Shared Decision Making, Social Media, Adult Learning, Palliative Care, and Hospice a Marriage Made In Heaven

January 3, 2013 Emily Oshima Lee, M.A. and Exekiel J. Emanuel, M.D. Ph.D published a perspective article in the NEJM on “Shared Decision Making to Improve Care and Reduce Costs” Here is the link.

The authors examined the current state of shared decision making (SDM) and how the Affordable Care Act (ACA) positions and expands its benefits. 

Shared decision making (SDM) ensures that medical care aligns with patient’s preferences and values. SDM applies decision aids to inform both patients and family of various treatment outcomes which in turn improves patient knowledge, minimizes anxiety, improves outcomes while helping to manage cost. It is a win win for patient, HCP, and institution. 

But sadly SDM is under used. The authors point out a study of over 1,000 office visits with more than 3,500 medical decisions showed less than 10% of the decisions met the minimum standard for SDM. Another study showed that only 41% of Medicare patients thought their treatment reflected their preference for palliative care over more aggressive treatment. 

Section 3506 in the ACA (found here) offers funding for consensus-based standards and would certify patient decision aids. Health care providers (HCP) would be eligible for grants in this area to test SDM models and approaches that show savings, improved quality of care, etc. 

The authors point to data that demonstrates SDM reduces cost shown by the fact that nearly 20% of patients who participate in SDM choose less invasive surgical options and the conservative treatment than patients who do not use decision aids. Using SDM for just 11 procedures could yield greater than $9 billion in savings across the nation.

It is interesting that the International Patient Decision Aid Standards Collaboration has evidence-based guideline for certification that includes questions in order to aid patient to gain insight on their values and those values that affect their decisions. All of this includes up-to-date data in simple plain language including side effects and complications. 

I would recommend you read the entire piece. It is short but filled with data, information, knowledge, and recommendations. 

For me SDM is part and parcel of adult learning and social media (SM). I am in no way questioning how SDM has worked, is working, and will work. Nor am I second guessing the data. In my view SDM integrates SM and adult learning to potentiate its benefits. 

The primary principle of adult learning tells us adults will learn when they are seeking solutions to problems they want to solve. Patients facing complicated and confusing treatments are seeking solutions to serious problems. SDM steps into to help solve the problem using aids, questionnaires, and electronic media. And by all studies is successful in achieving outcomes. SDM works and is in fact helping patients solve problems while at the same time solving problems for the HCP. There is nothing to change but, can we add a little something something to improve an already good idea?

Perhaps if prior to the first SDM discussion a short inventory is performed to determine what problems the patient wants to solve, what solutions do they know, what do they think about what they know, and based on that what would they do. This exercise is designed to improve the HCP knowledge of the patient prior to the SDM discussion and aids in focusing the patient on treatment decisions. It also aids in improving the decisions. For the HCP this should be considers a needs assessment for a specific patient on a specific topic. What is determined here is information that can be used to improve SDM. 

Palliative care is an ongoing decision making exercise. In a previous post (here) I examined the role of the palliative care physician and hospice care to improve patient care. SDM improves this process and fits so well with the entire continuum of palliative care through to hospice. SDM should be part of all cancer care and should be especially valuable with those patients facing a terminal outcome. SDM is a perfect tool in palliative care but would benefit from doing the type of needs assessment mentioned above and ongoing measurement of change in patient attitude and problems. The trajectory of the disease is one that requires continual learning and discussion. 

Finally, social media can aid this entire process through connecting of patients with each other and with their HCP. These communities of sharing and exchanging knowledge and information focused on a medical need can underpin and become the foundation for understanding those problems the patient wants to solve as well as the the HCP has regarding patients. Social media becomes part of SDM  strategy as a tactic to engage more patients with the process of decision making at a more robust level. 

SM is a tool a tactic whose application is critical to achieving goals through a strategy. SDM offers a very clear set of goals and path to achieve better patient outcomes. SM can be integrated into SDM to improve the process across the board.

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