Monday, 3 September 2018

The potential of shared decisions

The “Essencial” project of the Quality Agency and Health Evaluations of Catalonia (AQuAS) held a day of reflection on the level of implementation of the recommendations to avoid low-value clinical practices hence those responsible for “Essencial” had the good idea to invite Glyn Elwyn, a researcher specialized in shared decisions at the Dartmouth Institute, to give the inaugural lecture in Barcelona.

According to Elwyn, as seen in the slide: "Shared decisions are a way of acting in which doctors and patients make decisions together, making use of the best available evidence on the probabilities of benefits and adverse effects of each option, relying on patients receiving the necessary support to obtain contrasted information about their preferences." Along this line, a systematic review of the Cochrane Collaboration shows that people who have had the opportunity to make clinical decisions with the support of specific materials (decision aids) admit feeling more prepared, more informed and have the clearest ideas about the value of their clinical processes, and they are probably more aware of the risks of each step they take.

In the presentation, Glyn Elwyn made a small demonstration of the power of support materials by way of two examples taken from the Option Grid website, promoted by himself and his group. At this point, we must take note of a small detail of focus; in the traditional model, to help the patient, we would prepare an explanatory brochure to inform the pros and cons of the various options. In Option Grid the following guideline is showed: a) determining what concerns patients in these situations, and b) finding out how to present understandable information to answer these questions. Let's see one of the two examples that Elwyn explained at the conference, specifically the treatment options for a person with depression.

Shared decision for antidepressant treatment

Option Grid states that a person diagnosed with depression should be able to choose between 4 options: a) do nothing (with medical supervision), b) psychotherapy, c) pharmacological treatment, and d) combinatorial psychotherapy and pharmacological treatment.

First question. What does each option consist of? a) see the doctor often to assess the evolution of symptoms and talk about personal strategies to face the clinical situation, b) visit for 30-60 minutes with a therapist every week or every fortnight, for at least 8-10 weeks (usually involves following certain guidelines beyond the sessions), c) taking one tablet a day for 6-12 months of selective serotonin reuptake inhibitors (SSRIs), and d) combinatorial by c.

Second question. What results does each of the options have? a) without doing anything, after three months 23% of the people recover and within the year, 53%, b) in two months the psychotherapy adds, to the baseline results, 14% of recoveries, b) in one month antidepressants add 17% of recoveries to baseline results, and d) the combination of psychotherapy and antidepressants contributes 26% of recoveries over 23% of doing nothing.

Third question. What are the risks of the options? a) the wait and see attitude can give the feeling of abandonment, b) psychotherapy can cause uncomfortable situations, anxiety and even stress, c) antidepressants can have adverse effects such as nausea, diarrhoea or drowsiness in 17% of people and problems with sexual activities for 13%; other side effects to a lesser extent can be: sweating, tremor, insomnia and the feeling of dryness in the mouth.

Developing support materials is very necessary, especially if care is taken to correct the questions that are asked to patients, but what is essential is that in shared decision-making interviews, professionals know how to establish a collaborative and productive dynamic.

Jordi Varela

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