Decision aids in clinical practice
http://www.100md.com
《英国医生杂志》
1 Ottawa Hospital, 1053 Carling Avenue, Ottawa ON, Canada, K1Y 4E9 ancranney@ohri.ca
Decision aids can be a useful format to communicate evidence based information on harms and benefits of therapies to individual patients. When used as an adjunct to the consultation, decision aids can change the format of the consultation process; decision aids are designed to enhance communication and interaction between patient and practitioner—not to replace it. Decision aids are not indicated for each clinical decision or scenario and they may not appeal to all physicians. But trials evaluating decision aids in the United Kingdom concluded that they helped patients use information to clarify their values and preferences.1-3
I have had the opportunity to use a decision aid in the clinical setting. This decision aid incorporates detailed information about self care and multiple therapies and has recently been adapted for use in a UK research project. I have found that exposing patients to the current evidence on efficacy, benefits, and harms enhances the consultation by focusing the discussion and ensures that consistent information is given to each patient.
Many respondents on bmj.com questioned the availability of such tools that include evidence based data and the plausibility of their use in everyday practice. New initiatives are making decision aids available on the web, which can be reviewed by patients in their own time or discussed with a nurse educator. If easily accessible and used correctly, decision aids can save time during the consultation. By helping determine the patient's preferred role for participating in the decision—for example, "doctor, what should I do?" or "I want to decide"—decision aids can help practitioners judge whether they can move quickly from facilitating the decision making process to planning treatment.
When introduced at the point of care, decision aids can be used to develop individual risk factor profiles. Treatment options can then be tailored according to the individual's risk. In this case, the physician knew that Mrs Patell had responded well to a non-steroidal anti-inflammatory drug; there was no question that Mrs Patell could be one of 94 who do not benefit. Incorporation of absolute numbers in a graphical format, in addition to an explanation of the risks and benefits, helps patients to understand the concept of number needed to treat. Use of absolute numbers can also result in a more realistic interpretation of the individual's risk profile and the potential harms and benefits of each treatment.
Decision aids enhance knowledge of available treatment and self care options and, by involving the patient, improve satisfaction with the decision making process. They have the potential to increase long term adherence with chosen treatments. Future priorities include the integration of decision aids at the point of care and exploring the role of other team members to prepare patients for discussion with their physician.
Competing interests: None declared.
References
Kennedy AD, Sculpher MJ, Coulter A, Dwyer N, Rees M, Abrams KR, et al. Effects of decision aids for menorrhagia on treatment choices, health outcomes, and costs: a randomized controlled trial. JAMA 2002;288: 2701-8.
Murray E, Davis H, Tai SS, Coulter A, Gary A, Haines A. Randomised controlled trial of an interactive multimedia decision aid on hormone replacement therapy in primary care. BMJ 2001;323: 490-3.
Murray E, DavisH, Tai SS, Coulter A, Gray A, Haines A. Randomised controlled trial of an interactive multimedia decision aid on benign prostatic hypertrophy in primary care. BMJ 2001;323: 493-6.(A Cranney, rheumatologist)
Decision aids can be a useful format to communicate evidence based information on harms and benefits of therapies to individual patients. When used as an adjunct to the consultation, decision aids can change the format of the consultation process; decision aids are designed to enhance communication and interaction between patient and practitioner—not to replace it. Decision aids are not indicated for each clinical decision or scenario and they may not appeal to all physicians. But trials evaluating decision aids in the United Kingdom concluded that they helped patients use information to clarify their values and preferences.1-3
I have had the opportunity to use a decision aid in the clinical setting. This decision aid incorporates detailed information about self care and multiple therapies and has recently been adapted for use in a UK research project. I have found that exposing patients to the current evidence on efficacy, benefits, and harms enhances the consultation by focusing the discussion and ensures that consistent information is given to each patient.
Many respondents on bmj.com questioned the availability of such tools that include evidence based data and the plausibility of their use in everyday practice. New initiatives are making decision aids available on the web, which can be reviewed by patients in their own time or discussed with a nurse educator. If easily accessible and used correctly, decision aids can save time during the consultation. By helping determine the patient's preferred role for participating in the decision—for example, "doctor, what should I do?" or "I want to decide"—decision aids can help practitioners judge whether they can move quickly from facilitating the decision making process to planning treatment.
When introduced at the point of care, decision aids can be used to develop individual risk factor profiles. Treatment options can then be tailored according to the individual's risk. In this case, the physician knew that Mrs Patell had responded well to a non-steroidal anti-inflammatory drug; there was no question that Mrs Patell could be one of 94 who do not benefit. Incorporation of absolute numbers in a graphical format, in addition to an explanation of the risks and benefits, helps patients to understand the concept of number needed to treat. Use of absolute numbers can also result in a more realistic interpretation of the individual's risk profile and the potential harms and benefits of each treatment.
Decision aids enhance knowledge of available treatment and self care options and, by involving the patient, improve satisfaction with the decision making process. They have the potential to increase long term adherence with chosen treatments. Future priorities include the integration of decision aids at the point of care and exploring the role of other team members to prepare patients for discussion with their physician.
Competing interests: None declared.
References
Kennedy AD, Sculpher MJ, Coulter A, Dwyer N, Rees M, Abrams KR, et al. Effects of decision aids for menorrhagia on treatment choices, health outcomes, and costs: a randomized controlled trial. JAMA 2002;288: 2701-8.
Murray E, Davis H, Tai SS, Coulter A, Gary A, Haines A. Randomised controlled trial of an interactive multimedia decision aid on hormone replacement therapy in primary care. BMJ 2001;323: 490-3.
Murray E, DavisH, Tai SS, Coulter A, Gray A, Haines A. Randomised controlled trial of an interactive multimedia decision aid on benign prostatic hypertrophy in primary care. BMJ 2001;323: 493-6.(A Cranney, rheumatologist)