This post was authored by William R. Lewis, MD, FACC, chair of the ACC’s shared decision making workgroup and a member of the patient centered care steering committee.
In the current health care system, patients have traditionally played relatively passive roles in their own health care. They have little knowledge of their disease(s) and treatment options, leaving them not only ill-prepared to communicate their needs and wishes to their health care team, but to implement health plans when necessary. They have primarily relied on their physician for the majority of their medical information and have essentially left medical decision making up to their doctor.
Shared decision-making is one concept that is garnering closer attention for its ability to potentially improve outcomes, while at the same time facilitate patient involvement in their own health care decisions. The purpose behind shared decision-making is not to persuade but to improve patient knowledge and to provide information about the disease and clarify the risks and benefits of treatment or screening options and their associated outcomes. An article published in the Annals of Internal Medicine found that “patients who ask questions, elicit treatment options, express opinions, and state preferences about treatments during office visits with physicians have measurably better health outcomes than patients who do not.”
Key to shared decision-making is the ability of patients to become acquainted with the options available, the risks of each option and the outcomes anticipated from treatment with each option. Cardiovascular disease is particularly well-suited for the devel¬opment of shared decision-making tools that enable doctors to provide patients with an understanding of their options. Guidelines and evidence-based therapies form a solid foundation from which evidence can be distilled and shared with patients. In addition, there are many validated risk models of outcomes that can be used to inform patients of the outcomes of previously treated patients.
Cardiovascular care also involves many treatments for which small differ¬ences in outcomes exist, allowing opportunities for patients’ values and perspectives to play larger roles in the decision making process. For example, while bare metal stents result in more frequent repeat procedures than drug eluting stents, they require fewer blood thinners. As a result, patients concerned about bleeding or bruising, or who can’t afford medications, may select a bare metal stent, even if a drug eluting stent might minimize the likelihood of repeat coronary blockage.
Challenges of implementing shared decision making include lack of physician time to fully inform patients on all aspects of their treatment options including incorporating their values into the equation. Even if they did, the information retained during a single physician visit is limited, especially when there is additional stress involved.
In addition, patients need to know that the information they are reading is unbiased and complete. The solution to these problems is for a trusted organization, like the ACC, to build a website which can act as an extension of the physician’s office. With a tool like this, patients could gain the knowledge needed to make a quality decision and use tools to incorporate their values into the decision and develop questions for their doctor. The next physician visit then becomes a high quality meeting.
Other challenges involve aligning the goals of insurance companies with those of patients. Additionally, physicians are often judged on “quality measures” which, if contradictory to a patient’s values, might jeopardize a physician’s standing on a particular measure. For instance, if a patient chooses to take a lower dose of a cholesterol-lowering drug to avoid symptoms of muscle pain, their physician may be penalized for failing to achieve that lower cholesterol level.
The ACC is currently piloting several projects, one of which is focused on the use of ACC’s Appropriate Use Criteria for Coronary Revascularization. The goal is to use the results of these pilots to ensure that future shared decision-making models best meet the needs of patients and their families.
Additionally, CardioSmart.org is an excellent source of medical information and is trusted by patients and their cardiologists. The ultimate goal will be to develop shared decision making tools and make them interactive on CardioSmart.
If implemented correctly, shared decision making tools have the ability to drastically improve outcomes and will strengthen the provider/patient relationship.
To read more about the ACC’s plans for shared decision making, visit CardioSource.org.