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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

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
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
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
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
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
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
Focus Group Participants Information Sources

  • 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
Focus Group Characteristics Information Sources

  • 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
Preferences for Information Sources 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
Preferences for Content of Information Sources 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
Perspective about Interactions with Providers Information Sources

  • 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
Principles for the Use of Evidence in Decision Tools Information Sources

  • 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
Key Features of Eisenberg Center Summary Guides Information Sources

  • 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
Up Front Bottom Line Information Sources


Understanding the benefits
Understanding the Benefits Information Sources


Decision coaching
Decision Coaching Information Sources


Actionable numeric data
Actionable Numeric Data Information Sources

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
Conclusions about Evidence Translation Information Sources

  • 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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