Personal Value and its Place in Priority Setting...Personal Value and its Place in Priority Setting...
Transcript of Personal Value and its Place in Priority Setting...Personal Value and its Place in Priority Setting...
Personal Value and its Place in Priority Setting
Angela Coulter, PhD
Informed Medical Decisions Foundation
and
University of Oxford
@acpatient
Triple Value Healthcare
• Technical value
– Practice is evidence-based, efficient and effective
• Allocative value
– Resources are distributed equitably to maximise value for the whole population
• Personal value
– Individuals’ goals and preferences shape the care they receive
British Newspaper headlines 26/08/16
What to do? Service Transformation Plans (as reported by Nuffield Trust)
• Close hospital beds
• Shift care into the community
• Merge A&E departments
• Rethink staffing models
• Close community hospitals
• Get a grip on specialist services
• Reconfigure primary care
• Target high need, high cost patients
• Strengthen prevention
• STPs – 5-year plans for integrated care in 44 regions in England
• Tight timescales mean little patient/public engagement in STPs as yet
How Will the Public Respond?
More is Not Always Better
Primary Hip Replacements Case-mix adjusted CCG rates
Health Gain after Hip Replacement (EQ5D) Age-sex standardised CCG rates
NHS Atlas of Variations 2015
Benefits are often Marginal at Best
Gerd Gigerenzer BMJ 2016;352:bmj.h6967 ©2016 by British Medical Journal Publishing Group
Benefits may be Small and Risks High
Trade-Offs can be Complex and Outcomes Uncertain
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Improvement in symptoms
Commercial Pressures
We Must Change the Terms of the Debate
• Focus on personal value
• More is not always better
• Harms caused by medical intervention = patient safety issue
• Unnecessary care = unnecessary risk + cost
• Efficiency = better for everyone
Start with Individual Care
• One in three patients feel uninformed about their treatment
• About half want more involvement in decisions about their care
Patient Information Forum 2015
Were you involved as much as you wanted to be in decisions about your care and treatment?
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% responding ‘Yes, definitely’
Source: NHS inpatient surveys
Searching for Health Information
Harms
minimized
Benefits
exaggerated
Health Information is Often Unbalanced
Doctors and Patients may Disagree on Priorities
Condition: Goal Pat Dr p
Keep your breast? 71%
Live as long as possible? 96%
Look natural without clothes 80%
Avoid using prosthesis 0%
Lee C N et al. Ann Plast Surg 2010; 64(5): 563-6
Doctors and Patients may Disagree on Priorities
Condition: Goal Pat Dr p
Keep your breast? 7% 71% P<0.01
Live as long as possible? 59% 96% P=0.01
Look natural without clothes 33% 80% P=0.05
Avoid using prosthesis 33% 0% P<0.01
Lee C N et al. Ann Plast Surg 2010; 64(5): 563-6
Clinician
• Diagnosis
• Disease aetiology
• Prognosis
• Treatment options
• Outcome probabilities
Patient
• Experience of illness
• Social circumstances
• Attitude to risk
• Goals, values, preferences
Sharing Expertise
Shared Decision Making
Clinicians and patients working together to select tests, treatments, management or support options based on clinical evidence and the patient’s informed preferences.
What Patients Need to Know
• What are my options?
• What are the benefits and possible harms?
• How likely are these benefits and harms?
• How can you help me make a decision that right for me?
Key Components of Shared Decision Making
1. Information Reliable, balanced, evidence-based information outlining prevention, treatment, or management options, outcomes and uncertainties
2. Deliberation Decision support with clinician or health coach to clarify options, preferences, goals and action plan (personalised care planning)
3. Implementation System for recording, communicating and implementing patient’s preferences
Selecting Tests or Treatments
Wellness and Health
Promotion
Managing Long-Term Conditions
Shared Decision Making
Patient Decision Aids can Help
• Tools to help people participate in decision-making
• Provide information on options
• Help patients clarify and communicate their values and preferences
Breast Cancer Decision Explorer (BresDex; www.bresdex.com).
Ahmed H et al. BMJ 2012;344:bmj.e3996
©2012 by British Medical Journal Publishing Group
Patient Decision Aids: the Evidence
• In 115 trials involving 34,444
participants, use has led to:
–Greater knowledge
–More accurate risk perceptions
–Greater comfort with decisions
–Greater participation in decision-making
–Fewer people remaining undecided
–Fewer patients choosing major surgery
Stacey et al. Cochrane Database of Systematic Reviews, 2014
Patient Decision Aids Reduce Rates of Elective Surgery by 20%: Cochrane Review
Shared Decision Making Reduces Use of Antibiotics for Respiratory Tract Infection by 40%: Cochrane Review
Coxeter P, Del Mar CB, McGregor L, Beller EM, Hoffmann TC. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care. Cochrane Database of Systematic Reviews 2015, Issue 11. Art. No.: CD010907. DOI: 10.1002/14651858.CD010907.pub2.
Shared Decision Making in Orthopaedics
• Hip: 820 intervention vs 968 control
• Knee: 3,510 intervention vs 4,217 control
• 26% fewer hip replacements
• 38% fewer knee replacements
• Estimated cost reduction of 12-21% over six months
Arterburn et al. Health Affairs 2012
PROMs EQ-5D-5L
• Mobility
– I have no problems in walking about
– I have slight problems in walking about
– I have moderate problems in walking about
– I have severe problems in walking about
– I am unable to walk about
• Self-care
– washing, dressing
• Usual activities
– work, study, housework, family or leisure
• Pain/discomfort
– anxiety / depression
+ visual analogue scale
Personal Value for People with Long-Term Conditions
Impact of LTCs
Coping with LTC(s)
Empowerment / sense of control
Social participation
Safe environment
Roles and responsibilities
Achieving personal goals
Loneliness
Dependency / being a burden
Physical activity
Suitability of home
Burden of treatment and
services
Confidence to manage LTC(s)
Stigma
Knowledge & information
Feeling supported
Key Measures
Experience
• Impact of condition
• Quality of communications
• Knowledge and risk perceptions
• Decisions consistent with values
• Services and support
Outcomes
• Health status
• Capabilities
• Quality of life
• Resource use
• Costs
Achieving Personal Value
• Individuals’ goals and values should shape the care they receive
• Public needs to understand the limitations of medical care
• Start by involving patients in decisions about their own care
• Shared decision making leads to more appropriate care
• Personal outcome assessments should guide priority-setting