The final day of the ISDMISEHC conference took a closer look at some of the key issues of the future. Professor Sharon Straus started the day with a keynote address about the challenges of implementation (or why she has the best job in the world). I’m going to take some time to summarise her key messages because they are “gold.” Sharon thinks of “knowledge translation” as using evidence in decision making at any level of the health system. She encouraged us to get on with doing what we can, use what evidence is available, learn from our efforts and improve next time. Lack of knowledge is not the most significant barrier to implementing evidence, the issue is the assumption is that more is better. The amount of time taken to implement all the clinical practice guidelines recommendations for a diabetic patient is at least four times greater than the time available in clinical practice. Straus encourages us to work with patient groups to prioritise and reduce the use of ineffective, harmful, and wasteful interventions such as blood glucose monitoring.
These comments echoed those of Victor Montori on day one who charged us to “Be Careful and Kind,” and consider our patients’ context and circumstances. Straus has also suggested that clinicians need new “scripts” for discussing new evidence with patients. Different clinical conditions and tests evoke different responses and barriers. Sharon shared some excellent free resources such as the tool to measure organisational readiness to change and the database of critically appraised systematic reviews on implementation “Rx for Change.” We need more theory and development to inform design of complex interventions, but the challenge is how to accelerate this process and work out how to optimise effective interventions. She also urged us to consider sustainability early in our work, not just as an afterthought and this could be achieved through having the right partners in our work. Finally, capacity building and mentoring is fundamental to this work and Sharon’s book on mentoring deserves a big plug. I plan to read it soon!
We had parallel sessions on knowledge translation, implementation, patient safety, cancer screening and treatment and respiratory disease. The final plenary session was inspiring with CJ Chen speaking about shared decision making and culture. There are fundamental challenges in translating terms such as “shared decision making” into languages where there is no direct equivalent. Nevertheless, when asked, the majority of patients want involvement, but physicians’ perception of patient preferences is entirely different. The entrenched model of paternalistic care is a real challenge. CJ encouraged the inclusion of evidence about complimentary and alternative medicines because it facilitates disclosure of use by patients. We also need to recognise that family involvement is far more desirable than we think across a range of cultures and that religious beliefs can also be important to consider. Finally, cultural competence training for healthcare professionals is important for many countries and could perhaps be integrated in SDM and EBM curricula.
Lisa Bero from the Charles Perkins Centre at the University of Sydney highlighted some of the barriers in trying to get an evidence based approach to essential medicines listed for low-income countries. This list can have powerful effects on lowering medicine costs and in encouraging the manufacture of simple treatments such as zinc supplements for children with diarrhoea. However, the process responds to applications rather than taking a proactive approach and this means that many effective medicines or more effective formats of them remain unavailable to millions worldwide. This was a salient contrast to the problems of overdiagnosis, overtreatment, and waste discussed on the previous day. The underuse of effective treatments sits alongside overuse and we need to consider how we can redistribute this to reduce health inequalities.
Finally, a young researcher Thomas Agoritsas spoke about his dream to see some streamlining of evidence synthesis and decision-ready formats of these as decision tools through the MAGIC and SHARE-IT programs. This work from groups in Norway and Canada brings technology forward, building on the “clinical filters” work of Brian Haynes and aims to reduce the time taken for evidence uptakes to reach the decision point with patients and addressing some of the sustainability issues raised earlier in the day. It was a fitting note on which to finish as it brings evidence and shared decision making together in keeping with the conference theme.
This year we awarded two prizes. The inaugural David Sackett Memorial Prize for best oral paper by a young researcher which was won by Mr Logan Treneman for his cost-effectiveness analysis of a decision aid for knee arthroplasty. One of my favourite moments of the conference was the award of the Best Poster Prize to Siritree Suttajit, a young researcher from Thailand who was attending her first international conference with two colleagues, all of whom had received assisted places from the organising committee and it was the first time that all three had been outside Thailand. They had measured shared decision-making implementation in several hospitals and presented their work clearly and beautifully. Congratulations to the team!
It’s been an amazing conference with a rich exchange of ideas. We had new linkages to middle income countries in South America and Asia, both regions have pioneers in this space who welcomed support from colleagues abroad. There were powerful reflections from our consumer representatives inspired by our shared and genuine vision to improve patient care. As we all go back to our workplaces we hope these experiences and ideas will continue to be shared and developed. Having been to most ISEHC and ISDM conferences myself, and having hosted this “first date” between the two, I am confident that there will be more opportunities in the future for these two groups to work towards their shared vision to support clinicians, patients, and their loved ones in making health decisions. What a privilege to see this and reflect on it as I went back to my chemotherapy chair today. There’s wonderful work to be done and I agree with Sharon Straus—it really is the best job in the world as we support and facilitate better care for our patients.
Lyndal Trevena is Professor of Primary Health Care and Head of the Discipline of General Practice at the University of Sydney. She is Co-Chair of the ISDM-ISEHC Conference in Sydney 19-22 July, 2015.
Competing interests: None declared.