Hi Malcolm - here is what I think works reasonably well - fairly simply I think - would love comments on what I may be missing or how this could be improved.

In my experience, letting patients  know roughly for them what would happen if we do nothing and what might happen if we treat, and  then support their decision, is what is needed for many individual health decisions - especially when it comes to chronic use of medications.

For instance the following would be the process for discussing the decision to use or not use a statin - obviously only after all the activity/nutrition/stopping smoking messages have been tried/discussed.  The numbers below could likely be debated somewhat but the point is the process.

A) IDENTIFY AS BEST YOU CAN THE PATIENT'S CVD RISK

Use Framingham or your risk calculator "du jour" to get a rough estimate of the patient's risk - remember the estimates, if they are between 10-20% have around a +/- 5% confidence interval around the estimate.

For example if you calculate a 15% risk you could say - 

"Based on what I know about you, your risk of CVD (you may need to explain this as well) in the next 5 years (or 10) is roughly somewhere between 10 and 20%." 

You could even show roughly the impact each factor plays in this estimate.

B) IDENTIFY AS BEST YOU CAN THE POTENTIAL BENEFITS AND RISKS

BENEFITS
"There are two ways of figuring out your potential benefit - no-one really knows which is the right way - most clinical trials show the absolute reduction in CVD with a statin over 5 years is approximately 1-2% for primary prevention and approximately 5-6% for secondary prevention (you may need to explain these terms as well) 

"Some clinicians suggest using the relative benefit (this will need to be explained) seen with these drugs - with statins the relative benefit is say 25% so if your risk is around 15% then the potential benefit would be estimated to be around 3.5-4%. Interestingly, neither you nor I will ever be able to figure out if you have ever benefited from this drug"

I have found money - 30% OFF and 50% OFF etc - to be the best way to describe relative and absolute numbers. In other words as acoleague of mine said replace % with $ signs

RISKS
In general, approximately 10% of people seem to not "tolerate" these drugs. In addition, really bad side effects (liver muscle etc) likely occur in less 
than 1% of people but, in contrast to the benefit, we can usually figure this out by trying the drug and if you don't get any side effects then your risk is 0%.

COSTS
The cost of the therapy is $X a year

C) SUPPORT THE DECISION OF THE PATIENT NO MATTER WHAT IT IS
Given the above, If you would like to try it GREAT so why don't you try it for a while and see what you think. If you don't want to use it GREAT. i'll support you in your decision. We can always re-evaluate at a later date.

You will notice there is NO discussion about guidelines or targets.

I would love feedback on what this approach might be missing or how it could be improved upon

I and a family physician discuss these and many other issues on our weekly podcast Therapeutics Education Collaboration podcast at therapeuticseducation.org if anyone is interested.

Thanks.

James McCormack, BSc(Pharm), Pharm D
Professor
Faculty of Pharmaceutical Sciences
UBC, Vancouver, Canada
604-603-7898
 
On 1-Dec, at 8:38 AM, Malcolm Daniel wrote:

> Thank you to eveyone who has replied so far - the input and suggested reference
> sources have been very helpful.
> 
> I hope they have been helpful to others too.
> 
> The fourth of the 5 steps of EBM has been described as "Acting on the evidence,
> using patient values".
> 
> Let's see if we can expand this discussion beyond publications.
> 
> To everyone of this e-mail list, including those that have responded already,
> can anyone describe what tools, techniques, approaches they used to address
> this step in their clinical practice last month (November 2010)?
> 
> Sharing our own real-time clinical practice experiences may be really helpful
> for others on this list.
> 
> Sometimes the most innovative approaches may also appear the simplest - I am
> interested to hear from everyone.
> 
> I will put my hand up and say - I am taking a year out of clinical practice and
> am working at the Institute for Healthcare Improvement - I saw no patients last
> month - but I am thinking deeply about how we make health care more patient
> centred and include patients values and preferences in decision making to
> achieve better health outcomes.
> 
> I look forward to hearing what my colleagues on the evidence-based-health e-mail
> list have to contribute on this challenging issue.
> 
> Cheers
> 
> Malcolm
> 
> Health Foundation/Institute for Healthcare Improvement Fellow
> 
> Malcolm Daniel
> Department of Anaesthesia
> Walton Building
> Glasgow Royal Infirmary
> G4 0SF
> Tel: 44-(0)141-211-4620
> 
> 
> Quoting Rakesh Biswas <[log in to unmask]>:
> 
>> Thanks Piersante,
>> 
>> For (1) there is this other recent book:
>> 
>> http://www.igi-global.com/bookstore/TitleDetails.aspx?TitleId=41908&DetailsType=Preface
>> 
>> COI: A few of our current members in this list have contributed chapters to
>> it.
>> 
>> regards,
>> 
>> rakesh
>> 
>> On Fri, Nov 26, 2010 at 5:01 AM, Piersante Sestini <[log in to unmask]> wrote:
>> 
>>> This is a very important and neglected area of EBM.
>>> To the pointers that have been given, I would add a few further points:
>>> 1) Narrative medicine/counselling as tools to investigate patient's values
>>> 2) This topic mostly overlaps with "Shared decision making"
>>> 2)There is a growing interest of this topic (mostly outside the EBM
>>> community), under the term "context" and "contextual issues". For example
>>> see:
>>> 
>>> Schwartz A, Weiner SJ, Harris IB, Binns-Calvey A. An educational
>>> intervention
>>> for contextualizing patient care and medical students' abilities to probe
>>> for
>>> contextual issues in simulated patients. JAMA. 2010 Sep 15;304(11):1191-7.
>>> PubMed
>>> PMID: 20841532.
>>> 
>>> I can't help with your mathematical approach, since like most others that
>>> have tried it I found the utilitarian approach unpractical/unconvincing.
>>> Nevertheless, you could have a look to the simplified "Korean car" (can't
>>> remember the make of the car she used, but she contrasted it with the "Rolls
>>> Royce" approach of full decision analysis) approach proposed by Sharon
>>> Straus some year ago.
>>> 
>>> If you insist in using the full utilitarian approach, then Jonathan Baron
>>> "Thinking and Deciding" could be your guide
>>> 
>>> regards
>>> <http://www.cambridge.org/us/catalogue/catalogue.asp?isbn=9780521680431>Piersante
>>> Sestini
>>> 
>>> 
>>> 
>>> 
>>> On 29/11/2010 5.14, Malcolm Daniel wrote:
>>> 
>>>> 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]
>>>> 
>>>> 
>>>> 
>>>> 
>>>> 
>>>> ----------------------------------------------------------------
>>>> This message was sent using IMP, the Internet Messaging Program.
>>>> 
>>>> 
>>>> 
>>> 
>> 
> 
> 
> 
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James McCormack, BSc(Pharm), Pharm D
Professor
Faculty of Pharmaceutical Sciences
UBC, Vancouver, Canada
604-603-7898