Dear Malcolm
Like you and most of us, I have too struggled with the same issue. Most recently, we developed dual visual analog scale (DVAS) rephrased from the regret theory point of view, as the approach that I find most useful in my own practice (see http://www.biomedcentral.com/content/pdf/1472-6947-10-51.pdf). It enables elicitation of trade-offs (a key to decision-making), which traditional VAS could not do, but is simpler to understand that standard-gamble and time-trade-off methods ("gold" standard for elicitation of patient preferences). It also exploits both system 1 and system 2 cognitive processes.
It consists of two questions that I found most people understand with no major difficulties:
1. On a scale 0 to 100, where 0 indicates no regret and 100 indicates the maximum regret you could feel, how would you rate the level of your regret if I/we failed to provide you with the necessary treatment (i.e. did not prescribe treatment that, in retrospect, I should have)?
2. On a scale 0 to 100, where 0 indicates no regret and 100 indicates the maximum regret you could feel, how would you rate the level of your regret if I had prescribed unnecessary treatment to you
(i.e. administered treatment that, in retrospect, you should have not been given)?
This give you the threshold, which then you can contrast with other prognostic, treatment or diagnostic information (in the paper, we provide one such approach, which we are currently developing in terms of decision-support system), but getting to elicit patient values (via simple threshold, as we show) is really the most important step.
This may or may not be applicable to anesthesia setting, but I would be interested in yours (and other folks) thought of our proposal.
Thanks
Best
ben
Benjamin Djulbegovic, MD, PhD
Distinguished Professor
University of South Florida & H. Lee Moffitt Cancer Center & Research Institute
Department of Medicine
Chief, Division of Evidence-based Medicine and Health Outcomes Research
Co-Director of USF Clinical Translation Science Institute
Director of USF Center for Evidence-based Medicine and Health Outcomes Research
Tampa, FL 33612
-----Original Message-----
From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Malcolm Daniel
Sent: Sunday, November 28, 2010 11:15 PM
To: [log in to unmask]
Subject: Integrating patients values into clinical decision making
Dear all,
This is a request for information on how to do that essential but often
under-reported step in EBM: integrating the best available evidence with the
patient's values and preferences.
Situation: My colleagues and I are trying to figure out the best way to
introduce evidence into our conversations with patients and to integrate their
values with the best available evidence.
Background: We are familiar with one suggested way of integrating the evidence
with the patients values:
Users' Guides to the Medical Literature XX. Integrating Research Evidence With
the Care of the Individual Patient
http://jama.ama-assn.org/cgi/content/full/283/21/2829
The concept of factoring in the likelihood of being helped and harmed is
attractive - and while the arithmetic formula outlined in the above article
looks relative simple:
LHHA=[(1/NNT)*ft*s]: [(1/NNH)*fh]
Where
LHH = likelihood of being helped vs harmed
NNT= number needed to treat to help/benefit
NNH= number needed to treat to harm
ft = risk of the treatment outcome event relative to that of the average control
fh = risk of the harm outcome event relative to that of the average control
s=severity factor,
we wonder how many health professionals do easy it is to carry out this piece of
arithmetic in the real-life of every day clinical practice..
Assessment: We wonder if and how fellow healthcare professionals use this
approach in practice? Has anyone developed a systematic approach to do this
for the majority of patients they provide care for?
Recommendations: I am interested in finding out the following information:
1. It would be interesting to hear of other practitioners experience in using
such approach in their own practice.
2. If you have knowledge of other publications using a similar or easier
approach I would be grateful for your knowledge and sources of information.
3. If anyone is has tips / tools / experience of using this approach in regular
day-to-day clinical practice I would like to hear about them too.
Many thanks for your help
Malcolm
Malcolm Daniel
Consultant in Anaesthesia & Intensive Care, Glasgow Royal Infirmary
E-mail: [log in to unmask]
Health Foundation/IHI Fellow
Institute for Healthcare Improvement
20 University Road, 7th Floor
Cambridge, MA 02138
Tel: (617) 301-4854
Fax: (617) 301-4848
E-mail: [log in to unmask]
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