1. Shared Decision Making Richard Dubinsky, MD, MPH

2. Disclosures:  Narayanaswami P. (PI) AHRQ Grant Number: 1R18HS022004-01  AAN: Guidelines Development, Dissemination and Implementation subcommittee and Practice Committee  Allergan: Speakers bureau, advisory board, and injector training

3.  23 year old female  Newly diagnosed epilepsy  Which treatment to choose?

8. Help!

9. Basics of a therapeutic decision Judgment Evidence Principles Give Steroids?

10. Evidence Based Medicine Is  The conscientious, explicit, and judicious use of current best evidence in making decisions  The integration of individual clinical expertise with the best available evidence from systematic research  More effective and efficient diagnosis  The thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences Sackett, BMJ 1996:317

11. Judgment Evidence Principles Decision Concerns Value Preferences

13. Ottawa Decision Support Framework Decisional Needs Decision Support Decision Quality OHRI.CA/decisionaid

14. Return to our case  Divalproex sodium suggested as treatment  She is concerned about having children

18. Presenting the Data  When restricting the cohort to the 6584 children born to women with epilepsy, the absolute risk of autism spectrum disorder among 432 children exposed to valproate was 4.15% (95% CI, 2.20%-7.81%) (adjusted HR, 1.7 [95% CI, 0.9-3.2]), and the absolute risk of childhood autism was 2.95% (95% CI, 1.42%-6.11%) (adjusted HR, 2.9 [95% CI, 1.4-6.0]) vs 2.44% (95% CI,1.88%-3.16%) for autism spectrum disorder and 1.02% (95% CI, 0.70%-1.49%) for childhood autism among 6152 children not exposed to valproate. Christensen JAMA 2013;309:1696

19. Presenting the Data WWE on VPAWWE not on VPA

20. Framing the Question  Good or Bad?

21. Presenting the Data WWE on VPAWWE not on VPA

22. Clinical Efficacy of Tx for PHN Rice, 2002 GabapentinPlacebo

23. What are her  Concerns?  Values?

28. Values of WWE  Opposed to termination of pregnancy  Opposed to IUD

29. Value of the outcome 1 0

30. Value of the outcome 1 0 -1

31. Decision Aid  AHRQ proposal to develop DA for AF

34. Likelihood of Benefit  Exercise and Diet  Lottery

35. Perception of Benefit (and effort)  Exercise and Diet  Lottery

36. Imprecision and Uncertainty  Risk ratio 0.92 [ 0.83, 1.02 ]  Risk ratio 0.40 [ 0.26, 0.64 ]

37. Hypothetical Comparison 100%0%50%

38. Shared Decision Making Education by HCP Lay educator Interactive Decision Aid Concerns and Values Questions and Decisions Shared decision made