Promoting Patient Involvement in Medication Decisions

1. Promoting Patient Involvement in Medication Decisions David H. Hickam, MD, MPH Professor, Dept. of Medicine Oregon Health & Science University Portland, Oregon

2. Goals of this Session • Review concepts of shared decision making. • Describe results of fous groups to assess consumers’ perceptions of sources of medical information. • Describe our work developing tools to promote shared decision making.

3. The Role of Evidence in Shared Decision Making • What is evidence? • How does evidence inform medical decisions? • Can clinicians and patients communicate about evidence? • Are simple evidence-based decision tools useful?

4. Clinical Problems for which Decision Aids are Useful • Decisions that are complicated because: • There is no single best choice. • People vary in the values or personal importance that they place on the benefits vs the harms associated with each of the options. • There is scientific uncertainty about the benefits and harms associated with options. O'Connor A et al. Decision aids for people facing health treatment or screening decisions. The Cochrane Library 2006;Issue 4.

5. Options for Tools to Promote Shared Decision Making • Educational/Informational • Simple decision aids • provide probabilities, preference information, coached steps toward decision). • Detailed decision aids • all of above plus one or more of the following: customized risk tools, probabilities that adjust with risk level, explicit values clarification, etc.

6. Focus Groups to Assess Consumers’ Perceptions of Information Sources • Perceived need for information about conditions and treatments. • Perceptions about sharing decisions with clinicians. • Where the participants obtain information. • Brief review of examples.

7. Focus Group Participants • 18 focus groups (total of 113 participants) • Membership in each group defined by a particular chronic disease • Arthritis • Hypertension • Type 2 diabetes • Osteoporosis

8. Focus Group Characteristics • Two-thirds female • 60% age 60 or greater • 75% Caucasian • 43% college graduates • 44% had used Internet in last month. • One-third rated their health as fair or poor.

9. Preferences for Information Sources • Short and easy to read. • Many participants were not comfortable with Internet as information source. • Desire for positive information: often an issue when evidence is “negative.” • Framing of mortality information. • Trusted sources of information such as government and, AARP, or the Arthritis Foundation • Distrust in industry

10. Preferences for Content of Information Sources • Consensus that information about benefits is the most important. • Participants understand benefit/harm trade-offs. • Desire that side effect information be thorough. • Comparison to “non-medical” treatments.

11. Perspective about Interactions with Providers • Consensus on value of shared decision making. • Few participants reported collaborative, trusting relationships with clinicians. • Clinic visits tend to be rushed. • Some felt pressure to make hurried decisions. • Skepticism about recommendations to “talk to your doctor.” • Endorsement of tools that provide new information.

12. Principles for the Use of Evidence in Decision Tools • Include evidence about both benefits and harms of the alternatives. • Indicate where the evidence in inconclusive. • Make the information actionable. • Need clarity about what the decisions are and how to approach those decisions.

13. Key Features of Eisenberg Center Summary Guides • Brief & focused on key messages • Explicitly designed for audiences • Style template • Benefits, Risks, Trade-offs • Plain language • Appropriate literacy & numeracy levels • Actionable information

14. Up Front Bottom Line

15. Understanding the Benefits

16. Decision Coaching

17. Actionable Numeric Data For treatments of early stage prostate cancer: • Proportion of men reporting impotence following each treatment, at 2 years: • 58% after radical prostatectomy • 43% after radiation therapy • 86% with hormonal therapy • 33% with watchful waiting

18. Conclusions about Evidence Translation • Both clinicians and consumers are interested in evidence and believe that it influences decisions. • Credibility is crucial. • We do not know very much about how clinicians and patients communicate about evidence. • Consumers perceive that evidence-based decision tools might be useful.