Strategies for Engaging Patients in Health Decisions Laura Boland, MSc, SLP-C, PhD(c) Population Health University of Ottawa October 19 th, 2016
Overview Shared decision making Decision coaching Patient decision aids Simulated encounter Discussions
Getting Started What are some difficult health decisions that patients face in your practice? owhat makes them difficult? ohow can we support patients?
What Makes Decisions Hard? The Grey Zones! Benefits of 3000 health interventions Editorial team of BMJ Clinical Evidence 2014 http://clinicalevidence.bmj.com/x/set/static/cms/efficacy-categorisations.html
Supporting Patients: Patient Engagement Figure from: Carmen 2013
Paternalistic (Doctor/Team Decides) Shared Decision Making Autonomous (Patient Decides) Shared decision making (SDM) represents a middle ground where both the clinician and the patient partner in making the decision.
Information exchange: 2 experts Two way flow of information Partner in reaching agreement on the best treatment plan
Steps Legare et al., 2010
Why Shared Decision Making? Ethical and legal imperative Patient safety and high quality service delivery Unwarranted practice variations Improves patient outcomes Less likely to blame healthcare providers for poor outcomes Promotes optimal decisions in situations where results cannot be guaranteed O Connor 1998, 2003; Bekker 1999; Wennberg 2002; Keisler & Auerbach, 2006
Relevance to Nurses/ HCP Patients want nurses to: Advocate for them Mediate and explain information Listen to patient preferences Communicate patient preferences to physician and healthcare team Decision coaches Joseph-Williams, 2014
Decision Coaching Clinical strategy to support SDM with patients facing decisions where there is not one best answer
Decision Coaching o Trained healthcare professional o Help guide patient through decision making process o Non-directive and individualized guidance o Evidence: patient knowledge participation satisfaction Stacey et al., 2013
Patient Decision Aids Clinical tools to facilitate SDM
Patient Decision Aids Inform o A decision point o Evidence/facts: condition, options, benefits, harms o Communicate probabilities Clarify values o Patient experience o Benefits/harms matters most o Facilitate communication Support a process o Guide in steps in deliberation/communication o Provide worksheets, list of questions Stacey et al., 2014 Cochrane Review
Exercise and Discussion
Groups of 2 or 3 Person #1: think of a real decision Person #2: support decision making process using the OPDG Other: Observe
Discussion Do you think decision coaching with the PtDA changed the conversation? What did you like or dislike about the OPDG? Other comments?
Topics in Decision Aids Trials (N=115) Medication (n=36) 10 hormone replacement therapy 3 atrial fibrillation anti-coagulants 3 cardiovascular 3 diabetes 2 osteoporosis 2 chemotherapy 2 breast cancer prevention 2 osteoarthritis knee Hypertension Screening (n=46) 15 Prostate Specific Antigen (PSA) 7 BRCA1/2 genetic 11 colon cancer 6 prenatal 2 mammography 2 diabetes Colon cancer genetic Cervix cancer Stress testing for chest pain Surgery (n=23) 4 mastectomy +1 reconstruction 4 prostatectomy 4 hysterectomy 2 prophylactic BRCA1/2 2 coronary revascularization dental orchiectomy for advanced prostate ca Back Obstetrics (n=6) 2 vaginal birth after cesarean termination breech labour analgesia embryo transplant Other (n=4) Hepatitis B and influenza vaccine Autologous blood donation Cystic Fibrosis Transplant Referral Stacey et al., 2014 Cochrane Review
Impact Patient Decision Aids Improve decision quality 14% higher knowledge scores 79% more accurate risk perception 49% better match between values & choices Reduce decisional conflict (6%) Help undecided to decide (41%) Patients less passive in decisions Potential to reduce overuse 20% surgery 14% PSA 27% HRT Stacey et al., 2014 Cochrane Review
Decision Aid Formats 1. Print Passive or interactive 2. DVD/Video Passive 3. Online/computerbased Passive or interactive Stacey et al., 2014 Cochrane Review
Condition Specific Decision Aids International Patient Decision Aid Standards (IPDAS) Collaboration To enhance the quality and effectiveness of patient decision aids by establishing a shared evidenceinformed framework for improving their content, development, implementation, and evaluation. IPDAS Steering Committee: Glyn Elwyn & Dawn Stacey (Co-Leads), M Barry, N Col, A Coulter, K Eden, M Härter, M Holmes-Rovner, H Llewellyn-Thomas, V Montori, N Moumjid, M Pignone, R Thomson, L Trevena, R Volk, T van der Weijden Stacey et al., 2014 Cochrane Review
http://decisionaid.ohri.ca
Using Decision Aid in Practice: Video Exercise http://www.decision.chaire.fmed.ulaval.ca/en/tool-box/shared-decision-making-video/#c510
OPTION tool The clinician draws attention to an identified problem as one that requires 1 a decision-making process Yes No The clinician states that there is more than one way to deal with the identified problem 2 ( equipoise ) Yes No The clinician assesses patient s preferred approach to receiving information 3 to assist decision making (e.g. discussion, read printed material, assess graphical data, Yes No drawings, use videotapes or other media) 4 The clinician lists options, which can include the choice of no action Yes No The clinician explains the pros and cons of options to the patient (taking no action is an 5 option) Yes No The clinician explores the patient s expectations (or ideas) about how the problem(s) are to 6 be managed Yes No The clinician explores the patient s concerns (fears) about how the problem(s) are to be 7 managed Yes No 8 The clinician checks that the patient has understood the information Yes No The clinician offers the patient explicit opportunities to ask questions throughout the 9 decision-making process Yes No 10 The clinician elicits the patient s preferred level of involvement in decision making Yes No 11 The clinician indicates the need for a decision making (or deferring) stage Yes No 12 The clinician indicates the need to review the decision (or deferment) Yes No Elwyn et al, 2003
Discussion What behaviours described in the OPTION grid did you observed during the clinical encounter?
Key Messages To engage patients in shared decision making: Make explicit the decision Provide balanced information on options Ask patients what matters most TO MAKE SHARED DECISION MAKING A HABIT, PRACTICE IT EVERYDAY
Wrap up Thank you!
Surgery with lower mortality rate / higher likelihood of colostomy Effect of Doctor, what would you do? 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Colon Cancer Surgical Decision 76% 62% Choice for patient Choice for self Conclusion: Physicians make different choices for themselves than for their patients. Ubel et al, 2011
Informed consent vs SDM Patient/HCP discussion about treatment options Informed consent process Shared decisionmaking (SDM) Risks and benefits Options / alternatives Probabilities of various outcomes Clarification of patient values, preferences and personal situation May use a decision aid to help inform and guide decision Informed choice made in partnership between patient / family and HCP Page, 2015
When are Decision Aids Used?