Engaging Patients in their Own
Healthcare Decisions
Dawn Stacey RN, PhD
University 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)
1
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 evidencebased strategies for implementing
decision aids in clinical practice
2
Outline
1. Shared decision making (SDM)
2. Tools to facilitate SDM
•
•
Patient decision aids
Decision coaching
3. Implementation in practice
3
Shared decision making
A process by which a
healthcare choice is
made between the
patient and one or more
health professionals
The crux of patient
centred care
Facilitated by:
o Patient decision
aids
o Decision coaching
4
(Legare et al., 2010; Makoul & Clayman 2006; Stacey et al. 2011; Weston, 2001)
Client 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)
5
Steps in Shared
Decision Making
(Legare et al., 2010)
6
Patients involved in decision making…
 Improve
o quality of life
o sense of control over illness
o symptom relief
 Decrease
o fatigue
o depression
o illness concerns
However, most patients would prefer more active
involvement
(Kiesler & Auerbach 2006, Pt Ed Counsel, 61:319-341)
Evidence-based clinical decisions
(Guyatt, Haynes, DiCenso from McMaster University)
Patient preferences &
actions
Clinical state, setting, &
circumstances
Healthcare
Professionals
Research evidence
Healthcare resources
9
Outline
1. Shared decision making (SDM)
2. Tools to facilitate SDM
•
•
Patient decision aids
Decision coaching
3. Implementation in practice
10
Patient decision aids are thirdgeneration knowledge tools
whose purpose is to present
knowledge in user-friendly,
implementable formats.
11
Knowledge
to Action
Framework
(Graham et al. 2013)
Patient
Decision Aids
12
Patient Decision Aids
adjuncts to counseling
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
14
15
16
Consider which positive and negative
features matter most
17
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
18
To find decision aids
GOOGLE: ‘decision aid’
19
20
Chance of pregnancy by option
These figures show the chance of pregnancy for 1000 women over 1 year
for different contraceptive approaches
(1 sperm = 2 people)
Vasectomy
IUD
Tubal ligation
The Pill
Male Condoms
Rhythm method
IPDAS presenting probabilities
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
22
(Elwyn et al., (2006) in BMJ 333(7565):417; Trevena et al. (2006) in J Eval Clin Practice)
Cochrane Review of
Patient Decision Aids:
Update 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
23
Cochrane Review PtDAs Updates
140
117
120
IPDAS
Criteri
IPDAS
a
2005 55
100
80
60
35
40
20
86
17
0
1999
2003
2009
2011
2013
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•
Topics 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)
•
–
–
–
–
–
–
–
–
–
–
–
–
•
12 +4 PSA (Allen, Evans, Myers, Rubel)
7 BRCA1/2 genetic
6+5 colon cancer (Lewis, Miller, Schroy, Smith,
•
–
–
–
–
–
5+1 prenatal (Björklund)
1 colon ca genetic
1+1 mammography (Mathieu 2010)
2 diabetes (Mann E, Marteau)
1 cervix ca (McCaffery)
•
2 VBAC
1 termination
1 breech
(1) labour analgesia (Raynes-Greenow)
(1) embryo transplant (van Peperstraten)
Vaccine (n=1+2)
–
–
–
Steckelberg)
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)
–
–
–
–
–
Screening (n=32+14)
–
–
–
Surgical (n=19+6)
1 infant
1 Hep B
(1) influenza (Chambers)
Other (n=2)
–
–
1 autologous blood donation
1 CF referral for transplant
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ACUTE
RESPIRATORY
TRACT
INFECTIONS
(ARI)
INFECTIONS
AIGU
Ë S DES
VOIES RESPIRATOIRES
Shared Decision Making Support Tools
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
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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%.
BENEFITS
Cured with
Legend
no antibiotics
No Antibiotics
Antibiotics
Cured due
to antibiotics
On average, antibiotics reduce symptoms by a few hours to a day.
RISKS
Problems
Problems due
to antibiotics
Definition
of
problems
Health problems
Such as:
•Diarrhea
•Stomach ache
•Skin rash
No Antibiotics
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. »
Notof
cured
Definition
cured
Rhinosinusitis:
Better/cured 1 wk
Bronchitis:
No cough 2 wks
AOM:
No pain 2-3 days
Pharyngitis:
No pain 4-5 days
Legend
No problems
?
Antibiotics
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. »
Compared to usual care, PtDAs…
 Improve decision
quality
 14% 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
27
79% more accurate risk perceptions
2013-RR 1.79 [1.5, 2.1] – 17 trials
2011-RR 1.74 [1.5, 2.1] – 14 trials
Sub-analysis
Screening 1.87 [1.3, 2.7] – 6 trials; Treatment 1.74 [1.5, 2.1] – 11 trials
28
Higher improvement when presented as numbers not words
49% more Informed Values-based Choices
2013-RR 1.49 [1.14, 1.95] – 12 trials
2011-RR 1.25 [1.03, 1.52] – 8 trials
Sub-analysis
Screening 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
29
Cost-effective [Hysterectomy]
$0
$500
$1,000
$1,500
$2,000
$2,500
Standard
care, $2,751
Video
Decision Aid ,
$2,026
Video Decision
Aid plus
Coaching, $1,566
Kennedy et al. JAMA2002; 288: 2701-270830
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)
31
A guide for helping individuals making decisions
32
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,
33
satisfaction with process, values-choice agreement
Outline
1. Shared decision making (SDM)
2. Tools to facilitate SDM
•
•
Patient decision aids
Decision coaching
3. Implementation in practice
34
.USA: R. 3590 The Patient Protection
and Affordable Care Act (March 2010)
35
36
Of 5 studies, using 3rd
party observer measures…
2 had an impact
Study
Intervention 1
Intervention 2
Standard
Effect Size
95% I.C.
Stacey
2006
Multifaceted
intervention
Usual Care
2.11
(1.30;2.90)
Single
intervention
1.06
(0.62;
1.50)
Patient decision aid,
educational
workshop, audit and
feedback
Nannenga
2009
Single intervention
Patient decision aid:
Statin Choice decision
aid
Patient-mediated
intervention:
Standard Mayo
patient education
pamphlet
37
(Legare et al. 2010, Cochrane review)
Interventions to increase SDM:
a patient perspective
Of 21 RCTs, 3 had positive effect:
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
↑ SDM
X
74%
227%
P=0.003
(Legare, Turcotte, Stacey, Ratte, Kryworuchko, Graham, 2012)
38
Results: Target and effect of interventions
Target of the intervention
Patient
Healthcare professional
Both HCP and patient
Interprofessional team
Effective
Non effective
intervention intervention
N studies (%) N studies (%)
4 (20)
16 (80)
3 (37.5)
4 (50)
5 (62.5)
4 (50)
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)
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
40
Summary Report for Surgeons
41
Stacey, D. et al. BMJ 2008;0:bmj.39520.701748.94v2-bmj.39520.701748.94
http://decisionaid.ohri.ca