decision support as a clinical skill august 2008
TRANSCRIPT
Decision Support Decision Support as a Clinical Skillas a Clinical Skill
August 2008
Workshop OutlineWorkshop Outline Module 1: Context
Shared decision making Preference sensitive care Difficult decisions Decisional conflict
Module 3: Communicating risk information
Module 4: Decision support tools Decision aids Other resources
Module 2: Decision support process Ottawa Decision Support Framework Decision Support Ottawa Personal Decision Guide
Key ConceptsKey Concepts
Shared Decision MakingShared Decision Making
Effective vs. Preference Sensitive Effective vs. Preference Sensitive CareCare
Decisional Conflict Decisional Conflict
Decision Quality Decision Quality
Module 1: Module 1: Context
Shared decision makingValues-sensitive careDifficult decisionsDecisional conflict
Shared Decision Making
An integrative process between patient and clinician that: Engages the patient in decision making Provides the patient with information about alternative treatments
Facilitates the incorporation of patient preferences and values into the medical plan
(Charles C, Soc Sci Med 1997;44:681)
Original Model of Original Model of “Shared Decision Making”“Shared Decision Making”
Clinician shares medical expertise:
•diagnosis•treatment
choices•probabilities of
outcomes
Patient shares values and lifestyle preferences:
•may be based on past experience with medical choices•may depend on current social situation
Together they arrive at an informed, shared decisionTogether they arrive at an informed, shared decision
Physician RoleDiagnose problem; discuss options, roles; screen for decisional conflict; refer for decision support
Decision Support(Ottawa Decision Support Framework, 1998)
Prepare patient to participate in decisions in ways they prefer
1. Assess decisional needs (decisional conflict, knowledge, values clarity,
support)2. Provide decision support tailored to
needs (evidence-based patient decision aids, coaching)
3. Evaluate progress in resolving needs and decision quality
Patient RoleCommunicate informed values & preferences shaped by their social circumstances
(Charles C et al., 1997; Coulter A 2002; O’Connor A, Legare F, & Stacey D 2003; O'Connor A et al., 1998)
Goal:Informed,
values-baseddecision making
New model of shared decision making New model of shared decision making for values-sensitive decisionsfor values-sensitive decisions
Categories of CareCategories of CareEffective Effective
Benefits are Benefits are large compared to large compared to harmsharms
Goal is usually Goal is usually to increase to increase uptakeuptake
e.g. taking an e.g. taking an antibiotic for antibiotic for bacterial bacterial pneumonia; having pneumonia; having a pap smear, flu a pap smear, flu vaccinevaccine
Values-sensitiveValues-sensitive
Benefit/harm ratios are Benefit/harm ratios are either uncertain or either uncertain or depend on patient valuesdepend on patient values
Patient participation Patient participation Improves decision Improves decision quality;quality;
Prevents overuse of Prevents overuse of options patients do options patients do not valuenot value
e.g. elective surgery, e.g. elective surgery, PSA screening; tamoxifen PSA screening; tamoxifen for higherfor higher risk womenrisk women
(Wennberg, BMJ, 2002;325:961-4; O’Connor, Legare, Stacey BMJ; in press)
Canadian Task Force on Preventive Canadian Task Force on Preventive Health Care / US Task ForceHealth Care / US Task Force
(CMAJ 2003; 169: 207-8; Harris et al., Am J Prev Med, 2001; 20:21-35)
Recommendation of routine provision
Quality of evidence
Magnitude of benefit over
harm ‘A’ Strong recommend Good Substantial
‘B’ Recommend Good ------------
Fair---------------
Moderate
Substantial
‘C’ Close call Conflicting Small or sensitive to patient values
‘D’ Recommend against
Fair Zero or negative
‘E’ Strong recommend against
Good Zero or negative
‘I’ No recommendation
Insufficient quantity/quality
Sensitive to patient values
Decision Making is…Decision Making is…
A Process A Process of Choosingof Choosing between between
courses of courses of actionaction (including (including inaction)inaction)
We generally want to choose We generally want to choose options that achieve valued options that achieve valued outcomes and avoid undesirable outcomes and avoid undesirable outcomesoutcomes
Difficult DecisionsDifficult Decisions
What are What are difficult difficult decisions?decisions?
Diagnosing Decisional ConflictDiagnosing Decisional Conflict
Definition:Definition:
UncertaintyUncertainty about which about which course of action to course of action to take, resulting from… take, resulting from…
Simultaneous opposing Simultaneous opposing tendencies to accept tendencies to accept and reject a given and reject a given course of action course of action
Janis & Mann, Janis & Mann, Decision MakingDecision Making, 1977, 1977
Signs and SymptomsSigns and Symptoms
unsure what to unsure what to dodo
unclear about unclear about best choice for best choice for themthem
concern about concern about bad resultsbad results
waver between waver between choiceschoices
delay delay decisiondecision
question what question what is importantis important
distressed, distressed, anxious, anxious, tensetense
preoccupied preoccupied with decisionwith decision
Inherent (unchangeable) characteristics Inherent (unchangeable) characteristics of difficult decisions:of difficult decisions:
multiple options
outcomes: risky/uncertain
irrevocable
high stakes
values trade-offs: losses versus gains
anticipated regret(NANDA. Tenth conference for Classification of Nursing Diagnoses. 1992.)
Modifiable Factors Contributing to Modifiable Factors Contributing to Decisional ConflictDecisional Conflict
Lack knowledgeLack knowledge
Unrealistic Unrealistic expectationsexpectations
Unclear valuesUnclear values
Unclear about Unclear about others’ opinionsothers’ opinions
Social Social pressurepressure
Lack of Lack of support or support or resourcesresources
Lack skill or Lack skill or self-self-confidenceconfidence
59 times more likely to change 59 times more likely to change mindmind
23 times more likely to delay 23 times more likely to delay decisiondecision
5 times more likely to have regret5 times more likely to have regret
3 times more likely to fail 3 times more likely to fail knowledge testknowledge test
19% more likely to blame 19% more likely to blame practitioner for bad outcomespractitioner for bad outcomes
Sun, Q. [MSc thesis]. University of Ottawa, 2005. Gattelari & Ward J Med Screen 2004;11:165-169
Consequences of Consequences of unresolved decisional conflict unresolved decisional conflict
& related factors& related factors
Treating Decisional ConflictTreating Decisional Conflict
FrameworkFramework Ottawa Decision Support Framework (ODSF)Ottawa Decision Support Framework (ODSF)
Process (based on framework)Process (based on framework) Decision support using the Ottawa Personal Decision support using the Ottawa Personal
Decision GuideDecision Guide©© (OPDG) (OPDG) Walks patients through the process of making a decisionWalks patients through the process of making a decision
Tools:Tools: Decision AidsDecision Aids
Adjuncts to decision support counselingAdjuncts to decision support counseling Present content and implicit values clarificationPresent content and implicit values clarification
Module 2: Module 2: Decision support process
Ottawa Decision Support Framework Decision Support Ottawa Personal Decision Guide
Decisional Needs•Decisional conflict (uncertainty) •Decision: type, timing, stage, leaning•Knowledge & Expectations•Values clarity•Support/resources•Personal/Clinical Characteristics
Decision QualityInformed, values-based ActionsDelay, continuance ImpactValues-based health outcomes•Regret and blame•Appropriate use & cost of health services
Decision Support1. Clarify decision and needs2. Provide facts, probabilities3. Clarify values4. Support/Guide/Coach5. Monitor/Facilitate progress
British Medical Journal 327:736-740, 2003
OTTAWA DECISION SUPPORT FRAMEWORK (ODSF)
Health Decisions Health Decisions Best Suited to the ODSFBest Suited to the ODSF
• No clear “choice” that’s right for No clear “choice” that’s right for everyoneeveryone
• Stimulated by new circumstance, medical Stimulated by new circumstance, medical diagnosis, or developmental transitiondiagnosis, or developmental transition
• Options have different benefit/harm Options have different benefit/harm profiles that clients value differentlyprofiles that clients value differently
• Careful deliberation --- uncertain Careful deliberation --- uncertain outcomes (scientific uncertainty)outcomes (scientific uncertainty)
• More effort in deliberation than in More effort in deliberation than in implementation implementation
Decision Support ProcessDecision Support Process Decision supportDecision support is a process of:is a process of:
• assessing decisional needs:assessing decisional needs: modifiable modifiable factorsfactors
• intervening to address individual needsintervening to address individual needs
• evaluating the progress and quality of evaluating the progress and quality of decision makingdecision making
Quality decisionsQuality decisions::• informed informed
• congruent with personal valuescongruent with personal values
• acted uponacted upon
(O’Connor, Jacobsen, Stacey, JOGNN, 2002)
Ottawa Personal Decision Guide©:Ottawa Personal Decision Guide©: A tool for implementing decision supportA tool for implementing decision support
Step 1Step 1 Clarify the Decision Clarify the Decision
Step 2 Step 2 Identify Decision Making NeedsIdentify Decision Making Needs
Step 3Step 3Explore Decision Needs: Explore Decision Needs:
SupportSupport
Step 3Step 3Clarify ValuesClarify Values
Step 3Step 3ExampleExample
Assess Importance: How Much Assess Importance: How Much Each Pro and Con MattersEach Pro and Con Matters
Step 4Step 4Plan Next Steps based on identified Plan Next Steps based on identified
needsneeds
Using the Using the Ottawa Personal Decision Guide©Ottawa Personal Decision Guide©
1. Form groups of two• ‘Client’ making a difficult decision• ‘Practitioner’ coaching
2. ‘Client’ choose a real decision (health, career, education, move, buy a car)
3. ‘Practitioner’ interviews patient & documents on the Ottawa Guide
4. Discussion
What happened?What happened?
What helped?What helped?
Module 3:Module 3:Communicating risk informationCommunicating risk information
Presenting Risk InformationPresenting Risk Information
Similar profile:Similar profile: Probability of outcome Probability of outcome in people ‘like me’ who in people ‘like me’ who experience the problemexperience the problem
Format:Format: Use Use quantitative, quantitative, qualitative and graphic qualitative and graphic formats (100 faces) to formats (100 faces) to enhance understandingenhance understanding
Framing:Framing: Risk message + Risk message + ‘Positive’ message ‘Positive’ message improves message improves message framingframing
Helping patients interpret risk informationHelping patients interpret risk information11
Risk of what?Risk of what? Getting a disease? Getting a disease? Dying from it? Dying from it? Getting a symptom?Getting a symptom?
Does the risk information Does the risk information reasonably apply to your patient?reasonably apply to your patient?1 From: Schwartz LM, Woloshin, S and Welch HG, “Know Your Chances: Understanding Health Statistics.”
How big is the risk?How big is the risk? Chance that your patient will experience Chance that your patient will experience the outcome the outcome “ “Out of how many?” Out of how many?” Over what timeframe?Over what timeframe?
How big is the risk?How big is the risk?11
A person’s risk of getting colon cancer is:A person’s risk of getting colon cancer is: 1 in 211 in 21 48 in 100048 in 1000 0.0480.048 4.8%4.8%
And the chance of And the chance of dyingdying of colon cancer is of colon cancer is 17 out of 100017 out of 1000
The average person’s chance of The average person’s chance of gettinggetting colon colon cancer is…cancer is…
Less than 1 out of 1000 Less than 1 out of 1000 in the next yearin the next year 5 out of 1000 5 out of 1000 in the next 10 yearsin the next 10 years 20 out of 1000 20 out of 1000 in the next 20 yearsin the next 20 years 48 out of 100048 out of 1000 OVER A LIFETIME* OVER A LIFETIME*
*In this case, a lifetime is defined as 85 years…
Helping patients interpret risk informationHelping patients interpret risk information11
How big is the change in risk?How big is the change in risk? ““Lower than what?” Lower than what?” Explain your patient’s degree Explain your patient’s degree change inchange in risk if she does something (e.g., take a risk if she does something (e.g., take a drug, changes lifestyle) drug, changes lifestyle) vs. if she does notvs. if she does notDoes the change in risk information Does the change in risk information
reasonably apply to your patient?reasonably apply to your patient? Are the people this Are the people this change in riskchange in risk information is based on similar to your information is based on similar to your patient? Sex, age, health status?patient? Sex, age, health status?
How does this risk compare to other How does this risk compare to other risks?risks?
Provide some contextProvide some contextFrom: Schwartz LM, Woloshin, S and Welch HG, “Know Your Chances: Understanding Health Statistics.”
NUMBER TRANSLATOR1 1 in ____ ____ out of 1000 Percent
1 in 1 1000 100%
1 in 2 500 50%
1 in 3 333 33%
1 in 4 250 25%
1 in 5 200 20%
1 in 6 167 17%
1 in 7 143 14%
1 in 8 125 13%
1 in 9 111 11%
1 in 10 100 10%
1 in 20 50 5.0%
1 in 25 40 4.0%
1 in 50 20 2.0%
1 in 100 10 1.0%
1 in 200 5 0.50%
1 in 250 4 0.40%
1 in 300 3.3 0.33%
1 in 400 2.5 0.25%
1 in 500 2.0 0.20%
1 in 600 1.7 0.17%
1 in 700 1.4 0.14%
1 in 800 1.3 0.13%
1 From: Schwartz LM, Woloshin, S and Welch HG, “Know Your Chances: Understanding Health Statistics.”
From: Schwartz LM, Woloshin, S and Welch HG, “Know Your Chances: Understanding Health Statistics.”
Are there important downsides?
NoAction is easy, painless and safe(like taking a 20 minutes walk 3
times a week)
Is the benefit important?
No Yes
Consider doing it Consider doing itDon’t do itDo it
No Yes
YesAction involves pain, dangerous
side effects or a lot of time(like surgery, chemotherapy or
radiation
Definition of Important BenefitSmall change in risk of an important outcome
(e.g. death, outcome you care about)OR
Large change in risk of less important outcome(e.g. lab test, outcome you don’t really care about
Is the benefit important?
Module 4: Module 4: Decision Support ToolsDecision Support Tools
Decision AidsDecision Aids
DecisionDecision AidsAids adjunct to counselingadjunct to counseling informinform re options, benefits, re options, benefits, risksrisks
specify specify probabilitiesprobabilities of of outcomesoutcomes
clarifyclarify personal values & norms personal values & norms guide guide in deliberating & in deliberating & communicatingcommunicating
Cochrane ReviewCochrane Review
Decision Aids:Decision Aids: ImproveImprove knowledgeknowledge Improve Improve realistic expectationsrealistic expectations LowerLower decisional conflictdecisional conflict IncreaseIncrease patient involvementpatient involvement in in
decision making decision making DecreaseDecrease number undecidednumber undecided Increase Increase agreement between agreement between values & values & choice choice
Benefits and RisksBenefits and Risks Importance of benefits (pros)Importance of benefits (pros) Importance of risks (cons)Importance of risks (cons)
ProsPros ImportancImportancee
ConsCons ImportancImportancee
More focus More focus in schoolin school
**********
Don’t Don’t like like medicatiomedicationn
******
Less Less stressful stressful for family for family
******** Slowed Slowed growthgrowth
****
Get along Get along better better with with classmatesclassmates
******** Sleep Sleep problemsproblems
**
Ritalin for ADHD
Should I have a TURP if I am still Should I have a TURP if I am still bothered by BPH Symptoms?bothered by BPH Symptoms?
PROS
Better reduction in symptoms
(lowered by 80% compared to 32-48% with other options)
CONSMay 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
***
*
*
Providers’ PerspectivesProviders’ Perspectives
““It is helpful to have my It is helpful to have my patients arrive at the patients arrive at the consultation with familiarity of consultation with familiarity of the options and knowledge of the the options and knowledge of the risks and benefits” risks and benefits” Richard Barth, MD, surgical oncologistRichard Barth, MD, surgical oncologist
"With this process, I can focus on helping each individual patient decide the best treatment for her.”
Kari Rosenkranz, MD, surgical oncologist
Patient Perspective“At first I wondered what this was all for? It didn't take long for me to understand. The videos were the most helpful tools! I felt peace for the first time in a while. The whole shared decision making concept is wonderful and empowering. Thank you!”
Breast cancer patient
Patients’ Perspectives: Patients’ Perspectives: Herniated DiscHerniated Disc
““Before watching the video I was prepared for Before watching the video I was prepared for surgery. Now after watching it I am going to try surgery. Now after watching it I am going to try non-surgical treatments to see if it works.”non-surgical treatments to see if it works.”
““I found the video very informative and helpful I found the video very informative and helpful and because of it I am more inclined to consider and because of it I am more inclined to consider surgery, which is a new position.”surgery, which is a new position.”
““The video helps in that “real people” that The video helps in that “real people” that actually have back issues talked about their own actually have back issues talked about their own experiences and the choices they made. It helps experiences and the choices they made. It helps you understand that you are not alone in your you understand that you are not alone in your pain, decisions or hardships.”pain, decisions or hardships.”
““Nothing can replace a question & answer visit Nothing can replace a question & answer visit with the doctor. The video made it very clear with the doctor. The video made it very clear about how undependable the statistics were.”about how undependable the statistics were.”
““This video made me realize I need to be more in This video made me realize I need to be more in charge of myself. And that surgery should be a charge of myself. And that surgery should be a last resort and that other options should be last resort and that other options should be explored.”explored.”
Decision Support Decision Support ResourcesResources
50
Healthwise Decision PointsHealthwise Decision Points
>>100 Decision Points in Healthwise Knowledgebase100 Decision Points in Healthwise KnowledgebaseProvide Info re:Provide Info re: SummarySummary of ‘Key Points’ of ‘Key Points’ Health conditionHealth condition OptionsOptions
Who it is appropriate or not appropriate for Who it is appropriate or not appropriate for Reasons to Reasons to choosechoose & Reasons & Reasons not to choosenot to choose (Pros & (Pros &
Cons) Cons) Wise Health DecisionWise Health Decision What issues apply to you?What issues apply to you? What choice are you What choice are you leaningleaning toward?toward?
ReferencesReferences
(O’Connor et al., Cochrane Library, 2004; Issue 1: A Decision Aid: provides, at minimum, information on options and outcomes)
Shared Decision Making ResourcesShared Decision Making Resources
DHMC Center for Shared DecisionDHMC Center for Shared Decision MakingMaking http://www.dhmc.org/dept/csdm
Ottawa Health Research InstituteOttawa Health Research Institute http://decisionaid.ohri.ca/index.html
Healthwise Preferred CareHealthwise Preferred Care http://www.healthwise.net/preferredcare
WebMDWebMD http://www.webmd.com/
Foundation for InformedFoundation for Informed Medical Decision Medical Decision MakingMaking http://www.informedmedicaldecisions.org ww.informedmedicaldecisions.org
Health News ReviewHealth News Review http://www.healthnewsreview.org
ConclusionsConclusionsDecision supportDecision support is a is a process process of:of: assessing decisional needsassessing decisional needs intervening to address individual needsintervening to address individual needs evaluating the quality of decision makingevaluating the quality of decision making
A A high quality decisionhigh quality decision is informed, is informed, values-based, and acted uponvalues-based, and acted upon
Decision quality improvesDecision quality improves with: with: Patient decision aids Patient decision aids Personal health coaching using a structured Personal health coaching using a structured
decision guide decision guide
Acknowledgements and ThanksAcknowledgements and Thanks
The Foundation for Informed The Foundation for Informed Medical Decision MakingMedical Decision Making
Health Dialog, Inc.Health Dialog, Inc. Annette O’Connor, MScN, PhD, FCAHSAnnette O’Connor, MScN, PhD, FCAHS
and the Ottawa Health Research and the Ottawa Health Research Institute teamInstitute team
John Wennberg, MD, MPHJohn Wennberg, MD, MPH James N. Weinstein, DO, MSJames N. Weinstein, DO, MS