Patient decision aids: why, what, how, where? Dawn Stacey RN, PhD Research Chair in Knowledge...
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Patient decision aids: why, what, how, where?
Dawn Stacey RN, PhD
Research Chair in Knowledge Translation to Patients
Full Professor, School of Nursing
Director of the Patient Decision Aids Research Group
Scientist, Ottawa Hospital Research InstituteOctober, 2014
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Think about a health
decision that you or
someone you know
will make over the
next year
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SURE Test ©2008 O’Connor & Legare
Thinking about that health decision…
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Evolution of health information• < 1990:
– healthcare professionals were gate keepers to information
• 1990: www– passive viewing of information
• 2004: Web 2.0– allows users to interact with each other and
contribute to website's content (e.g. social networking, wikis, video-sharing, blogs)
• 2010: open access to publications of studies receiving public funds
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USA: R. 3590 The Patient Protection and Affordable Care Act (March 2010)
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Outline
• Shared decision making (SDM)
• Patient decision aids
– What are they?
– How do they work?
– What is a high quality one?
• Examples of patient decision aids
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Shared decision making
A process by which a
healthcare choice is
made between the
patient and one or more
health professionals
(Legare et al., 2010; Makoul et al. 2006; Stacey et al. 2011)
The crux of patient centred care
The crux of patient centred care
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Shared decision making
A process by which a
healthcare choice is
made between the
patient and one or
more health
professionals
(Legare et al., 2010; Makoul et al. 2006)
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Shared decision making
A process by which
a healthcare choice
is made between
the patient and one
or more health
professionals
(Legare et al., 2010; Makoul et al. 2006; Politi et al., 2013)
Deliberation
Determination
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Improve o quality of lifeo sense of control over illnesso symptom relief
Decreaseo fatigueo depressiono illness concerns
However, most patients would prefer more active involvement
Patients involved in decision making…
(Kiesler & Auerbach 2006; Hibbard & Greene 2013)
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Shared decision making
A process by which
a healthcare choice
is made between the
patient and one or
more health
professionals
(Couet et al 2014)
SDM is NOT happening in
clinical practice
33 Studies mean score
23 ± 14 (range 0 to 100)
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Outline
• Shared decision making (SDM)
• Patient decision aids
– What are they?
– How do they work?
– What is a high quality one?
• Examples of patient decision aids
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Inform• Provide facts
Condition, options, benefits, harms• Communicate probabilities
Clarify values• Ask which benefits/harms matters most• Share patient experiences• Facilitate communication
Support• Guide in steps in deliberation/communication• Worksheets, list of questions
Patient Decision Aids adjuncts to counseling
(Stacey et al., Cochrane Library, 2014)
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Formats for patient decision aids(used prior to or within consultations)
1. Print
2. DVD/Video
3. Online/computer-based
(Stacey et al., 2014)
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Topics of Decision Aids (N=115)• Medication (n=36)
– 10 hormone replacement therapy– 3 atrial fibrillation anti-coagulants– 3 cardiovascular– 3 diabetes – 2 osteoporosis– 2 chemotherapy– 2 breast cancer prevention– 2 osteoarthritis knee – hypertension– multiple sclerosis– schizophrenia– depression– natural health products– ovarian risk management– acute respiratory infection – contraceptives– coronary angiogram access site
• Screening (n=46)– 15 Prostate Specific Antigen (PSA)– 7 BRCA1/2 genetic– 11 colon cancer– 6 prenatal– 2 mammography – 2 diabetes– Colon cancer genetic– Cervix cancer– Stress testing for chest pain
• Surgery (n=23)– 4 mastectomy +1 reconstruction – 4 prostatectomy – 4 hysterectomy – 2 prophylactic BRCA1/2– 2 coronary revascularization– dental– orchiectomy for advanced prostate ca– back– bariatric– vasectomy – long term feeding tube placement
• Obstetrics (n=6)– 2 vaginal birth after cesarean– termination– breech– labour analgesia– embryo transplant
• Other (n=4)– Hepatitis B vaccine– influenza vaccine– Autologous blood donation– Cystic Fibrosis Transplant Referral
(Stacey et al., 2014 Cochrane Review)
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Patient education vs. decision supportPatient education vs. decision support
(RNAO Best Practice Guideline: Decision Support for CKD, 2009)
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Outline
• Shared decision making (SDM)
• Patient decision aids
– What are they?
– How do they work?
– What is a high quality one?
• Examples of patient decision aids
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Cochrane Review of Patient Decision Aids: updates
17
35
55
86
115
0
20
40
60
80
100
120
140
1999 2003 2009 2011 2014
(Stacey et al., 2014 Cochrane Review)
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Compared to usual care, PtDAs…Improve decision quality with… 13% higher knowledge
82% more accurate risk perception
51% better match between values & choices
6% reduced decisional conflict
Helps undecided to decide (41%)
Patients 34% less passive in decisions
Improved patient-practitioner communication (8/9 trials)
Potential to reduce over-use -20% surgery -14% PSA – prostate screening -27% Hormone replacement tx
(Stacey et al., 2014 Cochrane Review)
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Outline
• Shared decision making (SDM)
• Patient decision aids
– What are they?
– How do they work?
– What is a high quality one?
• Examples of patient decision aids
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International Patient Decision Aid Standards (IPDAS) Collaboration since 2003
IPDAS Steering Committee: Glyn Elwyn & Dawn Stacey (Co-Leads),
M Barry, N Col, A Coulter, K Eden, M Härter, M Holmes-Rovner, H Llewellyn-Thomas, V Montori, N Moumjid, M Pignone,
R Thomson, L Trevena, R Volk, T van der Weijden
To enhance the quality and effectiveness of patient decision
aids by establishing a shared evidence-informed framework
for improving their content, development, implementation,
and evaluation.
BMC Medical Informatics and Decision Making 2013, 13 (Suppl 2). http://www.biomedcentral.com/bmcmedinformdecismak/supplements/13/S2
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Outline
• Shared decision making (SDM)
• Patient decision aids
– What are they?
– How do they work?
– What is a high quality one?
• Examples of patient decision aids
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http://www.med-decs.org/nl
To find decision aids go to…
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To find decision aids
Google: ‘decision aid’
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Prostate CancerKnowing Your Options: A Decision Aid for Men With Clinically Localized Prostate Cancer
Agency for Healthcare Research and Quality (AHRQ)
Localised prostate cancer - low riskOption Grid Collaborative
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Compared to controls (n=59),those exposed to the decision aid (n=48) had:
-higher confidence in their immunization decision-higher intent to be immunized
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Key Messages
• Shared decision making is important for patient centred care
• Patient decision aids prepare patients by:
– Making explicit the decision
– Providing balanced evidence on options
– Asking patients what matters most
• Evidence supports their effectiveness & quality
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http://decisionaid.ohri.ca