Oui, non, peuttre: recent advances in supporting patients decisions presentation

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Title: Oui, non, peuttre: recent advances in supporting patients decisions

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Oui, non, peut-être recent advances in
supporting patients decisions

OConnor RN PhD FCAHS

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2 Scénarios
Interventions
Illustrations

2 Scénarios
Interventions
Illustrations

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Scénario 1

You.Vous

Pensez à une GRANDE décision que vous ou
quelqu'un que vous connaissez ferez dans l'année
prochaine.

Think about a BIG decision that you or someone
you know will make over the next year

Aggressive Rx when simpler options fail
Arthritis, back pain,
hot flashes, menorrhagia,
prostate enlargement
stable angina
Surgery/Radiation
breast cancer
prostate cancer
Bad Genes
active surveillance
medicine
surgery

Stades
reproduction
être parent
aidant naturel
retraite
vieillissement
Milieux de vie
naissance
maladie
chronicité
fin de vie
Intensité du niveau de soins
prématurité extrême
soins terminaux

I.C.U.
hospice
home
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Your needs Vos Besoins
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Do you feel sure about the best choice for you?
Do you know the benefits and risks of each
option?
Are you clear about which benefits and risks
matter most to you?
Do you have enough support and advice to make a
choice?

Êtes-vous certain de ce qui constitue le
meilleur choix pour vous? Est-ce que vous
connaissez les bénéfices et risques de chacune
des options ? Avez-vous le sentiment de savoir
ce qui est le plus important pour vous à légard
des risques et bénéfices ? Avez-vous
suffisamment de soutien afin de faire votre
choix ?
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Do you feel sure about the best choice for you?
Do you know the benefits and risks of each
option?
Are you clear about which benefits and risks
matter most to you?
Do you have enough support and advice to make a
choice?

Do you feel sure about the best choice for you?
Do you know the benefits and risks of each
option?
Are you clear about which benefits and risks
matter most to you?
Do you have enough support and advice to make a
choice?

Do you feel sure about the best choice for you?
Do you know the benefits and risks of each
option?
Are you clear about which benefits and risks
matter most to you?
Do you have enough support and advice to make a
choice?

Data from France Legare, U Laval
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Scénario 2 Marie

Ive had a sleepless night
J'ai eu une nuit sans sommeil

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Scénario 2 Marie

Douleur de genou m'a gardé éveillé? not
sure re surgery
Mon mari a une fièvre?
not sure re going to ER
J'ai oublié de remplir ma prescription ?
not sure how important it is

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Marie Marie n'est pas la seule qui est peu sûr

924 patients were questioned
From 5 family practices in Quebec
After making a decision with MD

France Legare, U Laval
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Data from France Legare, U Laval
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Data from France Legare, U Laval
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Data from France Legare, U Laval
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2 Scénarios
Interventions
Illustrations

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22 Reviews Clinical Decision Making
Interventions
67 Reviews Self Care Chronic Disease Self
Management interventions
25 Reviews Health Literacy Interventions
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22 Reviews Clinical Decision Making
67 Reviews Self Care Chronic Disease Self
Management
25 Reviews Health Literacy
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Decision Aids reduce rates of discretionary
surgery
RR0.76 (0.6, 0.9)

OConnor et al., Cochrane Library, 2007

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Review Conclusions

Patient education/ information ? knowledge.
To ? experience, service use, health outcomes,
behaviour change
? specificity/personalization of information
combine interventions with professional or other
social support
extend duration for long term behaviour change
Research gaps essential elements, duration, best
implementation strategies

2 Scénarios
Interventions
Illustrations

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Challenge 1
Need to train potential users
High school students
Post 2ndary students
Health science students day 1 of training
New mothers
Health departments
Call centers and help-lines

BIG Challenge 2
Embed just in time information for an
individual as part of the process of care

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Wagner Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
HHR Utilization
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcome
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Implementation Clinical Care

Dartmouth HMC, VA, Mass Gen. FIMDM Network
Group Health Cooperative
NHS Urology Orthopedics
Ottawa Pilot Orthopedic Intake Clinic
Breast/Prostate Ca Center

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Delivery Model
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Decision Aid
Personal Decision Form
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Summary Report for Surgeons
Stacey, D. et al. BMJ 20080bmj.39520.701748.94v2
-bmj.39520.701748.94
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Median Wait times
indicates censored individuals
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ONLINE QUALITY REPORTS
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Electronic Health Records

Nan Cochrane
Veterans Administration Centers-WRJ
Patients responses to patient decision aids

SDM Report Tab
--------------------------------------------------
------------
CERTAINTY
Prefers PSA TEST
Feels SURE about best choice
KNOWLEDGE
4/5 correct
Knows x
Knows y
Knows z
Knows t
DOESNT know t
Feels INFORMED about options, benefits, risks
VALUES 1-10
Feels CLEAR re personal import benefits/harms
Pros
9 know if has cancer

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Washington State New LegislationBill 5930 (May
2007) An act relating to providing high quality,
affordable healthcare to Washingtonians based on
the recommendations of the blue ribbon commission
on health care costs and access

if a patient/delegate signs an acknowledgement of
shared decision making, such acknowledgement
shall constitute evidence that the patient gave
his or her informed consent to the treatment
administered
Acknowledgement of SDM includes
Statement that patient and health care provider
have engaged in SDM
Brief description of the services the patient and
provider have jointly have agreed to
Brief description of the patient decision aid
used
Statement that patient understands risks or
seriousness of disease, available treatment
alternatives (including non-tx), risks, benefits
and uncertainties of treatment alternatives
Statement that patient had opportunity to ask the
provider questions and have questions answered to
patients satisfaction
SDM Defn process in which the physician or
other health care practitioner discusses with the
patient or his/her representative the information
specified above with the use of a patient
decision aid and the patient shares with the
provider such relevant personal info as might
make one treatment or side effect more or less
tolerable than others

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Key Messages Patient Oriented Interventions

Consistently improve knowledge
Improve patients experience, service use, health
outcomes, behaviour if PERSONALIZED, COMBINED
WITH SUPPORT, EXTENDED DURATION
2 challenges public/professional training,
implementation in routine care

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