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

A neglected research topicA neglected research topic

David L. Hahn, M.D., M.S. (Epidemiology)David L. Hahn, M.D., M.S. (Epidemiology)

Dept. Family Practice, Dean Medical CenterDept. Family Practice, Dean Medical Center

Clinical Professor, U. Wisconsin Dept. Family MedicineClinical Professor, U. Wisconsin Dept. Family Medicine

WREN Convocation 2009

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

DefinitionDefinition Components of SDM informationComponents of SDM information Communicating SDM informationCommunicating SDM information Point of service decision aids Point of service decision aids Research areasResearch areas

Evidence-based shared decision-Evidence-based shared decision-making (EB SDM) - An integral part making (EB SDM) - An integral part

of evidence-based practiceof evidence-based practice ““Integration of best research evidence with Integration of best research evidence with

clinical expertise and patient values.” clinical expertise and patient values.” Sackett, et al, 2000Sackett, et al, 2000

Care that meets the needs of patients and is Care that meets the needs of patients and is based on the best scientific knowledge. based on the best scientific knowledge. Institute of MedicineInstitute of Medicine

Evidence-based practice

Evidence BasedDecision Making

Science ofEvidence

BasedMedicine

Societal Values

Informed PatientPreference

Experience/Judgement/M.D.

Discretion

Evidence-based shared decision-making Evidence-based shared decision-making (EB SDM) - Two perspectives(EB SDM) - Two perspectives

What message is given?What message is given? What message is received?What message is received?

Evidence-based shared decision-making Evidence-based shared decision-making (EB SDM) - Two perspectives(EB SDM) - Two perspectives Medical professionalMedical professional

– Preferred formats?Preferred formats?– Tailored messages?Tailored messages?

PatientPatient– Numeracy?Numeracy?– Receptivity?Receptivity?

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

Cochrane CollaborationCochrane Collaboration USPSTFUSPSTF ACP Journal ClubACP Journal Club POEMSPOEMS FPINFPIN OthersOthers

What message is given? - Preferred What message is given? - Preferred formatsformats

DO NOT USE DO NOT USE relative termsrelative terms– Relative risk (RR)Relative risk (RR)– Odds ratios (OR)Odds ratios (OR)– % change% change

Except to illustrate how they can misleadExcept to illustrate how they can mislead

What message is given? - Preferred What message is given? - Preferred formatsformats

Do not depend onDo not depend on some absolute measures some absolute measures– Number needed to treat (NNT)Number needed to treat (NNT)– Number needed to harm (NNH)Number needed to harm (NNH)

Except as secondary explanationsExcept as secondary explanations These are more appropriate for clinician decision-These are more appropriate for clinician decision-

makingmaking

What message is given? - Preferred What message is given? - Preferred formatsformats

DO USEDO USE– BaselineBaseline events per 100, 1000, 10,000 events per 100, 1000, 10,000– InterventionIntervention events in identical numerical units events in identical numerical units– DifferencesDifferences in identical numerical units in identical numerical units

ALSOALSO– Use Use preferredpreferred graphical formats graphical formats

What message is received?What message is received?

Health literacyHealth literacy ““Receptivity” to SDMReceptivity” to SDM

– ““Willingness to acknowledge the Willingness to acknowledge the patient as the locus of control”patient as the locus of control”

Health Literacy -Health Literacy -The four faces of health The four faces of health

communicationcommunication What is intendedWhat is intended What is written/said - the symbolWhat is written/said - the symbol The received meaning - interpretation of the The received meaning - interpretation of the

symbolsymbol The power relationship in the communicationThe power relationship in the communication

Andrew Pleasant Phd 2009Wisconsin Third Biennial Health Literacy Summit

The power relationship in the The power relationship in the communication - two approachescommunication - two approaches

Informative communicationInformative communication

– Patient-orientedPatient-oriented Persuasive communicationPersuasive communication

– Not patient-orientedNot patient-oriented

Informative communication -Informative communication -Aims and methodsAims and methods

Promotes beneficence and autonomyPromotes beneficence and autonomy

– Encourages shared decision-makingEncourages shared decision-making

– Uses unbiased patient-oriented informationUses unbiased patient-oriented information

– Is understandable and balancedIs understandable and balanced

Persuasive communication -Persuasive communication - Aims and methods Aims and methods

Manipulates perception and behavior to accomplish Manipulates perception and behavior to accomplish an aiman aim– Motivates action via instilling fearMotivates action via instilling fear– Over-emphasizes/distorts (potential or real) Over-emphasizes/distorts (potential or real)

benefitsbenefits– De-emphasizes/conceals harms/risksDe-emphasizes/conceals harms/risks

Shared decision-making requires Shared decision-making requires informative communicationinformative communication

Point-of-service decision aidsPoint-of-service decision aids

Simple and straightforwardSimple and straightforward– 6th-8th grade level6th-8th grade level

InformativeInformative– Verbal, tabular and graphical formatsVerbal, tabular and graphical formats

Meant to serve as a basis for discussions Meant to serve as a basis for discussions during office visitsduring office visits

Point-of-service decision aids -Point-of-service decision aids -ExamplesExamples

Example #1Example #1– PSA screeningPSA screening

Example #2Example #2– Mammography between ages 40-49Mammography between ages 40-49

Mortality chartsMortality charts

Point-of-service decision aids - Point-of-service decision aids - Are they really needed?Are they really needed?

There are plenty of guidelines already There are plenty of guidelines already available!available!

Why reinvent the wheel?Why reinvent the wheel?

Point-of-service decision aids - Point-of-service decision aids - Are they really needed?Are they really needed?

Beware many clinical practice guidelinesBeware many clinical practice guidelines

– ““Pseudo-evidence-based”Pseudo-evidence-based” United States Preventive Services Task Force (USPSTF)United States Preventive Services Task Force (USPSTF)

– ““B-”rated recommendationsB-”rated recommendations Wisconsin Collaborative for Healthcare Quality (WCHQ)Wisconsin Collaborative for Healthcare Quality (WCHQ)

– Mostly SOR “B-” and “C-” level metricsMostly SOR “B-” and “C-” level metrics

Point-of-service decision aids - Point-of-service decision aids - Are they really needed?Are they really needed?

Few valid evidence-based guidelines include Few valid evidence-based guidelines include a “Plain Language Summary” for patientsa “Plain Language Summary” for patients– Cochrane is an exceptionCochrane is an exception

ConclusionConclusion

EB SDM is a promising EB SDM is a promising topic for practice-based topic for practice-based research into qualityresearch into quality

Possible research areasPossible research areas

Which clinical topics?Which clinical topics? What best approaches?What best approaches? Patient acceptance?Patient acceptance? Clinician Acceptance?Clinician Acceptance? Better outcomes?Better outcomes?

SDM website resourcesSDM website resources

http://ipdas.ohri.ca/http://ipdas.ohri.ca/ http://decisionaid.ohri.ca/http://decisionaid.ohri.ca/ http://www.cbdsm.org/introhttp://www.cbdsm.org/intro http://www.vaoutcomes.org/index.htmlhttp://www.vaoutcomes.org/index.html