Decision aids for people facing health treatment or screening decisions: What's the Evidence?
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Transcript of Decision aids for people facing health treatment or screening decisions: What's the Evidence?
Welcome! Decision aids for people
facing health treatment or screening decisions:
What's the Evidence?
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What’s the evidence?
Stacey D, Legare F, Col NF, Bennett CL, Barry MJ, Eden KB, et al. (2014). Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews, 2014(1), CD001431.
http://www.healthevidence.org/view-article.aspx?a=21567
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Welcome!
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Decision aids for people facing health treatment or
screening decisions: What's the Evidence?
The Health Evidence Team
Maureen Dobbins Scientific Director
Heather Husson Manager
Susannah Watson Project Coordinator
Robyn Traynor Publications Consultant
Research Assistants Yaso Gowrinathan Kelly Graham Kristin Read Emily Sully Alice Wang Students Reza Yousefi Nooraie PhD candidate)
Jennifer Yost Assistant Professor
Why use www.healthevidence.org?
1. Saves you time
2. Relevant & current evidence
3. Transparent process
4. Supports for EIDM available
5. Easy to use
A Model for Evidence-Informed Decision Making
National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]
Stages in the process of Evidence-Informed Public Health
National Collaborating Centre for Methods and Tools. Evidence-Informe Public Health. [http://www.nccmt.ca/eiph/index-eng.html]
Searchable Questions Think “PICOS”
1.Population (situation)
2.Intervention (exposure)
3.Comparison (other group)
4.Outcomes
5.Setting
Dawn Stacey RN PhD CON(C) holds a Research Chair in Knowledge Translation to Patients and is a Full Professor in the School of Nursing at the University of Ottawa. Dr. Stacey is a Scientist at the Ottawa Hospital Research Institute where she is Director of the Patient Decision Aids Research Group. She is the principal-investigator for the Cochrane Review of Patient Decision Aids, co-chair of the Steering Committee for the International Patient Decision Aid Standards Collaboration (IPDAS), and co-investigator for the Cochrane Review of Interventions to Improve the Adoption of Shared Decision Making. Her research includes: knowledge translation to patients; patient decision aid development, evaluation and appraisal; decision coaching; implementation of decision aids and decision coaching into practice; telephone-based care, and interprofessional approaches to shared decision making. She is collaborating with the Ministry of Health in Saskatchewan to implement shared decision making and patient decision aids across the province. Her research program website is http://decisionaid.ohri.ca.
Dawn Stacey
Is congruent
Choice
With the best
available evidence
and informed patient values
International Patient Decision Aids Standards 2006 & 2013; http://ipdas.ohri.ca/
Quality decision
Inform • Provide facts: Condition, options, benefits, harms • Communicate probabilities
Clarify values • Ask which benefits/harms matters most • Share patient experiences
Support • Guide in steps in
deliberation/communication • Worksheets, list of questions
Patient Decision Aids adjuncts to counseling
Stacey et al., Cochrane Library, 2014
If 100 men are screened If 100 men are not screened 18 diagnosed with prostate ca (15 due to screening, 3 due to symptoms)
11 diagnosed with prostate ca after developing symptoms (most >70 yr)
3 develop metastases 4 develop metastases
2 die of prostate cancer 16 with prostate cancer die of something else
3 die of prostate cancer 8 with prostate cancer die of something else
6 would never have known they had prostate cancer (overdiagnosis) 9 would die of other causes anyway 1 does not die of prostate ca because he was screened
FACTS: 100 men screened yearly 55-70 and followed to end of life VERSUS 100 men not screened
(College des Médecins du Quebec, 2013)
Reasons to get screened Reasons not to be screened Be reassured that you don’t have prostate ca
Being worried that you might have cancer when you don’t (false alarms) – most positive screening is simply enlarged due to age
Not having metastases and not dying of prostate ca
Being diagnosed with ca and having unnecessary treatments
Willing to accept the side effects of a prostate biopsy if needed
I don’t want the risks of side effects from a prostate biopsy
Willing to accept side effects of tx or to live with knowing I have prostate ca
I don’t want to take the risk of having side effects from treatment
Willing to accept that cancer found by screening would never have caused problems during my life if it hadn’t been found
I don’t think screening tests are reliable enough
What matters most? (College des Médecins du Quebec, 2013)
http://www.boitedecision.ulaval.ca/index.php?id=810&L=0
Review
Stacey D, Legare F, Col NF, Bennett CL, Barry MJ, Eden KB, et al. (2014). Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews, 2014(1), CD001431. Acknowledgements: A Saarimaki, S Beach, R Wu Funded by University of Ottawa Research Chair in KT to Patients
PICO
Eligible
Ineligible
Population Adults making decision for themselves or family member
Decisions: hypothetical, lifestyle, clinical trial entry, advance directives
Intervention Patient decision aid for treatment or screening decisions
Patient education; promotes compliance; passive informed consent
Comparison Usual care or alternate intervention
Same decision aid in both groups
Outcomes Decision quality; decision making process; patient, practitioner, system level
Study design RCT only All other designs
PICO
Eligible
Ineligible
Population Adults making decision for themselves or family member
Decisions: hypothetical, lifestyle, clinical trial entry, advance directives
Intervention Patient decision aid for treatment or screening decisions
Patient education; promotes compliance; passive informed consent
Comparison Usual care or alternate intervention
Same decision aid in both groups
Outcomes Decision quality; decision making process; patient, practitioner, system level
Study design RCT only All other designs
• Medline (1966 to June 2012)
• CINAHL (1982 to Sept 2008*)
• Embase (1980 to June 2012)
• PsychINFO (1806 to June 2012)
• Cochrane Central Register of Controlled Trials (June 2012)
* Not indexed on OVID after Sept 2008
Methods: Data Sources
• 2 reviewers independently screened and extracted data using structured forms
• RCT quality was assessed using Cochrane’s criteria for judging risk of bias: – sequence generation – allocation concealment – blinding – Completeness of outcome data – selective outcome reporting (published/registered protocols)
– other potential threats to validity
• Inconsistencies resolved by consensus
Data Screen & Extraction
Cochrane Review PtDAs Updates
17
35
55
86
115
0
20
40
60
80
100
120
140
1999 2003 2009 2011 2014
International patient
decision aid standards
(IPDAS) Criteria
2005
Search Results (Jan 2010 - Jun 2012)
38,069 + 247 citations
2,072 abstract screen
358 full-text screen
186 excluded 30 ongoing
82 + 33 =115 trials (142 citations)
Topics of Decision Aids (N=115) • Medical (n=27+9)
– 10 HRT – 3 atrial fib anti-coag – 2+1 cardiovascular (Sheridan) – 2+1 diabetes (Mann D) – 1 hypertension – 1+1 osteoporosis (Montori) – 1+1 chemotherapy (Leighl) – 1 multiple sclerosis – 1 schizophrenia – 1 depression – 1 natural health products – 1 ovarian risk management – 1+1 breast ca prevention (Fagerlin) – 1+1 osteoarthritis knee (de Achaval) – (1) acute respiratory infection (Légaré) – (1) contraceptives (Langston) – coronary angiogram access site (Schwalm)
• Screening (n=31+15) – 11+4 PSA (Allen, Evans, Myers, Rubel) – 7 BRCA1/2 genetic – 6+5 colon cancer (Lewis, Miller, Schroy, Smith, Steckelberg) – 5+1 prenatal (Björklund) – 1 colon ca genetic – 1+1 mammography (Mathieu 2010) – 2 diabetes (Mann E, Marteau) – 1 cervix ca (McCaffery) – Stress testing for chest pain (Hess)
• Surgical (n=17+6) – 4+1 mastectomy (Jibaja-Weiss)
+1 reconstruction – 3+1 prostatectomy (Berry) – 3+1 hysterectomy (Solberg) – 2 prophylactic BRCA1/2 – 1 dental – 2 coronary revascularization – 1 orchiectomy for prostate ca – 1 back – (1) bariatric (Arterburn) – (1) vasectomy (Labrecque) – (1) long term feeding tube placement
(Hanson) • Obstetrics (n=4+2)
– 2 VBAC – 1 termination – 1 breech – (1) labour analgesia (Raynes-Greenow) – (1) embryo transplant (van Peperstraten)
• Vaccine (n=1+1) – 1 Hep B – (1) influenza (Chambers)
• Other (n=2) – 1 autologous blood donation – 1 CF referral for transplant
Elements in Patient Decision Aids (N=115)
100% Options, outcomes, implicit values clarification
91% Clinical condition
88% Probabilities of benefits and harms
63% Guidance in steps of decision making
59% Explicit values clarification
50% Examples of others/ others’ opinions
34
13% Higher Knowledge RR 13.29 [11.3, 15.3] – 42 studies Sub-analysis - Screening 12.76 [9.7, 15.7] – 19 studies - Treatment 13.75 [11.1, 16.4] – 23 studies
82% More Accurate Risk Perceptions
RR 1.82 [1.5, 2.2] – 19 studies • Screening 2.03 [1.4, 2.9] – 7 studies • Treatment 1.72 [1.5, 2.0] – 12 studies
51% More Informed Values-Based Choices
RR 1.51 [1.17, 1.96] – 13 studies • Screening 1.56 [1.2, 2.1] – 10 studies (used MMIC approach) • Treatment 1.35 [0.8, 2.3] – 3 studies (used other measures)
Compared to Usual Care, PtDAs…
13% higher knowledge scores (14% 2011)
82% more accurate risk perception (74%
2011) 51% better match
between values & choices (25% 2011)
6% Reduce decisional conflict (6% 2011)
Help undecided to decide (41%) (43% 2011)
Patients 34% less passive in decisions (39% 2011)
Improved patient-practitioner communication
Potential to reduce over-use • 20% surgery (same 2011)
• 14% PSA (-15% 2011)
• 27% HRT (no new studies )
Findings similar for screening and treatment
Improve decision quality
2 (of 6) Trials Showed Savings $$$ • Kennedy 2002 - hysterectomy
– ↓ invasive surgical procedures resulting in PtDA with nurse coaching having lowest mean cost compared to DA alone or usual care
• van Peperstraten 2010 – IVF
– Saved $219.12 per patient in decision aid group compared to usual care
• Montgomery 2007/Hollinghurst 2010 – No difference in costs for decision about delivery mode after cesarean
• Murray 2001a, 2001b – HRT use, prostatectomy
– No difference in health service resource use; higher cost with expensive interactive videodisc PtDA but if substitute lower cost internet access, no diff
• Vuorma 2003 - hysterectomy
– No difference in health service resource use; no difference between PtDA and usual care for treatment costs and productivity loss
Summary of findings
• Patients exposed to PtDAs – more involved in making health decisions (+34%)
– fewer are undecided (-41%)
– improve knowledge (+13%) and expectations – enhance values-choice agreement (+51%)
• PtDAs may reduce the use of discretionary surgery (-20%) or screening (-14% PSA) particularly when base rates are higher
• More research: cost-effectiveness, adherence to chosen option, health outcomes linked to preferred outcomes, influence of context
Other research findings on… • Sub-analysis
– coaching (Stacey et al 2013); – context (Brown et al. in press); – low literacy (McCaffery et al 2013) – adherence (Trenaman et al. submitted) – values- choice measures (Munro et al. submitted) – Elements in the decision aid (IPDAS series of 13
papers, 2013)
Importance of this Review
• Patient decision aids are effective interventions for people facing treatment or screening decisions
• A to Z inventory
• BUT they are not being used! http://healthydebate.ca/2015/01/topic/quality/decision-aids
• Current research is focused on implementing them within health care services
A Model for Evidence-Informed Decision Making
National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]
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