Title: Support for Clinicians and Patients in Improving Decision Quality
1Support for Clinicians and Patients in Improving
Decision Quality
- International Forum on Quality and Safety in
Health Care - Barcelona, April 19, 2007
- Albert G. Mulley, MD, MPP
- Chief, General Medicine Division
- Massachusetts General Hospital
www.fimdm.org
2The origins of practice variation
Glover, 1938
Wennberg, 1969
3Adjusting practice variation for baseline rates
McPherson
Hovind
N Engl J Med 1982 307 1310
Wennberg
4Rates of back surgery National capacity and the
role of evidence
Which rate is right?
Country
1.0
U.S.
0.8
Evidence-based and patient-centered?
NET
DEN
0.6
Ratio of back surgery rate to U.S.
FIN
ONT
0.4
NZ
AUS
SWE
NOR
MAN
0.2
ENG
SCO
0.0
0
10
20
30
40
50
60
70
80
90
100
110
Orthopedic and Neurosurgeons per million
population
Cherkin et al, Spine, 1994
5Practice variation today Implications for
quality and costs
6 Improving decision quality Distinguishing
between unwarranted and warranted sources of
practice variation
Unwarranted
Warranted
- Clinical differences among patients
- Variable risk attitudes
- Variable values attached to health outcomes
- Variable willingness to make time trade-offs
- Variable tolerance for decision responsibility
- Variable coping styles
- Variable access to resources and expertise
- Insufficient research
- Unfounded enthusiasm
- Parochial perspective
- Faulty interpretation
- Poor information flow
- Poor communication
- Role confusion
Patient-Centered
Knowledge-Based
7Complex adaptive systems and complex decisions
High
Chaos
Disagreement about Preferences
Complexity
Patient-Centered
Control
Low
High
Low
Uncertainty about Outcomes
Knowledge-Based
8Supporting the partnerships necessary for
decision quality
Knowledge-Based
Patient-Centered
- Manage all relevant knowledge and expertise
- Access and critically appraise evidence
- Access and selectively use expertise of
colleagues - Access and use guidelines and other support when
appropriate - Acknowledge uncertainty
- Recognize uniqueness
- Avoid over-learning and selective inattention
maintain context - Communicate effectively
- Tailor evidence for individuals
- Frame problems from the patients perspective
- Communicate options and probabilities of outcomes
- Help patients to accurately imagine alternative
futures - Elicit and accommodate patients informed
preferences - Elicit motivation when needed
- Build patients confidence and affirm their
competence - Use patients experiences as a source of knowledge
Systems-Minded highest and best use
9Understanding decision quality and decision
support
Patient
Clinical
Alternative 1
Clinical decision
Outcome
Alternative 2
Practice
Alternative 1
Alternative 2
10Understanding decision quality and decision
support
Information about Outcome Probabilities
Clarification of Values regarding Outcomes
Urinary Dysfunction
Sexual Dysfunction
?
?
?
Least valued (Death)
Most valued (Symptom Relief)
Different value judgments for 3 patients facing
same probabilities
Different outcome probabilities for 3 patients
with different severity comorbidity
11Clarifying values Experienced and predicted
utilities
How bothersome is urinary dysfunction?
How bothersome will sexual dysfunction be?
12Continuously improving decision quality
Knowledge-Based
1
Health Professionals
DQKB?
Alternative 1
P
P
Alternative 1
Aggregate outcomes
Policy Makers
R
Alternative 2
DQPC?
P
Alternative 2
Patients and Family
Patient-Centered
13Measuring decision quality improvement
- Patient knowledge of options and outcomes
- Decisional conflict (information, values,
support) - Understanding of role and participation in
decision - Understanding uncertainty
- What can and cannot be controlled about the
future - Competing forces of morbidity and mortality
- Equipoise and participation in trials
- Treatment choice Concordance with preferences
- Treatment choice Competence, confidence,
treatment concordance - Disease-specific health status
- General health status
14Simple measures of decision quality BPH
Knowledge of relevant treatment options and
outcomes
Concordance between patient values and care
received
1. Are my symptoms likely to be life-threatening?
What if I do nothing? 2. Is surgery the only
option? How much can other treatments help? 3.
Will surgery change my sexual function? In what
ways?
1. How much am I bothered by my symptoms? 2. How
much will I be bothered by a possible change in
experience of sex?
15Impact of improved decision quality on surgery
rates BPH
16Simple measures of decision quality CHD
Knowledge of relevant treatment options and
outcomes
Concordance between patient values and care
received
1. Are my symptoms likely to be life-threatening?
What if I do nothing? 2. Is surgery the only
option? How much can other treatments help? 3.
Will surgery change my ability to think clearly?
In what ways? What else can I expect in the
future?
1. How much am I bothered by my symptoms? 2. How
much will I be bothered by a possible change in
cognitive abilities?
100
90
CABG
80
70
60
Medical Therapy
50
40
0
2
4
6
8
10
12
17Impact of improved decision quality on surgery
rates CHD
Knowledge of relevant treatment options and
outcomes
Concordance between patient values and care
received
Toronto trial
18Decision quality for chronic conditions Coronary
artery disease
Preparation and role clarification
Correcting misperceptions
The doctors view
19Competing priorities in chronic condition
management Diabetes
Respondents indicated that their measures were
About where I want it, yet there lab values
were above target levels
Percent of Medicare Diabetics Receiving Annual
Lipid Testing
20Evidence-based support for setting priorities
across conditions
Isolate impact areas for each
condition Identify behavior change(s) within
impact areas Estimate Number-Needed-to-Treat
(NNT) for desired outcome(s) assuming behavior
change Estimate registry/coaching impact on
behavior change Relative NNT for priority-setting
Clinical focus
21Systems-minded decision support for chronic
conditions
Priority impact areas
Different conditions
Different priorities
22Understanding barriers to patients motivation
and confidence
23Different goals, barriers, motivation and
confidence for different patients
Setting goals and making resolutions
Finding support and overcoming barriers
Motivation, confidence and competence
24Barriers to motivation and confidence diuretics
in CHF
25Registries to for proactively managing patients
and populations
Peer-comparison Reports
Registries for Proactive Care Management
Practice-level Reports
Individual Patient Reports
26Integrating decision support for patients with
chronic conditions
- Health coaches
- The Kaplan-Greenfield model and improved health
outcomes - Trained in shared decision making and
motivational interviewing - System support for decision making and priority
setting
Health Coach
Physician support
Patient and coach support
27Health systems of the future Will they support
wisdom?
- Support for the reflective practitioner
- Framing clinical problems from the patients
perspective - Avoiding tendencies toward situational control,
selective inattention, and over-learning - Acknowledging uncertainty, instability,
uniqueness, and value conflict - navigating in complex adaptive systems
- Simple rules
- Direction setting
- Boundaries and limits
- Incentives and rewards
- Integrating decision support
- Measuring and celebrating improvement in decision
quality