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Translating evidence for patient decision making using international standards

Translating evidence for patient decision making using international standards. Dawn Stacey RN, PhD Assistant Professor University of Ottawa. STIRRHS KT Workshop, April 2007. Outline. VBAC case example Patient decision aids IPDAS standards for patient decision aids

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Translating evidence for patient decision making using international standards

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  1. Translating evidence for patient decision making using international standards Dawn Stacey RN, PhD Assistant Professor University of Ottawa STIRRHS KT Workshop, April 2007

  2. Outline • VBAC case example • Patient decision aids • IPDAS standards for patient decision aids • Tools to facilitate translating evidence for patient decision making • Future directions

  3. Case study A 31 year old relative is pregnant with her 2nd child. Eighteen months ago she had an emergency cesarean because the infant was breech with the cord around its neck. Her physician said she can have a vaginal birth but there are risks to consider. She is concerned about the recovery from another cesarean now that she is also having to care for a toddler. She is not sure what to do and asks you to help her with the decision.

  4. Decisional Conflict • uncertainty about which course of action to take when choice among competing actions involves risk, loss, regret, or challenge to personal life values NANDA, 2002 yes no

  5. ‘Modifiable’ contributing factors Knowledge & Expectations Values Clarity Support & Resources

  6. Consequences:unresolved decisional conflict & related factors • 59 timesmore likely tochange mind • 23 timesmore likely todelay decision • 5 timesmore likely tohave regret • 3 timesmore likely tofail knowledge test • 19%more likely toblame practitioner for bad outcomes Sun, Q. [MSc thesis]. University of Ottawa, 2005. Gattelari & Ward J Med Screen 2004;11:165-169

  7. Decision Quality • informed • values-based Researcher opinions Mulley, Sepucha Health Affairs, 2004;Suppl Web Exclusive:VAR54-62 Briss, Rimer, Reilley, Coates, Lee, Mullen, ( US-CDC) Am J Prev Med 2004;26:67-80 Ratliff, Angell, Dow, Kupperman, Nease, Fisher , Fisher, Redelmeier, Faughnan, Rimer, Pauker, Pauker, Sox. Effective Clinical Practice 1999;2:185-97 O’Connor Med Decision Making 1995;15:25-30.; Nursing Diagnosis and Interventions 1989; JNCI 1999 Public surveyHealth Expectations 2003;6:97-109 Physician surveyPatient Education and Counseling. 30:143-153, 1997 International Patient Decision Aids Standards Collaboration 2005www.ohri.ca/decisionaid

  8. Patient Decision Aidsadjuncts to counseling • Inform • Provide facts • Condition, options, benefits, harms • Communicate probabilities • Clarify values • Patient experience • Ask which benefits/harms matters most • Facilitate communication • Support • Guide in steps in deliberation/communication • Worksheets, list of questions

  9. Cochrane • Systematic • review of • 55 trials • of patient • decision aids O’Connor et al., Cochrane Library, 2007

  10. Medical: 9 HRT 2 atrial fib. anti-coag. 1 hypertension 1 osteoporosis 1 chemotherapy Surgical: 4 mastectomy 3 prostatectomy 2 hysterectomy 2 dental 1 circumcision Screening: 8 PSA 4 BRCA1/2 gene 3 Colon cancer 2 prenatal Obstetrics: 1 VBAC 1 termination Vaccine 1 infant 1 hepatitis B Other: 1 pre-op autologous blood donation Topics of Decision Aids(N=51) O’Connor et al., Cochrane Library, 2007

  11. Improve decision quality 15% higher knowledge scores 70% more realistic expectations (probabilities) better match between values & choices Reduce decisional conflict (9 points) Help undecided to decide (50%) Patients 40% less passive in decisions Reduce over-use -25% surgery; -20% PSA; -29% HRT Potential to reduce under-use Compared to standard care, PtDAs… O’Connor et al., Cochrane Library, 2007

  12. Decisional Conflict Breast Ca Surgery n=187 T1 base T2 Post video T3 Post consult with surgeon DHMC data source: Collins 2007

  13. Other Results • More conservative results when detailed PtDAs compared to simpler ones • Minimal/no impact • Satisfaction • Anxiety • Health outcomes, not linked to values

  14. Kennedy et al. JAMA2002; 288: 2701-2708

  15. International Patient Decision Aid Standards (IPDAS) Collaboration What was the goal of the project? To establish an internationally approved set of criteria to determine the quality of patient decision aids. These criteria are helpful to a wide variety of individuals and organizations that use and/or develop patient decision aids. For example: Patients Practitioners Developers Researchers Policy makers or payers To learn more about the process visit us at:www.ohri.ca/decisionaid (Elwyn et al., (2006) in BMJ 333(7565):417)

  16. Essential Content Information Probabilities Values clarification Guidance Effectiveness Criteria Decision process Decision quality Generic Criteria Development process Disclosure Balance presentation Plain language Up to date evidence Internet delivery International Patient Decision Aid Standards (IPDAS) Collaboration: Quality Criteria (Elwyn et al., (2006) in BMJ 333(7565):417)

  17. Translating the evidence for patient decision making

  18. IPDAS Template for Developing Patient Decision Aids • Clarifies the decision • Provides information on options, including probabilities if available • Helps patients consider their values associated with the benefits and risks of each option • Assesses decision quality • Plans the next steps

  19. Authors and Editors: J Brownlee, M Walker, C Nimrod, Q Yang, S Wen, S Caughey, L Oppenheimer, K Eden & OHSU Evidence-based Practice Center, A O’Connor, S Khangura, C Bennett, A Saarimaki; Funder: Canadian Institutes of Health Research (CIHR) Date: 2006; For more information on this and other decision aids, visit http://decisionaid.ohri.ca

  20. Presents probabilities of outcomes related to options

  21. IPDAS presenting probabilities (Elwyn et al., (2006) in BMJ 333(7565):417)

  22. Presents probabilities of outcomes related to options

  23. Rates Evidence Quality using STARS   PLATINUM Systematic Review (meta-analysis) that is well-conducted and includes 2 or more randomised controlled trials GOLD Randomised controlled trial (1 or more) that tests at least 50 people with a treatment and 50 people without the treatment SILVER Observational studies or studies that did not assign people randomly to groups who receive or do not receive the treatment BRONZE Expert opinion or reports of specific cases  

  24. Helps patients clarify values by benefits and harms of options

  25. IPDAS Clarifying Values (Elwyn et al., (2006) in BMJ 333(7565):417)

  26. IPDAS Guide in Deliberation (Elwyn et al., (2006) in BMJ 333(7565):417)

  27. Assess Decision Quality

  28. IPDAS Establishing effectiveness (Elwyn et al., (2006) in BMJ 333(7565):417)

  29. VBAC Decision Aid – RCT in Australia • 99 women decision aid vs 92 controls • Women exposed to decision aid had: • increased knowledge (75% vs 61%) • lower decisional conflict (23 % vs 30%) • no diff in VBAC rates (49% vs 47%) • Preferences at 36 wks were not consistent with actual birth outcomes for many women • Conclusions “strategies are required to equip practitioners to empower women so that they can translate informed preferences into practice” (Shorten et al., 2005; Birth 32:4)

  30. Implementing Patient Decision Support Internet access to patient decision support tools Helplines / Call Centers Shared Decision Making Centers (CA, US, AU, Chile) (CA, US) Practice Settings Health Professional Curriculum (UOttawa, Humber College TO, Ontario NP Program, Pontificia Universidad de Chile) (CA, US, UK, Chile)

  31. Future Directions: Building Infrastructure • Evidence of efficacy - Cochrane • Resource Use/Costs - Cochrane • Library of PtDAs - Ottawa • International Standards - IPDAS • Service delivery models – care plans, consent • Certification: Practitioners, Organization • Decision Quality Measures (O’Connor et al., 2007 Tipping Point in Health Affairs)

  32. Accelerating Change • Standards: medical necessity includes patient preferences (e.g. knee replacement) • Payment strategies: reward for shared decision making (not just utilization) • Legal standards: change from consent for treatment to informed patient choice (O’Connor et al., 2007 Tipping Point in Health Affairs)

  33. When have decision aids been used? • More than one option • 2+ active Rx e.g. lumpectomy vs mastectomy • active Rx vs watchful waiting e.g. psa screening • No clear “right choice” for everyone • Best choice depends on patient values • Need +++ deliberation • ? to engage patients to participate in decisions about recommended options

  34. (O’Connor, Drake et al., Health Expectations, 2003)

  35. www.ohri.ca/decisionaid

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