A New Culture of Health Care: Who Chooses What…and Why?

A New Culture of Health Care: Who Chooses What…and Why? Tom Bartol, Nurse Practitioner Richmond Area Health Center bartolnp@gmail.com Twitter: @tombartol

Think Outside the Box • Think beyond • the way everybody is doing things • the way we have been paid to do things • A culture (way of thinking, behaving, or working) change • not on minimizing cost of each intervention • maximizing the value over the entire care cycle • Rather than treat the symptoms (rash, blood pressure, blood sugar, anxiety) engage patients to treat the cause (stress, low self-esteem, fear)

Disclosures • The presenter has no financial affiliations with pharmaceutical companies or the health care industry • The presenter works in a primary care clinic and has increased his appointment times to 30 minutes each

Objectives • Describe 3 key concepts in the relationship between patient and health care clinician when making decisions • State a working definition for “value” of care • Utilize some effective tolls for shared decision making

“What we really need is not a doctor who delivers more care but one who seems to care more—and has the time to make sure we understand what we need in order to be well.” Shannon Brownlee in “Overtreated” Brownlee, S. Overtreated: Why too much medicine is making us sicker and poorer. 2007

Who Makes Health Care Choices? • Clinician: based on authority, what is “needed” • Patient: • By recommendation (from clinician) • Rational decision making (considering pros, cons, alternatives, cost, and value) • Payer: Only certain things are covered • Clinical Guidelines: Population based recommendations that define “quality care” • Evidence: Does evidenced based mean it is best?

How do we do Shared Decision Making outside of Health Care? • Buying a car • The auto mechanic • Choosing a college • Financial investments …Are health care choices made like any of these?

Quality Care vs Value Care • Quality: • Degree of excellence • Degree of being very good • Value: • Usefulness • Importance

VALUE = Outcomes that Matter to the Patient Cost Per Patient

A Tale of Two Patients: Who is Heathier? 55 y/o Patient A with diabetes 55 y/o Patient B with diabetes A1c 7.4, no meds, down from 8.1% B/P 142/88, no meds, down from 160/100 LDL 108 on no meds, down from 157 Quit smoking 2 weeks ago cold turkey Weight measured BMI 33, down from 40 a year ago • A1c 6.8% on 3 oral agents and basal insulin, up from 6.4% • B/P 118/80 on 3 b/p medications • LDL-C 98 on simvastatin 40mg • Asked about smoking and gave Rx for Chantix • Weight measured: BMI 43, up from 39 six months ago It’s not just getting to the goals but HOW they get there that makes a difference!

Engaging Patients • Ask, “What matters to you?” as well as “What is the matter?” • Helping people find connection, purpose and hope in life. • Ascertaining the patients needs, values and goals at that point in time.

Building Self Esteem • Affirm the patient and find something positive • Celebrate the positive • Listen • Put positive, affirming notes in lab letters

Questions that Engage • What could be better? • What’s the hardest thing for you right now in dealing with your (diabetes or any condition)? • If you could change one thing in your life right now, what would you change? • Are you interested in working on your weight? • How was your childhood?

Empathy Associated with Better Outcomes in Diabetes • Correlational study in 891 patients with DM • Physicians rated as high, moderate or low on Jefferson Scale of Empathy • 29% more patients had A1c <7.0% in the high empathy group vs. low empathy (p<0.001) • 25% more patients had LDL-cholesterol <100 in high vs. low empathy group (p<0.001) • Highly empathetic physicians saw fewer patients Hojat et. al. Acad. Med. 2011;86:359-64

Shared Decision Making • Stratify Risk • Share information • Risks of problem/condition being checked or treated • Risks of intervention • Benefits of intervention • Costs • Let patients make choices But this takes more time

Assess Baseline Risk • Family History (genetics) • Lifestyle • Exercise • Dietary Intake • Habits (smoking, ETOH, etc) • Other risk factors/or medical history • Socioeconomic Status/Satisfaction/purpose in life (or “Are you happy?”)

BASELINE RISK Woloshin S et al. JNCI J Natl Cancer Inst 2008;100:845-853

Relative Risk Reduction • % Reduction from Baseline Risk • 50% off coupon • Save $0.50 on a $1.00 item • Saves $500.00 on a $1000.00 item • Higher baseline risk, higher the absolute reduction • Baseline risk is important in using Relative Risk Reduction

AFCAPS/TexCAPS:Results JAMA 1998;279:1615-1622

Framing: The Way the Data is Presented • 37% reduction in 1st major coronary events • 3304 patients treated with lovastatin for 5 years: • prevent 67 1st major coronary events • Has no preventive effect on 3118 patients (3301 in placebo – 183 events in placebo = 3118) • Taking lovastatin for ~5 years can reduce risk of 1st major coronary event from 5.5 in 100 to 3.5 in 100 • Risk of NOT having 1st major coronary event • 94.5 out of 100 without taking simvastatin • 96.5 out of 100 with taking simvastatin JAMA 1998;279:1615-1622

False Positive Results • Test is positive, but condition is not really present • Often leads to worry, more testing, and unnecessary treatment • The lower the baseline risk of a condition, the higher the false positive test results • Low-dose CT screening for Lung Cancer: 96% of people who screen positive don’t have lung cancer

https://www.harding-center.mpg.de/en/health-information/facts-boxes/mammography, accessed 12/5/14

Additional ways to reduce risk: “Physically active women have a lower risk of developing breast cancer than inactive women…risk reduction varies (between 20-80%). http://www.cancer.gov/cancertopics/factsheet/prevention/physicalactivity

Number Needed to Treat (NNT) • A tool to help give a perspective on a treatment risk vs benefit • Number of people who must be treated for given time period to prevent 1 event • Number Needed to Harm (NNH): Number needed to treat to get one harm event

Statin Drug Given for 5 Years for Heart Disease Prevention (Without known heart disease) Thennt.com http://www.thennt.com/nnt/statins-for-heart-disease-prevention-without-prior-heart-disease/, accessed 2/22/15

Low-Dose CT Screening for Lung Cancer http://www.thennt.com/nnt/ct-scans-to-screen-for-lung-cancer/, accessed 2/28/15

Coronary Stenting for Non-Acute CAD Compared to Medical Therapy http://www.thennt.com/nnt/coronary-stenting-for-non-acute-coronary-disease-compared-to-medical-therapy/, accessed 2/28/15

Strength and Balance Training Programs for Preventing Falls in the Elderly Thennt.com http://www.thennt.com/nnt/strength-and-balance-programs-for-elderly-falls/, accessed 2/22/15

Results of Shared Decision Making Data on file with speaker

Questions to Ask • How good is the evidence that this test (or drug) will reduce my risk of dying or having an event? • Is the test itself dangerous? • Could the test lead to my being treated unnecessarily? • Does the treatment I might face have side effects? • Can I make changes in my eating habits and lifestyle to reduce the risk of getting the disease? Brownlee, S. Overtreated: Why too much medicine is making us sicker and poorer. 2007

http://consumerhealthchoices.org/campaigns/choosing-wisely/ accessed 1/23/14

“People don’t care how much we know unless they know how much we care.” Phil Noe, NP

Tools and Resources Baseline Risk Chart Woloshin S, Schwartz LM, & Welch HG. The risk of death by age, sex, and smoking status in the United States: Putting health risk in context. J Natl Cancer Inst 2008;100:845-853 Harding Center for Risk Literacy Fact Boxes https://www.harding-center.mpg.de/en/health-information/facts-boxes Number Needed to Treat (NNT) http://www.thennt.com/home-nnt/ National Cancer Institute Physician Data Query (PDQ) http://www.cancer.gov/cancertopics/pdq#summaries

A New Culture of Health Care: Who Chooses What…and Why?