Option grids are tools that help clinicians and patients communicate and make shared decisions using evidence. A project tested implementing shared decision making across different clinical areas in the UK using a framework of action learning, social marketing, and organizational leadership. Early results found that simple decision aids like option grids can help but challenges include clinical complexity, time constraints, and medical culture. Measurement of decision quality provided clinically relevant feedback.

1. Option Grids: tools that make shared
decision making easier for clinicians and
patients
Professor Glyn Elwyn
Institute of Public Health and Primary Care

2. MAGIC
Implementing shared decision making
into practice in the UK

3. Newcastle Cardiff
Richard Thomson Glyn Elwyn
Acknowledgements: The Health Foundation, Cardiff and Vale Health
Board, Newcastle upon Tyne Hospitals NHS Foundation Trust, and most
importantly all staff and patients involved across both sites

4. Background:
The Health Foundation - An independent charity working to improve
the quality of healthcare in the UK
• Leadership and organisations
• Patient safety
• Changing relationships between people and health services
• Engaging healthcare professionals
18 months project: started August 2010
Further 18 months funding agreed February 2012

5. Are patients involved?
100
90
80
70
60
46 46 47 47 48 49 48 48
50
40
30
20
10
0
2002 2003 2004 2005 2006 2007 2008 2009
Wanted more involvement in treatment decisions
Source: NHS inpatient surveys

7. I prefer this
option …

8. Shared decision making
Shared decision making occurs when clinicians and
patients communicate together using the best available
evidence when faced with the task of making decisions

9. Shared decision making
Shared decision making occurs when clinicians and
patients communicate together using the best available
evidence when faced with the task of making decisions,
where patients are supported to deliberate about the
possible attributes and consequences of options

10. Shared decision making
Shared decision making occurs when clinicians and
patients communicate together using the best available
evidence when faced with the task of making decisions,
where patients are supported to deliberate about the
possible attributes and consequences of options, to
arrive at informed preferences in making a determination
about the best action and which respects patient
autonomy, where this is desired, ethical and legal.

11. Patient decision support / decision aids: The evidence
In 86 trials addressing 35 different screening or treatment
decisions, use has led to:
• greater knowledge
• more accurate risk perceptions
• greater comfort with decisions
• greater participation in decision-making
•F ewer people remaining undecided
• fewer patients choosing major surgery.
Stacey et al. Cochrane Database of Systematic Reviews, 2011

12. MAGIC Making Good Decisions in Collaboration with Patients
The MAGIC Framework: Action learning with indicator feedback, located in a social marketing context
and supported by organisational level leadership.
Indicator
ENT
Feedback
Breast Surgery
Project
Start Primary Care
Obstetrics
Social Urology
Marketing
Senior Management Clinical Leadership

13. • Evidence-based patient decision MAGIC Making Good Decisions in Collaboration with Patients
support The MAGIC Framework: Action learning with indicator feedback, located in a social marketing context
and supported by organisational level leadership.
Indicator
ENT
• Social marketing Feedback
Breast Surgery
• Clinical skills development
Project
Start Primary Care
Obstetrics
• Organisation and clinical team Social
engagement
Urology
Marketing
• Measurement with rapid feedback, Senior Management Clinical Leadership
Plan Study Do Act cycles.
• Patient and public engagement

14. Early learning from
MAGIC

15. Challenges of implementing shared decision making
• Response to change
• Clinical complexity
• Medical culture
• Paternalism
• Clinical care pathway
• Time and resources

16. Identifying challenges

20. Option
Grid Lumpectomy with
Radiotherapy
Mastectomy
Which surgery is best There is no difference There is no difference
for long term survival? between surgery options. between surgery options.
Breast cancer will come Breast cancer will come
back in the breast in back in the area of the
What are the chances
about 10 in 100 women in scar in about 5 in 100
of cancer coming back?
the 10 years after a women in the 10 years
lumpectomy. after a mastectomy.
The cancer lump is
The whole breast is
What is removed? removed with a margin of
removed.
tissue.
Possibly, if cancer cells
remain in the breast after
Will I need more than No, unless you choose
the lumpectomy. This can
one operation breast reconstruction.
occur in up to 5 in 100
women.
How long will it take to Most women are home 24 Most women spend a few
recover? hours after surgery nights in hospital.
Unlikely, radiotherapy is
Will I Yes, for up to 6 weeks
not routine after
need radiotherapy? after surgery.
mastectomy.
Some or all of the lymph Some or all of the lymph
Will I need to have my
glands in the armpit are glands in the armpit are
lymph glands removed?
usually removed. usually removed.
Yes, you may be offered Yes, you may be offered
chemotherapy as well, chemotherapy as well,
Will I
usually given after usually given after
need chemotherapy?
surgery and before surgery and before
radiotherapy. radiotherapy.
Hair loss is common after
Hair loss is common after

21. Option
Grid Lumpectomy with
Radiotherapy
Mastectomy
Which surgery is best There is no difference There is no difference
for long term survival? between surgery options. between surgery options.
Breast cancer will come Breast cancer will come
back in the breast in back in the area of the
What are the chances
about 10 in 100 women in scar in about 5 in 100
of cancer coming back?
the 10 years after a women in the 10 years
lumpectomy. after a mastectomy.
The cancer lump is
The whole breast is
What is removed? removed with a margin of
removed.
tissue.
Possibly, if cancer cells
remain in the breast after
Will I need more than No, unless you choose
the lumpectomy. This can
one operation breast reconstruction.
occur in up to 5 in 100
women.
How long will it take to Most women are home 24 Most women spend a few
recover? hours after surgery nights in hospital.
Unlikely, radiotherapy is
Will I Yes, for up to 6 weeks
not routine after
need radiotherapy? after surgery.
mastectomy.
Some or all of the lymph Some or all of the lymph
Will I need to have my
glands in the armpit are glands in the armpit are
lymph glands removed?
usually removed. usually removed.
Yes, you may be offered Yes, you may be offered
chemotherapy as well, chemotherapy as well,
Will I
usually given after usually given after
need chemotherapy?
surgery and before surgery and before
radiotherapy. radiotherapy.
Hair loss is common after
Hair loss is common after

22. Option
Grid Lumpectomy with
Radiotherapy
Mastectomy
Which surgery is best There is no difference There is no difference
for long term survival? between surgery options. between surgery options.
Breast cancer will come Breast cancer will come
back in the breast in back in the area of the
What are the chances
about 10 in 100 women in scar in about 5 in 100
of cancer coming back?
the 10 years after a women in the 10 years
lumpectomy. after a mastectomy.
The cancer lump is
The whole breast is
What is removed? removed with a margin of
removed.
tissue.
Possibly, if cancer cells
remain in the breast after
Will I need more than No, unless you choose
the lumpectomy. This can
one operation breast reconstruction.
occur in up to 5 in 100
women.
How long will it take to Most women are home 24 Most women spend a few
recover? hours after surgery nights in hospital.
Unlikely, radiotherapy is
Will I Yes, for up to 6 weeks
not routine after
need radiotherapy? after surgery.
mastectomy.
Some or all of the lymph Some or all of the lymph
Will I need to have my
glands in the armpit are glands in the armpit are
lymph glands removed?
usually removed. usually removed.
Yes, you may be offered Yes, you may be offered
chemotherapy as well, chemotherapy as well,
Will I
usually given after usually given after
need chemotherapy?
surgery and before surgery and before
radiotherapy. radiotherapy.
Hair loss is common after
Hair loss is common after

24. PRACTICE VARIATION 1938
10-fold variation in tonsillectomy
8-fold risk of death with surgical treatment
“…these strange bare facts of
incidence…”
“… tendency for the operation to be
performed for no particular reason and
no particular result.”
“…sad to reflect that many of the
anesthetic deaths… were due to
J Allison Glover, 1938 Report unnecessary operations.”
to Royal Academy of Medicine

25. VARIATION 2009 – 80 YEARS LATER
Even for some operations whose effectiveness has been
questioned, variations in treatment between PCTs are
widespread.
The removal of tonsils in children has been queried since the
1930s, yet the rate of tonsillectomies in Coventry PCT in
2009/10 was ten times higher than the rate in Kingston
PCT for example.

26. Meet Jennifer…

28. JENNIFER’S TONSILS
You are Tracy / Terry Collins, 36 - mother / father of Jennifer, aged 10. You work as a
technician at a busy dental practice and rely on your mother for after school care.
Jennifer was doing well at school. However. over the last two years she has had what seem
like endless colds and tonsillitis. She has an episode every few months.
She does not sleep well. She has missed a lot of school and you are worried that she will do
badly in her tests.
Your mother struggles when she is ill. She also, believes that Jennifer needs to have her
tonsils out.
You are not quite so sure. But you are beginning to wonder if your mother isn’t right. You
have booked an appointment to discuss your daughter and you are going without her.
When you left Jennifer at your mothers’ place on the way to the doctors, she told you not to
take no for an answer .

29. 29

30. An approach to measuring the quality of
breast cancer decisions. Sepucha K,
Ozanne E, Silvia K, Partridge A, Mulley
AG. Patient Education and Counseling.
2007: 65(2):261-9.
30

31. Decision Quality Measure
• Knowledge
• Readiness to decide “DelibeRATE”
• Preference
• Intention
31

32. Decision Quality Measure
Knowledge at diagnosis Knowledge at home visit
N=28 N=20
100
100
90
Percentage of Patients
90
Percentage of Patients
80
80
70
70
60
60
50
50
40 40
30 Unsure
30 Unsure
20 Correct 20
10 Correct
Incorrect 10
0 0 Incorrect
Question number Question Number

33. DelibeRATE Scale “readiness to decide”
At diagnosis (DQM1) At home visit (DQM2)
100
100
90
90
Percentage of Patients
Percentage of patients
80
80
70 70
60 60
50 50
40 40
30 30
Unsure Unsure
20 20
10 No No
10
0 Yes Yes
0
Question Number
Question Number

34. Decision Quality Measure
Intention at diagnosis (DQM1) Intention at home visit (DQM2)
100 100
90 90
80 80
70 70
60 60
50 50
40 40
30 30
20 20
10 10
0 0
Strong Leaning Not sure Leaning Strong Strong Leaning Not sure Leaning Strong
preference towards towards preference preference towards towards preference
for mastectomy lumpectomy for for mastectomy lumpectomy for
mastectomy lumpectomy mastectomy lumpectomy

35. “Decision Quality – it’s nothing to do
with MAGIC any more – it’s what we do
in the breast care team...”
Helen McGarrigle
Breast Care Nurse
Cardiff.

36. Social Marketing
• Social marketing to patients
• Shift from implementation team to clinical teams
• Clinicians and managers - awareness raising and profile

37. Three simple questions to increase information about treatment
options and patient involvement in healthcare consultations.
Shepherd, HL; Barratt, A; Trevena, LJ; McGeechan, K; Carey, K;
Epstein, RM; Butow, PN; Del Mar, CB; Entwistle, V; Tattersall, MHN
Patient Education and Counseling 2011.
37

38. Ask three Questions
38

39. Ask 3 Questions
Sometimes there will be choices to make about your healthcare. If you are asked to
make a choice, make sure you get the answers to these 3 questions:
What are my options?
What are the possible
benefits and risks of
those options?
How likely are the
benefits and risks of each
option to occur?
We want to know what’s important to you

40. Implementation into practice - Lessons learnt so far
• Needs multi-faceted, multi-level, sustained strategy
• Most important learning to date:
• Simple tools Option Grids act as catalysts
• DQM: measurement that has clinical relevance
• Quality Improvement methods are helpful but not well
understood
• Importance of policy drivers and incentives