Evidence-based shared decision-making (EB SDM) A neglected research topic

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WREN Convocation 2009
Evidence-based shared decision-making(EB SDM)A
neglected research topic
David L. Hahn, M.D., M.S. (Epidemiology) Dept.
Family Practice, Dean Medical Center Clinical
Professor, U. Wisconsin Dept. Family Medicine
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Evidence-based shared decision-making (EB SDM)

• Definition
• Components of SDM information
• Communicating SDM information
• Point of service decision aids
• Research areas

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Evidence-based shared decision-making (EB SDM) -
An integral part of evidence-based practice

• Integration of best research evidence with
  clinical expertise and patient values.
  Sackett, et al, 2000
• Care that meets the needs of patients and is
  based on the best scientific knowledge. Institute
  of Medicine

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Evidence-based practice
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Evidence-based shared decision-making (EB SDM) -
Two perspectives

• What message is given?
• What message is received?

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Evidence-based shared decision-making (EB SDM) -
Two perspectives

• Medical professional
• Preferred formats?
• Tailored messages?
• Patient
• Numeracy?
• Receptivity?

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Evidence-based shared decision-making (EB SDM) -
Resources

• Cochrane Collaboration
• USPSTF
• ACP Journal Club
• POEMS
• FPIN
• Others

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What message is given? - Preferred formats

• DO NOT USE relative terms
• Relative risk (RR)
• Odds ratios (OR)
• change
• Except to illustrate how they can mislead

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What message is given? - Preferred formats

• Do not depend on some absolute measures
• Number needed to treat (NNT)
• Number needed to harm (NNH)
• Except as secondary explanations
• These are more appropriate for clinician
  decision-making

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What message is given? - Preferred formats

• DO USE
• Baseline events per 100, 1000, 10,000
• Intervention events in identical numerical units
• Differences in identical numerical units
• ALSO
• Use preferred graphical formats

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What message is received?

• Health literacy
• Receptivity to SDM
• Willingness to acknowledge the patient as the
  locus of control

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Health Literacy -The four faces of health
communication

• What is intended
• What is written/said - the symbol
• The received meaning - interpretation of the
  symbol
• The power relationship in the communication

Andrew Pleasant Phd 2009 Wisconsin Third Biennial
Health Literacy Summit
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The power relationship in the communication - two
approaches

• Informative communication
• Patient-oriented
• Persuasive communication
• Not patient-oriented

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Informative communication -Aims and methods

• Promotes beneficence and autonomy
• Encourages shared decision-making
• Uses unbiased patient-oriented information
• Is understandable and balanced

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Persuasive communication - Aims and methods

• Manipulates perception and behavior to accomplish
  an aim
• Motivates action via instilling fear
• Over-emphasizes/distorts (potential or real)
  benefits
• De-emphasizes/conceals harms/risks

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Shared decision-making requires informative
communication
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Point-of-service decision aids

• Simple and straightforward
• 6th-8th grade level
• Informative
• Verbal, tabular and graphical formats
• Meant to serve as a basis for discussions during
  office visits

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Point-of-service decision aids -Examples

• Example 1
• PSA screening
• Example 2
• Mammography between ages 40-49
• Mortality charts

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Point-of-service decision aids - Are they really
needed?

• There are plenty of guidelines already available!
• Why reinvent the wheel?

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Point-of-service decision aids - Are they really
needed?

• Beware many clinical practice guidelines
• Pseudo-evidence-based
• United States Preventive Services Task Force
  (USPSTF)
• B-rated recommendations
• Wisconsin Collaborative for Healthcare Quality
  (WCHQ)
• Mostly SOR B- and C- level metrics

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Point-of-service decision aids - Are they really
needed?

• Few valid evidence-based guidelines include a
  Plain Language Summary for patients
• Cochrane is an exception

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Conclusion

• EB SDM is a promising topic for practice-based
  research into quality

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Possible research areas

• Which clinical topics?
• What best approaches?
• Patient acceptance?
• Clinician Acceptance?
• Better outcomes?

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SDM website resources

• http//ipdas.ohri.ca/
• http//decisionaid.ohri.ca/
• http//www.cbdsm.org/intro
• http//www.vaoutcomes.org/index.html