Using Decision Aids to Enhance Shared-Decision Making (Text Version)

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On September 14, 2009, Maria E. Suarez-Almazor made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (7 MB).

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Slide 1

Using Decision Aids to Enhance Shared-Decision Making

Maria E. Suarez-Almazor, MD, PhD
Houston CERTs

 

Slide 2

Outline

• Overview of decision aids
• Examples
• Methods for development
• Evidence
• Controversies

 

Slide 3

Overview

 

Slide 4

Health Decisions

• Good decisions
  • Informed
  • Supported by best evidence
  • Compatible with patients values
  • Considers patients preferences
  • Weigh pros and cons
  • Practical

• Poor decisions
  • Objective data inadequate
  • Too few options considered
  • Alternatives unclear
  • Values and preferences unexplored
  • Roles unclear
  • Communication is poor

Cornelia Ruland
http://www.dbmi.columbia.edu/homepages/cmr7001/sdm/html/decision_support.htm
 

 

Slide 5

Informed Decision Making

• When an individual:
  • Understands nature of condition (core knowledge)
  • Understands service, including risks, limitations, benefits, alternatives, uncertainties (core knowledge)
  • Considers preferences and values (values)
  • Chooses desired level of participation in decision (role preferences)
  • Makes (or defers) a decision based on his/her preferences and values (values-based decision)

Briss et al Am J Prev Med 2004

 

Slide 6

Shared Decision Making

Involvement of patients with their providers in making health care decisions that are informed by the best available evidence about options, potential benefits, and harms, and that consider patient preferences.

 

Slide 7

Shared Decision Making

• 2+ participants
  • Provider
  • Patient
• Information is shared
  • Knowledge (provider)
  • Values and preferences (patients)
• Participants build consensus
• Agreement is reached

 

Slide 8

Informed Decision Making vs. Shared Decision Making

IDM: Any intervention in communities or healthcare systems intended to promote informed decisions
SDM: The subset of informed decision making interventions that are carried out between one patient and his/her healthcare provider(s) in clinical settings
Briss et al Am J Prev Med 2004.
Sheridan et al., Am J Prev Med 2004.
 

 

Slide 9

Decision Aids

• Patient decision aids are tools designed to help people participate in decision making about health care options.
• They provide information on the options and help patients clarify and communicate the personal value they associate with different features of the options

International Patient Decision Aids Standards (IPDAS)

 

Slide 10

Why?

• Many decisions have no 'best choice'—more than one appropriate option
• Evidence uncertain
• Need to consider
  • Benefits and harms
  • Values & preferences
  • Practical aspects
• Time constraints during medical encounter

 

Slide 11

Decision Aids

• Designed to
  • Provide information on options
  • Help people participate in decision making
  • Help clarify and communicate personal values

• Not designed to
  • Advise people to choose one option over another
  • Not meant to replace physician consultation

Cornelia Ruland
http://www.dbmi.columbia.edu/homepages/cmr7001/sdm/html/decision_support.htm
PREPARE PATIENTS TO MAKE INFORMED, VALUES-BASED DECISIONS WITH THEIR PHYSICIANS

 

Slide 12

Examples

 

Slide 13

Types of Decision Aids

Format

• Paper and pencil
• Boards
• Audio booklets
• Videos
• Computer interactive
  • CDs
  • Web-based

To be used

• Alone
• With family members
• With practitioner
• With health educator

 

Slide 14

Treating Your High Cholesterol

Gossey T & Volk R

 

Slide 15

An image of page 2 and 3 of the audio book titled "Treating Your High Cholesterol" is shown.

 

Slide 16

An image of page 4 and 5 of the audio book titled "Treating Your High Cholesterol" is shown.

 

Slide 17

An image of page 6 and the CD of the audio book titled "Treating Your High Cholesterol" is shown.

 

Slide 18

A Patchwork of Life: One Woman's Story

For Women Making Breast Cancer Tretment Decisions

Jibaja-Weiss, M
http://www.bcm.edu/patchworkoflife/homepage_en.htm

 

Slide 19

Making a Surgery Decision

An image of the Story/video page on the interactive CD titled "A Patchwork of Life: One Woman's Story" is shown.

 

Slide 20

A Patchwork of Life: One Woman's Story

An image of the "How to Use this Section" page on the interactive CD titled "A Patchwork of Life: One Woman's Story" is shown.

 

Slide 21

A Patchwork of Life: One Woman's Story

An image of the "Radiation Therapy" page on the interactive CD titled "A Patchwork of Life: One Woman's Story" is shown.

 

Slide 22

A Patchwork of Life: One Woman's Story

An image of the "Steps for Making an Initial Decision" page on the interactive CD titled "A Patchwork of Life: One Woman's Story" is shown.

 

Slide 23

A Patchwork of Life: One Woman's Story

Possible surgical options to treat early stage breast cancer:
Lumpectomy, Mastectomy

My initial treatment decision: Lumpectomy

Things I want to discuss with my doctor:
Therapies and Tests Before Surgery
More chemotherapy after surgery

 

Slide 24

 

A Patchwork of Life: One Woman's Story

An image of the "Steps for Making an Initial Decision" page on the interactive CD titled "A Patchwork of Life: One Woman's Story" is shown.

 

Slide 25

Adaptive Conjoint Analysis

• Computer-administered, interactive conjoint method
• Situations with large number of attributes
• Exceeds what can reasonably done with other methods
• Asks respondents to choose between 2 scenarios
• The scenarios and attributes vary with each screen
• Avoids information overload by focusing on just a few attributes at a time
• Focuses on the attributes that are most relevant to the respondent

 

Slide 26

Total Knee Replacement

• Surgery vs. no surgery
• Attributes
  • Pain
  • Function
  • Complications
  • Mortality
  • Surgical revisions
  • Physical therapy

 

Slide 27

If these 2 treatment options were exactly the same except for the differences below, which would you prefer - the one on the LEFT, or the one on the RIGHT?
6 months fro now, 9 out of 10 people have mild or no pain at night	6 months fro now, 5 out of 10 people have mild or no pain at night
6 months from now, 10 out of 10 people continue to have difficulty doing activities like shopping or golfing	6 months from now, 9 out of 10 people can do activities like shopping or golfing with little or no difficultiey

http://www.sawtoothsoftware.com/products/ssiweb/ssiweb_capi.shtml

 

Slide 28

If these 2 treatment options were exactly the same except for the differences below, which would you prefer - the one on the LEFT, or the one on the RIGHT?
6 months fro now, 9 out of 10 people have mild or no pain at night	6 months fro now, 5 out of 10 people have mild or no pain at night
6 months from now, 10 out of 10 people continue to have difficulty doing activities like shopping or golfing	6 months from now, 9 out of 10 people can do activities like shopping or golfing with little or no difficultiey

 

Slide 29

An image of a decision aid that shows rated results depending on what facts are important to you.

 

Slide 30

Methods

 

Slide 31

IPDAS

• International Patient Decision Aids Standards Collaboration
• Http://ipdas.ohri.ca/
• Over 100 participants from 14 countries
• Glyn Elwyn, Annette O'Connor, Dawn Stacey, Robert Volk and others
• 'Developing a quality criteria framework for patient decision aids: online international Delphi consensus process'. BMJ 2006;333:417

 

Slide 32

IPDAS criteria for judging the quality of decision aids—checklist

• Content
• Development Process
• Effectiveness

 

Slide 33

Content -- Decision aid... ..

• Provides information about options in sufficient detail
• Presents probabilities of outcomes in an unbised and understandable way
• Includes methods for clarifying and expressing patients' values
• Include structured guidance in deliberation and communication

 

Slide 34

Table 3. IPDAS Patient Decision Aid Checklist for Users

Image: An image of the IPDAS Patient Decision Aid Checklist for Users is shown.

 

Slide 35

Development process—Decision aid...

• Presents information in a balanced manner
• Has a systematic development process
• Uses up-to-date evidence (cited)
• Discloses conflict of interes
• Uses plain language
• Additional criteria to be met if decision aid is:
  • Internet-based
  • Uses stories

 

Slide 36

Effectiveness (1)—Decision aid... .

• DECISION
• Improves the match between the chosen option and the features that matter most to the informed patient.

 

Slide 37

Effectiveness (2) -- Decision aid... .

O'Connor A. Cochrane Collaboration 2009
 

• DECISION PROCESS
• Helps patients:
  • recognize that a decision needs to be made
  • know options and their features
  • understand that values affect the decision
  • be clear about the option features that matter most
  • discuss values with their practitioner
  • become involved in preferred ways.

 

Slide 38

Evidence

 

Slide 39

Cochrane Systematic Review

O'Connor et al., Cochrane Library, 2009
 

• Last update 2006
• 55 RCTs
• Comparison to usual care
• 'True' decisions—not hypothetical
• Excluded 'education only' programs not leading to a decision
• Mapping to IPDAS criteria

 

Slide 40

Primary outcomes (IPDAS criteria)

• Attributes of decision
• Attributes of decision making process
• Other decision making process variables
  • Decisional conflict
  • Patient practitioner communication
  • Participation in decision making
  • Satisfaction

 

Slide 41

Secondary outcomes (IPDAS criteria)

• Behaviour
  • Decisions (proportion undecided, option selected).
  • Adherence to chosen option.
• Health outcomes
  • Health status and quality of life (generic and conditionspecific).
  • Anxiety, depression, emotional distress, regret, confidence.
• Healthcare system
  • Patients' and physicians' satisfaction.
  • Costs, cost effectiveness.
  • Consultation length.
  • Litigation rates.

 

Slide 42

Results

• Decision aids performed better in terms of:
  • Greater knowledge (MD 15.2 out of 100)
  • Lower decisional conflict related to feeling uninformed (MD -8.3 out of 100)
  • Lower decisional conflict related to feeling unclear about personal values (MD -6.4
  • Reduced the proportion of people who were passive in decision making (RR 0.6)
  • Reduced proportion of people who remained undecided post-intervention (RR 0.5)

 

Slide 43

Results

• Higher proportion of people with accurate risk perceptions (RR 1.6)
• Reduced rates of: elective invasive surgery in favour of conservative options (RR 0.8)
• Reduced use of menopausal hormones (RR 0.7)
• Reduced PSA screening (RR:0.8)

 

Slide 44

Results

• Decision aids were no better for:
  • Satisfaction with decision making
  • Anxiety
  • Health outcomes
• Inconclusive:
  • Patient-practitioner communication
  • Consultation length
  • Continuance
  • Resource use

 

Slide 45

Controversies

 

Slide 46

Controversies

• Patient-practitioner communication
• Effects on health outcomes
• Uncertainty is real—decisional conflict should not be avoided
• Best decisions based on 'gist'
• 'Loaded' choices

 

Slide 47

Acknowledgements

• Robert Volk
• Maria Jibaja-Weiss
• Travis Gossey
• Carol Looney
• Liana Frankel
• Annette O'Connor
• Rick Street

 

Slide 48

Thank you

msalmazor@mdanderson.org