An Ounce of Prevention
Are Decisions Shared?
The Patient Protection and Affordable Care Act of 2010 (ACA) created several new Medicare programs intended to improve healthcare quality using pay-for-performance (P4P) or value-based purchasing models rather than fee-based service models. In such programs, reimbursement reflects provider performance on metrics that are based on adherence to certain care processes, scores on patient satisfaction surveys, or patient outcomes.
Under Section 3506 (Program to Facilitate Shared Decisionmaking) of the ACA, the Secretary of Health and Human Services (HHS) is now required to contract with an entity to develop, test, and disseminate certified patient decision aids. This provision is meant to encourage the greater use of shared decision making in healthcare.
This growing emphasis on patient-centered care and shared decision making requires fully engaging the patient and family on treatment decisions. Physicians have an ethical responsibility to facilitate the patient’s involvement in treatment decisions. Helping patients become involved in the decision-making process results in better-informed patients and can ultimately lead to better outcomes.
Patient-Centered Care and Shared Decision Making
The patient-centered approach takes into account the individual’s needs, priorities, beliefs, culture, occupation, education, and learning styles. It is a mode of open and shared communication that encourages the physician to consider multiple factors during discussion with the patient about healthcare options. As they discuss management strategies, the physician asks the patient what he or she wants from care. This allows the patient to express concerns about the treatment.
A patient-centered approach can also help the physician determine the patient’s comprehension level of the material. The physician uses communication techniques to ensure understanding, encourage patient satisfaction, and decrease any discrepancy between treatment goals and the patient’s expected outcome. The approach facilitates realistic patient expectations, increases the clarity of patient needs, and aids the physician in adapting the treatment plan accordingly.
Inadequate communication was noted as a significant risk factor in a closed claims analysis of orthopedic cases published by The Doctors Company in 2015. Ralph A. Gambardella, MD, chairman and president of Kerlan-Jobe Orthopaedic Clinic in Los Angeles, responded to the study by stating, “These findings make it clear that healthcare teams and patients need to partner to achieve better outcomes. While improper performance of surgery was the top patient allegation, in most cases the risks had been disclosed to patients prior to the procedure, but the patient may not have understood. In nearly a third of claims, patients did not adhere to the treatment plan, and this behavior was more likely when there was inadequate communication.”1
AHRQ’s SHARE Approach
To help physicians implement a shared decision-making model, the Agency for Healthcare Research and Quality (AHRQ) developed the SHARE Approach, a model using a five-step process that includes exploring and comparing the benefits, harms, and risks of each treatment option through meaningful dialogue about what matters most to the patient.2 The process uses the mnemonic SHARE:
Step 1: Seek your patient’s participation. There are two experts: the physician, with the knowledge of evidence-based treatment options, risks, benefits, and effectiveness of each, and the patient, who knows his or her values, preferences, and what is important to his or her lifestyle. Communicate that a choice exists, and invite your patient to be involved in decisions.
Step 2: Help your patient explore and compare treatment options. Discuss the benefits and potential harms of each option. You can provide educational material and discuss it together.
Step 3: Assess your patient’s values and preferences. After discussing the different options, ask the patient which option fits best with his or her lifestyle and preference. Take into account what matters most to your patient.
Step 4: Reach a decision with your patient. Guide your patient to express what matters the most to him or her in deciding the best treatment option. When your patient is ready, he or she will make a decision. Your patient may also choose to delegate the decision to someone else. You and your patient decide on the best option. Additional education may be provided to ensure the patient can follow the treatment plan.
Step 5: Evaluate your patient’s decision. Support your patient so the treatment decision has a positive effect on health outcomes. A follow-up visit can be part of the treatment plan to evaluate how well the treatment is working.
Find more information and tools to implement at www.ahrq.gov.
A 40-year-old female with severe osteoarthritis in the right wrist received a referral from her primary care provider to an orthopedic specialist. The orthopedist asked the patient to explain her condition in her own words before he began the examination. Throughout the visit, the physician tried to understand the patient’s lifestyle demands and how her disease affected her daily functioning.
The orthopedist recommended arthroplasty based on his experience treating similar cases and the patient’s specific needs. He outlined the process of the surgery, including possible hospitalization time and physical therapy, and noted the most common risks. The physician took care to note that other treatment options were available, and he outlined them in detail. He explained that, in similar cases he had treated, arthroplasty yielded the most consistent and satisfactory results.
He asked the patient to describe what satisfactory results would mean to her. She replied that, as an avid tennis player, pain management and high functionality are important so she could resume playing. The physician considered her desires and explained why he still recommended arthroplasty but would encourage a different type of physical therapy. He took care not to pressure the patient into choosing his recommended option, and he answered her questions honestly about associated risks.
This case highlights the concepts of the SHARE Approach. The physician incorporated the patient’s values, preferences, and lifestyle in the decision-making process. He discussed different treatment options and the risks, benefits, and possible outcomes of each, and he answered all questions. He specifically sought the patient’s definition of a satisfactory outcome. He had the patient review the website for additional information and then recommended a different rehabilitation option following surgery that supported her expectation of being able to resume playing tennis.
Strategies to Improve Physician-Patient Communication:
- Consider using the AHRQ mnemonic SHARE in your practice.
- Use certified patient decision aids to enhance education.
- Always include possible health outcomes (and impact on functional status) and relative cost of treatment or, where appropriate, palliative care options.
- Determine what barriers are present that may prevent optimal treatment decisions
- Document the discussion:
- When and where it occurred.
- Who participated or was physically present.
- The options, risks, benefits, costs, and possible outcomes addressed.
- All of the patient's or his or her surrogate's questions were answered.
- Remember that effective patient-physician communication can reduce claims.
- Study analyzes medical malpractice allegations against orthopedists [news release]. The Doctors Company Press Room; August 27, 2015. www.thedoctors.com/TDC/PressRoom/PressContent/Study-Analyzes-Medical-Malpractice-Allegations-Against-Orthopedists. Accessed December 29, 2015.
- The SHARE Approach. September 2015. Agency for Healthcare Research and Quality, Rockville, MD. www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html.
The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.
The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.
The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.