Implementing Patient Decision Aids

in Clinical Practice

October 2014

Dawn Stacey RN, PhD

Research Chair in Knowledge Translation to Patients

Full Professor, School of Nursing

Director of the Patient Decision Aids Research Group

Scientist, Ottawa Hospital Research Institute

Outline

• Evidence in Interventions for Implementation

• Knowledge to Action Process Framework

• Examples of implementation strategies

Interventions to increase adoption of SDM in clinical practice (N=39)

Target of the intervention Effective intervention N studies (%)

Non effective interventionN studies (%)

Patient (SMD 1.42) 4 (20) 16 (80)

Healthcare professional 3 (37.5) 5 (62.5)

Both HCP and patient (SMD 2.83) 4 (50) 4 (50)

Interprofessional team 3 (100) 0 (0)

SMD=standardized mean difference for observer-based outcome measures

(Legare et al., 2014, Cochrane Review)

Results: Combination of interventions

(Legare et al., 2014, Cochrane Review)

Summary of Findings

• Any intervention is better than none• Interventions targeting patients and healthcare

professionals together worked somewhat better than interventions for just patients or health professionals

• Interventions were:– Training for healthcare professionals to develop their

SDM knowledge and skills– Patient decision aids or other resources for patients

• Difficult to know which intervention worked best

(Legare et al., 2014, Cochrane Review)

“Many miles to go…” a systematic review of the implementation of patient decision support interventions into routine clinical practice (N=17)

• Clinicians asked patients to use the decision aid – mailed to their home or directed to use it

• Systematic delivery had most efficient reach but some inappropriately received it and viewing rate 25% (colo-rectal cancer screening)

• Barriers:– Need for training in how to use them– Indifference amount healthcare professionals– Lack of confidence in the content of the decision aid– Concern about disruption to established workflows

Elwyn et al., 2013, BMC Medical Informatics & Decision Making

Patient identified barriers & facilitators to SDM

– .. – ..

(Joseph-Williams et al 2014)

(n=44 studies)

Patient identified barriers & facilitators to SDM

– .. – ..

(Joseph-Williams et al 2014)

KnowledgeKnowledge about

disease/condition, options, outcomes

&Knowledge about

personal values and preferences

PowerPerceived influence on

decision-making encounter:

- permission to participate- confidence in own

knowledge- self-efficacy in using SDM

skills

Individual capacity

to participate

in SDM

(n=44 studies)

Patient identified barriers & facilitators to SDM

– .. – .. To enhance workflow nurses should:-Explain information-Provide support by listening to patient preferences-Provide doctors with patient preferences

(Joseph-Williams et al 2014)

Outline

• Evidence in Interventions for Implementation

• Knowledge to Action Process Framework

• Examples of implementation strategies

MonitorMonitorKnowledgeKnowledge

UseUse

SustainSustainKnowledgeKnowledge

UseUse

EvaluateEvaluateOutcomesOutcomes

AdaptAdaptKnowledgeKnowledge

to Local Contextto Local Context

AssessAssessBarriers to Barriers to

Knowledge UseKnowledge Use

Select, Tailor,Select, Tailor,ImplementImplement

InterventionsInterventions

Identify ProblemIdentify Problem

Identify, Review,Identify, Review,Select KnowledgeSelect Knowledge

Products/Products/ToolsTools

SynthesisSynthesis

Knowledge Knowledge InquiryInquiry

Tailo

ring

Kno

wle

dge

KNOWLEDGE CREATIONKNOWLEDGE CREATION

(Graham I et al 2006 : Lost in KT)

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1. Identify the decision (and where in process of care?)

2. Find patient decision aids(s) to determine quality and relevance to setting

3. Assess factors likely to influence use (barriers, facilitators, champions)

4. Implement PtDA with training (multiple interventions, boosters)

5. Monitor use and outcomes

IP-SDM training

– Online tutorial (2h00)

– Skills building workshop (3h30)

– Tools:

DSAT-10 for self-appraisal

Ottawa Personal/Family Decision Guide

Video vignette

Outline

• Evidence in Interventions for Implementation

• Knowledge to Action Process Framework

• Examples of implementation strategies

Implementation Example “raise public awareness”

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http://www.youtube.com/watch?v=XPm5iEDEI8Y&feature=related

1. What are my options?

2. What are the possible benefits and harms of those options?

3. How likely are the benefits and harms of each option to occur?

Conclusion:

Asking 3 questions:•improved information given by family physicians;•increased physician facilitation of simulated patient involvement.

Implementation Example

“integrate in guidelines”

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Nursing Best Practice Guideline:

Decision Support for patients with Chronic Kidney Disease

2009

Guideline Goals:

• To help nurses recognize and support patients with CKD at risk of or experiencing decisional conflict related to making treatment decisions;

• To help nurses facilitate patient involvement in reaching quality health decisions that are informed by best available evidence and consistent with patients’ values.

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Implementation Example

““integrate in curriculumintegrate in curriculum””

Effect of implementation interventions

Interventions Number studies Effect size

Printed education materials

12 trials; 11 studies4.3% (range (-8 to +9.6%)

Educational meetings 81 trials6.0% (1.8-15.3%) higher with attendance

Educational outreach 69 trials 4.8% (3.0-16.0)

Local opinion leaders 18 trials 12% (6.0 – 14.5%)

Audit and feedback 118 trials 5.0% (3% to 11%)

Computerized reminders 28 trials 4.2% (0.8-18.8%)

Tailored interventions to overcome barriers

26 trials 1.52 OR (1.27-1.82)

(Grimshaw et al, 2012 – review of EPOC reviews)

Summary of Findings - Implementation

• Any intervention is better than none

• Interventions should target patients and healthcare professionals

• Consider a range of interventions

• Common interventions were:– Training healthcare professionals to develop their SDM

knowledge and skills

– Providing patient decision aids

• Legare/Stacey/Briere conducting cluster-RCT and step-wedge RCT in Quebec

For more information• Facebook group

– Shared@EACH

• http://decisionaid.ohri.ca• ISDM2015 – Sydney, Australia