Using patient decision aids to promote evidence-based decision making
TL;DR: An overview of patient decision aids is provided by defining them, identifying situations when they may be needed, describing their efficacy, and discussing practical issues in using them in clinical practice.
Abstract: Evidence-based medicine integrates clinical experience with patients' values and the best available evidence.1 In the past, clinicians took responsibility not only for being well informed about the benefits and harms of medical options but also for judging their value in the best interests of the patients. More recently, a shared decision making approach has been advocated in which patients are recognised as the best experts for judging values. Evidence-based decision aids are being developed and evaluated to supplement clinicians' counselling regarding values and sensitive options so that patients can understand the probable consequences of options, consider the value they place on the consequences, and participate actively with their clinician in selecting the best option for them. This editorial provides a brief overview of patient decision aids by defining them, identifying situations when they may be needed, describing their efficacy, and discussing practical issues in using them in clinical practice.
Decision aids help patients to participate with their practitioners in making deliberative, personalised choices among healthcare options. The key elements of decision aids have been described by the Cochrane Collaboration2 as
### INFORMATION TAILORED TO THE PATIENT'S HEALTH STATUS
Information is provided on the condition, disease, or developmental transition stimulating the decision; the healthcare options available; the outcomes of options, including how they affect patient functioning; and the probabilities associated with outcomes.
### VALUES CLASSIFICATION
Values clarification exercises are used to explicitly consider and communicate the personal importance of each benefit or harm by using such strategies as balance scales, relevance charts, or trade off techniques.
### EXAMPLES OF OTHER PATIENTS
Patients often like to learn from others who have faced the same situation, and aids can give a balanced illustration of how others deliberate about options and arrive at decisions based on their personal situation.
### GUIDANCE OR COACHING IN SHARED DECISION MAKING
Skills and confidence in participating in decision making are developed …
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TL;DR: Evidence from randomised controlled trials suggests that the use of PROs in clinical practice is valuable in improving the discussion and detection of HRQoL problems but has less of an impact on how clinicians manage patient problems or on subsequent patient outcomes.
Abstract: Background
Precisely defining the different applications of patient-reported outcome measures (PROs) in clinical practice can be difficult. This is because the intervention is complex and varies amongst different studies in terms of the type of PRO used, how the PRO is fed back, and to whom it is fed back.
523 citations
Cites background from "Using patient decision aids to prom..."
...Many of the treatment decisions that patients have to make involve weighing up risks and benefits, sometimes between survival and HRQoL or different aspects of HRQoL [33, 34]....
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TL;DR: An analysis of ‘decision aids’, interventions to support patients facing tough decisions, and proposes three categories, interventions that are used in face-to-face encounters, those designed for use outside clinical encounters and those which are mediated, using telephone or other communication media.
Abstract: This article provides an analysis of ‘decision aids’, interventions to support patients facing tough decisions. Interest has increased since the concept of shared decision making has become widely considered to be a means of achieving desirable clinical outcomes. We consider the aims of these interventions and examine assumptions about their use. We propose three categories, interventions that are used in face-to-face encounters, those designed for use outside clinical encounters and those which are mediated, using telephone or other communication media. We propose the following definition: decision support interventions help people think about choices they face; they describe where and why choice exists; they provide information about options, including, where reasonable, the option of taking no action. These interventions help people to deliberate, independently or in collaboration with others, about options, by considering relevantattributes; they support people to forecast how they might feel about short, intermediate and long-term outcomes which have relevant consequences, in ways which help the process of constructing preferences and eventual decision making, appropriate to their individual situation. Although quality standards have been published for these interventions, we are also cautious about premature closure and consider that the need for short versions for use inside clinical encounters and long versions for external use requires further research. More work is also needed on the use of narrative formats and the translation of theory into practical designs. The interest in decision support interventions for patients heralds a transformation in clinical practice although many important areas remain unresolved.
249 citations
TL;DR: The purpose of this paper is to explore the value and use of shared decision-making in health and mental health care, briefly examine the advantages and disadvantages of share decision making and propose next steps in advancing use ofshared decision- making in mental health health care.
Abstract: Active consumer participation is critical in contemporary mental health care and treatment planning and has been a staple of the field of psychiatric rehabilitation for the last three decades. Providing the opportunity for consumers to chose interventions that fit personal preferences and recovery increase the likelihood that these interventions will enhance personal meaning, satisfaction and quality of life (Improving the Quality of Health Care for Mental and Substance Use Conditions, 2006). Similarly, self-determination and shared decision-making are critical components of recovery. As stated in the President's New Freedom Commission on Mental Health Final Report, recovery from mental illnesses should be the expectation in mental health care with services and treatments that are consumer and family-driven. Mental health care should be planned and delivered to ensure that consumers and families with children with mental health problems receive real and meaningful choices about treatment options and providers. The purpose of this paper is to explore the value and use of shared decision-making in health and mental health care, briefly examine the advantages and disadvantages of shared decision making and propose next steps in advancing use of shared decision-making in mental health care.
114 citations
Journal Article•
TL;DR: No single approach is appropriate for every prescribing problem, health professional prescriber practice or health care setting, and even an intervention with a small effect size may yield important changes in drug use when applied on a population basis.
Abstract: Background Canadians receive over 422 million prescriptions and spend over $26 billion annually on drugs. Yet, we do not systematically capture information on whether the right drugs reach the right people with the intended benefits, while avoiding unintended harm. It is important to identify and understand the effectiveness of approaches used to improve prescribing and medication use. Objective To discuss the medication-use system, identify factors affecting prescribing, and assess effectiveness of interventions. Methods A literature review was conducted using electronic databases, federal agencies’, provincial health departments’, health service delivery organizations’ and Canadian health research organizations’ websites, the Internet, and some hand searching. Interventions identified were categorized according to the Effective Practice and Organization of Care Group (EPOC) classification, with effectiveness based on the literature. Results Factors affecting prescribing relate to the patient and society, medication, prescriber, practice environment and organization, available information and other external factors. Interventions reported as generally effective are multi-faceted interventions, academic detailing, and reminders. Interventions reported as sometimes effective are audit and feedback or physician profiling, local opinion leaders, drug utilization review, and local consensus guidelines. Passive dissemination of educational materials is deemed generally ineffective. Conclusions No single approach is appropriate for every prescribing problem, health professional prescriber practice or health care setting. Interventions to improve prescribing in community and institutional settings have variable effect sizes. Effectiveness is related to content, delivery mechanisms, intensity, intervention’s context, and implementation environment. Even an intervention with a small effect size (< 10%) may yield important changes in drug use when applied on a population basis. Further research and evaluation is needed to determine how or why the interventions work and identify barriers to effective implementation.
78 citations
TL;DR: The need for expanding the current concept of patient values in medical decision making should be highlighted, which should include patients’ priorities, life philosophy and their background when clarifying patient values.
Abstract: Background: Patient decisions are influenced by their personal values. However, there is a lack of clarity and attention on the concept of patient values in the clinical context despite clear emphasis on patient values in evidence-based medicine and shared decision making. The aim of the study was to explore the concept of patient values in the context of making decisions about insulin initiation among people with type 2 diabetes. Methods and Findings: We conducted individual in-depth interviews with people with type 2 diabetes who were making decisions about insulin treatment. Participants were selected purposively to achieve maximum variation. A semi-structured topic guide was used to guide the interviews which were audio-recorded and analysed using a thematic approach. We interviewed 21 participants between January 2011 and March 2012. The age range of participants was 28-67 years old. Our sample comprised 9 women and 12 men. Three main themes, 'treatment-specific values', 'life goals and philosophies', and 'personal and social background', emerged from the analysis. The patients reported a variety of insulin-specific values, which were negative and/or positive beliefs about insulin. They framed insulin according to their priorities and philosophies in life. Patients' decisions were influenced by sociocultural (e. g. religious background) and personal backgrounds (e. g. family situations). Conclusions: This study highlighted the need for expanding the current concept of patient values in medical decision making. Clinicians should address more than just values related to treatment options. Patient values should include patients' priorities, life philosophy and their background. Current decision support tools, such as patient decision aids, should consider these new dimensions when clarifying patient values.
73 citations
References
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TL;DR: Evidence Based Medicine (IBM) as discussed by the authors is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients, which is a hot topic for clinicians, public health practitioners, purchasers, planners and the public.
Abstract: It's about integrating individual clinical expertise and the best external evidence
Evidence based medicine, whose philosophical origins extend back to mid-19th century Paris and earlier, remains a hot topic for clinicians, public health practitioners, purchasers, planners, and the public. There are now frequent workshops in how to practice and teach it (one sponsored by the BMJ will be held in London on 24 April); undergraduate1 and postgraduate2 training programmes are incorporating it3 (or pondering how to do so); British centres for evidence based practice have been established or planned in adult medicine, child health, surgery, pathology, pharmacotherapy, nursing, general practice, and dentistry; the Cochrane Collaboration and Britain's Centre for Review and Dissemination in York are providing systematic reviews of the effects of health care; new evidence based practice journals are being launched; and it has become a common topic in the lay media. But enthusiasm has been mixed with some negative reaction.4 5 6 Criticism has ranged from evidence based medicine being old hat to it being a dangerous innovation, perpetrated by the arrogant to serve cost cutters and suppress clinical freedom. As evidence based medicine continues to evolve and adapt, now is a useful time to refine the discussion of what it is and what it is not.
Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The …
12,134 citations
TL;DR: In this paper, a systematic review of randomised trials of patient decision aids in improving decision making and outcomes was conducted, which included randomized trials of interventions providing structured, detailed, and specific information on treatment or screening options and outcomes to aid decision making.
Abstract: Objective: To conduct a systematic review of randomised trials of patient decision aids in improving decision making and outcomes. Design: We included randomised trials of interventions providing structured, detailed, and specific information on treatment or screening options and outcomes to aid decision making. Two reviewers independently screened and extracted data on several evaluation criteria. Results were pooled by using weighted mean differences and relative risks. Results: 17 studies met the inclusion criteria. Compared with the controls, decision aids produced higher knowledge scores (weighted mean difference=19/100, 95% confidence interval 14 to 25); lower decisional conflict scores (weighted mean difference=−0.3/5, −0.4 to −0.1); more active patient participation in decision making (relative risk = 2.27, 95% confidence interval 1.3 to 4); and no differences in anxiety, satisfaction with decisions (weighted mean difference=0.6/100, −3 to 4), or satisfaction with the decision making process (2/100,−3 to 7). Decision aids had a variable effect on decisions. When complex decision aids were compared with simpler versions, they were better at reducing decisional conflict, improved knowledge marginally, but did not affect satisfaction. Conclusions: Decision aids improve knowledge, reduce decisional conflict, and stimulate patients to be more active in decision making without increasing their anxiety. Decision aids have little effect on satisfaction and a variable effect on decisions. The effects on outcomes of decisions (persistence with choice, quality of life) remain uncertain.
835 citations
TL;DR: A decision analysis is presented of the choice between heparin alone and streptokinase plusHeparin in the treatment of deep venous thrombosis and the result helps identify a patient's preferences scrupulously.
Abstract: As our medical decisions become more and more standardized and codified, we should take care to ensure that critical therapeutic choices are not based exclusively on formal guidelines. Many decisions need to be individualized, especially when they involve choices between possible outcomes that may be viewed differently by different patients. In such cases we should identify a patient's preferences scrupulously -- a point underscored by O'Meara and colleagues in this issue of the Journal1. They present a decision analysis of the choice between heparin alone and streptokinase plus heparin in the treatment of deep venous thrombosis. The result helps . . .
395 citations
Book•
01 Feb 1992
TL;DR: This pioneering manual provides a scientifically based method for assessing health practices and establishing practice guidelines that helps physicians deal with one of the more difficult aspects of medical practice - determining what to do at a particular clinical moment, and how to do it.
Abstract: This pioneering manual provides a scientifically based method for assessing health practices and establishing practice guidelines It helps physicians deal with one of the more difficult aspects of medical practice - determining what to do at a particular clinical moment, and how to do it It reviews how to collect, interpret, and combine evidence; compare the benefits of procedures with the harms; use subjective and objective methods to compare health outcomes with costs; and compile the information to implement a policy
266 citations
"Using patient decision aids to prom..." refers methods in this paper
...Another useful strategy for determining the need for a decision aid is to classify treatment policies as standards, guidelines, or options by using Eddy's definitions....
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TL;DR: Decision aids for patients were found to be feasible and acceptable to patients and to increase the agreement between patients' values and decisions and patients' knowledge.
Abstract: Decision aids for patients have recently been introduced in health care. A literature review was conducted to address the following research questions: 1) which types of decision aids have been developed?; 2) to what extent are they feasible, and acceptable to patients and health care providers?; 3) do decision aids affect the decision-making process and patients' outcomes? Thirty non-controlled (e.g., one-group-only designs) and controlled studies (e.g., randomized experimental designs) were identified. Decision aids were found to be feasible and acceptable to patients and to increase the agreement between patients' values and decisions and patients' knowledge. The effects of decision aids on decisions and on patients' outcomes, including decision uncertainty, satisfaction, and health, have rarely been addressed. When studied, the beneficial effects of decision aids on these outcomes appear to be rather modest. Implications for future development of decision aids and the design of studies are discussed. ...
161 citations