Decision aids for people facing health treatment or screening decisions: What's the Evidence?

1. Welcome! Decision aids for people facing health treatment or screening decisions: What's the Evidence? You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the line.

2. What’s the evidence? Stacey D, Legare F, Col NF, Bennett CL, Barry MJ, Eden KB, et al. (2014). Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews, 2014(1), CD001431. http://www.healthevidence.org/view- article.aspx?a=21567

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4. Welcome! You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the line. Decision aids for people facing health treatment or screening decisions: What's the Evidence?

5. The Health Evidence Team Maureen Dobbins Scientific Director Heather Husson Manager Susannah Watson Project Coordinator Robyn Traynor Publications Consultant Research Assistants Yaso Gowrinathan Kelly Graham Kristin Read Emily Sully Alice Wang Students Reza Yousefi Nooraie PhD candidate) Jennifer Yost Assistant Professor

6. What is www.healthevidence.org? Evidence Decision Making inform

7. Why use www.healthevidence.org? 1. Saves you time 2. Relevant & current evidence 3. Transparent process 4. Supports for EIDM available 5. Easy to use

8. A Model for Evidence- Informed Decision Making National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

9. Stages in the process of Evidence-Informed Public Health National Collaborating Centre for Methods and Tools. Evidence-Informe Public Health. [http://www.nccmt.ca/eiph/index-eng.html]

10. Poll Question #1 Have you heard of a PICO(S) question before? 1. Yes 2. No

11. Searchable Questions Think “PICOS” 1.Population (situation) 2.Intervention (exposure) 3.Comparison (other group) 4.Outcomes 5.Setting

12. Dawn Stacey RN PhD CON(C) holds a Research Chair in Knowledge Translation to Patients and is a Full Professor in the School of Nursing at the University of Ottawa. Dr. Stacey is a Scientist at the Ottawa Hospital Research Institute where she is Director of the Patient Decision Aids Research Group. She is the principal-investigator for the Cochrane Review of Patient Decision Aids, co-chair of the Steering Committee for the International Patient Decision Aid Standards Collaboration (IPDAS), and co-investigator for the Cochrane Review of Interventions to Improve the Adoption of Shared Decision Making. Her research includes: knowledge translation to patients; patient decision aid development, evaluation and appraisal; decision coaching; implementation of decision aids and decision coaching into practice; telephone-based care, and interprofessional approaches to shared decision making. She is collaborating with the Ministry of Health in Saskatchewan to implement shared decision making and patient decision aids across the province. Her research program website is http://decisionaid.ohri.ca. Dawn Stacey

13. Should men have screening for prostate cancer? yes no

14. Is congruent Choice With the best available evidence and informed patient values International Patient Decision Aids Standards 2006 & 2013; http://ipdas.ohri.ca/ Quality decision

15. (College des Médecins du Quebec, 2013)

16. Inform • Provide facts: Condition, options, benefits, harms • Communicate probabilities Clarify values • Ask which benefits/harms matters most • Share patient experiences Support • Guide in steps in deliberation/communication • Worksheets, list of questions Patient Decision Aids adjuncts to counseling Stacey et al., Cochrane Library, 2014

17. If 100 men are screened If 100 men are not screened 18 diagnosed with prostate ca (15 due to screening, 3 due to symptoms) 11 diagnosed with prostate ca after developing symptoms (most >70 yr) 3 develop metastases 4 develop metastases 2 die of prostate cancer 16 with prostate cancer die of something else 3 die of prostate cancer 8 with prostate cancer die of something else 6 would never have known they had prostate cancer (overdiagnosis) 9 would die of other causes anyway 1 does not die of prostate ca because he was screened FACTS: 100 men screened yearly 55- 70 and followed to end of life VERSUS 100 men not screened (College des Médecins du Quebec, 2013)

18. Reasons to get screened Reasons not to be screened Be reassured that you don’t have prostate ca Being worried that you might have cancer when you don’t (false alarms) – most positive screening is simply enlarged due to age Not having metastases and not dying of prostate ca Being diagnosed with ca and having unnecessary treatments Willing to accept the side effects of a prostate biopsy if needed I don’t want the risks of side effects from a prostate biopsy Willing to accept side effects of tx or to live with knowing I have prostate ca I don’t want to take the risk of having side effects from treatment Willing to accept that cancer found by screening would never have caused problems during my life if it hadn’t been found I don’t think screening tests are reliable enough What matters most? (College des Médecins du Quebec, 2013)

19. http://www.boitedecision.ulaval.ca /index.php?id=810&L=0

20. Review Stacey D, Legare F, Col NF, Bennett CL, Barry MJ, Eden KB, et al. (2014). Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews, 2014(1), CD001431. Acknowledgements: A Saarimaki, S Beach, R Wu Funded by University of Ottawa Research Chair in KT to Patients

21. PICO Eligible Ineligible Population Adults making decision for themselves or family member Decisions: hypothetical, lifestyle, clinical trial entry, advance directives Intervention Patient decision aid for treatment or screening decisions Patient education; promotes compliance; passive informed consent Comparison Usual care or alternate intervention Same decision aid in both groups Outcomes Decision quality; decision making process; patient, practitioner, system level Study design RCT only All other designs

22. PICO Eligible Ineligible Population Adults making decision for themselves or family member Decisions: hypothetical, lifestyle, clinical trial entry, advance directives Intervention Patient decision aid for treatment or screening decisions Patient education; promotes compliance; passive informed consent Comparison Usual care or alternate intervention Same decision aid in both groups Outcomes Decision quality; decision making process; patient, practitioner, system level Study design RCT only All other designs

23. • Medline (1966 to June 2012) • CINAHL (1982 to Sept 2008*) • Embase (1980 to June 2012) • PsychINFO (1806 to June 2012) • Cochrane Central Register of Controlled Trials (June 2012) * Not indexed on OVID after Sept 2008 Methods: Data Sources

24. • 2 reviewers independently screened and extracted data using structured forms • RCT quality was assessed using Cochrane’s criteria for judging risk of bias: – sequence generation – allocation concealment – blinding – Completeness of outcome data – selective outcome reporting (published/registered protocols) – other potential threats to validity • Inconsistencies resolved by consensus Data Screen & Extraction

25. Cochrane Review PtDAs Updates 17 35 55 86 115 0 20 40 60 80 100 120 140 1999 2003 2009 2011 2014 International patient decision aid standards (IPDAS) Criteria 2005

26. Search Results (Jan 2010 - Jun 2012) 38,069 + 247 citations 2,072 abstract screen 358 full-text screen 186 excluded 30 ongoing 82 + 33 =115 trials (142 citations)

27. Topics of Decision Aids (N=115) • Medical (n=27+9) – 10 HRT – 3 atrial fib anti-coag – 2+1 cardiovascular (Sheridan) – 2+1 diabetes (Mann D) – 1 hypertension – 1+1 osteoporosis (Montori) – 1+1 chemotherapy (Leighl) – 1 multiple sclerosis – 1 schizophrenia – 1 depression – 1 natural health products – 1 ovarian risk management – 1+1 breast ca prevention (Fagerlin) – 1+1 osteoarthritis knee (de Achaval) – (1) acute respiratory infection (Légaré) – (1) contraceptives (Langston) – coronary angiogram access site (Schwalm) • Screening (n=31+15) – 11+4 PSA (Allen, Evans, Myers, Rubel) – 7 BRCA1/2 genetic – 6+5 colon cancer (Lewis, Miller, Schroy, Smith, Steckelberg) – 5+1 prenatal (Björklund) – 1 colon ca genetic – 1+1 mammography (Mathieu 2010) – 2 diabetes (Mann E, Marteau) – 1 cervix ca (McCaffery) – Stress testing for chest pain (Hess) • Surgical (n=17+6) – 4+1 mastectomy (Jibaja-Weiss) +1 reconstruction – 3+1 prostatectomy (Berry) – 3+1 hysterectomy (Solberg) – 2 prophylactic BRCA1/2 – 1 dental – 2 coronary revascularization – 1 orchiectomy for prostate ca – 1 back – (1) bariatric (Arterburn) – (1) vasectomy (Labrecque) – (1) long term feeding tube placement (Hanson) • Obstetrics (n=4+2) – 2 VBAC – 1 termination – 1 breech – (1) labour analgesia (Raynes-Greenow) – (1) embryo transplant (van Peperstraten) • Vaccine (n=1+1) – 1 Hep B – (1) influenza (Chambers) • Other (n=2) – 1 autologous blood donation – 1 CF referral for transplant

28. To Find Decision Aids Google: ‘decision aid’

29. Elements in Patient Decision Aids (N=115) 100% Options, outcomes, implicit values clarification 91% Clinical condition 88% Probabilities of benefits and harms 63% Guidance in steps of decision making 59% Explicit values clarification 50% Examples of others/ others’ opinions

30. Trials Reporting Attributes of Decision Quality 77% Used at Least 1 Measure

31. 34 13% Higher Knowledge RR 13.29 [11.3, 15.3] – 42 studies Sub-analysis - Screening 12.76 [9.7, 15.7] – 19 studies - Treatment 13.75 [11.1, 16.4] – 23 studies

32. 82% More Accurate Risk Perceptions RR 1.82 [1.5, 2.2] – 19 studies • Screening 2.03 [1.4, 2.9] – 7 studies • Treatment 1.72 [1.5, 2.0] – 12 studies

33. 51% More Informed Values-Based Choices RR 1.51 [1.17, 1.96] – 13 studies • Screening 1.56 [1.2, 2.1] – 10 studies (used MMIC approach) • Treatment 1.35 [0.8, 2.3] – 3 studies (used other measures)

34. -14% Uptake of PSA testing RR 0.87 [0.77, 0.98] – 9 studies

35. Compared to Usual Care, PtDAs…  13% higher knowledge scores (14% 2011)  82% more accurate risk perception (74% 2011)  51% better match between values & choices (25% 2011)  6% Reduce decisional conflict (6% 2011)  Help undecided to decide (41%) (43% 2011)  Patients 34% less passive in decisions (39% 2011)  Improved patient-practitioner communication  Potential to reduce over-use • 20% surgery (same 2011) • 14% PSA (-15% 2011) • 27% HRT (no new studies ) Findings similar for screening and treatment  Improve decision quality

36. Other Outcomes (N=115)

37. 2 (of 6) Trials Showed Savings $$$ • Kennedy 2002 - hysterectomy – ↓ invasive surgical procedures resulting in PtDA with nurse coaching having lowest mean cost compared to DA alone or usual care • van Peperstraten 2010 – IVF – Saved $219.12 per patient in decision aid group compared to usual care • Montgomery 2007/Hollinghurst 2010 – No difference in costs for decision about delivery mode after cesarean • Murray 2001a, 2001b – HRT use, prostatectomy – No difference in health service resource use; higher cost with expensive interactive videodisc PtDA but if substitute lower cost internet access, no diff • Vuorma 2003 - hysterectomy – No difference in health service resource use; no difference between PtDA and usual care for treatment costs and productivity loss

38. Summary of findings • Patients exposed to PtDAs – more involved in making health decisions (+34%) – fewer are undecided (-41%) – improve knowledge (+13%) and expectations – enhance values-choice agreement (+51%) • PtDAs may reduce the use of discretionary surgery (-20%) or screening (-14% PSA) particularly when base rates are higher • More research: cost-effectiveness, adherence to chosen option, health outcomes linked to preferred outcomes, influence of context

39. Other research findings on… • Sub-analysis – coaching (Stacey et al 2013); – context (Brown et al. in press); – low literacy (McCaffery et al 2013) – adherence (Trenaman et al. submitted) – values- choice measures (Munro et al. submitted) – Elements in the decision aid (IPDAS series of 13 papers, 2013)

40. Importance of this Review • Patient decision aids are effective interventions for people facing treatment or screening decisions • A to Z inventory • BUT they are not being used! http://healthydebate.ca/2015/01/topic/quality/decision-aids • Current research is focused on implementing them within health care services

41. USA: R. 3590 The Patient Protection and Affordable Care Act (March 2010)

42. http://decisionaid.ohri.ca

43. A Model for Evidence- Informed Decision Making National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

44. Poll Question #2 Did you find the information presented today helpful? 1. Yes 2. No

45. Poll Question #3 Was this information new to you? 1. Yes 2. No

46. Questions?

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