User centred care GPs’ perspective CAPHRI 02-04-12 Prof Trudy van der Weijden Dept General...

User centred careGPs’ perspectiveCAPHRI 02-04-12

Prof Trudy van der WeijdenDept General PracticeProgramme leader CAPHRI “Implementation of evidence”

School for Public Health and Primary Care CAPHRI

Content

• Definitions• User-centred research (evidence)• User-centred knowledge (guidelines)• User-centred care (performance)• Key messages


Key messages

- User-centred care has many faces- Providers and patients are users of

knowledge, new era of democratising knowledge

- Collective and individual preferences- From provider- to dialog-driven care


Content



Definitions user-centred care, patient centredness

• Respect, autonomy, dignity • Accessible, confidential, continuity of

care, holistic, emotional supportive• Care is responsive to patient

preferences, needs, and values, ensuring that patient values guide all clinical decisions

IOM, WHO, Picker Institute, Berwick, Mead, NPCF etc


Definition user-centred care

– multidimensional concept– difficult to grasp– difficult to measure– easy to acknowledge

High radiation doses?

Low radiation doses?

Early-stage prostate cancer

Stalmeier PF, et al. J Clin Oncol

2007;25:3096-100.


“All I deliver is user-centred care!”

• Videos of consultations– 25 patients early-stage prostate cancer– 10 radiation-therapists

• Mean 48 minutes (± 16 min)• >1 option discussed with 10 patients

(option no radiation 0x)• “Understood?” after 42m.,

“Questions?” after 45m.Pieterse A, et al. Patient Education and Counseling

2011;85:e251–e259


Participation ladder (Arnstein 1969)D

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f co

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Patients in control

Acting together

Deciding together

Consultation

Information


Content

• Definitions• User-centred research (evidence) • User-centred knowledge (guidelines)• User-centred care (performance)• Key messages


Participation in research project

It’s LiFe

Jos Donkers. “Former director Marriott HotelsInt, in 1978 diagnosed with severe COPD.”

Ina van Opstal. “I work for the Diabetes Association as a diabetes experiential expert, and health care advisor.”


Participation in research confer.


Patients in the lead in research


Content

• Definitions• User-centred research (evidence)• User-centred knowledge (guidelines)• User-centred care (performance)• User-centred change (implementation)• Key messages

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100%2%

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cardiologist GP


Patient participationin guideline development

patient


Med Dec Making 2011


GIN Guidelines International Network


User-centred knowledge

• Guidelines new style:– All stakeholders involved (patients!)– Declaration of interests– Short: < 10-15 recommendations – Easy accessible for patients– All relevant evidence – Patient decision aids linked to preference-

sensitive recommendations Van der Weijden T, et al. J Clin Epid 2012 Jan


All relevant evidence


JOEM 2012


Content



Medical decision makingGuideline:

Interpretation evidence

Patient: co-morbidity

genetic predispositionpreferences

Setting:expertise

organisation financial

conditions

Sackett BMJ 1996


Paternalism Informed patient

Information-transfer

Deliberation clinician patient

Decision making

clinician patient


SDM

Paternalism SDM Informed patient

Information-transfer

Deliberation clinician patient

Decision making

clinician patient

clinician and patient

clinician and patient

Charles et al. Soc Sci Med 1999;49:651-61.

Elwyn G et al. Med Decis Making 2010;30:701e11.


Koelewijn et al. Prev Med 2010;50;35

Koelewijn et al. CMAJ 2009;181:E267

Koelewijn et al. BMC Health Serv Res 2008;8;9

IMPALA study


BMJ 2009;339:485


http://epatientdave.com


65% of patients first visit google before ….


User-centred care GPs role

Moser A et al. Pat Educ Couns 2010;78:365-71.


Key messages

- User-centred care has many faces- Providers and patients are users of

knowledge, new era of democratising knowledge

- Collective and individual preferences- From provider- to dialog-driven care


Uncertainty

“Uncertainty creeps into medical practice through every pore. Whether a physician is defining a disease, making a diagnosis, selecting a procedure, observing outcomes, assessing probabilities, assigning preferences, or putting it all together, he is walking on very slippery terrain. It is difficult for nonphysicians, and for many physicians, to appreciate how complex these tasks are, how poorly we understand them, and how easy it is for honest people to come to different conclusions.”

Eddy DM. Health Aff (Millwood) 1984;3:74–89.


Review Cochrane Library

• Knowledge (options, pros cons)• Involvement in decision• Preference => decision• Patient adherence • Invasive treatments • Health• Anxiety / consultation length

Stacey D, et al. Cochrane Library 2011.

==

≈


Three sources of uncertainty

• probability (the risk of a future event)• ambiguity (uncertainty about the

strength or quality of risk estimates)• complexity (uncertainty arising from

the complexity of the information on risk, depends on personal judgments)

Han PK, et al. Med Dec Making 2011 Jan


Impl Science 2011;6:45

User centred care GPs’ perspective CAPHRI 02-04-12 Prof Trudy van der Weijden Dept General...

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