Transcript Cochrane Translation to Decision Aid Workshop

Translating evidence for patient
decision making using
international standards
Dawn Stacey RN, PhD
Assistant Professor
University of Ottawa
STIRRHS KT Workshop, April 2007
1
Outline
• VBAC case example
• Patient decision aids
• IPDAS standards for patient decision aids
• Tools to facilitate translating evidence for
patient decision making
• Future directions
2
Case study
A 31 year old relative is pregnant with her
2nd child. Eighteen months ago she had
an emergency cesarean because the
infant was breech with the cord around
its neck. Her physician said she can have
a vaginal birth but there are risks to
consider. She is concerned about the
recovery from another cesarean now that
she is also having to care for a toddler.
She is not sure what to do and asks you
to help her with the decision.
3
4
Decisional Conflict
yes
no
• uncertainty about
which course of
action to take when
choice among
competing actions
involves risk, loss,
regret, or challenge to
personal life values
NANDA, 2002
5
‘Modifiable’ contributing factors
Knowledge &
Expectations
Values Clarity
Support &
Resources
6
Consequences:
unresolved decisional
conflict & related factors
• 59 times
more likely to
change mind
• 23 times
more likely to
delay decision
• 5 times
more likely to
have regret
• 3 times
more likely to
fail knowledge test
• 19% more likely to blame practitioner for
bad outcomes
Sun, Q. [MSc thesis]. University of Ottawa, 2005.
Gattelari & Ward J Med Screen 2004;11:165-169
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Decision Quality
• informed
• values-based
Researcher opinions
Mulley, Sepucha Health Affairs, 2004;Suppl Web Exclusive:VAR54-62
Briss, Rimer, Reilley, Coates, Lee, Mullen, ( US-CDC) Am J Prev Med 2004;26:67-80
Ratliff, Angell, Dow, Kupperman, Nease, Fisher , Fisher, Redelmeier, Faughnan, Rimer, Pauker, Pauker, Sox. Effective
Clinical Practice 1999;2:185-97
O’Connor Med Decision Making 1995;15:25-30.; Nursing Diagnosis and Interventions 1989; JNCI 1999
Public survey Health Expectations 2003;6:97-109
Physician survey Patient Education and Counseling. 30:143-153, 1997
International Patient Decision Aids Standards Collaboration 2005 www.ohri.ca/decisionaid 8
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
Cochrane
Systematic
review of
55 trials
of patient
decision aids
O’Connor et al., Cochrane Library, 2007
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Topics of Decision Aids (N=51)
• Medical:
– 9 HRT
– 2 atrial fib. anti-coag.
– 1 hypertension
– 1 osteoporosis
– 1 chemotherapy
• Surgical:
– 4 mastectomy
– 3 prostatectomy
– 2 hysterectomy
– 2 dental
– 1 circumcision
O’Connor et al., Cochrane Library, 2007
• Screening:
– 8 PSA
– 4 BRCA1/2 gene
– 3 Colon cancer
– 2 prenatal
• Obstetrics:
– 1 VBAC
– 1 termination
• Vaccine
– 1 infant
– 1 hepatitis B
• Other:
– 1 pre-op autologous
blood donation
Compared to standard care,
PtDAs…
 Improve decision
quality
 15% higher knowledge
scores
 70% more realistic
expectations
(probabilities)
 better match between
values & choices
 Reduce decisional conflict
(9 points)
 Help undecided to decide
(50%)
 Patients 40% less passive
in decisions
 Reduce over-use
 -25% surgery; -20% PSA;
-29% HRT
 Potential to reduce underuse
O’Connor et al., Cochrane Library, 2007
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Decisional Conflict Breast Ca Surgery
n=187
T1 base
T2 Post video
T3 Post consult
with surgeon
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DHMC data source: Collins 2007
Other Results
• More conservative results when detailed
PtDAs compared to simpler ones
• Minimal/no impact
– Satisfaction
– Anxiety
– Health outcomes, not linked to values
$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: 2701-270815
International Patient Decision Aid Standards
(IPDAS) Collaboration
Home
What are
Patient Decision
Aids?
Who’s Involved?
Contact Us
What was the goal of the project?
To establish an internationally approved set of criteria to
determine the quality of patient decision aids. These
criteria are helpful to a wide variety of individuals and
organizations that use and/or develop patient decision
aids. For example:
– Patients
– Practitioners
– Developers
– Researchers
– Policy makers or payers
To learn more about the process visit us at:
www.ohri.ca/decisionaid
(Elwyn et al., (2006) in BMJ 333(7565):417)
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International Patient Decision Aid Standards
(IPDAS) Collaboration: Quality Criteria
•
Essential Content
• Generic Criteria
–
Information
– Development process
–
Probabilities
– Disclosure
–
Values clarification
– Balance presentation
–
Guidance
– Plain language
•
Effectiveness Criteria
–
Decision process
–
Decision quality
– Up to date evidence
– Internet delivery
(Elwyn et al., (2006) in BMJ 333(7565):417)
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Translating the
evidence for
patient decision
making
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IPDAS Template for Developing
Patient Decision Aids
1.
Clarifies the decision
2.
Provides information on options,
including probabilities if available
3.
Helps patients consider their values
associated with the benefits and
risks of each option
4.
Assesses decision quality
5.
Plans the next steps
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Authors and Editors: J Brownlee, M Walker, C Nimrod, Q Yang, S Wen, S Caughey, L
Oppenheimer, K Eden & OHSU Evidence-based Practice Center, A O’Connor, S Khangura, C
Bennett, A Saarimaki; Funder: Canadian Institutes of Health Research (CIHR) Date: 2006;
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For more information on this and other decision aids, visit http://decisionaid.ohri.ca
Presents probabilities of outcomes
related to options
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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
(Elwyn et al., (2006) in BMJ 333(7565):417)
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Presents probabilities of outcomes
related to options
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Rates Evidence Quality using STARS




PLATINUM
Systematic Review (meta-analysis) that is well-conducted and
includes 2 or more randomised controlled trials
GOLD
Randomised controlled trial (1 or more) that tests at least 50
people with a treatment and 50 people without the treatment
SILVER
Observational studies or studies that did not assign people
randomly to groups who receive or do not receive the treatment
BRONZE
Expert opinion or reports of specific cases
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Helps patients clarify values by benefits
and harms of options
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IPDAS Clarifying Values
The patient decision aid…
1. …describes the procedures and outcomes to
help patients imagine what it is like to experience
their physical, emotional, and social effects.
2.
…asks patients to consider which positive and
negative features matter most
(Elwyn et al., (2006) in BMJ 333(7565):417)
No
Yes
X
X
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IPDAS Guide in Deliberation
The patient decision aid…
No
Yes
X
1. …provide steps to make a decision
2.
…include tools [worksheet, list of questions] to
discuss options with others
(Elwyn et al., (2006) in BMJ 333(7565):417)
X
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Assess Decision Quality
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IPDAS Establishing effectiveness
There is evidence that the pt decision aid helps patients …
No
Yes
DECISION PROCESS
1. …recognize that a decision needs to be made
2. …know about the available options
3. …know about different features of the options
4. …understand that values affect the decision
5. …be clear about which features of options matter most to them
6. …discuss values with their health practitioners
7. …become involved in decision making in ways they prefer
DECISION QUALITY
8. …improves the match between the features that matter most to
the informed patient and the option that is chosen.
(Elwyn et al., (2006) in BMJ 333(7565):417)
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VBAC Decision Aid – RCT in
Australia
• 99 women decision aid vs 92 controls
• Women exposed to decision aid had:
– increased knowledge (75% vs 61%)
– lower decisional conflict (23 % vs 30%)
– no diff in VBAC rates (49% vs 47%)
• Preferences at 36 wks were not consistent with
actual birth outcomes for many women
• Conclusions
“strategies are required to equip practitioners to empower
women so that they can translate informed preferences into
practice”
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(Shorten et al., 2005; Birth 32:4)
Implementing Patient Decision Support
Internet access
to patient decision
support tools
Shared Decision
Making Centers
Helplines / Call
Centers
(CA, US, AU, Chile)
(CA, US)
Practice Settings
Health Professional Curriculum
(UOttawa, Humber College TO, Ontario NP
Program, Pontificia Universidad de Chile)
(CA, US, UK, Chile)
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Future Directions: Building Infrastructure
•
Evidence of efficacy - Cochrane
•
Resource Use/Costs - Cochrane
•
Library of PtDAs - Ottawa
•
International Standards - IPDAS
•
Service delivery models – care plans, consent
•
Certification: Practitioners, Organization
•
Decision Quality Measures
(O’Connor et al., 2007 Tipping Point in Health Affairs)
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Accelerating Change
•
Standards: medical necessity includes
patient preferences (e.g. knee
replacement)
•
Payment strategies: reward for shared
decision making (not just utilization)
•
Legal standards: change from consent for
treatment to informed patient choice
(O’Connor et al., 2007 Tipping Point in Health Affairs)
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When have decision aids been used?
• More than one option
• 2+ active Rx e.g. lumpectomy vs mastectomy
• active Rx vs watchful waiting e.g. psa
screening
• No clear “right choice” for everyone
• Best choice depends on patient values
• Need +++ deliberation
• ? to engage patients to participate in
decisions about recommended options
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Treatment
Decisions
Reproductive
Decisions
Investigation
Decisions
Other
Decisions
Surgery
(30%)
Contraception
(24%)
Diagnostic
Testing (1%)
End of life care
(0.5%)
• Hysterectomy
• Method
• Amniocentesis
• Tumour removal
• Sterilization
• Radiography
• Back surgery
• Abortion
• Ultrasound
• BPH
• Adoption
• HRT
family member in a
health facility
• Prostate cancer
Medications
(27%)
Placement of
Pregnancy
(5%)
• Delivery
• Breast feeding
(6%)
Screening
• PSA
• Maternal serum
screen
Lifestyle (5%)
• Nutrition
• Weight loss
• Atrial Fibrillation
• Stress
• Chemotherapy
• Smoking cessation
• Lipid lowering
• Alcohol or drug
addiction tx
• Antidepressants
(O’Connor, Drake et al., Health Expectations, 2003)
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www.ohri.ca/decisionaid
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