1. Implementing Patient Decision Aids in Clinical Practice October 2014 Dawn Stacey RN, PhD Research Chair in Knowledge Translation to Patients Full Professor, School of Nursing Director of the Patient Decision Aids Research Group Scientist, Ottawa Hospital Research Institute

2. Outline Evidence in Interventions for Implementation Knowledge to Action Process Framework Examples of implementation strategies

3. Interventions to increase adoption of SDM in clinical practice (N=39) Target of the interventionEffective intervention N studies (%) Non effective intervention N studies (%) Patient (SMD 1.42) 4 (20)16 (80) Healthcare professional 3 (37.5) 5 (62.5) Both HCP and patient (SMD 2.83) 4 (50) Interprofessional team 3 (100) 0 (0) SMD=standardized mean difference for observer-based outcome measures (Legare et al., 2014, Cochrane Review)

4. Results: Combination of interventions (Legare et al., 2014, Cochrane Review)

5. Summary of Findings Any intervention is better than none Interventions targeting patients and healthcare professionals together worked somewhat better than interventions for just patients or health professionals Interventions were: –Training for healthcare professionals to develop their SDM knowledge and skills –Patient decision aids or other resources for patients Difficult to know which intervention worked best (Legare et al., 2014, Cochrane Review)

6. “Many miles to go…” a systematic review of the implementation of patient decision support interventions into routine clinical practice (N=17) Clinicians asked patients to use the decision aid – mailed to their home or directed to use it Systematic delivery had most efficient reach but some inappropriately received it and viewing rate 25% (colo- rectal cancer screening) Barriers: –Need for training in how to use them –Indifference amount healthcare professionals –Lack of confidence in the content of the decision aid –Concern about disruption to established workflows Elwyn et al., 2013, BMC Medical Informatics & Decision Making

7. Patient identified barriers & facilitators to SDM –.. (Joseph-Williams et al 2014) (n=44 studies)

8. Patient identified barriers & facilitators to SDM –.. (Joseph-Williams et al 2014) Knowledge Knowledge about disease/condition, options, outcomes & Knowledge about personal values and preferences Power Perceived influence on decision-making encounter: -permission to participate -confidence in own knowledge -self-efficacy in using SDM skills Individual capacity to participate in SDM (n=44 studies)

9. Patient identified barriers & facilitators to SDM –.. To enhance workflow nurses should: -Explain information -Provide support by listening to patient preferences -Provide doctors with patient preferences (Joseph-Williams et al 2014)

10. Outline Evidence in Interventions for Implementation Knowledge to Action Process Framework Examples of implementation strategies

11. Monitor Knowledge Use Sustain Knowledge Use Evaluate Outcomes Adapt Knowledge to Local Context to Local Context Assess Barriers to Barriers to Knowledge Use Knowledge Use Select, Tailor, Select, Tailor, Implement Interventions Identify Problem Identify Problem Identify, Review, Identify, Review, Select Knowledge Select Knowledge Products/Tools Synthesis Knowledge Inquiry Tailoring Knowledge KNOWLEDGE CREATION (Graham I et al 2006 : Lost in KT)

12. 12 1.Identify the decision (and where in process of care?) 2.Find patient decision aids(s) to determine quality and relevance to setting 3.Assess factors likely to influence use (barriers, facilitators, champions) 4.Implement PtDA with training (multiple interventions, boosters) 5.Monitor use and outcomes

13. IP-SDM training –Online tutorial (2h00) –Skills building workshop (3h30) –Tools: DSAT-10 for self-appraisal Ottawa Personal/Family Decision Guide Video vignette

14. Outline Evidence in Interventions for Implementation Knowledge to Action Process Framework Examples of implementation strategies

15. Implementation Example “raise public awareness”

16. 16 http://www.youtube.com/watch?v=XPm5iEDEI8Y&feature=related

17. 1.What are my options? 2.What are the possible benefits and harms of those options? 3.How likely are the benefits and harms of each option to occur? Conclusion: Asking 3 questions: improved information given by family physicians; increased physician facilitation of simulated patient involvement.

18. Implementation Example “integrate in guidelines”

19. 19 Nursing Best Practice Guideline: Decision Support for patients with Chronic Kidney Disease 2009 Guideline Goals: To help nurses recognize and support patients with CKD at risk of or experiencing decisional conflict related to making treatment decisions; To help nurses facilitate patient involvement in reaching quality health decisions that are informed by best available evidence and consistent with patients’ values.

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21. “integrate in curriculum” Implementation Example “integrate in curriculum”

22. Effect of implementation interventions InterventionsNumber studiesEffect size Printed education materials 12 trials; 11 studies 4.3% (range (-8 to +9.6%) Educational meetings81 trials 6.0% (1.8-15.3%) higher with attendance Educational outreach69 trials4.8% (3.0-16.0) Local opinion leaders18 trials12% (6.0 – 14.5%) Audit and feedback118 trials5.0% (3% to 11%) Computerized reminders28 trials4.2% (0.8-18.8%) Tailored interventions to overcome barriers 26 trials1.52 OR (1.27-1.82) (Grimshaw et al, 2012 – review of EPOC reviews)

23. Summary of Findings - Implementation Any intervention is better than none Interventions should target patients and healthcare professionals Consider a range of interventions Common interventions were: –Training healthcare professionals to develop their SDM knowledge and skills –Providing patient decision aids Legare/Stacey/Briere conducting cluster-RCT and step- wedge RCT in Quebec

24. For more information Facebook group –Shared@EACH http://decisionaid.ohri.ca ISDM2015 – Sydney, Australia