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Welcome!
Decision aids for people
facing health treatment or
screening decisions:
What's the Evidence?
You will be placed ...
What’s the evidence?
Stacey D, Legare F, Col NF, Bennett CL,
Barry MJ, Eden KB, et al. (2014). Decision
aids for people fa...
• Use Q&A to post comments /
questions during the webinar
– ‘Send’ questions to All (not
privately to ‘Host’)
• Connection...
Welcome!
You will be placed on hold until the webinar begins.
The webinar will begin shortly, please remain on the line.
D...
The Health Evidence Team
Maureen Dobbins
Scientific Director
Heather Husson
Manager
Susannah Watson
Project Coordinator
Ro...
What is www.healthevidence.org?
Evidence
Decision
Making
inform
Why use www.healthevidence.org?
1. Saves you time
2. Relevant & current evidence
3. Transparent process
4. Supports for EI...
A Model for Evidence-
Informed Decision Making
National Collaborating Centre for Methods and Tools. (revised 2012). A
Mode...
Stages in the process of
Evidence-Informed Public Health
National Collaborating Centre for Methods and Tools. Evidence-Inf...
Poll Question #1
Have you heard of a PICO(S) question
before?
1. Yes
2. No
Searchable Questions Think “PICOS”
1.Population (situation)
2.Intervention (exposure)
3.Comparison (other group)
4.Outcome...
Dawn Stacey RN PhD CON(C) holds a Research Chair in
Knowledge Translation to Patients and is a Full Professor in the
Schoo...
Should men have screening for
prostate cancer?
yes
no
Is congruent
Choice
With the
best
available
evidence
and
informed
patient
values
International Patient Decision Aids Stand...
(College des Médecins
du Quebec, 2013)
Inform
• Provide facts: Condition, options, benefits, harms
• Communicate probabilities
Clarify values
• Ask which benefit...
If 100 men are screened If 100 men are not screened
18 diagnosed with prostate ca
(15 due to screening, 3 due to symptoms)...
Reasons to get screened Reasons not to be screened
Be reassured that you don’t have
prostate ca
Being worried that you mig...
http://www.boitedecision.ulaval.ca
/index.php?id=810&L=0
Review
Stacey D, Legare F, Col NF, Bennett CL, Barry MJ,
Eden KB, et al. (2014). Decision aids for people
facing health tr...
PICO Eligible Ineligible
Population
Adults making decision
for themselves or family
member
Decisions: hypothetical,
lifest...
PICO Eligible Ineligible
Population
Adults making decision
for themselves or family
member
Decisions: hypothetical,
lifest...
• Medline (1966 to June 2012)
• CINAHL (1982 to Sept 2008*)
• Embase (1980 to June 2012)
• PsychINFO (1806 to June 2012)
•...
• 2 reviewers independently screened and
extracted data using structured forms
• RCT quality was assessed using Cochrane’s...
Cochrane Review PtDAs Updates
17
35
55
86
115
0
20
40
60
80
100
120
140
1999 2003 2009 2011 2014
International
patient
dec...
Search Results (Jan 2010 - Jun 2012)
38,069 + 247 citations
2,072 abstract screen
358 full-text screen
186 excluded
30 ong...
Topics of Decision Aids (N=115)
• Medical (n=27+9)
– 10 HRT
– 3 atrial fib anti-coag
– 2+1 cardiovascular (Sheridan)
– 2+1...
To Find Decision Aids
Google: ‘decision aid’
Elements in Patient Decision Aids
(N=115)
100% Options, outcomes, implicit values clarification
91% Clinical condition
88%...
Trials Reporting Attributes of Decision Quality
77% Used at Least 1 Measure
34
13% Higher Knowledge
RR 13.29 [11.3, 15.3] – 42 studies
Sub-analysis
- Screening 12.76 [9.7, 15.7] – 19 studies
- Treat...
82% More Accurate Risk Perceptions
RR 1.82 [1.5, 2.2] – 19 studies
• Screening 2.03 [1.4, 2.9] – 7 studies
• Treatment 1.7...
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 MM...
-14% Uptake of PSA testing
RR 0.87 [0.77, 0.98] – 9 studies
Compared to Usual Care, PtDAs…
 13% higher
knowledge scores
(14% 2011)
 82% more
accurate risk
perception (74%
2011)
 5...
Other Outcomes (N=115)
2 (of 6) Trials Showed Savings $$$
• Kennedy 2002 - hysterectomy
– ↓ invasive surgical procedures resulting in PtDA with n...
Summary of findings
• Patients exposed to PtDAs
– more involved in making health decisions (+34%)
– fewer are undecided (-...
Other research findings on…
• Sub-analysis
– coaching (Stacey et al 2013);
– context (Brown et al. in press);
– low litera...
Importance of this Review
• Patient decision aids are effective
interventions for people facing treatment or
screening dec...
USA: R. 3590 The Patient Protection
and Affordable Care Act (March 2010)
http://decisionaid.ohri.ca
A Model for Evidence-
Informed Decision Making
National Collaborating Centre for Methods and Tools. (revised 2012). A
Mode...
Poll Question #2
Did you find the information presented
today helpful?
1. Yes
2. No
Poll Question #3
Was this information new to you?
1. Yes
2. No
Questions?
Thank you!
Contact us:
info@healthevidence.org
For a copy of the presentation please visit:
http://www.healthevidence.org/...
Decision aids for people facing health treatment or screening decisions: What's the Evidence?
Decision aids for people facing health treatment or screening decisions: What's the Evidence?
Decision aids for people facing health treatment or screening decisions: What's the Evidence?
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Decision aids for people facing health treatment or screening decisions: What's the Evidence?

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Dr. Dawn Stacey, University Research Chair in Knowledge Translation to Patients, and Director, Patient Decision Aids Research Group, Ottawa Hospital Research Institute, University of Ottawa, provides an overview of findings from her recent Cochrane review examining use of decision aids for identifying and making decisions about health treatment or screening options:

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.

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

  1. 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. 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
  3. 3. • Use Q&A to post comments / questions during the webinar – ‘Send’ questions to All (not privately to ‘Host’) • Connection issues – Recommend using a wired Internet connection (vs. wireless), • WebEx 24/7 help line – 1-866-229-3239 Q&A Participant Side Panel in WebEx Housekeeping
  4. 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. 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. 6. What is www.healthevidence.org? Evidence Decision Making inform
  7. 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. 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. 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. 10. Poll Question #1 Have you heard of a PICO(S) question before? 1. Yes 2. No
  11. 11. Searchable Questions Think “PICOS” 1.Population (situation) 2.Intervention (exposure) 3.Comparison (other group) 4.Outcomes 5.Setting
  12. 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. 13. Should men have screening for prostate cancer? yes no
  14. 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. 15. (College des Médecins du Quebec, 2013)
  16. 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. 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. 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. 19. http://www.boitedecision.ulaval.ca /index.php?id=810&L=0
  20. 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. 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. 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. 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. 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. 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. 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. 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. 28. To Find Decision Aids Google: ‘decision aid’
  29. 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. 30. Trials Reporting Attributes of Decision Quality 77% Used at Least 1 Measure
  31. 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. 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. 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. 34. -14% Uptake of PSA testing RR 0.87 [0.77, 0.98] – 9 studies
  35. 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. 36. Other Outcomes (N=115)
  37. 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. 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. 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. 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. 41. USA: R. 3590 The Patient Protection and Affordable Care Act (March 2010)
  42. 42. http://decisionaid.ohri.ca
  43. 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. 44. Poll Question #2 Did you find the information presented today helpful? 1. Yes 2. No
  45. 45. Poll Question #3 Was this information new to you? 1. Yes 2. No
  46. 46. Questions?
  47. 47. Thank you! Contact us: info@healthevidence.org For a copy of the presentation please visit: http://www.healthevidence.org/webinars.asp x Login with your Health Evidence username and password, or register if you aren’t a member yet.

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