Transcript Slide 1

Shared Decision
Making in Practice: An
Overview of MAGIC
Richard Thomson
On behalf of MAGIC Cardiff and Newcastle
Newcastle
Richard Thomson
Cardiff
Glyn Elwyn/Maureen Fallon
Acknowledgements: The Health Foundation, Cardiff and Vale
Health Board, Newcastle upon Tyne Hospitals NHS Foundation
Trust, staff and patients involved across both sites.
What is shared decision making
(SDM) ?
Models of clinical decision
making in the consultation
SDM is an approach where clinicians and patients make
decisions together using the best available evidence.
(Elwyn et al. BMJ 2010)
Paternalistic
Shared
Decision
Making
Patient well informed (Knowledge)
Knows what’s important to them
(Values elicited)
Decision consistent with values
Informed Choice
Examples of preference –
sensitive decisions
• Breast conserving therapy or mastectomy for
early breast cancer
• Repeat c-section or trial of labour after previous
c-section
• Watchful waiting or surgery for benign prostatic
hypertrophy
• Statins or diet and exercise to reduce CVD risk
• Diet and weight loss or medication in diabetes
Spectrum of SDM to SSM
SKILLS
TOOLS
“Shall I have a
knee
replacement?”
“Shall I take a
statin tablet for the
rest of my life?”
“I would like to
lose weight”
“Shall I have a
prostate
operation?”
“Should I use
insulin or an
alternative?”
“I would like to
eat/smoke/drink
less”
SDM – evidence
Cochrane Review of Patient Decision Aids(O’Connor et al
2011):
Improve knowledge
More accurate risk perceptions
Feeling better informed and clear about values
More active involvement
Fewer undecided after PDA
More patients achieving decisions that were informed and consistent
with their values
Reduced rates of: major elective invasive surgery in favour of
conservative options; PSA screening; menopausal hormones
Improves adherence to medication (Joosten, 2008)
Better outcomes in long term care
Are patients involved?
Patients who would like more involvement in decisions about
their care (source: NHS Inpatient Surveys 2002 - 2011)
100
90
80
Percentage
70
60
50
45
46
47
47
48
49
48
48
48
48
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
40
30
20
10
0
Year
So why aren’t we doing it?
• Multiple barriers
- “We’re doing it already”
- “It’s too difficult” (time
constraints)
- Accessible knowledge
- Skills & Experience
- Decision support for patients /
professionals
- Fit into clinical systems and
pathways
Lack of implementation
strategy
Key features of the MAGIC
programme
Key elements: Phase 1
• effective engagement of multidisciplinary clinical
teams through clinical champions, skills
development, trained facilitators, and embedding
change into clinical pathways and practice
• Awareness, attitude,, skills development
• drawing upon what we know works in change
management and professional behaviour change,
whilst testing some additional innovative elements
• used decision aid tools both decision-specific and
generic tools
• rapid action learning and feedback (implementation
monitoring)
• patient and public engagement
MAGIC – Phase II
 Moving implementation from pilot departments and general
practices to hospitals and health communities: embedding
and sustainability
 Leadership and organisational engagement, including
working with new commissioning structures (Newcastle)
and Welsh Govt (Cardiff)
 Expanding and accelerating clinical engagement and
impact, by testing learning from Phase 1
 Enhanced patient and public involvement, including an
emphasis on patient activation and the wider community.
 More efficient ways of delivering education and training
 Quality metrics: demonstrating value to commissioners and
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primary and secondary care organisations.
Key learning from the MAGIC
programme: headlines.
“When we want your opinion, we’ll give it to you”
Evidence-based decision support
• Timely and appropriate access for clinicians and
patients
• Needs facilitation
• In consultation or outside?
• Value of brief in-consultation tools (Option Grids and
Brief Decision Aids)
• Fit to clinical pathways
• Adapt pathway or tools? (VBAC, BPH)
Brief Decision Aids/Option Grids
Heavy Menstrual Bleeding (Heavy Periods)
Management Options[1]
A Brief Decision Aid
There are four options for the management of heavy menstrual bleeding:
Watchful waiting - seeing how things go with no active
treatment.
Intrauterine system (IUS) – a hormonal device placed in
the womb that lasts five years.
Medication - tablets taken before and during periods, the
combined oral contraceptive pill, or progestogens either
as tablets or a 3 monthly injection.
Surgery - endometrial ablation or hysterectomy. These
are hospital procedures that are usually considered only
if other options have not worked well or have been
unacceptable.
[1]
Only for use once other causes of HMB such as fibroids or polyps have been excluded
Benefits
Risks or Consequences
No side effects or hospital treatment
– can choose another option at any
time.
Your periods will eventually
disappear – average age of
menopause is 51.
It is already having an impact on your life
and wellbeing.
It is possible that periods will get worse
running up to the menopause
Treatment option
Watchful waiting no active treatment
Benefits and Risks of Intrauterine System (IUS)
Benefits
Risks or Consequences
Blood loss is normally reduced by
about 90%
About 25 in every 100 women will
have no periods at 1 year
It lasts five years but can be removed
at any stage.
It is more often considered if the
treatment is wanted for longer than a
year.
It usually reduces period pain.
It is an effective contraceptive.(see
separate leaflet)
Bleeding can become more unpredictable
especially in the first 3-6 months. This
usually, but not always, settles down
At the time of fitting, an IUS may
rarely be placed through the wall of
the uterus (about 1 in 1000 fittings).
IUS falls out 5 times in every 100
times it is put in. (this is usually
obvious at the time)
Treatment option
Intrauterine
system (IUS)
Involves a minor
procedure done in the
GP practice/sexual
health clinic. Majority
of women say that the
fitting is similar to
moderate period
discomfort
Menorrhagia BDA
Option Grid
Mastectomy
Lumpectomy with
Radiotherapy
Which surgery is best for long There is no difference between There is no difference between
term survival?
surgery options.
surgery options.
Breast cancer will come back in Breast cancer will come back in
What are the chances of
the breast in about 10 in 100 the area of the scar in about 5
cancer coming back?
women in the 10 years after a in 100 women in the 10 years
lumpectomy.
after a mastectomy.
The cancer lump is removed
What is removed?
The whole breast is removed.
with a margin of tissue.
Possibly, if cancer cells remain
Will I need more than one
in the breast after the
No, unless you choose breast
operation
lumpectomy. This can occur in reconstruction.
up to 5 in 100 women.
How long will it take to
recover?
Most women are home 24
Most women spend a few
hours after surgery
nights in hospital.
Yes, for up to 6 weeks after
Unlikely, radiotherapy is not
Will I need radiotherapy?
surgery.
routine after mastectomy.
Some or all of the lymph
Some or all of the lymph
Will I need to have my lymph
glands in the armpit are usually glands in the armpit are usually
glands removed?
removed.
removed.
Measuring impact of change in clinical practice (Option
Grid)
Patients’ knowledge post diagnostic consultation
Percentage of Patients
Before routine use of Option Grid
February – June 2011 (n=27)
After routine use of Option Grid
July-September 2011 (n=29)
100
100
90
90
80
80
70
70
60
60
50
50
Unsure
40
Correct
30
40
Unsure
30
Correct
20
20
Incorrect
10
10
0
0
Incorrect
Question Topic
Question Topic
Clinical skills development
• Cornerstone of implementation
• Attitudes and awareness critical
• Interactive, advanced skills-based training is core
• Eye opening and valued – moving from “we do this already” to
“I think we do this, but we could do it better”
• What is important to patient (values) is key learning
• Challenge of getting senior clinicians to attend
• Role of the model of the consultation
• Attitudes and skills trump tools
• Needs resourcing - MAGIC-Lite model: possible to deliver more
efficiently
SDM model for clinical practice
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Clinical team engagement
• Leadership and champions
• Team of champions (including non-clinical)
• Learning sets (in primary care)
• Importance of medical leadership & role of nurse specialists
• Different facilitators for different teams
• Keeping SDM on the agenda of the team
• Patient experience – decision quality
• Support new developments (place of birth)
• Support for model of delivery (MDT in head and neck cancer)
• Practice payments
• Peer pressure/CCG and national initiatives (1000 lives)
Measurement & rapid feedback
• Action learning model
• Regular meetings to share good practice and
experiences
• Measurement for monitoring, research or QI?
• History and experience
• Local skills
• Driver diagrams and PDSA in Cardiff
• Role of rapid testing locally and ownership
• Patient experience data a challenge
• Validity, reliability, social acceptability bias
• Role of decision quality measures
Measuring patients’ readiness to decide
Readiness to decide, using DelibeRATE (Feb 2011 – Jan 2012)
Average DelibeRATE Scores
Post home visit (n=67)
100
100
90
90
80
80
70
70
60
Yes
50
No
40
Unsure
30
Blank
Percentage of Patients
Percentage of Patients
Average DelibeRATE Scores
Post diagnostic consultation (n=82)
60
50
40
30
20
20
10
10
0
0
Feb-May (n=27)
Jun-Sep (n=29)
Oct-Dec (n=26)
Time Period (number of patients)
Feb-May (n=21)
Jun-Sep (n=23)
Oct-Dec (n=23)
Time Period (number of patients)
Measuring patients’ choice of treatment
Choice of treatment (Feb 2011 – Jan 2012)
Choice of Treatment
Post home visit (n=67)
Choice of Treatment
Post diagnostic consultation (n=82)
100
100
90
90
80
Percentage of Patients
80
Strong preference for
mastectomy
70
60
Leaning towards
mastectomy
50
Not sure
40
30
20
70
60
50
40
Leaning towards
lumpectomy
30
Strong preference for
lumpectomy
20
10
10
0
0
Feb-May (n=27)
Jun-Sep (n=29)
Oct-Dec (n=26)
Time Period (number of patients)
Feb-May (n=21)
Jun-Sep (n=23)
Oct-Dec (n=23)
Time Period (number of patients)
Quality Improvement & MAGIC
•Cardiff used the model for
improvement (known as QI) as
the basis for implementing SDM.
This methodology is adopted on
a pan-Wales basis.
•The PDSA (Plan, Do, Study, Act)
cycle is ideally suited to SDM
implementation as it allows you
to test a change in the work
setting by planning it, trying it,
observing the results and acting
on what is learned e.g DQM
changes in Breast; Surescore
use in Mental Health
Patient and public involvement
• Role of patient narratives/stories
• Role to challenge
• “Patient activation”: PPI role
• Patient materials design and content – MAGIC or SDM
• Ask 3 questions –well received and adaptable
• How to better support activated patients?
• Challenge of PPI in clinical teams
• Wider bi-directional PPI – range of stakeholders –
External Advisory Group (Newcastle)
Ask 3 Questions
A6 flyer for use in
appointment letters,
waiting areas,
consulting rooms.
Posters for use in
waiting areas and
consulting rooms.
Short film to
encourage patient
Involvement: ‘So
Just Ask’
Acknowledgement to Shepherd et al, School of Public Health, University of Sydney
Commissioning
• Challenging in rapidly changing systems
and new organisations alongside
efficiency savings!!
• MAGIC Lite: possible to deliver training to
large numbers quickly
• Link to other priorities – e.g. referral
management, long term conditions
Key learning: Summary
• SDM is so much more than tools; more to do with
skills and new ways of consulting (aided by
decision support)
• Complex PDAs have a role, but also need simpler
in-consultation support (Option Grids/Brief
Decision Aids).
• Need to embed within clinical pathways (or adapt)
and show value to clinicians
• Need for wider PPI at all levels
Key learning: Summary
• Important emerging role of patient activation
(provided service is ready to respond)
• Measurement of patient experience hard at local
level, but local measures likely to be of value if
they stimulate change and inform clinical practice
(e.g. DQM)
• Link to QI/service improvement – local context
Wider policy and systems issues
• SDM needs to be incentivised within the system
(e.g. key metrics/performance management;
national/ professional body support;
commissioner buy in; board buy in)
• Tensions exist
–
–
–
–
Rapid progress through cancer care pathways
QOF ( e.g. for hypertension treatment targets)
Tendering processes within the English market
Criterion based models of referral management and
NICE guidance may create tensions with SDM
Wider policy and systems issues
• Need for national coordination around education
and training
• Coordination nationally between patient
experience/SDM and LTC/SSM
• Access to resources at the time needed – e.g.
within info systems
• Use of routine data for monitoring and QI
• Research needed (e.g. NIHR) to develop valid
and reliable measurement of SDM
THANK YOU
[email protected]