This webinar discussed a Cochrane review on the effectiveness of patient decision aids. It found that compared to usual care, decision aids improve patient knowledge by 13%, accuracy of risk perceptions by 82%, and the match between patient values and the health choices made by 51%. Decision aids may also reduce the use of discretionary treatments or screening by up to 20% and 14% respectively. While decision aids are effective, they are not being widely used in practice. The webinar provided an overview of the evidence on decision aids and highlighted their potential for improving shared decision making.
Decision aids for people facing health treatment or screening decisions: What's the Evidence?
1. Welcome!
Decision aids for people
facing health treatment or
screening decisions:
What's the Evidence?
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2. What’s the evidence?
Stacey D, Legare F, Col NF, Bennett CL,
Barry MJ, Eden KB, et al. (2014). Decision
aids for people facing health treatment or
screening decisions. Cochrane Database of
Systematic Reviews, 2014(1), CD001431.
http://www.healthevidence.org/view-
article.aspx?a=21567
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Decision aids for people
facing health treatment or
screening decisions:
What's the Evidence?
5. The Health Evidence Team
Maureen Dobbins
Scientific Director
Heather Husson
Manager
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Project Coordinator
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Publications Consultant
Research Assistants
Yaso Gowrinathan
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Reza Yousefi Nooraie
PhD candidate)
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Assistant Professor
7. Why use www.healthevidence.org?
1. Saves you time
2. Relevant & current evidence
3. Transparent process
4. Supports for EIDM available
5. Easy to use
8. A Model for Evidence-
Informed Decision Making
National Collaborating Centre for Methods and Tools. (revised 2012). A
Model for Evidence-Informed Decision-Making in Public Health (Fact
Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]
9. Stages in the process of
Evidence-Informed Public Health
National Collaborating Centre for Methods and Tools. Evidence-Informe
Public Health. [http://www.nccmt.ca/eiph/index-eng.html]
12. Dawn Stacey RN PhD CON(C) holds a Research Chair in
Knowledge Translation to Patients and is a Full Professor in the
School of Nursing at the University of Ottawa.
Dr. Stacey is a Scientist at the Ottawa Hospital Research Institute where she is Director
of the Patient Decision Aids Research Group. She is the principal-investigator for the
Cochrane Review of Patient Decision Aids, co-chair of the Steering Committee for the
International Patient Decision Aid Standards Collaboration (IPDAS), and co-investigator
for the Cochrane Review of Interventions to Improve the Adoption of Shared Decision
Making.
Her research includes: knowledge translation to patients; patient decision aid
development, evaluation and appraisal; decision coaching; implementation of decision
aids and decision coaching into practice; telephone-based care, and interprofessional
approaches to shared decision making. She is collaborating with the Ministry of Health
in Saskatchewan to implement shared decision making and patient decision aids across
the province. Her research program website is http://decisionaid.ohri.ca.
Dawn Stacey
16. Inform
• Provide facts: Condition, options, benefits, harms
• Communicate probabilities
Clarify values
• Ask which benefits/harms matters most
• Share patient experiences
Support
• Guide in steps in
deliberation/communication
• Worksheets, list of questions
Patient Decision Aids adjuncts to counseling
Stacey et al., Cochrane Library, 2014
17. If 100 men are screened If 100 men are not screened
18 diagnosed with prostate ca
(15 due to screening, 3 due to symptoms)
11 diagnosed with prostate ca after
developing symptoms (most >70 yr)
3 develop metastases 4 develop metastases
2 die of prostate cancer
16 with prostate cancer die of
something else
3 die of prostate cancer
8 with prostate cancer die of
something else
6 would never have known they had
prostate cancer (overdiagnosis)
9 would die of other causes anyway
1 does not die of prostate ca because
he was screened
FACTS: 100 men screened yearly 55-
70 and followed to end of life
VERSUS 100 men not screened
(College des Médecins
du Quebec, 2013)
18. Reasons to get screened Reasons not to be screened
Be reassured that you don’t have
prostate ca
Being worried that you might have
cancer when you don’t (false alarms) –
most positive screening is simply
enlarged due to age
Not having metastases and not dying
of prostate ca
Being diagnosed with ca and having
unnecessary treatments
Willing to accept the side effects of a
prostate biopsy if needed
I don’t want the risks of side effects
from a prostate biopsy
Willing to accept side effects of tx or
to live with knowing I have prostate ca
I don’t want to take the risk of having
side effects from treatment
Willing to accept that cancer found by
screening would never have caused
problems during my life if it hadn’t
been found
I don’t think screening tests are
reliable enough
What matters most?
(College des Médecins
du Quebec, 2013)
22. Review
Stacey D, Legare F, Col NF, Bennett CL, Barry MJ,
Eden KB, et al. (2014). Decision aids for people
facing health treatment or screening
decisions. Cochrane Database of Systematic
Reviews, 2014(1), CD001431.
Acknowledgements: A Saarimaki, S Beach, R Wu
Funded by University of Ottawa Research Chair in KT to Patients
23. PICO Eligible Ineligible
Population
Adults making decision
for themselves or family
member
Decisions: hypothetical,
lifestyle, clinical trial
entry, advance directives
Intervention
Patient decision aid for
treatment or screening
decisions
Patient education;
promotes compliance;
passive informed consent
Comparison
Usual care or alternate
intervention
Same decision aid in both
groups
Outcomes
Decision quality; decision
making process; patient,
practitioner, system level
Study design RCT only All other designs
24. PICO Eligible Ineligible
Population
Adults making decision
for themselves or family
member
Decisions: hypothetical,
lifestyle, clinical trial
entry, advance directives
Intervention
Patient decision aid for
treatment or screening
decisions
Patient education;
promotes compliance;
passive informed consent
Comparison
Usual care or alternate
intervention
Same decision aid in both
groups
Outcomes
Decision quality; decision
making process; patient,
practitioner, system level
Study design RCT only All other designs
25. • Medline (1966 to June 2012)
• CINAHL (1982 to Sept 2008*)
• Embase (1980 to June 2012)
• PsychINFO (1806 to June 2012)
• Cochrane Central Register of
Controlled Trials (June 2012)
* Not indexed on OVID after Sept 2008
Methods: Data Sources
26. • 2 reviewers independently screened and
extracted data using structured forms
• RCT quality was assessed using Cochrane’s
criteria for judging risk of bias:
– sequence generation
– allocation concealment
– blinding
– Completeness of outcome data
– selective outcome reporting (published/registered protocols)
– other potential threats to validity
• Inconsistencies resolved by consensus
Data Screen & Extraction
32. Elements in Patient Decision Aids
(N=115)
100% Options, outcomes, implicit values clarification
91% Clinical condition
88% Probabilities of benefits and harms
63% Guidance in steps of decision making
59% Explicit values clarification
50% Examples of others/ others’ opinions
40. 2 (of 6) Trials Showed Savings $$$
• Kennedy 2002 - hysterectomy
– ↓ invasive surgical procedures resulting in PtDA with nurse coaching having
lowest mean cost compared to DA alone or usual care
• van Peperstraten 2010 – IVF
– Saved $219.12 per patient in decision aid group compared to usual care
• Montgomery 2007/Hollinghurst 2010
– No difference in costs for decision about delivery mode after cesarean
• Murray 2001a, 2001b – HRT use, prostatectomy
– No difference in health service resource use; higher cost with expensive
interactive videodisc PtDA but if substitute lower cost internet access, no diff
• Vuorma 2003 - hysterectomy
– No difference in health service resource use; no difference between PtDA and
usual care for treatment costs and productivity loss
41. Summary of findings
• Patients exposed to PtDAs
– more involved in making health decisions (+34%)
– fewer are undecided (-41%)
– improve knowledge (+13%) and expectations
– enhance values-choice agreement (+51%)
• PtDAs may reduce the use of discretionary surgery
(-20%) or screening (-14% PSA) particularly when base
rates are higher
• More research: cost-effectiveness, adherence to chosen option,
health outcomes linked to preferred outcomes, influence of context
42. Other research findings on…
• Sub-analysis
– coaching (Stacey et al 2013);
– context (Brown et al. in press);
– low literacy (McCaffery et al 2013)
– adherence (Trenaman et al. submitted)
– values- choice measures (Munro et al. submitted)
– Elements in the decision aid (IPDAS series of 13
papers, 2013)
43. Importance of this Review
• Patient decision aids are effective
interventions for people facing treatment or
screening decisions
• A to Z inventory
• BUT they are not being used!
http://healthydebate.ca/2015/01/topic/quality/decision-aids
• Current research is focused on implementing
them within health care services
44. USA: R. 3590 The Patient Protection
and Affordable Care Act (March 2010)
46. A Model for Evidence-
Informed Decision Making
National Collaborating Centre for Methods and Tools. (revised 2012). A
Model for Evidence-Informed Decision-Making in Public Health (Fact
Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]
47. Poll Question #2
Did you find the information presented
today helpful?
1. Yes
2. No
50. Thank you!
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