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Engaging Patients in their Own Engaging Patients in their Own Healthcare DecisionsHealthcare Decisions

Dawn Stacey RN, PhDDawn Stacey RN, PhDUniversity Research Chair in Knowledge Translation to Patients

Associate Professor, University of Ottawa

Scientist and Director of the Patient Decision Aids Research Group, Ottawa Hospital Research Institute

TEACH Workshop, New York (August 7, 2013)

Objectives

• To understand the concept of shared decision making

• To be aware of current evidence on interventions for engaging patients in their health decisions

• To consider leavers and evidence-based strategies for implementing decision aids in clinical practice

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1. Shared decision making (SDM)

2. Tools to facilitate SDM• Patient decision aids

• Decision coaching

3. Implementation in practice

OutlineOutline

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Shared decision makingShared decision making

A process by which a

healthcare choice is

made between the

patient and one or more

health professionalsThe crux of patient

centred careThe crux of patient

centred care

Facilitated by:o Patient decision

aidso Decision coaching

Facilitated by:o Patient decision

aidso Decision coaching

(Legare et al., 2010; Makoul & Clayman 2006; Stacey et al. 2011; Weston, 2001)

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Client Centred CareClient Centred Care

“Providing care that is respectful of

and responsive to individual patient

preferences, needs and values, and

ensuring that patient values guide

all clinical decisions”

(p.6, Institute of Medicine, 2001)

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Steps in Shared Steps in Shared Decision MakingDecision Making

(Legare et al., 2010)

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…Patients involved in decision making…

(Kiesler & Auerbach 2006, Pt Ed Counsel, 61:319-341)

99Research evidence Healthcare resources

Clinical state, setting, & circumstances

Healthcare Professionals

Patient preferences & actions

Evidence-based clinical decisions Evidence-based clinical decisions (Guyatt, Haynes, DiCenso from McMaster University)

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1. Shared decision making (SDM)

2. Tools to facilitate SDM• Patient decision aids

• Decision coaching

3. Implementation in practice

OutlineOutline

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Patient decision aids are third-generation knowledge tools whose purpose is to present knowledge in user-friendly, implementable formats.

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Patient Patient Decision AidsDecision Aids

Knowledge Knowledge to Action to Action

FrameworkFramework(Graham et al. 2013)(Graham et al. 2013)

Inform•Provide facts

•Condition, options, benefits, harms•Communicate probabilities

Clarify values•Patient experience•Ask which benefits/harms matters most•Facilitate communication

Support•Guide in steps in deliberation/communication•Worksheets, list of questions

Patient Decision AidsPatient Decision Aids adjuncts to counseling

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Consider which positive and negative Consider which positive and negative features matter mostfeatures matter most

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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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To find decision aidsTo find decision aidsGOOGLE: ‘decision aid’GOOGLE: ‘decision aid’

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Chance of pregnancy by optionThese figures show the chance of pregnancy for 1000 women over 1 year for different contraceptive approaches(1 sperm = 2 people)

Vasectomy Tubal ligation The Pill

IUD Male Condoms Rhythm method

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The patient decision aid presents probabilities … No Yes

1.…using event rates… X

2. …using the same denominator X

3. …over the same period of time X

4. …with uncertainty X

5. …using visual diagrams (e.g. faces, bar charts) X

6. …using the same scales X

7. …with more than 1 way of viewing probabilities (e.g. words, numbers, diagrams).

X

8. …based on patient’s own situation (e.g. specific to their age or severity of their disease)

X

9. …using both positive and negative frames X

IPDAS presenting probabilitiesIPDAS presenting probabilities

(Elwyn et al., (2006) in BMJ 333(7565):417; Trevena et al. (2006) in J Eval Clin Practice)

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Cochrane Review of Cochrane Review of

Patient Decision Aids: Patient Decision Aids:

Update in processUpdate in process

D Stacey, C Countemanche, M Barry, C Bennett, N Col, K Eden, M Holmes-Rovner, F Legare, H Llewellyn-Thomas,

A Lyddiatt, R Thomson, L Trevena

Acknowledgements: A Saarimaki, S Beach, R Wu

Funded by University Research Chair in KT to Patients

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Cochrane Review PtDAs UpdatesCochrane Review PtDAs Updates

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35

55

86

117

0

20

40

60

80

100

120

140

1999 2003 2009 2011 2013

IPDASCriteri

a2005

IPDAS

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Topics of Decision AidsTopics of Decision Aids (N=117)• Medical (n=27+8)

– 10 HRT– 3 atrial fib anti-coagulation– 2 + 1 cardiovascular (Sheridan)– 2+1 diabetes (Mann D) – 1 hypertension– 1 +1 osteoporosis (Montori)– 1 +1 chemotherapy (Leighl)– 1 multiple sclerosis– 1 schizophrenia– 1 depression– 1 natural health products– 1 ovarian risk management– 1 +1 breast ca prevention (Fagerlin)– 1 +1 osteoarthritis knee (de Achaval)– (1) acute respiratory infection (Légaré)– (1) contraceptives (Langston)

• Screening (n=32+14)– 12 +4 PSA (Allen, Evans, Myers, Rubel)– 7 BRCA1/2 genetic– 6+5 colon cancer (Lewis, Miller, Schroy, Smith,

Steckelberg)– 5+1 prenatal (Björklund)– 1 colon ca genetic– 1+1 mammography (Mathieu 2010)– 2 diabetes (Mann E, Marteau)– 1 cervix ca (McCaffery)

• Surgical (n=19+6)– 4-+1 mastectomy (Jibaja-Weiss)+1 reconstruction – 3+1 prostatectomy (Berry)– 3+1 hysterectomy (Solberg)– 2 prophylactic BRCA1/2– 2 dental– 2 coronary revascularization– 1 orchiectomy for prostate ca– 1 circumcision– 1 back– (1) bariatric (Arterburn)– (1) vasectomy (Labrecque)– (1) long term feeding tube placement (Hanson)

• Obstetrics (n=4+2)– 2 VBAC– 1 termination– 1 breech– (1) labour analgesia (Raynes-Greenow)– (1) embryo transplant (van Peperstraten)

• Vaccine (n=1+2)– 1 infant– 1 Hep B– (1) influenza (Chambers)

• Other (n=2)– 1 autologous blood donation– 1 CF referral for transplant

Show your patient his/her probability to have a bacterial

…………………………...............(Specify the ARI)

by illustrating his/her probability and explicitly share the uncertainty associated to this estimate

?INFECTIONS AIGU Ë S DES VOIES RESPIRATOIRESACUTE RESPIRATORY TRACT INFECTIONS (ARI) ?Shared Decision Making Support Tools

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Explain the figure adapting to the specific ARI :« On 100 patients who have complaints similar to yours, X have an infection caused by a bacteria and Y have an infection caused by a virus. I cannot tell you if you are in the X or the Y.”Offer additional relevant therapeutic or diagnostic options.

Notice: For acute pharyngitis, options are: 1) culture, rapid test or AB if ≥ 50%), 2) culture or rapid test if ≥15%, and 3) neither culture nor rapid test if <15%.

Explain the figures:« You have 2 options: taking an antibiotic or not taking antibiotic. »

Benefits« If 100 patients similar to you don’t take an antibiotic, 70 won’t have…. (define the symptom according to the specific ARI) ….after … days/weeks, and 30 will still have…after … days/weeks. If 100 patients similar to you take an antibiotic, 10 more (in green) won’t have … after …days/weeks. These 10 on 100 are the only one who benefit from taking an antibiotic. »

Risks « On the other hand, among the 100 patients similar to you who take an antibiotic, 5 (in brown) will have significant side effects caused by the antibiotic such as diarrhea, stomach aches, or allergic reactions.  »

« I can’t tell you if you will be in these who will benefit (in green), these who will have side effects (in brown) or, as the majority, those who will take them for nothing. »

On average, antibiotics reduce symptoms by a few hours to a day.

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BENEFITS

RISKS

Cured withno antibiotics

Cured due to antibiotics

Not cured

Legend No Antibiotics Antibiotics

AntibioticsNo Antibiotics

Definition of cured

Rhinosinusitis:Better/cured 1 wkBronchitis:No cough 2 wksAOM:No pain 2-3 daysPharyngitis:No pain 4-5 days

No problems

Problems

Problems dueto antibiotics

Legend

Definition of problems

Health problemsSuch as:•Diarrhea•Stomach ache•Skin rash

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Compared to usual care, PtDAs…Compared to usual care, PtDAs…

Improve decision quality14% higher

knowledge scores (14% 2011)

79% more accurate risk perception (74% 2011)

49% better match between values & choices (25% 2011)

6% Reduce decisional conflict (6% 2011)

Help undecided to decide (41%) (43% 2011)

Patients 34% less passive in decisions (39% 2011)

Improved patient-practitioner communication (8/8 trials)

Potential to reduce over-use -20% surgery (same 2011)

-14% PSA (-15% 2011) -27% HRT (no new studies )

Findings similar for screening and treatment

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79% more accurate risk perceptions79% more accurate risk perceptions

2013-RR 1.79 [1.5, 2.1] – 17 trials2011-RR 1.74 [1.5, 2.1] – 14 trialsSub-analysisScreening 1.87 [1.3, 2.7] – 6 trials; Treatment 1.74 [1.5, 2.1] – 11 trialsHigher improvement when presented as numbers not words

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49% more Informed Values-based Choices49% more Informed Values-based Choices

2013-RR 1.49 [1.14, 1.95] – 12 trials2011-RR 1.25 [1.03, 1.52] – 8 trialsSub-analysisScreening 1.56 [ 1.2, 2.1] – 10 trials(used *MMIC)

Treatment 1.07 [ 0.7, 1.6] – 2 trials (used other measures)*Marteau’s Multi-dimensional Measure of Informed Choice

30Kennedy et al. JAMA2002; 288: 2701-2708

Cost-effective Cost-effective [Hysterectomy][Hysterectomy]

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What is decision coaching?What is decision coaching?

Develops patients’ skills in deliberating about options, preparing for a consultation, and implementing change.

Trained facilitators are supportive but non-directive

Delivery: face to face, groups, telephone, email, internet, automated (telephone, e-tools)

(O’Connor et al., 2008; Stacey et al., 2008)

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A guide for helping individuals making decisionsA guide for helping individuals making decisions

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N=10 trials; Compared with usual care, coaching showed:- improved knowledge- similar increase to those exposed to decision aid alone - mixed results for other outcomes - costs, participation, satisfaction with process, values-choice agreement

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1. Shared decision making (SDM)

2. Tools to facilitate SDM• Patient decision aids

• Decision coaching

3. Implementation in practice

OutlineOutline

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.USA: R. 3590 The Patient Protection and Affordable Care Act (March 2010)

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Study Intervention 1 Intervention 2 Standard Effect Size

95% I.C.

Stacey 2006

Multifaceted intervention

Patient decision aid, educational workshop,

audit and feedback

Usual Care 2.11 (1.30;2.90)

Nannenga 2009

Single interventionPatient decision aid: Statin Choice decision

aid

Single intervention

Patient-mediated intervention:

Standard Mayo patient education

pamphlet

1.06 (0.62; 1.50)

Of 5 studies, using 3rd party observer measures…2 had an impact

(Legare et al. 2010, Cochrane review)

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Interventions to increase SDM:Interventions to increase SDM:a patient perspectivea patient perspective

Of 21 RCTs, 3 had positive effect:

(Legare, Turcotte, Stacey, Ratte, Kryworuchko, Graham, 2012)

Bieber 2006 Krones 2008 Loh 2007

Compared to Pt mediated alone

Control Usual care

Educational meeting

X X X

Pt mediated intervention

X X X

Audit / feedback

X

↑ SDM 74% 227% P=0.003

Results: Target and effect of interventionsResults: Target and effect of interventions

Target of the intervention Effective intervention N studies (%)

Non effective interventionN studies (%)

Patient 4 (20) 16 (80)

Healthcare professional 3 (37.5) 5 (62.5)

Both HCP and patient 4 (50) 4 (50)

Interprofessional team 3 (100) 0 (0)

Fisher: p=0.038

There is a statistically significant link between the target and the effect of the intervention

(Legare et al. Cochrane review Interventions for adoption of SDM; in review)

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1. Identify the decision (and where in process of care?)

2. Find patient decision aids(s) to determine quality and relevance to setting

3. Assess factors likely to influence use (barriers, facilitators, champions)

4. Implement PtDA with training (multiple interventions, boosters)

5. Monitor use and outcomes

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Stacey, D. et al. BMJ 2008;0:bmj.39520.701748.94v2-bmj.39520.701748.94

Summary Report for SurgeonsSummary Report for Surgeons

http://decisionaid.ohri.ca