Open Communication and Shared Decision-Making in Pharmacy

As pharmacists are now embedded in many healthcare teams with responsibilities for medication therapy management, teaching shared decision-making skills is essential in our pharmacy curriculum. In the 2nd year of a 4-year longitudinal evidence-based medicine (EBM) doctor of pharmacy school curriculum, student pharmacists are taught how to communicate evidence to patients and health care team members, and how to use a shared decision-making process with patients, using tools from the Mayo Clinic Shared Decision Making National Resource Center.  The following is a reflection of their experience, as future pharmacists, with the shared decision-making activity:

In a society where patients have a plethora of information at their fingertips, curiosity and involvement in self-care have become increasingly popular. However, with readily available information, particularly on the internet, both credible and deceptive, it is crucial that patients and health care providers work together in developing effective therapeutic plans. There are certain clinical scenarios that merit the implementation of swift, solitary decision-making by healthcare professionals. However, more often, there are cases where there is no definitive correct answer – situations in which priorities and values should be taken into consideration. We believe that the shared decision-making model is an optimal system, by which patients and health care providers can work together to formulate a clear picture of an effective action plan.

As doctor of pharmacy candidates at Western University of Health Sciences, we have had the valuable opportunity of engaging in progressive, interactive workshops that mimic the shared-decision making model. During one of these workshops, we were divided into teams and given hypothetical cases, modeling clinical scenarios. The goal of this workshop was for us to role-play as patients and pharmacists in a clinical setting to practice the shared decision making model and to learn how to effectively communicate with patients to discuss their risk, health history, and preferences to unite on healthcare decisions that are mutually agreed upon. This exercise was effective in shedding light onto the experience of a patient, as well as a practicing pharmacist in  shared-decision making.

For each of the two example cases, we were supplied with shared decision-making tools to assist us in formulating a decision for our patients’ therapy options. For the first case regarding diabetes management, we were exposed to the Diabetes Medication Choice decision aid cards (https://shareddecisions.mayoclinic.org/decision-aid-information/decision-aids-for-chronic-disease/diabetes-medication-management/), each of which focused on one topic and all pertinent information that may affect patients’ decisions, such as cost, lifestyle modifications, fear of needles and insulin therapy, blood sugar levels, side effect concerns, among other topics. In essence, these cards help  both the patient and healthcare provider discuss aspects that the patient valued in order to choose the most appropriate treatment option. For instance, the patient in this one case study did not have any cost limitations, was most interested in minimizing alterations to her daily routine and enhancing weight loss. We began looking at her options based on these topics, and moved our way to other topics based on her priority scale. We simultaneously integrated clinical expertise and scientific evidence into the equation in order to make the best possible decision.

Another tool we used was the online interactive tool for determining fracture risk, developed by the Mayo Clinic Shared Decision Making National Resource Center for our osteoporosis patient case. This was a great resource because  it allowed us to engage with our patients, as healthcare providers, by asking questions about their history, potential risk factors for developing osteoporosis, and preferences in their lifestyle or therapy. After we gathered all pertinent information, we input our patient’s specific data into the website, which then generated a user-friendly 100-face Cate’s plot, a visual aid that displays the patient’s personalized fracture risk with and without treatment, so that the patient could better understand the level of improvement offered by the potential treatment plan. Additionally, other tabs included tips on lifestyle modifications and other therapy options for patients to consider. This tool provided patients with a visual aid to better understand their risk for developing osteoporosis and the benefit of initiating osteoporosis therapy. Tools like these give healthcare providers, and patients alike, an opportunity to communicate with each other interactively and highlight the importance of EBM, especially when it comes to making important healthcare decisions. This allowed us another chance to interact with the patient and provide them with an outline of key points to focus on during the SDM session.

In essence, the shared decision-making model is the application of EBM. With the adoption of EBM in clincal practice, we believe that the SDM model will become organically integrated into most (if not all) health care practices. Participating in the SDM simulation workshop was very valuable as it fostered a patient-pharmacist interaction that remained focused on the patient’s priorities and values, while still catering to the pharmacist’s goals of achieving therapeutic efficacy. This is important because, based on our experience, it seems that patients respond best to information that is organized in a fashion they can appreciate and understand, without being clouded by hazy, complex information. This experience also allowed us to hone our clinical skills by showing us how to frame our questions and topics while effectively communicating evidence-based information to patients. We believe that due to their increased involvement in reaching a decision about the treatment plan, patients will be more likely to adhere to the designated agenda – as a proactive contributor to their healthcare plan, they will be more aware of the risks and benefits of adherence, as well as the risks of non-adherence. In situations where there is no definitive therapeutic plan, the patient and pharmacist can work together to figure out whether a treatment is necessary, and if so, which treatment option is most suitable. Ultimately, the SDM model will help us address clinical siutations that require a collaborative effort from both health care provider and patient.

Submitted by:

Doctor of Pharmacy Candidates, Western University of Health Sciences:
Ani Arsenyan, BSBA, Dara Nguyen, BS, Sona Sourenian, BS
EBM Curriculum Coordinator/Faculty and Professor, College of Pharmacy:
Cynthia Jackevicius, BScPhm, PharmD, MSc, BCPS-AQ Cardiology, FCSHP, FAHA, FCCP, FCCS

MAGIC: Time to create guidelines and decision aids we can trust, use, and share


By Per Olav Vandvik, Anja Fog Heen, Thomas Agoritsas

Some problems with current guidelines

To succeed in evidence-based diagnosis and treatment at the point of care, health care personnel need access to the best current research evidence, for example through trustworthy clinical practice guidelines. Most guidelines suffer from methodological weaknesses (e.g., identification and assessment of research evidence, development of recommendations), suboptimal presentation formats and infrequent updating of content. New standards for trustworthy guidelines  and advanced systems for evidence assessment and creating recommendations  provide better opportunities to succeed in development of guidelines but also illuminate the demand for methodological competence, clinical expertise and time. Equally important as providing trustworthy content in guidelines is to achieve effective dissemination at the point of care, to allow shared decision-making with patients and to perform timely updates of content.

Solutions through MAGIC

Our insights on current limitations with guidelines has resulted in an urge to provide solutions to current problems with creating, disseminating and updating guidelines. We have operationalized the solutions through what we call the MAking GRADE the Irresistible Choice (MAGIC) research and innovation program and non-profit initiative (1). A key innovation in the MAGIC program is a web-based authoring- and publication-platform (MAGICapp) that allows parallel development and publication of guidelines on the web, in tablets and smartphones, as well as integration of guidelines into electronic health records.

The guideline content is presented to end-users in what we call “top layer formats” that defines the minimum amount of information clinicians need to apply recommendations in practice. This multilayered presentation format has been developed through extensive research in the MAGIC and the DECIDE project (2).

Importantly, the MAGICapp includes structured content of all guideline content in a database based on the PICO questions that underlie all recommendations. Structured guideline content facilitates not only the development and publication of the guidelines but also facilitates dynamic updates of the guidelines on a recommendation per recommendation basis once new evidence emerges.

Decision aids that really promote shared decision-making

Most recommendations in trustworthy guidelines are weak. Weak recommendations reflect a fine balance between benefits and harms of treatment alternatives and implies that clinicians should apply the recommendations in a balanced manner in encounters with individual patients. In such situations shared decision-making – through use of decision aids available through the MAGICapp – may come into play (3). The clinician and patient can together deliberate on treatment options  through the use of a decision aid on a tablet computer, designed to create conversations. The decision aid visualizes anticipated benefits, harms and practical issues of the possible treatment alternatives. Our decision aids are based on pioneering work by – and fruitful collaboration with – Dr. Victor Montori and colleagues the Mayo clinic.

What next for MAGIC?

The MAGICapp is available for use for organizations charged with development of guidelines. We are now expanding our scope to include the development of multilayered evidence summaries and decision aids also in the context of trustworthy systematic reviews. We welcome you to test MAGICapp and provide feedback to further improve functionality of the authoring process and publication outputs, to the benefit of clinicians and patients at the point of care.

References:

  1. Vandvik PO, Alonso-Coello P, Treweek S, Akl EA, Kristiansen A, Heen AF, Agoritsas T, Montori VM, Guyatt GH. Creating clinical practice guidelines we can trust, use and share: A new era is imminent. Chest. 2013;144:381-9.
  2. Kristiansen A, Brandt L, Agoritsas T, Akl EA, Granan LP, Guyatt G, Vandvik PO. Applying new strategies for the national adaptation, updating and dissemination of trustworthy guidelines: Results from the Norwegian adaptation of the American College of Chest Physicians Evidence-based Guidelines on Antithrombotic Therapy and the Prevention of Thrombosis, 9th Edition. CHEST, 2014. doi:10.1378/chest.13-299
  3. Agoritsas T, Heen AF, Brandt L, Alonso-Coello P, Kristiansen A, Akl E, Neumann I, Tikkinen K, van der Weijden T, Elwyn G, Montori VM, Guyatt G, Vandvik PO. Decision aids that really promote shared decision making:the pace quickens. BMJ 2015 350:g7624 doi

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