DHMC - Dartmouth-Hitchcock Medical Center, General Internal Medicine
WRJVA - White River Junction VA Medical Center
PGH - Pittsburgh VA Health Care System
Researchers and clinicians in the Division of General Internal Medicine at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, New Hampshire and at White River Junction VA Medical Center have been studying shared decision-making in the primary care setting for several years. They are now joining with a primary care site within the Pittsburgh VA Health Care System (PGH). The more than one hundred primary care clinicians at these practices perform about 80,000 patient visits each year.
Staff and health care providers at the academic practices are continuing the work DHMC and WRJVA began in a previous Foundation demonstration project, during which they studied two different models for distributing decision aids: delivery before and delivery after the clinician visit. In addition to delivery method, the team studied how to best market decision aids to clinicians, timing of decision aid use, use of feedback loops, and mechanisms to “close the loop” after decision aid viewing. The project team distributed decision aids on prevention (prostate cancer screening and colon cancer screening), discrete medical decisions (benign prostatic hyperplasia, knee osteoarthritis, low back pain, depression, advance directives, spinal stenosis, and hip osteoarthritis), and chronic disease (congestive heart failure and diabetes).
From the initial study, the team learned that decision aid viewing prior to the index visit is preferable; that providers don’t consistently prescribe decision aids; that an “opt out” method, in which decision aids are automatically sent to all eligible patients, is the most effective means for distributing decision aids; and that systematic distribution prior to the visit is preferable but more challenging to implement. Based on these results, the team will focus on strategies to maximize the delivery of decision aids in the primary care setting, assess the impact of decision aids on decisions regarding treatments for preference-sensitive conditions, and study methods for encouraging clinicians to prescribe decision aids more consistently.
The team also will try to shift the use of preference-sensitive decision aids earlier in the process of care to increase patient involvement in the decision-making process and have a greater impact on the care received. Earlier use of decision aids may allow patients to clarify their treatment preferences and decide whether or not to seek specialty consultation, potentially reducing unnecessary referrals.
Through previously held focus groups with providers, the team discovered a number of barriers to prescription of decision aids, including reluctance to prescribe decision aids without being familiar with the content; sense of intrusion into the provider-patient relationship; and lack of familiarity with the goals and concepts of shared decision-making. To address these barriers, the team plans to launch clinician educational programs, create a tool summarizing each decision aid; enhance cues and reminders; market decision aids to providers and patients; and optimize use of the electronic medical record for communicating key data about the decision-making process. The team will assess the effectiveness of the current demonstration project by evaluating decision aid prescription rates, treatment choice, patient preparedness for visits, patient satisfaction, and other metrics. For more information about this implementation project, please contact Martha M. Coutermarsh, RN at gimsupport@hitchcock.org .