SYDNEY MEDICAL SCHOOL

Patient-clinician decision support tools – How can quality tools be assessed and adapted for use in Australia?

Context for use of decision support tools in clinical practice: 1. Good quality and fit for purpose

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Context for use of decision support tools in clinical practice: 2. Skilled users willing to use them

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Context for use of decision support tools in clinical practice: 3. Supportive environment

› Sophie (3yo) – should she start antibiotics for her acute otitis media or use analgesics?

› Graham (68yo) – should he try CBT or medication for anxiety/depression? Should he have surgery for Dupuytren’s contracture in right hand or wait?

› Julie (49yo) – should she add LBC with conventional pap test? Should she restart anti-hypertensives or wait? What method should she use to stop smoking? Should she start having mammogram or wait?

› Zara (33yo) – should she start bromocryptine to assist breast milk supply or keep trying demand feeds?

› Annabel (24yo) – should she have a trial of metronidazole treatment for chronic diarrhoea following travel or continue with elimination diets prescribed by dietitian?

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-Oliver (7yo) – should he have an X-ray for injured ankle? -Rebecca (11 yo) – will adenoidectomy improve her recurrent sinusitis/rhinitis or should she use nasal steroid sprays or both?

-.........and there’s more.....

A typical afternoon of decisions in Australian general practice.....

Deciding: Putting it all together to make a decision

Clinical state and circumstances

Patients’ preferences and actions Research evidence

Haynes 2002

‘The practice of evidence-based medicine means integrating clinical

expertise [proficiency, judgement acquired through clinical practice and

use of individual patient’s right, predicaments, preferences] with the

best available expert evidence from systematic research.’

David Sackett (1996)

Tools fit for purpose – considering the evidence

› GRADE takes into account: - The overall confidence in the estimates (quality of evidence)

- Balance of benefits versus harms and burdens

- Values and Preferences (How important?)

- Resources and implications

- Equity, feasibility and acceptability

Derive recommendations based on the body of evidence

Strong recommendation for

Weak recommendation for

Strong recommendation against

Weak recommendation against

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www.gradeworkinggroup.org

Strong recommendation for or against

› Based on the available evidence, if clinicians are very certain that benefits do, or do not, outweigh risks and burdens they will make a strong recommendation

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Evidence summaries: Free and subscription – Push and pull – Clinician, patient and both

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When do patients want more involvement in health decisions?

› 1. Preventive healthcare decisions

› 2. Situations with potential negative future consequences e.g. Chronic diseases

› 3. Where the evidence is lacking or uncertain e.g. A weak recommendation with GRADE

› 4. Decisions involving potential side effects e.g. Immunisation, antihypertensive therapy

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Muller-Engelmann M et. al. Medical Decision Making 2013, 33(1):37-47.

Even under these circumstances many will prefer to accept an offer or recommendation

Entwistle VA, Carter SM, Trevena L, Flitcroft K, Irwig L, McCaffery K, Salkeld G: Communicating about screening. BMJ 2008, 337:a1591.

Even under these circumstances many will prefer to accept an offer or recommendation

› This approach tested in 1964 UK residents aged 50-80 years re colorectal cancer screening

› Indicate their preferences for (1) a strong recommendation to participate in CRC screening, (2) a recommendation alongside advice to make an individual decision, and (3) no recommendation but advice to make an individual decision.

› Most respondents (84%) preferred a recommendation (47% strong recommendation, 37% recommendation plus individual decision-making advice), but the majority also wanted full information on risks (77%) and benefits (78%)

› Those with low trust in the NHS were less likely to want a recommendation

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Waller J et.al. Communication about colorectal cancer screening in Britain: public preferences for an expert recommendation. British journal of cancer 2012, 107(12):1938-1943.

What sort of tools are available for these more shared contexts?

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www.optiongrid.org/ http://decision.ohri.ca/azinvent.php http://www.cancerinstitute.org.au/patient-support/what-i-need-to-ask

Communication frameworks

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www.askshareknow.com.au Irwig, Irwig, Trevena Sweet. Smart Health Choices (2007) www.sensiblehealthadvice.org.au

How do we assess quality of these tools

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Recent update of quality dimensions and background documentation

› IPDAS collaboration is working towards defining the evidence for effectiveness of different components in a recent set of review underpinning the checklist (in press with BMC Informatics and Medical Decision-Making and available http://ipdas.ohri.ca/resources.html): - Chapter A: Using a Systematic Development Process

- Chapter B: Providing Information About Options*

- Chapter C: Presenting Probabilities**

- Chapter D: Clarifying and Expressing Values

- Chapter E: Using Personal Stories*

- Chapter F: Guiding / Coaching in Deliberation and Communication

- Chapter G: Disclosing Conflicts of Interest*

- Chapter H: Delivering Decision Aids on the Internet*

- Chapter I: Balancing The Presentation of Information and Options

- Chapter J: Addressing Health Literacy**

- Chapter K: Basing Information On Comprehensive, Critically Appraised, And Up-To-Date Syntheses Of The Scientific Evidence

- Chapter L: Establishing the Effectiveness

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Evolution of the IPDAS checklist

› 2005-2006 IPDAS Checklist developed through international consensus process following an evidence review - 12 quality dimensions and 74 specific criteria (present/absent)

- Quantitative tool refined IPDASi (v3.0)across 10 quality dimension and 47 specific criteria Items rated on 4-point scale but no decision about thresholds for quality.

- IPDASi (v4.0) developed as certification tool through expert consensus

- 6 Qualifying criteria, 10 certification criteria and 28 Quality criteria

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Joseph-Williams N et.al. Toward Minimum Standards for Certifying Patient Decision Aids: A Modified Delphi Consensus Process. Medical Decision-Making (online ahead of print)

Adaptation for Australia

› Local acceptance of decision support tools is crucial and adaptation might include the following: - Applicability of research evidence

- Medical Terminology

- Local clinical practice, health system issues

- Culture and style

- Existing local resources

- Attitudes and awareness of shared decision-making

- (Adapted from Coulter 2010 and Barratt et. al. 2010 – personal correspondence)

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