Leigh H. Simmons

Ten Years, Forty Decision Aids, And Thousands Of Patient Uses: Shared Decision Making At Massachusetts General Hospital

Shared decision making is a core component of population health strategies aimed at improving patient engagement. Massachusetts General Hospitals integration of shared decision making into practice has focused on the following three elements: developing a culture receptive to, and health care providers skilled in, shared decision making conversations; using patient decision aids to help inform and engage patients; and providing infrastructure and resources to support the implementation of shared decision making in practice. In the period 2005-15, more than 900 clinicians and other staff members were trained in shared decision making, and more than 28,000 orders for one of about forty patient decision aids were placed to support informed patient-centered decisions. We profile two different implementation initiatives that increased the use of patient decision aids at the hospitals eighteen adult primary care practices, and we summarize key elements of the shared decision making program.

Responses to a Decision Aid on Prostate Cancer Screening in Primary Care Practices.

INTRODUCTION Prostate-specific antigen (PSA) testing remains controversial, with most guidelines recommending shared decision making. This study describes mens PSA screening preferences before and after viewing a decision aid and relates these preferences to subsequent clinician visit content. METHODS Men were recruited from two health systems in 2009-2013. Participants answered a questionnaire before and after decision aid viewing addressing PSA screening preferences and five basic knowledge questions. At one health system, participants also answered a survey after a subsequent clinician visit. Data were analyzed in 2014. RESULTS One thousand forty-one predominantly white, well-educated men responded to the pre- and post-viewing questionnaire (25% and 29% response rates at the two sites). After viewing, the proportion of patients leaning away from PSA screening increased significantly (p<0.001), with 386 (38%) leaning toward PSA screening versus 436 (43%) before viewing; 174 (17%) unsure versus 319 (32%) before; and 448 (44%) leaning away versus 253 (25%) before. Higher knowledge scores were associated with being more likely to lean against screening and less likely to be unsure (p<0.001). Among 278 men who also completed a questionnaire after a subsequent clinician visit, participants who planned to discuss PSA screening with their clinicians were significantly more likely to report such discussions than participants who did not (148/217 [68%] vs 16/46 [35%], respectively [p<0.001]). CONCLUSIONS A decision aid reduces mens interest in PSA screening, particularly among the initially unsure. Men who plan to discuss PSA screening with their clinician after a decision aid are more likely to do so.

Tethered capsule endomicroscopy: from bench to bedside at a primary care practice

Abstract. Due to the relatively high cost and inconvenience of upper endoscopic biopsy and the rising incidence of esophageal adenocarcinoma, there is currently a need for an improved method for screening for Barrett’s esophagus. Ideally, such a test would be applied in the primary care setting and patients referred to endoscopy if the result is suspicious for Barrett’s. Tethered capsule endomicroscopy (TCE) is a recently developed technology that rapidly acquires microscopic images of the entire esophagus in unsedated subjects. Here, we present our first experience with clinical translation and feasibility of TCE in a primary care practice. The acceptance of the TCE device by the primary care clinical staff and patients shows the potential of this device to be useful as a screening tool for a broader population.

Case records of the Massachusetts General Hospital. Case 12-2014. A 59-year-old man with fatigue, abdominal pain, anemia, and abnormal liver function.

From the Departments of Medicine (L.S.F., L.H.S.) and Pathology (A.R.S.), Massachusetts General Hospital, the Departments of Medicine (L.S.F., L.H.S., R.H.G.) and Pathology (A.R.S.), Harvard Medical School, and the Department of Medicine, Tufts University School of Medicine (L.S.F.), Boston; the Department of Medicine, NewtonWellesley Hospital, Newton (L.S.F.); and the Department of Medicine, Cambridge Health Alliance, Cambridge (R.H.G.) — all in Massachusetts.

Patient Decision Aids Improve Decision Quality and Patient Experience and Reduce Surgical Rates in Routine Orthopaedic Care: A Prospective Cohort Study

Background: Patient decision aids are effective in randomized controlled trials, yet little is known about their impact in routine care. The purpose of this study was to examine whether decision aids increase shared decision-making when used in routine care. Methods: A prospective study was designed to evaluate the impact of a quality improvement project to increase the use of decision aids for patients with hip or knee osteoarthritis, lumbar disc herniation, or lumbar spinal stenosis. A usual care cohort was enrolled before the quality improvement project and an intervention cohort was enrolled after the project. Participants were surveyed 1 week after a specialist visit, and surgical status was collected at 6 months. Regression analyses adjusted for clustering of patients within clinicians and examined the impact on knowledge, patient reports of shared decision-making in the visit, and surgical rates. With 550 surveys, the study had 80% to 90% power to detect a difference in these key outcomes. Results: The response rates to the 1-week survey were 70.6% (324 of 459) for the usual care cohort and 70.2% (328 of 467) for the intervention cohort. There was no significant difference (p > 0.05) in any patient characteristic between the 2 cohorts. More patients received decision aids in the intervention cohort at 63.6% compared with the usual care cohort at 27.3% (p = 0.007). Decision aid use was associated with higher knowledge scores, with a mean difference of 18.7 points (95% confidence interval [CI], 11.4 to 26.1 points; p < 0.001) for the usual care cohort and 15.3 points (95% CI, 7.5 to 23.0 points; p = 0.002) for the intervention cohort. Patients reported more shared decision-making (p = 0.009) in the visit with their surgeon in the intervention cohort, with a mean Shared Decision-Making Process score (and standard deviation) of 66.9 ± 27.5 points, compared with the usual care cohort at 62.5 ± 28.6 points. The majority of patients received their preferred treatment, and this did not differ by cohort or decision aid use. Surgical rates were lower in the intervention cohort for those who received the decision aids at 42.3% compared with 58.8% for those who did not receive decision aids (p = 0.023) and in the usual care cohort at 44.3% for those who received decision aids compared with 55.7% for those who did not receive them (p = 0.45). Conclusions: The quality improvement project successfully integrated patient decision aids into a busy orthopaedic clinic. When used in routine care, decision aids are associated with increased knowledge, more shared decision-making, and lower surgical rates. Clinical Relevance: There is increasing pressure to design systems of care that inform and involve patients in decisions about elective surgery. In this study, the authors found that patient decision aids, when used as part of routine orthopaedic care, were associated with increased knowledge, more shared decision-making, higher patient experience ratings, and lower surgical rates.

Shared Decision Making in Common Chronic Conditions: Impact of a Resident Training Workshop

Abstract Problem: Physicians must be competent in several different kinds of communication skills in order to implement shared decision making; however, these skills are not part of routine medical student education, nor are they formally taught during residency training. Intervention: We developed a 1- and 2-hour workshop curriculum for internal medicine residents to promote shared decision making in treatment decisions for four common chronic conditions: diabetes, depression, hypertension, and hyperlipidemia. The workshops included a written case exercise, a short didactic presentation on shared decision-making concepts and strategies for risk communication, and two role-playing exercises focused on decision making for depression and hyperlipidemia treatment. Context: We delivered the workshop as a required component of the resident curriculum in ambulatory medicine. To evaluate the impact of the workshop, we used written course evaluations, tracked the use of the newly introduced Decision Worksheets, and asked preceptors to perform direct observation of treatment decision conversations. Outcome: Residents were involved in the development of the workshop and helped identify key content, suggested framing for difficult topics, and confirmed the need for the skills workshop. One hundred thirty internal medicine and medicine-pediatrics residents attended 8 workshops over a 4-month period. In written cases completed before the workshop, the majority of residents indicated that they would discuss medications, but few mentioned other treatment options or documented patients’ goals and preferences in a sample encounter note with a patient with new depression symptoms. Overall, most participants (89.7%) rated the workshop as excellent or very good, and 93.5% said that they would change their practice based on what they learned. Decision Worksheets addressing diabetes, depression, hyperlipidemia, and hypertension were available on a primary care-focused intranet site and were downloaded almost 1,200 times in the first 8 months following the workshops. Preceptors were able to observe only one consult during which one of the four topics was discussed. Lessons Learned: Internal medicine residents had considerable gaps in shared decision-making skills as measured in a baseline written exercise. Residents provided valuable contributions to the development of a Decision Worksheet to be used at the point of care. Participants rated the skills workshop highly, though interns rated the exercise more useful than PGY-2 and PGY-3 residents did. The Decision Worksheets were accessed often following the sessions; however, observing the Decision Worksheets in use in real time was a challenge in the resident-faculty clinic. Additional studies are warranted to examine whether the workshop was successful in increasing residents’ ability to implement skills in practice.

Case records of the Massachusetts General Hospital. Case 38-2014. An 87-year-old man with sore throat, hoarseness, fatigue, and dyspnea.

Dr. Leigh H. Simmons: An 87-year-old man with multiple chronic medical problems was seen in an outpatient clinic of this hospital because of sore throat and fatigue. The patient had been in his usual health until several weeks before presentation, when hoarseness, sore throat, and increasing fatigue developed. At the urging of his family, he was seen by his physician in an outpatient clinic of this hospital. He reported hoarseness, increasing facial puffiness, and periorbital swelling, with no chest pain, dyspnea, or new joint pains or muscle aches. The patient had hypertension, hyperlipidemia, and chronic kidney disease. Two months earlier, the creatinine level was 2.22 mg per deciliter (196 μmol per liter; reference range, 0.60 to 1.50 mg per deciliter [53 to 133 μmol per liter]), which was stable, as compared with values obtained the previous year. He also had hypothyroidism, with a normal thyrotropin level 8 months earlier (3.38 μU per milliliter [reference range, 0.40 to 5.00]), as well as gastroesophageal reflux disease, esophageal motility disorder, an abdominal aortic aneurysm, chronic back pain, depression related to the death of his wife several years before, and recurrent urinary tract infections. In the past, he had had pneumonia and had undergone angioplasty of the right renal artery (10 years earlier), a cholecystectomy, a lobectomy of the right middle lobe due to a spiculated nodule that was found to be benign, photoselective vaporization of the prostate due to obstructive benign prostatic hypertrophy (2 months before this presentation), and wrist surgery. Medications included atenolol, vitamin D3, a fluticasone propionate and salmeterol inhaler, aspirin, citalopram, a fluticasone nasal spray, atorvastatin, omeprazole, and levothyroxine. Lisinopril had caused a cough, and zolpidem tartrate had caused nightmares. The patient was retired and lived alone. He could independently perform activities of daily living, and he managed his own medications. His three children lived nearby and were in frequent contact with him, but he came to most medical appointments unaccompanied. He was under the regular care of an internist, a nephrologist, a cardiologist, and a urologist. Immunizations were up to date. He had stopped smoking many years earlier and did not drink alcohol. His father had died of liver cancer, and a son had sarcoidosis; his two other children were healthy. On examination, the patient was pleasant, smiling, and in no distress; he spoke From the Departments of Medicine (C.A.I.), Internal Medicine (L.H.S.), Radi‐ ology (F.J.F.), and Pathology (A.S.D.), Massachusetts General Hospital, and the Departments of Medicine (C.A.I.), Inter‐ nal Medicine (L.H.S.), Radiology (F.J.F.), and Pathology (A.S.D.), Harvard Medical School — both in Boston.

Case 12-2014

From the Departments of Medicine (L.S.F., L.H.S.) and Pathology (A.R.S.), Massachusetts General Hospital, the Departments of Medicine (L.S.F., L.H.S., R.H.G.) and Pathology (A.R.S.), Harvard Medical School, and the Department of Medicine, Tufts University School of Medicine (L.S.F.), Boston; the Department of Medicine, NewtonWellesley Hospital, Newton (L.S.F.); and the Department of Medicine, Cambridge Health Alliance, Cambridge (R.H.G.) — all in Massachusetts.

Case 38-2014

Dr. Leigh H. Simmons: An 87-year-old man with multiple chronic medical problems was seen in an outpatient clinic of this hospital because of sore throat and fatigue. The patient had been in his usual health until several weeks before presentation, when hoarseness, sore throat, and increasing fatigue developed. At the urging of his family, he was seen by his physician in an outpatient clinic of this hospital. He reported hoarseness, increasing facial puffiness, and periorbital swelling, with no chest pain, dyspnea, or new joint pains or muscle aches. The patient had hypertension, hyperlipidemia, and chronic kidney disease. Two months earlier, the creatinine level was 2.22 mg per deciliter (196 μmol per liter; reference range, 0.60 to 1.50 mg per deciliter [53 to 133 μmol per liter]), which was stable, as compared with values obtained the previous year. He also had hypothyroidism, with a normal thyrotropin level 8 months earlier (3.38 μU per milliliter [reference range, 0.40 to 5.00]), as well as gastroesophageal reflux disease, esophageal motility disorder, an abdominal aortic aneurysm, chronic back pain, depression related to the death of his wife several years before, and recurrent urinary tract infections. In the past, he had had pneumonia and had undergone angioplasty of the right renal artery (10 years earlier), a cholecystectomy, a lobectomy of the right middle lobe due to a spiculated nodule that was found to be benign, photoselective vaporization of the prostate due to obstructive benign prostatic hypertrophy (2 months before this presentation), and wrist surgery. Medications included atenolol, vitamin D3, a fluticasone propionate and salmeterol inhaler, aspirin, citalopram, a fluticasone nasal spray, atorvastatin, omeprazole, and levothyroxine. Lisinopril had caused a cough, and zolpidem tartrate had caused nightmares. The patient was retired and lived alone. He could independently perform activities of daily living, and he managed his own medications. His three children lived nearby and were in frequent contact with him, but he came to most medical appointments unaccompanied. He was under the regular care of an internist, a nephrologist, a cardiologist, and a urologist. Immunizations were up to date. He had stopped smoking many years earlier and did not drink alcohol. His father had died of liver cancer, and a son had sarcoidosis; his two other children were healthy. On examination, the patient was pleasant, smiling, and in no distress; he spoke From the Departments of Medicine (C.A.I.), Internal Medicine (L.H.S.), Radi‐ ology (F.J.F.), and Pathology (A.S.D.), Massachusetts General Hospital, and the Departments of Medicine (C.A.I.), Inter‐ nal Medicine (L.H.S.), Radiology (F.J.F.), and Pathology (A.S.D.), Harvard Medical School — both in Boston.

Increasing the use of patient decision aids in orthopaedic care: results of a quality improvement project

Objective To integrate patient decision aid (DA) delivery to promote shared decision-making and provide more patient-centred care within an orthopaedic surgery department for treatment of hip and knee osteoarthritis, lumbar herniated disc and lumbar spinal stenosis. Methods Different strategies were used across three distinct phases to promote DA delivery. First, we used a quality improvement bonus to generate awareness and interest in the DAs among specialists. Second, we adapted the electronic referral management system to enable DA orders at referral to a specialist. Third, we engaged clinic staff and specialists to design workflows that promoted DA delivery. We tracked the number of patients who received a DA, who ordered the DA, and collected usage data from a subset of patients. Our target was to reach 60% of patients with DAs. Results In phase 1, 28% (43/155) of spine patients and 37% (114/308) of hip/knee patients received a DA. In phase 2, 54% (64/118) of spine referrals and 58% (189/324) of hip/knee referrals included a request to send a patient a DA. In phase 3, 56% (90/162) of spine patients and 69% (213/307) of hip/knee patients received a DA, significantly more than in phase 1 (P<0.0001). In phase 3, both more DAs were ordered by clinic staff compared with specialists (56% phase 3 vs 34% phase 1, P<0.001) and sent before the visit (74% phase 3 vs 17% phase 1, P<0.001). Patients were more likely to report reviewing the DA when delivered before the visit (63% before vs 50% after, P=0.005). Conclusion DA implementation into clinic workflow is possible and facilitated by engagement of the entire care team and the support of health information technology.