Fighting Healthcare Disparities | Utilizing Shared Decision-Making

Paul Anderson: Welcome to Smart Healthcare Safety from ECRI, the most trusted voice in healthcare, committed to advancing effective, evidence- based care. I'm your host, Paul Anderson. And for more than 10 years, I've overseen our patient safety, risk, and quality membership programs here at ECRI. Tens of thousands of healthcare leaders rely on us as an independent, trusted authority to improve the safety, quality and cost effectiveness of care across all healthcare settings worldwide. You can learn more about our unique capabilities to improve outcomes at www. ecri. org. Today's episode is part of a series we're recording for the ECRI and the ISMP Patient Safety Organization's Annual Deep Dive Report. This year's deep dive focuses on issues of racial and ethnic disparities in healthcare and we're talking to PSO members and others to hear about their initiatives to fight against these disparities. Our guest, Dr. Emily Transue, is Medical Director for Employee& Retiree Benefits and Clinical Quality& Care Transformation at the Washington State Healthcare Authority, or HCA. HCA is committed to whole person care, integrating physical health and behavioral health services for better results and healthier residents. As the largest healthcare purchaser in the state, HCA leads the effort to transform healthcare, helping ensure that more than two and half million Washington residents have access to better health and better care at a lower cost. So Dr. Transue, as medical director, wonder if you could tell us a little bit more than I was just able to about HCA and the agency's role and your role within the agency.

Dr. Emily Transue: Sure. Thank you. Healthcare Authority is the cabinet agency that oversees Medicaid as well as public and school employee benefits. So we purchase healthcare for about a third of the state and as such, we really try to drive health policy for the state as well as our direct role in purchasing. As a medical director, I oversee the public and school employee benefits programs, and I also have a big role across both sides of the agency in quality, and I also get to lead to our shared decision making program as well.

Paul Anderson: So I know we're going to talk a lot about shared decision making. That's something I'm really interested in as a patient, as much as anything else, but I wonder if you... I know the part of our focus is also in the role of HCA in supporting health equity and access. So I wonder if you could tell me about some of the structures and processes that HCA has in place to support health equity.

Dr. Emily Transue: Absolutely. We have lots of work happening in different ways to support health equity. Obviously, our work in Medicaid is intrinsically really a lot about health equity and looking at how to bring high quality healthcare to the most disadvantaged populations in the state and looking at improving both physical and mental health to improve the lives and opportunities of those who need it most. We've become over the last few years a lot more explicit in focusing our work on health equity. We've created a new senior management position to lead our health equity and social justice work. We've developed an agency strategic plan about health equity, and we're really trying to evaluate all of our work and our programs to think very explicitly about our health equity impact. For a long time, we've had a big focus on quality, but of course it's possible to improve quality on average while actually worsening equity if you aren't carefully measuring and paying attention to how the work you're doing impacts different subgroups. For example, we're starting to really look at our quality performance and stratify that by race and ethnicity, as well as looking at social determinants of health to really identify disparities and then figure out how we're going to address those.

Paul Anderson: What are some of the big barriers to equity that you're seeing, some of the big drivers of the disparities that you see in your patient population?

Dr. Emily Transue: Well, that's such a hard answer because there's just so many pieces to it. I always have in my mind that image of a... There's a child and a tall man and a woman in a wheelchair, and they're all being given a regular bicycle. And of course, as you offer the same thing to all three of them, that may be equal on some level, but you're really not improving anything since how each of them is able to respond to that is really, really different. I think healthcare has a long way to go, even in providing that equal care. We know that people continue to experience active bias, both explicit and implicit in healthcare settings, and that has a big impact on health outcomes, but we also live in such an unequal society and that impacts people's health in so many different kinds of ways. So we know that chronic stress drives many chronic diseases and also socioeconomic status, and other factors impact access to healthy foods and ability to safely exercise and other things that have a really direct impact on health. So as a healthcare system, we really both need to figure out how to stop being part of the problem and also play a really active role in creating solutions. So there's lots of pieces for us to work on. Lots of opportunities, I guess.

Paul Anderson: Well, and one of those opportunities, one of those pieces that you mentioned earlier is this idea of shared decision making. We came to learn about HCA through your role in developing some shared decision making principles that are really focused on improving the communication between patients and clinicians. So I wonder if you could define a little bit more about what we mean by shared decision making, and maybe I wonder if you could give an example of a scenario where shared decision making is and is not happening between a patient and provider?

Dr. Emily Transue: Yeah. Great question. So shared decision making, we often use a definition from the National Learning Consortium, which defines shared decision making as a process in which clinicians and patients work together to make decisions and select tests, treatments, and care plans based on clinical evidence that balances risks and expected outcomes with patient preferences and values. Within that, there are a number of key components and one is that in shared decision making, you're really looking at all of the available options and that can include conservative care or doing nothing or various treatment options. It involves really looking at the pros and cons of each of those options. And I would call that out as a little bit of a difference from say, informed consent, where I'm doing this thing, what are all the things I need to know about that? How do I know that I really know what I'm getting into? This is about exploring all the things that you could do in a situation that would be reasonable. And then it involves really exploring the patient's values and how those play out relative to the different possible choices. So imagine someone is considering having a back surgery and you might have someone whose passion in life is dancing, and they're just not able to do that of their back condition. And they place a really, really high value on being able to get that back. And then you might have someone else who has really the same level of impact from their back at a medical level, but they tolerate the pain well, and it doesn't limit them in any of the things that they care about. But on the other hand, they might be terrified of medical complications of surgery or risks like blood clots and infections. So the right choice for those two people might be very, very different even though the medical condition itself is the same. And that's really where shared decision making comes in, is where there are multiple options that are reasonable, but the patient's values will really impact what the right choice is for them. If you look at something like I had an accident once and shattered my wrist, there was no real question about whether my wrist needed surgery. It was not an option. And there again, I needed informed consent. I needed to know these are the things that could happen, but there wasn't more than one reasonable option in that situation. It's really those what we call preference sensitive conditions that are appropriate, particularly for this.

Paul Anderson: What is the crossover then between this idea of shared decision making and then its relationship to support for health equity?

Dr. Emily Transue: Yeah, so there's a fascinating body of literature that indicates that shared decision making addresses both under- utilization and over- utilization of services. So if you look at say, knee and hip replacements, those are really traditionally under- utilized in African American populations. But if you implement a systematic shared decision making program, you see those rates go up. And on the other hand, utilization by Caucasian populations which is generally very high will tend to go down. So empowering the patient to make a decision that's really congruent with their values tends to be an equalizer. There are a number of different things that may go into that effect. Part of it may be that without shared decision makers, providers are for whatever reason offering more aggressive care to certain populations, or they're making assumptions about what people need or want, or maybe on the other side, that there's a mistrust of the medical system that gets addressed by a good shared decision making process. Probably a lot of things in play, but what we're really finding is that it's an important tool for improving equity in outcomes, which I think is one of the most exciting pieces of this.

Paul Anderson: So what do you say to a provider who says something like, " Yeah, that's great, but I don't have time for shared decision making?"

Dr. Emily Transue: So my first answer on that is absolutely, we hear you. Providers are really pressed for time. I did primary care full time for many, many years, and we are just pushing people to do more and more in the time that they have. But what we've found is that while implementing shared decision making takes a lot of time upfront, you have to do training, you have to figure out how to build it into workflows. But once it's in place, it actually doesn't take longer than usual care. And that's partly conversations are more structured and organized. So they flow well, partly people's concerns get addressed as you're doing this so you don't have that situation where your hand's on the doorknob and somebody suddenly has three or four more questions, or they schedule surgery and then cancel it because it turns out that there was an issue going on you didn't know about. So yeah, it's time and work up front, but in the longer term, it really pays off. And the other thing is that these kinds of conversations are really the reason that most people went into medicine in the first place. So it can also be a real satisfier for providers as well as for patients.

Paul Anderson: You know, Dr. Transue, for folks who want to get involved, you've convinced them now. They want to get involved. They know this is a good thing to do for their patients. How do they get started? How do they get support to get started rather than trying to make it up as they go?

Dr. Emily Transue: Great question. We have actually a online self- paced training that we've had really, really good responses to. One of the challenges in this work is that we as providers think we already do this. I care about engaging people in decisions and all that kind of thing, so I must be already doing it. But one of the things that you discover after going through more training is that there are a lot of pieces to this that we just don't naturally instinctively do, but that are well supported by training. So we can give you that information for people to access it, and it's just going through some different scenarios, practicing different approaches, thinking about the principles. And again, we've found that works really well for folks.

Paul Anderson: And is that training something that we can share a link with to accompany this podcast?

Dr. Emily Transue: Absolutely. We'd be happy to share that.

Paul Anderson: Okay, great. We'll make sure we do that. Do you ever see scenarios where you see patients maybe not wanting to take an active a role as you wish they would? Because it's the opposite of that overcoming mistrust, it's maybe too... I don't want to say too much trust, but it's too much offloading of the decision.

Dr. Emily Transue: Absolutely. I work a fair bit with medical students, and they always have this question of what do patients want? Do they want to be told what to do? Do they want to... and of course the answer is it's individual to every patient what role they want to play. Part of your job is to really understand that through the dynamic. One of the things that I think is great about shared decision making and is again a little bit different from some of the paradigms out there, it's not just handing it off to you and saying, " You figure it out." It really is saying, " Here are the things that you need to know, and here are the points that are choices for you." So I'm not asking you to figure out what are the risks of a knee surgery. I'm going to tell you all that, but I'm asking you how do you feel about this amount of pain versus this amount of rehab? So I think it's giving the piece of the decision that the patient needs to make to them, but without just wholesale handing off that responsibility, which I think is a little bit the way the pendulum can swing sometimes. And of course, it's going to be measured to what an individual patient wants, but at the very least, you should know what your options are. And I may ultimately have a recommendation about that based on what you tell me about yourself. But even that should really take into account your values. It's funny how we use that phrasing of, " Well, I would do this," or " I would tell my mother to do that," but my mother's different from you. So again, we should be thinking about your own values.

Paul Anderson: I know that one of the tools that you use to support this shared decision making is what's called a patient decision aid, a PDA. Again, first off, let's start with basics. What is a patient decision aid?

Dr. Emily Transue: We do love our three- letter acronyms. So a patient decision aid is a tool that supports shared decision making. It does that first by providing information that somebody needs to make an informed choice, helping make clear what the choice is, what the options are. And then it also helps them to explore their values around the decision. It also helps to give structure to that patient/ provider discussion. There are many, many forms of PDAs, they can be anything from a single- paged grid that just goes through the options, pros and cons, to something like an interactive video program that could take an hour or more to go through exploring all the options. So they come in many forms, but essentially they're all designed to really support that decision process.

Paul Anderson: I know you've had a couple... several, actually I should say, PDA certified, and they're touching on a lot of different areas of care from maternity and labor and delivery, through joint replacement, through cancer screening, so I wonder if you could give an example of a couple specific tools and maybe the decisions that they're intended to help the patient and the provider work through.

Dr. Emily Transue: One of the first areas that we certified PDAs in was around maternity, including aids around trial of labor after a caesarian section. So someone who's had a prior C- section and is debating whether to try to have a natural birth or not, and that's again, an area where there's some real pros and cons. There's an increased risk of uterine rupture and on the other hand, there are some real advantages to natural birth. So that's a very preference- sensitive condition. We do have them around joint replacements, which we talked about a little bit earlier and spine care, we've done a number around end of life care, which I think of in some ways is the ultimate preference- sensitive condition. How do you rate quality of life versus length of life? How do you assess those things at different points along the spectrum? There's some very neat short videos that really give people a sense of what those options would look like. We have others that are longer written explorations of those options of some of the areas we've covered.

Paul Anderson: And I mentioned that a number of these decision aids have been certified. What is that process like to have a... I imagine there's a tremendous amount of work that goes into just conceiving of and creating a decision aid and then to get it certified is more. So what is that certification process?

Dr. Emily Transue: Yeah, one of the challenges is that there are great PBAs out there, and there are others that are not so high quality. So we created the certification process to help people navigate that a little bit. So in our certification process in the state of Washington, we'll ask for submissions around a given topic. We have a panel that reviews each of the submissions and assesses them according to criteria that were developed by the International Patient Decision Aid Standards Collaboration, known as IPDASC, that looks at some of the things we talked about. Does it really describe the problem and the choice in question? Does it help look at each of those options and help the patient assess their values relative to those options? So our panel reviews that, and then we also have a scientific review process to assess whether the most up- to- date evidence was used in developing the aid. And ultimately, our chief medical officer at the HCA has the authority in Washington to make final determinations about certification. It's quite a process.

Paul Anderson: Yeah. Well, no, but it's important, because I'm thinking of again, tying that back into equity, I'm thinking of all those layers of health literacy and language barriers and all those barriers that you've got to make sure on top of just the medical soundness of the information that's presented.

Dr. Emily Transue: Yeah. And I'm glad that you brought up literacy because I think that's a key point here is how do you make the information clear to people who may have very varied levels of health literacy and often aids will use different diagrams to show that. There's some really interesting presentation of statistics in ways that are clear to people who don't necessarily come in with statistical knowledge. So there's some pretty neat stuff out there in terms of how to make these choices clear to someone who doesn't have that background to really analyze those.

Paul Anderson: So what are some other initiatives or programs at HCA that you want to highlight, especially as they affect equity issues?

Dr. Emily Transue: Yeah. We have so many different things going on, but a few to call out, we're really proud of our collaboration with other partners in this state. We can do so much more when we're working with others than we can do alone. One of those is the Free Collaborative, which is a group of stakeholders that look at areas of variation in care in the state, including variations in equity, and they create best practices and guidelines to improve care. They convened a work group on shared decision making a few years ago and we are really continuing to work to implement those recommendations in addition to the other projects that they are working on. Other things, we recently received a CMS chart model grant, and that is designed to transform healthcare systems in rural communities. Washington is a very mixed state. We have big urban areas of course, but we have a lot of rural and remote communities as well. So we're really excited to be beginning work on that. Another piece that we've done a lot with is supporting transformation in primary care. And I think that improving our ability to support primary care is really such a cornerstone of improving health equity, specifically. We have need for more primary care in communities that are underserved and we are really, really trying to support that better.

Paul Anderson: So I always like to wrap these conversations up by asking for something that somebody who's listening, where can they start? What's something they can do today to get the ball in motion? And I know HCA isn't providing direct care. You're not a provider organization at HCA. But if somebody is a provider organization and they're not doing shared decision making now, but they really want to, is this a situation where they can dip their toe in? Do they start with just one condition or one treatment modality? Do they focus on one patient population? Where's the way to get started down this road?

Dr. Emily Transue: Yeah. I always advise starting small. It's so easy to get overwhelmed and also to really start with things that are in your wheelhouse and under your control. We have some great training wheels for providers on how to do shared decision making, which can really help people think about how to build these principles into all of their conversations with patients, and then do it in a more structured way for more important decisions. Using a PDA really, really helps. So I'd recommend that if possible. So I would say for a provider thinking about this, think about a condition that you see a lot and that you really care about. And particularly in areas where you know that there are inequities out there, don't only use it in those populations, but think about those conditions that you know are sensitive to that. And then find a PDA, go through the training and just start to practice it. Once an institution has a champion who's really passionate about this work, it's a lot easier to spread, but start with yourself and learn to do it around something that you really care about. Go from there.

Paul Anderson: That's awesome. Dr. Emily Transue, thanks so much for joining us today.

Dr. Emily Transue: It's been such a pleasure. Thanks for having me.

Paul Anderson: You can learn more about ECRI and the ISMP PSO from the ECRI website at www. ecri. org, where you'll find past conversations in this podcast series about disparities in care, and you can register to download the First Steps document from the PSO Deep Dive. You can find out more about the Washington State Healthcare Authority at www. hca. wa.gov. Be sure to subscribe to Smart Healthcare Safety on Spotify, iTunes, Google Play, or wherever you get your podcasts to get our latest episodes. We welcome your feedback. Visit us at ecri. org or email us at ecri- podcasts @ ecri. org.