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The EBM Information Quest: Is it true? Is it useful? Is it usable?™
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Evidence-based Information & Decision Aid Examples for Health Care Professionals & Patients—Putting Everyone on the Same Page
Patient-centered Resources: Doctor-Patient Communications
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The strongest association for improved patient outcomes with physician behavior is for providing information to patients. Numerous studies have showed a statistically significant association between providing information and satisfaction, symptom improvement, trust, comprehension, adherence.
We especially like these studies:
Stewart MA. Effective Physician-Patient Communication and Health Outcomes: A Review Abstract
Hall JA; Roter DL; Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Medical Care;1988, 26:657-675. PMID: 3292851. Abstract.
Beck RS, Daughtridge R, Sloane PD. Physician-Patient Communication in the Primary Care Office: A Systematic Review. JABFP 2002. 15:25-38. The Journal of the American Board of Family Practice. PMID: 11841136. Abstract.
Here's our critical appraisal of their review: Beck
with Patients — A Clinician-centered "Map" for
Information & Engagement
Discussing Information and Decisions with Patients
Say R, Thomson
According to Shepherd et al , 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. 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). Pamphlets, videos, tools of various sorts may be employed to facilitate SDM. Tactics and tools that appear to increase SDM include—
*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:
Examples of decision-aids are available from the following:
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.
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.
of Decision Aids for Menorrhagia on Treatment Choices, Health
Outcomes, and Costs
This RCT (JAMA. 2002;288:2701-2708) reports that information alone did not affect treatment choices for menorrhagia when compared to usual care, but that adding the engagement of a physician did. Also, costs were reduced when decision-aids and a clinician interview were utilized. Enter PMID number in search window at www.pubmed.gov to read the abstract.
AD, Sculpher MJ, Coulter A, Dwyer N, Rees M, Abrams KR, Horsley
S, Cowley D, Kidson C, Kirwin C, Naish C, Stirrat G. Effects
of decision aids for menorrhagia on treatment choices, health
outcomes, and costs: a randomized controlled trial. JAMA. 2002
Dec 4;288(21):2701-8. Erratum in: JAMA. 2003 Feb
For several years we have suggested that QI staff consider the use of messaging scripts — targeted treatment messaging & decision support tools for specific clinical topics. In brief, messaging scripts can be used for a variety of purposes.
Some examples —
Although their approach differs from ours by including endorsements from opinion leaders rather than evidence statements with references, a Canadian group from Alberta has reported in CMAJ impressive results in creating clinical change using “messages,” also referred to as “guidelines” as part of a multifaceted intervention to improve care.
The study was a double-blind, randomized clinical trial of patients older than 50 seen in the emergency room with an acute wrist fracture. 137 patients were randomized to the control group and 135 patients to the intervention group with concealed allocation, blinded assessment and ITT analysis.
The control group
received a copy of the Osteoporosis Canada pamphlet with encouragement
to read it and discuss it with their respective primary care
In the intervention arm, messages were mailed or faxed to physicians and written along with verbal messages, and “printed materials” were delivered to patients by an experienced registered nurse. The messages sent to physicians were endorsed by 5 local opinion leaders.
The messages and guidelines are available at http://www.cmaj.ca/cgi/content/full/178/5/569/DC2.
The primary outcome was starting treatment with a bisphosphonate within 6 months after the fracture. This outcome was determined by patient self-report and was confirmed through dispensing records of local community pharmacies. There was 100% agreement between self-reporting and dispensing records.
Secondary outcomes included bone mineral density testing, “appropriate care” (consisting of bone mineral density testing with treatment if bone mass was low) and quality of life.
Six months after the fracture, 30 (22%) of the 137 intervention patients, as compared with 10 (7%) of the 135 controls, had achieved the primary study outcome of bisphosphonate treatment for osteoporosis (unadjusted RR 3.0; adjusted RR 2.6, 95% CI 1.3–5.1, p = 0.008). Absolute increase in bisphosphonate treatment was 15%, NNT=7. The authors state that, “overall, the intervention led to a 27% absolute increase in the delivery of guideline-concordant (“appropriate”) care, which translates into an NNT of 4 patients.”
To summarize our preferences for messaging scripts — they are —
More details and templates ( Delfini Rx Messaging Scripts ™) can be found on the Delfini website at http://www.delfini.org/page_SamePage_RxMessagingScripts.htm
Widespread uncritical support for screening is a major problem and this article provides valuable information and guidance.
Use of decision aids to support informed choices about screening.
BMJ. 2004 Aug 28;329(7464):507-10
Full text available at: http://bmj.bmjjournals.com/cgi/content/full/329/7464/507
for Increasing Adherence
Unfortunately the evidence is weak, and the answer does not appear simple. More evidence is needed.
It does appear that about half the studied interventions are associated with statistically significant medication adherence and fewer are associated with improvements in treatment outcomes. For long-term care, adherence appears to be increased by utilizing a combination of strategies. This is in keeping with the evidence regarding successful implementation of clinical guidelines.
Strategies to keep in mind include:
This systematic review of this topic can be found in JAMA.
JAMA 2002 Dec 11;288(22):2868-79
The Review is available to subscribers of ACP Journal Club:
ACP Journal Club. The Resourceful Patient. 2002 Nov-Dec;137:A14.