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Patients’ medical decisions benefit from DVD guidance

An evidence-based video that reviews the pros and cons of back surgery to treat a herniated disk can help patients learn more about their condition and make medical decisions in line with their goals and preferences, stated a study published Aug. 16 in Spine.

The 38-minute DVD was part of a tool known as a patient decision aid. These are videos, booklets and other materials designed to supplement face-to-face doctor counselling on complex medical choices. The tools encourage patients to interpret the ideal available evidence in light of their care goals and often include stories from other patients to provide meaningful context about likely outcomes.

The Ottawa Hospital Research Institute lists almost 300 English-language decision aids covering a wide variety of clinical areas, including allergies, depression and weight control. The tools promise to help time-squeezed physicians walk patients through tough choices while tapping unbiased and reliable sources of information as part of a process dubbed shared decision-making.

Yet evidence on how well decision aids improve patient knowledge and yield better decisions has lagged behind promotion of the tools.

The items covered essential questions about the condition, such as whether bed rest could help relieve the pain caused by a herniated disk. The evidence shows that bed rest does not help. Although 60% of the decision-aid patients knew that, only 51% of the other patients answered correctly.

“The goal with the knowledge questions is not to be tricky or pick out obscure facts,” stated Karen R. Sepucha, PhD, the study’s lead author. “We need to do a better job of informing our patients.”Similar studies of how decision aids affect patients considering breast cancer surgery and coronary artery bypass graft surgery have yielded better results. Patient knowledge scores for those conditions have been in the 70%-to-90% range, stated Sepucha, senior scientist with the Health Decision Sciences Center at Massachusetts General Hospital in Boston.

The herniated disk decision aid was created by the non-profit Informed Medical Decisions Foundation, also in Boston. The foundation has been developing these kinds of materials since 1990, and is working to implement and test the tools with physicians and patients at 10 health care organizations around the country, including the Stillwater Medical Group in Minnesota and the University of California, San Francisco’s Breast Care Center.

Massachusetts General is expanding its use of decision aids, stated internist Creagh Milford, DO, a fellow in health policy and management at the Massachusetts General Physicians Organization, the medical group that serves the hospital. In September, the hospital is starting a pilot with cardiovascular care materials and will expand to orthopedic care in the fall.

The decision aids are part of a broader effort to avoid inappropriate procedures, an initiative that could mean shared savings for the hospital as part of the new pioneer accountable care organization. The plan is not to steer patients away from surgery, but to make sure their decisions are informed and well-deliberated, Dr. Milford said.

“The first phase is ensuring that every patient receives these shared decision-making materials,” stated Dr. Milford, who also is an teacher of medicine at Harvard Medical School. “Even after patients have better education in some of these procedures, sometimes they select to do the procedure, and in some cases they select not to do it. It will be interesting to see which way the preferences go.”

With or without these decision aids, there are some ways physicians can help patients work through their options, according to the Informed Medical Decisions Foundation. These steps include:

Letting patients know that they have medical options and encouraging discussions about them. Presenting choices with information on risks and benefits. Helping patients assess options based on their care goals and concerns. Asking patients what else they want or need to know before deciding. Defining the next steps once a choice is made.

“We’re trying to figure out ways to help the physicians to shift their conversations, so it’s more about engaging with patients and less about just giving straight recommendations,” Sepucha said. “The patients have a large role in this, too.”

How decision aids inform patient choices

Patients who watched an evidence-based video to help them decide on treatment for a herniated disk scored 17 percentage points higher on a test of knowledge than patients who did not receive a decision aid. On questions covering topics such as surgical outcomes and medication risks, patients who got the decision aid reliably scored better.

Question (Correct response)Decision aidNo decision aidFor most people with a herniated disk, how likely is it that doing normal activities will make their herniated disk worse? (Not very likely)43%27%Over time, without surgery, does back and leg pain caused by a herniated disk usually get better, stay the same, or get worse? (Gets better)53%13%Which treatment is most likely to provide faster relief from pain caused by a herniated disk? (Surgery)53%36%Is excessive bleeding a possible side effect of using over-the-counter pain medicine for a long time? (Yes)86%67%

Copyright 2012 American Medical Association. All rights reserved.

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Submited at Tuesday, September 11th, 2012 at 4:15 pm on Uncategorized by jessica
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