Shared-decision-making interventions

Last time I posted I promised that I would talk more in depth about models that help health professionals implement shared-decision-making (SDM). The evidence suggests that such a model would be useful since health professionals find it difficult to implement SDM even when they feel it would positively impact patient outcomes.¹

I was hoping to find something like the PLISSIT model.* PLISSIT outlines the steps that a health professional can take to address the issue of sexuality with cancer patients, and one of the steps involves addressing their information needs:

P = permission (follow above link for explanation)

LI = limited information i.e. addressing the patient's information needs, conducting the reference interview, either providing information, discussing information that has already been found, or directing the patient to trustworthy information on the topic. Here's where a librarian or an information service might come in handy.

SS = Specific suggestion (follow above link for explanation)
IT = Intensive therapy (follow above link for explanation)

Unfortunately, besides LI, these steps are not particularly relevant to SDM, so the model is not transferable.

I have since had the chance to take a closer look at the literature and found exactly just such a model: The Ottawa Decision Support Framework (ODSF). Hurray! I love when I find exactly what I'm looking for. It also comes with a handy implementation toolkit, and evidence to support that it reduces decisional conflict between patients and physicians.²

Unfortunately the model does not provide a clear point at which information needs are addressed, making it more difficult to use it in conjunction with an information service. At the very least however, such a service could support the process by providing on-demand access to decision aids, which are known to

help patients participate in decision making, leading to informed choices that are consistent with their values.³

I also found a useful scale for measuring patient involvement,⁴ which seems like an important step to take before attempting to facilitate or improve implementation of SDM.



*
As mentioned in my last post, I came across this model recently while researching the question of how to help HPs bring up sexuality issues with gynecologic cancer patients.

1 Gravel K, Légaré F, Graham ID. Barriers and facilitators to implementing shared decision-making in clinical practice: a systematic review of health professionals' perceptions. Implementation Science 2006; 1:16

2 Légaré F, O’Connor AM, Graham ID, Wells GA, Tremblay S. Impact of the Ottawa Decision Support Framework on the Agreement and the Difference between Patients’ and Physicians’ Decisional Conflict. Med Decis Making 2006; 26:373–390

3 O’Connor AM, Wennberg JE, Legare F, Llewellyn-Thomas HA, Moulton BW, Sepucha KR, Sodano AG, King JS. Toward The ‘Tipping Point’: Decision Aids And Informed Patient Choice. Health Affairs 2007;26(3): 716–725

4 G Elwyn, A Edwards, M Wensing, K Hood, C Atwell, R Grol. Shared decision making: developing the OPTION scale for measuring patient involvement. Qual Saf Health Care 2003;12:93–99

Prostate cancer treatment options and decision aids: case

I have gotten several requests for information on the topic of prostate cancer, both from patients and from health professionals, so I thought I would share what I found.

Before I do so, I thought it might be helpful to explain what a decision aid (or guide) is, in case anybody reading this has never seen one or is not sure what one is.

I had a hell of a time finding a definition. I checked MedlinePlus' medical dictionary and encyclopedia, and neither had one. Cambridge Dictionaries Online didn't list the term, and neither did the Merriam-Webster online medical dictionary. This time even Google failed me. (I am searching online since I am at the clinic and so don't have access to print resources, much as the average patient or family member wouldn't.) I am finally able to find one definition though. According to the US Department of Health and Human Services,

Decision aids are mechanisms or interventions that have been developed to improve communication between health professionals and patients, and to help involve patients in making decisions regarding their health care. Decision aids can include brochures, videotapes or interactive computer programs. Recent reviews have suggested that decision aids may be effective in supporting general health care decisions.

But what does that mean in plain English? You could say that any information that helps you make a decision could be considered a decision aid, but there two types of tools that are usually referred to using the term decision aid or decision guide.

One kind works like a sort of "choose your own adventure." At each step in the process you are given your options and depending on which you pick, or which is recommended based on test results, other choices are then offered and so on, branching out like a little tree. This makes it possible to see what might happen if you chose one treatment over another.

The other kind brings up important questions and help you make a list of pros and cons, much the same way you might do if you were making any other decision.

Scenario

Information on prostate cancer treatment options and decision aids.

Resolution

Here are a few resources that I found useful:

Treatment options:

National Cancer Institute: What you need to know about prostate cancer.

National Cancer Institute: Prostate cancer treatment

Family Doctor: Prostate cancer treatment options

Canadian Cancer Society: What is prostate cancer?


Decision aids:

Mayo Clinic: Prostate cancer guide

American Cancer Society: Detailed guide- prostate cancer

National Comprehensive Cancer Network treatment guidelines for patients: prostate cancer (for very advanced readers)


These are for screening but might still be of interest:

Centres for Disease Control and Prevention: Prostate cancer screening decision guide

Lab Tests Online: Prostate cancer tests

Depression: case

Scenario

A young man visits me at the clinic. He believes he is suffering from depression and would like to have some information on the topic, as well as about various medications, and alternative therapies. He admits that he is hesitant to go on medication, but also realizes that this may be his best option. He would like to be better informed before discussing his situation with his doctor. He has already looked online, but admits that most of what he's read is not particularly trustworthy and would like some advice on better resources.

Resolution

The first thing I do is show him MedlinePlus. I run a sample search and show him how he can also search the encyclopedia, and the drugs and supplements. It occurs to me that a decision aid might be useful to him, since he is in the process of trying to make a decision. I search the Ottawa health research Institute A-Z Inventory of Patient decision aids and find the Mayo Clinic's Depression guide which includes information on antidepressant meds, complementary and alternative therapies, personal stories and things to consider.

While we are talking it becomes apparent that he is a voracious reader, and quite prepared to actively participate in managing his own health, so I decide to also recommend a couple of books that he might find useful:

The Noonday demon: An atlas of depression, by Andrew Solomon, provides an astute and in depth look at depression through the ages and the controversy. The book is an engrossing read, is well researched, and provides a balanced look at the pros and cons of medication as treatment.

Full catastrophy living: Using the wisdom of your body and mind to face stress, pain and illness, by Jon Kabat-Zin. This book is a companion to the Stress Reduction Clinic at the University of Massachusetts Medical Centre, founded by the author. Yoga and mindfulness meditation are taken out of the realm of spirituality and religion, and used as practical and effective stress, pain and illness management tools. The program can be followed independently using guided yoga and medication tapes.

Discussion

It feels good to recommend books as well as online resources for a change. I don't often get the chance to do so since most of the questions I get are better answered in a relatively quick and dirty way. Usually people who come to me are looking for immediate and timely answers: information about clinical trials, medications, back exercises, dietary recommendations related to various conditions etc.

Total time: 1 hr

Staff requests: 2 cases and Ethics: challenge

It has recently been brought to my attention that there may be ethical problems with posting cases the way I have been, even though I have been very careful to remove any personally identifying information. Hopefully I will be able to continue once I have spoken to the ethics consultant at the hospital in order to confirm that all is indeed okay.

In the meantime I have taken the cases offline (hopefully temporarily), and today I will write about a couple of requests I've gotten from staff.

Case#1

Scenario

One of the health professionals (HP) at the clinic asks me to find some information regarding which vaccines that do not contain thimerosal (a mercury-based preservative used in multi-dose vials to prevent contamination) are available in Canada, as one of his patients has expressed concerns over the additive. He gives me a list of possible vaccines.

Resolution

I run several searches in Google which verify the correct spelling and allow me to narrow my results to those pertinent to Canada. Unfortunately, as I write this, I do not remember my exact searches, except that I did not include the vaccines from the list in my searches. I do remember running several relatively convoluted ones before I was able to find the information I was looking for. I have tried to reproduce my search for the purposes of this post and for some reason I am only able to find an older 1 March 2003 version of the 2007 document I am ultimately able to find for the HP:

Canada Communicable Disease Report
Volume 33 • ACS-6
1 July 2007 An Advisory Committee Statement (ACS) National Advisory Committee on Immunization (NACI)
Thimerosal: Updated Statement

Discussion

I find the older version by typing in thimerosal canada which is a search I know I would have run the last time, so I am doubly confused at to why I did not find the older version last time but have now found it so easily. Having found it there would have been no reason to keep looking as there is no indication that there is a more recent version available. This is yet another example of why searching for information using Google can be hit and miss. I have tried to reproduce searches before and have had similar problems, something I demonstrate in the Google course I developed for the Health Sciences Library: Google-eyed? Don't despair! How often do we take screen captures of our search results? It is way too easy for us to doubt ourselves and not the tool we have become so dependent on.

Total time: 30 mins

Case#2

Scenario

One of the GPs at the clinic asks me where he can find decision aids to use with his patients and their families.

Resolution

I happen to have a very useful site already bookmarked in MyHq so I show it to him: Ottawa health research Institute A-Z Inventory of Patient decision aids.

I also show him a really neat one I have found recently during an encounter with a family member in the Gynecologic Oncology department: Ovarian Cancer Treatment Guidelines for Patients– Version III, April 2007. The reason I like this one so much is that is not just a list you can print out and tick off, but rather a fully interactive tool that works something like a choose you own adventure.

Total time: 5 mins

CAM for HCV: case

Case

Scenario

One of the health professionals (HP) at Herzl comes to me asking that I meet with one of her patients (a young man) who has Hepatitis C and is resisting interferon. The HP tells me her patient is interested in complementary and alternative therapies (CAM). Although she would prefer that he accept the recommended treatment she is open to discussing alternatives with him. She hopes the young man's specialist will be open to exploring CAM treatments.

Resolution

When the young man meets with me I mention to him that since he is not sure about interferon a decision aide might help him decide. He hesitates but is amenable once I explain that the aid will not force him to decide one way or another but will rather give him a structure for clearing his thoughts. While we talk he shows me a link to a resource he has already accessed on the subject. It turns out to be a good resource, www.hepatitis-central.com, that has HONcode accreditation which is at present undergoing annual review.

I give the patient some information I had prepared ahead of time: information about HCV and CAM on the Public Health Agency of Canada website and about interferon from MedlinePlus, a decision aid from the Ottawa Health Research Institute, and a research report from the National Centre for Complementary and Alternative Medicine, as well as some fact sheets from the HCV Advocate website.

The patient is very happy with what I have printed for him. In addition he would like to find some information about the use of vitamine C as a therapy, having heard that it can cure HCV completely. We look together and find a few references to vitamin C and HCV but I am not able to find anything definitive or evidence-based, although something is mentioned on Hepatitis Central that might be worth showing to his specialist. We discuss some criteria to use in order to judge whether a website can be trusted including: who maintains the site? who wrote the article? when was it updated? is the information cited?

Discussion

It remains to be seen whether the patient will decide to accept the interferon treatment or whether his specialist will be amenable to exploring CAM therapies.