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Promoting Patient Involvement in Medication Decisions. David H. Hickam, MD, MPH Professor, Dept. of Medicine Oregon Health & Science University Portland, Oregon. Goals of this Session. Review concepts of shared decision making.

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Promoting Patient Involvement in Medication Decisions

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Promoting Patient Involvement in Medication Decisions

David H. Hickam, MD, MPH

Professor, Dept. of Medicine

Oregon Health & Science University

Portland, Oregon


Goals of this Session

  • Review concepts of shared decision making.

  • Describe results of fous groups to assess consumers’ perceptions of sources of medical information.

  • Describe our work developing tools to promote shared decision making.


The Role of Evidence in Shared Decision Making

  • What is evidence?

  • How does evidence inform medical decisions?

  • Can clinicians and patients communicate about evidence?

  • Are simple evidence-based decision tools useful?


Clinical Problems for which Decision Aids are Useful

  • Decisions that are complicated because:

  • There is no single best choice.

  • People vary in the values or personal importance that they place on the benefits vs the harms associated with each of the options.

  • There is scientific uncertainty about the benefits and harms associated with options.

O'Connor A et al. Decision aids for people facing health treatment or screening decisions. The Cochrane Library 2006;Issue 4.


Options for Tools to Promote Shared Decision Making

  • Educational/Informational

  • Simple decision aids

    • provide probabilities, preference information, coached steps toward decision).

  • Detailed decision aids

    • all of above plus one or more of the following: customized risk tools, probabilities that adjust with risk level, explicit values clarification, etc.


Focus Groups to Assess Consumers’ Perceptions of Information Sources

  • Perceived need for information about conditions and treatments.

  • Perceptions about sharing decisions with clinicians.

  • Where the participants obtain information.

  • Brief review of examples.


Focus Group Participants

  • 18 focus groups (total of 113 participants)

  • Membership in each group defined by a particular chronic disease

    • Arthritis

    • Hypertension

    • Type 2 diabetes

    • Osteoporosis


Focus Group Characteristics

  • Two-thirds female

  • 60% age 60 or greater

  • 75% Caucasian

  • 43% college graduates

  • 44% had used Internet in last month.

  • One-third rated their health as fair or poor.


Preferences for Information Sources

  • Short and easy to read.

  • Many participants were not comfortable with Internet as information source.

  • Desire for positive information: often an issue when evidence is “negative.”

    • Framing of mortality information.

  • Trusted sources of information such as government and, AARP, or the Arthritis Foundation

    • Distrust in industry


Preferences for Content of Information Sources

  • Consensus that information about benefits is the most important.

  • Participants understand benefit/harm trade-offs.

  • Desire that side effect information be thorough.

  • Comparison to “non-medical” treatments.


Perspective about Interactions with Providers

  • Consensus on value of shared decision making.

  • Few participants reported collaborative, trusting relationships with clinicians.

  • Clinic visits tend to be rushed.

  • Some felt pressure to make hurried decisions.

  • Skepticism about recommendations to “talk to your doctor.”

  • Endorsement of tools that provide new information.


Principles for the Use of Evidence in Decision Tools

  • Include evidence about both benefits and harms of the alternatives.

  • Indicate where the evidence in inconclusive.

  • Make the information actionable.

    • Need clarity about what the decisions are and how to approach those decisions.


Key Features of Eisenberg Center Summary Guides

  • Brief & focused on key messages

  • Explicitly designed for audiences

  • Style template

    • Benefits, Risks, Trade-offs

  • Plain language

  • Appropriate literacy & numeracy levels

  • Actionable information


Up Front Bottom Line


Understanding the Benefits


Decision Coaching


Actionable Numeric Data

For treatments of early stage prostate cancer:

  • Proportion of men reporting impotence following each treatment, at 2 years:

    • 58% after radical prostatectomy

    • 43% after radiation therapy

    • 86% with hormonal therapy

    • 33% with watchful waiting


Conclusions about Evidence Translation

  • Both clinicians and consumers are interested in evidence and believe that it influences decisions.

  • Credibility is crucial.

  • We do not know very much about how clinicians and patients communicate about evidence.

  • Consumers perceive that evidence-based decision tools might be useful.


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