Theres a time bomb inside your which could

“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 Acted on Agreed Adhered lub. 2005 Mar-Apr; 142(2): A 8 -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): A 8 -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 • Psyc. INFO • 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 50 year 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 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 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 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%, 2%, 50%, 95%, 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 Mc. Evoy 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