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March 4th, 2015

REPOST: Stop blaming “demanding patients” for driving up health care costs (2/24/2015)

By Victor M. Montori manosin

Posts like this, make http://www.healthnewsreview.org/blog/ our go-to blog for news reviews from an evidence-based patient-centered perspective.  You must bookmark it, follow it on Facebook and twitter and do what you do to keep connected to its content. Thank you, Gary Schwitzer (@garyschwitzer) and your team for keeping this going on and strong!



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Tags: evidence based medicine, Shared Decision Making

February 17th, 2015

Was a decision made? An assessment of patient-clinician discordance in medical oncology encounters.

By Victor M. Montori manosin

Oncology encounters are highly complex. Communication is suboptimal and there is evidence that patients and clinicians often fail to "get on the same page." Shared decision making is being promoted as a means of facilitating effective and patient-centered communication in oncology. Here, Dr. Aaron Leppin and colleagues survey patients and clinicians immediately after an oncology encounter to determine the extent to which they agree on whether a cancer care decision was made during that encounter. The extent of agreement is impressively low. These findings have implications for the way we think about shared decision making and the validity of its measurement in oncology. (click here for  abstract)

by Aaron Leppin


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December 12th, 2014

New Shared Decision Making iPad® Supplement for Circulation: Cardiovascular Quality and Outcomes

By Victor M. Montori manosin

Circulation: Cardiovascular Quality and Outcomes has released a free iPad® Supplement devoted to the topic of Shared Decision Making (SDM). The topics included in the supplement are intended to provide a comprehensive overview of the state of the art in SDM within cardiovascular diseases.

Featured articles include:

1.    Shared Decision Making: Science and Action
Henry H. Ting, Juan Pablo Brito, and Victor M. Montori

2.    Shared Decision Making: State of the Science
Grace A. Lin and Angela Fagerlin

3.    Design and Testing of Tools for Shared Decision Making
Daniel D. Matlock and Erica S. Spatz

4.    Measuring Shared Decision Making: A Review of Constructs, Measures, and Opportunities for Cardiovascular Care
Karen R. Sepucha and Isabelle Scholl

5.    Implementation of Shared Decision Making in Cardiovascular Care: Past, Present, and Future
Erik P. Hess, Megan Coylewright, Dominick L. Frosch, and Nilay D. Shah

6.    Higher Integrity Health Care: Evidence-Based Shared Decision Making
Glyn Elwyn and Elliott Fisher

To access the free supplement, visit the App Store℠ and download Circulation: Cardiovascular Quality and Outcomes for the iPad® for free. Both the app and the supplement are available free of charge.


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November 19th, 2014

The New Statin Choice Decision Aid

By Victor M. Montori manosin

With a new interface that includes versions in English, Spanish, and Chinese, the Statin Choice decision aid (http://statindecisionaid.mayoclinic.org) is out. With over 70,000 uses worldwide year-to-date and new policy endorsements for its use (JAMA Article), the Statin Choice decision aid is helping patients and their clinicians have meaningful conversations about whether to use statins to reduce cardiovascular risk. It helps them adhere to the new guidelines, in a patient-centered manner. And with new work to integrate the tool into all major EHR providers, it may be the best demonstration of meaningful use.

Enhancements from the first version also include two options for printing in the office: color and black-and-white, in addition to the existing option to emailing the tool after its use to the patient, a family member, or another clinician. In terms of new content, the biggest difference is the exclusion of the aspirin component (see below).  We have also beefed up the Documentation tab, an copy-and-paste interim solution before full integration into EHR to enable documentation of shared decision making, a key step toward advancing these conversations as a measure of quality of care.

This version is the result of hundreds of notes suggesting changes and enhancements that result form the experience of using it in practice. We hope to have responded properly. And thank you.

Why was aspirin removed from the latest version of the Statin Choice decision aid?

In response to the new AHA/ACC guidelines for cardiovascular prevention, there has been renewed interest in using the Statin Choice decision aid to translate the recommendations in a patient-centered way.  With this attention, there has been interest from preventive cardiologists in using this tool. They brought to our attention that indeed the evidence about efficacy of aspirin for the primary prevention of cardiovascular disease is inconsistent: clearer effect in men in relation to heart attacks but not stroke, in women about preventing strokes but no so much heart attacks and a series of negative trials in patients with diabetes and peripheral vascular disease have made it difficult to provide a simple message to all at-risk patients: a baby aspirin can reduce your risk of cardiovascular events. Also, emerging evidence suggests that the risk of bleeding with aspirin goes up as the risk of cardiovascular events, such that those who may benefit the most are also most likely to be harmed (although most aspirin bleeds are relatively inconsequential compared to a heart attack or a stroke).

This inconsistency is reflected, for example, in the US Preventive Services Task Force guidelines: http://www.ahrq.gov/professionals/clinicians-providers/resources/aspprovider.html.

Concerns are best reflected in this FDA advisory against primary prevention with aspirin from May 2014: http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ucm390574.htm

It is telling when experts are talking more about using aspirin to prevent colon cancer than to prevent cardiovascular events (to our knowledge no one is yet recommending it for this purpose).

We will continue to monitor this evidence as we, the producers of Statin Choice, thought the evidence was good enough to add to and keep in the tool, and we will have a low threshold to put it back in as new evidence emerges, both of its efficacy and harm.

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Tags: AHA/ACC guidelines, Shared Decision Making, statin choice

October 31st, 2014

Making a case for patient-centered care

By Victor M. Montori manosin

During the period 2013-2014, authors in the KER UNIT have published JAMA viewpoints that have expressed our philosophy of clinical care and research.

In June 2013, Hassan Murad and I wrote a viewpoint paper called Synthesizing Evidence: shifting the focus from individual studies to the body of evidence. In this article, we pointed out five reasons why it was important to focus on the body of evidence rather than on individual studies. Among these, was the importance of avoiding misleading evidence that results from design features focused on enhancing the stand-alone value of the single paper. Our bottom line was to rescue the importance of generosity in the construction of systematic reviews and meta-analysis that offer evidence that can support people at the frontline trying to practice evidence-based care.

In December 2013, again with that Hassan Murad and Juan Pablo Brito, we published the viewpoint entitled The Optimal Practice of Evidence-based Medicine: incorporating patient preferences in practice guidelines. In this article, which was focused on the challenges of incorporating preferences guidelines, we pointed out the importance of taking into account patient view in the consideration of the full range of outcomes that patient experience and consider critical, and in deciding the relative importance of these outcomes. We also made the case that guideline panels should not make strong recommendations when the best course of action heavily depends in patients’ context, values, and preferences. This opened the door to connecting guidelines with decision aids that could support the construction of informed preferences in patients who face clinical dilemmas with their clinicians. Of interest we also pointed out that the clinicians should remember that taking care of patients is supposed to be difficult and that guidelines while simplifying this task cannot really do so when patient preferences and context matter and in that case they cannot replace “clinicians’ compassionate and mindful engagement of the patient in making decisions together”. We pointed out that this, patient-centered care, is indeed the optimal practice of evidence-based medicine.

A couple of months later, again with Dr. Brito and Dr. Ting, we published a viewpoint applying these principles to the new cholesterol guidelines. In this instance, we were able to offer a video of the process of using the Statin Choice decision aid in patients that the guideline considered for the use of statins. We point out in this paper that the principal value of the new cholesterol guidelines was their ability to realize the opportunity to advance patient centered care and shared decision-making, enabling new conversations between clinicians and patients. We also invited policymakers to consider that the new performance measure target should be the proportion of eligible patients who were able to take part in shared decision-making.

Finally in October 2014, in collaboration with my colleagues Tammy Hoffman and Chris del Mar, we published a viewpoint making the connection between evidence-based medicine and shared decision-making, presenting shared decision-making as a manifestation of evidence-based medicine that uses patient centered communication to engage patients (figure). Perhaps the most important message of this paper was a statement that medicine cannot and should not be practice without up-to-date evidence and without knowing and respecting the informed preferences of patients. It called for clinicians, researchers, teachers, and patients to be aware of and actively facilitate the interdependent relationship of these approaches. The piece concluded with the notion that evidence-based medicine needs shared decision-making and that shared decision-making needs evidence based medicine. It finished by stating that patients need both. The two indeed will come together to some extent at the International Society for Evidence-based Healthcare meeting in Taipei and more fully in the joint meeting of this society and the International Shared Decision Making conference in July in Sydney.

This has been a wonderful year for a journey in which we have been able to make statements connecting the tools of evidence-based medicine (guidelines) with tools for shared decision making (decision aids) with our principles of patient centered care, integrity, and generosity that underpin the work of the KER UNIT.

 Victor Montori

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Tags: Chris del Mar, decision aids, evidence based medicine, Hassan Murad, Henry Ting, Jaun Pablo Brito, KER Unit, Minimally Disruptive Medicine, Montori, patient-centered care, Shared Decision Making, Tamy Hoffman, viewpoint

April 2nd, 2013

Share decisions because it is the right thing to do

By Kasey Boehmer kaseyboehmer

Written by Victor M. Montori, MD and Jon C. Tilburt, MD

Lee and Emanuel raise the profile of the shared decision making (SDM) provisions in the Patient Protection and Affordable Care Act. We concur that those provisions should spur research and development in SDM. However, their claims, that we already know how to implement SDM and that it is time for pay-for-performance for use of certified decision aids, are both premature and misguided.

Studies of decision aids implemented outside clinical visits show improvements in patient knowledge about the available options and about their risks and benefits, but not in actual sharing of decision making. Decision aids for use by patients and clinicians during the visit may work better. Video data from hundreds of recorded visits show a stark difference: patients in decision aid visits are better informed and participate more in making decisions. Patients and clinicians end up more comfortable with decisions they made together. In-visit decision aids galvanize patients and clinicians around a shared a purpose – to make the best possible evidence-based decision given the patient's values, preferences, goals, and context. Yet, getting this degree of patient engagement does not happen with the flip of a switch and routine implementation remains untested.

Lee and Emanuel rightly point out the potential utilitarian benefits of SDM, particularly about surgical decisions. However, in so doing they jeopardize the patient-centered vision at the core of SDM. Moreover, their economic claim of cost-savings overreaches the current state of the evidence, making their SDM-linked pay for performance proposal premature. Research on SDM implementation is green, clinicians and patients are not ready, training and tools are just evolving. Thus, we support the law's push for research and development. Their proposal is also dangerous. A focus on cost containment and pay for performance can corrupt the journey toward implementing SDM for all: we fear that the next time a clinician pulls out a decision aid, the clinician will be thinking about reimbursement while the patient wonders whether the clinician has her back.

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February 19th, 2013

National Cancer Institute Launches SDM Measures Repository

By Kasey Boehmer kaseyboehmer

From the NCI Website:

In the last twenty years, numerous studies have empirically examined decision making processes and outcomes in clinical settings. One of challenges that the shared decision making (SDM) research community faces is a paucity of standardized measures of the SDM antecedents, process, quality, and outcomes.

The GEM-Shared Decision Making Workspace (GEM-SDM), a project initiated by the National Cancer Institute's Process of Care Research and Science of Research and Technology Branches, is intended to facilitate discussion in the research community about priority SDM antecedent, process and outcome measures. Specifically, this project aims to identify measures related to shared decisions taking place in a clinical setting, involving patients and health care providers, and is limited to acute (one-time or very infrequent) decisions, as opposed to frequent or often recurring decisions.

GEM-SDM allows the research community to contribute their own SDM measures in the workspace and to provide feedback on the suggested measures. Measures added to the GEM-SDM workspace may include observational or self-reported measures examining the antecedents, process, quality, and outcomes of interactions between patient and medical providers (example: decision quality, prevalence of SDM in various clinical settings.)

The goal of this project is to build consensus around SDM measures for use in future studies, increase standardization of measurement, and promote data harmoniza...tion across studies. Increased use of standardized SDM measures will enable comparability across future studies and help the research community articulate research agendas in SDM.

Visit the website here

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November 16th, 2012

Diabetes Decision Aids in the Media


Dr. Montori was recently featured on Mayo Clinic Medical Edge Radio, which produces a daily 60-second health segment. His discussion about the diabetes decision aids and shared decision making can be heard here.

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November 16th, 2012

ISDM 2013: Call for Abstracts extended


The deadline for abstract submissions for ISDM 2013 has been extended until January 11, 2013. Abstracts are to submitted electronically at the conference website.

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October 2nd, 2012

What is shared decision making?


Mayo Clinic's Dr. Montori recently spoke with IHI Open School regarding shared decision making.  The discussion was captured in two brief videos that can be viewed here. In the first video Dr. Montori discusses the impact of shared decision making on healthcare, and decision aid tools are described in the second video.

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