Use your B.R.A.I.N. A Decision Support Tool

The Centre for Collaboration, Motivation, and Innovation (CCMI) is a non-profit organization dedicated to building skills and confidence for better health and health care. Their vision is "to improve health outcomes through helping people take active roles in their health."

The BRAIN Informed Decision Making Aid

Achieving this vision entails the development of tools that can facilitate patient-provider conversations. To that end, they have adapted the BRAIN Informed Decision Making tool from the International Childbirth Association.

At the recent BC Patient Safety Quality Council's Quality Forum (#QF16), I was asked to give a talk on Choosing Wisely and was put into the "Patient Empowerment" breakout session. It was fortuitous that my talk preceded that of the CCMI team as I got to see their presentation on the tool and learn about its development (slides accessible here).

Helping a patient to explore the [B]enefits, [R]isks, [A]lternatives, their [I]ntuition, and [N]ext steps, the BRAIN tool can assist people navigating any significant health choice.

You can view and download the PDF on the CCMI's website. The simple format and generalizability means it could easily become a 'go to' tool for patients and clinicians who wish to engage in shared decision-making.

Please feel free to leave your feedback on this tool in the comments section below; the input can be forwarded to the CCMI team. Has it been a helpful tool for you as a patient or caregiver? Do your patients find the format straightforward?
 

More

Seeking more tools like this to facilitate patient-provider discussions around important health choices? Less is More includes a list of mainly Shared Decision Making Tools, in the hands-on resource section.

Source: http://www.centrecmi.ca/wp-content/uploads...

MedStopper de-prescribing online app now live!

It is with great pleasure that I introduce: 

MedStopper 
 

Polypharmacy, the state of being on multiple (too many) medications, is an increasingly recognized problem. Though variably defined, everyone agrees that polypharmacy leads to dangerous consequences for patients, particularly in the elderly.

It is so much easier to start than to stop a medication. Now, there is help!

An incredible team, mostly from British Columbia, many of whom I'm had the pleasure of working with, have developed this superb resource. MedStopper is an online tool to help stop medications for patients.

Aimed at clinicians, this deprescribing aid allows you to created a medication list, suggests which medications need to be stopped first, and advises the safest way to go about stopping them. 

Screen Shot 2015-09-19 at 12.50.18 PM.png

Smiley/frowny faces show you the extent to which the medicine: may improve symptoms, may reduce risk for future illness, and may cause harm. If the patient is considered frail, the recommendations are adjusted accordingly.

The tool is a synthesis of many things, so you can view the Beers/STOPP criteria, the NNT or a risk/benefit calculator if available, and print out the plan if you desire.

Not sure if you (or your patients) are on too many medications? Use the Rxisk questionnaire.

Try out MedStopper today and be sure to use the feedback section to let the team know if there are any glitches or errors.

Congratulations to the group on creating this hands-on, easy to use, and practice changing tool. 

Source: http://medstopper.com/

Better informed women probably less likely to choose mammography

Screen Shot 2015-02-19 at 8.53.24 PM.png

An interesting article was published in the latest Lancet: Use of a decision aid including information on overdetection to support informed choice about breast cancer screening: a randomised controlled trial.

In brief, women who got information about the risk and possible harms of breast cancer screening (by mammography) were less likely to intend to be screened. The study didn't go on to look at what the women actually chose (only what they intended to choose). However, it still confidently suggests that women who have all of the information are less likely to get screened.

Contrast this informed approach with the classic approach from the well-intentioned doctor: "You need a mammogram to screen for breast cancer. Here is the requisition."

It is not wrong to say no. (These are the words of Dr Iona Heath - well ahead of the curve - in the title of a  BMJ paper in 2009 regarding this same topic).

It is not wrong to say no. And the more you know, the more likely you'll say no. 
 

Not sure what to do for yourself?
Not sure how to start discussing this with patients?
 

- Here is a Canadian resource to help you decide if Mammography is right for you; it's not perfect but it is a start

- Below is an icon array from the Harding Center for Risk Literacy that helps visually represent the benefits vs. harms of mammography:


Source: http://www.thelancet.com/journals/lancet/a...

Disutility: Finding the balance between benefit and hassle

James McCormack (@medmyths, The Best Science Medicine Podcast) sent me a great article: "Patient-Accessible Tool for Shared Decision Making in Cardiovascular Primary Prevention."

The UK group looked at the problem of patients discontinuing medication and focussed in particular on statins for primary prevention of cardiovascular events. A lot of research assumes that the 'burden' of taking a pill is a negligible factor in medication adherence, but these researchers thought otherwise. They surveyed 360 people to see how they might balance their potential cardiac risk with the 'disutility' of a preventative, once a day medication as intervention. Paraphrasing, they wanted to know:

how much longer would a person need to live (thanks to a medication) in order to make it worth the hassle of taking the medication

The article is worth sharing because it introduced a few new ideas to me:

  • "disutility" : a word the researchers use to capture the idea of inconvenience or burden of care
  • there is some good evidence that educating people more and more about their risk will not change their adherence to medication
  • talking about reasons they would not want to take the medication may be more important
  • as every person has a different tolerance of disutility, individualized discussions (shared decision-making) still remains a good strategy
  • for people who fall in the middle ground when balancing utility and disutility, factors like gender, smoking, blood pressure, and cholesterol factor into the decision whereas they do not for those with high or low disutility

Figure 4.

Disutility vs utility. Frequency distribution of disutility, longevity benefit that subjects expressed a desire to make tablet therapy worthwhile (top), and the frequency distribution of utility, actual expected gain in lifespan from statin therapy in the English population (bottom). The difference between the 2 values is the net benefit of tablet therapy. Because utility has a very much narrower spectrum than disutility, for those with a high disutility, regardless of utility, statins are a net harm; for those with low disutility, regardless of utility statins are a net benefit. It is only for those in the middle gray zone (top) that sex, smoking status, blood pressure, and cholesterol are the deciding factors.

Read the full article here, in Circulation. 

If you are very interested in the idea of 'disutility,' you may enjoy Dr Victor Montori (@vmontori)'s work on "Minimally Disruptive Medicine."

Ask | Share | Know : Patient Resource for talking with your healthcare provider

Here is a snappy resource from Australia that can help patients (and advocates) create meaningful interactions with their healthcare providers.

The Ask | Share | Know project aims to empower patients to discover the information they need in order to make shared decisions with the health professionals they encounter. They suggest three key questions:

Asking the questions is a start, but even more important is the sharing of values and information with health care providers (HCPs). Patients have lives, values, and needs beyond their diseases, of course!

When your HCP can understand you and your needs better, they can help give you the knowledge you need to make an informed decision that goes beyond just medical facts and is tailored to your situation and goals.

Detailed follow-up questions, time to think, and opportunity to discuss with your main supports may also be needed before you make a decision. Try it out!