Deciding how to decide – and how to support decisions

Jack Dowie, PhD London School of Hygiene and Tropical Medicine

Honorary Professor, Sydney School of Public Health Mette Kjer Kaltoft, MPH RN

Odense University Hospital Svendborg Sygehus

Nuffield Webinar 21 November 2011

Family spacing consultation in Timor-Leste

2 thanks to Lyndal Trevena, GP, Sydney School of Public Health

• Informed • Shared • Evidence-based • Preference-sensitive • Cost-effective • Minimally-disruptive or maybe just …Better MDM

The (r)evolution of the Patient Hippocrates c400 BC

“perform your duties calmly and adroitly, concealing most things from the patient while attending to him… revealing nothing of the patient’s future or present condition”

“NOTHING ABOUT ME, WITH ME”

Donald Berwick 2009 “The experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care.” “NOTHING ABOUT ME, WITHOUT ME”

Evidence

Expertise Values

‘Taking Into Account and Bearing In Mind’ • Taking things into account • Giving considerations due weight • Establishing the right balance • Keeping things in proportion • Taking a measured view • Bringing everything into the equation • Seeking a degree of consensus • Gauging the impact • Making sure things add up • Summing up

Note how TIABIM discourse, basically qualitative, is given a quantitative flavour

Interventional- Observational Border Conflicts

Qualitative- Quantitative Border Conflicts

BELIEF SYNTHESIS

PREFER ENCE

SYNTHESIS

Annalisa

Decision Technologies

Not Decision- Aided

Decision- Aided

Not MCDA-based MCDA-based

Analytic Hierarchy Process,

HiView, Visa

MyOsteoScreenAL

Multi-Criteria Decision Analysis

Annalisa

TECHNIQUE

TEMPLATE

TOOL Jim Dolan’s AHP aids

Adam Neate

What should we do?

What do we prefer? What do we know?

The Annalisa screen

Evidence Base

Preference Base

Option Scores Options

Options

Attributes

Thanks to my colleague Rebecca French for two following slides

http://www.brook.org.uk/contraception/my-contraception-tool

Rachael’s results

Link to survey 57

Source: PROSPECT instrument

Deciding how to decide

(and deciding how to aid deciding):

the Meta-decision

via MCDA/Annalisa

Criteria for a good decision A personal selection of attributes, for illustrative purposes only (with set of hypothetical options)

• Time required (minimise) • Cheapness(maximise) • User-demands(minimise) • Transparency (maximise) • Separation of beliefs and preferences (maximise) • Comprehensiveness (maximise) • Recommendation produced (maximise) • Revision ease (maximise)

Annalisa/Elicia Beyond ‘Tipping Point’

Level of complexity

Bene

fits o

f com

plex

ity

Walking the talk à la Escher

thanks for attending

References

Berlin, I. (1953). The Hedgehog and the Fox: An Essay on Tolstoy’s View of History. London, Weidenfeld & Nicolson. Berwick, D. M. (2009). "What 'Patient-Centered' Should Mean: Confessions Of An Extremist." Health Affairs 28(4): w555-565. Davis, S. R., C. Kirby, et al. (2011). "Simplifying screening for osteoporosis in Australian primary care: the Prospective Screening for Osteoporosis; Australian Primary Care Evaluation of Clinical Tests (PROSPECT) study." Menopause 18(1): 53-59 10.1097/gme.1090b1013e3181e77468. Dolan, J. G. (2008). "Shared decision-making--transferring research into practice: the Analytic Hierarchy Process (AHP)." Patient Education and Counselling 73(3): 418-425. Dolan, J. G. (2010). "Multi-Criteria Clinical Decision Support: A Primer on the Use of Multiple-Criteria Decision-Making Methods to Promote Evidence-Based, Patient-Centered Healthcare." The Patient: Patient-Centered Outcomes Research 3(4): 229-248. Dowie, J. (2006). "JUDEMAKIA: a map of the world of judgment and decision-making in health." http://knol.google.com/k/judemakia-a-map-of-the-world-of-judgement-and-decision-making-in-health#. Dowie, J. (2007). "Decision Day with Annalisa: the Little Mermaid." http://knol.google.com/k/decision-day-with-annalisa-the-little-mermaid#. Dowie, J. (2008). "Decision Day with Annalisa: Hamlet, Prince of Denmark." http://knol.google.com/k/decision-day-with-annalisa-hamlet-prince-of-denmark#. Dowie, J. (2008). "Decision Resource-Decision Effectiveness Analysis." http://knol.google.com/k/decision-resource-effectiveness-analysis#. Dowie, J. (2009). "Decision Day with Annalisa: John Snow." http://knol.google.com/k/decision-day-with-annalisa-john-snow#. Dowie, J. (2009). "Decision Day with Annalisa: Sir Colenso Ridgeon." http://knol.google.com/k/decision-day-with-annalisa-sir-colenso-ridgeon#. Gould, S. J. (2003). The Hedgehog, the Fox, and the Magister's Pox: Mending the Gap Between Science and the Humanities. Hammond, K. R. (1996). Human Judgment and Social Policy: Irreducible Uncertainty, Inevitable Error, Unavoidable Injustice. New York, Oxford University Press. Keeney, R. L. and D. A. Vernik (2007). "Analysis of the Biological Clock Decision." Decision Analysis 4(3): 114-135. King, J. S. and B. W. Moulton (2006). "Rethinking Informed Consent: The Case for Shared Medical Decision-Making." American Journal of Law and Medicine 32(4): 429-501. Nelson, W. A. and K. Clay (2011). "Transitioning to "Perfected" Informed Consent." Healthcare Executive (July/August). Stacey, D., M. A. Murray, et al. (2008). "Decision Coaching to Support Shared Decision Making: A Framework, Evidence, and Implications for Nursing Practice, Education, and Policy." Worldviews on Evidence-Based Nursing 5(1): 25-35.

Software Full details and demo are available at http://elicia.org.uk