implementing patient decision aids in clinical practice
DESCRIPTION
Implementing Patient Decision Aids in Clinical Practice. 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. October 2014. Outline. - PowerPoint PPT PresentationTRANSCRIPT
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”
19
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