Maria E. Suarez-Almazor, MD, PhD Houston CERTs

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Using Decision Aids to Enhance Shared-Decision
Making

• Maria E. Suarez-Almazor, MD, PhDHouston CERTs

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Outline

• Overview of decision aids
• Examples
• Methods for development
• Evidence
• Controversies

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Overview
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Health Decisions

• Good decisions
• Informed
• Supported by best evidence
• Compatible with patients values
• Considers patients preferences
• Weigh pros and cons
• Practical

• Poor decisions
• Objective data inadequate
• Too few options considered
• Alternatives unclear
• Values and preferences unexplored
• Roles unclear
• Communication is poor

Cornelia Ruland http//www.dbmi.columbia.edu/homep
ages/cmr7001/sdm/html/decision_support.htm
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Informed Decision Making

• When an individual
• Understands nature of condition (core knowledge)
• Understands service, including risks,
  limitations, benefits, alternatives,
  uncertainties (core knowledge)
• Considers preferences and values (values)
• Chooses desired level of participation in
  decision (role preferences)
• Makes (or defers) a decision based on his/her
  preferences and values (values-based decision)

Briss et al Am J Prev Med 2004
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Shared Decision Making

• Involvement of patients with their providers in
  making health care decisions that are informed by
  the best available evidence about options,
  potential benefits, and harms, and that consider
  patient preferences.

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Shared Decision Making

• 2 participants
• Provider
• Patient
• Information is shared
• Knowledge (provider)
• Values and preferences (patients)
• Participants build consensus
• Agreement is reached

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Informed Decision Making vs. Shared Decision
Making
IDM Any intervention in communities or
healthcare systems intended to promote informed
decisions
SDM The subset of informed decision making
interventions that are carried out between one
patient and his/her healthcare provider(s) in
clinical settings
Briss et al Am J Prev Med 2004. Sheridan et al.,
Am J Prev Med 2004.
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Decision Aids

• Patient decision aids are tools designed to help
  people participate in decision making about
  health care options.
• They provide information on the options and help
  patients clarify and communicate the personal
  value they associate with different features of
  the options

International Patient Decision Aids Standards
(IPDAS)
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Why?

• Many decisions have no best choice more than
  one appropriate option
• Evidence uncertain
• Need to consider
• benefits and harms
• values preferences
• practical aspects
• Time constraints during medical encounter

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Decision Aids

• Designed to
• Provide information on options
• Help people participate in decision making
• Help clarify and communicate personal values

• NOT designed to
• Advise people to choose one option over another
• Not meant to replace physician consultation

PREPARE PATIENTS TO MAKE INFORMED, VALUES-BASED
DECISIONS WITH THEIR PHYSICIANS
Cornelia Ruland http//www.dbmi.columbia.edu/homep
ages/cmr7001/sdm/html/decision_support.htm
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Examples
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Types of Decision Aids

• Format
• Paper and pencil
• Boards
• Audio booklets
• Videos
• Computer interactive
• CDs
• Web-based

• To be used
• Alone
• With family members
• With practitioner
• With health educator

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Gossey T Volk R
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Jibaja-Weiss, M http//www.bcm.edu/patchworkoflife
/homepage_en.htm
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Adaptive Conjoint Analysis

• Computer-administered, interactive conjoint
  method
• Situations with large number of attributes
• Exceeds what can reasonably done with other
  methods
• Asks respondents to choose between 2 scenarios
• The scenarios and attributes vary with each
  screen
• Avoids information overload by focusing on just a
  few attributes at a time
• Focuses on the attributes that are most relevant
  to the respondent

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Total Knee Replacement

• Surgery vs. no surgery
• Attributes
• Pain
• Function
• Complications
• Mortality
• Surgical revisions
• Physical therapy

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http//www.sawtoothsoftware.com/products/ssiweb/ss
iweb_capi.shtml
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Methods
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IPDAS

• International Patient Decision Aids Standards
  Collaboration
• http//ipdas.ohri.ca/
• Over 100 participants from 14 countries
• Glyn Elwyn, Annette OConnor, Dawn Stacey, Robert
  Volk and others
• Developing a quality criteria framework for
  patient decision aids online international
  Delphi consensus process. BMJ 2006333417

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IPDAS criteria for judging the quality of
decision aids checklist

• Content
• Development Process
• Effectiveness

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Content -- Decision aid..

• Provides information about options in sufficient
  detail
• Presents probabilities of outcomes in an unbised
  and understandable way
• Includes methods for clarifying and expressing
  patients values
• Include structured guidance in deliberation and
  communication

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Development process Decision aid

• Presents information in a balanced manner
• Has a systematic development process
• Uses up-to-date evidence (cited)
• Discloses conflict of interes
• Uses plain language
• Additional criteria to be met if decision aid
  is
• Internet-based
• Uses stories

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Effectiveness (1) Decision aid.

• DECISION
• Improves the match between the chosen option and
  the features that matter most to the informed
  patient.

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Effectiveness (2) -- Decision aid.

• DECISION PROCESS
• Helps patients
• recognize that a decision needs to be made
• know options and their features
• understand that values affect the decision
• be clear about the option features that matter
  most
• discuss values with their practitioner
• become involved in preferred ways.

O'Connor A. Cochrane Collaboration 2009
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Evidence
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Cochrane Systematic Review

• Last update 2006
• 55 RCTs
• Comparison to usual care
• True decisions not hypothetical
• Excluded education only programs not leading to
  a decision
• Mapping to IPDAS criteria

• OConnor et al., Cochrane Library, 2009

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Primary outcomes (IPDAS criteria)

• Attributes of decision
• Attributes of decision making process
• Other decision making process variables
• Decisional conflict
• Patient practitioner communication
• Participation in decision making
• Satisfaction

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Secondary outcomes (IPDAS criteria)

• Behaviour
• Decisions (proportion undecided, option
  selected).
• Adherence to chosen option.
• Health outcomes
• Health status and quality of life (generic and
  conditionspecific).
• Anxiety, depression, emotional distress,
  regret, confidence.
• Healthcare system
• Patients and physicians satisfaction.
• Costs, cost effectiveness.
• Consultation length.
• Litigation rates.

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Results

• Decision aids performed better in terms of
• Greater knowledge (MD 15.2 out of 100)
• Lower decisional conflict related to feeling
  uninformed (MD -8.3 out of 100)
• Lower decisional conflict related to feeling
  unclear about personal values (MD -6.4
• Reduced the proportion of people who were passive
  in decision making (RR 0.6)
• Reduced proportion of people who remained
  undecided post-intervention (RR 0.5)

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Results

• Higher proportion of people with accurate risk
  perceptions (RR 1.6)
• Reduced rates of elective invasive surgery in
  favour of conservative options (RR 0.8)
• Reduced use of menopausal hormones (RR 0.7)
• Reduced PSA screening (RR0.8)

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Results

• Decision aids were no better for
• Satisfaction with decision making
• Anxiety
• Health outcomes
• Inconclusive
• Patient-practitioner communication
• Consultation length
• Continuance
• Resource use

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Controversies
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Controversies

• Patient-practitioner communication
• Effects on health outcomes
• Uncertainty is real decisional conflict should
  not be avoided
• Best decisions based on gist
• Loaded choices

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Acknowledgements

• Robert Volk
• Maria Jibaja-Weiss
• Travis Gossey
• Carol Looney
• Liana Frankel
• Annette OConnor
• Rick Street

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Thank you msalmazor_at_mdanderson.org