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Shared Decision Making
Its role in reducing antibiotic use in primary care
@Tammy_Hoffmann
Professor Tammy Hoffmann
On behalf of CREMARA, Professor Chris Del Mar and Peter Coxeter
Acute Respiratory Infections (ARI)
~5.9 million prescriptions for ARIs in Australia per year in general practice
>80% are unnecessary
“Patients expect antibiotics”
“Patients demand antibiotics”!
“
“kills bacteria”
“treats the infection”
“won’t get better unless you treat it”
“relieves the pain”
“it gets better quicker”
Patients’ beliefs about WHY antibiotics are needed for ARIs…
Annals of Family Medicine. 2017; 15: 149-152.
Annals of Family Medicine. 2017; 15: 149-152.
Expected benefits up to 5-10 times greater than actual benefit
How can we manage these expectations and beliefs?
“
…where a clinician and patient jointly participate in making a health decision, having discussed
- the options - their benefits and harms, and - having considered the patient’s values,
preferences and circumstances
Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014;201:35-39.
What is Shared Decision Making?
“Inappropriate antibiotic use is driven by both health care workers and consumers
The state of the world's antibiotics. Centre for Disease Dynamics, Economics & Policy, 2015.
WANT BIG IMPACT?Use big image.
Perceived expectations
Not just patients who overestimate the benefits of antibiotics
‘Wants’ often inaccurately perceived
Often active avoidance of asking
Expectations of benefit
Mustafa et al. Managing expectations of antibiotics for upper respiratory tract infections: a qualitative study. Ann Fam Med 2014;12:29–36.
van Driel et al. Are sore throat patients who hope for antibiotics actually asking for pain relief? Ann Fam Med 2006;4:494–9.
Clinicians’ expectations
• 50% overestimated benefit of antibiotics for AOM • 44% overestimated the risk of not prescribing antibiotics
Shared decision making
- to elicit and manage expectations- to facilitate conversation about benefits and
harms (and correct any misperceptions)- to ensure patients’ preferences are
considered- to achieve a ‘way forward’ that patient and
doctor collaborate on
It can help…
? But does it work?
10 reports of 9 RCTs >1100 primary care doctors~492,000 patients
Cochrane Database of Systematic Reviews, 2015, Issue 11
But….implementation of SDM is limited
Low awareness of what it is and
how to do it
Need for brief interventions
Brief decision aids for:
- Acute otitis media- Sore throat- Acute bronchitis
INFORMED BY…
Nation-wide survey of patients’ experiences and expectations
Risk communication literature on optimal methods for presenting benefit and harm data
Qualitative research
o Benefits of antibiotics overestimatedo Many misunderstandings about harms
(side-effects and resistance)o 75% wanted more involvement in
future decisions
INFORMED BY…
Systematic reviews of antibiotic benefits…
and harms
Systematic reviews on public and clinicians’ understanding of antibiotic resistance
INFORMED BY…
Iterative development- Piloted with patients and GPs
RCT in community sample -hypothetical situation
Cluster RCT in general practices- underway!
28% (95% CI 11 to 45; p <0.002) more participants (57%) who viewed a decision aid demonstrated informed choice than those who received a standard NPS fact sheet (29%)
Liked the decision aids, easy to understand, right length…
CREDITS
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