1. Evidence-based shared decision-making (EB SDM) A neglected research topic David L. Hahn, M.D., M.S. (Epidemiology) Dept. Family Practice, Dean Medical Center Clinical Professor, U. Wisconsin Dept. Family Medicine WREN Convocation 2009

2. Evidence-based shared decision- making (EB SDM) l Definition l Components of SDM information l Communicating SDM information l Point of service decision aids l Research areas

3. Evidence-based shared decision- making (EB SDM) - An integral part of evidence-based practice l “Integration of best research evidence with clinical expertise and patient values.” Sackett, et al, 2000 l Care that meets the needs of patients and is based on the best scientific knowledge. Institute of Medicine

4. Evidence-based practice

5. Evidence-based shared decision-making (EB SDM) - Two perspectives l What message is given? l What message is received?

6. Evidence-based shared decision-making (EB SDM) - Two perspectives l Medical professional –Preferred formats? –Tailored messages? l Patient –Numeracy? –Receptivity?

7. Evidence-based shared decision-making (EB SDM) - Resources l Cochrane Collaboration l USPSTF l ACP Journal Club l POEMS l FPIN l Others

8. What message is given? - Preferred formats l DO NOT USE relative terms – Relative risk (RR) –Odds ratios (OR) –% change l Except to illustrate how they can mislead

9. What message is given? - Preferred formats l Do not depend on some absolute measures –Number needed to treat (NNT) –Number needed to harm (NNH) l Except as secondary explanations l These are more appropriate for clinician decision- making

10. What message is given? - Preferred formats l DO USE –Baseline events per 100, 1000, 10,000 –Intervention events in identical numerical units –Differences in identical numerical units l ALSO –Use preferred graphical formats

13. What message is received? l Health literacy l “Receptivity” to SDM –“Willingness to acknowledge the patient as the locus of control”

14. Health Literacy - The four faces of health communication l What is intended l What is written/said - the symbol l The received meaning - interpretation of the symbol l The power relationship in the communication Andrew Pleasant Phd 2009 Wisconsin Third Biennial Health Literacy Summit

15. The power relationship in the communication - two approaches l Informative communication –Patient-oriented l Persuasive communication –Not patient-oriented

16. Informative communication - Aims and methods l Promotes beneficence and autonomy –Encourages shared decision-making –Uses unbiased patient-oriented information –Is understandable and balanced

17. Persuasive communication - Aims and methods l Manipulates perception and behavior to accomplish an aim –Motivates action via instilling fear –Over-emphasizes/distorts (potential or real) benefits –De-emphasizes/conceals harms/risks

18. Shared decision-making requires informative communication

19. Point-of-service decision aids l Simple and straightforward –6th-8th grade level l Informative –Verbal, tabular and graphical formats l Meant to serve as a basis for discussions during office visits

20. Point-of-service decision aids - Examples l Example #1 –PSA screening l Example #2 –Mammography between ages 40-49 l Mortality charts

21. Point-of-service decision aids - Are they really needed? l There are plenty of guidelines already available! l Why reinvent the wheel?

22. Point-of-service decision aids - Are they really needed? l Beware many clinical practice guidelines –“Pseudo-evidence-based” l United States Preventive Services Task Force (USPSTF) –“B-”rated recommendations l Wisconsin Collaborative for Healthcare Quality (WCHQ) –Mostly SOR “B-” and “C-” level metrics

23. Point-of-service decision aids - Are they really needed? l Few valid evidence-based guidelines include a “Plain Language Summary” for patients –Cochrane is an exception

24. Conclusion l EB SDM is a promising topic for practice-based research into quality

25. Possible research areas l Which clinical topics? l What best approaches? l Patient acceptance? l Clinician Acceptance? l Better outcomes?

26. SDM website resources l http://ipdas.ohri.ca/ l http://decisionaid.ohri.ca/ l http://www.cbdsm.org/intro l http://www.vaoutcomes.org/index.html