Transcript Hahn-Numerical Communication DFM

DFM Faculty Development 2015
Communicating Numbers
to Ensure Patient-Provider
Partnership Decisions
Health numeracyCommunicating evidence to the patient
David L. Hahn, M.D., M.S.
Director, Wisconsin Research and Education Network (WREN)
Department of Family Medicine
University of Wisconsin School of Medicine and Public Health
Disclosures
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I have no conflicts of interest to disclose
Objectives
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Review concepts and processes of shared
decision making (SDM)
Discuss the fundamental importance of
quantifiable information to the SDM
process, including its uses and abuses.
Present examples from the cancer
screening and treatment environment.
To clarify
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Risk assessment TOOLS
Patient Decision AIDS
Shared decision making PROCESS
Medical decision making
Then and Now
Carling et al. PLoS Medicine 2009
Shared decision making (SDM)
Process
A process by which a healthcare
choice is made jointly by the
practitioner and the patient, and
is said to be the crux of patientcentered care.
Légaré et al. Cochrane Database of Systematic Reviews 2014
SDM Process
Légaré et al. Cochrane Database of Systematic Reviews 2014
AHRQ Approach to SDM
http://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/
SDM exists within a continuum of
patient-doctor relationships
The Paternalism <--> Autonomy spectrum
 What is the patient expectation?
 Communication approaches may change
over time (even within the same visit)
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Shared decision-making really does not
pertain to sharing choices, but rather
involves sharing information.
McNutt JAMA 2004
… physicians should ensure that that the
information used in the patient’s
decision-making is reasonable for the
individual patient and that the patient
understands the ramifications of choice.
McNutt JAMA 2004
A choice is made after reflecting on the
numeric estimates of benefit and harm.
Numbers alone may fall short of being a
language for decision making, but are a
necessary place to start.
McNutt JAMA 2004
Eleven key components of
numerical communication
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Presenting the chance an event will occur
Presenting changes in numeric outcomes
Outcome estimates for test and screening
decisions
Numeric estimates in context and with
evaluative labels
Conveying uncertainty
Visual formats
Trevena et al. Presenting quantitative information about decision outcomes: a risk
communication primer for patient decision aid developers. BMC Medical Informatics and
Decision Making 2013, 13(Suppl 2) 57 http://www.biomedcentral.com/1472-6947/13/52/57
Eleven key components of
numerical communication
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Tailoring estimates
Formats for understanding outcomes over
time
Narrative methods for conveying the chance
of an event
Important skills for understanding
numerical estimates
Interactive web-based formats
Trevena et al. Presenting quantitative information about decision outcomes: a risk
communication primer for patient decision aid developers. BMC Medical Informatics and
Decision Making 2013, 13(Suppl 2) 57 http://www.biomedcentral.com/1472-6947/13/52/57
Quantifiable information:
Uses and abuses
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The WHAT - Patient-oriented v
Disease-oriented Outcomes
The HOW - Informative v
Persuasive Communication
Patient-oriented v Disease-oriented
Outcomes
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Patient-oriented outcomes
– Outcomes that matter to patients and help them live
longer and better lives, including reduced morbidity,
reduced mortality, symptom improvement, improved
quality of life, or reduced cost
Strength of Recommendation Taxonomy (SORT)
JABFP, JFP, AFP 2004
Patient-oriented v Disease-oriented
Outcomes
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Disease-oriented outcomes
– These outcomes include intermediate,
histopathologic, physiologic, or surrogate results
(e.g., blood sugar, blood pressure, flow rate, coronary
plaque thickness) that may or may not reflect
improvement in patient outcomes.
Strength of Recommendation Taxonomy (SORT)
JABFP, JFP, AFP 2004
Persuasive v Informative
Communication
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Persuasive communication
– Designed to influence and manipulate
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Informative communication
– Designed to inform and enhance
autonomy
Schwartz & Woloshin Eff Clin Pract 2001;4:76-79
Which correct statement is more
informative? more persuasive?
1 in 8 women will get breast cancer
 In the next 10 years a 40 year old woman
has a 2 in 1,000 chance of dying from
breast cancer
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Woloshin et al. JNCI 2008
Informative numerical communication
Pearls
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Use natural frequencies over a defined time period
– E.g., “ N per 1,000 over 10 years”
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Compare options
– E.g., Side-by-side discrete choices
Informative numerical communication
Pearls
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Present all relevant benefits and harms
– Using patient-oriented outcomes
Use multiple formats
– E.g., Text, Table, Graphic, Video
Frame in both positive and negative formats
– E.g., Survival and Death
Why multiple formats?
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People have different preferences
Descriptions of the anticipated outcomes may
influence patient willingness to accept a
recommended intervention
– Halvorsen et al. Different ways to describe the benefits
of risk-reducing treatments. A randomized trial. Annals
of Internal Medicine 2007;146:848-856
Use with caution:
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Numbers needed to treat (NNT)
Numbers needed to harm (NNH)
– The are more useful for clinicians than for
patients
– May be helpful as secondary or illustrative
examples
Use with extreme caution:
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Relative measures (unlinked to baseline)
– Percentages, Relative Risks, Odds ratios
 Appropriate for testing statistical
significance
 Pictographs can illustrate the true meaning
of relative risk
Relative risk: example
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A Newspaper Headline reads:
“Azithromycin Doubles the Risk of
Sudden Cardiovascular Death”
Ray 2012 New Engl J Med
Natural Frequencies: example
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From 1 in 20,000 to 1 in 10,000
– 1 in 4000 for those at highest heart disease risk
– Subsequent studies indicated
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No increased risk for the average healthy person
Ray 2012 New Engl J Med
Provide Sufficient Context
This risk was already known for other
macrolides (and some quinolones)
 Compare to other common risks
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– Fatal motor vehicle accidents in 2006
1 in 7500 cars
 1 in 1400 motorcycles
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Examples
Tables
 Text
 Pictographs
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Tabular format example
Hahn DL. J Fam Pract 2007
Some people
preferred this
tabular format
Pictograph formats
Adjuvant chemotherapy for breast cancer
adjuvantonline.com
Adjuvant chemotherapy for breast cancer
cbssm.org
“Two simple changes, displaying only risk
information related to treatment options that
included hormonal therapy...and using pictographs
instead of horizontal bars, resulted in significant
improvements in both comprehension accuracy and
speed of use.....”
cbssm.org
Pictograph format example:
Mammography
One-Page Summary
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Express that virtually all interventions have benefits AND
risks
Use numbers, not just words, to quantify these
Balance the frame (e.g. survival AND death)
Clear reference class (who does the risk refer to?)
Use natural frequencies and a consistent denominator
Use visual aids
Explore the significance of the risk(s) and benefit(s) to the
individual
Share uncertainty
Naik G et al. Communicating risk to patients
and the public. Br J Gen Pract 2012; 62:213-6
Decision Aids - Where can I find them?
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Informed Medical Decisions Foundation
(IMDF)
– http://informedmedicaldecisions.org/shared-decisionmaking-in-practice/decision-aids/
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Ottawa Hospital Research Institute (OHRI)
– http://decisionaid.ohri.ca/index.html
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Development Toolkit
Decision Aid Library and Standards
– International Decision Aids Standards (IPDAS) Collaboration
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Implementation Toolkit
Online Tutorial
Questions?