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How can shared decision making impact on evidence-based practice? Paul Glasziou, Bond University, Australia ?

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Page 1: How can shared decision making impact on evidence-based practice? · How can shared decision making impact on evidence-based practice? Paul Glasziou, Bond University, Australia ?

How can shared decision making impact on evidence-based practice?

Paul Glasziou, Bond University, Australia

?

Page 2: How can shared decision making impact on evidence-based practice? · How can shared decision making impact on evidence-based practice? Paul Glasziou, Bond University, Australia ?

Evidence-based medicine: Does it imply SDM?

“Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values” - Dave Sackett

Patient Concerns

Clinical Expertise

Best Research

Presenter
Presentation Notes
Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2. This definition of what EBM is and isn’t has gained wide acceptance and made it easier for us to get our points across.
Page 3: How can shared decision making impact on evidence-based practice? · How can shared decision making impact on evidence-based practice? Paul Glasziou, Bond University, Australia ?

GRADE Evidence & Recommendations

Shared Decisions

Page 4: How can shared decision making impact on evidence-based practice? · How can shared decision making impact on evidence-based practice? Paul Glasziou, Bond University, Australia ?

What SDM do GPs use?

Page 5: How can shared decision making impact on evidence-based practice? · How can shared decision making impact on evidence-based practice? Paul Glasziou, Bond University, Australia ?

Modes of shared decisions

1. In-consultation tools CVD risk tools; acute otitis media handout

2. “Homework” tools Choice of Contraception PSA decision sheet

3. Shared decision process; no patient tools Irwigs’ 4 step process (Smart Health Choices)

Page 6: How can shared decision making impact on evidence-based practice? · How can shared decision making impact on evidence-based practice? Paul Glasziou, Bond University, Australia ?

1. What would happen if I do nothing? 2. What treatments can you suggest? 3. Which might be best for me? 4. What are the likely benefits? Are

there any downsides for me?

So the tests confirm our diagnosis. We need to decide the best course of action for you.

SDM without tools

From: Ch12 “Testing Treatments”

Page 7: How can shared decision making impact on evidence-based practice? · How can shared decision making impact on evidence-based practice? Paul Glasziou, Bond University, Australia ?

Copyright ©2006 BMJ Publishing Group Ltd. Bisset, L. et al. BMJ 2006;333:939

Tennis Elbow What happens if I do nothing?

Success (cure) 1. Median time to? 2. % at 6 months 3. % at 1 year

Page 8: How can shared decision making impact on evidence-based practice? · How can shared decision making impact on evidence-based practice? Paul Glasziou, Bond University, Australia ?

Nobody is average

“As no two faces, so no two cases are alike in all respects, and unfortunately it is not only the disease itself which is so varied, but the subjects themselves have peculiarities which modify its action.”

William Osler .

Presenter
Presentation Notes
Note: two elements of P here Patient and Problem
Page 9: How can shared decision making impact on evidence-based practice? · How can shared decision making impact on evidence-based practice? Paul Glasziou, Bond University, Australia ?

Which treatments are worthwhile for this patient with a history of TIA?

81 year old male with: 1. Transient ischemic attacks (TIA) 2. Non-H.pylori ulcers & Severe GERD 3. NSAID intolerance 4. Chronic neck pain CT scan shows small infarcts Cholesterol “normal” 5.8mmol/l BP is 125/80

Should he take Rothwell triple therapy: aspirin? Antihypertensive? statin?

Page 10: How can shared decision making impact on evidence-based practice? · How can shared decision making impact on evidence-based practice? Paul Glasziou, Bond University, Australia ?

harm

Benefit (trial)

Low Severity / risk high

outc

ome

A. Threshold

A general model for treatment decisions • Higher risk patients (usually) have higher benefits • Lower risk patients (usually) have lower benefits

Glasziou, Irwig BMJ, 1995

Co-morbidities May alter the risk/severity, benefits or harms

Page 11: How can shared decision making impact on evidence-based practice? · How can shared decision making impact on evidence-based practice? Paul Glasziou, Bond University, Australia ?

The “half-life” of knowledge

Of 100 systematic reviews: Median time to a change that

would effect clinical decisions was 5.5 years.

7 out of date when published

Shojania Ann Intern Med, 2007

Presenter
Presentation Notes
From JAMA article: Shojania KG, Sampson M, Ansari MT, Ji J, Doucette S, Moher D. How quickly do systematic reviews go out of date? A survival analysis. Ann Intern Med. 2007 Aug 21;147(4):224-33. Epub 2007 Jul 16.Links Moher D, Tsertsvadze A (2006) Systematic reviews: When is an update an update? Lancet 367: 881–883.
Page 12: How can shared decision making impact on evidence-based practice? · How can shared decision making impact on evidence-based practice? Paul Glasziou, Bond University, Australia ?

Many “Leaks” from research & practice

Aware Accept Target Doable Recall Agree Done

Valid Research

If 80% achieved at each stage then 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 x 0.8 = 0.21

Page 13: How can shared decision making impact on evidence-based practice? · How can shared decision making impact on evidence-based practice? Paul Glasziou, Bond University, Australia ?

Many “Leaks” from SDM tool to practice

Appropriate Usable Up To Date Patient fit

Page 14: How can shared decision making impact on evidence-based practice? · How can shared decision making impact on evidence-based practice? Paul Glasziou, Bond University, Australia ?

Modes of shared decisions

1. Shared decision process; no patient tools Irwigs’ 4 step process (Smart Health Choices)

2. In-consultation tools CVD risk tools; acute otitis media handout; acne options

3. “Homework” tools Choice of Contraception PSA decision sheet


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