The psychometric properties of Observer OPTION(5), an observer measure of shared decision making

Clinician Factors Rather Than Patient Factors Affect Discussion of Treatment Options

BACKGROUND

Shared decision-making aims to combine what matters most to a patient with clinician expertise to develop a personalized health strategy. It is a dialogue between patient and clinician in which preferences are expressed, misconceptions reoriented, and available options are considered. To improve patient involvement, it would help to know more about specific barriers and facilitators of patient-clinician communication. Health literacy, the ability to obtain, process, and understand health information, may affect patient participation in decision-making. If the patient is quiet, deferential, and asks few questions, the clinician may assume a more paternalistic style. A patient with greater agency and engagement could be the catalyst for shared decisions.

QUESTIONS/PURPOSES

We assessed (1) whether effective clinician communication and effort is related to patient health literacy, and (2) if there are other factors associated with effective clinician communication and effort.

METHODS

We combined a prospective, cross-sectional cohort of 86 audio-recorded visits of adult patients seeking specialist hand care for a new problem at an urban community hospital in the Netherlands with a cohort of 72 audio-recorded hand surgery visits from a tertiary hospital in the United States collected for a prior study. The American cohort represents a secondary use of data from a set of patients from a separate study using audio-recorded visits and administering similar questionnaires that assessed different endpoints. In both cohorts, adult patients seeking specialist hand care for a new problem were screened. In total, 165 patients were initially screened, of which 96% (158) participated. Eight percent (13) of visits were excluded since the final diagnosis remained unclear, 8% (12) since it was not the first consultation for the current problem, 5% (8) in which only one treatment option was available, and < 1% (1) since there was a language barrier. A total of 123 patients were analyzed, 68 from the Netherlands and 55 from the United States. The Newest Vital Sign (NVS) health literacy test, validated in both English and Dutch, measures the ability to use health information and is based on a nutrition label from an ice cream container. It was used to assess patient health literacy on a scale ranging from 0 (low) to 6 (high). The 5-item Observing Patient Involvement (OPTION5) instrument is commonly used to assess the quality of patient-clinician discussion of options. Scores may be influenced by clinician effort to involve patients in decision-making as well as patient engagement and agency. Each item is scored from 0 (no effort) to 4 (maximum effort), with a total maximum score of 20. Two independent raters reached agreement (kappa value 0.8; strong agreement), after which all recordings were scored by one investigator. Visit duration and patient questions were assessed using the audio recordings. Patients had a median (interquartile range) age of 54 (38 to 66) years, 50% were men, 89% were white, 66% had a nontraumatic diagnosis, median (IRQ) years of education was 16 (12 to 18) years, and median (IQR) health literacy score was 5 (2 to 6). Median (IQR) visit duration was 9 (7 to 12) minutes. Cohorts did not differ in important ways. The number of visits per clinician ranged from 14 to 29, and the mean overall communication effectiveness and effort score for the visits was low (8.5 ± 4.2 points of 20 points). A multivariate linear regression model was used to assess factors associated with communication effectiveness and effort.

RESULTS

There was no correlation between health literacy and clinician communication effectiveness and effort (r = 0.087 [95% CI -0.09 to 0.26]; p = 0.34), nor was there a difference in means (SD) when categorizing health literacy as inadequate (7.8 ± 3.8 points) and adequate (8.9 ± 4.5 points; mean difference 1.0 [95% CI -2.6 to 0.54]; p = 0.20). After controlling for potential confounding variables such as gender, patient questions, and health literacy, we found that longer visit duration (per 1 minute increase: r2 = 0.31 [95% CI -0.14 to 0.48]; p < 0.001), clinician 3 (compared with clinician 1: OR 33 [95% CI 4.8 to 229]; p < 0.001) and clinician 5 (compared with clinician 1: OR 11 [95% CI 1.5 to 80]; p = < 0.02) were independently associated with more effective communication and effort, whereas clinician 6 was associated with less effective communication and effort (compared with clinician 1: OR 0.08 [95% CI 0.01 to 0.75]; p = 0.03). Clinicians' communication strategies (the clinician variable on its own) accounted for 29% of the variation in communication effectiveness and effort, longer visit duration accounted for 11%, and the full model accounted for 47% of the variation (p < 0.001).

CONCLUSION

The finding that the overall low mean communication effectiveness and effort differed between clinicians and was not influenced by patient factors including health literacy suggests clinicians may benefit from training that moves them away from a teaching or lecturing style where patients receive rote directives regarding their health. Clinicians can learn to adapt their communication to specific patient values and needs using a guiding rather than directing communication style (motivational interviewing).Level of Evidence Level II, prognostic study.

The Multifocal Approach to Sharing in Shared Decision Making: A Critical Appraisal of the MAPPIN'SDM

OBJECTIVE

Shared decision making integrates health care provider expertise with patient values and preferences. The MAPPIN'SDM is a recently developed measurement instrument that incorporates physician, patient, and observer perspectives during medical consultations. This review sought to critically appraise the development, sensibility, reliability, and validity of the MAPPIN'SDM and to determine in which settings it has been used.

METHODS

This critical appraisal was performed through a targeted review of the literature. Articles outlining the development or measurement property assessment of the MAPPIN'SDM or that used the instrument for predictor or outcome purposes were identified.

RESULTS

Thirteen studies were included. The MAPPIN'SDM was developed by both adapting and building on previous shared decision making measurement instruments, as well as through creation of novel items. Content validity, face validity, and item quality of the MAPPIN'SDM are adequate. Internal consistency ranged from 0.91 to 0.94 and agreement statistics from 0.41 to 0.92. The MAPPIN'SDM has been evaluated in several populations and settings, ranging from chronic disease to acute oncological settings. Limitations include high reading levels required for self-administered patient questionnaires and the small number of studies that have employed the instrument to date.

CONCLUSION

The MAPPIN'SDM generally shows adequate development, sensibility, reliability, and validity in preliminary testing and holds promise for shared decision making research integrating multiple perspectives. Further research is needed to develop its use in other patient populations and to assess patient understanding of complex item wording.

Patient, clinician and independent observer perspectives of shared decision making in adult orthodontics

OBJECTIVES

To investigate and compare the extent of shared decision making (SDM) in orthodontics from the perspective of patients, clinicians and independent observers.

DESIGN

A cross-sectional, observational study.

SETTING

NHS teaching hospital.

PARTICIPANTS

A total of 31 adult patients and their treating clinicians were included in the study.

METHODS

The extent of SDM in new patient orthodontic consultations was measured using three versions of a validated instrument: the self-administered patient dyadic-OPTION scale; the self-administered clinician dyadic-OPTION scale; and an independent observer-rated OPTION¹² scale. Patients and clinicians completed the 12-item dyadic-OPTION questionnaire independently at the end of the consultation to rate their perceived levels of SDM. The consultations were also audio-recorded and two calibrated raters independently rated the extent of SDM in these consultations using the OPTION¹² scale.

RESULTS

There was excellent inter-rater reliability between the two independent raters using the OPTION¹² scale (intraclass correlation coefficient (ICC) = 0.909). The mean patient, clinician and independent observer OPTION scores for SDM were 90.4% (SD 9.1%, range 70.8% to 100%), 76.2% (SD 8.95%, range 62.5% to 95.8%) and 42.6% (SD 17.4%, range 13.5% to 68.8%), respectively. There was no significant correlation between the OPTION scores for the three groups (ICC = -0.323).

CONCLUSIONS

The results showed that generally high levels of SDM were perceived by patients and clinicians but lower levels of SDM were scored by the independent observers. However, it could be argued that the patient's perception of SDM is the most important measure as it is their care that is affected by their involvement.

A large-scale internal validation study of unsupervised virtual trichrome staining technologies on nonalcoholic steatohepatitis liver biopsies

Non-alcoholic steatohepatitis (NASH) is a fatty liver disease characterized by accumulation of fat in hepatocytes with concurrent inflammation and is associated with morbidity, cirrhosis and liver failure. After extraction of a liver core biopsy, tissue sections are stained with hematoxylin and eosin (H&E) to grade NASH activity, and stained with trichrome to stage fibrosis. Methods to computationally transform one stain into another on digital whole slide images (WSI) can lessen the need for additional physical staining besides H&E, reducing personnel, equipment, and time costs. Generative adversarial networks (GAN) have shown promise for virtual staining of tissue. We conducted a large-scale validation study of the viability of GANs for H&E to trichrome conversion on WSI (n = 574). Pathologists were largely unable to distinguish real images from virtual/synthetic images given a set of twelve Turing Tests. We report high correlation between staging of real and virtual stains ([Formula: see text]; 95% CI: 0.84-0.88). Stages assigned to both virtual and real stains correlated similarly with a number of clinical biomarkers and progression to End Stage Liver Disease (Hazard Ratio HR = 2.06, 95% CI: 1.36-3.12, p < 0.001 for real stains; HR = 2.02, 95% CI: 1.40-2.92, p < 0.001 for virtual stains). Our results demonstrate that virtual trichrome technologies may offer a software solution that can be employed in the clinical setting as a diagnostic decision aid.

Development and Evaluation of the Shared Decision Making Process Scale: A Short Patient-Reported Measure

BACKGROUND

The Shared Decision Making (SDM) Process scale is a short patient-reported measure of the amount of SDM that occurs around a medical decision. SDM Process items have been used previously in studies of surgical decision making and exhibited discriminant and construct validity.

METHOD

Secondary data analysis was conducted across 8 studies of 11 surgical conditions with 3965 responses. Each study contained SDM Process items that assessed the discussion of options, pros and cons, and preferences. Item wording, content, and number of items varied, as did inclusion of measures assessing decision quality, decisional conflict (SURE scale), and regret. Several approaches for scoring, weighting, and the number of items were compared to identify an optimal approach. Optimal SDM Process scores were compared with measures of decision quality, conflict, and regret to examine construct validity; meta-analysis generated summary results.

RESULTS

Although all versions of the scale were highly correlated, a short, partial credit, equally weighted version of the scale showed favorable properties. Overall, higher SDM Process scores were related to higher decision quality (d = 0.18, P = 0.029), higher SURE scale scores (d = 0.57, P < 0.001), and lower decision regret (d = -0.34, P < 0.001). Significant heterogeneity was present in all validity analyses.

LIMITATIONS

Included studies all focused on surgical decisions, several had small sample sizes, and many were retrospective.

CONCLUSION

SDM Process scores showed resilience to coding changes, and a scheme using the short, partial credit, with equal weights was adopted. The SDM Process scores demonstrated a small, positive relationship with decision quality and were consistently related to lower decision conflict and less regret, providing evidence of validity across several surgical decisions.

Observer Ratings of Shared Decision Making Do Not Match Patient Reports: An Observational Study in 5 Family Medicine Practices

BACKGROUND

Measuring shared decision making (SDM) in clinical practice is important to improve the quality of health care. Measurement can be done by trained observers and by people participating in the clinical encounter, namely, patients. This study aimed to describe the correlations between patients' and observers' ratings of SDM using 2 validated and 2 nonvalidated SDM measures in clinical consultations.

METHODS

In this cross-sectional study, we recruited 238 complete dyads of health professionals and patients in 5 university-affiliated family medicine clinics in Canada. Participants completed self-administered questionnaires before and after audio-recorded medical consultations. Observers rated the occurrence of SDM during medical consultations using both the validated OPTION-5 (the 5-item "observing patient involvement" score) and binary questions on risk communication and values clarification (RCVC-observer). Patients rated SDM using both the 9-item Shared Decision-Making Questionnaire (SDM-Q9) and binary questions on risk communication and values clarification (RCVC-patient).

RESULTS

Agreement was low between observers' and patients' ratings of SDM using validated OPTION-5 and SDM-Q9, respectively (ρ = 0.07; P = 0.38). Observers' ratings using RCVC-observer were correlated to patients' ratings using either SDM-Q9 (r_pb = -0.16; P = 0.01) or RCVC-patients (r_pb = 0.24; P = 0.03). Observers' OPTION-5 scores and patients' ratings using RCVC-questions were moderately correlated (r_φ = 0.33; P = 0.04).

CONCLUSION

There was moderate to no alignment between observers' and patients' ratings of SDM using both validated and nonvalidated measures. This lack of strong correlation emphasizes that observer and patient perspectives are not interchangeable. When assessing the presence, absence, or extent of SDM, it is important to clearly state whose perspectives are reflected.

Psychometric properties of the simplified Chinese version of the observer OPTION5 scale

Background

OPTION⁵ is a scale used to evaluate shared decision making (SDM) in health care from an observer’s perspective; however, to date, there is no simplified Chinese version of this scale.

Objectives

This study aims to produce a simplified Chinese version of the OPTION⁵ scale and to test its psychometric properties.

Methods

One rater observed and audio-recorded consultations between general practitioners (GPs) and chronically ill patients in a Beijing community health service center (CHSC) from May to June 2019. Meanwhile, demographic data of the patients and GPs were collected via information forms. Two raters assessed inter- and intra-rater reliability by calculating the intraclass correlation coefficient (ICC) and weighted Cohen’s Kappa values. Internal consistency was assessed using Cronbach’s α value. Concurrent was calculated by Spearman’s rank correlation coefficient.

Results

A total of 209 consultations were recorded and evaluated. As concerns inter-rater reliability, the ICC of the OPTION⁵ was 0.859 on the total score level, with Cohen’s weighted k ranging from 0.376 (item 5) to 0.649 (item 2) on the single item level. With regard to intra-rater reliability, the ICC was 0.945 on the total score level, with Cohen’s weighted k ranging from 0.469 (item 5) to 0.883 (item1) on the single item level. Cronbach’s α value of all 5 items amounted to 0.746. Spearman’s rank correlation coefficient between OPTION⁵ and OPTION¹² for Chinese versions was 0.660.

Conclusions

The simplified Chinese version of the OPTION⁵ scale, developed using stringent translation procedures, demonstrated satisfactory psychometric characteristics. Specifically, inter- and intra-rater reliabilities were excellent, while criterion validity was moderate. The simplified Chinese version of the OPTION⁵ scale can be implemented in clinical settings to evaluate SDM of treatment during consultations between GPs and chronically ill patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-020-01335-2.

What matters most: Randomized controlled trial of breast cancer surgery conversation aids across socioeconomic strata

Background

Women of lower socioeconomic status (SES) with early‐stage breast cancer are more likely to report poorer physician‐patient communication, lower satisfaction with surgery, lower involvement in decision making, and higher decision regret compared to women of higher SES. The objective of this study was to understand how to support women across socioeconomic strata in making breast cancer surgery choices.

Methods

We conducted a 3‐arm (Option Grid, Picture Option Grid, and usual care), multisite, randomized controlled superiority trial with surgeon‐level randomization. The Option Grid (text only) and Picture Option Grid (pictures plus text) conversation aids were evidence‐based summaries of available breast cancer surgery options on paper. Decision quality (primary outcome), treatment choice, treatment intention, shared decision making (SDM), anxiety, quality of life, decision regret, and coordination of care were measured from T0 (pre‐consultation) to T5 (1‐year after surgery.

Results

Sixteen surgeons saw 571 of 622 consented patients. Patients in the Picture Option Grid arm (n = 248) had higher knowledge (immediately after the visit [T2] and 1 week after surgery or within 2 weeks of the first postoperative visit [T3]), an improved decision process (T2 and T3), lower decision regret (T3), and more SDM (observed and self‐reported) compared to usual care (n = 257). Patients in the Option Grid arm (n = 66) had higher decision process scores (T2 and T3), better coordination of care (12 weeks after surgery or within 2 weeks of the second postoperative visit [T4]), and more observed SDM (during the surgical visit [T1]) compared to usual care arm. Subgroup analyses suggested that the Picture Option Grid had more impact among women of lower SES and health literacy. Neither intervention affected concordance, treatment choice, or anxiety.

Conclusions

Paper‐based conversation aids improved key outcomes over usual care. The Picture Option Grid had more impact among disadvantaged patients.

Lay Summary

The objective of this study was to understand how to help women with lower incomes or less formal education to make breast cancer surgery choices.

Compared with usual care, a conversation aid with pictures and text led to higher knowledge. It improved the decision process and shared decision making (SDM) and lowered decision regret. A text‐only conversation aid led to an improved decision process, more coordinated care, and higher SDM compared to usual care. The conversation aid with pictures was more helpful for women with lower income or less formal education.

Conversation aids with pictures and text helped women make better breast cancer surgery choices.

A paper‐based pictorial conversation aid (pictures plus text) is beneficial to all patients with early‐stage breast cancer and particularly to disadvantaged patients. Between‐surgeon variation suggests that the maximal impact of such interventions requires standardized physician training combined with these interventions.

Text-only and picture conversation aids both supported shared decision making for breast cancer surgery: Analysis from a cluster randomized trial

OBJECTIVES

To determine if two encounter conversation aids for early-stage breast cancer surgery increased observed and patient-reported shared decision making (SDM) compared with usual care and if observed and patient-reported SDM were associated.

METHODS

Surgeons in a cluster randomized trial at four cancer centers were randomized to use an Option Grid, Picture Option Grid, or usual care. We used bivariate statistics, linear regression, and multilevel models to evaluate the influence of trial arm, patient socioeconomic status and health literacy on observed SDM (via OPTION-5) and patient-reported SDM (via collaboRATE).

RESULTS

From 311 recordings, OPTION-5 scores were 73/100 for Option Grid (n = 40), 56.3/100 for Picture Option Grid (n = 144), and 41.0/100 for usual care (n = 127; p < 0.0001). Top collaboRATE scores were 81.6 % for Option Grid, 80.0 % for Picture Option Grid, and 56.4 % for usual care (p < 0.001). Top collaboRATE scores correlated with an 8.60 point (95 %CI 0.66, 13.7) higher OPTION-5 score (p = 0.008) with no correlation in the multilevel analysis. Patients of lower socioeconomic status had lower OPTION-5 scores before accounting for clustering.

CONCLUSIONS

Both conversation aids led to meaningfully higher observed and patient-reported SDM. Observed and patient-reported SDM were not strongly correlated.

PRACTICE IMPLICATIONS

Healthcare providers could implement these conversation aids in real-world settings.

Pelvic organ prolapse and treatment decisions- developing an online preference-sensitive tool to support shared decisions

Background

Female patients with pelvic organ prolapse and clinicians need to take decisions regarding treatment that are often unpredictable in relation to how they impact the future everyday lives of the patients.

This study formed the developmental phase of a larger study to develop and test an online tool to support shared decision-making.

Methods

Patients, health care professionals and other stakeholders participated in the development and evaluation process of this tool. The collected data was generated from observational studies, exploratory interviews with prompt cards and workshops with end users from four Danish gynecology outpatient clinics.

Results

Content analysis led to important themes. For the patients three themes emerged: 1) how the impact of symptoms on everyday life affected the need for relief, 2) their bodily perception and sex life and 3) their worries about the future. For clinicians the different symptoms and their severity was a main theme.

Conclusions

This article provides an overall description and discussion of the development methodology. It demonstrates how user involvement informed the prototyping process and how patients’ preferences were included in the final prototype. Whether the tool actually increases SDM, remains to be tested in a pilot feasibility study.

A skills network approach to physicians' competence in shared decision making

BACKGROUND

Measurement of physicians' competence in shared decision making (SDM) remains challenging with frequent disagreement between assessment methods.

OBJECTIVE

To conceptualize and measure physicians' SDM competence as an organized network of behavioural skills and to determine whether processing patient-reported data according to this model can be used to predict observer-rated competence.

DESIGN

Secondary analysis of an observational study.

SETTING AND PARTICIPANTS

Primary and specialty outpatient care physicians and consecutively recruited adult patients with a chronic condition who faced a treatment decision with multiple acceptable choices.

MEASURES

Network parameters constructed from patients' assessment of physicians' SDM skills as measured by the 9-item Shared Decision Making Questionnaire (SDM-Q-9) and observer-rated SDM competence of physicians measured by three widely used observer-rated instruments.

RESULTS

29 physicians (12 female, 17 male; mean age 50.3 years) recruited 310 patients (59.4% female, 40.6% male; mean age 54.0 years) facing a decision mainly regarding type 2 diabetes (36.4%), chronic back pain (32.8%) or depressive disorder (26.8%). Although most investigated skills were interrelated, elicitation of the patient's treatment preferences showed the strongest associations with the other skills. Network parameters of this skill were also decisive in predicting observer-rated competence. Correlation between predicted competence scores and observer-rated measurements ranged from 0.710 to 0.785.

CONCLUSIONS

Conceptualizing physicians' SDM competence as a network of interacting skills enables the measurement of observer-rated competence using patient-reported data. In addition to theoretical implications for defining and training medical competences, the findings open a new way to measure physicians' SDM competence under routine conditions.

Shared Decision Making for Syncope in the Emergency Department: A Randomized Controlled Feasibility Trial

OBJECTIVES

Significant practice variation is seen in the management of syncope in the emergency department (ED). We sought to evaluate the feasibility of performing a randomized controlled trial of a shared decision making (SDM) tool for low-to-intermediate-risk syncope patients presenting to the ED.

METHODS

We performed a randomized controlled trial of adults (≥30 years) with unexplained syncope who presented to an academic ED in the United States. Patients with a serious diagnosis identified in the ED were excluded. Patients were randomized, 1:1, to receive either usual care or a personalized syncope decision aid (SynDA) meant to facilitate SDM. Our primary outcome was feasibility, i.e., ability to enroll 50 patients in 24 months. Secondary outcomes included patient knowledge, involvement (measured with OPTION-5), rating of care, and clinical outcomes at 30 days post-ED visit.

RESULTS

After screening 351 patients, we enrolled 50 participants with unexplained syncope from January 2017 to January 2019. The most common reason for exclusion was lack of clinical equipoise to justify SDM (n = 124). Patients in the SynDA arm tended to have greater patient involvement, as shown by higher OPTION-5 scores: 52/100 versus 27/100 (between-group difference = -25.4, 95% confidence interval = -13.5 to -37.3). Both groups had similar levels of clinical knowledge, ratings of care, and serious clinical outcomes at 30 days.

CONCLUSIONS

Among ED patients with unexplained syncope, a randomized controlled trial of a shared decision-making tool is feasible. Although this study was not powered to detect differences in clinical outcomes, it demonstrates feasibility, while providing key lessons and effect sizes that could inform the design of future SDM trials.

Effect of a Prostate Cancer Screening Decision Aid for African-American Men in Primary Care Settings

BACKGROUND

African-American men have an elevated risk of developing and dying from prostate cancer. Shared decision-making (SDM) about prostate cancer screening is recommended but does not always occur.

METHODS

We pilot-tested an online decision aid (DA) in primary care settings using a pre/postevaluation design among African-American men ages 45 to 70 years. Men completed surveys before and after using the DA, which had interactive segments (e.g., values clarification) and provided individualized assessment of prostate cancer risk. Primary outcomes included prostate cancer knowledge, confidence in ability to make informed decisions, decisional conflict, and satisfaction with the decision. Immediately after the clinical visit, patients reported the degree to which they were engaged by their provider in SDM.

RESULTS

Among this sample of men (n = 49), use of the DA was associated with increased knowledge about prostate cancer [mean = 55.3% vs. 71.2%; 95% confidence interval (CI), 9.8-22.1; P < 0.001], reduced decisional conflict (mean = 33.4 vs. 23.6; 95% CI, -18.1 to -1.6; P = 0.002) on a scale from 0 to 100, and a decreased preference to be screened (88% vs. 69%; 95% CI, 0.09-0.64; P = 0.01). Most (89%) reported that the DA prepared them well/very well for SDM with their provider. Following the clinical visit with providers, scores on perceived involvement in SDM were 68.1 (SD 29.1) on a 0 to 100 scale.

CONCLUSIONS

The DA improved men's knowledge, reduced decisional conflict, and promoted the perception of being prepared for SDM.

IMPACT

Findings suggest that use of an online DA to improve SDM outcomes warrants further testing in a future trial.

Measuring shared decision-making and collaborative goal setting in community rehabilitation: a focused ethnography using cross-sectional surveys in Canada

OBJECTIVE

To describe and measure the shared decision-making (SDM) experience, including goal-setting experiences, from the perspective of patients and providers in diverse community-rehabilitation settings.

DESIGN

Prospective, longitudinal surveys.

SETTING

13 primary level-of-care community-rehabilitation sites in diverse areas varying in geography, patient population and provider discipline341 adult, English-speaking patient-participants, and 66 provider-participants.

MEASURES

Alberta Shared decision-maKing Measurement Instrument (dyadic tool measuring SDM), WatLX (outpatient rehabilitation experience) and demographic questionnaire. Survey packages distributed at two timepoints (T0=recruitment; T1=3 months later).

RESULTS

We found that among 341 patient-provider dyads, 26.4% agreed that the appointment at recruitment involved high-quality SDM. Patient perceptions of goal-setting suggested that 19.6% of patients did not set a goal for their care, and only 11.4% set goals in functional language that tied directly to an activity/role/responsibility that was meaningful to their life. Better SDM was clinically associated with higher total family income (p=0.045).

CONCLUSIONS

These findings provide evidence for the importance of SDM and goal setting in community rehabilitation. Among patients, lower ratings of SDM corresponded with less recognition of their preferences. Actionable strategies include supporting financially vulnerable patients in realising SDM through training of providers to make extra space for such patients to share their preferences and better preparing patients to articulate their preferences. We recommend more research into strategies that advance highly functional goal setting with patients, and that lessen survey ceiling effects.

The current extent of and need for shared decision making in atopic dermatitis and psoriasis in the Netherlands: an online survey study amongst patients and physicians

Background

In shared decision making (SDM), patients and physicians work together to choose the best treatment option for an individual patient. Atopic dermatitis (AD) and psoriasis are particularly suitable for SDM, considering that the best treatment option depends on a patient’s preferences and values (preference‐sensitive decisions). Currently, it is unknown to what extent SDM is applied in treatment decisions for these diseases in the Netherlands.

Objectives

Primary, to assess the current extent of SDM in AD and psoriasis in the Netherlands amongst patients and dermatologists. Secondary, to assess the degree to which patients and physicians endorse SDM, to explore which characteristics are related to their preference to be involved in SDM and to identify which barriers and facilitators for SDM they perceive.

Methods

Two similar online surveys, one for patients with AD or psoriasis and one for (resident) dermatologists, were carried out. The surveys comprised validated questionnaires (shared decision making questionnaire (SDM‐Q; range 0–100), Control Preference Scale) and study‐specific statements mainly regarding barriers and facilitators for SDM.

Results

The responses of 219 patients and 147 physicians were analysed. Dermatologists experienced significantly more SDM than patients (SDM‐Q 82 vs 55; P < 0.01).

Most patients and dermatologists prefer to share treatment decisions. Mainly facilitators for SDM were perceived, including the positive perception of patients and dermatologists regarding SDM. The perceived barriers included lack of continuity of care by the same physician and lack of time.

Conclusion

Despite the dermatologists’ optimistic perspective, patients experience a limited extent of SDM and physicians should be aware of this gap. Improvement of SDM in AD and psoriasis is needed. The positive attitude of patients and dermatologists towards the process and outcome of SDM is important facilitators, while barriers were mainly perceived on an organizational level.

Improving shared decision-making in vascular surgery by implementing decision support tools: study protocol for the stepped-wedge cluster-randomised OVIDIUS trial

Background

Shared decision-making improves the quality of patient care. Unfortunately, shared decision-making is not yet common practice among vascular surgeons. Thus, decision support tools were developed to assist vascular surgeons and their patients in using shared decision-making. This trial aims to evaluate the effectiveness and implementation of decision support tools to improve shared decision-making during vascular surgical consultations in which a treatment decision is to be made.

Methods

The study design is a multicentre stepped-wedge cluster-randomised trial. Eligible patients are adult patients, visiting the outpatient clinic of a participating medical centre for whom several treatment options are feasible and who face a primary treatment decision for their abdominal aortic aneurysm, carotid artery disease, intermittent claudication, or varicose veins. Patients and vascular surgeons in the intervention group receive decision support tools that may help them adopt shared decision-making when making the final treatment decision. These decision support tools are decision aids, consultation cards, decision cards, and a practical training. Decision aids are informative websites that help patients become more aware of the pros and cons of the treatment options and their preferences regarding the treatment choice. Consultation cards with text or decision cards with images are used by vascular surgeons during consultation to determine which aspect of a treatment is most important to their patient. In the training vascular surgeons can practice shared decision-making with a patient actor, guided by a medical psychologist. This trial aims to include 502 vascular surgical patients to achieve a clinically relevant improvement in shared decision-making of 10 out of 100 points, using the 5-item OPTION instrument to score the audio-recordings of consultations.

Discussion

In the OVIDIUS trial the available decision support tools for vascular surgical patients are implemented in clinical practice. We will evaluate whether these tools actually improve shared decision-making in the consultation room. The stepped-wedge cluster-randomised study design will ensure that at the end of the study all participating centres have implemented at least some of the decision support tools and thereby a certain level of shared decision-making.

Trial registration

Netherlands Trial Registry, NTR6487. Registered 7 June 2017. URL: http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6487

Direct-Observation Cohort Study of Shared Decision Making in a Primary Care Clinic

Background. Observational studies suggest that shared medical decision making (SMDM) is suboptimal. Our objective was to assess patient preferences, ratings, and objective measurements of decision making and their impact on patient outcomes. Methods. Hypertensive adults presenting for routine care with their primary care physician completed previsit surveys assessing SMDM preferences. Postvisit surveys assessed the degree of SMDM during the encounter, patient satisfaction, and trust. Encounters were audiotaped and transcripts were coded for type of decisions made as well as SMDM quality using OPTION-5. Adherence and blood pressure were measured at baseline and at 4 weeks. Results. Among 105 encounters, there were 7.4 decisions per visit; most were basic, such as refills and routine testing. Objective measures of decision making indicated that the degree of SMDM was lower than reported by patients or physicians, although physician ratings were more accurate. Previsit, 54% of patients expressed a desire for equally shared medical decision making, 24% preferred physician dominated decision making, and 18% preferred that they make the decisions. Postvisit, patients reported experiencing SMDM in 57% of encounters, with high concordance between desired and perceived decision making. Discordance between the patient's desired and experienced SMDM reduced trust and satisfaction. The quality of shared decisions had no impact on adherence or blood pressure at 4 weeks. Limitations. Single site, small sample. Conclusions. Decisions are common during internal medicine primary care visits, and most are basic. Most patients preferred SMDM, and their perceptions of the visit decision-making style were concordant with their preferences although higher than objective measures suggested. Physician ratings of the quality of SMDM were more accurate than patient ratings. Discordance between patients' expected and experienced SMDM lowered satisfaction and trust.

Realizing better doctor-patient dialogue about choices in palliative care and early phase clinical trial participation: towards an online value clarification tool (OnVaCT)

BACKGROUND

Patients with advanced cancer for whom standard systemic treatment is no longer available may be offered participation in early phase clinical trials. In the decision making process, both medical-technical information and patient values and preferences are important. Since patients report decisional conflict after deciding on participation in these trials, improving the decision making process is essential. We aim to develop and evaluate an Online Value Clarification Tool (OnVaCT) to assist patients in clarifying their values around this end-of-life decision. This improved sharing of values is hypothesized to support medical oncologists in tailoring their information to individual patients' needs and, consequently, to support patients in taking decisions in line with their values and reduce decisional conflict.

METHODS

In the first part, patients' values and preferences and medical oncologists' views hereupon will be explored in interviews and focus groups to build a first prototype OnVaCT using digital communication (serious gaming). Next, we will test feasibility during think aloud sessions, to deliver a ready-to-implement OnVaCT. In the second part, the OnVaCT, with accompanied training module, will be evaluated in a pre-test (12-18 months before implementation) post-test (12-18 months after implementation) study in three major Dutch cancer centres. We will include 276 patients (> 18 years) with advanced cancer for whom standard systemic therapy is no longer available, and who are referred for participation in early phase clinical trials. The first consultation will be recorded to analyse patient-physician communication regarding the discussion of patients' values and the decision making process. Three weeks afterwards, decisional conflict will be measured.

DISCUSSION

This project aims to support the discussion of patient values when considering participation in early phase clinical trials. By including patients before their first appointment with the medical oncologist and recording that consultation, we are able to link decisional conflict to the decision making process, e.g. the communication during consultation. The study faces challenges such as timely including patients within the short period between referral and first consultation. Furthermore, with new treatments being developed rapidly, molecular stratification may affect the patient populations included in the pre-test and post-test periods.

TRIAL REGISTRATION

Netherlands Trial Registry number: NTR7551 (prospective; July 17, 2018).

Measuring triadic decision making in older patients with multiple chronic conditions: Observer OPTIONMCC

OBJECTIVE

To develop a valid and reliable tool to measure triadic decision making between older adults with multiple chronic conditions (MCC), their informal caregivers and geriatricians.

METHODS

Video observational study with cross-sectional assessment of interaction during medical consultations between geriatricians (n = 10), patients (n = 108) and informal caregivers (68) by three calibrated raters at the geriatric outpatient department of two Dutch hospitals. The Observer OPTION^MCC instrument was developed, based on the 'Dynamic model of SDM in frail older patients' and the 'Observing Patient Involvement in Decision Making - 5 item scale' (Observer OPTION-5).

RESULTS

Factor analysis confirms that it is acceptable to regard the new scale as a single construct. The 7-item single factor solution explained 62.76% of the variability for geriatricians, 61.60% of the variability for patients and 54.32% of the variability for informal caregivers. The inter-rater ICC for the total Observer OPTION^MCC score was .96, .96, and .95 (resp. geriatricians, patients, informal caregivers), with values ranging from .60 to .95 for individual items, showing good levels of agreement.

CONCLUSION AND PRACTICE IMPLICATIONS

We conclude that Observer OPTION^MCC is sufficiently valid and reliable to be used for the assessment of triadic SDM in populations of older patients with MCC.

Shared decision making in routine clinical care of patients with rheumatoid arthritis: an assessment of audio-recorded consultations

Objectives

Although shared decision making (SDM) is advocated in rheumatoid arthritis (RA) treatment, it is largely unclear when, how and to what extent SDM is applied in routine clinical care of patients with RA. This study aimed to investigate the level of SDM in RA treatment from an observer perspective and to assess associations between the level of SDM and characteristics of the clinician, patient and consultation.

Methods

The level of SDM was investigated by scoring audio-recordings of 168 routine consultations with unique patients with the observer patient involvement (OPTION) scale (scale 0–100, higher OPTION scores indicating higher levels of SDM). Associations between the level of SDM and characteristics of the clinician, patient and consultation were assessed using multilevel modelling. Statistical significance was set at p<0.05.

Results

The mean OPTION score was 28.3 (SD=15.1). The multilevel model included four characteristics: clinician age, patient age, consultation duration and type of treatment decision. There were significant, positive associations between the level of SDM and the consultation duration (b=0.63, 95% CI 0.16 to 1.11), decision for stopping and/or starting medication (b=14.30, 95% CI 5.62 to 22.98), decision for adjusting medication doses (b=8.36, 95% CI 3.92 to 12.81) and decision for administering single dose glucocorticoids (b=15.03, 95% CI 9.12 to 20.93). Thus, a higher level of SDM was significantly associated with a longer consultation duration and the type of treatment decision. No other significant associations were found.

Conclusions

Overall, the level of SDM in RA treatment leaves room for improvement. To foster SDM in routine clinical care, training programmes on patient-centred communication skills may be helpful.

Interventions for involving older patients with multi-morbidity in decision-making during primary care consultations

BACKGROUND

Older patients with multiple health problems (multi-morbidity) value being involved in decision-making about their health care. However, they are less frequently involved than younger patients. To maximise quality of life, day-to-day function, and patient safety, older patients require support to identify unmet healthcare needs and to prioritise treatment options.

OBJECTIVES

To assess the effects of interventions for older patients with multi-morbidity aiming to involve them in decision-making about their health care during primary care consultations.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; all years to August 2018), in the Cochrane Library; MEDLINE (OvidSP) (1966 to August 2018); Embase (OvidSP) (1988 to August 2018); PsycINFO (OvidSP) (1806 to August 2018); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (Ovid) (1982 to September 2008), then in Ebsco (2009 to August 2018); Centre for Reviews and Dissemination Databases (Database of Abstracts and Reviews of Effects (DARE)) (all years to August 2018); the Health Technology Assessment (HTA) Database (all years to August 2018); the Ongoing Reviews Database (all years to August 2018); and Dissertation Abstracts International (1861 to August 2018).

SELECTION CRITERIA

We sought randomised controlled trials (RCTs), cluster-RCTs, and quasi-RCTs of interventions to involve patients in decision-making about their health care versus usual care/control/another intervention, for patients aged 65 years and older with multi-morbidity in primary care.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Meta-analysis was not possible; therefore we prepared a narrative synthesis.

MAIN RESULTS

We included three studies involving 1879 participants: two RCTs and one cluster-RCT. Interventions consisted of: · patient workshop and individual coaching using behaviour change techniques; · individual patient coaching utilising cognitive-behavioural therapy and motivational interviewing; and · holistic patient review, multi-disciplinary practitioner training, and organisational change. No studies reported the primary outcome 'patient involvement in decision-making' or the primary adverse outcome 'less patient involvement as a result of the intervention'. Comparing interventions (patient workshop and individual coaching, holistic patient review plus practitioner training, and organisational change) to usual care: we are uncertain whether interventions had any effect on patient reports of high self-rated health (risk ratio (RR) 1.40, 95% confidence interval (CI) 0.36 to 5.49; very low-certainty evidence) or on patient enablement (mean difference (MD) 0.60, 95% CI -9.23 to 10.43; very low-certainty evidence) compared with usual care. Interventions probably had no effect on health-related quality of life (adjusted difference in means 0.00, 95% CI -0.02 to 0.02; moderate-certainty evidence) or on medication adherence (MD 0.06, 95% CI -0.05 to 0.17; moderate-certainty evidence) but probably improved the number of patients discussing their priorities (adjusted odds ratio 1.85, 95% CI 1.44 to 2.38; moderate-certainty evidence) and probably increased the number of nurse consultations (incident rate ratio from adjusted multi-level Poisson model 1.37, 95% CI 1.17 to 1.61; moderate-certainty evidence) compared with usual care. Practitioner outcomes were not measured. Interventions were not reported to adversely affect rates of participant death or anxiety, emergency department attendance, or hospital admission compared with usual care. Comparing interventions (patient workshop and coaching, individual patient coaching) to attention-control conditions: we are uncertain whether interventions affect patient-reported high self-rated health (RR 0.38, 95% CI 0.15 to 1.00, favouring attention control, with very low-certainty evidence; RR 2.17, 95% CI 0.85 to 5.52, favouring the intervention, with very low-certainty evidence). We are uncertain whether interventions affect patient enablement and engagement by increasing either patient activation (MD 1.20, 95% CI -8.21 to 10.61; very low-certainty evidence) or self-efficacy (MD 0.29, 95% CI -0.21 to 0.79; very low-certainty evidence); or whether interventions affect the number of general practice visits (MD 0.51, 95% CI -0.34 to 1.36; very low-certainty evidence), compared to attention-control conditions. The intervention may however lead to more patient-reported changes in management of their health conditions (RR 1.82, 95% CI 1.35 to 2.44; low-certainty evidence). Practitioner outcomes were not measured. Interventions were not reported to adversely affect emergency department attendance nor hospital admission when compared with attention control. Comparing one form of intervention with another: not measured. There was 'unclear' risk across studies for performance bias, detection bias, and reporting bias; however, no aspects were 'high' risk. Evidence was downgraded via GRADE, most often because of 'small sample size' and 'evidence from a single study'.

AUTHORS' CONCLUSIONS

Limited available evidence does not allow a robust conclusion regarding the objectives of this review. Whilst patient involvement in decision-making is seen as a key mechanism for improving care, it is rarely examined as an intervention and was not measured by included studies. Consistency in design, analysis, and evaluation of interventions would enable a greater likelihood of robust conclusions in future reviews.

Shared decision making in IBD: A novel approach to trial consent and timing

Background

Shared decision making (SDM) between families and physicians may facilitate informed, timely decisions to proceed with biologic therapy in children with inflammatory bowel disease (IBD). Our team previously developed an SDM tool to aid communication between physicians and families when considering biologic therapy for children with IBD.

Objective

We are conducting a prospective, pre-post pilot trial of a new SDM tool. The primary aim of the study is to assess feasibility of both the intervention and trial procedures for a future large-scale trial.

Methods

We are enrolling physicians with experience prescribing biologic therapy in the past year and families of children with IBD. Families in the intervention arm receive a 3-step intervention including a letter sent before trial consent or clinic appointment, an in-clinic decision tool and a follow-up phone call. Our primary trial outcome is a measure of feasibility, with measures of clinical and decision outcomes secondary. We seek to enroll 27 families in each of 2 arms (usual-care and intervention) and plan data collection at the time of the initial visit or hospital stay, and at 1 week, 3 months, and 6 months after the initial visit.

Conclusion

This study protocol is designed to demonstrate that integrating novel consent procedures, including timing and multiple versions of written consent, may increase trial feasibility while maintaining scientific rigor and full protection of study participants.

Implementation of the uterine fibroids Option Grid patient decision aids across five organizational settings: a randomized stepped-wedge study protocol

BACKGROUND

Uterine fibroids are non-cancerous overgrowths of the smooth muscle in the uterus. As they grow, some cause problems such as heavy menstrual bleeding, pelvic pain, discomfort during sexual intercourse, and rarely pregnancy complications or difficulty becoming pregnant. Multiple treatment options are available. The lack of comparative evidence demonstrating superiority of any one treatment means that choosing the best option is sensitive to individual preferences. Women with fibroids wish to consider treatment trade-offs. Tools known as patient decision aids (PDAs) are effective in increasing patient engagement in the decision-making process. However, the implementation of PDAs in routine care remains challenging. Our aim is to use a multi-component implementation strategy to implement the uterine fibroids Option Grid™ PDAs at five organizational settings in the USA.

METHODS

We will conduct a randomized stepped-wedge implementation study where five sites will be randomized to implement the uterine fibroid Option Grid PDA in practice at different time points. Implementation will be guided by the Consolidated Framework for Implementation Research (CFIR) and Normalization Process Theory (NPT). There will be a 6-month pre-implementation phase, a 2-month initiation phase where participating clinicians will receive training and be introduced to the Option Grid PDAs (available in text, picture, or online formats), and a 6-month active implementation phase where clinicians will be expected to use the PDAs with patients who are assigned female sex at birth, are at least 18 years of age, speak fluent English or Spanish, and have new or recurrent symptoms of uterine fibroids. We will exclude postmenopausal patients. Our primary outcome measure is the number of eligible patients who receive the Option Grid PDAs. We will use logistic and linear regression analyses to compare binary and continuous quantitative outcome measures (including survey scores and Option Grid use) between the pre- and active implementation phases while adjusting for patient and clinician characteristics.

DISCUSSION

This study may help identify the factors that impact the implementation and sustained use of a PDA in clinic workflow from various stakeholder perspectives while helping patients with uterine fibroids make treatment decisions that align with their preferences.

TRIAL REGISTRATION

Clinicaltrials.gov , NCT03985449. Registered 13 July 2019, https://clinicaltrials.gov/ct2/show/NCT03985449.

Evaluation of a shared decision-making communication skills training for physicians treating patients with asthma: a mixed methods study using simulated patients

Background

Shared decision-making (SDM) is a key principle in asthma management, but continues to be poorly implemented in routine care. This study aimed to evaluate the impact of a SDM communication skills training for physicians treating patients with asthma on the SDM behaviors of physicians, and to analyze physician views on the training.

Methods

A mixed methods study with a partially mixed sequential equal status design was conducted to evaluate a 12 h SDM communication skills training for physicians treating patients with asthma. It included a short introductory talk, videotaped consultations with simulated asthma patients, video analysis in small group sessions, individual feedback, short presentations, group discussions, and practical exercises. The quantitative evaluation phase consisted of a before (t0) after (t1) comparison of SDM performance using the observer-rated OPTION⁵, the physician questionnaire SDM-Q-Doc, and the patient questionnaire SDM-Q-9, using dependent t-tests. The qualitative evaluation phase (t2) consisted of a content analysis of audiotaped and transcribed interviews.

Results

Initially, 29 physicians participated in the study, 27 physicians provided quantitative data, and 22 physicians provided qualitative data for analysis. Quantitative results showed significantly improved performance in SDM following the training (t1) when compared with performance in SDM before the training (t0) (OPTION⁵: t (26) = − 5.16; p < 0.001) (SDM-Q-Doc: t (26) = − 4.39; p < 0.001) (SDM-Q-9: t (26) = − 5.86; p < 0.001). The qualitative evaluation showed that most physicians experienced a change in attitude and behavior after the training, and positively appraised the training program. Physicians considered simulated patient consultations, including feedback and video analysis, beneficial and suggested the future use of real patient consultations.

Conclusion

The SDM communication skills training for physicians treating patients with asthma has potential to improve SDM performance, but would benefit from using real patient consultations.

Ability of observer and self-report measures to capture shared decision-making in clinical practice in the UK: a mixed-methods study

OBJECTIVES

To examine how observer and self-report measures of shared decision-making (SDM) evaluate the decision-making activities that patients and clinicians undertake in routine consultations.

DESIGN

Multi-method study using observational and self-reported measures of SDM and qualitative analysis.

SETTING

Breast care and predialysis teams who had already implemented SDM.

PARTICIPANTS

Breast care consultants, clinical nurse specialists and patients who were making decisions about treatment for early-stage breast cancer. Predialysis clinical nurse specialists and patients who needed to make dialysis treatment decisions.

METHODS

Consultations were audio recorded, transcribed and thematically analysed. SDM was measured using Observer OPTION-5 and a dyadic SureScore self-reported measure.

RESULTS

Twenty-two breast and 21 renal consultations were analysed. SureScore indicated that clinicians and patients felt SDM was occurring, but scores showed ceiling effects for most participants, making differentiation difficult. There was mismatch between SureScore and OPTION-5 score data, the latter showing that each consultation lacked at least some elements of SDM. Highest scoring items using OPTION-5 were 'incorporating patient preferences into decisions' for the breast team (mean 18.5, range 12.5-20, SD 2.39) and 'eliciting patient preferences to options' for the renal team (mean 16.15, range 10-20, SD 3.48). Thematic analysis identified that the SDM encounter is difficult to measure because decision-making is often distributed across encounters and time, with multiple people, it is contextually adapted and can involve multiple decisions.

CONCLUSIONS

Self-reported measures can broadly indicate satisfaction with SDM, but do not tell us about the quality of the interaction and are unlikely to capture the multi-staged nature of the SDM process. Observational measures provide an indication of the extent to which elements of SDM are present in the observed consultation, but cannot explain why some elements might not be present or scored lower. Findings are important when considering measuring SDM in practice.

Can goal-setting for patients with multimorbidity improve outcomes in primary care? Cluster randomised feasibility trial

INTRODUCTION

Goal-setting is recommended for patients with multimorbidity, but there is little evidence to support its use in general practice.

OBJECTIVE

To assess the feasibility of goal-setting for patients with multimorbidity, before undertaking a definitive trial.

DESIGN AND SETTING

Cluster-randomised controlled feasibility trial of goal-setting compared with control in six general practices.

PARTICIPANTS

Adults with two or more long term health conditions and at risk of unplanned hospital admission.

INTERVENTIONS

General practitioners (GPs) underwent training and patients were asked to consider goals before an initial goal-setting consultation and a follow-up consultation 6 months later. The control group received usual care planning.

OUTCOME MEASURES

Health-related quality of life (EQ-5D-5L), capability (ICEpop CAPability measure for Older people), Patient Assessment of Chronic Illness Care and healthcare use. All consultations were video-recorded or audio-recorded, and focus groups were held with participating GPs and patients.

RESULTS

Fifty-two participants were recruited with a response rate of 12%. Full follow-up data were available for 41. In the goal-setting group, mean age was 80.4 years, 54% were female and the median number of prescribed medications was 13, compared with 77.2 years, 39% female and 11.5 medications in the control group. The mean initial consultation time was 23.0 min in the goal-setting group and 19.2 in the control group. Overall 28% of patient participants had no cognitive impairment. Participants set between one and three goals on a wide range of subjects, such as chronic disease management, walking, maintaining social and leisure interests, and weight management. Patient participants found goal-setting acceptable and would have liked more frequent follow-up. GPs unanimously liked goal-setting and felt it delivered more patient-centred care, and they highlighted the importance of training.

CONCLUSIONS

This goal-setting intervention was feasible to deliver in general practice. A larger, definitive study is needed to test its effectiveness.

TRIAL REGISTRATION NUMBER

ISRCTN13248305; Post-results.

Discussions about evidence and preferences in real-life general practice consultations with older patients

OBJECTIVES

To explore how decisions are made in real-life general practice consultations with older patients (65+ years), and examine how general practitioners (GPs) communicate risk and benefit information and evidence, and integrate patient preferences.

METHODS

Secondary analysis of 20 video-recorded consultations with older patients in Australian primary healthcare settings. Consultations were analysed qualitatively using the Framework method and quantitatively using the Observer OPTION⁵ scale and the Assessing Communication about Evidence and Patient Preferences (ACEPP) tool.

RESULTS

Overall, Observer OPTION⁵ and ACEPP scores were low, with mean total scores of 11.3 (out of 100) and 10.4 (out of 40) respectively. Together with qualitative findings, these results suggest that shared decision-making did not occur, and that healthcare options (including anticipated benefits and risks), evidence and patient preferences were rarely discussed in our sample of consultations with older people. GPs often unilaterally made treatment decisions (usually pharmacotherapy) while patients reverted to a passive decision-making role.

CONCLUSION

We observed a lack of shared decision-making in our primary care study, with little engagement of older patients in decisions about their health.

PRACTICE IMPLICATIONS

Training and support tools may be needed to enhance the capacity and self-efficacy of providers and older patients to share healthcare decisions.

Heading in a new direction? Recommendations for future research on patient decision aids

Decision aids can improve a number of patient outcomes, but they are not commonly used in clinical practice. This commentary paper provides suggestions for potential next steps of decision aid research, with the aim to facilitate their implementation. We suggest to further standardise clinically meaningful outcomes and outcome measures that should be used to examine the impact of decision aids. Second, using mediation analysis and active control groups could help tease out and explore variables that influence decision aids' effectiveness to help healthcare providers decide when and how to use them in clinical practice. Third, effectiveness trials should be clearly reported and replicated to investigate under what circumstances decision aids work best. Specific checklists for decision aid trials should be used to ensure that all relevant factors are reported in detail. Addressing the above issues will help identify what specific components of decision aids are effective and should be implemented. We can then move towards conducting implementation trials which help increase the use of decision aids in "real-world" healthcare.

'We DECide optimized' - training nursing home staff in shared decision-making skills for advance care planning conversations in dementia care: protocol of a pretest-posttest cluster randomized trial

Background

Due to the gradual loss of function, it is crucial for persons with dementia to discuss advance care planning in due course. However, nursing home staff, residents and their families feel uncomfortable to start this type of conversation, resulting in unknown (care) preferences. ‘We DECide optimized’ will provide tools to nursing home staff for discussing advance care planning. The primary objective is to enhance the level of shared decision-making in advance care planning conversations. We hypothesize that the training will enhance the perception of the importance, competence and frequency in which participants engage in advance care planning conversations. The secondary objective is to assess barriers and facilitators in the implementation of advance care planning policies at the ward level.

Methods

‘We DECide optimized’ will consist of two four-hour workshops and a homework assignment between sessions. Training components will include information on advance care planning and shared decision-making, role-play exercises and group discussions on implementation barriers at the ward level. Participating wards will receive supporting materials to stimulate residents and their families to initiate conversations. The study uses a cluster randomized controlled design, with 65 Flemish nursing home wards taking part (311 staff members). Data will be collected through a pretest-posttest model, with measurements up to 9 months after training. The RE-AIM framework will be used to evaluate the effectiveness of the implementation. Quantitative and qualitative data at the clinical, organizational and resident level will be collected.

Discussion

This study describes a hands-on, in-depth and multi-level training approach to improve shared decision-making in advance care planning conversations. By providing tools to ward staff, engaging the management and informing residents and their families, ‘We DECide optimized’ aims to decrease evidence-based barriers and to provide all stakeholders with incentives to engage in conversations about (care) preferences in an informative and participatory manner.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1044-z) contains supplementary material, which is available to authorized users.

Does lack of deeper understanding of shared decision making explains the suboptimal performance on crucial parts of it? An example from breast cancer care

PURPOSE

Although most of the clinicians in breast cancer care seem to approve of shared decision making (SDM), actual implementation is limited. The aim of this study was to explore the experiences, issues and concerns of early-adopter professionals with regards to shared decision making.

METHODS

This qualitative descriptive study was part of a pilot study aimed at implementing SDM in breast cancer teams. We interviewed 27 clinicians; 9 breast cancer surgeons, 11 nurse practitioners and 7 nurses. The teams were exposed to a multifaceted implementation programme, among others: a patient decision aid (PtDA), a procedure to disseminate the PtDA and advice on redesigning the clinical pathway.

RESULTS

Participants considered SDM, including the delivery of the PtDA, to be a team effort, in which every professional should take responsibility. Most clinicians primarily focused on the first steps of SDM ignoring preference and decision talk. The remaining steps, like the uptake of the PtDA in the clinical pathway, were regarded as challenging, with surgeons, intentionally or unconsciously, delegating this responsibility to nurses. One barrier to successfully implementing SDM seems to lie in the fact that clinicians were unaware of their lack of competency regarding SDM.

CONCLUSIONS

A deeper understanding is needed among clinicians of what SDM actually is and how a PtDA contributes to this process. Nurses play an important role in the delivery of the PtDA, but their role is not clearly defined. Teams should consider a clear realignment of tasks between surgeons and nurses, which implies redesign of the pathway.

Shared decision-making in older patients with colorectal or pancreatic cancer: Determinants of patients' and observers' perceptions

OBJECTIVE

To identify determinants of older patients' perceptions of involvement in decision-making on colorectal (CRC) or pancreatic cancer (PC) treatment, and to compare these with determinants of observers' perceptions.

METHODS

Patients' perceptions of involvement were constructed by the 9-item SDM questionnaire (SDM-Q-9) and a Visual Analogue Scale for Involvement (VAS-I). Observers' perceptions were constructed by the OPTION5, OPTION12, and MAPPIN'SDM. Convergent validities were calculated between the patient-sided and observer instruments using Spearman's correlation coefficient. Linear regression was used to identify determinants per criterion.

RESULTS

58 CRC and 22 PC patients were included (mean age: 71.8 ± 5.2 years, 45.0% female). No significant correlations were found between the patient-sided and observer instruments. Patients' impression of involvement was influenced by patient characteristics such as quality of life and satisfaction, while observers' perceptions mainly referred to encounter characteristics such as the mean duration of consultations and general communication skills.

CONCLUSION

Due to evident differences in determinants, older CRC/PC patients' and observers' perceptions of involvement should both be collected in evaluating the quality of medical decision-making.

PRACTICE IMPLICATIONS

General communication skills should be integrated in SDM training interventions. New SDM measurement tools for patients are needed to sufficiently discriminate between the constructs of involvement and satisfaction.

Estimation of an inter-rater intra-class correlation coefficient that overcomes common assumption violations in the assessment of health measurement scales

Background

Intraclass correlation coefficients (ICC) are recommended for the assessment of the reliability of measurement scales. However, the ICC is subject to a variety of statistical assumptions such as normality and stable variance, which are rarely considered in health applications.

Methods

A Bayesian approach using hierarchical regression and variance-function modeling is proposed to estimate the ICC with emphasis on accounting for heterogeneous variances across a measurement scale. As an application, we review the implementation of using an ICC to evaluate the reliability of Observer OPTION⁵, an instrument which used trained raters to evaluate the level of Shared Decision Making between clinicians and patients. The study used two raters to evaluate recordings of 311 clinical encounters across three studies to evaluate the impact of using a Personal Decision Aid over usual care. We particularly focus on deriving an estimate for the ICC when multiple studies are being considered as part of the data.

Results

The results demonstrate that ICC varies substantially across studies and patient-physician encounters within studies. Using the new framework we developed, the study-specific ICCs were estimated to be 0.821, 0.295, and 0.644. If the within- and between-encounter variances were assumed to be the same across studies, the estimated within-study ICC was 0.609. If heteroscedasticity is not properly adjusted for, the within-study ICC estimate was inflated to be as high as 0.640. Finally, if the data were pooled across studies without accounting for the variability between studies then ICC estimates were further inflated by approximately 0.02 while formerly allowing for between study variation in the ICC inflated its estimated value by approximately 0.066 to 0.072 depending on the model.

Conclusion

We demonstrated that misuse of the ICC statistics under common assumption violations leads to misleading and likely inflated estimates of interrater reliability. A statistical analysis that overcomes these violations by expanding the standard statistical model to account for them leads to estimates that are a better reflection of a measurement scale’s reliability while maintaining ease of interpretation. Bayesian methods are particularly well suited to estimating the expanded statistical model.

Assessing Shared Decision-Making Clinical Behaviors Among Genetic Counsellors

Shared decision-making (SDM) is a collaborative approach in which clinicians educate, support, and guide patients as they make informed, value-congruent decisions. SDM improves patients' health-related outcomes through increasing knowledge, reducing decisional conflict, and enhancing experience of care. We measured SDM in genetic counselling appointments with 27 pregnant women who were at increased risk to have a baby with a genetic abnormality. The eight experienced genetic counsellors who participated had no specific SDM training and were unaware that SDM was being assessed. Audio transcripts of appointments were scored using 'Observing Patient Involvement in Decision Making' (OPTION12). Patients' anxiety and decisional conflict were also assessed. The genetic counsellors' mean OPTION12 score was 42.4% (SD 9.0%; possible range 0-100%). Specific SDM behaviours that scored highest included introducing the concept of equipoise and listing all options with their pros and cons. Behaviours that scored lowest included eliciting patients' preferred approach to receiving information and desired degree of involvement in decision-making. Patients' levels of anxiety and decisional conflict were unassociated with genetic counsellors' OPTION12 scores. Some SDM behaviours were better demonstrated in this prenatal genetic counselling study than others. Formal training of genetic counsellors in SDM may enhance use of this approach in their professional practice.

Interventions for increasing the use of shared decision making by healthcare professionals

BACKGROUND

Shared decision making (SDM) is a process by which a healthcare choice is made by the patient, significant others, or both with one or more healthcare professionals. However, it has not yet been widely adopted in practice. This is the second update of this Cochrane review.

OBJECTIVES

To determine the effectiveness of interventions for increasing the use of SDM by healthcare professionals. We considered interventions targeting patients, interventions targeting healthcare professionals, and interventions targeting both.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and five other databases on 15 June 2017. We also searched two clinical trials registries and proceedings of relevant conferences. We checked reference lists and contacted study authors to identify additional studies.

SELECTION CRITERIA

Randomized and non-randomized trials, controlled before-after studies and interrupted time series studies evaluating interventions for increasing the use of SDM in which the primary outcomes were evaluated using observer-based or patient-reported measures.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 87 studies (45,641 patients and 3113 healthcare professionals) conducted mainly in the USA, Germany, Canada and the Netherlands. Risk of bias was high or unclear for protection against contamination, low for differences in the baseline characteristics of patients, and unclear for other domains.Forty-four studies evaluated interventions targeting patients. They included decision aids, patient activation, question prompt lists and training for patients among others and were administered alone (single intervention) or in combination (multifaceted intervention). The certainty of the evidence was very low. It is uncertain if interventions targeting patients when compared with usual care increase SDM whether measured by observation (standardized mean difference (SMD) 0.54, 95% confidence interval (CI) -0.13 to 1.22; 4 studies; N = 424) or reported by patients (SMD 0.32, 95% CI 0.16 to 0.48; 9 studies; N = 1386; risk difference (RD) -0.09, 95% CI -0.19 to 0.01; 6 studies; N = 754), reduce decision regret (SMD -0.10, 95% CI -0.39 to 0.19; 1 study; N = 212), improve physical (SMD 0.00, 95% CI -0.36 to 0.36; 1 study; N = 116) or mental health-related quality of life (QOL) (SMD 0.10, 95% CI -0.26 to 0.46; 1 study; N = 116), affect consultation length (SMD 0.10, 95% CI -0.39 to 0.58; 2 studies; N = 224) or cost (SMD 0.82, 95% CI 0.42 to 1.22; 1 study; N = 105).It is uncertain if interventions targeting patients when compared with interventions of the same type increase SDM whether measured by observation (SMD 0.88, 95% CI 0.39 to 1.37; 3 studies; N = 271) or reported by patients (SMD 0.03, 95% CI -0.18 to 0.24; 11 studies; N = 1906); (RD 0.03, 95% CI -0.02 to 0.08; 10 studies; N = 2272); affect consultation length (SMD -0.65, 95% CI -1.29 to -0.00; 1 study; N = 39) or costs. No data were reported for decision regret, physical or mental health-related QOL.Fifteen studies evaluated interventions targeting healthcare professionals. They included educational meetings, educational material, educational outreach visits and reminders among others. The certainty of evidence is very low. It is uncertain if these interventions when compared with usual care increase SDM whether measured by observation (SMD 0.70, 95% CI 0.21 to 1.19; 6 studies; N = 479) or reported by patients (SMD 0.03, 95% CI -0.15 to 0.20; 5 studies; N = 5772); (RD 0.01, 95%C: -0.03 to 0.06; 2 studies; N = 6303); reduce decision regret (SMD 0.29, 95% CI 0.07 to 0.51; 1 study; N = 326), affect consultation length (SMD 0.51, 95% CI 0.21 to 0.81; 1 study, N = 175), cost (no data available) or physical health-related QOL (SMD 0.16, 95% CI -0.05 to 0.36; 1 study; N = 359). Mental health-related QOL may slightly improve (SMD 0.28, 95% CI 0.07 to 0.49; 1 study, N = 359; low-certainty evidence).It is uncertain if interventions targeting healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.30, 95% CI -1.19 to 0.59; 1 study; N = 20) or reported by patients (SMD 0.24, 95% CI -0.10 to 0.58; 2 studies; N = 1459) as the certainty of the evidence is very low. There was insufficient information to determine the effect on decision regret, physical or mental health-related QOL, consultation length or costs.Twenty-eight studies targeted both patients and healthcare professionals. The interventions used a combination of patient-mediated and healthcare professional directed interventions. Based on low certainty evidence, it is uncertain whether these interventions, when compared with usual care, increase SDM whether measured by observation (SMD 1.10, 95% CI 0.42 to 1.79; 6 studies; N = 1270) or reported by patients (SMD 0.13, 95% CI -0.02 to 0.28; 7 studies; N = 1479); (RD -0.01, 95% CI -0.20 to 0.19; 2 studies; N = 266); improve physical (SMD 0.08, -0.37 to 0.54; 1 study; N = 75) or mental health-related QOL (SMD 0.01, -0.44 to 0.46; 1 study; N = 75), affect consultation length (SMD 3.72, 95% CI 3.44 to 4.01; 1 study; N = 36) or costs (no data available) and may make little or no difference to decision regret (SMD 0.13, 95% CI -0.08 to 0.33; 1 study; low-certainty evidence).It is uncertain whether interventions targeting both patients and healthcare professionals compared to interventions of the same type increase SDM whether measured by observation (SMD -0.29, 95% CI -1.17 to 0.60; 1 study; N = 20); (RD -0.04, 95% CI -0.13 to 0.04; 1 study; N = 134) or reported by patients (SMD 0.00, 95% CI -0.32 to 0.32; 1 study; N = 150 ) as the certainty of the evidence was very low. There was insuffient information to determine the effects on decision regret, physical or mental health-related quality of life, or consultation length or costs.

AUTHORS' CONCLUSIONS

It is uncertain whether any interventions for increasing the use of SDM by healthcare professionals are effective because the certainty of the evidence is low or very low.

Comparison of audio vs. audio + video for the rating of shared decision making in oncology using the observer OPTION5 instrument: an exploratory analysis

BACKGROUND

How non-verbal data may influence observer-administered ratings of shared decision making is unknown. Our objective for this exploratory analysis was to determine the effect of mode of data collection (audio+video vs. audio only) on the scoring of the OPTION⁵ instrument, an observer rated measure of shared decision making.

METHODS

We analyzed recordings of 15 encounters between cancer patients and clinicians in which a clinical decision was made. Audio+video or audio only recordings of the encounters were randomly assigned to four trained raters, who reviewed them independently. We compared the adjusted mean scores of audio+video and audio only.

RESULTS

Forty-one unique decisions were identified within the 15 encounters. The mean OPTION⁵ score for audio+video was 17.5 (95% CI 13.5, 21.6) and for audio only was 21.8 (95% CI 17.2, 26.4) with a mean difference of 4.28 (95% CI = 0.36, 8.21; p = 0.032).

CONCLUSION

A rigorous and well established measure of shared decision making performs differently when the data source is audio only. Data source may influence rating of observer administered measures of shared decision making. This potential bias needs to be confirmed as video recording to examine communication behaviors becomes more common.

Evaluation of a program for routine implementation of shared decision-making in cancer care: study protocol of a stepped wedge cluster randomized trial

BACKGROUND

Shared decision-making (SDM) has become increasingly important in health care. However, despite scientific evidence, effective implementation strategies, and a prominent position on the health policy agenda, SDM is not widely implemented in routine practice so far. Therefore, we developed a program for routine implementation of SDM in oncology by conducting an analysis of the current state and a needs assessment in a pilot study based on the Consolidated Framework for Implementation Research (CFIR). Based on these results, the main aim of our current study is to evaluate the process and outcome of this theoretically and empirically grounded multicomponent implementation program designed to foster SDM in routine cancer care.

METHODS

We use a stepped wedge design, a variant of the cluster randomized controlled trial. The intervention to be implemented is SDM. Three participating clinics of one comprehensive cancer center will be randomized and receive the multicomponent SDM implementation program in a time-delayed sequence. The program consists of the following strategies: (a) SDM training for health care professionals, (b) individual coaching for physicians, (c) patient activation strategy, (d) provision of patient information material and decision aids, (e) revision of the clinics' quality management documents, and (f) critical reflection of current organization of multidisciplinary team meetings. We will conduct a mixed methods outcome and process evaluation. The outcome evaluation will consist of four measurement points. The primary outcome is adoption of SDM, measured by the 9-item Shared Decision Making Questionnaire. A range of other implementation outcomes will be assessed (i.e., acceptability, readiness for implementing change, appropriateness, penetration). The implementation process will be evaluated using stakeholder interviews and field notes. This will allow adapting interventions if necessary.

DISCUSSION

This study is the first large study on routine implementation of SDM conducted in German cancer care. We expect to foster implementation of SDM at the enrolled clinics. Insights gained from this study, using a theoretically and empirically grounded approach, can inform other SDM implementation studies and health policy developments, both nationally and internationally.

TRIAL REGISTRATION

clinicaltrials.gov, NCT03393351 . Registered 8 January 2018.

The quality of instruments to assess the process of shared decision making: A systematic review

OBJECTIVE

To inventory instruments assessing the process of shared decision making and appraise their measurement quality, taking into account the methodological quality of their validation studies.

METHODS

In a systematic review we searched seven databases (PubMed, Embase, Emcare, Cochrane, PsycINFO, Web of Science, Academic Search Premier) for studies investigating instruments measuring the process of shared decision making. Per identified instrument, we assessed the level of evidence separately for 10 measurement properties following a three-step procedure: 1) appraisal of the methodological quality using the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist, 2) appraisal of the psychometric quality of the measurement property using three possible quality scores, 3) best-evidence synthesis based on the number of studies, their methodological and psychometrical quality, and the direction and consistency of the results. The study protocol was registered at PROSPERO: CRD42015023397.

RESULTS

We included 51 articles describing the development and/or evaluation of 40 shared decision-making process instruments: 16 patient questionnaires, 4 provider questionnaires, 18 coding schemes and 2 instruments measuring multiple perspectives. There is an overall lack of evidence for their measurement quality, either because validation is missing or methods are poor. The best-evidence synthesis indicated positive results for a major part of instruments for content validity (50%) and structural validity (53%) if these were evaluated, but negative results for a major part of instruments when inter-rater reliability (47%) and hypotheses testing (59%) were evaluated.

CONCLUSIONS

Due to the lack of evidence on measurement quality, the choice for the most appropriate instrument can best be based on the instrument's content and characteristics such as the perspective that they assess. We recommend refinement and validation of existing instruments, and the use of COSMIN-guidelines to help guarantee high-quality evaluations.

What matters most: protocol for a randomized controlled trial of breast cancer surgery encounter decision aids across socioeconomic strata

Background

Breast cancer is the most commonly diagnosed malignancy in women. Mastectomy and breast-conserving surgery (BCS) have equivalent survival for early stage breast cancer. However, each surgery has different benefits and harms that women may value differently. Women of lower socioeconomic status (SES) diagnosed with early stage breast cancer are more likely to experience poorer doctor-patient communication, lower satisfaction with surgery and decision-making, and higher decision regret compared to women of higher SES. They often play a more passive role in decision-making and are less likely to undergo BCS. Our aim is to understand how best to support women of lower SES in making decisions about early stage breast cancer treatments and to reduce disparities in decision quality across socioeconomic strata.

Methods

We will conduct a three-arm, multi-site randomized controlled superiority trial with stratification by SES and clinician-level randomization. At four large cancer centers in the United States, 1100 patients (half higher SES and half lower SES) will be randomized to: (1) Option Grid, (2) Picture Option Grid, or (3) usual care. Interviews, field-notes, and observations will be used to explore strategies that promote the interventions’ sustained use and dissemination. Community-Based Participatory Research will be used throughout. We will include women aged at least 18 years of age with a confirmed diagnosis of early stage breast cancer (I to IIIA) from both higher and lower SES, provided they speak English, Spanish, or Mandarin Chinese. Our primary outcome measure is the 16-item validated Decision Quality Instrument. We will use a regression framework, mediation analyses, and multiple informants analysis. Heterogeneity of treatment effects analyses for SES, age, ethnicity, race, literacy, language, and study site will be performed.

Discussion

Currently, women of lower SES are more likely to make treatment decisions based on incomplete or uninformed preferences, potentially leading to poorer decision quality, quality of life, and decision regret. This study hopes to identify solutions that effectively improve patient-centered care across socioeconomic strata and reduce disparities in decision and care quality.

Trial registration

NCT03136367 at ClinicalTrials.gov

Protocol version: Manuscript based on study protocol version 2.2, 7 November 2017.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5109-2) contains supplementary material, which is available to authorized users.

Psychometric properties of the German version of Observer OPTION5

BACKGROUND

In order to conduct studies on shared decision-making (SDM) and to implement SDM in routine practice, psychometrically tested measures are needed. The development of the short 5-item version of the OPTION scale (Observer OPTION⁵) allows to assess SDM from an observer perspective. Observer OPTION⁵ is so far only available in English and Dutch. The aim of this study was to translate the Observer OPTION⁵ rating scale into German and to test its psychometric properties.

METHODS

The German Observer OPTION⁵ was tested in a secondary data analysis of audio-recordings of patient-physician-consultations (N = 79) in German primary care practices. Demographic data were analysed using descriptive statistics. To assess inter- and intra-rater reliability, intraclass correlation coefficients (ICCs) were calculated. For assessing concurrent validity, a correlation (Spearman's Rho) of the sum score of Observer OPTION⁵ and Observer OPTION¹² was calculated.

RESULTS

The consultations dealt with decisions regarding type 2 diabetes (N = 31), chronic back pain (N = 23), depression (N = 20), and other diseases (N = 5). Analysis of inter-rater reliability yielded an ICC of 0.82 for the sum score; across the five single items ICCs ranged between 0.45 and 0.77. For the intra-rater reliability an ICC of 0.83 was observed for the total score; across the five single items ICCs ranged between 0.45 and 0.86. The Observer OPTION⁵ had a mean total score of 11.84 (SD = 11.92) and the Observer OPTION¹² had a mean total score of 10.3 (SD = 7.9), both on a potential range of 0 to 100. The correlation between the total scores of Observer OPTION⁵ and Observer OPTION¹² was r = 0.47 (p = 0.01).

CONCLUSIONS

The results regarding inter- and intra-rater reliability were excellent on the total score level. Observer OPTION⁵ showed moderate concurrent validity using Observer OPTON¹². The results are generally comparable to the results of the original English version of Observer OPTION⁵. The German version of Observer OPTION⁵ can be used in research and evaluation of clinical practice. Nevertheless, further testing is adviced.

Prostatectomy versus radiotherapy for early-stage prostate cancer (PREPaRE) study: protocol for a mixed-methods study of treatment decision-making in men with localised prostate cancer

BACKGROUND

Men diagnosed with localised prostate cancer (LPC) wanting curative treatment face a highly preference-sensitive choice between prostatectomy and radiotherapy, which offer similar cure rates but different side effects. This study aims to determine the information, decision-making needs and preferences of men with LPC choosing between robotic prostatectomy and standard external beam or stereotactic radiotherapy.

METHODS AND ANALYSIS

This study will be conducted at a large public teaching hospital in Australia offering the choice between robotic prostatectomy and radiotherapy from early 2017. Men (20-30) diagnosed with LPC who want curative treatment and meet criteria for either treatment will be invited to participate. In this mixed-methods study, patients will complete semistructured interviews before and after attending a combined clinic in which they consult a urologist and a radiation oncologist regarding treatment and four questionnaires (one before treatment decision-making and three after) assessing demographic and clinical characteristics, involvement in decision-making, decisional conflict, satisfaction and regret. Combined clinic consultations will also be audio-recorded and clinicians will report their perceptions regarding patients' suitability for, openness to and preferences for each treatment. Qualitative data will be transcribed verbatim and thematically analysed and descriptive statistical analyses will explore quantitative decision-making outcomes, with comparison according to treatment choice.

DISCUSSION

Results from this study will inform how to best support men diagnosed with LPC deciding which curative treatment option best suits their needs and may identify the need for and content required in a decision aid to support these men.

ETHICS AND DISSEMINATION

All participants will provide written informed consent. Data will be rigorously managed in accordance with national legislation. Results will be disseminated via presentations to both scientific and layperson audiences and publications in peer-reviewed scientific journals.

An evaluation of two interventions to enhance patient-physician communication using the observer OPTION5 measure of shared decision making

OBJECTIVE

Evaluate interventions to enhance patient-physician communication and shared decision making (SDM).

METHODS

We used Observer OPTION⁵ to evaluate primary care visits within a cluster randomized controlled trial in a California delivery organization. Trial interventions included Open Communication (OpenComm), combining patient activation and physician coaching, and AskShareKnow, a patient activation tool, and were compared to a usual care arm. Scores were analyzed with descriptive statistics and generalized estimating equation analysis for 40 visits containing 200 decision topics.

RESULTS

The mean overall OPTION⁵ score was 26.5 out of 100 (s.d.=15.2). Compared to visits in the usual care arm, OpenComm visits had higher mean item scores (0-4 scale) for eliciting (mean=1.0 vs 0.8) and integrating patient preferences (mean=1.0 vs 0.8). OpenComm and AskShareKnow visits had higher scores for presenting options (mean=1.5, 1.5 vs 1.3). AskShareKnow visits had higher scores for discussing pros/cons (mean=1.5 vs 1.1). Lower patient education attainment was associated with lower scores.

CONCLUSIONS

OpenComm and AskShareKnow were associated with improved SDM relative to usual care.

PRACTICE IMPLICATIONS

Results suggest targeting patient and physician behaviors promotes SDM better than patient activation only. Improving SDM for less educated patients is crucial.

Shared decision making for stroke prevention in atrial fibrillation: study protocol for a randomized controlled trial

Background

Nonvalvular atrial fibrillation (AF) is a common ongoing health problem that places patients at risk of stroke. Whether and how a patient addresses this risk depends on each patient’s goals, context, and values. Consequently, leading cardiovascular societies recommend using shared decision making (SDM) to individualize antithrombotic treatment in patients with AF. The aim of this study is to assess the extent to which the Anticoagulation Choice conversation tool promotes high-quality SDM and influences anticoagulation uptake and adherence in patients with AF at risk of strokes.

Methods

This study protocol describes a multicenter, encounter-level, randomized trial to assess the effect of using the Anticoagulation Choice conversation tool in the clinical encounter, compared to usual care. The participating centers include an academic hospital system, a suburban community group practice, and an urban safety net hospital, all in Minnesota, USA. Patients with ongoing nonvalvular AF at risk of strokes (CHA₂DS₂-VASc score ≥ 1 in men, or ≥ 2 in women) will be eligible for participation. We aim to include 999 patients and their clinicians. The primary outcome is the quality of SDM as perceived by participants, and as assessed by a post-encounter survey that ascertains (a) knowledge transfer, (b) concordance of the decision made, (c) quality of communication, and (d) satisfaction with the decision-making process. Recordings of encounters will be reviewed to assess the extent of patient involvement and how participants use the tool (fidelity). Anticoagulant use, choice of agent, and adherence will be drawn from patients’ medical and pharmacy records. Strokes and bleeding events will be drawn from patient records.

Discussion

This study will provide a valid and precise measure of the effect of the Anticoagulation Choice conversation tool on SDM quality and processes, and on the treatment choices and adherence to therapy among AF patients at risk of stroke.

Trial registration

ClinicalTrials.gov, NCT02905032. Registered on 9 September 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2178-y) contains supplementary material, which is available to authorized users.

Clinician-patient communication measures: drilling down into assumptions, approaches, and analyses

OBJECTIVE

To critically examine properties of clinician-patient communication measures and offer suggestions for selecting measures appropriate to the purposes of research or clinical practice assessment.

METHODS

We analyzed different types of communication measures by focusing on their ontological properties. We describe their relative advantages and disadvantages with respect to different types of research questions.

RESULTS

Communication measures vary along dimensions of reporter (observer vs. participant), focus of measurement (behavior, meaning, or quality), target, and timing. Observer coded measures of communication behavior function well as dependent variables (e.g., evaluating communication skill interventions, examining variability related to gender or race), but are less effective as predictors of perceptions and health outcomes. Measures of participants' judgments (e.g., what the communication means or how well it was done) capture patients' or clinicians' experiences (e.g., satisfaction) and can be useful for predicting outcomes, especially in longitudinal designs.

CONCLUSION

In the absence of a theoretically coherent set of measures that could be used across research programs and applied setting, users should take steps to select measures with properties that are optimally matched to specific questions.

PRACTICE IMPLICATIONS

Quality assessments of clinician-patient communication should take into account the timing of the assessment and use measures that drill down into specific aspects of patient experience to mitigate ceiling effects.

The current level of shared decision-making in anesthesiology: an exploratory study

BACKGROUND

Shared decision-making (SDM) seeks to involve both patients and clinicians in decision-making about possible health management strategies, using patients' preferences and best available evidence. SDM seems readily applicable in anesthesiology. We aimed to determine the current level of SDM among preoperative patients and anesthesiology clinicians.

METHODS

We invited 115 consecutive preoperative patients, visiting the pre-assessment outpatient clinic of the department of Anesthesiology at the Academic Medical Center of Amsterdam. Inclusion criteria were patients who needed surgery in the arms, lower abdomen or legs, and in whom three anesthesia techniques were feasible. The SDM-level of the consultation was scored objectively by independent observers who judged audio-recordings of the consultation using the OPTION⁵-scale, ranging from 0% (no SDM) to 100% (optimum SDM), as well as subjectively by patients (using the SDM-Q-9 and CollaboRATE questionnaires) and clinicians (SDM-Q-Doc questionnaire). Objective and subjective SDM-levels were assessed on five-point and six-point Likert scales, respectively. Both scores were expressed as percentages.

RESULTS

Data of 80 patients could be analysed. Objective SDM-scores were low (30.5%). Subjective scores of the SDM-Q-9 and CollaboRATE were high among patients (91.7% and 96.3%, respectively) and among clinicians (SDM-Q-Doc; 84.3%). Apparently, they appreciated satisfaction rather than SDM, being poorly aware of what SDM entails.

CONCLUSION

The level of SDM in an outpatient anesthesiology clinic where preoperative patients receive information about various possible anesthesia options, was found to be low. Thus, there is room for improving the level of SDM. Some suggestions are given how this can be achieved.

Shared Decision-Making in the Management of Congenital Vascular Malformations

BACKGROUND

In shared decision-making, clinicians and patients arrive at a joint treatment decision, by incorporating best available evidence and the patients' personal values and preferences. Little is known about the role of shared decision-making in managing patients with congenital vascular malformations, for which preference-sensitive decision-making seems obvious. The authors investigated preferences regarding decision-making and current shared decision-making behavior during physician-patient encounters.

METHODS

In two Dutch university hospitals, adults and children with congenital vascular malformations facing a treatment-related decision were enrolled. Before the consultation, patients (or parents of children) expressed their preference regarding decision-making (Control Preferences Scale). Afterward, participants completed shared decision-making-specific questionnaires (nine-item Shared Decision-Making Questionnaire, CollaboRATE, and satisfaction), and physicians completed the Shared Decision-Making Questionnaire-Physician questionnaire. Consultations were audiotaped and patient involvement was scored by two independent researchers using the five-item Observing Patient Involvement instrument. All questionnaire results were expressed on a scale of 0 to 100 (optimum shared decision-making).

RESULTS

Fifty-five participants (24 parents and 31 adult patients) were included. Two-thirds preferred the shared decision-making approach (Control Preferences Scale). Objective five-item Observing Patient Involvement scores were low (mean ± SD, 31 ± 15), whereas patient and physician Shared Decision-Making Questionnaire scores were high, with means of 68 ± 18 and 68 ± 19, respectively. The median CollaboRATE score was 93. There was no clear relationship between shared decision-making and satisfaction scores.

CONCLUSIONS

Although adults and parents of children with vascular malformations express a strong desire for shared decision-making, objective shared decision-making behavior is still lacking, most likely because of poor awareness of the shared decision-making concept among patients, parents, and physicians. To improve shared decision-making practice, targeted interventions (e.g., decision aids, staff training) are essential.

PCI Choice: Cardiovascular clinicians' perceptions of shared decision making in stable coronary artery disease

OBJECTIVE

Describe cardiovascular clinicians' perceptions of Shared Decision Making following use of a decision aid (DA) for stable coronary artery disease (CAD) "PCI Choice", in a randomized controlled trial.

METHODS

We conducted a semi-structured qualitative interview study with cardiologists and physician extenders (n=13) after using PCI Choice in practice. Interviews were transcribed then coded. Codes were organized into salient themes. Final themes were determined by consensus with all authors.

RESULTS

Most clinicians (70%) had no prior knowledge of SDM or DAs. Mixed views about the role of the DA in the visit were related to misconceptions of how patient education differed from SDM. Qualitative assessment of clinician perceptions generated three themes: 1) Gaps exist in clinician knowledge around SDM; 2) Clinicians are often uncomfortable with modifying baseline practice; and 3) Clinicians express interest in using DAs after initial exposure within a research setting.

CONCLUSIONS

Use of DAs by clinicians during clinic visits may improve understanding of SDM. Initial use is marked by a reluctance to modify established practice patterns.

PRACTICE IMPLICATIONS

As clinicians explore new approaches to benefit their patients, there is an opportunity for DAs that provide clinician instruction on core elements of SDM to lead to enhanced SDM in clinical practice.

Use of the 9-item Shared Decision Making Questionnaire (SDM-Q-9 and SDM-Q-Doc) in intervention studies-A systematic review

BACKGROUND

The Shared Decision Making Questionnaire (SDM-Q-9 and SDM-Q-Doc) is a 9-item measure of the decisional process in medical encounters from both patients' and physicians' perspectives. It has good acceptance, feasibility, and reliability. This systematic review aimed to 1) evaluate the use of the SDM-Q-9 and SDM-Q-Doc in intervention studies on shared decision making (SDM) in clinical settings, 2) describe how the SDM-Q-9 and SDM-Q-Doc performed regarding sensitivity to change, and 3) assess the methodological quality of studies and study protocols that use the measure.

METHODS

We conducted a systematic review of studies published between 2010 and October 2015 that evaluated interventions to facilitate SDM. The search strategy comprised three databases (EMBASE, PsycINFO, and Medline), reference tracking, citation tracking, and personal knowledge. Two independent reviewers screened titles and abstracts as well as full texts of potentially relevant records. We extracted the data using a pilot tested sheet, and we assessed the methodological quality of included studies using the Quality Assessment Tools from the U.S. National Institute of Health (NIH).

RESULTS

Five completed studies and six study protocols fulfilled the inclusion criteria. The measure was used in a variety of health care settings, mainly in Europe, to evaluate several types of interventions. The reported mean sum scores ranged from 42 to 75 on a scale from 0 to 100. In four studies no significant change was detected in the mean-differences between main groups. In the fifth study the difference was small. Quality assessment revealed a high risk of bias in four of the five completed studies, while the study protocols received moderate quality ratings.

CONCLUSIONS

We found a wide range of areas in which the SDM-Q-9 and SDM-Q-Doc were applied. In the future this review may help researchers decide whether the measure fits their purposes. Furthermore, the review revealed risk of bias in previous trials that used the measure, and may help future trials decrease this risk. More research on the measure's sensitivity to change is strongly suggested.

Validation of the Norwegian version of MAPPIN'SDM, an observation-based instrument to measure shared decision-making in clinical encounters

OBJECTIVE

To validate the Norwegian version of MAPPIN'SDM observer scales with regard to reliability, accuracy and the extent to which the scales include the essentials of the shared decision-making concept.

METHODS

Three MAPPIN'SDM scales, focusing on the skills of doctor, patient and dyad, were applied to audiovisual records of 35 decision sequences. Inter-rater reliabilities were determined based on kappa coefficients. Sensitivities and specificities were calculated with regard to an expert reference standard. Convergent validities were calculated with the OPTION₅ scale. MAPPIN'SDM was qualitatively compared to OPTION5 using Makoul & Clayman's Integrative Model structure.

RESULTS

Inter-rater reliabilities were high on average over 11 items in each of three observer scales (MAPPIN_doctor=0.77, MAPPIN_patient=0.82, MAPPIN_dyad=0.77). Patient involvement was detected accurately (MAPPIN_dyad: mean sensitivity/specificity 93/91%). Comparison with OPTION₅ showed weak to moderate correlation (Spearman's ρ/p-value: MAPPIN_doctor:=0.44/0.009, MAPPIN_patient: 0.38/0.024, MAPPIN_dyad 0.40/0.016) and little content overlap.

CONCLUSION

MAPPIN'SDM_norge is capable of assessing SDM highly reliably and accurately. Divergence from OPTION₅ reflects explicit disagreement regarding the concept's assumptions.

PRACTICE IMPLICATIONS

MAPPIN'SDM_norge is ready for use in Norway. In-depth debate on the SDM concept's essentials is urgently needed.