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

infocritique.fmed.ulaval.ca 7 modules x 3 hours How to access online access to clinical information How to interact with drug industry How to appraise Therapy articles Systematic reviews Clinical practice guidelines Diagnostic test articles Clinical practice rule articles

infocritique.fmed.ulaval.ca Used in: Family Medicine, Internal Medicine, Anesthesiology, Psychiatry, Pediatric, and Radiology Residency programs at Laval Family Medicine at University of Montreal, Sherbrooke (Chicoutimi), McGill (Gatineau) and Ottawa (Montfort) Over 1000 residents have completed the web-based tutorial Over 100 residents have published a critical appraisal topic on cma.ca

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

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

11 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

A Decision Box Prostate Cancer Screening With PSA

A Decision Box Trisomy 21 Screening With Serum Integrated Test

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

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

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?

18 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 ± –

21 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%

« 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