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- 3. Decision making in arthritis? • Decision making is complex • and poorly understood • Big Decisions • Surgery • Disease Modifying Anti-Rheumatic Drugs • ‘Small’ Decisions • Exercises • Appliances • Drugs
- 4. Drugs for osteoarthritis • Small everyday decision in GP’s surgery & the pharmacy • >1,000,000 GP consultations per year for OA • >17,000,000 prescriptions for anti-inflammatory drugs • >4,000,000 topical preparations
- 5. Big consequences • Consultations, prescriptions, and treating side effects cost >£400,000,000 PA. • Drug side effects • Gastric Bleeding • Raised Blood Pressure • Cardiovascular Disease • Risk for an individual is not clear • Comparative risks are different for different drugs
- 6. Preferences • Most people with arthritis prefer anti-inflammatory drugs to paracetamol • More effective? • Studies suggest that many people might prefer a less effective but safer medication • Many people prefer topical preparations to oral medications
- 7. Decision making • More benefit if made jointly with clinician that they trust • Take into account, benefits, risks and availability of alternative treatments • Information quality? • Risk evaluation affected by perceived severity of condition
- 8. Where does patient information come from? • Past experience • Theirs and that of friends/relatives • Tradition • Medical advisors • Written material (traditional & modern) • Folk models of illness
- 9. Do patients make the correct choices? • Effectiveness relatively easy • Adverse events harder • Poor data • Most people not affected • Topical or Oral Ibuprofen study (TOIB) • People who chose oral medication had fewer side effects than those randomised to oral medication
- 10. Perception of risk and benefit High risk •(Oral) Beneficial High tolerance to adverse effect effects Little effect Low risk Low tolerance to adverse •(Topical) effects
- 11. How did they decide GP knows best Uncritical acceptance of various information sources Nature of pain - -constant /transient – Regular or as required Trade off between pain relief, side effects and, improved function.
- 12. Types of pain and medication use Regular NSAID use Constant pain More pain more Regular NSAID use with reserve medication As required Transient pain Pre-emptive
- 13. A balanced decision making process?
- 14. Factors influencing patient preferences for topical or oral ibuprofen Carnes, D. et al. BMJ 2008;336:142-145 Copyright ©2008 BMJ Publishing Group Ltd.
- 15. On the other hand Normalisation of – arthritis pain • not aspiring to improvement – minor side effects • possible increased risk of serious side effects
- 17. Conclusions • Most patients are pretty good at making informed choices • Shared informed decision making key to getting right balance of risks/benefits • Practitioners - data on risks and benefits • Patients – relative values of risk and benefits