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Evidence-based shared decision-making (EB SDM) A neglected research topic

WREN Convocation 2009. Evidence-based shared decision-making (EB SDM) A neglected research topic. David L. Hahn, M.D., M.S. (Epidemiology) Dept. Family Practice, Dean Medical Center Clinical Professor, U. Wisconsin Dept. Family Medicine. Evidence-based shared decision-making (EB SDM).

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Evidence-based shared decision-making (EB SDM) A neglected research topic

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  1. WREN Convocation 2009 Evidence-based shared decision-making(EB SDM)A neglected research topic David L. Hahn, M.D., M.S. (Epidemiology) Dept. Family Practice, Dean Medical Center Clinical Professor, U. Wisconsin Dept. Family Medicine

  2. Evidence-based shared decision-making (EB SDM) • Definition • Components of SDM information • Communicating SDM information • Point of service decision aids • Research areas

  3. Evidence-based shared decision-making (EB SDM) - An integral part of evidence-based practice • “Integration of best research evidence with clinical expertise and patient values.” Sackett, et al, 2000 • Care that meets the needs of patients and is based on the best scientific knowledge. Institute of Medicine

  4. Evidence-based practice

  5. Evidence-based shared decision-making (EB SDM) - Two perspectives • What message is given? • What message is received?

  6. Evidence-based shared decision-making (EB SDM) - Two perspectives • Medical professional • Preferred formats? • Tailored messages? • Patient • Numeracy? • Receptivity?

  7. Evidence-based shared decision-making (EB SDM) - Resources • Cochrane Collaboration • USPSTF • ACP Journal Club • POEMS • FPIN • Others

  8. What message is given? - Preferred formats • DO NOT USE relative terms • Relative risk (RR) • Odds ratios (OR) • % change • Except to illustrate how they can mislead

  9. What message is given? - Preferred formats • Do not depend on some absolute measures • Number needed to treat (NNT) • Number needed to harm (NNH) • Except as secondary explanations • These are more appropriate for clinician decision-making

  10. What message is given? - Preferred formats • DO USE • Baseline events per 100, 1000, 10,000 • Intervention events in identical numerical units • Differences in identical numerical units • ALSO • Use preferred graphical formats

  11. What message is received? • Health literacy • “Receptivity” to SDM • “Willingness to acknowledge the patient as the locus of control”

  12. Health Literacy -The four faces of health communication • What is intended • What is written/said - the symbol • The received meaning - interpretation of the symbol • The power relationship in the communication Andrew Pleasant Phd 2009 Wisconsin Third Biennial Health Literacy Summit

  13. The power relationship in the communication - two approaches • Informative communication • Patient-oriented • Persuasive communication • Not patient-oriented

  14. Informative communication -Aims and methods • Promotes beneficence and autonomy • Encourages shared decision-making • Uses unbiased patient-oriented information • Is understandable and balanced

  15. Persuasive communication - Aims and methods • Manipulates perception and behavior to accomplish an aim • Motivates action via instilling fear • Over-emphasizes/distorts (potential or real) benefits • De-emphasizes/conceals harms/risks

  16. Shared decision-making requires informative communication

  17. Point-of-service decision aids • Simple and straightforward • 6th-8th grade level • Informative • Verbal, tabular and graphical formats • Meant to serve as a basis for discussions during office visits

  18. Point-of-service decision aids -Examples • Example #1 • PSA screening • Example #2 • Mammography between ages 40-49 • Mortality charts

  19. Point-of-service decision aids - Are they really needed? • There are plenty of guidelines already available! • Why reinvent the wheel?

  20. Point-of-service decision aids - Are they really needed? • Beware many clinical practice guidelines • “Pseudo-evidence-based” • United States Preventive Services Task Force (USPSTF) • “B-”rated recommendations • Wisconsin Collaborative for Healthcare Quality (WCHQ) • Mostly SOR “B-” and “C-” level metrics

  21. Point-of-service decision aids - Are they really needed? • Few valid evidence-based guidelines include a “Plain Language Summary” for patients • Cochrane is an exception

  22. Conclusion • EB SDM is a promising topic for practice-based research into quality

  23. Possible research areas • Which clinical topics? • What best approaches? • Patient acceptance? • Clinician Acceptance? • Better outcomes?

  24. SDM website resources • http://ipdas.ohri.ca/ • http://decisionaid.ohri.ca/ • http://www.cbdsm.org/intro • http://www.vaoutcomes.org/index.html

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