Transcript Decision Support as a Clinical Skill - Dartmouth

Decision Support
as a Clinical Skill
August 2008
Workshop Outline

Module 1: Context
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Shared decision making
Preference sensitive care
Difficult decisions
Decisional conflict
 Module 2: Decision support process
 Ottawa Decision Support Framework
 Decision Support
 Ottawa Personal Decision Guide
 Module 3: Communicating risk information
 Module 4: Decision support tools
 Decision aids
 Other resources
Key Concepts

Shared Decision Making

Effective vs. Preference Sensitive Care
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Decisional Conflict

Decision Quality
Module 1: Context
Shared decision making
Values-sensitive care
Difficult decisions
Decisional 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
“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 decision
New model of shared decision making
for values-sensitive decisions
Physician Role
Diagnose problem;
discuss options, roles;
screen for decisional
conflict;
refer for decision
support
Goal:
Informed,
values-based
decision making
Patient Role
Communicate informed
values & preferences
shaped by their social
circumstances
Decision Support
(Ottawa Decision Support Framework, 1998)
(Charles C et al., 1997;
Coulter A 2002; O’Connor A,
Legare F, & Stacey D 2003;
O'Connor A et al., 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
Categories of Care
Values-sensitive
Effective


Benefits are large
compared to harms
Goal is usually to
increase uptake
e.g. taking an
antibiotic for
bacterial
pneumonia; having
a pap smear, flu
vaccine


Benefit/harm ratios are
either uncertain or depend on
patient values
Patient participation
 Improves decision quality;
 Prevents overuse of
options patients do not
value
e.g. elective surgery, PSA
screening; tamoxifen for
higher risk women
(Wennberg, BMJ, 2002;325:961-4; O’Connor, Legare, Stacey BMJ; in press)
Canadian Task Force on Preventive
Health Care / US Task Force
Recommendation
of routine
provision
Quality of
evidence
‘A’ Strong recommend Good
Magnitude of
benefit over
harm
Substantial
‘B’ Recommend
Good ------------ Moderate
Fair--------------- Substantial
‘C’ Close call
Conflicting
‘D’ Recommend
Fair
against
‘E’ Strong recommend Good
against
‘I’ No
recommendation
Small or sensitive
to patient values
Zero or negative
Zero or negative
Insufficient
Sensitive to
quantity/quality patient values
(CMAJ 2003; 169: 207-8; Harris et al., Am J Prev Med, 2001; 20:21-35)
Decision Making is…


A Process of Choosing between
courses of action (including inaction)
We generally want to choose options that
achieve valued outcomes and avoid
undesirable outcomes
Difficult Decisions
What are difficult
decisions?
Diagnosing Decisional Conflict
Definition:


Uncertainty about which
course of action to take,
resulting from…
Simultaneous opposing
tendencies to accept and
reject a given course of
action
Janis & Mann, Decision Making, 1977
Signs and Symptoms
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unsure what to do
unclear about best
choice for them
concern about bad
results
waver between
choices
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delay decision
question what is
important
distressed,
anxious, tense
preoccupied
with decision
Inherent (unchangeable) characteristics
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
Decisional Conflict
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Lack knowledge
Unrealistic
expectations


Unclear values
Unclear about
others’ opinions

Social
pressure
Lack of
support or
resources
Lack skill or
selfconfidence
Consequences of
unresolved decisional conflict
& related factors

59 times more likely to change mind

23 times more likely to delay decision

5 times more likely to have regret

3 times more likely to fail knowledge test

19% more likely to blame practitioner for
bad outcomes
Sun, Q. [MSc thesis]. University of Ottawa, 2005. Gattelari & Ward J Med Screen 2004;11:165-169
Treating Decisional Conflict
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Framework
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Ottawa Decision Support Framework (ODSF)
Process (based on framework)
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Decision support using the Ottawa Personal
Decision Guide© (OPDG)
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Walks patients through the process of making a decision
Tools:

Decision Aids
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Adjuncts to decision support counseling
Present content and implicit values clarification
Module 2: Decision support process
Ottawa Decision Support Framework
Decision Support
Ottawa Personal Decision Guide
OTTAWA DECISION SUPPORT
FRAMEWORK (ODSF)
British Medical Journal 327:736-740, 2003
Decisional Needs
•Decisional conflict
(uncertainty)
•Decision: type, timing, stage,
leaning
•Knowledge & Expectations
•Values clarity
•Support/resources
•Personal/Clinical
Characteristics
1.
2.
3.
4.
5.
Decision Support
Clarify decision and needs
Provide facts, probabilities
Clarify values
Support/Guide/Coach
Monitor/Facilitate progress
Decision Quality
Informed, values-based
Actions
Delay, continuance
Impact
Values-based health
outcomes
•Regret and blame
•Appropriate use & cost
of health services
Health Decisions
Best Suited to the ODSF
•
•
•
•
•
No clear “choice” that’s right for everyone
Stimulated by new circumstance, medical
diagnosis, or developmental transition
Options have different benefit/harm profiles
that clients value differently
Careful deliberation --- uncertain outcomes
(scientific uncertainty)
More effort in deliberation than in
implementation
Decision Support Process
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Decision support is a process of:
•
assessing decisional needs: modifiable factors
•
intervening to address individual needs
evaluating the progress and quality of decision
making
•

Quality decisions:
•
informed
•
congruent with personal values
•
acted upon
(O’Connor, Jacobsen, Stacey, JOGNN, 2002)
Ottawa Personal Decision Guide©:
A tool for implementing decision support
Step 1
Clarify the Decision
Step 2
Identify Decision Making Needs
Step 3
Explore Decision Needs:
Support
Step 3
Clarify Values
Step 3
Example
Assess Importance: How Much
Each Pro and Con Matters
Step 4
Plan Next Steps based on identified
needs
Using the
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 helped?
Module 3:
Communicating risk information
Presenting Risk Information
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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
Helping patients interpret risk information1
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Risk of what?
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Getting a disease?
Dying from it?
Getting a symptom?
How big is the risk?
 Chance that your patient will experience the outcome
 “Out of how many?”
 Over what timeframe?
Does the risk information 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?1
A person’s risk of getting colon cancer is:
 1 in 21
 48 in 1000
 0.048
 4.8%
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 The average person’s chance of getting colon cancer is…
 Less than 1 out of 1000 in the next year
 5 out of 1000 in the next 10 years
 20 out of 1000 in the next 20 years
 48 out of 1000 OVER A LIFETIME*
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And the chance of dying of colon cancer is 17 out of 1000
*In this case, a lifetime is defined as 85 years…
Helping patients interpret risk information
1
How big is the change in risk?
 “Lower than what?”
 Explain your patient’s degree change in risk if she
does something (e.g., take a drug, changes lifestyle)
vs. if she does not
Does the change in risk information
reasonably apply to your patient?
 Are the people this change in risk information is
based on similar to your patient? Sex, age, health
status?
How does this risk compare to other risks?
 Provide some context
From: Schwartz LM, Woloshin, S and Welch HG, “Know Your Chances:
Understanding Health Statistics.”
NUMBER TRANSLATOR1
1 From: Schwartz LM, Woloshin, S
and Welch HG, “Know Your
Chances: Understanding Health
Statistics.”
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%
Are there important
downsides?
No
Yes
Action is easy, painless and safe
(like taking a 20 minutes walk 3
times a week)
Action involves pain, dangerous
side effects or a lot of time
(like surgery, chemotherapy or
radiation
Is the benefit important?
Is the benefit important?
No
Yes
No
Consider doing it
Do it
Don’t do it
Yes
Consider doing it
Definition of Important Benefit
From: Schwartz LM, Woloshin, S
and Welch HG, “Know Your Chances:
Understanding Health Statistics.”
Small 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
Module 4:
Decision Support Tools
Decision Aids
Decision Aids
adjunct to counseling
 inform re options, benefits, risks
 specify probabilities of outcomes
 clarify personal values & norms
 guide in deliberating &
communicating

Cochrane Review
Decision Aids:
 Improve
knowledge
 Improve
realistic expectations
 Lower
decisional conflict
 Increase
patient involvement in
decision making
 Decrease number undecided
 Increase
agreement between values &
choice
Benefits and Risks
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Importance of benefits (pros)
Importance of risks (cons)
Ritalin for ADHD
Pros
Importance
Cons
Importance
More focus in
school
Less stressful
for family
Get along
better with
classmates
*****
Don’t like
medication
Slowed
growth
Sleep
problems
***
****
****
**
*
Should I have a TURP if I am still
bothered by BPH Symptoms?
CONS
PROS
Better reduction in
symptoms
(lowered by 80%
compared to 3248% with other
options)
Importance
*****
May die from surgery
(1 man in 100)
Importance
***
May not have normal
ejaculations
(75 men in 100)
*
May not have normal
sexual erections
(12 more men in 100)
*
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.”
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:
Herniated Disc
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“Before watching the video I was prepared for surgery. Now after
watching it I am going to try non-surgical treatments to see if it
works.”
“I found the video very informative and helpful and because of it I
am more inclined to consider surgery, which is a new position.”
“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.”
“Nothing can replace a question & answer visit with the doctor. The
video made it very clear about how undependable the statistics
were.”
“The video helps in that “real people” that actually have back issues
talked about their own experiences and the choices they made. It
helps you understand that you are not alone in your pain, decisions
or hardships.”
Decision Support
Resources
Healthwise Decision Points
>100 Decision Points in Healthwise Knowledgebase
Provide Info re:
 Summary of ‘Key Points’
 Health condition
 Options
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Reasons to choose & Reasons not to choose (Pros & Cons)
Wise Health Decision
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Who it is appropriate or not appropriate for
What issues apply to you?
What choice are you leaning toward?
References
(O’Connor et al., Cochrane Library, 2004; Issue 1: A Decision Aid: provides, at minimum,
information on options and outcomes)
50
Shared Decision Making Resources
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DHMC Center for Shared Decision Making
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Ottawa Health Research Institute
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http://www.webmd.com/
Foundation for Informed Medical Decision Making
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http://www.healthwise.net/preferredcare
WebMD
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http://decisionaid.ohri.ca/index.html
Healthwise Preferred Care
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http://www.dhmc.org/dept/csdm
http://www.informedmedicaldecisions.org
Health News Review
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http://www.healthnewsreview.org
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, and acted upon
Decision quality improves with:
 Patient decision aids
 Personal health coaching using a structured
decision guide
Acknowledgements and Thanks
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The Foundation for Informed Medical
Decision Making
Health Dialog, Inc.
Annette O’Connor, MScN, PhD, FCAHS
and the Ottawa Health Research Institute
team
John Wennberg, MD, MPH
James N. Weinstein, DO, MS