1. Promoting Patient Involvement in Medication Decisions David H. Hickam, MD, MPH Professor, Dept. of Medicine Oregon Health & Science University Portland, Oregon

2. 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.

3. 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?

4. 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.

5. 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.

6. 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.

7. 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

8. 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.

9. 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

10. 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.

11. 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.

12. 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.

13. 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

14. Up Front Bottom Line

15. Understanding the Benefits

16. Decision Coaching

17. 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

18. 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.