1. No category

NewYork-Presbyterian Healthcare System
2014 Quality Symposium
Quality 2020: A Vision of the Future
November 21, 2014
Patient-Centered
Shared Decision Making:
What, Why, and How?
Henry H. Ting, MD, MBA
Senior Vice President & Chief Quality Officer
NewYork-Presbyterian Hospital
Disclosures
A.  No relationships with industry
B.  Research grants: AHRQ (PI); NHLBI (Co-PI)
C.  Foundations, Boards, & Professional Societies:
NQF, ABIM, AHA, ACC
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Objectives
1.  What is shared decision making (SDM)?
2.  Why do it?
3.  How to do it?
Evidence-based medicine
1.  Make decisions based on all the relevant
research evidence
2.  Make decisions with more confidence when the
evidence is better
3.  Evidence based medicine alone is never
sufficient to make a decision
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Confidence in estimates of benefit & risk
1.  Bias design
2.  Imprecision
3.  Inconsistency
4.  Indirectness
5.  Biased reporting
Fibrinolytic Therapy
Textbook/Review
Recommendations
2.0
1965
1970
1980
1985
1990
Specific
23
1960
Experimental
Pts
Not Mentioned
1.0
Rare/Never
1
0.5
Routine
Cumulative
Year
RCTs
2
65
3
149
21
5
4
316
7
1793
10
11
15
17
22
2544
2651
3311
3929
5452
23
5767
27
30
33
43
54
65
67
70
P<.01
1
10
1
2
2
8
7
8
1
6125
6346
6571
21 059
22 051
47 185
47 531
48 154
P<.001
P<.00001
Odds Ratio (Log Scale)
Favors Treatment
Favors Control
12
M
1
8
M
1
7
3
2
1
M
5
2
M
15
8
M
6
1
4
1
Lau J. NEJM 1992; 327:248-254
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What would you do?
1.  30 year old mother of two and otherwise healthy
develops pneumococcal pneumonia.
2.  80 year old man, demented, incontinent, and mute,
without family or friends and in apparent discomfort. He
develops pneumococcal pneumonia.
3.  Woman with terminal cancer and chronic pain has come
to terms with her condition, has issues in order, said her
goodbyes. She wishes to receive palliative care. She
develops pneumococcal pneumonia.
What would you do?
Atrial Fibrillation without treatment:
•  In 2 years, 100 patients will have:
10 strokes (5 major, 5 minor)
2 serious upper GI bleeds
Atrial Fibrillation with anticoagulation:
•  In 2 years, 100 patients will have:
2 strokes (8 fewer strokes)
How many more serious GI bleeds would you accept in 100
patients and still be willing to use anticoagulation?
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Decision making models
Parental
Clinician-asperfect agent
Shared
decision-making
Informed
Choice talk
Implicit
Clinician
Team
Patient
Option talk
Informed
consent
Deliberation
Clinician
Clinician
Joint
Patient
Decision talk
Clinician
orders
Clinician
recommends
Consensus
Patient
requests
Consistent with
EBM principles
No
Yes
Yes
Yes
Clinician
Patient
Modified from Charles C et al
CEO checklist for high-value health care
IOM Roundtable, June 2012
Delos Cosgrove Cleveland Clinic
Micheal Fischer Cincinnati Children’s
Patricia Gabow Denver Health
Gary Gottlieb Partners HealthCare
George Halvorson Kaiser
Brent James Intermountain
Gary Kaplan Virginia Mason
Jonathan Perlin HCA
Robert Petzel Dept Veterans Affairs
Glenn Steele Geisinger
John Toussaint ThedaCare
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2016
2014
2011-2012
6
Shared decision making
Why do it?
1.  Payment and policy
2.  Efficiency – time, cost, utilization
3.  Patient Safety
4.  Patient Engagement
5.  Patient Experience
6.  Ethics
ACC/AHA cholesterol guidelines
1.  Four high risk groups
• 
Secondary prevention in patients with prior ACS,
revascularization, stroke/TIA, PAD
• 
Primary prevention for LDL ≥190
• 
Primary prevention for diabetes (age 40-75) and
LDL 70-189
• 
Primary prevention if 10-year risk ≥7.5%
2.  Treat to risk, not treat to target LDL
3.  Use of statins
Stone NJ. Circulation. 2014;129(25 Suppl 2):S1-45.
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ACC/AHA cholesterol guidelines
Pencina MJ. NEJM. 2014; 370(15):1422-31
Glasziou and Haynes ACP JC 2005
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Patients taking statins (%)
% Patients taking statins as prescribed
100
80
Acute coronary syndrome
60
40
Coronary artery disease
20
0
0.00
Primary prevention
0.25
0.50
0.75
1.00
1.25
1.50
1.75
2.00
Follow-up (yr)
Jackevicius CA. JAMA 2002; 288:462.
Employees & dependents with insurance
100
Beta blockers
80
Statins
60
%
40
ACE-I/ARB
20
0
0
6
12
18
24
30
36
Months since incident MI
Shah ND, Ting HH. Am J Med 2009;122:961
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ACC/AHA cholesterol guidelines
Montori VM, Ting HH. JAMA . 2014; 311:465-466.
Participatory research
Coylewright M, Ting HH. PLoS One 2012; 7(11):e49827
10
Web
Statin choice
Video / Web
Diabetes Medication Choice
11
% Responding Positively
Reasons for performing elective PCI
100
93
83
80
89
Interventional
cardiologists
Patients
75
60
40
20
0
18
21
8
Reduce
mortality
Prevent MI
Reduce
angina
Improve
LV function
8
Other
Rothberg M. Ann Intern Med 2010; 153(5):307-13.
Class I-II angina decision aid
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Class I-II Angina Decision Aid
The Body of Evidence
Systematic review of 115 RCTs
Compared to usual care, decision aids:
Increase patient involvement by 34%
Increase patient knowledge of options by 13%
Increase consultation time by ~2.6 minutes
Reduce decisional conflict by ~7%
Reduce % undecided by 40%
No consistent effect on choice, adherence,
health outcomes or costs
Stacey D et al. Cochrane review 2014
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Opportunities for SDM in practice
1.  When pros and cons are closely balanced
2.  When pros>cons only if patients adhere
3.  When pros and cons are not well known
Contact Information
[email protected]
@HenryTingMD
http://kerunit.e-bm.org
(212) 746-0386
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