How can we bridge physician guidelines, based on the best available evidence, and patient preferences? This workshop was given at the Society of General Internal Medicine 2015 Annual Meeting in Toronto, Canada.
Session Coordinator: Zackary Berger, MD, PhD
Additional Faculty: Michael J. Barry, MD, Kathleen Fairfield, MD, Leigh H. Simmons, MD, James Yeh, MD, Daniella A. Zipkin, MD, Dave deBronkart
Aligning Incentives for Patient Engagement: Enabling Widespread Implementation of Shared Decision Making
May 23, 2013
Karen Sepucha, Massachusetts General Hospital
Dale Collins Vidal, The Dartmouth Institute for Health Policy & Clinical Practice
The Broad Picture - recent developments in long-term condition managmentepicyclops
This lecture was given by Dr Aileen Keel, Deputy Chief Medical Officer for Scotland, to the North British Pain Association Spring Scientific Meeting on Friday 18th May, 2007 and forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
Reproduced with permission.
Guidelines - what difference do they make? A Dutch perspectiveepicyclops
This lecture was given by Dr Raymond Ostelo of the EMGO Institute, VU University Medical Center, Amsterdam, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. His lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
This document discusses using decision aids to promote shared decision making between clinicians and patients. It summarizes research showing that decision aids increase patient involvement and knowledge, reduce decisional conflict, and save consultation time without negatively impacting health outcomes or costs. Examples of effective decision aids for conditions like statin use, osteoporosis, and depression medication are provided. Implementing decision aids in clinical practice adds only a few minutes to visits but significantly improves patient understanding and involvement in healthcare decisions.
Current State of Pain Management Services in Primary Care in the UKepicyclops
This lecture was given by Dr Martin Johnson, a General Practitioner from Barnsley, Yorkshire, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. This lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
www.wspg.org.uk
La toma de decisiones compartidas y las guías de práctica clínica.GuíaSalud
This document discusses shared decision making (SDM) and clinical practice guidelines (CPGs). It notes that while EBM and SDM aim to improve healthcare, implementing them faces challenges. CPGs often don't sufficiently consider patient preferences, making it difficult to incorporate SDM. The document also discusses barriers to SDM implementation, such as time constraints and unclear guidelines. It suggests developing patient decision aids based on CPGs, and providing training and incentives to encourage clinician adoption of SDM.
Karen Sepucha, PhD, describes what a good decision is, how we measure decision quality and how the decision quality instrument might be used.
This presentation was part of a Shared Decision Making Month webinar -- What Makes a Good Medical Decision? Defining and Implementing Decision Quality Measures.
Antiretroviral Medication Adherence
The document summarizes evidence and recommendations for improving adherence to antiretroviral (ART) medication. It discusses how adherence is critical for treatment success and preventing HIV transmission. Current adherence levels tend to be suboptimal, around 50-60% on average. Key factors that influence adherence include treatment regimen complexity, mental health issues, social support, and the patient-provider relationship. The evidence shows that adherence interventions can effectively improve adherence when they address knowledge, barriers, medication management skills, and provide ongoing support. The recommendations focus on assessing and addressing individual patient barriers, simplifying treatment regimens, maintaining open communication, and involving adherence support teams.
Aligning Incentives for Patient Engagement: Enabling Widespread Implementation of Shared Decision Making
May 23, 2013
Karen Sepucha, Massachusetts General Hospital
Dale Collins Vidal, The Dartmouth Institute for Health Policy & Clinical Practice
The Broad Picture - recent developments in long-term condition managmentepicyclops
This lecture was given by Dr Aileen Keel, Deputy Chief Medical Officer for Scotland, to the North British Pain Association Spring Scientific Meeting on Friday 18th May, 2007 and forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
Reproduced with permission.
Guidelines - what difference do they make? A Dutch perspectiveepicyclops
This lecture was given by Dr Raymond Ostelo of the EMGO Institute, VU University Medical Center, Amsterdam, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. His lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
This document discusses using decision aids to promote shared decision making between clinicians and patients. It summarizes research showing that decision aids increase patient involvement and knowledge, reduce decisional conflict, and save consultation time without negatively impacting health outcomes or costs. Examples of effective decision aids for conditions like statin use, osteoporosis, and depression medication are provided. Implementing decision aids in clinical practice adds only a few minutes to visits but significantly improves patient understanding and involvement in healthcare decisions.
Current State of Pain Management Services in Primary Care in the UKepicyclops
This lecture was given by Dr Martin Johnson, a General Practitioner from Barnsley, Yorkshire, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. This lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
www.wspg.org.uk
La toma de decisiones compartidas y las guías de práctica clínica.GuíaSalud
This document discusses shared decision making (SDM) and clinical practice guidelines (CPGs). It notes that while EBM and SDM aim to improve healthcare, implementing them faces challenges. CPGs often don't sufficiently consider patient preferences, making it difficult to incorporate SDM. The document also discusses barriers to SDM implementation, such as time constraints and unclear guidelines. It suggests developing patient decision aids based on CPGs, and providing training and incentives to encourage clinician adoption of SDM.
Karen Sepucha, PhD, describes what a good decision is, how we measure decision quality and how the decision quality instrument might be used.
This presentation was part of a Shared Decision Making Month webinar -- What Makes a Good Medical Decision? Defining and Implementing Decision Quality Measures.
Antiretroviral Medication Adherence
The document summarizes evidence and recommendations for improving adherence to antiretroviral (ART) medication. It discusses how adherence is critical for treatment success and preventing HIV transmission. Current adherence levels tend to be suboptimal, around 50-60% on average. Key factors that influence adherence include treatment regimen complexity, mental health issues, social support, and the patient-provider relationship. The evidence shows that adherence interventions can effectively improve adherence when they address knowledge, barriers, medication management skills, and provide ongoing support. The recommendations focus on assessing and addressing individual patient barriers, simplifying treatment regimens, maintaining open communication, and involving adherence support teams.
Decide treatment - a new approach to better healthØystein Eiring
Better treatment, better health! People often experience suboptimal health because treatment is not optimal. A new approach is being developed - enabling patients and doctors to improve treatment and improve health.
Utilización de la evidencia cualitativa para mejorar la inclusión de las pref...GuíaSalud
Tercera intervención de la Mesa 1 de la Jornada científica GuíaSalud 2017: La implicación de pacientes en el desarrollo de GPC. Una estrategia necesaria para mejorar la toma de decisiones. Simon Lewin
Weitzman 2013 Relative patient benefits of a hospital-PCMH collaboration with...CHC Connecticut
Anuj K Dalal presents information on a PCORI research grant: Relative patient benefits of a hospital-PCMH collaboration within an ACO to improve care transitions.
The document discusses improving patient communication standards through evidence-based practice. It outlines the problem of communication vulnerabilities for certain patient populations and the complications that can arise. An evidence-based solution is proposed using standardized communication boards to improve outcomes. Research studies are cited that show communication boards reduce patient frustration and increase satisfaction.
Where’s the evidence that screening for distress benefits cancer patients?James Coyne
“The case against screening for distress.” A presentation delivered as part of an invited debate with Alex Mitchell at the International Psycho Oncology Conference, Rotterdam, November 7, 2013
This document summarizes a session at the 2015 CADTH conference on engaging patients in defining value and drug development. It provides an overview of the session which included panels discussing defining value from the patient perspective and models of patient engagement. It also summarizes some of the key points discussed, such as the need to include patient perspectives throughout the drug development process to better measure what is meaningful to patients and alternative approaches to patient engagement like patient and community engagement researchers. The document advocates that embedding meaningful patient measures can help weight evidence from the patient perspective.
This study investigated whether providing a document template for patients to describe their values and preferences to their physician improves shared decision making when deciding to start a new medication. The study found that the template did not significantly reduce decision conflict or regret, but did increase agreement between the physician's recommendation and the patient's final decision. It also increased the rate of patients carefully considering the physician's opinion rather than immediately agreeing or refusing. The template may enhance dialogue and encourage patients to consider their physician's professional advice.
Patient- and Family Centered Care: "Resident Performance from the Patient's V...hanscomhh5
This document summarizes a presentation about patient and family centered care (PFCC) in graduate medical education. It discusses the history and core values of PFCC, provides examples of how PFCC has been successfully implemented at institutions like the Medical College of Georgia, and shares results from a study that assessed resident performance through patient feedback surveys. The study found patient feedback improved residents' communication, patient care, and systems-based practice skills compared to traditional attending evaluations alone. The presentation concludes PFCC can enhance graduate medical education by providing meaningful feedback to help residents improve.
The Importance of measuring outcomes, including Patient Reported Outcome Measures (PROMS)
BAOT Lifelong Learning Event
10 November 2010
Dr Alison Laver-Fawcett
Head of Programme, BHSC(Hons) Occupational Therapy
York St John University
This lecture was given by Dr Rhian Lewis, Consultant in Pain Management from Bangor, North Wales, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. Her lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
www.wspg.org.uk
Assessing and reporting outcomes that are important to patients in trials and...cmaverga
The document discusses the importance of including patient-reported outcomes (PROs) in clinical trials and Cochrane reviews. PROs are any reports coming directly from patients about how they function or feel in relation to their health condition or treatment, without interpretation by clinicians. It is important to include PROs because they capture effects only known to patients, like symptoms, function, and feelings. The document provides examples of PROs being incorporated into Cochrane reviews and identifies some of the methodological challenges in doing so.
CHI's Lunchtime Learning is open to all researchers, decision-makers, clinicians, patients and members of the public who want to learn more about the theory and practice of meaningful, inclusive, and safe patient and public engagement.
Following this session, attendees should be able to:
Describe the theoretical foundations of the Valuing All Voices framework;
Describe methods used in co-development of the framework; and
Apply the framework to development of a patient engagement strategy for health research and services projects and/or programs.
This document summarizes a presentation about patient- and family-centered care. It defines patient- and family-centered care as a philosophy that treats patients and families as partners in care decisions and sees them as unique individuals. The presentation outlines 10 core components of patient- and family-centered care like human interaction, information and education, and family involvement. It discusses benefits like better outcomes, satisfaction, and financial performance. It also provides examples of best practice volunteer programs that support this philosophy and ways to evaluate existing programs based on patient- and family-centered care standards.
Dr. Dee Mangin, Professor of Family Medicine and the Associate Chair and Director, Research, at McMaster University, will join practicing pharmacist, and Vice President, Pharmacy Affairs, Sandra Hanna of the Neighbourhood Pharmacy Association of Canada to discuss medication risks, deprescribing and the dangers of polypharmacy in this one hour webinar. Learn more at www.asklistentalk.ca
This document discusses patient-reported outcome measures (PROMs) and their importance in drug development and clinical trials for Duchenne muscular dystrophy (DMD). It outlines how multistakeholder meetings including patients, regulators, industry, researchers, and clinicians can provide input to help develop DMD-specific PROMs and guidelines. It also describes the development of the Performance of Upper Limb module, a DMD-specific PROM created with input from DMD patients to measure important functional outcomes.
This document discusses using patient-reported outcomes (PROs) to measure healthcare quality from the patient's perspective. It argues that PROs capture patients' experiences with illness, impairment, and disability, which is important because patients seek healthcare to improve their ability to function and reduce symptoms. The document also notes that treatments may improve clinical markers but not subjective patient outcomes. It advocates routinely collecting PRO data electronically to develop new performance metrics focused on whether treatments actually improve how patients feel and function. This would help align healthcare with how patients define quality.
Provider Based Patient Engagement - An Essential Strategy for Population HealthPhytel
As the healthcare industry starts to re-engineer care delivery to accommodate new reimbursement models, providers on the front lines of change recognize the need for population health management and for increasing patients’ engagement in their own care. These two approaches are inextricably bound together, because it is impossible to manage the health of a population without getting patients more involved in self-management and the modification of their own risk factors. This paper discusses the fundamentals of patient engagement and shows how automation tools and web-based care management can facilitate this key process.
The document discusses randomization and blinding in clinical trials. It defines randomization as a process that assigns participants to experimental and control groups randomly to reduce bias. Randomization ensures groups are similar and comparable. Blinding refers to keeping participants and investigators unaware of group assignments to prevent bias in assessing outcomes. The document outlines various randomization techniques like simple randomization and stratification. It also discusses types of sampling and limitations of non-randomized trials in comparing interventions. In summary, the key points are that randomization and blinding are important design elements in clinical trials to reduce bias and ensure validity of results.
The presentation details the value of standardized therapy assessment as it relates to patient care treatment planning and evidencing Medicare audits. Standardized assessments can help evidence your patients’ progress. In addition, standardized assessment can better define deficits and assist in treatment planning.
1. Learn to identify the Benefits of utilizing Standardized assessments
2. Learn to summarize appropriate use of standardized therapy assessments
3. Learn the reasons standardized assessments can be used to evidence progress and support Medicare Part G-codes
"Improving Decision Making in Health & Social Care Through Quality Information & Technology": Dr. Mark Davies (Director of Clinical and Public Assurance) of the Health and Social Care Information Centre (HSCIC) discusses this at the Healthcare Efficiency Through Technology Expo 2013.
This document provides an overview and discussion of ethics issues for school social workers presented by Gary R. Schoener. It discusses standards for conduct including roles and responsibilities, ethical principles from the NASW code, and ethical decision making frameworks. It also covers challenges around professional boundaries, dual relationships, confidentiality, communication technologies, social media, and privacy in the digital age. The presentation aims to help social workers navigate complex ethical situations that arise in school settings.
This document discusses risk assessment in social work. It notes that risk assessment aims to improve decisions by making risks explicit and reducing unpredictable events. The document examines different types of risk assessment schedules and considers whether they can accurately predict risk levels. It also discusses the strengths and weaknesses of various risk assessment tools, noting they have particular strengths and weaknesses. Researchers have found risk assessment tools are not always scientific or objective and may rely on value judgments rather than facts.
Decide treatment - a new approach to better healthØystein Eiring
Better treatment, better health! People often experience suboptimal health because treatment is not optimal. A new approach is being developed - enabling patients and doctors to improve treatment and improve health.
Utilización de la evidencia cualitativa para mejorar la inclusión de las pref...GuíaSalud
Tercera intervención de la Mesa 1 de la Jornada científica GuíaSalud 2017: La implicación de pacientes en el desarrollo de GPC. Una estrategia necesaria para mejorar la toma de decisiones. Simon Lewin
Weitzman 2013 Relative patient benefits of a hospital-PCMH collaboration with...CHC Connecticut
Anuj K Dalal presents information on a PCORI research grant: Relative patient benefits of a hospital-PCMH collaboration within an ACO to improve care transitions.
The document discusses improving patient communication standards through evidence-based practice. It outlines the problem of communication vulnerabilities for certain patient populations and the complications that can arise. An evidence-based solution is proposed using standardized communication boards to improve outcomes. Research studies are cited that show communication boards reduce patient frustration and increase satisfaction.
Where’s the evidence that screening for distress benefits cancer patients?James Coyne
“The case against screening for distress.” A presentation delivered as part of an invited debate with Alex Mitchell at the International Psycho Oncology Conference, Rotterdam, November 7, 2013
This document summarizes a session at the 2015 CADTH conference on engaging patients in defining value and drug development. It provides an overview of the session which included panels discussing defining value from the patient perspective and models of patient engagement. It also summarizes some of the key points discussed, such as the need to include patient perspectives throughout the drug development process to better measure what is meaningful to patients and alternative approaches to patient engagement like patient and community engagement researchers. The document advocates that embedding meaningful patient measures can help weight evidence from the patient perspective.
This study investigated whether providing a document template for patients to describe their values and preferences to their physician improves shared decision making when deciding to start a new medication. The study found that the template did not significantly reduce decision conflict or regret, but did increase agreement between the physician's recommendation and the patient's final decision. It also increased the rate of patients carefully considering the physician's opinion rather than immediately agreeing or refusing. The template may enhance dialogue and encourage patients to consider their physician's professional advice.
Patient- and Family Centered Care: "Resident Performance from the Patient's V...hanscomhh5
This document summarizes a presentation about patient and family centered care (PFCC) in graduate medical education. It discusses the history and core values of PFCC, provides examples of how PFCC has been successfully implemented at institutions like the Medical College of Georgia, and shares results from a study that assessed resident performance through patient feedback surveys. The study found patient feedback improved residents' communication, patient care, and systems-based practice skills compared to traditional attending evaluations alone. The presentation concludes PFCC can enhance graduate medical education by providing meaningful feedback to help residents improve.
The Importance of measuring outcomes, including Patient Reported Outcome Measures (PROMS)
BAOT Lifelong Learning Event
10 November 2010
Dr Alison Laver-Fawcett
Head of Programme, BHSC(Hons) Occupational Therapy
York St John University
This lecture was given by Dr Rhian Lewis, Consultant in Pain Management from Bangor, North Wales, to the North British Pain Association Spring Scientific Meeting in Edinburgh on Friday 18th May, 2007. Her lecture forms part of a conference "Blurring the Boundaries - Managing Pain in Primary Care and Secondary Care".
www.wspg.org.uk
Assessing and reporting outcomes that are important to patients in trials and...cmaverga
The document discusses the importance of including patient-reported outcomes (PROs) in clinical trials and Cochrane reviews. PROs are any reports coming directly from patients about how they function or feel in relation to their health condition or treatment, without interpretation by clinicians. It is important to include PROs because they capture effects only known to patients, like symptoms, function, and feelings. The document provides examples of PROs being incorporated into Cochrane reviews and identifies some of the methodological challenges in doing so.
CHI's Lunchtime Learning is open to all researchers, decision-makers, clinicians, patients and members of the public who want to learn more about the theory and practice of meaningful, inclusive, and safe patient and public engagement.
Following this session, attendees should be able to:
Describe the theoretical foundations of the Valuing All Voices framework;
Describe methods used in co-development of the framework; and
Apply the framework to development of a patient engagement strategy for health research and services projects and/or programs.
This document summarizes a presentation about patient- and family-centered care. It defines patient- and family-centered care as a philosophy that treats patients and families as partners in care decisions and sees them as unique individuals. The presentation outlines 10 core components of patient- and family-centered care like human interaction, information and education, and family involvement. It discusses benefits like better outcomes, satisfaction, and financial performance. It also provides examples of best practice volunteer programs that support this philosophy and ways to evaluate existing programs based on patient- and family-centered care standards.
Dr. Dee Mangin, Professor of Family Medicine and the Associate Chair and Director, Research, at McMaster University, will join practicing pharmacist, and Vice President, Pharmacy Affairs, Sandra Hanna of the Neighbourhood Pharmacy Association of Canada to discuss medication risks, deprescribing and the dangers of polypharmacy in this one hour webinar. Learn more at www.asklistentalk.ca
This document discusses patient-reported outcome measures (PROMs) and their importance in drug development and clinical trials for Duchenne muscular dystrophy (DMD). It outlines how multistakeholder meetings including patients, regulators, industry, researchers, and clinicians can provide input to help develop DMD-specific PROMs and guidelines. It also describes the development of the Performance of Upper Limb module, a DMD-specific PROM created with input from DMD patients to measure important functional outcomes.
This document discusses using patient-reported outcomes (PROs) to measure healthcare quality from the patient's perspective. It argues that PROs capture patients' experiences with illness, impairment, and disability, which is important because patients seek healthcare to improve their ability to function and reduce symptoms. The document also notes that treatments may improve clinical markers but not subjective patient outcomes. It advocates routinely collecting PRO data electronically to develop new performance metrics focused on whether treatments actually improve how patients feel and function. This would help align healthcare with how patients define quality.
Provider Based Patient Engagement - An Essential Strategy for Population HealthPhytel
As the healthcare industry starts to re-engineer care delivery to accommodate new reimbursement models, providers on the front lines of change recognize the need for population health management and for increasing patients’ engagement in their own care. These two approaches are inextricably bound together, because it is impossible to manage the health of a population without getting patients more involved in self-management and the modification of their own risk factors. This paper discusses the fundamentals of patient engagement and shows how automation tools and web-based care management can facilitate this key process.
The document discusses randomization and blinding in clinical trials. It defines randomization as a process that assigns participants to experimental and control groups randomly to reduce bias. Randomization ensures groups are similar and comparable. Blinding refers to keeping participants and investigators unaware of group assignments to prevent bias in assessing outcomes. The document outlines various randomization techniques like simple randomization and stratification. It also discusses types of sampling and limitations of non-randomized trials in comparing interventions. In summary, the key points are that randomization and blinding are important design elements in clinical trials to reduce bias and ensure validity of results.
The presentation details the value of standardized therapy assessment as it relates to patient care treatment planning and evidencing Medicare audits. Standardized assessments can help evidence your patients’ progress. In addition, standardized assessment can better define deficits and assist in treatment planning.
1. Learn to identify the Benefits of utilizing Standardized assessments
2. Learn to summarize appropriate use of standardized therapy assessments
3. Learn the reasons standardized assessments can be used to evidence progress and support Medicare Part G-codes
"Improving Decision Making in Health & Social Care Through Quality Information & Technology": Dr. Mark Davies (Director of Clinical and Public Assurance) of the Health and Social Care Information Centre (HSCIC) discusses this at the Healthcare Efficiency Through Technology Expo 2013.
This document provides an overview and discussion of ethics issues for school social workers presented by Gary R. Schoener. It discusses standards for conduct including roles and responsibilities, ethical principles from the NASW code, and ethical decision making frameworks. It also covers challenges around professional boundaries, dual relationships, confidentiality, communication technologies, social media, and privacy in the digital age. The presentation aims to help social workers navigate complex ethical situations that arise in school settings.
This document discusses risk assessment in social work. It notes that risk assessment aims to improve decisions by making risks explicit and reducing unpredictable events. The document examines different types of risk assessment schedules and considers whether they can accurately predict risk levels. It also discusses the strengths and weaknesses of various risk assessment tools, noting they have particular strengths and weaknesses. Researchers have found risk assessment tools are not always scientific or objective and may rely on value judgments rather than facts.
This document discusses heuristics and biases that affect human judgment and decision-making. It notes that cognition is not fully under our conscious control and verbal reports on decision-making cannot be fully trusted. Common heuristics discussed include availability, representativeness, anchoring and adjustment, and overconfidence. Experts are also susceptible to heuristics. The document advocates recognizing heuristics to overcome their effects and make more accurate risk assessments. Decision-making in social work often involves satisficing due to incomplete information and multiple goals.
Impact 99 Vancouver Strategic Decision Making in Social BusinessTyrell Mara
Seeing the forest above the trees: 5 Guiding Principles empowering leaders to make strategic decisions and effectively implement in the world of social business!
This document outlines a 10-step framework for ethical decision making presented by Nyla McCarthy. The framework includes steps such as describing the problem, determining if there is an ethical dilemma, identifying key values and principles, gathering information, reviewing codes of ethics, determining options, selecting a course of action, implementing the plan, evaluating results, and submitting cases for review. The document provides details about each step and gives an example of applying the framework to a case study in small groups.
Guideline for the management of heart failureIqbal Dar
This document provides guidelines for the management of heart failure. It defines heart failure and outlines the stages from A to D. It recommends obtaining a thorough history and physical exam, diagnostic tests including biomarkers, and noninvasive cardiac imaging for initial and serial evaluation of heart failure patients. Invasive hemodynamic monitoring is recommended for selected patients with acute heart failure and impaired perfusion. Invasive coronary angiography is reasonable when ischemia may be contributing to heart failure.
This document summarizes the PARADIGM-HF clinical trial which compared the angiotensin receptor-neprilysin inhibitor LCZ696 to the ACE inhibitor enalapril in patients with heart failure and reduced ejection fraction. The trial found that LCZ696 was superior to enalapril in reducing cardiovascular death and hospitalization for heart failure. Specifically, LCZ696 reduced the risk of the primary composite outcome of death from cardiovascular causes or hospitalization for heart failure by 16% compared to enalapril. LCZ696 also reduced deaths from any cause by 16% compared to enalapril.
This document discusses decision support systems (DSS) and online analytical processing (OLAP). It defines DSS as interactive computer systems that help managers make decisions, using tools like analytical models, databases, and modeling processes. OLAP enables examining and manipulating large amounts of consolidated data from different perspectives. Both DSS and OLAP support analysis of operational data, markets, sales, and customers to help with decisions around pricing, forecasting, and risk.
ReadySetPresent (Decision Making PowerPoint Presentation Content): 100+ PowerPoint presentation content slides. Successful and effective strategic decision making is a guarantee to increase productivity in every workplace. Decision Making PowerPoint Presentation Content slides include topics such as: the 6 C’s of decision making, inherent personal and system traps, 10+ slides on decision trees, 10+ slides on decision making methods and tips, 4 slides on the GOR approach to decision making, 8 slides on common pitfalls in decision making, 4 slides on effective strategies in making decisions, 35+ slides on the 8 major decision making traps and how to effectively minimize each, 7 slides on different decision making perspectives, 25 slides on the 3 different types of analysis (grid analysis – paired comparison analysis, and cost/benefit analysis), 4 slides on utilizing planning and overarching questions, 4 modes of decision making and 6 factors in decision making and more!
The document discusses decision making and problem solving. It covers defining problems, gathering relevant information to analyze problems, and generating and selecting alternatives. The problem solving process involves defining the problem, collecting information and measures, analyzing the problem, generating alternatives, selecting alternatives, and deciding on and implementing a solution. Cause and effect diagrams like fishbone diagrams can be used to identify and analyze the root causes of problems. Collecting the right information through questions is important for fully understanding problems before attempting to solve them.
1) The document discusses the steps of the decision making process which includes identifying the problem, criteria, weighting criteria, developing alternatives, analyzing alternatives, selecting the best alternative, implementing it, and evaluating.
2) It provides an example of getting a job in a school and lists the relevant criteria as salary, opportunity to progress, job environment, incentives, facilities, job security, location, and timings.
3) The alternatives provided are jobs at Unique, American Lycetuff, LDA, Allied, and Cathedral schools. Each alternative is then analyzed and weighted against the criteria to select the best option.
The document discusses various aspects of decision making. It defines decision making as choosing one alternative from among options. It describes the decision making process as recognizing the need for a decision, identifying alternatives, choosing the best option, and implementing it. Decision making can occur under certainty, risk, or uncertainty. Rational models of decision making propose a logical, step-by-step process while behavioral models recognize limitations and biases that influence decisions. Political forces, intuition, escalation of commitment, risk tolerance, and ethics also shape organizational decision making.
This document provides guidance on making decisions through a 7 step process. It uses the example of a person named Amy who wants a new cell phone that costs more than she has saved. The 7 steps are: 1) Relax 2) Say something positive 3) Identify the problem 4) Consider choices 5) Weigh consequences 6) Prioritize what's important 7) Make the decision. For Amy, the document outlines her choices, consequences, and recommends waiting to save more money as the best option based on her priorities.
Similar to Evidence-Based Practice Guidelines and Shared Decision Making: Conflicting or Complementary Strategies for “Doing the Right Thing” in Health Care?
SHARE Webinar: Why Should I Join a Clinical Trial with Dr. Hershmanbkling
Dr. Dawn L. Hershman of the Herbert Irving Comprehensive Cancer Center at Columbia University presented the basics of clinical trials and emphasized how important it is for more patients to participate in them. She also discussed trials currently available for early stage and metastatic breast cancers. The webinar was presented on June 25, 2014. To hear the webinar, visit www.sharecancersupport.org/hershman
Rethinking, rebuilding psychosocial care for cancer patientsJames Coyne
Presented as the 8th Trevor Anderson Psycho-Oncology Lecture, September 8, 2014, Melbourne, Australia.
Discusses how psychosocial care for cancer patients needs to be reorganized so that a broader range of cancer patients are served. Routine screening for distress is unlikely to be an efficient means of countering tendencies of cancer care more generally becoming more organized around time efficiency and billable procedures. Psychosocial care for many cancer patients involves discussions, negotiations, and care coordination they cannot be well fit into the idea of a counseling session. The unsung heroes of providing such care are underappreciated social workers and oncology nurses.
Angela Coulter: Getting the best value for patientsThe King's Fund
Dr Angela Coulter, Director of Global Initiatives, Foundation for Informed Medical Decision Making, spoke at The King's Fund's 'Reducing unwarranted variations in health care' conference, giving her expert opinion on how to give the best value for patients: with the right intervention, in the right place, at the right time with the right level of involvement.
Patient, carer & public involvement in clinical guidelines: the NICE experienceGuíaSalud
Presentación de Victoria Thomas, Associate Director, Patient & Public Involvement Programme de NICE, sobre la participación de pacientes, ciudadanos y público en general en el desarrollo de guías de práctica clínica del NICE. Ponencia realizada en la Jornada Científica GuíaSalud 2010 "La participación de los pacientes en las Guías de Práctica Clínica".
Presented in:
Pre-Conference Workshop on Communication Skills in Management of Cancer Patients,
World Cancer Day Conference & Expo 2015
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The document discusses the ethics of prognostication in medicine. It begins with an introduction to palliative and curative models of medicine. It then reviews key ethical principles of autonomy, beneficence, non-maleficence, justice and veracity as they relate to prognosis. Finally, it discusses Downing's 10 steps to better prognosis, focusing on using tools and judgment to foresee a patient's situation, while centering the discussion on a patient's goals and framing prognosis in a way that respects ethical values.
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The document discusses how The Assessment Group conducts evaluations and assessments exclusively for the healthcare industry using MDs, PhDs, biostatisticians and market research experts. They use case-based clinician surveys and vignettes to measure the effectiveness and impact of promotional programs on physician decisions and clinical practice patterns. The evaluations provide data to demonstrate return on investment of promotional activities and guide future initiatives.
Ethics and Learning Health Care: an overview of the differences between what is considered research and what is considered clinical care, and an introduction to the ethical issues that arise from this boundary being blurred.
How to Define Effective and Efficient Real World TrialsTodd Berner MD
This document discusses strategies for designing effective and efficient real-world clinical trials. It covers topics such as using real-world evidence to inform clinical trial design, the differences between efficacy and effectiveness, challenges around representativeness in trial populations, and the value of pragmatic clinical trials. It also discusses leveraging electronic health records for condition-specific prompts and clinical decision support to improve performance and quality of care.
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The document discusses the benefits of group medical visits for patients, providers, and practices. It notes that group visits can enhance patient education, improve access to care, and increase practice productivity and revenue. Group visits allow for more time with patients to focus on lifestyle education and chronic disease management. They also provide social support from sharing experiences with other patients. The document outlines strategies for implementing group visits, including selecting topics, planning logistics, ensuring regulatory compliance, and billing insurance.
As new payment models emerge that emphasize value over volume, providers are being compelled to look more closely at how to motivate patients—especially those with multiple chronic conditions—to actively manage their care, make better decisions and change behaviors. This editorial webinar will explore the relationships between engagement and improved health outcomes, greater patient satisfaction and better resource utilization. Our panel of experts will share proven strategies for building patients' confidence, disseminating self-management tools and making the best use of your care team.
Study from the American College of Wound Healing & Tissue Repair (ACWHTR)
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The Surgical Initiative concluded on March 31, 2014; the first system Hoshin to “graduate” to everyday work. Join us for an interactive discussion of the lessons learned over four years of transformational change.
Η διαχείριση των μειζόνων συμπεριφορικών παραγόντων κινδύνου στην ΠΦΥEvangelos Fragkoulis
Παρουσίαση μου στα πλαίσια του Consensus Meeting: "Η διαχείριση και ο έλεγχος των Μείζονων Συμπεριφορικών Παραγόντων Κινδύνου για την Υγεία: η συμβολή νέων "εργαλείων" για την αντιμετώπιση τους", Ελληνική Επιστημονική Εταιρεία Οικονομίας και Πολιτικής της Υγείας, Ξυλόκαστρο 6-8 Ιουλίου 2018
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How Do You Deal With Uncertainty In Healthcare?Zackary Berger
This document discusses a bioethical project exploring how patients and families deal with medical uncertainty. It presents the case of Ms. A, who has severe back pain but no identifiable cause, and wants an MRI despite evidence it will not help or provide reassurance. The biggest challenges are providing care and reassurance while avoiding unnecessary tests that could harm the patient, healthcare system, or society. The document seeks experiences with and strategies for managing medical uncertainty, and willingness to participate in a focus group on this topic.
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Patient-centered communication is important because of the 5 E's: ethics, emotions, efficiency, effectiveness, and equity. This talk was originally given October 1, 2014, at the Baltimore City Medical Society.
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This document discusses the role of spirituality in helping cancer patients cope with uncertainty. It defines spirituality as a broader concept than religion that speaks to basic human needs. While spirituality can help some patients, it makes others uncomfortable. The primary care physician has a role in addressing patients' psychosocial and spiritual needs by providing hope, accepting uncertainty, and helping patients reframe problems. Future research should examine how spirituality can be implemented as an intervention and whether it should be universally offered.
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This document discusses bridging evidence-based medicine and patient-centered care in the context of localized prostate cancer treatment decisions. Around 90% of men diagnosed with localized prostate cancer receive immediate treatment, while 10% opt for active surveillance which involves regular monitoring without initial treatment. However, some men eventually choose to leave active surveillance due to disease reclassification or personal preference. The document examines factors influencing men's decisions regarding active surveillance versus treatment and explores how addressing patients' anxieties, concerns, and partnering with primary care providers could help bridge evidence-based medicine and patient-centered approaches.
Zackary Berger gave a seminar discussing patient autonomy in theory and practice. He explained that while autonomy is viewed as important in principle, in reality patients do not always exercise full decision-making control. Berger presented research finding that doctors do not typically elicit patient concerns or collaboratively set visit agendas. For hospitalized patients, communication is often poor with plans changing without patient input. Berger concluded that educating doctors and encouraging relational autonomy could help promote patient participation in their own care.
Zackary Berger gave a seminar on encouraging patient autonomy in practice. He discussed how patient autonomy is viewed in theory as patients evaluating treatment options based on their own values, but in reality patients often do not feel able to make autonomous decisions. The study examined how physicians elicit patient concerns in HIV clinic visits. It found that generic opening questions did not effectively elicit concerns, and physicians did not typically probe further after patients responded that they were "fine". When setting visit agendas, physicians often directed the agenda rather than exploring patient priorities.
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Background: Although studies have demonstrated that physicians often fail to elicit the full spectrum of patient concerns, few studies have described the ways in which physicians elicit concerns and the extent to which they set an explicit agenda.
Methods: We performed a qualitative analysis of audio recorded, transcribed routine patient-provider encounters from the Enhancing Communication and HIV Outcomes (ECHO) Study. We developed themes related to whether and how providers elicit patient concerns and then set an agenda for the visit. We developed a coding scheme that we applied to a random selection of 2 encounters per provider (33 providers, 66 encounters total).
Findings: In 41/66 encounters, providers opened the visit with a general question (“How are you doing?”). Seven visits opened with a leading question (“Everything’s okay?”) and 1 with the provider explicitly asking which concerns s/the patient wanted to discuss. Patients more often responded to these opening questions with brief positive statements (“Fine”, n=30) than with actual concerns (n=14). In 12 encounters (18%), the provider continued to elicit concerns until the patient stated that s/he had no further concerns (probe to exhaustion). In 30 encounters, there was no agenda statement. When an agenda statement was made, it most often (n=20) centered on physicians’ priorities. Rarely, there was an agenda statement made by the patient (n=3) or one that was collaboratively negotiated (n=3). In 53% of encounters (n=35), patients brought up new concerns later in their visit.
Implications: Providers frequently use generic opening questions that may not be effective in eliciting patients’ concerns, and then do not continue to elicit further concerns. Negotiation of the visit agenda is rare, and new concerns continue to arise later in most encounters. Providers need further training to more effectively invest in the beginning of each encounter.
Word Count 293
KEY WORDS HIV - communication - decision-making preferences
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Evidence-Based Practice Guidelines and Shared Decision Making: Conflicting or Complementary Strategies for “Doing the Right Thing” in Health Care?
1. Society of General Internal Medicine Annual Meeting 2015
Evidence-Based Practice Guidelines and Shared Decision Making: Conflicting or
Complementary Strategies for “Doing the Right Thing” in Health Care?
Workshop WE02, Thursday, April 23, 2015, 3:15-4:45 pm
Session Coordinator: Zackary Berger, MD, PhD
Additional Faculty: Michael J. Barry, MD, Kathleen Fairfield, MD, Leigh H. Simmons, MD, James
Yeh, MD, Daniella A. Zipkin, MD, Dave deBronkart
15 min: Large group presentation: The divide between guideline-based care and patient
preferences: examples from current guidelines – Michael
5 min: Patient involvement in guidelines: the physician’s view – Zack
5 min: Patient involvement in guidelines: the patient’s view – Dave
5 min: Zack introduces small-group discussion about factoring patient preference into use of
guidelines, e.g. through decision aids. Also participants to start sharing with their small group,
or writing down, “surprises” they have had when discussing guidelines with patients, for
discussion at the end
20 min: Case-based discussion on potential solutions to the problem: patient centered
guidelines. Participants self-select into one group. Faculty please bring printouts for your
section.
Statins - Kathleen
Hypertension – James
Glycemic targets – Leigh
Prostate screening – Michael
25 min: Moderated audience discussion on solutions – Zack with participation of all faculty,
esp. Dave
o 10-15min: wrapup from small groups – each group picks a spokesperson
o 6-10min: Dani discusses evidence-based findings on risk communication, draft
to come
5 min: Wrap up/Conclusion/Distribute link to slide set
2. S G I M 20 1 5 A n n u a l M e e t i n g Wo r k s h o p
Evidence-Based Practice Guidelines
and Shared Decision Making
Michael Barry, MD
President
Date
3. • Six Aims of High Quality Health Care:
• Safety – Avoid injuries
• Effective – Provide services based on
scientific knowledge to all who can
benefit
• Patient-centered – Care that is respectful
& responsive to individual needs &
preferences
• Timely – Reduce waits & delays
• Efficient – Eliminate waste
• Equitable – Provide consistent quality of
care to all
(Institute of Medicine. National Academy Press, 2001)
Crossing the Quality Chasm
4. Definition:
“Clinical practice guidelines are systematically
developed statements to assist practitioner and
patient decisions about appropriate health care
for specific clinical circumstances.”
(Institute of Medicine. National Academy Press, 1990)
Clinical Practice Guideline
5. • David Eddy of Duke University
developed the first classification
system of treatment policies:
• “Standard”
• “Guideline”
• “Option”
(Eddy D. JAMA 1990; 263:3077, 3081, 3084)
Classification of “Treatment Policies”
6. • “Standard”
• Evidence shows the intervention is clearly
superior to all alternatives
• Almost all (>95%) people agree they want the
treatment, relative to the alternatives
Classification of Treatment Policies
(Eddy D. JAMA 1990; 263:3077, 3081, 3084)
7. • “Guideline”
• Evidence shows the intervention is probably
better than all alternatives
Classification of Treatment Policies
(Eddy D. JAMA 1990; 263:3077, 3081, 3084)
– Most (60-95%) people agree they want
the treatment, relative
to the alternatives
8. • “Option”
• Outcomes or preferences are not known with
certainty
• About half (40-60%) of the people choose the
treatment relative to the alternatives
Classification of Treatment Policies
(Eddy D. JAMA 1990; 263:3077, 3081, 3084)
9. • Benign Prostatic Hyperplasia is a
common condition among older men
• Morbidity is produced through
annoying urinary tract symptoms
• Treatments include waiting &
observing, medication, device
therapy, surgery
• Key issue is whether symptoms are
bothersome enough to choose
treatment
(BPH Guideline Panel. AHCPR Publication No.94-0582, 1994)
Benign Prostatic Hyperplasia Guideline
10. • Grading of symptoms is
recommended to quantify level of
symptoms
• In addition to a systematic review
of treatment effectiveness and side
effects, a “patient preference analysis”
was done:
Benign Prostatic Hyperplasia Guideline
(BPH Guideline Panel. AHCPR Publication No.94-0582, 1994)
– For men with mild symptoms, 80%
preferred waiting & observing
– For men with moderate to severe
symptoms, no one treatment was preferred
11. • Standard: Patients with mild
symptoms (symptom score 0-7)
should be followed with “watchful
waiting”
• Guideline: Patients with moderate
and severe symptoms (symptom
score 9-35) should be given
information on the benefits and
harms of watchful waiting,
medications, and surgery
Benign Prostatic Hyperplasia Guideline
(BPH Guideline Panel. AHCPR Publication No.94-0582, 1994)
12. • “Do it” or “Don’t do It”
• Indicating a choice that most well informed
people would choose
• “Probably do it” or “Probably don’t do it”
• Indicating a choice that a majority of well
informed people would choose
GRADE Approach to Recommendations
(GRADE Working Group. BMJ 2004;328: 1)
13. • Increasing emphasis on
reliability of evidence and
use of systematic reviews
to quantify the balance of
benefits and harms
• Insufficient focus on
people’s preferences;
opinions of panel members
often substituted
Evolution of Guidelines
14. Zackary Berger, Johns Hopkins GIM
Michael Barry, Healthwise
Kathleen Fairfield, Maine Medical
Center
Leigh H. Simmons, Massachusetts
General Hospital
James Yeh, Brigham and Women’s
Daniella A. Zipkin, Duke University
Dave deBronkart, e-Patient Dave
15. Zackary Berger, MD, PhD, Johns Hopkins GIM
Dave deBronkart, Proprietor, e-Patient Dave
16. “Practice guidelines …
rarely account for how
patients feel about their
symptoms”
Nease RF, Jr, Kneeland T, O'Connor GT, et al. JAMA.
1995;273(15):1185-1190
17.
18. Are based on a systematic review of the existing
evidence
Are developed by a multidisciplinary panel of
experts and representatives from affected groups
Consider patient subgroups and patient
preferences
Are based on an explicit and transparent process
Explain relationships between care options and
health outcomes
Provide ratings of quality of evidence and
19. Ethical
◦ Respect for persons
◦ Attention to disparities
Participative
◦ “Let Patients Help”
◦ Relevant outcomes, experience with system of
care
Transparency
Sensitivity to lived experience of disease
Safeguard against COI
◦ Consumers as proxy for patients?
20. Lack of health literacy
“Personal experience with the disease or an
advocacy role interfering with the ability to examine
evidence and recommendations dispassionately.”
(IOM)
Guidelines themselves are based on biomedical
model, not patient-centered
Patients might be involved with their disease and
not able to participate
Unrepresentative patient sample might reinforce
21. “Little evidence from RCTs of the
effects of consumer involvement
in healthcare decisions at the
population level.“
22. Knowledge
(professional, methodological, structural)
Integration in the role
(initial discomfort, comfort in the
role, accepting the responsibility)
Recognition
(respect, integration of patient-
relevant topics)
Möhler R, Suhr R, Meyer G. [Methods of
patient involvement in the development of
guidelines - a systematic review]. Z Evid
Fortbild Qual Gesundhwes.
2014;108(10):569-75. German. PubMed
PMID: 25499109.
23. G-I-N PUBLIC Toolkit: Patient
and Public Involvement in
Guidelines
http://
www.g-i-n.net/working-
groups/gin-public/toolkit
28. Evidence-Based Practice Guidelines and Shared Decision Making: Conflicting or Complementary
Strategies for “Doing the Right Thing” in Health Care?
Glycemic Targets
Leigh Simmons
Mr G is an 85yo man who has longstanding diabetes (for at least 15 years), hypertension, and glaucoma.
He also has some mild depression following the death of his wife 5 years ago. He lives independently,
and is meticulous about his medication management and his blood sugar recordings. He checks his
blood sugar readings 3 times a day. His current medications include glyburide 10mg daily, metformin
1000mg twice daily, lisinopril 40mg daily, atorvastatin 10mg daily, and aspirin 81mg daily.
His most recent A1C value was 7.1%. He had an LDL of 60 on a recent check. He has regular eye exams
and does not have retinopathy. He has good kidney function with a GFR of 60, and no microalbuminuria.
His primary care physician recently moved. His new primary care physician’s office has instituted a new
workflow in which medical assistants are responsible for reviewing diabetes monitoring measures,
including A1C checks, urine microalbumin collection, and cholesterol measurement for all patients with
diabetes. The office intake form for patients with diabetes includes a reminder to Mr. G that his sugar
levels are “above goal” and should be under 7%.
Glycemic Targets: Clinical Questions
At the time of his first visit, Mr G mentions on his intake form that one of his main concerns is keeping
his blood sugar in good control. He is particularly concerned because he fears developing diabetic eye
disease, and he fears having to take insulin if he cannot keep his blood sugar under good control.
What is the evidence to support our glycemic targets for patients with diabetes mellitus type 2?
How should we adjust glycemic targets for patients of advanced age?
Many patients with longstanding diabetes have been coached to achieve low glycemic targets;
how can the therapeutic alliance be maintained between patient and clinician as clinical goals
are reset?
A look to the guidelines:
ADA/EASD 2012 Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered
Approach: “Choice is based on patient and drug characteristics, with the overriding goal of
improving glycemic control while minimizing side effects. Shared decision making with the
patient may help in the selection of therapeutic options.”
ADA Framework for treatment of older adults 2012: Healthy older adults A1C goal <7.5%: older
adults with moderately complex illness A1C goal <8%; ill, frail older adults A1C goal <8.5%
29. American Geriatrics Society: Goal >8% for those who are frail, and/or have life expectancy of <5
years
Decision aids:
http://diabetesdecisionaid.mayoclinic.org/
In UK only:
http://sdm.rightcare.nhs.uk/pda/diabetes-improving-control/
30. Evidence-Based Practice Guidelines and Shared Decision Making: Conflicting or Complementary
Strategies for “Doing the Right Thing” in Health Care?
Statin use
Kathleen Fairfield
A 46 year old African American male is in general good health, without specific complaints. He has HTN,
on HCTZ. He is not diabetic. There is no family history of premature CAD or DM. His job is sedentary
but he does cardio exercise 30 min, 3-4 times per week, weight training 2-3 times per week. He drinks 1
alcoholic beverage several days per week; he reports his diet is excellent with little red meat. He is a
lifelong nonsmoker.
On exam, BP: 135/85, not obese
Screening fasting lipid panel: total 215, HDL 42, LDL 120
ASCVD risk estimator: 8.5% 10 year risk
New ACC-AHA guidelines recommend if risk >7.5% moderate to high intensity statin therapy.
He is resistant to starting a new medication, indefinitely, when he feels well and is doing his best to stay
fit and healthy.
Questions
1. For this patient, would you feel comfortable not following the guideline, assuming you were able to
complete a shared decision making process and the patient understands the risks and benefits of his
choices?
2. Is there a clear place in your EMR to document shared decision making?
3. How often would you want to revisit this decision?
4. Would you feel compelled to act differently if your PHO includes adherence to statin
recommendations in the physician metrics it reports?
33. Evidence-Based Practice Guidelines and Shared Decision Making: Conflicting or Complementary
Strategies for “Doing the Right Thing” in Health Care?
Hypertension
James Yeh
A 55 year old white female is at her primary care doctor’s office for an annual physical exam. She is in
generally good health. Her cholesterol level from 6 months ago showed a LDL level of 110 and HDL level
of 65. Her CBC and BMP lab results from that time were also unremarkable. She is currently not taking
any medications. She has never been a smoker and she runs 2 miles a day for exercise. Her body mass
index is 22. Her physical exam today was unremarkable except for a BP measurement of 146/82 mm Hg.
In reviewing her medical record, it appears that her sBP measurements in the past 2 years have
consistently been in the mid-high 140s mm Hg. She wondered whether she needs to take a medication
for high blood pressure?
Guideline and evidence, in brief:
• Based on observational studies of 1+ million individuals from ages 40-89, deaths from Ischemic
heart disease and stroke doubles for every increase in 20 mmHg systolic or 10 mmHg diastolic in
blood pressure. This effect can seen in blood pressure as low as 115 mm Hg sBP and 75 mm Hg
dBP (The Lancet 2002:360:1903–13).
• JNC-8 guideline recommends targeting sBP < 140 and dBP < 90 for those 60 and younger and
without diabetes or chronic kidney disease.
• One systematic review of 4 trials with nearly 9,000 participants found that treating individuals
with mild hypertension (sBP 140-159 mm Hg or dSBP 90-99 mm Hg) may not reduce mortality or
cardiovascular events (Cochrane Database Syst Rev 2012 Aug 15;(8):CD006742).
• Another systematic review with 13 trials and over 15,000 participants found that there were
significant reductions in stroke (OR 0.72), cardiovascular related deaths (OR 0.75), and overall
death (OR 0.78) (Ann Intern Med. 2015 Feb 3;162(3):184-91).
Questions
1. Should this patient be offered treatment for hypertension?
2. How does one reconcile and use clinical guidelines that have different thresholds for initiating
therapy for hypertension? (e.g., JNC-8, ASH/ISH)
JAMA. 2014 Feb 5;311(5):507-20
J Hypertens. 2014 Jan;32(1):3-15
3. What additional information would you and the patient need in order to make an informed
decision about treatment?
JNC-8 Guideline
34. I’ve only listed the relevant recommendations pertaining to the specific case
Recommendation 2
In the general population <60 years, initiate pharmacologic treatment to lower BP at DBP ≥90 mm Hg
and treat to a goal DBP <90 mm Hg. (For ages 30-59 years, Strong Recommendation – Grade A; For ages
18-29 years, Expert Opinion – Grade E)
Recommendation 3
In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg
and treat to a goal SBP <140 mm Hg. (Expert Opinion – Grade E)
SDM tools:
http://www.massgeneral.org/decisionsciences/research/Choice_Report.aspx
35.
36.
37. Evidence-Based Practice Guidelines and Shared Decision Making: Conflicting or Complementary
Strategies for “Doing the Right Thing” in Health Care?
PSA Screening
Michael Barry
A 56 year old white man makes a primary care visit. He is in generally good health. His father had
prostate cancer diagnosed in his 70’s. The father was treated with radiation and is still living. His
electronic record shows no evidence of a prior PSA test. He has no significant lower urinary tract
symptoms and his digital rectal is normal. He doesn’t ask about PSA screening.
The evidence, briefly:
The latest data from the European Randomized Trial of Screening for Prostate Cancer (ERSPC), for men
age 55-69 at 13 years of median follow-up (Schroder FH, et al. Lancet 2014; 384:2027):
Benefits Harms
1.3 fewer PCa death/1000 men 17% risk of ≥1 positive test (mean 2.3 tests/participant)
87% positive tests led to biopsies
10% risk of “getting” prostate cancer (v. 7% controls)
Ratio of extra diagnoses to each PCA death avoided is 27
Guidelines (2015):
ACS: Offer prostate cancer screening at 50, at 45 with risk factors (40 for very high risk) if >10 yr LE
USPSTF: “D” recommendation against routine PSA screening men of for all ages
ACP: Recommends discussing benefits and harms of screening for men age 50-69
AUA: Recommends shared decision making for men age 55-69
Questions:
1. Should the option of PSA screening be raised with the patient?
2. How do current clinical practice guidelines help with the decision?
3. If testing is offered, what should be said?
39. Systematic Review
• All prospective studies comparing a method
of communicating risk or benefit to any
other method
• 91 studies (74 randomized)
• Ann Intern Med. 2014; 161:270-280
40. Definitions
• “Event rates” = percentages =
proportion of people affected
• Example: 3%
• “Natural frequency” = raw numbers,
preserve the whole integer
• Example: 3 in 100
41. Key Findings – Visual Aids
• Adding visuals to numbers improves
accuracy and comprehension
• Icon arrays and bar graphs were most
studied, and equivalent in performance
44. Icon Array - example
Also note:
Incremental
risk display
45. Key Findings – Numeric Format
• Event rates (percentages) better than
natural frequencies for accuracy in 2 large
studies, no different in 1 study
• Natural frequencies better than event rates
for self-reported understanding and
satisfaction in 1 study
• NF vs. ER is an ongoing question, needs
further study
46. Key Findings – Absolute risk reduction
vs. Relative risk reduction
• Accuracy is better with ARR
• Decision making is more impacted by RRR
than ARR in 5 studies, however in 2 studies
where an icon array or bar graph was
added to the ARR, this effect was not seen
• Can visuals help bridge this divide?
47. Conclusions – Take Home Points
• Add visual aids to numbers
• Use icon arrays or bar graphs
• Provide baseline risks when presenting risk
differences
• Present risk differences in absolute terms
• NF vs. ER needs further study