Perioperative Medicine
The Future of Anesthesiology
Shared Decision Making
Shared decision making means moving towards recognizing the patient as a person with core belief and values. It means realizing that the patient is an expert in knowing what is right for them.
Making Shared Decision Making a Reality: No decision about me, without me
Coulter A, Collins A. London: King's Fund, 2011.
Bottom Line: Shared decision making is when patients and clinicians work together to make decisions based on evidence and patient's informed preferences. It is when the patient's get "the care they need and no less, the care they want and no more".
​
​
Major points:
​
1. Shared decision making can be used for decisions about undergoing a screening or diagnostic test, medical or surgical procedure, self management education programme or psychological intervention, taking medication or attempting a lifestyle change.
2. Three main components: reliable and balanced evidence based information, decision support counselling, system for recording, communicating and implementing the patients preferences.
​
3.Despite benefits of patient involvement with their healthcare, there have been challenges in making this a meaningful reality.
Sturgess J, Clapp JT, Fleisher LA. Shared decision-making in peri-operative medicine: a narrative review. Anaesthesia. 2019;74 Suppl 1:13-19. doi:10.1111/anae.14504
Bottom line: This review highlights the evolution of shared decision making in addition to the challenges faced by Anesthesiologists for adoption of shared decision making.
​
Major points:
​
1. Shared decision making was first described in the 1980's and its development has some legal background.
​
2. Within the peri-operative setting, there are many challenges in implementing shared decision making including: time, anesthesia being a task-focused specialty in addition to the systemic barriers of seeing a patient immediately prior to surgery.
​
3. Shared decision making is more than informed consented and transfer of information but it is important for high quality, patient centred healthcare.
Decision Aids
Decision aids ensure that information is presented clearly, in a simple manner in an effort to present the treatment options and outcomes. For example, the difference between conservative management versus surgical management.
​
Decision aids can be options grids, brief decision aids or patient decision aids.
Stacey D, Légaré F, Lewis K, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2017;4(4):CD001431. Published 2017 Apr 12. doi:10.1002/14651858.CD001431.pub5
Bottom Line: This Cochrane review included 105 studies and 31,043 people. There is high-quality evidence showing that decision aids improve knowledge of the options and feel better informed and more clear about what matters most to them. Moderate-quality evidence proves that people have more accurate expectations of benefits and harms of options and probably participate more in decision making.
​
​
Main points:
​
1. Decision aids increased participants' knowledge, accuracy of risk perceptions and congruency between informed values and care choices.
2. Decision aids and the decision-making process decreased decisional conflict, indecision about personal values and the proportion of people who were passive in decision making.
​
3. Decision aids had a positive effect on patient-clinician communication and only increased length of consultation by 2.6 minutes.
Patient Centered Outcomes
We must ensure that we measure outcomes that are meaningful and important to patients.
​
Who decides what is successful for our patients? Administrators? Healthcare providers?
​
What about the patient themself?
Heidegger T, Saal D, Nübling M. Patient satisfaction with anaesthesia - Part 1: satisfaction as part of outcome - and what satisfies patients. Anaesthesia. 2013;68(11):1165-1172. doi:10.1111/anae.12347
Bottom Line: This review highlights the importance of patient satisfaction as part of an outcome quality, what part of anesthesia care can improve patient satisfaction and the challenges with measuring patient satisfaction.
​
Major points:
​
1. There is no single, unifying definition of satisfaction but the congruence between what is expected by, and what occurs to, the patients is important.
​
2. Information/communication and personal approach with patients are found to be the most important factors influencing satisfaction with peri-operative care in Anesthesia.
​
3. Patient satisfaction should include adherence to patient safety, treatment of fear, pain and complications of anesthesia but ultimately communication and empathy are main tenants of patient satisfaction.
Myles PS, Boney O, Botti M, et al. Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative: patient comfort. Br J Anaesth. 2018;120(4):705-711. doi:10.1016/j.bja.2017.12.037
Bottom Line: This systematic review which included 122 studies used a multi-round Delphi consensus process to identify six standardized endpoints that represent key aspects of patient comfort in the perioperative setting.
​
Major points:
​
1. Clinical researchers don't always measure what is important to patients.
​
2. 6 clinical endpoints were identified: pain (rest and during movement), 24 hour postoperative nausea and vomiting, quality-of-recovery scales, gastrointestinal recovery, time to mobilization, and sleep quality.
​
3. The QoR-9 and QoR-15 scales have been externally validated, provide patient-centred global assessments of postoperative recovery and are recommended.
Trinh LN, Fortier MA, Kain ZN. Primer on adult patient satisfaction in perioperative settings. Perioper Med (Lond). 2019;8:11. Published 2019 Sep 19. doi:10.1186/s13741-019-0122-2
Bottom line: Patient satisfaction is difficult to study and there is no "gold standard" to measure patient satisfaction. There are modifiable and non-modifiable factors that can impact patient experience and potentially associated clinical and financial outcomes.
​
Major points:
​
1. The modifiable factors that affect patient satisfaction include clinical communication skills, information provision to patients, operational function of hospital, physician skills and behaviours, and an interdisciplinary model of care.
​
2. Non-modifiable factors that may affect patient satisfaction include: age, health status, and education.
​
3. Ways to increase patient satisfaction include improving clinician communication skills, providing appropriately tailored information to patients to increase their involvement in care, and optimizing patient recovery i.e. ERAS.