1. Implementation of Patient Decision Aids: Lessons from North America Dawn Stacey RN, PhD University Research Chair in Knowledge Translation to Patients Full Professor, UOttawa Director, Patient Decision Aids Research Group October 2014, Australia

2. 2 Implementation approaches Internet access to patient decision support tools Practice Settings Helplines / Call Centers Shared Decision Making Centers (CA, US, AU, Chile) (CA, US) (CA, US, UK, Chile)

3. Outline United States of America: Dartmouth Medical Centre Health Dialog Canada The Ottawa Hospital Province of Saskatchewan

4. Practice Variations: Knee Replacement Rates per 1,000 Medicare Enrollees by State (2007)

5. Practice Variation: Knee Replacement per 1,000 Medicare Enrollees (2007) LocationRate per 1,000 Medicare Enrollees Utah12.5 Ohio9.6 Connecticut7.3 New York6.0 Honolulu, HI2.9

7. Dartmouth-Hitchcock Medical Centre Passive dissemination – research shows about 5% uptake (Grimshaw et al., 2012)

8. What is decision coaching? Develops patients’ skills in: - thinking/deliberating about options - preparing for a consultation - implementing change Coaches are trained to be supportive but non-directive (O’Connor et al., 2008; Stacey et al., 2008; 2013)

9. 9 A guide for helping individuals making decisions

10. Outline United States of America: Dartmouth Medical Centre Health Dialog Canada The Ottawa Hospital Province of Saskatchewan

13. Outline United States of America: Dartmouth Medical Centre Health Dialog Canada The Ottawa Hospital Province of Saskatchewan

14. Decisional Conflict uncertainty about what option to choose because: –risk –loss –regret –challenge to personal life values yes no (NANDA International, 2010)

15. 15

16. The Ottawa Hospital Inter-Professional Model of Patient Care© Guiding Principles: 12. Patient/family will have access to information to assist in decision making, treatment management options, support, and self-care. 13. Patient/family will be active participants, in the decision-making process about their plan of care. The degree of involvement will be defined by the patient.

17. 1.Identify the decision (and where in process of care?) 2.Find patient decision aid(s) to determine quality and relevance to setting 3.Assess factors likely to influence use (barriers, facilitators, champions) 4.Implement PtDA with training (interventions to address barriers) 5.Monitor use and outcomes http://decisionaid.ohri.ca

18. Referral Indicators: Elevated PSA; Rising PSA; Abnormal DRE; Positive family history; Intractable bony pain (urgent consult); Patients diagnosed with prostate cancer seeking a second opinion. Referral to CAC Prostate DAU Consult visit Trus biopsy Follow-up Visit: Result & treatment plan discussion Supportive care needs assessment Patient education Decision support 2 weeks Treatment decision Care map for Prostate Cancer

19. http://www.massgeneral.org/decisionsciences/research /DQ_Instrument_List.aspx To clarify values and verify knowledge

20. http://www.decision.chaire.fmed.ulaval.ca/en/tool -box/list-of-programs Legare et al (2012). Training health professionals in shared decision- making: An international environmental scan. Pt Edu Counsel. 88(2), 159-69.

21. Preferred option Knowledge test results ( =correct;  =wrong) Preference report Strong values favouring outcomes of choosing active treatment, completed quickly, avoids brachytherapy and bowel problems Has enough support (Stacey et al., BMJ, 2008)

22. Outline United States of America: Dartmouth Medical Centre Health Dialog Canada The Ottawa Hospital Province of Saskatchewan

23. Saskatchewan, Canada

24. Patient First Review: What Patients Want Good 2-way communications and adequate time with providers Involvement in care / treatment decisions Timely access to needed services (e.g. emergency, elective surgery, and diagnosis) Providers who show they care

25. http://health.gov.sk.ca/healthline-online

26. Integrated into surgical pathways Hip/knee replacement surgery Prostate cancer treatment Back surgery Uro-gyne surgery

27. 27 Research Funding Favourable policy climate Decision Support Info. & Tools Feasible implement. plan Reg., Profess., & Legal Standards Patient Champions Clinician Champions Clinician Training Financial & other incentives Zeitschrift für Evidenz, Fortbildung und Qualität im GesundheitswesenZeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen 2011;105 (4)105 (4)