International Experience with Evidence Dissemination about HTA

- The Case of Shared Decision Making -

Mirhelen Mendes de Abreu, M.D., Ph.D.

Professor of Rheumatology - UFRJ

II Simpósio Internacional de Farmacoeconomia para o SUS

Disseminação da ATS para a Tomada de Decisão

Agenda

Understanding the Concept

• Framing the Concept

• Priority Research Issues

• Barriers and Challenges to Implement SDM

Shared decision making around the globe

• The state of the art

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International Experience with Evidence Dissemination about HTA - The Case of Shared Decision Making -

Shared Decision Making

Understanding the Concept

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Understanding the Concept

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A Conceptual Framework - Summary

Types od decision-making - Summary

Paternalistic

Informative

Shared

Physician

Physician

Physician

Opinion

Information

Information and opinion

Patient

Patient

Patient

Shared Decision Making

What Are the Priority Research Issues?

8 Journal of Interprofessional Care, 2011

Priority Research Issues

Levels of investigations

Micro

– Groups of providers; individual providers; individual patients; group of patients

Meso

– Health care system practices; academic health center training

Macro

– Governmental policies; national research funding agenda

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Priority Research Issues

Journal of Interprofessional Care, 2011

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Priority Research Issues

Shared Decision Making

How Do We Implement It? - The Role of Health Policy -

Governments are increasingly urged to develop evidence-based policies with support from their technical arms and advisers and in collaboration with the research community.

This translation of evidence into policy and subsequently practice is seen as an important contribution to improving health.

The greater availability of systematic reviews on clinical topics and especially the expansion of the Cochrane Library should in theory have made this process considerably easier.

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M. English, N. Opiyo / Journal of Clinical Epidemiology 64 (2011) 708e710

Health Policy, Guidelines and Recommendations

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NEJM, 2012

SDM - How Do We Implement It? The Role of Health Policy

Shared Decision Making: How Do We Implement It?

- Skills and Abilities -

Risk Communication – Definition

“The open two-way exchange of information and opinion about risk, leading to better understanding

and better (clinical) decisions”.

Ahl et al. RSTOIE 1993;12:1045-1053

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Communicating the Uncertainty of Harms and Benefits of Medical Interventions

Communicating Risks

One of the stages of shared decision making

Provide information in preferred format

Checking: understanding & reactions

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Communicating the Uncertainty of Harms and Benefits of Medical Interventions

Politi MC, Han PKJ, Col NF. Communicating the uncertainty of harms and benefits of medical interventions. Med Decis Making 2007; 27: 681

Shared Decision Making:

How Do We Teach It?

How Do We Teach It?

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How Do We Teach It?

Shared Decision Making Around the Globe

- Some Initiatives -

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Shared Decision Making Around the Globe ZEFQG 2011, 105 (4)

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Shared Decision Making Around the Globe ZEFQG 2011, 105 (4)

Shared Decision Making in Peru

Policy

A shift for SDM healthcare model.

Decision supports: academic environment; focus on reduction of health

inequalities.

Professional interest and implementation: significant challenges for

implementation of a country-wide SDM policy.

Future perspectives: promoting an active and informed participation of

patients in their healthcare process

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Shared Decision Making Around the Globe ZEFQG 2011, 105 (4)

Shared Decision Making in Chile

Policy

(1) Health Reform in 2003

(2) Sanitary Objectives 2011-2020 (brief section on client participation

and SDM)

Decision supports

limited in Chilean academics environment.

focus on type 2 diabetes.

Professional interest and implementation: significant challenges for

implementation of a country-wide SDM policy.

Future perspectives: promising given the new health policies, local

Chilean research projects, and international initiatives and

collaborations.

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Shared Decision Making Around the Globe ZEFQG 2011, 105 (4)

Shared Decision Making in USA

Policy

Health Care Reform includes SDM in agenda.

Decision supports: academic environment; implementation in

clinical practice.

Professional interest and implementation: growing.

Future perspectives: international collaboration, grants and

fundings for researches.

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Shared Decision Making in USA, Europe, Canada

Policy

Decision support Research

Implementation

Barriers and challenges are

similar among the countries

Z. Evid. Fortbild. Qual. Gesundh, 2011

27 http://portal.saude.gov.br/portal/arquivos/pdf/doc_base.pdf

Shared Decision Making in Brazil

Policy

28 http://portal.mec.gov.br/cne/arquivos/pdf/CES04.pdf

Medical Scholar Policy

Shared Decision Making in Brazil

- Potential Barriers and Challenges -

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Shared Decision Making: How Do We Implement SDM in Clinical Practice?

- The Role of Decision Aids -

Rev Bras Reumatol 2006; 46 (4), 266 - 272

• Decision Aids (DAs)

How to present/translate risk information to the lay

public?

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Charles & Gafni, 2006

• Decision Aids (DAs)

Tools designed to provide information to patients

about options, probabilities of harms and benefits, and

to enable values to be clarified: can be paper- or web-

based, decision boards, CDs.

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Patient Clinician Others

Others

Others Others

Others

The Decision Process

Patient

Patient

before after during

Decision Support

Abreu MM et al

Abreu MM et al,Value in Health, 2011

The Role of Decision Aids

Abreu MM et al,Value in Health, 2011

Abreu MM et al,Value in Health, 2011

Shared Decision Making

How Do We Implement SDM in Clinical Practice?

How Do We Implement SDM in Clinical Practice?

Particular emphasis might be placed on:

(i) Underserved populations (low literacy, low numeracy,

low income, non-native language speaking, rural patients and

inner-city patients)

(ii) Patients with chronic conditions; and

(iii) Cross-cultural adaptation and dissemination of DAs and

SDM

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The Integration of Implementation of Practice Guidelines

with Implementation of SDM

The Challenges

Guidelines evolve and increasingly call for the

incorporation of patient’s preferences, goals and concerns.

It is critical to ensure that providers have the skills to do

this well.

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Future Perspectives

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Future Perspectives

Obrigada

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