Using Internet Technologies to Improve and Simplify Counseling about Menopause

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Using Internet Technologies to Improve and
Simplify Counseling about Menopause

• Nananda F. Col, MD, MPP, MPH, FACP
• Dept of Medicine, Division of General Medicine
• Brown Medical School and Rhode Island Hospital
• Ncol_at_Lifespan.org

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INTRODUCTION

• Patients who are more involved in decisions about
  their health have better outcomes
• Despite repeated calls for participatory decision
  making, it remains uncommon
• Quality of menopausal counseling low
• Why?

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Participatory Decision Making

• Present all relevant information, choices,
  expected outcomes, trade-offs
• Patient attaches her own weights and preferences
• For menopause, very complex
• Many treatments each with risks, benefits
• HT is most effective treatment for vasomotor
  symptoms
• risks for CHD, VTE, stroke, breast cancer
• Benefits on osteoporosis and colorectal cancer

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Challenges

• How to balance the risks and benefits of HT at
  the individual level?
• Simple calculations from WHI not applicable to
  all women

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10,000 women taking HT for 1 year
WHI BenefitRisk Ratio

• 7 more CHD events
• 8 more strokes
• 8 more pulmonary emboli
• __________________
• 23 more life-threatening events

• 6 fewer colorectal cancers
• 5 fewer hip fractures
• __________________
• 11 fewer life-threatening events
• Difference 12 events/ 10,000 women

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APPLYING WHI FINDINGS

• WHI women not representative of each individual
  woman
• Baseline risks and starting age affect the net
  benefitrisk of HT
• How can we translate what we have learned from
  the WHI to individual women?

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Applying WHI Findings

• Women at higher risk for CHD are more likely to
  develop CHD, etc
• Translate relative risks to absolute risks
• RR 1.29 of HT on CHD Abs. Risk
• Baseline risk 1 ? 1.3 ? 0.3
• Baseline risk 35 ? 45.2 ? 12.2

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Needed Decision Support

• Translate relative benefits and risks of HT into
  absolute benefits and risks
• Take into consideration age, baseline risks
• Long-term vs short-term effects
• Why do we need tools?
• Cognitively challenging Too many risks, risk
  factors
• Time, reimbursement
• Not trained

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Available Decision Support Tools

• Information
• diagnostic tests
• Where to order
• Costs

Clinical trials
Information cancer, risk factors, diagnostic
tests
??
personal health journal
MD-pt interaction
PATIENT
DOCTOR
Risk self-assessment
Tools to assess risk
Patient portals Tricare
disease tracking management tools
Patient electronic medical record (EMR)
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A Web-based, Patient-Specific Markov Model

• To determine which women benefit from HT
• To explore the trade-off between short-term
  symptom relief and the risks of inducing chronic
  disease

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The Web-based Model

• Developed a patient-specific web-based Markov
  model simulates the effect of short-term HT on
• Chronic disease risks
• life expectancy (LE)
• quality-adjusted life expectancy (QALE)
• adjusts for quality of life over time

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Patient-Specific Disease Risks

• Includes all conditions affected by HT
• CHD and stroke risk based on Framingham Models
• Risk factors age, cholesterol, blood pressure,
  diabetes, smoking
• Breast cancer risk Gail model
• Osteoporosis risk Cummings model

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Impact of HT WHI Data
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Quality of Life Estimates

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The Impact of HT on QOL

• HT affects QOL only during the 2-year menopause
  transition
• HT reduces menopause symptoms by 80

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Results Impact of 2 Years HT on QALE

• No symptoms - 1-3 months
• Mild symptoms 3-4 months
• Severe symptoms 7-8 months
• Magnitude of gain or loss depend on CVD risk
• Higher CVD risk lower expected gains in QALE

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Limitations of Utility Scores

• Utilities for menopausal symptoms based on 2
  studies
• Mild 0.73 severe 0.52
• Climacteric is a temporary state, but was treated
  as a chronic state

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Threshold Analyses

• What is the minimum severity of menopausal
  symptoms that would warrant HT?
• Low CVD risk if symptoms lowered menopausal QOL
  to 0.96 or less
• High CVD risk if QOL 0.88 or less

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Limitations

• Models balance the benefits and risks of HT and
  impact on survival and QALE
• Translates WHI findings to individual patients
• To help patients and clinicians understand this
  information, we need to embed this into a
  decision aid that can be used by patients and
  doctors

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Womens Interactive System for Decisions on
Menopause

• Jennifer Fortin, MPH
• Rhode Island Hospital/Brown Medical School
• Providence, RI USA

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WISDOM

• Purpose
• empower women to make better decisions about
  menopausal treatments and disease prevention
• Help doctors counsel menopausal patients
• Reduce medical errors concerning menopausal
  therapies

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Components of WISDOM

• INPUT
• Symptom Assessment
• Risk Assessment
• Prevention Goals

• FEEDBACK
• Treatment Chart
• Risk Report
• Prevention Options

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Screen Shot from WISDOM
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Symptom Assessment
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Treatment Options Chart
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Personalized Risk Report
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Prevention Options Chart
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Clinician Summary
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Management/Tracking Tools
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Current Status of WISDOM

• Website complete
• Results from both patient and doctor testing have
  been very favorable
• Website currently being evaluated in a multi-site
  randomized, controlled trial (n120, goal200)

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Expected Outcomes

• Improve quality of counseling
• Increase knowledge
• Improve risk perception
• Decrease decisional conflict
• Increase compliance
• Promote behavioral change

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Preliminary RCT Results
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Preliminary RCT Results
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Preliminary RCT Results
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Feedback from Doctors
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WISDOM Next Steps

• Goal To make WISDOM available for widespread
  dissemination
• Obstacles to overcome
• Technical capacity
• Keeping information current
• Simplifying data entry
• Reaching wide audience, especially less educated
• Collaborations pursued with medical associations,
  private foundations, womens health
  organizations, government agencies, and third
  party insurers

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Access to WISDOM

• URL www.medwisdom.org
• Currently password protected
• Username/Password guestN for both (where N is
  any number from 1-100)

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Can Patient-Centered Technology Transform Health
Care?

• Help doctors counsel patients about treatments
• Help identify high-risk patients, prioritize
  risks
• Facilitate targeted counseling, risk reduction,
  appropriate treatment
• More efficient use of doctors time
• Shift time consuming tasks to those better
  equipped computers and patients
• Technology performs data collection, integration,
  synthesis, mapping
• Doctor has more time to address other areas
• Less error, less bias

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Advantages of Internet Interventions

• Easy to update to accommodate new evidence
• Easy to disseminate among those with Internet
  access
• Easy to track exact usage patterns
• Distribution less costly than the production and
  distribution of interventions using other media
  (paper, CD-ROM)

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Challenges in Internet Interventions

• Internet access is variable among populations
• Difficult to recruit and retain diverse
  participants for evaluation studies
• Skepticism about security of transmitting
  clinical data online

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Beyond Red Flags

• Medical decision making is complex
• Solutions must
• reflect the complexity and multidimensionality of
  clinical decisions
• be based upon evidence-based medicine,
  epidemiological principles, psychology, social
  marketing, and sound simulation techniques
• be available at point-of-care
• involve patients in decisions that affect them

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• THANK YOU!
• Project Manager
• Jen Fortin, MPH, Jfortin_at_lifespan.org
• Principal Investigator
• Nananda Col, MD, ncol_at_lifespan.org

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Future PATHS

• Practical Approach to Transient Health States
  (PATHS)
• Incorporate preferences (utilities) for
  short-term health states into decision support
• Develop prototype to assist with
  preference-dependent decisions
• Measure impact on patients and clinicians
• Establish feasibility of this approach as a
  menopause registry
• Partner with Drs. Les Lenert and Anne Stiggelbout
  (Leiden)

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Clinical Decision Making
Patient
Doctor
communication
Preferences
Risk level
Diagnostic Testing?
Treatment?
Education/Counseling?
Follow-up, Monitoring
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Clinical Decision Making
Patient
Doctor
communication
Risk level
Preferences
High enough to merit further testing or treatment?
Diagnostic Testing

• Cost?
• Covered by insurance?

• Which tests available?
• Accuracy of test sensitivity/specificity?
• Will it affect treatment?

Which test to order?

• Exact name of test
• billing code
• Special considerations?
• Fasting?
• Informed consent?
• Referral?

How to order?
Explain test to patient
Interpret results
Treatment
Explain drug to patient

• Cost?
• Covered by insurance
• Pre-approval needed?

Counseling
Follow-up, monitoring
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10,000 women taking HT for 1 year
WHI Results

• 7 more CHD events
• 8 more strokes
• 8 more pulmonary emboli
• __________________
• 23 more life-threatening events

• 6 fewer colorectal cancers
• 5 fewer hip fractures
• __________________
• 11 fewer life-threatening events
• Difference 12 events/ 10,000 women

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10,000 women taking HT for 1 year
WHI Results

• 7 more CHD events
• 8 more strokes
• 8 more pulmonary emboli
• __________________
• 23 more life-threatening events

• 6 fewer colorectal cancers
• 5 fewer hip fractures
• __________________
• 11 fewer life-threatening events
• Difference 12 events/ 10,000 women