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Martin Underwood
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Martin Underwood



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  • 1. Supporting Informed Choices Martin Underwood
  • 2. Talking about Arthur
  • 3. Decision making in arthritis? • Decision making is complex • and poorly understood • Big Decisions • Surgery • Disease Modifying Anti-Rheumatic Drugs • ‘Small’ Decisions • Exercises • Appliances • Drugs
  • 4. Drugs for osteoarthritis • Small everyday decision in GP’s surgery & the pharmacy • >1,000,000 GP consultations per year for OA • >17,000,000 prescriptions for anti-inflammatory drugs • >4,000,000 topical preparations
  • 5. Big consequences • Consultations, prescriptions, and treating side effects cost >£400,000,000 PA. • Drug side effects • Gastric Bleeding • Raised Blood Pressure • Cardiovascular Disease • Risk for an individual is not clear • Comparative risks are different for different drugs
  • 6. Preferences • Most people with arthritis prefer anti-inflammatory drugs to paracetamol • More effective? • Studies suggest that many people might prefer a less effective but safer medication • Many people prefer topical preparations to oral medications
  • 7. Decision making • More benefit if made jointly with clinician that they trust • Take into account, benefits, risks and availability of alternative treatments • Information quality? • Risk evaluation affected by perceived severity of condition
  • 8. Where does patient information come from? • Past experience • Theirs and that of friends/relatives • Tradition • Medical advisors • Written material (traditional & modern) • Folk models of illness
  • 9. Do patients make the correct choices? • Effectiveness relatively easy • Adverse events harder • Poor data • Most people not affected • Topical or Oral Ibuprofen study (TOIB) • People who chose oral medication had fewer side effects than those randomised to oral medication
  • 10. Perception of risk and benefit High risk •(Oral) Beneficial High tolerance to adverse effect effects Little effect Low risk Low tolerance to adverse •(Topical) effects
  • 11. How did they decide GP knows best Uncritical acceptance of various information sources Nature of pain - -constant /transient – Regular or as required Trade off between pain relief, side effects and, improved function.
  • 12. Types of pain and medication use Regular NSAID use Constant pain More pain more Regular NSAID use with reserve medication As required Transient pain Pre-emptive
  • 13. A balanced decision making process?
  • 14. Factors influencing patient preferences for topical or oral ibuprofen Carnes, D. et al. BMJ 2008;336:142-145 Copyright ©2008 BMJ Publishing Group Ltd.
  • 15. On the other hand Normalisation of – arthritis pain • not aspiring to improvement – minor side effects • possible increased risk of serious side effects
  • 16. Supporting Informed Choices
  • 17. Conclusions • Most patients are pretty good at making informed choices • Shared informed decision making key to getting right balance of risks/benefits • Practitioners - data on risks and benefits • Patients – relative values of risk and benefits