Theres a time bomb inside your ''''''''''''''''''', which could go off if you dont

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Theres a time bomb inside your
..................., which could go off
if you dont

• have this procedure.
• take this medication.
• have this test.

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making decisions about tests and treatments
National Health and Medical Research Council 2006

• principles for better communication between
  healthcare consumers and healthcare professionals

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context

• knowledge translation
  multiple steps between research and
  uptake
• healthcare consumer/professional interface
  complex communication processes
• for consumers facing tests or treatments
  awareness
  
  understanding
  decision

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Studies (primary research studies)
Systems Synopses Guidelines Systematic
Reviews
ACP J Club. 2005 Mar-Apr142(2)A8-10.
adapted from Glasziou P, Haynes B. ACP J Club.
2005 Mar-Apr142(2)A8-10.
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better communication between healthcare consumers
and healthcare professionals potential benefits

• for consumers
  more informed decisions,
  greater
  satisfaction with healthcare
• for professionals
  greater professional
  satisfaction,
  fewer complaints, less litigation
• for communities
  more appropriate care
  
  doing what should be done
  not doing what should not be done

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background NHMRC
HAC resolved to develop a toolkit in 2004

• on communicating with healthcare consumers about
  the risks, benefits and outcomes of elective
  therapeutic and diagnostic interventions.
• to extend advice in previous publications
  General guidelines for medical practitioners
  on providing information to patients. NHMRC 1993
  10 tips for safer health care. ( for
  consumers)
  ACSQHC 2003
  
  
  
  Communicating with patients advice
  for medical practitioners.
  AHEC/NHMRC 2004
• for consumers (and carers and families) and
  clinicians

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development process

• systematic literature review to define principles
• draft toolkit to address
  options for
  consumer/clinician interactions
  barriers eg. functional health literacy
  framing of data modes of
  communication sources
  of more information
• modification after 75 responses to public
  consultation
• publication and dissemination

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systematic literature reviewissues

• channels of communication (including oral, print
  media, multimedia, decision aids and models, but
  excluding nonverbal communication)
• barriers to exchange and utilisation of
  information, including the importance of
  cultural, socioeconomic, language and linguistic
  considerations for effective communication
• efficacy and effectiveness of different
  communication channels, content and styles for
  communicating the risks, benefits and outcomes of
  elective therapeutic and diagnostic interventions
  between consumers and clinicians in achieving
  outcomes including better knowledge and
  satisfaction

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systematic literature reviewdatabases

• MEDLINE
• PsycINFO
• Cochrane Database of Systematic Reviews and
  Consumers and Communication Review Group
• National Health and Medical Research Council
• Health Technology Assessment Database
• Centre for Reviews and Dissemination

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making decisions about tests and treatments
National Health and Medical Research Council 2006

• Introduction/Summary scope, uses, structure,
  development
• Part 1 5 principles
• Part 2 3 case studies (1 diagnostic and 2
  therapeutic) examples of 3 interventions to
  illustrate each of the 5 principles
• Part 3
  
  further information Australian and international
  organisations, websites and other resources
  bibliography
  composite bibliography for Parts 1 and 2
  appendicies
  1)
  development process
  2)
  publication, dissemination and implementation
  strategies
  3) working
  committee members
  4) list of
  individuals and organisations making submissions

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principles for effective communication

• Principle 1
  good
  communication between healthcare consumers and
  healthcare professionals has many benefits
• Principle 2
  healthcare
  consumers vary in how much participation in
  decision-making they desire
• Principle 3
  good
  communication depends on recognising and meeting
  the needs of healthcare consumers
• Principle 4
  perceptions of
  risks and benefits are complex, and healthcare
  consumers and healthcare professionals may have
  different priorities
• Principle 5
  information
  on risks and benefits needs to be comprehensive
  and accessible

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5 Principle chapters structure

• background
• what this means for healthcare consumers
• what this means for healthcare professionals
• examples
• putting this principle into practice
  tools for healthcare consumers
  tools for healthcare professionals
  exercises, based on clinical scenarios
• find out more

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clinical scenario from Principle 3
good communication depends on
recognising and meeting the needs of healthcare
consumers

• Anna is a 50year old Aboriginal woman who visits
  a nurse practitioner after being recalled for a
  check up for her non-insulin-dependent diabetes
  mellitus. Anna is obese and has mild
  hypertension, and a blood test shows that her
  blood glucose levels are poorly controlled. She
  is on the highest doses of oral anti-diabetic
  medications, and most of the time she takes the
  medication as recommended.
  The nurse practitioner
  explains to Anna that she will need to start
  insulin injections to properly control her
  diabetes, but Anna is reluctant to do so.

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questions for healthcare consumers

• do I have particular cultural issues that are
  relevant in this consultation?
• are those issues affecting my feelings about the
  suggested options for treatment?
• what could I do to let the healthcare
  professional know about those issues?

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questions for healthcare professionals

• how could I explore the source of this persons
  anxiety?
• is there anything in what the person has told me
  that has cultural origins?
• if so, how can I best meet the persons needs?

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case studies of interventions

• diagnosis
  prostate specific antigen (PSA) testing
• therapy
  procedural coronary angioplasty
  pharmacological glucocorticoids

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3 case study chapters structure

• introduction
  
  background to the case study
  current status
  of communicating this intervention
• applying each of the 5 principles to this case
  study
• hypothetical examples, from consumer or
  professional perspectives
• resources
• references

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dissemination

• healthcare consumer groups/individuals
• healthcare professional groups/individuals
• educational and training groups/institutions

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dissemination
educational and training groups/institutions

• healthcare consumer groups
  carer organisations
  support groups
• healthcare professionals
  eg. nurses,
  medical practitioners, dentists,
  physiotherapists, etc at undergraduate and
  postgraduate levels and their teachers, and
  teaching and training institutions
• overseas-trained healthcare professionals
  eg. certification
  boards
• professional development
  eg. professional
  societies, group practices, area health services,
  general practice divisions
• staff within health services
• medical defence organisations
• senior school and college students
  eg. as part of
  a module about health

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toolkit strengths

• one document for consumers and professionals
• the principles focus on key issues
• data on health literacy
• framing of data
  eg.
  absolute/relative benefits of treatments
• adaptable clinical scenarios

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• What do we mean by literacy and health literacy?
• Literacy ?
• Health literacy ?

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• What do we mean by literacy and health literacy?
• Literacy is the ability to read and write. A
  person who has only basic literacy can do very
  simple things, such as sign their name, whereas
  someone who has functional literacy can recognise
  words and phrases in specific contexts.
• Health literacy is a form of functional literacy.
  It refers to a persons capacity to obtain,
  process and understand information needed to make
  appropriate health decisions that is, their
  ability to understand and act on health
  information
• Being health literate means more than simply
  being able to read and use numbers someone who
  is health literate is likely to understand and
  use health information so that they can make the
  best decisions for their situation. Even some
  well-educated people can have problems with
  health literacy Health literacy also has a
  cultural dimension, in that some cultures do not
  believe accepted medical explanations (rather
  than not understanding them).

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toolkit strengths

• one document for consumers and professionals
• the principles focus on key issues
• data on health literacy
• framing of data
  eg.
  absolute/relative benefits of treatments
• adaptable clinical scenarios

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• changing perceptions and comprehension by
  framing information.
• understanding the difference between
  relative and absolute risk

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what is the NNT?

• your patient is a healthy 62 years old woman, who
  asks about preventing osteoporotic fractures. As
  her clinician, you explain to her that there 2
  drugs which are known to prevent fractures.
• A will reduce her fracture risk by 50 over 3
  years
• B 1 in every 100 ( ie 1 ) women like her will
  have a fracture prevented if treated for 3 years
• what is the NNT, ie the Number Needed to
  Treat for I person to benefit?

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which drug is she likely to choose?

• your patient is a healthy 62 years old woman, who
  asks about preventing osteoporotic fractures. As
  her clinician, you explain to her that there 2
  drugs which are known to prevent fractures.
• A will reduce her fracture risk by 50 over 3
  years
• B 1 in every 100 ( ie 1 ) women like her will
  have a fracture prevented, if treated for 3 years
• which drug will she probably choose A or B?

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which drug is she likely to choose?

• in this case the relative data ( A 50 ) appear
  much more impressive than the absolute data ( B
  1 ), so she is likely to choose A
• the treatments could be identical, if the risk of
  fracture with no treatment over 3 years is 2
• studies show that consumers, non-clinical and
  clinical health professionals tend to choose data
  with big numbers for benefits from interventions
• relative data, however, cannot be interpreted
  without a numerator or denominator, so always
  provide absolute data at least, with relative
  data when necessary
  
• advertisements often use relative data, with
  bigger numbers.

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• changing perceptions by framing information
• Emphasising one aspect of a health decision
  while leaving out another may change how people
  understand and perceive risks and benefits. This
  effect is called framing of information. For
  example, health information can be framed as
• negative or positivefor example, giving
  the chances of an operation failing (negative
  framing) versus the chances of it succeeding
  (positive framing)
  loss or gain
  for example, emphasising the risks or
  disadvantages of not having a particular
  screening procedure (loss) versus emphasising the
  benefits or advantages of having the procedure
  (gain)
• 
  
  understanding
  the difference between relative and absolute risk
• Another factor that affects how people perceive
  risks and benefits is whether they are presented
  with absolute or relative risks.
• relative risk the drug reduces the chance
  of a heart attack by 50
  absolute risk the drug
  reduces the chance of a heart attack from 0.05
  (1 in 2000) to 0.025 (1 in 4000). Although the
  drug reduces the chance of a heart attack by 50
  when compared to not using the drug, in real
  terms, the risk for the individual patient is
  reduced from 1 in 2000 if the drug is not taken,
  to 1 in 4000 if it is.

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• you are discussing the pros and cons of having a
  mammogram with a 49 year old woman
• you know that breast cancer occurs in about
  1/1000 women of 45-50 years
• you also know that a mammogram has a sensitivity
  of 95 ( ie 5 of women with breast cancer have
  a negative test) and a specificity of 95 ( ie 5
  of women who dont have breast cancer have a
  positive test).
• what is the chance that a woman has breast
  cancer if the mammogram is positive? (assume you
  know nothing else about this woman)
• what is the correct answer?
  0.1, 1, 2,
  50, 95, 99, 99.5

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Limitations 1) the toolkit does not address

• non-verbal communication during consultations
• the specific communication needs of particular
  subgroups of people, such as
• infants, children, elderly
• people from lower socio-economic groups
• people from non-English speaking backgrounds
• people from different cultures
• Aboriginal and Torres Strait Islander people
• people with low health literacy
• people with mental health problem
• people with intellectual disabilities.
• the complicated processes of communication when
  many different professionals are involved, like
  hospitals

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Limitations 2) the toolkit has 160 pages.
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Limitations 2) the toolkit has 160 pages.

• each principle section is self contained
• the introduction/summary ( 4 pages) will be
  posted separately on the NHMRC website soon

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better communication between healthcare consumers
and healthcare professionals benefits

• for consumers
  
  more informed decisions,
  greater
  satisfaction with healthcare
• for professionals?
  
  greater professional satisfaction
  fewer
  complaints, less litigation
• for communities?
  more
  appropriate care ?
  doing what should be
  done
  not doing what should not be
  done
  see Trevena LJ et al. A systematic review on
  communicating with patients about evidence. J
  Eval Clin Pract 2006 12 13-23.

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further reading

• Making decisions about tests and treatments.
  Principles for better communication between
  healthcare consumers and healthcare
  professionals. NHMRC 2006
  
  whole document
  
  nhmrc.gov.au
• summary (not yet posted on website)
  nhmrc.gov.au
• Trevena LJ et al. A systematic review on
  communicating with patients about evidence. J
  Eval Clin Pract 2006 12 13-23.
• Greenberg PB, Walker C, Buchbinder R. Optimising
  communication between consumers and clinicians.
  Med J Aus 2006 (in press)
• Health Literacy see J Gen Intern Med Aug 2006
• Cochrane consumers and communication review group

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acknowledgments

• 
  
• 2) NHMRC Health Advisory Committee
• 3) Technical writers
• 4) Systematic reviewers

• 1) Working Committee

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acknowledgments

• 
  
• 2) NHMRC Health Advisory Committee
  
  HAC members
  Ms Stephanie Gates
  Mr P. Callan, Ms A.
  Peristeri, Ms C.
  Clutton
• 3) Technical writers
  BIOTEXT Pty Ltd Canberra
  Hilary Cadman and Janet
  Salisbury
• 4) Systematic reviewers
  National Cancer Control Initiative
  Dr B McEvoy and Dr F Howes
  La Trobe University
  Dr C Peterson, A/Prof
  G Murphy

• 1) Working Committee
• Dr Rosemary Aldrich
  HAC public health
  physician journalism
• A/Professor Rachelle Buchbinder
  rheumatology clinical epidemiology
• Ms Rosemary Clerehan
  linguistics
• Dr Peter Greenberg
  HAC general
  physician
• Dr Peter Joseph
  HAC general
  practice
• Professor Judy Lumby
  nursing
• Dr Christine Walker
  sociology chronic disease
  alliance
• Ms Ros Wood consumer
  received attendance fees and travel
  support from NHMRC

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making decisions about tests and treatments
National Health and Medical Research Council 2006

• principles for better communication between
  healthcare consumers and healthcare professionals