The right choice

Annabel McGilvray
Med J Aust
Published online: 4 November 2013

Doctor–patient collaboration is at the heart of moves to make health care more collaborative

There is a new approach to health care that proponents say will reduce overdiagnosis, improve compliance and potentially save money for both patients and governments.

Evidence to back these claims has been growing for years and now Australia’s national health care safety and quality body is looking at how best to implement it across our health system.

And rather than rearranging our health care institutions, reconstituting the funding arrangements, or relocating the population’s health records, at the crux of this initiative is the communication between doctors and their patients.

Shared decision making (SDM) involves a clinician and patient being jointly able to consider the best available evidence regarding treatment and supporting the patient to reach an informed preference based on the likely risks and benefits of treatment and his or her own values.

Discussed and researched for many years, the concept is now being adopted by some of the world’s most advanced health systems.

In practice, SDM can entail the use of online or in-print decision aids for patients, which set out the various options and evidence regarding treatment of a particular condition. It can also be fostered by clinicians structuring consultations to prompt questions and further discussions with patients, or by information available in the waiting room that encourages patients to probe more about their own health care.

Questions suggested for patients may be as simple as: “What are my options?”

The approach has been adopted by the National Health Service (NHS) in the United Kingdom and has been labelled the “sleeper provision” in the United States’ Affordable Care Act, aka “Obamacare”, but has not yet been widely implemented or adopted in Australia.

However, Australia does have some of the world’s leading SDM researchers, and late last month many of them gathered at events in Sydney and on the Gold Coast to discuss how to move from a strong evidence base and enthusiasm towards implementation in practice.

“It’s really a natural extension of good evidence-based practice”, University of Sydney researcher and general practitioner, Associate Professor Lyndal Trevena says.

Professor Trevena has led the field with her work looking at the use of decision aids to inform patients when making decisions about cancer screening and, more recently, with immunisation.

“What it does is actually make the decision-making process more explicit. We as GPs always try to personalise decision making to our patients, but as information becomes more sophisticated and complex, it’s impossible for us to be able to cover complex decision making in our time-poor environment across the whole range of conditions, and we need good summaries of evidence and the tools to make our lives easier.

“We just can’t go away and look up every single thing every single time a new condition comes along.”

Decision aids are one such tool, she says.

Shared decision making in practice can also help prevent any mistakes in anticipating what a patient would prefer when it comes to treatment.

“We think we know what our patients want and we think we know what’s important to them but actually a lot of the time we don’t get that quite right”, Professor Trevena says. “It’s really good to have a process that allows you to get the patient to volunteer that [information].”

Research also shows that when patients are well informed, in many cases they will choose the less expensive, less invasive interventions.

Professor Trevena was part of a team at the University of Sydney’s School of Public Health that examined what occurred when patients asked three particular questions of their GP: “What are my options?”, “What are the benefits and harms?” and “How likely are these?”.

The small-scale study showed that in response to the questions, the quality of the information provided by the GPs improved, and it encouraged them to increase the patients’ involvement in the decision-making processes.

So would an SDM consultation take more time? The research on this topic is not clear-cut. If unnecessary treatments can be avoided, then it will save time.

However, clinical psychologist Dr Simon Rice, who was involved in an SDM trial with a decision aid for use by young people suffering depression, says that in his experience additional time is required to talk through the options properly with patients before coming to a decision.

Dr Rice points out that this extra time may be crucial because “when there’s someone presenting with a quite severe level of disorder there’s usually an onus on wanting to hurry up and intervene and get planning and get them on the right track”, he says.

But, ultimately, he says that with SDM, the buy-in from the patients can be much higher and the outcome more positive.

“Typically, once the decision is made, the young person tends to have more invested in the decision, when there is a degree of collaboration around.

“I think that they have more information than they would have otherwise without using the structured decision aid in that process.”

In this way any concerns about treatments can be addressed up-front in consultation.

Dr Rice refers to one instance in particular in which a young man he had been working with who had been very intermittent in his medication, and whose condition had been unstable as a result, had clearly benefitted from having an explicit voice in the decision-making process and had re-engaged in his treatment.

Professor France Légaré of the Université Laval in Quebec, Canada, has been conducting large-scale studies of how structured decision-making tools work in practice in the past decade.

She says the response from the primary care practitioners who have been taking part in the studies has been encouraging and concerns about time consumption can be overcome by restructuring consultations to include SDM rather than adding it on at the end.

“We’ve never been kicked out of a practice. If you’re bringing problems to a clinic you don’t survive there. It may be a sign that we were bringing a useful tool to the practice”, Professor Légaré says.

She is one of the world leaders in research looking at how to implement SDM in practice and was in Australia last month conducting workshops and addressing the Royal Australian College of General Practitioner’s 2013 annual conference as a guest of the Australian Commission on Safety and Quality in Health Care (ACSQHC).

In her opinion, it is a good thing that the Commission is taking a national leadership role and that Australia is well placed to implement SDM more widely.

“You have very good researchers, you have people who know about this, who work on this and talk about this carefully. You have the policymakers and you have the consumer and patient organisations buying into this”, she says.

Dr Heather Buchan is director of implementation support with the ACSQHC and says they are at an information-gathering phase to find out how much formal SDM is already occurring.

Contact has been made with the medical colleges and the Commission is likely to do further work to both encourage health literacy in the patient population and improve the communication skills of clinicians at the same time, looking at what kinds of decision aids would be most valuable in the Australian context and how they can be made more easily available.

“There is evidence that people want to be more involved in the decisions than they currently are and that risk communication in particular is not done as well as it should be. We have great opportunities to improve on that”, Dr Buchan says.

“That’s the point of care isn’t it? It’s that people get a good outcome and have the care that they most value and most want and are prepared to accept the likely risks and the likely benefits and understand what they are.”

For now, Dr Buchan says, it’s working out the most intelligent way to make it happen

  • Annabel McGilvray



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