Oct 16, 2013 - It takes at least two to tango! Charles & Gafni 1997. Page 18. Not everyone wants this! Page 19. At l
Shared Decision Making: Building on research to help it happen in practice France Légaré MD, PhD, CCFP, FCFP
Shared Decision Making Public Lecture Mercure Hotel, Sydney Thursday, October 16th , 2013
Presentation outline • What is shared decision making? • What are decision aids and how do they differ from standard patient information? • What are some of the misconceptions and key research findings about SDM? • How can SDM be implemented?
Shared Decision Making (SDM) Process in which the health professional and the patient collaborate in making the best use of evidence to make informed, values‐based decisions that they can both agree upon.
SDM steps 1. 2. 3. 4. 5. 6. 7. 8.
Define problem/identify decision to be made Present options Discuss potential benefits/risks Identify patient values/preferences Explore patient ability Present recommendations Check understanding Make/defer decision & arrange for follow‐up Makoul & Clayman 2006
Potential contribution of SDM •Address unwarranted variation in the quality of health care •Increase agreement between providers and patients •Reinforce patient rights and informed consent •Improve safety and quality: doing things right vs. doing the right thing O’Connor 2007; Joosten 2008; Straus 2010; Wennberg, 2004, 2011; Barry 2011; Stacey, 2013
Decision Aids • Inform • Provide facts: Condition, options, benefits, harms • Communicate probabilities
• Clarify values • Explore patient experience • Ask which benefits/harms matters most • Facilitate communication
• Support a process • Guide in steps in deliberation/communication • Provide worksheets, list of questions Stacey et al., 2011 Cochrane Review
Impact of decision aids Improve decision quality ‐14% higher level of knowledge ‐74% more realistic expectations ‐25% better match of values & choices
Patients 39% less passive in decisions Reduce over‐use of surgery ‐ 20% PSA ‐ 15% HRT ‐ 27%
(Stacey et al., 2011 Cochrane Review Patient Decision Aids)
How do they compare? Standard knowledge information tool
Patient decision aids
Improve knowledge
Support decision making
Identify decision point
‐
+
Process‐ oriented
‐
+
Probabilistic nature of evidence
‐
+
Main goal
Google: decision aids
Impact of SDM In a context of overuse of antibiotics, to assess the effect of DECISION+2, a shared decision‐ making training program, on the percentage of patients who decided to take antibiotics for ARI after consultation with a family physician
Légaré, Labrecque et al. CMAJ 184(13): E726‐E734
Results
Légaré, Labrecque et al. CMAJ 184(13): E726‐E734
Misconceptions and key research findings about SDM
It’s a fad!
At least since 1959 “The doctor should not be mystical. He should consider the patient as an equal partner‐as intelligent as himself‐ and give the patient a chance to help the doctor by trying to figure out problems together. The patient should have the freedom and the chance to say what he thinks about a certain therapeutic approach.”
Menzel H, Coleman J, Katz E. Dimensions of being modern in medical practice. J Chronic Dis. 1959 Jan;9(1):20‐40
Patients are left alone!
It takes at least two to tango!
Charles & Gafni 1997
Not everyone wants this!
At least some people do! • 26% to 95%, with a median of 52%, would prefer a more active role • Time trend: 50% of studies before 2000 compared to 71% of the studies from 2000 and later • Most vulnerable people not wanting SDM may reflect a systematic bias Kiesler, Auerbach, 2006 Chewning, et al. 2012
Not everyone can do this!
SDM can be learned and implemented • Healthcare professional training COMBINED WITH
• Patient-mediated interventions such as decision aids
Third observer reported SDM Study
Intervention 1
Intervention 2
Standard Effect Size
95% I.C.
Stacey 2006
Multifaceted intervention: Distribution of educational material, educational meeting, audit and feedback
Usual care
2.11
(1.30;2.90)
Nannenga 2009
Single intervention patient-mediated intervention: Statin Choice decision aid
Single intervention patient-mediated intervention: Standard Mayo patient education pamphlet
1.06
(0.62; 1.50)
Legare F, Ratte S, Stacey D, Kryworuchko J, Gravel K, Graham ID, et al. Cochrane Database Syst Rev. 2010; CD006732
Patient reported SDM Compared to
Bieber 2006
Krones 2008
Loh 2007
Pt mediated alone
Usual care
Usual care
Educational meeting
X
X
X
Pt mediated intervention
X
X
X
Audit / feedback
X
↑ SDM
74%
227%
P=0.003
Legare F, Turcotte S, Stacey D, Ratte S, Kryworuchko J, Graham ID. Patient. 2012; 5: 1-19.
It takes too much time!
Barriers to change Knowledge
Attitude Lack of outcome expectancy
Lack of familiarity
Lack of awareness
Behaviour
Lack of agreement
-Time
Lack of self-efficacy
-Patient characteristics
Lack of motivation
-Environment: Clinical situation
Adapted from Cabana & al. JAMA, 1999; Légaré & al. 2008 Légaré & al. Cochrane, 2013 Stacey & al. Cochrane, 2011
We’re already doing it!
Still some room for improvement! SDM component
% of studies reporting observation N=33
(2 studies from Australia)
Mean OPTION Acknowledges there is more than one way to deal score : with the problem Explores the patient’s expectations and ideas 23 ± 14%
82
Explores the patient’s concerns
44
Verifies patient understands information
50
Verifies patient’s desire to be involved
0
Acknowledges a decision needs to be made
31 63
Couët & al. 2012
Key messages • SDM is relevant to a large % of clinical situations • Impact of SDM includes decisions that are informed by evidence and match what patients value the most • SDM can be learned • Implementation of SDM in clinical practice requires BOTH patient activation (e.g. decision aids) and training of health professionals