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Dartmouth-Hitchcock Medical Center (DHMC) is comprised of physicians, specialists and other providers working together at different locations to meet the health care needs of patients in northern New England. The Center for Shared Decision Making (CSDM) at DHMC, opened its doors in 1999 as the first center in the U.S. to be dedicated to shared decision making, and became a Foundation-funded primary and specialty care demonstration site at that time. True pioneers in the shared decision making arena, DHMC continues to perfect the process of providing access to decision aids and decision support to patients as a routine process of care.
Blair Brooks, MD discusses the use of a patient decision aid during a PSA consultation.
Current Shared Decision Making Activities
The DHMC demonstration site consists of the general internal medicine department and multiple specialty care units including the DHMC Comprehensive Breast Program, Spine Center, Orthopedics department, and Urology and Radiation Oncology departments. Together, they currently offer a suite of more than 30 Foundation decision aids (Shared Decision-Making® programs) to their patients. Topics include back pain, breast cancer, heart disease, prostate cancer and women’s health, among others.
An Innovative Model for Shared Decision Making
Decision support counselors at the CSDM offer one-on-one decision support to patients who have been referred by their health care provider or are self-referred. The staff assists patients in preparing to fully participate in decisions about their health care. The CSDM contains a decision aid library of educational tools for patients and their families to use before, during or after a medical appointment.
General Internal Medicine
All men turning 50 who are scheduled for their annual physical exam are mailed the PSA test decision aid along with their appointment letter. A cover letter encourages the patient to view the decision aid prior to their appointment. For a number of other conditions, including type 2 diabetes, back pain, depression and BPH, providers prescribe a relevant decision aid after an appointment. DHMC is studying whether provision of a decision aid prior to referring to a specialist “provisional referral” impacts the intent to be seen by a specialist.
Comprehensive Breast Program
A primary goal of the Comprehensive Breast Program is to identify optimal strategies for helping patients make good decisions about their breast cancer care. To achieve this goal, program staff has integrated a pre-visit model of distribution of the breast cancer suite of Foundation decision aids into the standard care path for women with early stage breast cancer. In addition to improving the real-life care of patients with breast cancer, the team has learned a great deal about patient decision-making for the surgical and adjuvant therapy treatment of early stage breast cancer.
Health care providers at the DHMC Spine Center refer patients to the CSDM to receive a decision aid about treatment options for spinal stenosis or a herniated disc. Patients who have already made a choice to proceed with surgery for one of these conditions are also referred to the decision aid as part of the informed consent process for surgery, ensuring that patients have reasonable expectations of surgical outcomes. Providers may also refer patients for the chronic low back pain or chronic pain management decision aids. The team is currently conducting a randomized study of patients with spinal stenosis to assess whether speaking with a decision coach by telephone after viewing the decision aid impacts the level of knowledge or decisional conflict, and whether those who receive coaching perceive this intervention to be beneficial.
Providers in the orthopedics department refer patients who are considering joint replacement for hip or knee osteoarthritis to the CSDM. The team has recently redesigned the workflow process to move from a post-visit model to a pre-visit model of distribution. Shared decision making questions have been incorporated into the electronic health questionnaire patients complete at multiple points during their care.
Urology and Radiation Oncology
Health care providers within the urology and radiation oncology departments at DHMC have successfully integrated a pre-visit model for delivering the Foundation decision aid “Treatment Choices for Prostate Cancer” to all newly diagnosed men with early stage prostate cancer. Prior to visits, all patients complete an electronic health questionnaire that incorporates shared decision making questions. This allows the counseling provider to easily assess the knowledge and decisional support needs of the patient. The team is currently in the process of collecting data to assess the distress and decisional conflict experienced by men newly diagnosed with prostate cancer. This data will be used to compare distress and decisional conflict in newly diagnosed breast and prostate cancer patients.