Update on Decision Support for Clinicians and Patients

Status

Update on Decision Support for Clinicians and Patients

We have written extensively and provide many examples of decision support materials on our website. An easy way to round them up is to go to our website search window http://www.delfini.org/index_SiteGoogleSearch.htm and type in the terms “decision support.”

A nice systematic review of the topic funded by AHRQ—Clinical Decision Support Systems (CDSSs)— has recently been published in the Annals of Internal Medicine.[1]  The aim of the review was to evaluate the effect of CDSSs on clinical outcomes, health care processes, workload and efficiency, patient satisfaction, cost, and provider use and implementation. CDSSs include alerts, reminders, order sets, drug-dose information, care summary dashboards that provide performance feedback on quality indicators, and information and other aids designed to improve clinical decision-making.

Findings:  148 randomized controlled trials were included in the review. A total of 128 (86%) assessed health care process measures, 29 (20%) assessed clinical outcomes, and 22 (15%) measured costs. Both commercially and locally developed CDSSs improved health care process measures related to performing preventive services (n =25; odds ratio [OR] 1.42, 95% CI [1.27 to 1.58]), ordering clinical studies (n=20; OR 1.72, 95% CI [1.47 to 2.00]), and prescribing therapies (n=46; OR 1.57, 95% CI [1.35 to 1.82]). There was heterogeneity in interventions, populations, settings and outcomes as would be expected. The authors conclude that commercially and locally developed CDSSs are effective at improving health care process measures across diverse settings, but evidence for clinical, economic, workload and efficiency outcomes remains sparse.

Delfini Comment: Although this review focused on decision support systems, the entire realm of decision support for end users is of great importance to all health care decision-makers. Without good decision support, we will all make suboptimal decisions. This area is huge and is worth spending time understanding how to move evidence from a synthesis to decision support. Interested readers might want to look at some examples of wonderful decision support materials created at the Mayo Clinic. The URL is—

http://webpages.charter.net/vmontori/Wiser_Choices_Program_Aids_Site/Welcome.html

Reference

1.  Bright TJ, Wong A, Dhurjati R, Bristow E, Bastian L, Coeytaux RR, Samsa G, Hasselblad V, Williams JW, Musty MD, Wing L, Kendrick AS, Sanders GD, Lobach D. Effect of clinical decision-support systems: a systematic review. Ann Intern Med. 2012 Jul 3;157(1):29-43. PubMed PMID: 22751758.

Facebook Twitter Linkedin Digg Delicious Reddit Stumbleupon Tumblr Email

Why People Tend to Overuse Healthcare Interventions

Status

Why People Tend to Overuse Healthcare Interventions

This nice piece in Time Magazine by Maia Szalavitz provides some clues about our major problem of overuse. Ms. Szalavitz documents the convincing power of anecdotes compared to statistics which are poorly understood by most people. She provides a really nice example of decision support from the Harding Center for Risk Literacy for prostate cancer screening that illustrates graphically how prostate cancer screening is likely to create more harms than benefits.  For more information go to—

http://healthland.time.com/2012/05/25/why-people-cling-to-cancer-screening-and-other-questionable-medical-interventions-even-when-they-cause-harm/

Facebook Twitter Linkedin Digg Delicious Reddit Stumbleupon Tumblr Email

Three Questions Patients Should Ask To Improve the Information They Receive

Status

Three Questions Patients Should Ask To Improve the Information They Receive

According to Shepherd  et al [1], the following questions appear to be powerful catalysts for good information exchanges between clinicians and patients:

1. “What are my options?”

2. “What are the benefits and harms of each?”

3. “How likely are the benefits and harms?”

Let’s start with Shepherd’s cross-over trial using the three questions above.[1]  In order to make informed decisions and improve outcomes, patients need reliable information about benefits and risks of the various options.  In this randomized cross-over trial, Shepherd et al. used two standardized patients with identical symptoms— one patient asked the three questions (and also about doing nothing if the physician did not mention this option), the other did not. The patient presented as an otherwise healthy divorced middle-aged female with one prior undiagnosed episode of depression and 3 months of worsening moderate symptoms of depression. Depression was chosen as the condition because evidence is available and patients express differences in preference for treatment. The authors found that the 3 questions were associated with greater provision of information and behavior supporting patient involvement without extending appointment time.

Stiggelbout et al. remind us that shared decision-making (SDM) should be routinely employed to ensure patient autonomy, beneficence (balancing risks and benefits), non-malfeasance (avoiding harm) and justice (patients frequently decline procedures when adequate information has been provided and this may result in improved sharing of limited resources).[2] Pamphlets, videos, tools of various sorts may be employed to facilitate SDM. Tactics and tools that appear to increase SDM include—

  • Creating awareness of equipoise (there is no best choice but a decision must be made—even if it is to do nothing);
  • Presenting or encouraging patients to ask about options and benefits and risks of each option;
  • Use of graphical displays to present risks;
  • Use absolute risk information such as the number of similar patients/100 or number/1000 who will benefit*;
  • Encouraging patients to pay attention to their preferences;
  • Provide appropriate support to help patients make decisions—respect the patient’s preference about his or her role—independent, shared or delegated decision-making role.

*We would add that this information is only useful when also providing information  that provides a more complete picture.  To hear that one’s chance of benefiting from an intervention is 5 out of a hundred has a very different meaning depending upon the specific context:

  • Scenario 1: Out of 100 patients, 10 taking drug A improved as compared to 5 taking placebo, versus—
  • Scenario 2: Out of 100 patients, 90 taking drug A improved as compared to 95 taking placebo.

Examples of decision-aids are available from the following: http://shareddecisions.mayoclinic.org.

Delfini Comment: “Patient demand,”  i.e., activating patients to voice their information needs, has been proposed as a method of improving healthcare consultations for several decades. In our experience, educational programs aimed at increasing the use of  evidence-based information sharing with patients has been hampered by clinicians frequently not possessing accurate answers to the three questions studied here. The two studies discussed above [3,4] indicate  that patient-mediated approaches may be at least part of the answer to improved clinical decision-making.

References

1. Shepherd HL et al. Three questions that patients can ask to improve the quality of information physicians give about treatment options: a cross-over trial. Patient Educ Couns. 2011 Sep;84(3):379-85. Epub 2011 Aug 9.PubMed PMID: 21831558.

2. Stiggelbout AM et al.  Shared decision making: really putting patients at the centre of healthcare. BMJ. 2012 Jan 27;344:e256. doi: 10.1136/bmj.e256. PubMed PMID:22286508.

3. Bell RA et al. Encouraging patients with depressive symptoms to seek care: a mixed methods approach to message development. Patient Educ Couns. 2010 Feb;78(2):198-205. Epub 2009 Aug 11. PubMed PMID: 19674862.

4. Kravitz RL et al. Influence of patients’ requests for direct-to-consumer advertised antidepressants: a randomized controlled trial. JAMA. 2005 Apr 27;293(16):1995-2002. Erratum in: JAMA. 2005 Nov 16;294(19):2436. PubMed PMID: 15855433; PubMed Central PMCID: PMC3155410.

 

Facebook Twitter Linkedin Digg Delicious Reddit Stumbleupon Tumblr Email