Decision Support Decision Support as a Clinical Skillas a Clinical Skill

Module III:Module III:Decision aids designed Decision aids designed for specific decisionsfor specific decisions

Last update: September 2008

Condition Specific Decision Aids

Combine evidence based information with values

clarification.

Decision Aids adjunct to counselingadjunct to counseling informinform re options, benefits, risks re options, benefits, risks specify specify probabilitiesprobabilities of outcomes of outcomes clarifyclarify personal values & norms personal values & norms guide guide in deliberating & in deliberating &

communicatingcommunicating empowerempower patient patient

100 researchers, practitioners and stakeholders from 14 countries around the world, lead by professors Annette O’Connor in Canada, and Glyn Elwyn in the United Kingdom.

goal is to establish an internationally approved set of criteria to determine the quality of patient decision aids.

International Patient Decision International Patient Decision Aid Standards (IPDAS) Aid Standards (IPDAS)

CollaborationCollaboration

Cochrane ReviewCochrane Review

Decision Aids:Decision Aids: ImproveImprove knowledgeknowledge Improve Improve realistic expectationsrealistic expectations LowerLower decisional conflictdecisional conflict IncreaseIncrease patient involvementpatient involvement in in

decision decision making making DecreaseDecrease number undecidednumber undecided Increase Increase agreement between values & agreement between values &

choicechoice

Risk PresentationRisk Presentation

Similar profile:Similar profile: Probability Probability of outcome in people ‘like of outcome in people ‘like me’ who experience the me’ who experience the problemproblem

Format:Format: Use quantitative, Use quantitative, qualitative and graphic qualitative and graphic formats (100 faces) to formats (100 faces) to enhance understandingenhance understanding

Framing:Framing: Risk message + Risk message + ‘Positive’ message improves ‘Positive’ message improves message framingmessage framing

Benefits and RisksBenefits and Risks

Importance of benefits (pros)Importance of benefits (pros) Importance of harms (cons)Importance of harms (cons)

ProsPros ImportancImportancee

ConsCons ImportanceImportance

More focus More focus in schoolin school

********** Don’t like Don’t like medicationmedication

******

Less Less stressful for stressful for family family

******** Slowed Slowed growthgrowth

****

Get along Get along better with better with classmatesclassmates

******** Sleep Sleep problemsproblems

**

Should I give my child Ritalin for ADHD?

Should I have a TURP (transurethral resection of the prostate) if I have Symptoms of BPH (benign prostatic hyperplasia)?

PROSPROS

Better reduction Better reduction in symptomsin symptoms

(lowered by 80% (lowered by 80% compared to 32-compared to 32-48% with other 48% with other options)options)

   

 

  

 

CONSMay die from surgery (1 man in 100)

May not have normal ejaculations (75 men in 100)

May not have normal sexual erections(12 more men in 100)

Importance

*****

Importance

***

*

*

Decision AidsDecision Aidson the Webon the Web

10

Healthwise Decision PointsHealthwise Decision Points

>>100 Decision Points in Healthwise Knowledgebase100 Decision Points in Healthwise KnowledgebaseProvide Info re:Provide Info re: Summary of ‘Key Points’ Health condition Options available & description available & description [[some evidence some evidence

summaries]summaries] Who it is appropriate or not appropriate for Who it is appropriate or not appropriate for

Reasons to Reasons to choose & Reasons & Reasons not to choose (Pros & (Pros & Cons) Cons) [table could be used to rate importance][table could be used to rate importance]

Wise Health Decision What issues apply to you? What issues apply to you? [[requires some interpretationrequires some interpretation]]

Leaning References

(O’Connor et al., Cochrane Library, 2004; Issue 1: A Decision Aid: provides, at minimum, information on options and outcomes)

HealthWise Decision AidHealthWise Decision Aid

Video Video Decision AidsDecision Aids

Providers’ Perspectives

“It is helpful to have my patients arrive at the consultation with familiarity of the options and knowledge of the risks and benefits” Richard Barth, MD, surgical oncologist

"With this process, I can focus on "With this process, I can focus on helping each individual patient helping each individual patient decide the best treatment for her.” decide the best treatment for her.”

Kari Rosenkranz, MD, surgical oncologistKari Rosenkranz, MD, surgical oncologist

Patients’ Perspectives “Not ever experiencing such a drastic surgery, this

video helped provide information to help make the

decision that is best for me”” This woman went from being unsure to deciding not to pursue breast reconstruction.

“The tape was very helpful – I hesitated 8 yrs ago but I have no hesitation after reading the booklet

and viewing the video.” This woman opted for breast reconstruction and chose the type of reconstruction she preferred.

“This video made me realize I need to be more in charge of myself. And that surgery should be a last resort and that other options should be explored.” Patient considering surgery for herniated disc.

“I found the video very informative and helpful and because of it I am more inclined to consider surgery, which is a new position.” Patient considering surgery for herniated disc.

ConclusionsConclusionsDecision support is a process of:Decision support is a process of: Assessing decisional needs Intervening to address individual needs Evaluating the quality of decision making

A high quality decision is:A high quality decision is:

Informed Values-based Acted upon

Decision quality improves with:Decision quality improves with: Patient decision aids Personal health coaching using a structured

decision guide