1. Decision Support as a Clinical Skill Module III: Decision aids designed for specific decisions Last update: September 2008

2. Condition Specific Decision Aids Combine evidence based information with values clarification.

3. Decision Aids adjunct to counseling adjunct to counseling inform re options, benefits, risks inform re options, benefits, risks specify probabilities of outcomes specify probabilities of outcomes clarify personal values & norms clarify personal values & norms guide in deliberating & communicating guide in deliberating & communicating empower patient empower patient

4. 100 researchers, practitioners and stakeholders from 14 countries around the world, lead by professors Annette O’Connor in Canada, and Glyn Elwyn in the United Kingdom. goal is to establish an internationally approved set of criteria to determine the quality of patient decision aids. International Patient Decision Aid Standards (IPDAS) Collaboration

5. Cochrane Review Decision Aids: Improve knowledge Improve knowledge Improve realistic expectations Improve realistic expectations Lower decisional conflict Lower decisional conflict Increase patient involvement in decision making Increase patient involvement in decision making Decrease number undecided Decrease number undecided Increase agreement between values & choice Increase agreement between values & choice

6. Risk Presentation Similar profile: Probability of outcome in people ‘like me’ who experience the problem Format: Use quantitative, qualitative and graphic formats (100 faces) to enhance understanding Framing: Risk message + ‘Positive’ message improves message framing

7. Benefits and Risks Importance of benefits (pros) Importance of benefits (pros) Importance of harms (cons) Importance of harms (cons) ProsImportanceConsImportance More focus in school ***** Don’t like medication *** Less stressful for family **** Slowed growth ** Get along better with classmates **** Sleep problems * Should I give my child Ritalin for ADHD?

8. Should I have a TURP (transurethral resection of the prostate) if I have Symptoms of BPH (benign prostatic hyperplasia)? PROS Better reduction in symptoms (lowered by 80% compared to 32- 48% with other options) CONS May die from surgery (1 man in 100) May not have normal ejaculations (75 men in 100) May not have normal sexual erections (12 more men in 100) Importance ***** Importance *** *

9. Decision Aids on the Web

10. 10 Healthwise Decision Points > 100 Decision Points in Healthwise Knowledgebase Provide Info re: Summary of ‘Key Points’ Health condition available & description [ some evidence summaries] Options available & description [ some evidence summaries] Who it is appropriate or not appropriate for Who it is appropriate or not appropriate for Reasons to & Reasons (Pros & Cons) [table could be used to rate importance] Reasons to choose & Reasons not to choose (Pros & Cons) [table could be used to rate importance] Wise Health Decision What issues apply to you? [requires some interpretation] What issues apply to you? [requires some interpretation] Leaning References (O’Connor et al., Cochrane Library, 2004; Issue 1: A Decision Aid: provides, at minimum, information on options and outcomes)

12. HealthWise Decision Aid

13. Video Decision Aids

15. Providers’ Perspectives “It is helpful to have my patients arrive at the consultation with familiarity of the options and knowledge of the risks and benefits” Richard Barth, MD, surgical oncologist "With this process, I can focus on helping each individual patient decide the best treatment for her.” "With this process, I can focus on helping each individual patient decide the best treatment for her.” Kari Rosenkranz, MD, surgical oncologist Kari Rosenkranz, MD, surgical oncologist

16. Patients’ Perspectives  ”  “Not ever experiencing such a drastic surgery, this video helped provide information to help make the decision that is best for me” This woman went from being unsure to deciding not to pursue breast reconstruction.   “The tape was very helpful – I hesitated 8 yrs ago but I have no hesitation after reading the booklet and viewing the video.” This woman opted for breast reconstruction and chose the type of reconstruction she preferred.   “This video made me realize I need to be more in charge of myself. And that surgery should be a last resort and that other options should be explored.” Patient considering surgery for herniated disc.   “I found the video very informative and helpful and because of it I am more inclined to consider surgery, which is a new position.” Patient considering surgery for herniated disc.

17. Conclusions Decision support is a process of: Assessing decisional needs Intervening to address individual needs Evaluating the quality of decision making A high quality decision is:   Informed   Values-based   Acted upon Decision quality improves with: Patient decision aids Personal health coaching using a structured decision guide