Program planners predict shared decision making (SDM) will be a hot topic when the American College of Cardiology (ACC) hosts its 2018 Scientific Session March 10-12 in Orlando. They’ve planned a two-part intensive, as well as several other sessions, around the subject.
The right timing
While the idea of patients and families participating in their care decisions is hardly new, SDM is catching the attention of the cardiology community now more than ever, says ACC.18 Program Chair Jeffrey T. Kuvin, MD. In the era of big data and fast news, where patients may have several acceptable therapeutic options, clinicians need to ensure that patients truly understand “the routes they might take, what each route entails, what the data are for each as well as the risks and benefits,” explains Kuvin, chief of cardiovascular medicine at Dartmouth-Hitchcock Medical Center’s Heart & Vascular Center in Lebanon, N.H.
Kuvin tasked members of the ACC.18 planning committee with developing a four-hour intensive session that would guide attendees through the science of helping patients choose among care options where tradeoffs can be confusing and the better choice may have more to do with the individual’s values than data or guidelines.
People may not know it, but “there really is science to decision making,” says Shane J. LaRue, MD, who helped plan the SDM intensive. Now an assistant professor of medicine at Washington University School of Medicine in St. Louis, Mo., LaRue’s experience with SDM grew out of his work with the University of Colorado School of Medicine left ventricular assist device (LVAD) program and participation in the LVAD-DECIDE trial.
The LVAD decision “is very preference oriented, which is when SDM is the most appropriate,” LaRue says, “because it’s not for us, the clinicians, to make a decision on the values of another person. [He or she needs to consider] years of life vs. complications, time in hospitals, expense, time with family and so on. And there are other things that are less obvious that we’ll look at during the ACC.18 intensive.”
Kuvin and LaRue stress how challenging and time-consuming—but still important—it can be for clinicians to outline factors that impact a treatment choice, from safety and comparative effectiveness to cost and health literacy. Their goal for the ACC.18 SDM intensive is to explore how to navigate that complexity, including how to “mainstream” decision aids into cardiovascular practice. Highlights from their conversations with Cardiovascular Business follow:
Why the focus on SDM at ACC.18?
LaRue: SDM has been important for decades, but its value is being recognized much more now for several reasons. It got a big boost in 2001 when the Institute of Medicine identified six characteristics of high-quality care, including that care should be patient centered. Next, the Affordable Care Act called for the development of more patient decision aids and a focus on metrics for quality decision making. And then, most recently, the Centers for Medicare & Medicaid Services approved left atrial appendage closure (LAAC) procedures with a requirement for a SDM interaction with a non-implanting physician. Tying reimbursement to SDM was a huge step. The cardiology world started asking, “What is this, and what do I need to know about it?” So, it’s the right time to bring SDM to a bigger audience and help people with it.
Kuvin: It also fits with the ACC’s approach to purposeful education. By that, we mean informative, innovative education delivered in an interactive way for an interdisciplinary audience. SDM is based on those four ideas, too. It’s the sharing of critical information between healthcare providers and patients and their families, how the healthcare provider is interactive with the family. It’s also how the clinician thinks innovatively about all the possibilities for treating a patient and shares that information with the patient and family. And, finally, it’s interdisciplinary—not just the provider and the patient but many others from the healthcare community who contribute to the process.
We’re highlighting SDM at ACC.18 in large part because SDM is critically important to patient-centered healthcare. SDM occurs when healthcare providers, patients and families work together to make important medical and life decisions regarding testing, treatment and care plans that are based on clinical evidence—especially now, when we know a lot in terms of evidence-based medicine and we often have many options.
Wouldn’t many cardiologists say they’ve been doing SDM?
LaRue: There are people who do it more than others, but I would argue it’s not being done as much or with as much rigor as it should be. One goal for the ACC.18 intensive is to share the science of SDM with people who may not know how it works or when it’s appropriate.
The clinician is supposed to be agnostic—neutral and balanced with regard to some decisions. It can be hard to truly not bias a treatment one way or another. Obviously, there are times that’s appropriate because there’s really a big difference between the options, but there are other times when the patient’s preference needs to drive the decision, and both sides should be represented fairly equally. That’s where a good decision aid can help.
Kuvin: SDM may be less important in some things, such as STEMI, where the evidence is clear what’s best for the patient. There’s the standard of care without much controversy and there’s less need for SDM or a decision aid. But there are many examples today where we need to use SDM daily because of the complexity of available options. For example, anticoagulation vs. LAAC to prevent stroke in atrial fibrillation; surgical or percutaneous treatment for some forms of valvular heart disease; surgical and temporary mechanical device options that, with medical therapy, are options for some patients with advanced heart failure; alcohol septal ablation compared to surgical myectomy for hypertrophic cardiomyopathy; whether to implant an ICD for a patient with ventricular arrhythmia; and palliative care vs. forging ahead with advanced therapies.
LaRue: SDM may be more or less important in some specialties, perhaps more where treatments are preference sensitive and less where there’s a preponderance of evidence of benefit and little risk. But it’s becoming more important across the spectrum as new data come out. With ORBITA, for example, the SDM around stenting might be harder.
Kuvin: The complexity is another reason that ACC.18 is offering the intensive on SDM as well as other SDM sessions, and why we introduced a new abstract category dedicated to SDM. In fact, as part of the SDM intensive, participants will take a break—we call it a field trip—to see the abstracts. First, the in-class portion will be panel discussions and cases focused on the science of SDM and decision aids. Then we’ll move toward the new findings as shown by the abstracts and, last, we’ll come back to the classroom and discuss how to take the science back to our practices and to the bedside.
LaRue: That’s where we’ll talk about mainstreaming SDM and demonstrate practical resources. We’ll walk through decision aids with the people who developed them. They’ll explain what informed their process and how the aids can be used in practice. It’s ambitious, but it’s important that ACC.18, a clinician-oriented meeting, really show how to do something differently in practice to more consistently use SDM.
Don’t patients sometimes ask, “What would you choose for your parent, Doctor?” Do some want to cede the decision to their doctor?
LaRue: Almost every time there’s an involved discussion. And that’s a reason to value decision aids, because it’s another way your bias can sneak in, such as when you say, “Well, my mom would definitely get an LVAD or my mom would have the TAVR.” I hope to handle it by saying, “My mom and my dad are different people from you and they have their own values, just as you do. I think I know how my mom or dad would choose based on how they’ve lived their lives, but that doesn’t necessarily reflect what’s important to you in all this.” In other words, I try to not answer that question directly because it’s a bias. It takes the decision away from the patient.
It’s important to add that some patients really don’t want to be forced to make the decision on their own. And that’s an opportunity to use a decision aid to help them clarify their own values. The decision aid invites them to dig deeper than which treatment they want. It asks, “Is it more important to live every extra minute you can in the hospital with machine help, or do you want to be outside of the hospital but maybe not feeling as well and not living as long?” The decision aid helps you help them understand what they value.
What about cost considerations? Will ACC.18 faculty demonstrate how to talk with patients about their deductibles and co-pays?
Kuvin: Cost should be part of the SDM discussion. It can have very important implications for choosing one pathway vs. another. It gets complex in terms of insurance, deductibles and many other things. Part of the ACC.18 intensive is looking at real-world examples, with the goal of arming clinicians with practical tools and resources to use in daily practice.
LaRue: The intensive will include things like cost, such as with the angiotensin receptor/neprolysin decision aid, which does address cost. But a lot of today’s decision aids don’t address cost directly, so we’ll highlight ways we all can do better.
Keep in mind a good decision aid should be looked at as a tool to facilitate SDM, rather than be the decision maker itself. It should help people understand the big picture, the pros and cons of treatment alternatives, but also help them think of potential questions. We may not be able to spell out exactly what the costs will be, but certainly there should be a trigger to point out that cost could be an issue.
The intensive agenda refers to “controversies and conversations.” Is navigating controversy a driver for teaching physicians how to approach SDM?
Kuvin: With so much data out there, there will be controversies over what’s best. Clinicians want to hear thought-leaders discuss these important topics. At an in-person meeting, attendees can ask questions and join the conversation, whether it’s anonymously through the ACC.18 app, with the audience-response system or during the discussion portion of each session. We need to explore experiences that attendees are having all around the world to understand the nuances of real-world practice.