National Strategies for Implementing Shared Decision Making

[Annette McKinnon]

It's by Angela Coulter, and you do need to download it to read it -

National Strategies for Implementing Shared Decision Making

. Here's the link: http://bit.ly/2miyEa1

If that's too much trouble, I am going to cut and paste the section about Canada here. It is 3 pages long.

11.2 Canada
Health system	Responsibility for healthcare provision is devolved to the ten provinces and three territo-ries that make up Canada. The provincial and territorial governments are responsible for the management, organization and delivery of care services health, while the federal gov-ernment sets standards and provides funds through the publicly-funded Medicare system. The federal government also provides services for certain specific groups, including First Nations people and the military.
Leadership
Policy	Canada has a long history of supporting SDM research, mainly through the Canadian In-stitutes of Health Research, and two leading Canadian research groups have influenced policy developments and implementation, both nationally and internationally. The Ottawa Patient Decision Aids Research Group began work in 1989 and since then they have launched the Ottawa Decision Support Framework, developed the Ottawa De-cision Support tutorial, created a global inventory of PDAs assessed against IPDAS criteria, and led and regularly updated the Cochrane review on the effects of PDAs (9). Their bilingual website, which also includes a generic personal decision guide for use in any situation, attracts large numbers of visitors from around the world and is now availa-ble in English, French, Swedish, Dutch, Danish, Spanish, German and Japanese. Prof Dawn Stacey, who leads this work, is the Canada Research Chair in Knowledge Transla-tion to Patients. Prof France Legaré, Canada Research Chair in Shared Decision Making and Knowledge Translation, is based at the Centre for Research on Primary Care and Services at Laval University, Quebec. She leads the Laboratory for the Implementation of Shared Deci-sion Making in Primary Care, led the Cochrane review on interventions for improving the adoption of shared decision making by healthcare professionals (36), and has developed an inventory of programs and training activities dedicated to shared decision making. Saskatchewan, one of the country's smallest and least populous provinces, was the first to develop a strategy for implementing SDM across the province (18, 116). Their Patient First initiative included implementing SDM as one of its main goals.
Professional	The College of Family Physicians of Canada has called for a patient-centred approach to care, stating: "patients, their families, and their personal caregivers should be listened to and respected as active participants in their care decisions and their ongoing care" (117). A number of specialty groups have instituted collaborative research projects in SDM in areas such as elder care, paediatrics, emergency and critical care medicine, cardiology, nutrition, arthritis, occupational therapy, and social care (18). The Canadian Task Force on Preventive Healthcare has a patient engagement strategy for its guidelines programme and is beginning to promote SDM (118) . There are currently no direct legal or financial incentives for clinicians in Canada to prac-tice SDM.
Patient	Patients Canada campaigns for improvements in patients' experience, but SDM has not been a specific focus of their work. While it seems that no Canadian patient organisations have majored on SDM, various individual patient leaders have been prominent in calling for it.

Infrastructure
Training	SDM training for clinicians is not coordinated across Canada and not specifically as-sessed in the exams for medical students, residents or specialists. Little is known about the extent to which SDM skills are taught, or who receives such training. The University of Montreal's medical school has initiated a major patient partnership initi-ative, including a pioneering project to integrate patient-partners into oncology teams, at both clinical and organizational levels. The University of British Columbia's Patient and Community Partnership for Education works to promote a partnership model of client-health professional communication in line with current trends in health care including evidence-based practice, client-centred care and informed and shared decision making. The Ottawa Decision Support tutorial, an online training programme that has been pub-licly available since 2007, includes a knowledge test that has been completed by 6,500 users to date.
Tools	The Ottawa Hospital Research Institute's global A-Z Inventory of PDAs provides links to a large number of PDAs covering nearly 150 different conditions Laval University produces the decision box, an evidence-based summary of the most im-portant benefits and harms of a health care intervention. The clinician version of the Decision box prepares healthcare professionals to translate evidence to patients, an es-sential step to evidence-based practice and shared decision making. The patient version is a PDA to support discussion between patients, their health care providers and their family relatives. A US not-for-profit company Healthwise, markets their information products in Canada. These are used in several provinces, including Alberta, British Columbia and Saskatche-wan, but the extent to which the SDM elements of their package are used in Canada is not known. Other decision aid producers include academic groups such as the Ottawa Patient Deci-sion Aids Research Group, the Centre for Research and Primary Care Services in Quebec, and the Decision Sciences Programme at the University of British Columbia. Many of the PDAs produced by academic groups were designed for use in specific re-search studies and are not available for wider use. Health Quality Ontario produces clinical quality standards and is intending to develop pa-tient decision aids to complement these. Apart from Healthwise, there is currently no Canadian organisation dedicated to produc-ing PDAs and keeping them up-to-date.
Campaigns	Choosing Wisely Canada aims to reduce unnecessary care by promoting better conver-sations between patients and clinicians. It's More is not always better campaign uses advertising techniques to encourage patients to talk to doctors about when they might need a particular test or treatment and when they don't. Many of the priority lists submit-ted by specialty societies recommend shared decision making. Choosing Wisely Canada also hosts the international secretariat for Choosing Wisely which is promoting patient in-volvement in decisions about their care (119). They also produce campaign materials, including posters and videos, to encourage patients to ask four questions: Do I really need this test, treatment or procedure? What are the downsides? Are there simpler, safer options? What happens if I do nothing?

But these questions are focused on reducing over-treatment rather than providing balanced information (120).
Practice
Demonstration	The Saskatchewan Surgical Initiative introduced SDM into specific clinical pathways, in-cluding hip and knee replacement, prostate cancer screening, spine and pelvic floor problems (121). Since 2009 the Children's Hospital of Eastern Ontario has implemented a hospital-wide programme to provide paediatric PDAs and training for health professionals (18).
Measurement	In 2015 the Canadian Institute for Health Information (CIHI) launched a pan-Canadian pa-tient experience survey. This includes the following question: Were you involved as much as you wanted to be in decisions about your care and treatment? No results have been published yet, but when they are this may give an indication of the extent to which SDM is practised across Canada. Meanwhile patient surveys have been undertaken in various Canadian provinces reveal-ing shortfalls in SDM practice. For example, a 2016 survey report from Quebec found that only 35% of family physicians claimed to discuss treatment options with their patients, compared to 67% in the UK, and Quebec patients were less likely to feel involved in treat-ment decisions, with only 60% of those aged over 55 saying they were, compared to 76% in Switzerland (122). The Ministry of Health in Saskatchewan uses the SURE instrument to screen for deci-sional conflict in surgical pathways as part of their Patient First programme.
Coordination	There is no central coordinating function for work on SDM and no dedicated funding source for further development of these. However, the Ottawa Hospital Research Insti-tute's inventory of PDAs and their other materials play a key role in disseminating learning about SDM, not just in Canada but also internationally.
Overview
Much of the impetus to implement SDM in Canada has come from academic groups to date. While some provinces have made progress, there has been no attempt to coordi-nate initiatives across the country, professional leadership has been relatively weak, patient/public leadership non-existent and there is a lack of infrastructure support. How-ever, change is in the air and the desire for greater involvement in decisions is becoming more apparent.