UP FRONT
Personally , I like to ask a simple , direct question like , “ Could you tell me the treatment regimen that we have agreed on ?” Or “ What are the different chemotherapies that are part of the combination therapy we are going to initiate ?” If the patient is able to verbalize and repeat the treatment regimen , I feel confident that he or she has a good understanding of the treatment and – the key to SDM – has agreed to the treatment plan .
SDM Roadblocks Research from a number of government agencies , including the Agency for Healthcare Research and Quality ( AHRQ ), point to better short- and long-term outcomes when clinicians and patients engage in SDM . 6 According to data from the AHRQ , SDM has multiple short-term benefits ; chief among these is the increase in patients ’ confidence in treatment decisions and trust in the health-care team . In addition , the patient empowerment inherent in the SDM process leads to a decrease in patient stress and anxiety related to cancer treatment decisions . In the long term , research also has shown that SDM leads to better treatment adherence , better quality of life , and longer-term remissions . ( The AHRQ has also developed a five-step process , called the SHARE Approach , for SDM . See the SIDEBAR for more information .)
So , given the apparent benefits , why hasn ’ t SDM been adopted by health-care organizations on a larger scale ?
Colleagues and I conducted a systematic review of 30 inpatient and outpatient oncology settings to help answer this question . 7 Our interviews with APPs revealed several barriers to participation in SDM , which we categorized into seven main themes :
• Practice barriers : There is no standard , uniform approach to SDM , and the model varies within each institution .
• Patient barriers : Patients may not be emotionally or mentally ready to participate in treatment decisionmaking .
• Institutional policy barriers : Institutions may have enacted policies requiring physician supervision , as opposed to collaboration between the physician and the APP . Having undefined roles for APPs could also result in a lack of direction .
• Professional barriers : APPs may lack the professional training and experience to fully participate in SDM , and the professional culture they practice in may be non-conducive to participation .
• Scope of practice barriers : Regulations by state or federal laws may prohibit APPs from initiating new cancer therapy or practicing independently in cancer SDM .
• Insurance coverage as a barrier : When insurance payment for service is low , the APP is required to see more patients ; time constraints and increased patient volume can limit SDM participation .
• Administration as a barrier : Full participation in SDM requires time , training , and resources that administration may not provide .
On the other hand , we found several promoters of SDM among the APPs we interviewed :
• Multidisciplinary team approach : APPs have increased participation in SDM when there is a consistent multidisciplinary or team approach in the practice .
We are in the era of shared decisionmaking , in which advanced practice professionals act as patient advocates and patient educators .
• APPs having a voice during cancer SDM : When APPs perceive that their input is valued , they feel they are more likely to participate in cancer SDM .
• Increased knowledge level : APPs feel they can better participate in the SDM process when they know more about the disease and its treatment .
• Personal values : APPs who personally value participation in cancer SDM are more actively involved in the treatment decision-making process .
Embracing SDM In our review of the centers ’ relationships with SDM , a central theme emerged : To be truly effective , SDM has to be implemented and supported from the top down . It may require a culture change . It is not just the physician or the APP who needs to embrace SDM , but everybody in the health-care team – from administrators to practitioners .
Are we there yet ? Not quite , but we are on the right track to continue our efforts to implement SDM . From what I ’ ve observed in practice , health-care organizations are participating in SDM to an extent , but it is not explicitly part of the organizations ’ policies , culture , or – perhaps , most importantly – budget .
Many organizations are advocating for SDM , including the AHRQ , the Institute of Medicine , and the Department of Health and Human Services . We still have a way to go , though . Hopefully , more education , training , and research will change the naysayers ’ opinions . ●
references
1 . Legare F , Ratte S , Gravel K , Graham ID . Barriers and facilitators to implementing shared decision-making in clinical practice : update of a systematic review of health professionals ’ perceptions . Patient Educ Couns . 2008 ; 73:526-35 .
2 . Kane HL , Halperin MT , Squiers LB , et al . Implementing and evaluating shared decision making in oncology practice . CA Cancer J Clin . 2014 ; 64:377-88 .
3 . Affordable Care Act , Section 5306 .
4 . Charles C , Gafni A , Whelan T . Shared decision-making in the medical encounter : what does it mean ? ( or it takes at least two to tango ). Soc Sci Med . 1997 ; 44:681-92 .
5 . Sandman L , Granger BB , Ekman I , Munthe C . Adherence , shared decisionmaking and patient autonomy . 2012 ; 15:115-27 .
6 . Agency for Healthcare Research and Quality . “ The SHARE Approach .” Accessed June 7 , 2016 , from http :// www . ahrq . gov / professionals / education / curriculum-tools / shareddecisionmaking / index . html .
7 . McCarter SP , Tariman JD , Spawn N , et al . Barriers and promoters to participation in the era of shared treatment decision-making . West J Nurs Res . 2016 May 18 . [ Epub ahead of print ]
Joseph Tariman , PhD , is assistant professor in nursing at DePaul University ’ s College of Science and Health in Chicago , IL .
FREE CME SUMMIT ON MYELODYSPLASTIC SYNDROMES
Improving MDS Outcomes from Diagnosis to Treatment : A Multidisciplinary Approach
There are many complexities associated with myelodysplastic syndromes ( MDS ) that a multispecialty team must address as a clinical-care unit . These complexities include obtaining adequate bone marrow specimens , identification and classification of MDS , the comorbidity rate of MDS patients , and the decision-making process for treatment . To address educational gaps associated with these complexities , the American Society for Clinical Pathology ( ASCP ), the American Society of Hematology ( ASH ), and the France Foundation have designed comprehensive MDS-directed educational summits that feature live events designed by world-class subject matter experts . Participants in these summits will actively engage in multidisciplinary , interactive small-group activities including case-based tumor board discussions and four break-out sessions on :
• The role of molecular testing
• Distinguishing morphologic mimics from MDS
• Assessing low or high grade MDS
• Applying new prognostic scoring to cytogenetics
Who should attend ?
• Hematologists
• Medical oncologists
• Hematopathologists
• General pathologists
• Pathologists ’ assistants
• Physician assistants
• Hematology and oncology nurse practitioners and physicians assistants
• Medical laboratory scientists
Dates and Locations
Registration is free . Go to either hematology . org / Meetings / 4127 . aspx or pathologylearning . org / mds / summits to register .
July 29 , 2016 Washington , DC ASH Headquarters Held in conjunction with the ASCP Pathology Update Meeting
September 15 , 2016 Chicago , IL Chicago Fairmont Held in conjunction with the ASH Meeting on Hematologic Malignancies
November 4 , 2016 Austin , TX Hyatt Regency Austin
ASHClinicalNews . org ASH Clinical News
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