Implementing Patient Decision Aids in Clinical Practice

1. 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

2. Outline • Evidence in Interventions for Implementation • Knowledge to Action Process Framework • Examples of implementation strategies

3. Interventions to increase adoption of SDM in clinical practice (N=39) SMD=standardized mean difference for observer-based outcome measures (Legare et al., 2014, Cochrane Review)

4. Results: Combination of interventions (Legare et al., 2014, Cochrane Review)

5. 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)

6. “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

7. Patient identified barriers & facilitators to SDM (n=44 studies) • .. • .. (Joseph-Williams et al 2014)

8. Patient identifiedbarriers & facilitators to SDM (n=44 studies) • .. • .. Knowledge Knowledge about disease/condition, options, outcomes & Knowledge aboutpersonal values and preferences Power Perceived influence on decision-making encounter: - permission to participate - confidence in own knowledge - self-efficacy in using SDM skills Individual capacity to participate in SDM (Joseph-Williams et al 2014)

9. Patient identifiedbarriers & 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)

10. Outline • Evidence in Interventions for Implementation • Knowledge to Action Process Framework • Examples of implementation strategies

11. KNOWLEDGE CREATION Knowledge Inquiry Tailoring Knowledge Synthesis Products/ Tools Monitor Knowledge Use Select, Tailor, Implement Interventions Evaluate Outcomes Assess Barriers to Knowledge Use Sustain Knowledge Use Adapt Knowledge to Local Context Identify Problem Identify, Review, Select Knowledge (Graham I et al 2006 : Lost in KT)

12. Identify the decision (and where in process of care?) • Find patient decision aids(s) to determine quality and relevance to setting • Assess factors likely to influence use (barriers, facilitators, champions) • Implement PtDA with training (multiple interventions, boosters) • Monitor use and outcomes

13. IP-SDM training • Online tutorial (2h00) • Skills building workshop (3h30) • Tools: • DSAT-10 for self-appraisal • Ottawa Personal/FamilyDecision Guide • Video vignette

14. Outline • Evidence in Interventions for Implementation • Knowledge to Action Process Framework • Examples of implementation strategies

15. Implementation Example “raise public awareness”

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

17. What are my options? • What are the possible benefits and harms of those options? • 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.

18. 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.

21. Implementation Example“integrate in curriculum”

22. Effect of implementation interventions (Grimshaw et al, 2012 – review of EPOC reviews)

23. 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

24. For more information • Facebook group • Shared@EACH • http://decisionaid.ohri.ca • ISDM2015 – Sydney, Australia