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The value and place of decision support Richard Thomson

The value and place of decision support Richard Thomson. SDM – evidence. Cochrane Review of Patient Decision Aids(O’Connor et al 2011): Improve knowledge More accurate risk perceptions Feeling better informed and clear about values More active involvement Fewer undecided after PDA

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The value and place of decision support Richard Thomson

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  1. The value and place of decision support Richard Thomson

  2. SDM – evidence Cochrane Review of Patient Decision Aids(O’Connor et al 2011): Improve knowledge More accurate risk perceptions Feeling better informed and clear about values More active involvement Fewer undecided after PDA More patients achieving decisions that were informed and consistent with their values Reduced rates of: major elective invasive surgery in favour of conservative options; PSA screening; menopausal hormones Improves adherence to medication (Joosten, 2008) Better outcomes in long term care

  3. Evidence-based decision support • Timely and appropriate access for clinicians and patients • Needs facilitation • In consultation or outside? • Value of brief in-consultation tools (Option Grids and Brief Decision Aids) • Fit to clinical pathways • Adapt pathway or tools? (VBAC, BPH)

  4. Decision Support Interventions • Generic tools • Decision specific tools • Variety of formats • Websites • Leaflets • DVD

  5. Brief Decision Aids/Option Grids Heavy Menstrual Bleeding (Heavy Periods) Management Options[1] A Brief Decision Aid There are four options for the management of heavy menstrual bleeding: • Watchful waiting - seeing how things go with no active treatment. • Intrauterine system (IUS)– a hormonal device placed in the womb that lasts five years. • Medication - tablets taken before and during periods, the combined oral contraceptive pill, or progestogens either as tablets or a 3 monthly injection. • Surgery - endometrial ablation or hysterectomy. These are hospital procedures that are usually considered only if other options have not worked well or have been unacceptable. [1] Only for use once other causes of HMB such as fibroids or polyps have been excluded

  6. Benefits and Risks of Intrauterine System (IUS) Menorrhagia BDA

  7. Results • In 11 months from April 2012 31259 downloads (2842/month)

  8. Results: patients • A much better document than provided previously by my GP. Less waffle than many other information sheets. • The clearest information on possible treatments and their effects I have found to date! • Very good: for the first time i understand my condition • The info was so clear, I could make a decision immediately. • Good to include weblinks to more detailed information • Please check for English: not 'less than', but 'FEWER THAN 4 PEOPLE...'

  9. Results: clinicians 113 responses; 60% GP/GP registrar; 12% nurse; 5% pharmacist; 4% hospital doctor; 19% other (e.g. med students, physio, podiatrist) 32% discussed with patient; 30% gave to patient

  10. Results: clinicians • I work for NHS Direct and the format of BDA`s will make it my advice to patients easy to deliver and allow discussion • I particularly like the way the research figures are presented e.g. x in 100 people would/wouldn't improve with certain intervention • Really helped my patient decide what she needed. Helped me help her • Really useful. I've used the Smoking and Tennis Elbow documents with patients and found them very helpful. I have read and saved the others for future use too. • Very informative, especially for patients who may want some figures to inform their decisions. • More info would be good - a bit basic • Much as all the management options would be options at some point in time, not all are appropriate or available for new presentations of carpal tunnel syndrome (ie surgery)

  11. Option Grid

  12. Measuring impact of change in clinical practice (Option Grid) Patients’ knowledge post diagnostic consultation

  13. Vaginal birth after previous caesarean section Ninety one per cent read the information before attending the clinic and 81% used the adapted Ottawa Decision Guide

  14. Urology clinic • Lower urinary tract symptoms • One stop clinic • Introduction of NHS decision aid • Revised pathway – telephone follow-up

  15. Final thoughts • PDAs have much value, but need to be accessible at the right time and designed for purpose • We will never have enough PDAs for all decisions • PDAs are an adjunct to good clinical practice • Attitudes and skills trump PDAs

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