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DECISION SUPPORT FOR

CONSUMERS

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INTRODUCTION :>Patients who are more informed and knowledgeable about clinical andquality of life aspects of their disease and its treatment are more likely tohave a satisfaction with their care process and treatment outcomes .>Applications of computer technologies, including telecommunicationssystems, Internet and the World Wide Web and multimedia informationdisplay showed patients, their family caregivers, bad concerned others tobecome active informed participants in the management of the health-careprocess .

*Because of the computer-based applications designed, patients can nowmake better decisions about the health services they need.

There were tools that employed decision theories to guide patients in understanding andperforming a structured analysis.

**computer tool is used to provide information, advice, and coaching based on theexperiences of other patients.

**may refer to the WWW that allows to autonomously collect health-related information**tools may let the patients know or view their clinical records

HEALTH-RELATED DECISION-MAKING

>Humans employ simplifying mental mechanisms as coping strategies to help themsort significant from insignificant facts, to organize and interpret complexobservations, to facilitate recall and synthesis of known knowledge with new facts.>Health-related decision-making is complicated because the substance of theproblems and choices is itself complex and exceeds the knowledge and educationof most laypersons

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> n a on, ea -re a e ec s on ma ng s comp ex ecause genera y nvo ves morethan a single person. For this must involve the family members and the healthcaredelivery team.

SHARED DECISION-MAKING AND INFORMEDCHOICE>By involving patients in healthcare decision making, they

are best able to determine which values should governtheir care.>Shared decision-making is also known as relationship or collaborative decision-making which empowers patients to chooseamong the options available to them .>Shared decision-making is the concept of evidence-informed choice .

-informed consent involves the patient acknowledging that they havereceived adequate information to assent to the care that isrecommended by their clinician

PATIENT PREFERENCES>There were theoretical foundation for building health informatics tools that aid in theassessment of patient preferences:

*Von Neumann and Morgenstern (1964)- they proposed that values and

attitudes that drive individual choice could be understood throughmathematical formulations.

*Ledley and Lusted (1999)- they introduced the concept of mathematical reasoning to medical decision-making

*Raiffa (1968)- explicated decision analytic strategies that broughttreatment of personal preference and uncertainty

*Pauker and McNeil (1981)- demonstrated the feasibility of using

decision analysis to better understand treatment choices that arecomplicated by multiple uncertainties

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Two main branches of decision theory:*decision analysis-helps in choosing one course of action*normative decision theory

MAUT (Multiattribute utility theory)- provides the mechanism for quantifying

the subjective value of health states and therefore can be very useful topatients.- it is based on compensatory rules that allow for assessingtradeoffs among entities in such a way that a high value for one entity is compensated for by a low value

ALTERNATE MEANINGS OF THE TERM"PREFERENCES"

>Some consider preferences as an input to a decision whileothers view preferences as the final choice resulting from adecision.>Some use the term "preference" to represent an individual's finalchoice of one option from many possible treatment options

CHALLENGES TO USING PATIENT PREFERENCES FOR HEALTH-RELATED

DECISION-MAKING>Although the value of understanding and using patient preferencesin healthcare decision-making is well-recognized, still it can present adaunting challenge to patient for such a reason that many patientslack experience with thinking about abstract concepts like values,preferences, and risks.

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>Those who were basing their decision on survival data preferred the treatment in questionless often than those of who were basing on mortality data.

>A study shows that the use of multimedia testimonials in which patient describes his/her experience with a health state or with a treatment decision process found that a mismatchbetween the race or gender of the patient in the video and the patient viewing affected thepreference for predicted health states.

>Preference assessment is an iterative, cognitive process designed to help a personunderstand and clarify personal values, healthcare situations treatment options and likelyoutcomes and to elicit statements of preference.

>Use of computer technologies reduce the demand for repetition of analysis or communicationon the part of the patient and helps to insure that data collected is transmitted in a timelyfashion to involved clinicians.

>The patient is considered to be the direct user of these ethnology preference applications, butthe results are used collaboratively in a shared decision process with his/her clinician.

>Achieving congruence between a patient's preferred and actual role in the decision-makingprocess contributes to the level of satisfaction with the treatment process.

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Computer Technology and Patient Decision-MakingComputer Technology and Patient Decision-Making*Stanford Center for the Study of Patient Preference-pioneer in the use of computers and the internet for low-cost elicitation of patient preferencesfor health states

Methods used for Preference assessments

1. Standers Gamble (SG) method-asks the patient to determine the indifference point where living in specified health state isperceived to be equivalently preferable to a specific probability of death2. Visual Analog Scales (VAS) method-uses a visual representation of a linear scale with one end representing the best possible

health state and the other representing the worst possible health state3. Pair-wise Comparisons(PWC) method-asks patient to evaluate their preferences for each possible heath state or treatment in apair-wise fashion4. Trade-off (TT) methods-asks the patient to determine the number of years that life in perfect health would be equallypreferable to a longer period in the health state in question

* Shared Decision-Making Program (SDP)

-Developed within a framework grounded in the idea that rational treatment decisionmaking considers both what the patient wants and what the clinician views asappropriate-designed for use in the clinical setting to aid patients facing complex treatment choices

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F acilitating data management*Health related quality of life (HRQOL)-the value assigned to the duration of life as modified by the social opportunities, perceptions,functional states, and impairments that are influenced by disease, injuries treatment or policy.

L inking preference with treatment decisions

*Health Touch-designed by the Department of Family Practice at the Medical College of Virginia,Virginia Commonwealth University-a computerized health information system for health promotion and disease preventionfro use in the primary care-Intended to supplement clinician involvement in patient focused preventive services-incorporated in the health practice in two ways:

>Actively- by staff directing the patient to complete the survey>Passively-by placing the computers in the waiting area and allowing use

based on patient choice

Decision aids

-developed to provide assistance to patients who are facing complex healthcaredecisions-goal: to support and enhance patient ability to choose a course of treatment that isconsistent with their values-targeted to providing the patient with a level of information adequate to allow them tomake informed choices and participate in the shared decision process-can function as an intelligent disease management agent

-effective at assisting patients with assessments of the individual risks of having thelatent disease along with understanding the implications of the result of the test as

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*Ottawa Health Research Institute (OHRI)-developed a set of evaluation measures and instruments that can be used by implementers of DDS to assess their system performance Acute Disease Decision Support Systems-DDSs that are employed in the support of acute disease states-focused on supporting the patient by providing for their informational and preferencedetermination needs regarding a single episode of treatment choices

Chronic Disease Management Decision Support Systems-enable the patient to better monitor and treat chronic diseases resulting in increased lifespanand QOL

Primary Components:>assessment-used to measure the patients health state along the key dimensions of physical condition,functional status, and behavioral tendencies>information-used to provide information and guidance that is customized to the current health status of the patient>communication-provides an integrated mechanism for communicating with clinician-public/private options:1. An unrestricted public bulletin board2. Private electronic mail3. A question and answer area

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Decision-Making to Promote Health Behavior ChangeThere are dozens of theoretical models have been proposed for how to bring about achange in health behavior and lifestyles and these proposed changes fall into three broadcategories.

1. Individual changeFour theories of individual change;a. health belief modelb. stages of change modelc. reasoned actiond. stress and coping model of changeThese theory focus on the individual and imply that a change or the lack of it can be explained byindividual characteristics.

2. Interpersonal changeThree theories of interpersonal health behavior;

a. social cognitive theoryb. social support theoryc. patient provider communication

These focus on the interaction of two or a group of individuals and how these interactions canpromote change.

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3 .Community changeFour theories of community group intervention models;a. community organizationb. diffusions of innovations

c. organizational changed. communication theoryThese models are helpful for leaders who want to make changes in organizations.

Most behavior change models assume that individuals are aware of their alternatives,know their own values, and process information quickly and efficiently to choose what is in their best interest.

When actions are repeated frequently over time, habits are formed. Decisions are linked to

many prior large and small choices, and affect future options. To change habits, it is notenough to change a single act. All related decisions and reinforcements also must beexamined and modified. Successful change requires careful study of reinforcements and anunderstanding of linkages among decisions so that all decisions support the same action. Itis proposed that to change the system that maintains a habit one must;

1. Identify and examine the linkages among decisions.

2. Measure and receive feedback about behaviors.3. Proposed and try out new activities to improve these habits.4. Build these decisions and behaviors into everyday routines and continue over a longperiod of time.In this context, willpower and discipline are organized and enhanced by changing thesystem of linked decisions.

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Decision Support in Screening for L atent Health Conditions

Patient decision making in the context of application of screening test has a different set of characteristics than those applied in acute, chronic disease management, or behavioralmodification situations. Screening test may have an effects on a patients life that are far broader than just their state of health and carry a different sets of side effects including thepotential for individual and family psychologic harm as well as for affecting a persons abilityto obtain insurance.

In the event the patient chooses to undergo screening, an additional layer of decisionmaking requiring decision support is undertaken to determine what clinical course of

treatment is to be followed in the context of the test results. Decisions regarding screeninginvoke an additional layer of uncertainty that involves the correctness of the test results,which is their sensitivity and specifity.

Sensitivity is the ability of a test to determine which patients have a disease.Specifity is the ability of a test to determine which patients do not have a disease .

SUMMARY: Decision Making and Choice in Healthcare

Decision-making is a choice in healthcare is shaped by three important trends;

a. recognition of both the value and limits of a science as a guide for careb. a philosophy of care management that emphasizes standards and coordinationc. a growing importance of a patient as a key participant in selecting and implementing clinicaltreatment

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Each of these trends supports the need for explicit consideration of patient preferences as aguide to choosing healthcare

In summary, computer technology can solve some, but not all, of the challengesinherent in employing patient references practices. As a new computer tools are developedto support health-related decisions, clarity about the models of decision-making beingemployed and their and their match to the type of decisions being addressed is crucial.Computer networks can insure the rapid, efficient transmission of their patient preferencesin the privacy of their homes or away from the anxiety-producing health encounter.Computer algorithms build and integrated into a computer based patient record, have theability to insure that care is in accord with patient preferences. The WWW, CD-ROMs, andother computer tools can deliver informational interventions tailored to the needs, interest,and display requirements of individuals.