From EBM to SDM: Michel Labrecque MD PhD Michel Cauchon MD Department of Family and Emergency Medicine Université Laval Teaching how to apply evidence into practice

Copyright ©2002 BMJ Publishing Group Ltd. Haynes, R B. et al. BMJ 2002;324:1350 Evidence-Based Medicine Ask Access Appraise Apply Shared Decision Making

What is shared decision making (SDM)? Shared decision making (SDM) is a process by which a healthcare decision is made jointly by the healthcare professional and the patient, based on the best available evidence on the risks and the benefits of all available options, while considering patients’ values and preferences. SDM integrates principles of both EBM and Patient-Centered Care

What evidence-based information are needed for SDM to occur? 1. Health condition 2. All therapeutic or preventive options 3. Benefits (outcome measures, baseline risk, absolute gain, time) 4. Uncertainty of benefits (validity of data) 5. Uncertainty of benefits (statistical significance of data) 6. Harms (outcome measures, baseline risk, absolute harm, time) 7. Uncertainty of harms (validity of data) 8. Uncertainty of harms (statistical significance of data) 9. Benefits and harms according to a same denominator 10. A method or a tool to facilitate communication with patients Labrecque et al, JCEHP 2010

But… Légaré et al. Patient Education and Counselling 2008 Do I have time? Will he understand ? Where do I find the data ? How to explain all that? Do I know the data ? Are data valid? Is he a “good” patient?

A Solution! Having residents creating Summaries of Evidence Table as part of their EBM training curriculum

7 A Summary of Evidence Table Prostate cancer screening Asymptomatic men aged 60 or over No screening Annual screening during 10 years What are the benefits of screening with prostatic specific antigen (PSA) and digital rectal examination (DRE)? Less chance to die from prostate cancer over 10 years (1 less death for every 1000 men screened) 1 NNT : /10003/1000 Same chance to die from any cause over 10 years 1 160/1000 What are the harms of screening with PSA and DRE? Higher chance of prostate biopsies over 10 years (140 more biopsies for every 1000 men screened) 1 NNH : 7 200/ /1000 Higher chance of complications associated with prostate biopsy over 10 years:  Infections treated with antibiotics (20 more for every 1000 men screened) 1 NNH : 50  Hospitalization (1 more for every 1000 men screened) 1 NNH : 1000 Higher chance of unnecessary diagnoses and treatments of prostate cancer over 10 years (30 more for every 1000 men screened) 1 NNH : 33 50/100080/1000 Higher chance of complications associated with treatment of prostate cancer over 10 years:  Impotency (15 more for every 1000 men screened) ) 1 NNH : 67  Incontinence (3 more for every 1000 men screened) ) 1 NNH : 333 Target Population Intervention Time Frame Risk without intervention Risk with intervention NNT Absolute risk change Additional comments and references NNH

Summaries of Evidence: A National Resident Project Imagine 1000 residents each creating/updating one SofE table during their residency Creating/reviewing one SofE table on a standardized template Reviewing alerts on the topic over 2 years Pre-appraised evidence New research findings Updating the SofE table as needed Posting the updated SofE table on the EBM Web site Are we ready to move together from EBM to SDM?

9 Adequate estimation of the risk of benefits and harms of 10 common interventions Mean Score : 25% ± 12% 95% CI : 23% to 27% Median Score: 24% Range:0% to 52%

Harms Benefits Target population Effects with placebo Effects with drug Intervention (drug)

Mean and Median Score (on 10) of the 30 CME Articles According to Journal Mean ± SDMedianRange 3.1 ± –

12 Distribution of the 122 Respondents by Correct Answer Score Mean Score : 25% ± 12% 95% CI : 23% to 27% Median Score: 24% Range:0% to 52%

Copyright ©2002 BMJ Publishing Group Ltd. Haynes, R B. et al. BMJ 2002;324:1350 Shared Decision Making Access Pre appraised summaries Facts boxes Patient decision aids Summaries of findings Apply

« Facts Box » Target population Time frame Effects with drug Effects with placebo Benefits Harms Intervention (drug) Absolute risk change Schwartz et al, Ann Intern Med 2009

PaternalisticSharedConsumerism Role of health professional Active present information decide Active present information and options May recommend one option Passive present information and options Role of patient Passive Accept professional’s decision Active Receive information judge what is most important for himself/herself Communicate his/her preference Active Receive information Judge what is most important for himself/herself decide Prevalent perspective Professional is the expert Negotiation and consensus Decision is shared Patient is the expert Adapted from Charles 1999; Hamann 2003 Decision making models