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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…

Thank you

Questions?

thoffmann@bond.edu.au

CREDITS

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