Work Package 1

1. Work Package 1 Health Professional Focused Strategies for Communicating Evidence-Based Recommendations Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

2. WP-1 Objectives WP1 To develop and evaluate strategies for communicating evidence-based recommendations to health professionals. • We identified and are working on four main areas of research: • Presentation (including electronic) and layering of recommendations. • Presentation of “Evidence to Recommendation” process to guideline developers. • Presentation of “Evidence to Recommendation” process to guideline users. • Presentation of Decision Aids in guidelines Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

3. 1- Presentation and layering of recommendations We have developed in a collaboration with the MAGIC research program a top layer format as a strategy to provide health professionals with the content is necessary to act on the recommendations This format needs to be easy to understand and use at the point of care. This presentation needs to be feasible to produce (for guideline developers), acceptable to other stakeholders (e.g. publishers) and publishable across different kinds of media. Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

4. Top layer • Recommendations is what clinicians will want to see first • Additional information available just one click away • Key information section • Benefits and harms • Confidence in effect • Preferences and values • Resources • Recommendation rationale Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

5. Development – phase I User tests round I 2011 7 individual user test sessions in 3 countries + 3 group sessions Introducing the top layer format: Recommendation + strength Benefits & harms Confidence in effect estimates Preferences & values Resources Rationale Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

6. Round II 2012 28 individual user test sessions in 6 countries + 1 group session Refining the top layer format: Larger screen Different ways of conveying the strength of the recommendation Removing CI Introducing burden of treatment Renaming ”confidence…” to ”quality of the evidence” Re-writing the text Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

7. Benefits and harms Per 1000 patients over 1 year: Non-fatal stroke: 10 without treatment. 3 fewer with warfarin. 3 fewer with a novel oral anticoagulant (NOAC). Mortality: 10 without treatment. 3 fewer with warfarin. 4 fewer with NOAC. Major bleeding: 10 without treatment. 15 more with warfarin. 9 more with NOAC. Burden of treatment: Warfarin = dietary restrictions and daily medication. NOAC = daily medication. Quallity of evidence Moderate. The relative effect of warfarin and NOAC is based on two systematic reviews of high quality. There is however some uncertainty about the baseline risk estimates. Preferences and values Studies on patient preferences and values have shown that the average patient is prepared to suffer three major bleeds to avoid one stroke, and these studies have guided our recommendation. The studies are however deemed to be of low quality with a high degree of variability in preferences. We therefore suggest that the decision concerning treatment is made together with the patient. Resources There are substantial societal costs related to treatment of atrial fibrillation. For this particular risk group the cost effectiveness of treatment is not established. Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

8. Analysis on progress: • Overall feedback has been good • Still many issues to fine tune • Several iterations to follow • Future steps: • Future research on the optimal top layer format will be done in phase II • We will perform RCTs comparing alternative presentations Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

9. 2-Evidence to recommendation framework for guideline developers A communication strategy that aims to: Inform decision makers’ judgments about the advantages and disadvantages of the considered options (therapeutic interventions) Ensure that all important factors (criteria) that determine a decision are considered Help structure discussion and identify reasons for disagreements Provide a concise summary of the best available research evidence to inform judgments about each criterion. Make the basis for a decision transparent to guideline users Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

10. Development – phase I • So far we have done: • Brainstorming sessions through a series of e-mail discussions and face to face meetings, and teleconferences. • During the second year, we have completed first round of user testing (4 participants) and group feedback (42 participants) both at International Symposium (GIN 2012, Berlin) • Harmonized the framework with the rest of the other WPs • Designed an updated version to be further tested Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

11. Main findings from user tests The table was overall well rated Most of the comments were related to the aspect, format and wording Found that B&H judgment needs to be more explicit There is a need to provide alternatives to convey V&P Resource use should be described in much more detail Need to provide a general guidance for the framework Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

12. TABLE Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

13. Next steps: Further brainstorming Further user testing and real guideline implementation Stakeholder feedback Further harmonize with other WPs Integration within the authoring tool How to deal with more complex situations such as multiple comparisons Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

14. 3-Evidence to Recommendation table for guideline users A communication strategy that aims to: Make recommendations transparent to guideline users in a table format Inform guideline users about the pros and cons of an intervention under consideration Provide a concise summary of the best available research evidence used to inform judgments of the guideline panel Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

15. Development – phase I • So far we have done: • Brainstorming sessions through a series of e-mail discussions and face to face meetings, and teleconferences • Produced a first prototype • Completed first round of user testing and group feedback (15 participants; 3 countries) • Designed an updated version to be further tested Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

16. Main findings from user tests The table was well rated overall by users (usefulness) Found it useful to understand in more depth the rationale of the recommendation and for teaching sessions Some users found it potentially useful for shared decision making while others did not find it useful at the point of care Most frustrations came from the too methodological terminology, not grasping the purpose of the table or about the GRADE system in general Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

17. Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

18. Next steps: - Further brainstorming and user testing - Obtain stakeholder feedback primarily from guideline developers and users Design iEtR table. in a similar format to the iSoF table Compare with the SoF table in the context of guideline consultation, both in user testing and in an RCT in the second half of 2013 Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

19. Decision Aids – WP1 / SHARE-IT project Decision Aids linked to GRADE Guidelines to improve Shared-Decision Making in the Clinical Encounter • A collaboration between WP1/DECIDE & MAGIC research program:Sharing Evidence to Inform Treatment decisions (SHARE-IT) Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

20. Decision Aids – WP1 / SHARE-IT projectBackground & rationale • Decision aids (DA) can enhance Shared Decision Making, but: • Not the desired uptake in clinical practice • Production time-consuming • Often not based on current best evidence / rapidly outdated… Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

21. Decision Aids – WP1 / SHARE-IT projectBackground & rationale • Necessity to link DA with Guidelines • A lucky combination of opportunities • GRADE: Weak recommendations are ideally framed for SDM • IPDAS: international standarts for DA were recently updated • Promising development for DA to be used in the clinicalencounter:E.g. Montori(Decision Cards), Elwyn (Option Grids)… • Technology: interactivity, automatic production, continuous updating Updated International Patient Decision Aid Standards (IPDAS 2012) to improve content, development, implementation and evaluation. Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

22. Decision Aids – WP1 / SHARE-IT projectObjectives • Develop a framework for the automated production of generic and interactive DA from GRADE guidelines • Produce a set of alternative presentation formats to be displayed on computer tablets during the clinical encounter • Patient-relevant outcomes (interactivity) • Include Burden of treatment and cost issues • Explore how to convey (or not!) uncertainty / confidence • Explore how to discuss multiple treatment alternatives • Evaluate these DA on real life Shared-Decision Making • Different diseases • Different contexts (inpatients, outpatients, chronic) Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

23. Decision Aids – WP1 / SHARE-IT projectWork progress & next steps • Gathering backgroundinformation (SDM, DA, IPDAS) • Brainstorming on framework(content, presentation)3-days meetings at McMaster Nov 2012 • Designing prototypeof DA automatically producedfrom GRADE (currently using MAGIC tool, link with iSoF) • User-testing & Stakeholder’s feedback • Observation in real-life patient-clinicians encounters • Followed by semi-structured interviews • Focus groups of patients? • RCT to evaluate effectiveness in real life shared-decision making Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

24. Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential

25. Work Package 1 Health Professional Focused Strategies for Communicating Evidence-Based Recommendations Health professional focused strategies for communicating evidence-based recommendations - February 2013, Confidential