Clinician Assessment Tools for Patients with Diabetic Foot ...
Patient-clinician decision support tools – How can … › sites › default › files ›...
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SYDNEY MEDICAL SCHOOL
Patient-clinician decision support tools – How can quality tools be assessed and adapted for use in Australia?
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Context for use of decision support tools in clinical practice: 1. Good quality and fit for purpose
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Context for use of decision support tools in clinical practice: 2. Skilled users willing to use them
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Context for use of decision support tools in clinical practice: 3. Supportive environment
› Sophie (3yo) – should she start antibiotics for her acute otitis media or use analgesics?
› Graham (68yo) – should he try CBT or medication for anxiety/depression? Should he have surgery for Dupuytren’s contracture in right hand or wait?
› Julie (49yo) – should she add LBC with conventional pap test? Should she restart anti-hypertensives or wait? What method should she use to stop smoking? Should she start having mammogram or wait?
› Zara (33yo) – should she start bromocryptine to assist breast milk supply or keep trying demand feeds?
› Annabel (24yo) – should she have a trial of metronidazole treatment for chronic diarrhoea following travel or continue with elimination diets prescribed by dietitian?
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-Oliver (7yo) – should he have an X-ray for injured ankle? -Rebecca (11 yo) – will adenoidectomy improve her recurrent sinusitis/rhinitis or should she use nasal steroid sprays or both?
-.........and there’s more.....
A typical afternoon of decisions in Australian general practice.....
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Deciding: Putting it all together to make a decision
Clinical state and circumstances
Patients’ preferences and actions Research evidence
Haynes 2002
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‘The practice of evidence-based medicine means integrating clinical
expertise [proficiency, judgement acquired through clinical practice and
use of individual patient’s right, predicaments, preferences] with the
best available expert evidence from systematic research.’
David Sackett (1996)
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Tools fit for purpose – considering the evidence
› GRADE takes into account: - The overall confidence in the estimates (quality of evidence)
- Balance of benefits versus harms and burdens
- Values and Preferences (How important?)
- Resources and implications
- Equity, feasibility and acceptability
Derive recommendations based on the body of evidence
Strong recommendation for
Weak recommendation for
Strong recommendation against
Weak recommendation against
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www.gradeworkinggroup.org
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Strong recommendation for or against
› Based on the available evidence, if clinicians are very certain that benefits do, or do not, outweigh risks and burdens they will make a strong recommendation
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Evidence summaries: Free and subscription – Push and pull – Clinician, patient and both
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When do patients want more involvement in health decisions?
› 1. Preventive healthcare decisions
› 2. Situations with potential negative future consequences e.g. Chronic diseases
› 3. Where the evidence is lacking or uncertain e.g. A weak recommendation with GRADE
› 4. Decisions involving potential side effects e.g. Immunisation, antihypertensive therapy
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Muller-Engelmann M et. al. Medical Decision Making 2013, 33(1):37-47.
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Even under these circumstances many will prefer to accept an offer or recommendation
Entwistle VA, Carter SM, Trevena L, Flitcroft K, Irwig L, McCaffery K, Salkeld G: Communicating about screening. BMJ 2008, 337:a1591.
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Even under these circumstances many will prefer to accept an offer or recommendation
› This approach tested in 1964 UK residents aged 50-80 years re colorectal cancer screening
› Indicate their preferences for (1) a strong recommendation to participate in CRC screening, (2) a recommendation alongside advice to make an individual decision, and (3) no recommendation but advice to make an individual decision.
› Most respondents (84%) preferred a recommendation (47% strong recommendation, 37% recommendation plus individual decision-making advice), but the majority also wanted full information on risks (77%) and benefits (78%)
› Those with low trust in the NHS were less likely to want a recommendation
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Waller J et.al. Communication about colorectal cancer screening in Britain: public preferences for an expert recommendation. British journal of cancer 2012, 107(12):1938-1943.
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What sort of tools are available for these more shared contexts?
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www.optiongrid.org/ http://decision.ohri.ca/azinvent.php http://www.cancerinstitute.org.au/patient-support/what-i-need-to-ask
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Communication frameworks
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www.askshareknow.com.au Irwig, Irwig, Trevena Sweet. Smart Health Choices (2007) www.sensiblehealthadvice.org.au
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How do we assess quality of these tools
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Recent update of quality dimensions and background documentation
› IPDAS collaboration is working towards defining the evidence for effectiveness of different components in a recent set of review underpinning the checklist (in press with BMC Informatics and Medical Decision-Making and available http://ipdas.ohri.ca/resources.html): - Chapter A: Using a Systematic Development Process
- Chapter B: Providing Information About Options*
- Chapter C: Presenting Probabilities**
- Chapter D: Clarifying and Expressing Values
- Chapter E: Using Personal Stories*
- Chapter F: Guiding / Coaching in Deliberation and Communication
- Chapter G: Disclosing Conflicts of Interest*
- Chapter H: Delivering Decision Aids on the Internet*
- Chapter I: Balancing The Presentation of Information and Options
- Chapter J: Addressing Health Literacy**
- Chapter K: Basing Information On Comprehensive, Critically Appraised, And Up-To-Date Syntheses Of The Scientific Evidence
- Chapter L: Establishing the Effectiveness
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Evolution of the IPDAS checklist
› 2005-2006 IPDAS Checklist developed through international consensus process following an evidence review - 12 quality dimensions and 74 specific criteria (present/absent)
- Quantitative tool refined IPDASi (v3.0)across 10 quality dimension and 47 specific criteria Items rated on 4-point scale but no decision about thresholds for quality.
- IPDASi (v4.0) developed as certification tool through expert consensus
- 6 Qualifying criteria, 10 certification criteria and 28 Quality criteria
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Joseph-Williams N et.al. Toward Minimum Standards for Certifying Patient Decision Aids: A Modified Delphi Consensus Process. Medical Decision-Making (online ahead of print)
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Adaptation for Australia
› Local acceptance of decision support tools is crucial and adaptation might include the following: - Applicability of research evidence
- Medical Terminology
- Local clinical practice, health system issues
- Culture and style
- Existing local resources
- Attitudes and awareness of shared decision-making
- (Adapted from Coulter 2010 and Barratt et. al. 2010 – personal correspondence)
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