Is evidence based patient choice feasible?
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《英国医生杂志》
1 Department of General Practice, National University of Ireland, Galway, Ireland peter.cantillon@nuigalway.ie
What could be more ordinary and humdrum (for a clinician) than a case of a woman with osteoarthritis of the knee? Yet a doctor's potential responses to her uncertainty about whether to take a non-steroidal anti-inflammatory drug (NSAID) or paracetomol has stimulated an interesting debate. Tugwell and colleagues have used this case to demonstrate the use of a decision aid as a tool in helping a patient to make an informed choice. The decision aid is clearly very patient centred. It asks the patient to consider exactly what needs to be decided and the pros and cons of different options using visual representations of risk and benefit. It also encourages the patient to decide who should have what role in making the decision. It is clear that such a tool could be of enormous benefit in helping patients make decisions where the balance of the relative benefits and risks of competing options is not obvious.1
There are, however, clear sources of potential bias in the construction of decision aids. Are all the potential risks considered (in this case gastrointestinal bleeding was the only risk assessed for NSAIDs)? Were all the relevant sources of evidence appraised, and is the representation of the synthesised findings appropriate? Should decision aids aim to be more comprehensive? For example, should Mrs Patell be told about alternative therapies and about the other risks associated with taking NSAIDs? If a decision aid becomes more comprehensive will it be too complicated for patients to interpret? Does a partial consideration of the benefits and risks constitute informed choice? Is there not an element of "framing" involved in selecting what to put into a decision aid and what to leave out?
I can see a clear value in using decision aids as tools for teaching students about the concepts of contextual complexity, shared decision making, informed choice, and the explanation of risk. They represent an excellent vehicle for explaining the relevance of numbers needed to treat, numbers needed to harm, etc. If doctors are to use such tools in practice, decision aids need to be readily available (internet or desktop reference), sufficiently flexible to meet different idiosyncratic patient values, and appropriately comprehensive to cover the main risks and benefits that a patient needs to consider. To interpret and explain a decision aid, doctors need to be statistically numerate,2 and other visual means of communicating risk should be considered.3 Above all, doctors need to value the time required to help patients to make informed choices.
Competing interests: None declared.
References
O'Connor AM, Légaré F, Stacey D. Risk communication in practice: the contribution of decision aids. BMJ 2003;327: 736-40.
Gigerenzer G, Edwards A. Simple tools for understanding risks: from innumeracy to insight. BMJ 2003;327: 741-4.
Paling J. Strategies to help patients understand risks. BMJ 2003;327: 745-8.(Peter Cantillon, senior l)
What could be more ordinary and humdrum (for a clinician) than a case of a woman with osteoarthritis of the knee? Yet a doctor's potential responses to her uncertainty about whether to take a non-steroidal anti-inflammatory drug (NSAID) or paracetomol has stimulated an interesting debate. Tugwell and colleagues have used this case to demonstrate the use of a decision aid as a tool in helping a patient to make an informed choice. The decision aid is clearly very patient centred. It asks the patient to consider exactly what needs to be decided and the pros and cons of different options using visual representations of risk and benefit. It also encourages the patient to decide who should have what role in making the decision. It is clear that such a tool could be of enormous benefit in helping patients make decisions where the balance of the relative benefits and risks of competing options is not obvious.1
There are, however, clear sources of potential bias in the construction of decision aids. Are all the potential risks considered (in this case gastrointestinal bleeding was the only risk assessed for NSAIDs)? Were all the relevant sources of evidence appraised, and is the representation of the synthesised findings appropriate? Should decision aids aim to be more comprehensive? For example, should Mrs Patell be told about alternative therapies and about the other risks associated with taking NSAIDs? If a decision aid becomes more comprehensive will it be too complicated for patients to interpret? Does a partial consideration of the benefits and risks constitute informed choice? Is there not an element of "framing" involved in selecting what to put into a decision aid and what to leave out?
I can see a clear value in using decision aids as tools for teaching students about the concepts of contextual complexity, shared decision making, informed choice, and the explanation of risk. They represent an excellent vehicle for explaining the relevance of numbers needed to treat, numbers needed to harm, etc. If doctors are to use such tools in practice, decision aids need to be readily available (internet or desktop reference), sufficiently flexible to meet different idiosyncratic patient values, and appropriately comprehensive to cover the main risks and benefits that a patient needs to consider. To interpret and explain a decision aid, doctors need to be statistically numerate,2 and other visual means of communicating risk should be considered.3 Above all, doctors need to value the time required to help patients to make informed choices.
Competing interests: None declared.
References
O'Connor AM, Légaré F, Stacey D. Risk communication in practice: the contribution of decision aids. BMJ 2003;327: 736-40.
Gigerenzer G, Edwards A. Simple tools for understanding risks: from innumeracy to insight. BMJ 2003;327: 741-4.
Paling J. Strategies to help patients understand risks. BMJ 2003;327: 745-8.(Peter Cantillon, senior l)