Download Dr Peter Greenberg`s presentation

“There’s a time bomb inside your
..................., which could go off
if you don’t………………………
• have this procedure.”
• take this medication.”
• have this test.”
‘making decisions about tests and treatments’
National Health and Medical Research Council 2006
principles for better communication
between healthcare consumers and
healthcare professionals
context
• knowledge translation
multiple steps between research and uptake
• healthcare consumer/professional interface
complex communication processes
• for consumers facing tests or treatments:
* awareness
* understanding
* decision
clinicians
Evidence Based Practice
•
asking questions
•
other EBP steps
myths,
feelings and
opinions
•
•
•
consumers
awareness
understanding
decision
Aware Accepted Applicable Able Acted on Agreed Adhered to
lub. 2005 Mar-Apr;142(2):A8-10.
Systems
Synopses
quality improvement
(eg health services/
governments)
Guidelines
Systematic Reviews
Studies
research
adapted from Glasziou P, Haynes B.
ACP J Club. 2005 Mar-Apr;142(2):A8-10.
better communication between healthcare
consumers and healthcare professionals
potential benefits
• for consumers
* more informed decisions,
* greater satisfaction with healthcare
• for professionals
* greater professional satisfaction,
* fewer complaints, less litigation
• for communities
more ‘appropriate’ care
* doing what should be done
* not doing what should not be done
background
NHMRC HAC resolved to develop a ‘toolkit’ in 2004
• on
communicating with healthcare consumers about the
risks, benefits and outcomes of elective therapeutic and
diagnostic interventions.
• to
extend advice in previous publications:
* General guidelines for medical practitioners on providing information to patients. NHMRC 1993
* 10 tips for safer health care. ( for consumers)
ACSQHC
2003
* Communicating with patients: advice for medical practitioners.
AHEC/NHMRC 2004
• for
consumers (and carers and families) and clinicians
development process
• systematic literature review to define principles
• draft ‘toolkit’ to address:
*options for consumer/clinician interactions
*barriers eg. functional health literacy
*‘framing’ of data; modes of communication
*sources of more information
• modification after 75 responses to public consultation
• publication and dissemination
systematic literature review
issues
• channels of communication (including oral, print media, multimedia,
decision aids and models, but excluding nonverbal communication)
• barriers to exchange and utilisation of information, including the
importance of cultural, socioeconomic, language and linguistic
considerations for effective communication
• efficacy and effectiveness of different communication channels,
content and styles for communicating the risks, benefits and outcomes
of elective therapeutic and diagnostic interventions between
consumers and clinicians in achieving outcomes including better
knowledge and satisfaction
systematic literature review
databases
• MEDLINE
• PsycINFO
• Cochrane: Database of Systematic Reviews and
Consumers and Communication Review Group
• National Health and Medical Research Council
• Health Technology Assessment Database
• Centre for Reviews and Dissemination
‘making decisions about tests and treatments’
National Health and Medical Research Council 2006
• Introduction/Summary: scope, uses, structure, development
• Part 1: 5 principles
• Part 2: 3 case studies (1 diagnostic and 2 therapeutic):
examples of 3 interventions to illustrate each of the 5 principles
• Part 3:
* further information: Australian and international
organisations, websites and other resources
* bibliography: composite bibliography for Parts 1 and 2
* appendicies
1)
2)
3)
4)
development process;
publication, dissemination and implementation strategies;
working committee members;
list of individuals and organisations making submissions
principles for effective communication
· Principle 1
good communication between healthcare consumers and
healthcare professionals has many benefits
· Principle 2
healthcare consumers vary in how much participation in
decision-making they desire
· Principle 3
good communication depends on recognising and meeting
the needs of healthcare consumers
· Principle 4
perceptions of risks and benefits are complex, and
healthcare consumers and healthcare professionals may
have different priorities
· Principle 5
information on risks and benefits needs to be
comprehensive and accessible
5 ‘Principle’ chapters: structure
•
•
•
•
•
background
what this means for healthcare consumers
what this means for healthcare professionals
examples
putting this principle into practice
*tools for healthcare consumers
*tools for healthcare professionals
*exercises, based on clinical scenarios
• find out more
clinical scenario from Principle 3
good communication depends on recognising and meeting the needs of
healthcare consumers
• Anna is a 50year old Aboriginal woman who visits a nurse practitioner
after being recalled for a check up for her non-insulin-dependent
diabetes mellitus. Anna is obese and has mild hypertension, and a
blood test shows that her blood glucose levels are poorly controlled.
She is on the highest doses of oral anti-diabetic medications, and most
of the time she takes the medication as recommended.
The nurse practitioner explains to Anna that she will need to start
insulin injections to properly control her diabetes, but Anna is
reluctant to do so.
questions for healthcare consumers
• do I have particular cultural issues that are
relevant in this consultation?
• are those issues affecting my feelings about
the suggested options for treatment?
• what could I do to let the healthcare
professional know about those issues?
questions for healthcare professionals
• how could I explore the source of this
person’s anxiety?
• is there anything in what the person has told
me that has cultural origins?
• if so, how can I best meet the person’s
needs?
case studies of interventions
• diagnosis
*prostate specific antigen (PSA) testing
• therapy
*procedural: coronary angioplasty
*pharmacological: glucocorticoids
3 ‘case study’ chapters: structure
• introduction
* background to the case study
* current status of communicating this intervention
• applying each of the 5 principles to this case study
• hypothetical examples, from consumer or professional
perspectives
• resources
• references
dissemination
• healthcare consumer groups/individuals
• healthcare professional groups/individuals
• educational and training groups/institutions
dissemination
educational and training groups/institutions
– healthcare consumer groups
carer organisations; support groups
– healthcare professionals
eg. nurses, medical practitioners, dentists, physiotherapists,
etc at undergraduate and postgraduate levels and their
teachers, and teaching and training institutions
– overseas-trained healthcare professionals
eg. certification boards
– professional development
eg. professional societies, group practices, area health
services, general practice divisions
– staff within health services
– medical defence organisations
– senior school and college students
eg. as part of a module about health
toolkit strengths
•
•
•
•
one document for consumers and professionals
the ‘principles’ focus on key issues
data on health literacy
‘framing’ of data
*eg. absolute/relative benefits of treatments
• adaptable clinical scenarios
What do we mean by literacy and health literacy?
Literacy ?
Health literacy ?
What do we mean by literacy and health literacy?
Literacy is the ability to read and write. A person who has only basic literacy can do
very simple things, such as sign their name, whereas someone who has functional
literacy can recognise words and phrases in specific contexts.
Health literacy is a form of functional literacy. It refers to a person’s capacity to
obtain, process and understand information needed to make appropriate health
decisions; that is, their ability to understand and act on health information………
Being health literate means more than simply being able to read and use numbers:
someone who is health literate is likely to understand and use health information so
that they can make the best decisions for their situation. Even some well-educated
people can have problems with health literacy……………… Health literacy also
has a cultural dimension, in that some cultures do not believe ‘accepted’ medical
explanations (rather than not understanding them).
toolkit strengths
•
•
•
•
one document for consumers and professionals
the ‘principles’ focus on key issues
data on health literacy
‘framing’ of data
*eg. absolute/relative benefits of treatments
• adaptable clinical scenarios
* changing perceptions and comprehension
by ‘framing’ information.
* understanding the difference between
relative and absolute risk
what is the ‘NNT’?
• your patient is a healthy 62 years old woman, who
asks about preventing osteoporotic fractures. As her
clinician, you explain to her that there 2 drugs which
are known to prevent fractures.
• A: will reduce her fracture risk by 50% over 3 years
• B: 1 in every 100 ( ie 1% ) women like her will
have a fracture prevented if treated for 3 years
• what is the ‘NNT’, ie the ‘Number Needed to
Treat’ for I person to benefit?
which drug is she likely to choose?
• your patient is a healthy 62 years old woman, who
asks about preventing osteoporotic fractures. As her
clinician, you explain to her that there 2 drugs which
are known to prevent fractures.
• A: will reduce her fracture risk by 50% over 3 years
• B: 1 in every 100 ( ie 1% ) women like her will
have a fracture prevented, if treated for 3 years
• which drug will she probably choose: A or B?
which drug is she likely to choose?
• in this case the relative data ( A: 50% ) appear much
more impressive than the absolute data ( B: 1% ), so she
is likely to choose A*
• the treatments could be identical, if the risk of fracture
with no treatment over 3 years is 2%
• studies show that consumers, non-clinical and clinical
health professionals tend to choose data with big numbers
for benefits from interventions
• relative data, however, cannot be interpreted without a
numerator or denominator, so always provide absolute
data at least, with relative data when necessary
*advertisements often use relative data, with bigger
numbers.
changing perceptions by ‘framing’ information
Emphasising one aspect of a health decision while leaving out another may change
how people understand and perceive risks and benefits. This effect is called
‘framing’ of information. For example, health information can be framed as:
negative or positive:for example, giving the chances of an operation failing
(negative framing) versus the chances of it succeeding (positive framing)
loss or gain: for example, emphasising the risks or disadvantages of not having a
particular screening procedure (loss) versus emphasising the benefits or advantages
of having the procedure (gain)
understanding the difference between relative and absolute risk
Another factor that affects how people perceive risks and benefits is whether they
are presented with absolute or relative risks………………….
relative risk: the drug reduces the chance of a heart attack by 50%
absolute risk: the drug reduces the chance of a heart attack from 0.05% (1 in 2000)
to 0.025% (1 in 4000). Although the drug reduces the chance of a heart attack by
50% when compared to not using the drug, in real terms, the risk for the individual
patient is reduced from 1 in 2000 if the drug is not taken, to 1 in 4000 if it is.
• you are discussing the pros and cons of having a
mammogram with a 49 year old woman
• you know that breast cancer occurs in about
1/1000 women of 45-50 years
• you also know that a mammogram has a
sensitivity of ~95% ( ie 5% of women with breast cancer have
a negative test) and a specificity of 95% ( ie 5% of women
who don’t have breast cancer have a positive test).
• what is the chance that a woman has breast cancer
if the mammogram is positive? (assume you know
nothing else about this woman)
• what is the correct answer?
0.1%, 1%, 2%, 50%, 95%, 99%, 99.5%
Limitations: 1) the ‘toolkit’ does not address
•
non-verbal communication during consultations
•
the specific communication needs of particular subgroups of people, such as:
•

infants, children, elderly

people from lower socio-economic groups

people from non-English speaking backgrounds

people from different cultures

Aboriginal and Torres Strait Islander people

people with low health literacy

people with mental health problem

people with intellectual disabilities.
the complicated processes of communication when many different professionals are
involved, like hospitals
Limitations: 2) the ‘toolkit’ has 160 pages.
Limitations: 2) the ‘toolkit’ has 160 pages.
• each ‘principle’ section is self contained
• the introduction/summary (~ 4 pages) will be posted separately on the
NHMRC website soon
better communication between healthcare
consumers and healthcare professionals
benefits
• for consumers*
* more informed decisions,
* greater satisfaction with healthcare
• for professionals?
* greater professional satisfaction
* fewer complaints, less litigation
• for communities?
more ‘appropriate’ care ?
* doing what should be done
* not doing what should not be done
*see Trevena LJ et al. A systematic review on communicating with patients about
evidence. J Eval Clin Pract 2006; 12: 13-23.
further reading
• Making decisions about tests and treatments. Principles for better
communication between healthcare consumers and healthcare
professionals. NHMRC 2006
* whole document
nhmrc.gov.au
* summary (not yet posted on website)
nhmrc.gov.au
• Trevena LJ et al. A systematic review on communicating with patients
about evidence. J Eval Clin Pract 2006; 12: 13-23.
• Greenberg PB, Walker C, Buchbinder R. Optimising communication
between consumers and clinicians. Med J Aus 2006 (in press)
• Health Literacy: see J Gen Intern Med Aug 2006
• Cochrane consumers and communication review group
acknowledgments
•
1) Working Committee
•
2) NHMRC Health Advisory Committee
•
3) Technical writers
•
4) Systematic reviewers
acknowledgments
•
•
•
•
•
•
•
•
•
1) Working Committee*
Dr Rosemary Aldrich
HAC; public health physician; journalism
A/Professor Rachelle Buchbinder
rheumatology; clinical epidemiology
Ms Rosemary Clerehan
linguistics
Dr Peter Greenberg
HAC; general physician
Dr Peter Joseph
HAC; general practice
Professor Judy Lumby
nursing
Dr Christine Walker
sociology; chronic disease alliance
Ms Ros Wood consumer
* received attendance fees and travel
support from NHMRC
•
2) NHMRC Health Advisory Committee
HAC members
Ms Stephanie Gates
Mr P. Callan, Ms A. Peristeri,
Ms C. Clutton
•
3) Technical writers
‘BIOTEXT’ Pty Ltd Canberra
Hilary Cadman and Janet Salisbury
•
4) Systematic reviewers
National Cancer Control Initiative
Dr B McEvoy and Dr F Howes
La Trobe University
Dr C Peterson, A/Prof G Murphy
‘making decisions about tests and treatments’
National Health and Medical Research Council 2006
principles for better communication
between healthcare consumers and
healthcare professionals