Support for shared decision making—a process defined as patients and clinicians mutually engaging to align clinical decisions with patient values and preferences—is gaining momentum among patients, physicians, payers, and policymakers. As shared decision making has been associated with better-informed patients and the selection of less invasive—and thus less costly—treatment modalities, its widespread implementation is a key strategic goal for private and public health systems across the nation.
The Current State of Shared Decision Making
While patient-centeredness and evidence-based medicine have been acknowledged as two central tenets of shared decision making, effectively embedding these concepts into clinical workflows has proven challenging. Tools that support patients and physicians in shared decision making have been developed for many conditions and clinical decisions; for example, decision aids have been shown to improve patient understanding of treatment options available for their conditions, and risk calculators have been created to estimate the risk of complications and other adverse outcomes resulting from procedures such as total joint arthroplasty. However, existing tools provide estimates that are based on average risks and outcomes for a population of patients, and patients and their providers often find themselves asking, “Do these risk estimates apply to me?” This question illustrates a need for personalized shared decision making programs from which patients and their providers can gain a more precise understanding of potential risks and likely outcomes. Patient Reported Outcomes Measures (PROMs)—validated instruments that provide quantifiable measures of health outcome from a patient’s direct input—are increasingly being used in clinical practice. With shared decision making being a key focus of new care delivery models, incorporating PROMs into shared decision making ensures that outcomes that matter to patients are accounted for in clinical decisions.
Shifting the Paradigm to Personalized Shared Decision Making
Dell Medical School at The University of Texas at Austin has implemented a shared decision making process that facilitates personalized, patient-centered, evidence-based clinical decision making. General health and condition-specific PROMs are collected for every patient seen in our Musculoskeletal Institute with use of several short, validated health questionnaires that are administered through an electronic interface prior to the clinic visit. An assessment of anxiety, depression, and overall mental health is generated through patient responses to the PHQ-2 (a 2-question depression screening tool) and the mental health component of the PROMIS Global-10 (a 10-question survey of overall health). A physical function score is calculated with use of the physical component of the PROMIS Global-10 along with condition-specific pain questionnaires such as the HOOS JR and KOOS JR (questionnaires designed for patients with hip and knee osteoarthritis, respectively).
PROM surveys are completed by patients either prior to their visit or at the time of registration, and both mental and physical function scores are available in real time for the care team to discuss with the patient during the visit. Particular attention is given to how the patient’s function compares with that of other patients of similar age and sex with osteoarthritis and how this factor impacts the patient’s likelihood of achieving a clinically meaningful benefit from surgical and nonsurgical treatment options. Using PROMs to augment the clinical decision making process provides patients with a more personalized estimate of the risks and benefits associated with various treatment modalities; leads to clinical decisions that are better aligned with patients’ preferences, values, and goals; and thus facilitates more appropriate treatment.
Osteoarthritis care, which is characterized by a high resource burden and multiple treatment options ranging from lifestyle modifications to total joint replacement surgery, is particularly suited to highlight the impact of personalized shared decision making through the integration of PROMs. As primary total joint replacement for the treatment of osteoarthritis is an elective procedure that is undertaken to achieve the goals of reducing pain and improving function and quality of life, treatment decisions should be informed by patient preferences and values rather than provider preferences. In a previous study of shared decision making in patients with hip and knee osteoarthritis, we found that patients who participated in a clinical program that emphasized shared decision making through the use of clinical decision aids and health coaches demonstrated a greater likelihood of arriving at an informed decision during the initial clinical encounter and had higher confidence in knowing which questions to ask their doctor. There was no significant difference in the duration of the in-office consultation or the proportion of patients opting for surgery between the shared decision making group and the control group, and surgeons reported greater satisfaction with consultations under the shared decision making program. While the study documented the benefits of shared decision making in the care of patients who suffer from osteoarthritis, the methodology utilized conventional education materials and decision aids as opposed to personalized decision tools based on individual patient characteristics and PROMs.
Clinical Practice and Policy Implications
The dearth of personalized shared decision making tools highlights a significant opportunity to improve clinical decision making. Specific opportunities include (1) providing quantifiable estimates regarding the potential benefits of treatment modalities rather than just the risks, (2) personalizing estimates of benefits and risks on the basis of a patient’s PROMs and demographic and clinical characteristics, and (3) providing those estimates in terms of the likelihood of achieving clinically meaningful improvements in quality of life, function, and pain. Furthermore, as patient-reported baseline functional status and mental health have been linked to the probability of achieving a clinically meaningful benefit from total hip and total knee arthroplasty, providers using PROMs in shared decision making are better able to identify patients who are most likely to benefit from these procedures.
As a result of the implementation in 2016 of the Centers for Medicare and Medicaid Services (CMS) Comprehensive Care for Joint Replacement model, which bundles reimbursements for hip and knee arthroplasty episodes, providers are now incentivized to work toward novel solutions that will drive improvements in patient outcomes and reduce costs associated with the care of patients with hip and knee arthritis. Incorporating PROMs into shared decision making has the potential to enhance the delivery of care to patients with a variety of preference-sensitive conditions. Harnessing the full potential of shared decision making requires a bilateral understanding: the patient should be sufficiently informed about the evidence behind a potential treatment intervention, and the provider should fully appreciate the patient’s preferences and values. By promoting care that is appropriate, patient-centered, and evidence-based, personalized shared decision making processes that incorporate PROMs represent an integral component of that partnership.
This article originally appeared in NEJM Catalyst on August 30, 2017.