Supporting
Informed Choices
Martin Underwood
Talking about Arthur
Decision making in arthritis?

• Decision making is complex
  • and poorly understood
• Big Decisions
  • Surgery
  • Dise...
Drugs for osteoarthritis

• Small everyday decision in GP’s surgery
  & the pharmacy
  •   >1,000,000 GP consultations per...
Big consequences
• Consultations, prescriptions, and treating
  side effects cost >£400,000,000 PA.
• Drug side effects
  ...
Preferences

• Most people with arthritis prefer
  anti-inflammatory drugs to paracetamol
  • More effective?
• Studies su...
Decision making

• More benefit if made jointly with clinician
  that they trust
• Take into account, benefits, risks and
...
Where does patient
information come from?
• Past experience
    • Theirs and that of friends/relatives
•   Tradition
•   M...
Do patients make the correct
choices?
• Effectiveness relatively easy
• Adverse events harder
  • Poor data
  • Most peopl...
Perception of risk and benefit

High risk
•(Oral)        Beneficial        High tolerance to adverse
               effect...
How did they decide

GP knows best
Uncritical acceptance of various information
 sources
Nature of pain - -constant /trans...
Types of pain and medication use
                                  Regular NSAID use



                 Constant pain



...
A balanced decision making
         process?
Factors influencing patient preferences for
                        topical or oral ibuprofen




                        ...
On the other hand

Normalisation of
  – arthritis pain
     • not aspiring to improvement
  – minor side effects
     • po...
Supporting
Informed Choices
Conclusions

• Most patients are pretty good at making
  informed choices
• Shared informed decision making key to
  getti...
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Martin Underwood

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Martin Underwood

  1. 1. Supporting Informed Choices Martin Underwood
  2. 2. Talking about Arthur
  3. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 13. A balanced decision making process?
  14. 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. 15. On the other hand Normalisation of – arthritis pain • not aspiring to improvement – minor side effects • possible increased risk of serious side effects
  16. 16. Supporting Informed Choices
  17. 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

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