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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

Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

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Page 1: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

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

Page 2: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

Acute Respiratory Infections (ARI)

~5.9 million prescriptions for ARIs in Australia per year in general practice

>80% are unnecessary

Page 3: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

“Patients expect antibiotics”

“Patients demand antibiotics”!

Page 4: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

“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.

Page 5: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

Annals of Family Medicine. 2017; 15: 149-152.

Expected benefits up to 5-10 times greater than actual benefit

Page 6: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

How can we manage these expectations and beliefs?

Page 7: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

…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?

Page 8: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

“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.

Page 9: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve
Page 10: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

WANT BIG IMPACT?Use big image.

Page 11: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

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.

Page 12: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

Clinicians’ expectations

• 50% overestimated benefit of antibiotics for AOM • 44% overestimated the risk of not prescribing antibiotics

Page 13: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

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…

Page 14: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

? But does it work?

Page 15: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

10 reports of 9 RCTs >1100 primary care doctors~492,000 patients

Cochrane Database of Systematic Reviews, 2015, Issue 11

Page 16: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve
Page 17: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

But….implementation of SDM is limited

Low awareness of what it is and

how to do it

Need for brief interventions

Page 18: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

Brief decision aids for:

- Acute otitis media- Sore throat- Acute bronchitis

Page 19: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

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

Page 20: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

INFORMED BY…

Systematic reviews of antibiotic benefits…

and harms

Systematic reviews on public and clinicians’ understanding of antibiotic resistance

Page 21: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

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…

Page 22: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

Thank you

Questions?

[email protected]

Page 23: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve

CREDITS

Template by SlidesCarnival; Line icons by Mirko Monti

Page 24: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve
Page 25: Shared Decision Making decision making - Its role... · Hoffmann et al. Shared decision making: what do clinicians need to know and why should they bother ? MJA 2014; ... - to achieve