Doctors are using new tools to help patients make choices about treatment options.
When Thomas Stormont, M.D., first heard about shared decision-making, he admits he was skeptical. “I used to think it was just another unnecessary layer,” Stormont says of the process by which health care providers and patients work together to weigh the pros and cons of various treatments before deciding on a course of action.
But now, after using the process for nearly two years, the Stillwater Medical Group urologist and surgeon is a believer. He has seen how it has helped patients with prostate cancer better understand their options. “It’s made my job easier,” he says, “and the patients feel more empowered and in control of their cancer.”
The concept of shared decision-making emerged more than 30 years ago after John Wennberg, M.D., former director of the Dartmouth Institute for Health Policy and Clinical Practice, identified wide variations in surgical treatment for common conditions and suggested that some unnecessary treatments could be eliminated if patients were better informed about the benefits and drawbacks.
Since then, physicians, primarily in academic centers, have been testing and refining the shared decision-making model. Those efforts have resulted in a growing body of literature from pilot and demonstration projects across the country that have found patients benefit from a more formal process for making decisions about their treatment options.
Marcus Thygeson, M.D., vice president and medical director for HealthPartners, says the need for shared decision-making has increased as patients have faced increasingly complex treatment choices for conditions where no one treatment is clearly superior. “A big reason why shared decision-making is needed is that we need to be more systematic and expert in helping people make choices about these preference-sensitive conditions, when the best choice often depends on their preferences and values,” he says.
In addition, the research shows that physicians have a tendency to downplay negative side effects of treatments and to make unwarranted assumptions about what patients want. A University of Michigan survey of 375 patients who had discussed prostate-specific antigen (PSA) testing with a health care provider found that the providers emphasized the pros of testing in 71 percent of discussions but addressed the cons only 32 percent of the time. In an article published in the September 2009 issue of Archives of Internal Medicine, the authors report that subjects did not have discussions about the downsides of testing, had limited knowledge about what the test would tell them and of the mortality risk associated with prostate cancer, and were not routinely asked about their preferences regarding testing.
Some policymakers and health plans have embraced shared decision-making in the belief that it will result in cost savings and reduce unnecessary medical procedures. Thygeson says the evidence does not indicate that shared decision-making necessarily reduces utilization but does show it limits unwanted care. At the national level, Senate and House health care reform bills include provisions for shared decision-making studies. In Minnesota, the state’s provider groups and payer organizations formed a collaborative to identify best practices for implementing shared decision-making in clinical practice. Also, the state of Minnesota is studying whether to require that people enrolled in public insurance programs participate in shared decision-making.
The Stillwater Experience
The Stillwater Medical Group, a multispecialty practice, began testing shared decision-making in 2006, after Thygeson approached the group about conducting a pilot program for patients with uterine fibroids.
In March 2008, the group extended its use of shared decision-making to patients diagnosed with prostate cancer and, shortly after, to patients with breast cancer. “We’ve been interested in pursuing this because we think it is the right thing to do and we want to be a patient-centered organization, not because we think it’s going to save money,” says Lawrence Morrissey, M.D., a pediatrician and medical director for quality at Stillwater Medical Group. Here’s how the process works: When a Stillwater Medical Group patient is newly diagnosed with prostate cancer, he meets with Joyce Kramer, R.N., a clinical care coordinator. Kramer assesses the patient’s knowledge of the disease; reviews treatment options and their risks, benefits, and side effects; and documents the patient’s concerns and preferences regarding treatment in the medical record. She also gives the patient a DVD to watch at home and a booklet to review at home or as part of the visit.
Before meeting with Stormont, the patient has learned about a half-dozen competing treatment options including watchful waiting, surgery, and radiation. “By the time they get to me, they are less anxious and better informed and better able to talk through the decision,” he says.
The prostate cancer shared decision-making program received high satisfaction scores based on an informal survey of 38 patients who went through the program, Morrissey says. The group has not tracked whether shared decision- making has changed treatment patterns for either prostate or breast cancer patients.
The Stillwater Medical Group is now expanding its use of shared decision-making. Earlier this year, it was chosen by the Foundation for Shared Decision Making, a Boston-based nonprofit that produces shared decision-making materials for providers, to be one of 11 sites taking part in a demonstration project on integrating shared decision-making into primary care.
The grant has allowed the group to hire a nurse to do shared decision-making consultations with patients who have benign prostatic hyperplasia (BPH), a common condition with multiple treatment options. The group’s goal is to have about 300 patients go through a shared decision-making process for BPH in the next year. They eventually hope to use shared decision-making for patients with back pain and diabetes as well.
Other Minnesota Efforts
The Stillwater Medical Group isn’t the only practice in Minnesota that’s been exploring ways to help patients with decision-making. Victor Montori, M.D., an endocrinologist at Mayo Clinic, has been developing decision aids for patients with diabetes and other chronic conditions. The Coburn Cancer Center in St. Cloud has developed a monthly educational program for community members about making difficult health care decisions. The approach may be adopted by even more providers as the Institute for Clinical Systems Improvement incorporates shared decision-making into a palliative care initiative.
Resources for Clinicians
Finding the right decision-support aids is a challenge for clinics and is one reason why shared decision-making has not caught on widely. Mayo Clinic produces its own decision-support tools, but smaller providers may not have the resources to create their own. Here are a few places where you can find decision aids:
•The Ottawa Hospital Research Institute (http://decisionaid.ohri.ca/) has an inventory of decision aids.
•The Foundation for Informed Medical Decision Making (www.informedmedicaldecisions.org/) offers decision aids for about 30 conditions including breast and prostate cancer, knee surgery, end-of-life care, and uterine fibroids.
•Health Dialog (http://sdm.healthdialog.com/psa/PSAVideo.html) offers three decision-support videos for viewing online at no cost.
•Healthwise (www.healthwise.com) offers interactive decision aids and information on a number of medical topics.—S.D.S.
In 2008, the Minnesota Legislature considered a bill that would have required patients enrolled in public programs to participate in a patient-centered decision-making process before providers could be reimbursed for surgeries for a number of conditions including abnormal uterine bleeding, benign prostate enlargement, chronic back pain, and early-stage breast or prostate cancers. Instead of passing legislation, lawmakers called for the Minnesota Department of Human Services to study the issue of making payment dependent on shared decision-making. Human services officials are expected to report back to lawmakers this month.
The Minnesota shared decision-making collaborative has gone on record in opposition to mandating the use of shared decision-making or requiring it for payment. The group issued a white paper last fall, which it shared with the Department of Human Services, arguing that providers aren’t ready to put shared decision-making into practice on a large scale. HealthPartners, for example, has found that some physicians are confused about the difference between shared decision-making and informed consent, for example.
The collaborative argues in the white paper that until providers and patients understand how shared decision-making works and until the practice is more widely adopted, a government mandate would be a mistake.
“I think a bottom-up, community-based, collaborative approach, where we do some pilots and demonstrate we know how to do this, will move shared decision-making forward more rapidly,” Thygeson says.—Scott D. Smith