Using Decision Aids to Help Specialty Patients in New Hampshire

Dartmouth-Hitchcock Medical Center, in Lebanon, N.H., is home to a 10-year-old research program, The Center for Shared Decision Making, which loans out video decision aids to patients to enhance decision making. For example, the decision aid for women with early-stage breast cancer walks patients through the pros and cons of lumpectomy versus mastectomy.

“We’ve found out from our research that after watching a video-based decision aid, patients who are unsure tend to move toward a decision,” says Kate Clay, MA, BSN, RN, the Center’s program director. In addition, decision aids tend to reinforce decisions in people who have already selected their choice.

Support for Breast Cancer Patients

One area where the program has seen high participation from patients is in selecting a breast cancer surgery. To encourage the use of shared decision making among providers and minimize additional clinical time required, Dartmouth-Hitchcock’s Comprehensive Breast Program has implemented standing orders to mail video-based treatment decision aids to breast cancer patients prior to their first meeting with a surgeon. “The process begins right after the patient receives biopsy results,” says Clay.

After watching the video, patients complete a web-based survey that measures if and how their treatment preferences change. Patients are asked if they feel clearer about what their decision is, as well as their ability to understand the “next steps” in their care.

Before a consultation with a surgeon, some women may meet with Clay, who borrows from her role as a nurse to help coach the patients toward the best decision for them. In addition, social workers and a nurse clinical coordinator will meet with patients after they view the video to answer patients’ questions about financial issues, what to expect during surgery, and similar concerns.

Recently, the care team at Dartmouth-Hitchcock expanded its focus to patients facing decisions about adjuvant treatment and breast reconstruction after mastectomy. For example, does a woman prefer a lumpectomy with radiation or a mastectomy with reconstruction? Patients receive a second video about breast reconstruction—Breast Reconstruction: Is It Right For You?—usually at the same time they are making the decision about initial surgery. The hospital has a multidisciplinary breast cancer clinic and can schedule consultations with the general surgeon and the plastic surgeon in sequence.

“Women considering mastectomy need to understand the pros, cons, and realities of reconstruction before choosing immediate or delayed reconstruction or no reconstruction,” says Clay. These patients receive a third video decision aid—Early Breast Cancer: Hormone Therapy and Chemotherapy—Are They Right For You?—if they are scheduled to meet with a medical oncologist after surgery.

Prostate Treatment Pros and Cons

Prostate patients are another target group for shared decision making at Dartmouth-Hitchcock. Specifically, physicians and nurses are focusing their attention on men diagnosed with early-stage prostate cancer. Prostate patients receive a decision aid on treatment options as well as a set of surveys that measure their level of conflict over some of their treatment decisions. For example, are patients more concerned about survival or quality-of-life issues? These results are shared with the physician to help address areas of uncertainty, so the physician can provide more valuable information to help the patient make the decision.

Spine Disorder Treatment Risks

In addition, the Dartmouth-Hitchcock Spine Center, a multidisciplinary clinic that treats back pain, recommends that all patients with herniated discs, spinal stenosis, and chronic low back pain watch a decision aid about diagnosis and treatment choices. This is documented in the medical record as an extra layer of quality control to help ensure patients understand the benefits and risks of the treatment choices for spine disorders, says Clay.

The videos work in this regard: About 90 percent of patients who viewed the spine video reported understanding the benefits and risks of the treatment alternatives (see the exhibit).

How to Start a Program

Organizations that wish to start shared decision making libraries should have the proper infrastructure to support them, says Clay. She estimates a start-up cost of $100,000 for organizations to staff the program with an administrative assistant and to create a database to track resource use, record patient contacts, and generate reports.

Clay offers the following advice for organizations that want to adopt shared decision making processes:

• Investigate the decision aids that are available, and decide if you want to use an existing tool or create your own.
• Begin efforts with a patient-sensitive treatment in a specialty service; it’s usually easier to start in specialty areas than in primary care.
• Write a proposal.
• Invite physicians to watch a decision aid, such as a video, over lunch.
• Encourage open dialogue about clinical issues, as well as any potential financial fallout that could occur if more patients end up choosing less invasive treatments.
• Build upon your hospital’s or clinic’s existing patient education program, resources center, or quality improvement program; these areas already have staff and processes in place that can help support shared decision making.

Patients Like This

Patient satisfaction with the Dartmouth-Hitchcock program is high. For example, 95 percent of patients who used the spinal stenosis treatment video would recommend the decision tool to other patients.

“The majority of healthcare decisions—as many as 75 percent—are patient sensitive,” says Clay. “What we’re trying to do is align the treatment to the patient’s values. And a lot of patients don’t realize they have a choice.”