The rapid assessment workshop to elicit expert consensus ...
Shared Decision Making · systematic reviews •reviewed by Medical Editor •regularly updated...
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Shared Decision Making
Rebekah E. Gee MD, MPH, MS, FACOG Medicaid Medical Director, Louisiana
Assistant Professor LSU Schools of Medicine and Public Health
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ACOG and Informed Consent
As an ethical doctrine, informed consent is a process of communication whereby a patient is enabled to make an informed and voluntary decision about accepting or declining medical care.
ACOG Committee Opinion 439 august 2009*Reaffirmed 2012
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Informed Consent Reality
• Inadequate time
• Lack of financial incentives
• Low health literacy/numeracy
• Clinician and patient miscommunication
• Focus liability protection, not on the needs and rights of patients
Informed consent as a
piece of paper, not a
process
photo credit: http://www.flickr.com/photos/denisemattox/4413044798/
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Listening to Mothers
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Evidence of Inadequate Informed Consent
• Majority unable to correctly answer basic
questions about adverse effects of induction
and cesarean section.
• “Not sure” was most common response
• When mothers did respond they were as
likely to be incorrect as correct
• Having had the intervention did not increase
proportion of correct answers
Listening to Mothers III Survey, 2013
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Evidence of Inadequate Informed Consent
• Mothers felt pressure from a health
professional to have induction (25%)
and cesarean (25%)
• 82% of women having episiotomies did
not give consent
Listening to Mothers III Survey, 2013
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Summary of Problems with Informed Consent
• Inadequate standards for informed consent
• Inadequate processes for informed consent
• Clear evidence that most health care decisions remain uninformed
• Caregiver attitudes, preferences, and incentives strongly impact use of interventions
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Mothers’ Ratings of Trustworthiness of Possible Sources of Pregnancy and Childbirth Information
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Solution: Shared Decision Making
www.informedmedicaldecisions.org
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Trevor
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Trevor Play video
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Broad Consensus About SDM
Affordable Care Act
State Legislation
National Quality Strategy
Policy and clinical reports
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Shared Decision Making
• Facilitates decision making when:
– multiple reasonable options
– insufficient outcomes data, leading to clinical uncertainty among options
– trade-offs among benefits and harms
These are known as “preference-sensitive” decisions
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Six Steps to Shared Decision Making
1. Invite the patient to participate - she may not realize she is making a decision
2. Present options - including the option of doing nothing
3. Provide information on benefits and risks - quantify if possible
4. Assist patients in evaluating options based on their goals/concerns - no one choice is right for all women
5. Facilitate deliberation and decision making - deal with lingering concerns or questions
6. Assist with implementation - plan next steps
http://informedmedicaldecisions.org/
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Decision Aids
• Tools or technologies designed to facilitate SDM
– DVD
– Web
– Patient portal of EHR
– Mobile app
• Developed and evaluated according to international standards.
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Cochrane Review of DAs
• Improved knowledge – better when more detailed
• More accurate expectations of possible benefits and harms – better with quantified probabilities
• Choices that are more consistent with patients’ informed values – better with explicit values clarification
• Increased participation in decision making • Less decisional conflict • Lower likelihood of choosing interventions
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Existing Maternity DAs
• Prenatal testing – Routine early ultrasound
– Amniocentesis
– Chorionic Villus Sampling
– Triple/quad screen
• Treatments for pregnancy-related conditions – Antidepressant use in pregnancy
– Multiple pregnancy - fetal reduction
– Treatment options for incomplete miscarriage
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• Labor/Birth – VBAC vs. ERCS
– VBAC vs. ERCS
– Epidural
– Elective Induction
• Postpartum/Newborn – Breastfeeding
– Banking umbilical cord blood
– Male circumcision
Existing Maternity DAs
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Is SDM Feasible?
Commonly cited barriers to SDM:
• Take too much time
• Patients do not want to participate in decisions
• Patients will not understand clinical information
• Decision aids not relevant to individual circumstances
None borne out by the evidence.
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• First national maternity SDM initiative funded by the Informed Medical Decisions Foundation
• Web-based, open access decision aids and other decision support tools for major maternity decisions
• Support tools to carry out informed decisions
• Partnering with stakeholders to test implementation models
transform.childbirthconnection.org
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Pregnant Me
• Multi-media decision aids and decision support content for women at 6th grade health literacy level (user-testing in CA and LA) available in early 2014, including:
• Induction of labor for suspected macrosomia
• Induction of labor at 40-41 weeks
• Elective repeat cesarean vs. planned vaginal birth
• Choosing a caregiver and birth setting
• Gestational diabetes screening and treatment
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Evidence-based
• literature on preferences, attitudes, and knowledge
• clinical studies including well-designed systematic reviews
• reviewed by Medical Editor
• regularly updated
Woman-centered
• Based on surveys of women to elicit high priority knowledge and concerns
• focus group testing s
• user-centered design / usability testing
• featuring women’s perspectives throughout
• explicit values clarification
Clinically Appropriate
• survey to elicit high priority knowledge and concerns
• reviewed by Clinical Advisors
• featuring variety of clinicians’ perspectives throughout
Rigorous Content & Development Standards
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www.transform.childbirthconnection.org | www.childbirthconnection.org
read the full report at: http://bit.ly/LTM-III
twitter: #LTM3
“I switched to a doctor
who was more willing to
give me the care I wanted
in a much friendlier and
supportive environment. - Listening to MothersSMIII: New Mothers Speak Out
survey participant
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References
• Angood, P. B., Armstrong, E. M., Ashton, D., Burstin, H., Corry, M. P., Delbanco, S. F., et al. (2010). Blueprint for action: Steps toward a high-quality, high-value maternity care system. Women's Health Issues, 20(1, Supplement 1), S18-S49.
• Coulter, A., & Collins, A. (2011). Making shared decision-making a reality: No decision about me, without me. London, U.K.: The King's Fund.
• Declercq, E. R., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to mothers II: Report of the second national U.S. survey of women’s childbearing experiences. New York: Childbirth Connection.
• Frosch, D.L., Moulton, B.W., Wexler, R.M., Holmes-Rovner, M., Volk, R.J., & Levin, C.A. (2011) Shared decision making in the United States: policy and implementation activity on multiple fronts. Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen (ZEFQ) 105, 305–312.
• Goldenberg, R. L., McClure, E. M., Bhattacharya, A., Groat, T. D., & Stahl, P. J. (2009). Women's perceptions regarding the safety of births at various gestational ages. Obstetrics and Gynecology,114(6), 1254-1258. doi:10.1097/AOG.0b013e3181c2d6a0
• O'Malley, A. S., Carrier, E. R., Docteur, E., Shmerling, A. C., & Rich, E. C. (2011). Policy options to encourage patient-physician shared decision making No. 5). Washington, DC: National Institute of Health Care Reform.
• Sakala, C., & Corry, M. P. (2008). Evidence-based maternity care: What it is and what it can achieve. New York: Milbank Memorial Fund.
• 19. Yong, P. L., Saunders, R. S., & Olsen, L. (2011). The healthcare imperative: Lowering costs and improving outcomes. Washington, DC: National Academies Press.
• Stacey, D., Bennett, C. L., Barry, M. J., Col, N. F., Eden, K. B., Holmes-Rovner, M., et al. (2011). Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews (Online), 10, CD001431. doi:10.1002/14651858.CD001431.pub3
• Say R, Robson S, Thomson R. Helping pregnant women make better decisions: a systematic review of the benefits of patient decision aids in obstetrics. BMJ Open 2010;1:e000261.
• Simpson, K. R., Newman, G., & Chirino, O. R. (2010). Patient education to reduce elective labor inductions. MCN, The American Journal of Maternal Child Nursing, 35(4), 188-94.