My name is Christina Kutras. I'll be presenting Shared Decision Making, Finding a Process Right for Patient and Hospital. After this presentation, the viewer should be able to state two different decision tools which are available for performing a shared decision making interaction. To define shared decision making and to identify two benefits resulting from the shared decision making interaction. When we think about the shared decision making picture from the treetop view, it involves the provider sharing evidence-based medicine information to the patient in an effort to help the patient develop an informed preference to make an informed decision. However, the roots go much deeper than this. There are a few key points to understanding the foundation of what creates a successful shared decision making interaction. It should not be a one-way process of only delivering information. It should be a collaborative process between the patient and their provider where clinical evidence-based information is shared. The patient and provider are then able to incorporate the patient's goals, values, and preferences in their discussion so that an informed decision can be made together. As part of this process, there are shared decision making aids or tools which can be a valuable enhancement to only having a verbal discussion. These are aids and clinical tools that a patient and their provider can use to facilitate the education and discussion. Some examples include videos, handouts, apps, and web resources. Decision aids help further foster the provider-patient relationship. They help show there is effort toward ensuring the patient is understanding their health issues along with the risk and benefits of the treatment options available. These aids can help foster discussion, to listen to all that matters to the patient, and also help in narrowing down what matters most to the patient for choosing next steps and making a decision regarding their health care. Beyond what has been discussed, benefits include increased patient satisfaction and knowledge which helps empower patients to play a more active role in their care and decreases the demand on health care resources, thus decreasing health care costs. The literature has noted when patients have felt there was a shared decision making occurring, it tends to result in improved affective cognitive outcomes. Evidence is lacking for the association between empirical measures of shared decision making and patient behavioral and health outcomes. Some older literature has suggested decreased anxiety, quicker recovery, and increased compliance with treatment regimens as an additional benefit. While we've just discussed the value of engaging in shared decision making, and this may already be a part of everyday workflow and process, there are a few items to consider when evaluating processes specific to the percutaneous left atrial appendage closure procedures on Medicare patients. The Centers for Medicare and Medicaid Services have included in the decision memo for coverage of these procedures that the patient must have a shared decision making interaction with an independent, non-interventional physician using an evidence-based decision tool on oral anticoagulation in patients with non-valvular atrial fibrillation prior to left atrial appendage closure. Additionally, the shared decision making interaction must be documented in the medical record. Some hospitals may find the documentation of this shared decision making process may be the one area where gaps are identified and improvements are needed. As part of the CMS decision memo within the analysis plan section, it is mentioned there are evidence-based decision tools available for helping patients reach a decision about whether to take an anticoagulant to reduce the risk of stroke. Tools such as the National Institute for Health and Care Excellence, or NICE tool, and the American College of Physicians are mentioned as being available. There are additional evidence-based tools available, such as ones through the American College of Cardiology and the Agency for Healthcare Research and Quality. Other tools hospitals have shared with the NCDR, which they are using, include the SPARK tool and healthdecision.org. Based on previous polling of the LAAO Registry participant community, the majority of hospitals asked the referring provider to document the shared decision making interaction. In most cases, this is a general cardiologist who is the referring provider. The second most common approach is to have the patient meet with a non-interventional provider in the same practice. The majority actually utilize a shared decision tool. There are a variety of processes which can be implemented to ensure the shared decision making interaction occurs and is actually documented. Every setting will have unique characteristics which will make one process more effective and efficient for their workflow over another process. The next few slides will share some processes which have been successfully implemented by LAAO Registry participants and shared with the NCDR. These are presented to share hospital experiences and not meant to be an NCDR endorsement of any one process. It is always most helpful to share and learn from each other. For systems working with internal referrals and providers utilizing a shared electronic medical record, the concept of utilizing a virtual encounter has been implemented where the virtual encounter is created within the EMR. The primary care provider can then have the shared decision making interaction with the patient and document the encounter in the EMR. This will also include additional information in a templated form to document the CHADS-VAS score, HAZ-BLED score, utilize the NICE decision tool, modified ranking scale, and include a plan of care. Along these same lines, with an integrated physician model, there are options to build in smart phrases to the EMR systems to include all the elements to meet the shared decision standard and include a second opinion physician to review documentation. In a similar fashion, in a setting without internal referrals, there is still the process where the referring provider is required to complete the National Institute for Health and Care Excellence tool or NICE tool. The referring physician is sent the NICE shared decision making tool to fill out based on past and current health history for the patient. The tool includes the CHADS-VAS risk score and HAZ-BLED risk score along with guidelines for atrial fibrillation management. After completing and attesting, the referring physician returns the tool to the implanting physician. The implanting physician then completes a more detailed screening tool. All of this information is collated for each patient so the care team can perform patient case reviews during a weekly meeting, which will include collaboration with specialists such as Neuro, GI, etc. As an example, the weekly patient case review model utilized at one facility includes two reviewing physicians who actually perform LAAO procedures but would not be the actual implanting physician for that particular case. A qualifying echo or CT of the heart are also reviewed to rule out thrombus and any appendage size or depth concerns. The reviewing physicians go over the risk scores along with any outside specialist clinical summaries and their consent for short-term anticoagulation if needed. Once approved, the two reviewers sign the document and the case, date, and time are then confirmed. In conclusion, the shared experiences leading to successful implementation of processes all include the key components of team collaboration and communication. Next, we will hear from Amanda Jensen on the shared decision process utilized at Manatee Memorial. Next, we will hear from Amanda Jensen on the shared decision process utilized at Manatee

shared decision making

healthcare

evidence-based medicine

collaborative process

decision aids