that offer that service.  The point is that doctors, in the course of patient care don't need to be routinely involved in SDM.  They can rely on non-physicians to also provide that service.

By the way, more on SDM, courtesy of AHRQ, here.