1. Maria E. Suarez-Almazor, MD, PhD Houston CERTs Using Decision Aids to Enhance Shared-Decision Making

2. Outline Overview of decision aids Examples Methods for development Evidence Controversies

3. Overview

4. Health Decisions Good decisions – Informed – Supported by best evidence – Compatible with patients values – Considers patients preferences – Weigh pros and cons – Practical Poor decisions – Objective data inadequate – Too few options considered – Alternatives unclear – Values and preferences unexplored – Roles unclear – Communication is poor Cornelia Ruland http://www.dbmi.columbia.edu/homepages/cmr7001/sdm/html/decision_support.htm

5. Informed Decision Making When an individual: 1. Understands nature of condition (core knowledge) 2. Understands service, including risks, limitations, benefits, alternatives, uncertainties (core knowledge) 3. Considers preferences and values (values) 4. Chooses desired level of participation in decision (role preferences) 5. Makes (or defers) a decision based on his/her preferences and values (values-based decision) Briss et al Am J Prev Med 2004

6. Shared Decision Making Involvement of patients with their providers in making health care decisions that are informed by the best available evidence about options, potential benefits, and harms, and that consider patient preferences.

7. Shared Decision Making 2+ participants – Provider – Patient Information is shared – Knowledge (provider) – Values and preferences (patients) Participants build consensus Agreement is reached

8. IDM: Any intervention in communities or healthcare systems intended to promote informed decisions SDM: The subset of informed decision making interventions that are carried out between one patient and his/her healthcare provider(s) in clinical settings Briss et al Am J Prev Med 2004. Sheridan et al., Am J Prev Med 2004. Informed Decision Making vs. Shared Decision Making

9. Decision Aids Patient decision aids are tools designed to help people participate in decision making about health care options. They provide information on the options and help patients clarify and communicate the personal value they associate with different features of the options International Patient Decision Aids Standards (IPDAS)

10. Why? Many decisions have no ‘best choice’ – more than one appropriate option Evidence uncertain Need to consider – benefits and harms – values & preferences – practical aspects Time constraints during medical encounter

11. Decision Aids Designed to – Provide information on options – Help people participate in decision making – Help clarify and communicate personal values NOT designed to – Advise people to choose one option over another – Not meant to replace physician consultation Cornelia Ruland http://www.dbmi.columbia.edu/homepages/cmr7001/sdm/html/decision_support.htm PREPARE PATIENTS TO MAKE INFORMED, VALUES-BASED DECISIONS WITH THEIR PHYSICIANS

12. Examples

13. Types of Decision Aids Format Paper and pencil Boards Audio booklets Videos Computer interactive – CDs – Web-based To be used Alone With family members With practitioner With health educator

14. Gossey T & Volk R

18. Jibaja-Weiss, M http://www.bcm.edu/patchworkoflife/homepage_en.htm

25. Adaptive Conjoint Analysis Computer-administered, interactive conjoint method Situations with large number of attributes Exceeds what can reasonably done with other methods Asks respondents to choose between 2 scenarios The scenarios and attributes vary with each screen Avoids information overload by focusing on just a few attributes at a time Focuses on the attributes that are most relevant to the respondent

26. Total Knee Replacement Surgery vs. no surgery Attributes – Pain – Function – Complications – Mortality – Surgical revisions – Physical therapy

27. http://www.sawtoothsoftware.com/products/ssiweb/ssiweb_capi.shtml

30. Methods

31. IPDAS International Patient Decision Aids Standards Collaboration http://ipdas.ohri.ca/ Over 100 participants from 14 countries Glyn Elwyn, Annette O’Connor, Dawn Stacey, Robert Volk and others ‘Developing a quality criteria framework for patient decision aids: online international Delphi consensus process’. BMJ 2006;333:417

32. IPDAS criteria for judging the quality of decision aids – checklist Content Development Process Effectiveness

33. Content -- Decision aid….. Provides information about options in sufficient detail Presents probabilities of outcomes in an unbised and understandable way Includes methods for clarifying and expressing patients’ values Include structured guidance in deliberation and communication

35. Development process – Decision aid… Presents information in a balanced manner Has a systematic development process Uses up-to-date evidence (cited) Discloses conflict of interes Uses plain language Additional criteria to be met if decision aid is: – Internet-based – Uses stories

36. Effectiveness (1) – Decision aid…. DECISION Improves the match between the chosen option and the features that matter most to the informed patient.

37. DECISION PROCESS Helps patients: recognize that a decision needs to be made know options and their features understand that values affect the decision be clear about the option features that matter most discuss values with their practitioner become involved in preferred ways. Effectiveness (2) -- Decision aid…. O'Connor A. Cochrane Collaboration 2009

38. Evidence

39. Cochrane Systematic Review Last update 2006 55 RCTs Comparison to usual care ‘True’ decisions – not hypothetical Excluded ‘education only’ programs not leading to a decision Mapping to IPDAS criteria O’Connor et al., Cochrane Library, 2009

40. Primary outcomes (IPDAS criteria) Attributes of decision Attributes of decision making process Other decision making process variables Decisional conflict Patient practitioner communication Participation in decision making Satisfaction

41. Behaviour Decisions (proportion undecided, option selected). Adherence to chosen option. Health outcomes Health status and quality of life (generic and conditionspecific). Anxiety, depression, emotional distress, regret, confidence. Healthcare system Patients’ and physicians’ satisfaction. Costs, cost effectiveness. Consultation length. Litigation rates. Secondary outcomes (IPDAS criteria)

42. Results Decision aids performed better in terms of: – Greater knowledge (MD 15.2 out of 100) – Lower decisional conflict related to feeling uninformed (MD -8.3 out of 100) – Lower decisional conflict related to feeling unclear about personal values (MD -6.4 – Reduced the proportion of people who were passive in decision making (RR 0.6) – Reduced proportion of people who remained undecided post-intervention (RR 0.5)

43. Results Higher proportion of people with accurate risk perceptions (RR 1.6) Reduced rates of: elective invasive surgery in favour of conservative options (RR 0.8) Reduced use of menopausal hormones (RR 0.7) Reduced PSA screening (RR:0.8)

44. Results Decision aids were no better for: – Satisfaction with decision making – Anxiety – Health outcomes Inconclusive: – Patient-practitioner communication – Consultation length – Continuance – Resource use

45. Controversies

46. Patient-practitioner communication Effects on health outcomes Uncertainty is real – decisional conflict should not be avoided Best decisions based on ‘gist’ ‘Loaded’ choices

47. Acknowledgements Robert Volk Maria Jibaja-Weiss Travis Gossey Carol Looney Liana Frankel Annette O’Connor Rick Street

48. Thank you msalmazor@mdanderson.org