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Guyatt G, Rennie D, Meade MO, Cook DJ
Part G Moving from Evidence to Action
Chapter 22.2. Decision Making and the Patient
Victor M. Montori, P. J. Devereaux, Sharon Straus, Brian Haynes, Gordon Guyatt
Devereaux et al9 used a technique called probability tradeoff (including clear...

Topics Discussed: alteplase, atrial fibrillation, cerebrovascular accident, clinical decision making, decision analysis, decision making, decision support techniques, gastrointestinal bleeding, incorporating patient values and preferences, measuring patient experience, myocardial infarction, patient-important outcome, streptokinase, stroke prevention, visual analogue pain scale

Excerpt: "Table 22.2-1 summarizes decision-making approaches theoretically available to the clinician and patient facing an important decision.When clinicians offer patients minimal information about the options and make the decision without patient input, a style commonly referred as parental or paternalistic, they are not considering patient values and preferences. This does not mean that patients do not have an opportunity to express their wishes, but they may do so in a delayed fashion and through actions. For instance, if the choice was not consistent with their values and preferences, then patients may not act on the decision or may quickly abandon the plan shortly after the visit with the clinician. To the extent that EBM requires the incorporation of patient values and preferences in decision making, a parental approach to clinical decisions is inconsistent with the practice of EBM.Heyland et al5 asked 120 at-risk patients to consider whether they would prefer streptokinase or tissue plasminogen activator (TPA) if they were to have a myocardial infarction. To obtain their informed preference, they used a decision tool that described the outcomes (myocardial infarctions, death, and thrombolytic-associated stroke) and the likelihood of death and stroke when using TPA and streptokinase (ie, TPA use was associated with 9 fewer deaths and 4 more strokes per 1000 patients treated compared with streptokinase) derived from the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) trial.6 The tool worked insofar as all patients chose TPA when the difference in stroke risk was reduced to 0, and all patients chose streptokinase when the difference in mortality risk was reduced to 0. Decision analyses under the expected utility theory assumptions found TPA to be the dominant option. In the study, only half of the patients, however, chose TPA. The other half might have considered the additional 1% mortality benefit TPA afforded to not be worth the 0.33% additional stroke risk and therefore opted for streptokinase.Devereaux et al9 used a technique called probability tradeoff (including clear descriptions of the outcomes of interest and iterative testing of preferences with changing likelihood of competing outcomes) to determine the strength of preference for anticoagulation to prevent stroke in 61 at-risk patients and 63 physicians who treated patients with atrial fibrillation. The figure in this box shows the maximum number of excess upper gastrointestinal bleeding episodes per 100 patients treated to prevent 8 additional strokes (4 major and 4 minor) that patients and physicians found acceptable. The figure shows the following: (1) there is variability in stroke aversion among patients and among physicians; (2) patients seem more stroke averse than physicians; (3) physicians seem more averse to adverse outcomes that they "cause" with their prescription (eg, bleeding) than to adverse outcomes that result from clinical course (eg, strokes). If one believes that patient preferences should guide treatment, these data suggest the following: if clinicians fail to incorporate patient values and preferences in the decision-making process, they will recommend against anticoagulation more often than is appropriate and, depending on which physician patients see, they will or will not get the treatment they would prefer.To effectively communicate the nature of the options, researchers have devised and tested tools called decision aids. These tools are an alternative to the use of intuitive approaches to communicating concepts of risk and risk reduction that clinicians may have developed through clinical experience. Decision aids present, in a patient-friendly manner, descriptive and probabilistic information about the disease, treatment options, and potential outcomes.16-18 A well-constructed decision aid is valuable in that someone has performed a systematic review of the literature and produced a rigorous summary of the outcomes and their probabilities. Clinicians who doubt that the summary of probabilities is rigorous can review the primary studies on which those probabilities are based and, using the principles of this book, determine their accuracy. Furthermore, a well-constructed decision aid offers a pretested and effective way of communicating information to patients who may have little background in quantitative decision making. Most commonly, decision aids use visual props to present the proportion of people who experience the outcomes of importance with and without the intervention (Figure 22.2-2A and B).Having a mild stroke causes you to slur your words. After a mild stroke, you are able to fully understand what is being said to you. Your thoughts remain clear and you can carry out a conversation without much trouble, but sometimes you cannot find the right word to use. Your thinking ability is otherwise normal. There is some weakness and numbness in your right arm and your face has a slight droop. You are able to feed, dress, and bathe yourself. However, you cannot grip objects as tightly as you could before the stroke, objects sometimes fall from your hands, and you have difficulty writing. Your condition will not get better.Should clinicians interested in practicing EBM and expecting to make clinical decisions that incorporate the values and preferences of the informed patient use one or more of the above approaches for all decisions? The ultimate constraint of clinical practice is time. Many clinicians have more to do in each encounter than they did in the past.24-26 Attention to the patient's agenda competes with other activities that clinicians ought to do (eg, documentation, routine preventive care27) during visits that have not increased in duration to accommodate these additional activities and demands. Thus, it is not surprising that clinicians frequently cite time as a key barrier to patient education about options and to enhanced patient participation in decision making.28-32  Table 22.2-2 provides some suggestions for what to do when time is limited...."
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