Implementation of Patient Decision Aids:

Lessons from North America

Dawn Stacey RN, PhD

University Research Chair in Knowledge Translation to PatientsFull Professor, UOttawa

Director, Patient Decision Aids Research Group

October 2014, Australia

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Implementation approaches Internet access

to patient decision

support tools

Practice Settings

Helplines / Call Centers

Shared Decision Making Centers (CA, US, AU, Chile)

(CA, US)

(CA, US, UK, Chile)

Outline

United States of America:•Dartmouth Medical Centre•Health Dialog

Canada•The Ottawa Hospital•Province of Saskatchewan

Practice Variations: Knee Replacement Rates per 1,000 Medicare Enrollees by State (2007)

Practice Variation: Knee Replacement per 1,000 Medicare Enrollees (2007)

Location Rate per 1,000 Medicare Enrollees

Utah 12.5

Ohio 9.6

Connecticut 7.3

New York 6.0

Honolulu, HI 2.9

Dartmouth-Hitchcock Medical Centre

Passive dissemination – research shows about 5% uptake (Grimshaw et al., 2012)

What is decision coaching?

• Develops patients’ skills in:- thinking/deliberating about

options- preparing for a consultation - implementing change

• Coaches are trained to be supportive but non-directive

(O’Connor et al., 2008; Stacey et al., 2008; 2013)

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A guide for helping individuals making decisions

Outline

United States of America:•Dartmouth Medical Centre•Health Dialog

Canada•The Ottawa Hospital•Province of Saskatchewan

Outline

United States of America:•Dartmouth Medical Centre•Health Dialog

Canada•The Ottawa Hospital•Province of Saskatchewan

Decisional Conflict

• uncertainty about what option to choose because:– risk – loss – regret– challenge to

personal life values

yes

no

(NANDA International, 2010)

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The Ottawa HospitalInter-Professional Model of Patient Care©

Guiding Principles:

12. Patient/family will have access to information to assist in decision making, treatment management options, support, and self-care.

13. Patient/family will be active participants, in the decision-making process about their plan of care. The degree of involvement will be defined by the patient.

1. Identify the decision(and where in process of care?)

2. Find patient decision aid(s) to determine quality and relevance to setting

3. Assess factors likely to influence use (barriers, facilitators, champions)

4. Implement PtDA with training (interventions to address barriers)

5. Monitor use and outcomes http://decisionaid.ohri.ca

Referral Indicators:Elevated PSA; Rising PSA; Abnormal DRE; Positive family history; Intractable bony pain (urgent consult); Patients diagnosed with prostate cancer seeking a second opinion.

Referral to CAC Prostate DAU

Consult visit

Trus biopsy

Follow-up Visit:Result & treatment plan discussionSupportive care needs assessmentPatient education

Decision support

2 weeks

2 weeks

2 weeks

Treatment decision

Care map for Prostate Cancer

http://www.massgeneral.org/decisionsciences/research/DQ_Instrument_List.aspx

To clarify values and verify knowledge

http://www.decision.chaire.fmed.ulaval.ca/en/tool-box/list-of-programs

Legare et al (2012). Training health professionals in shared decision-making: An international environmental scan. Pt Edu Counsel. 88(2), 159-69.

Preferred option

Knowledge test results (=correct; =wrong)

Preference report

Strong values favouring outcomes of choosing active treatment, completed quickly, avoids brachytherapy and bowel problems

Has enough support

(Stacey et al., BMJ, 2008)

Outline

United States of America:•Dartmouth Medical Centre•Health Dialog

Canada•The Ottawa Hospital•Province of Saskatchewan

Saskatchewan, Canada

Patient First Review: What Patients Want

• Good 2-way communications and adequate time with providers

• Involvement in care / treatment decisions

• Timely access to needed services (e.g. emergency, elective surgery, and diagnosis)

• Providers who show they care

http://health.gov.sk.ca/healthline-online

Integrated into surgical pathways

• Hip/knee replacement surgery

• Prostate cancer treatment

• Back surgery

• Uro-gyne surgery

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Research Funding

Favourable policy climate

Decision Support Info. & Tools

Feasible implement. plan

Reg., Profess., & Legal Standards

Patient Champions

Clinician Champions

Clinician Training

Financial & other incentives

Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen 2011;105 (4)