Transcript Evidence-based shared decision-making (EB SDM)

WREN Convocation 2009
Evidence-based shared decision-making
(EB SDM)
A neglected research topic
David L. Hahn, M.D., M.S. (Epidemiology)
Dept. Family Practice, Dean Medical Center
Clinical Professor, U. Wisconsin Dept. Family Medicine
Evidence-based shared decisionmaking (EB SDM)
Definition
 Components of SDM information
 Communicating SDM information
 Point of service decision aids
 Research areas
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Evidence-based shared decisionmaking (EB SDM) - An integral part
of evidence-based practice
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“Integration of best research evidence with
clinical expertise and patient values.”
Sackett, et al, 2000
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Care that meets the needs of patients and is
based on the best scientific knowledge.
Institute of Medicine
Evidence-based practice
Evidence Based
Decision Making
Science of
Evidence
Based
Medicine
Societal Values
Informed Patient
Preference
Experience/
Judgement/M.D.
Discretion
Evidence-based shared decision-making
(EB SDM) - Two perspectives
 What
message is given?
 What message is received?
Evidence-based shared decision-making
(EB SDM) - Two perspectives
 Medical professional
– Preferred formats?
– Tailored messages?
 Patient
– Numeracy?
– Receptivity?
Evidence-based shared decision-making
(EB SDM) - Resources
 Cochrane
Collaboration
 USPSTF
 ACP Journal
 POEMS
 FPIN
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Others
Club
What message is given? - Preferred
formats
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DO NOT USE relative terms
– Relative risk (RR)
– Odds ratios (OR)
– % change
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Except to illustrate how they can mislead
What message is given? - Preferred
formats
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Do not depend on some absolute measures
– Number needed to treat (NNT)
– Number needed to harm (NNH)
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Except as secondary explanations
These are more appropriate for clinician decisionmaking
What message is given? - Preferred
formats
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DO USE
– Baseline events per 100, 1000, 10,000
– Intervention events in identical numerical units
– Differences in identical numerical units
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ALSO
– Use preferred graphical formats
What message is received?
Health literacy
 “Receptivity” to SDM
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– “Willingness to acknowledge the
patient as the locus of control”
Health Literacy The four faces of health
communication
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What is intended
What is written/said - the symbol
The received meaning - interpretation of the
symbol
The power relationship in the communication
Andrew Pleasant Phd 2009
Wisconsin Third Biennial Health Literacy Summit
The power relationship in the
communication - two approaches
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Informative communication
– Patient-oriented
Persuasive communication
– Not patient-oriented
Informative communication Aims and methods
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Promotes beneficence and autonomy
– Encourages shared decision-making
– Uses unbiased patient-oriented information
– Is understandable and balanced
Persuasive communication Aims and methods
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Manipulates perception and behavior to accomplish
an aim
– Motivates action via instilling fear
– Over-emphasizes/distorts (potential or real)
benefits
– De-emphasizes/conceals harms/risks
Shared decision-making requires
informative communication
Point-of-service decision aids

Simple and straightforward
– 6th-8th grade level
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Informative
– Verbal, tabular and graphical formats
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Meant to serve as a basis for discussions
during office visits
Point-of-service decision aids Examples
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Example #1
– PSA screening
Example #2
– Mammography between ages 40-49
Mortality charts
Point-of-service decision aids Are they really needed?
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There are plenty of guidelines already
available!
Why reinvent the wheel?
Point-of-service decision aids Are they really needed?
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Beware many clinical practice guidelines
– “Pseudo-evidence-based”
United States Preventive Services Task Force (USPSTF)
– “B-”rated recommendations
Wisconsin Collaborative for Healthcare Quality (WCHQ)
– Mostly SOR “B-” and “C-” level metrics
Point-of-service decision aids Are they really needed?
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Few valid evidence-based guidelines include
a “Plain Language Summary” for patients
– Cochrane is an exception
Conclusion
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EB SDM is a promising
topic for practice-based
research into quality
Possible research areas
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Which clinical topics?
What best approaches?
Patient acceptance?
Clinician Acceptance?
Better outcomes?
SDM website resources
http://ipdas.ohri.ca/
 http://decisionaid.ohri.ca/
 http://www.cbdsm.org/intro
 http://www.vaoutcomes.org/index.html
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