Twelve myths about shared decision making

A Shared Decision-Making Toolkit for Mode of Birth After Cesarean

This study evaluated a shared decision-making (SDM) Toolkit (decision aid, counseling guide, and provider scripts) designed to prepare and engage racially diverse women in shared decision-making discussions about the mode of birth after cesarean. The pilot study, involving 27 pregnant women and 63 prenatal providers, assessed women's knowledge, preferences, and satisfaction with decision making, as well as provider perspectives on the Toolkit's acceptability. Most women experienced knowledge improvement, felt more in control and that providers listened to their concerns and supported them. Providers reported that the Toolkit helped women understand their options and supported their counseling. The SDM Toolkit could be used to help women and providers improve their SDM regarding mode of birth after cesarean.

Learning health systems and the future of clinical research

Pediatric surgeons are collectively passionate about prioritizing the healthcare needs of children. We contend that this passion is deeply ingrained in how we drive clinical care and influence scientific discovery. Thus, the future of clinical research in our field will be deeply embedded in our history as a "patient-centric" profession. Service to pediatric patients requires an understanding of their needs and expectations, and designing research that acknowledges both. In this article we detail how future pragmatic clinical research will look in the evolving and learning health system.

Automated Tool for Health Utility Assessments: The Gambler II

Background. The Gambler II is a web-based utility assessment tool supporting visual analogue scale (VAS), standard gamble (SG), and time trade-off (TTO) utility assessments. It contains novel features, including an easy to use project development authoring tool and use of multimedia clips for health state descriptions. Objectives. Evaluate the usability and understandability of the patient-facing side of The Gambler. Investigate the feasibility of using The Gambler and evaluate its impact on patient knowledge regarding the relevant health states. Materials and Methods. We used The Gambler to assess utilities on a convenience sample of 55 users for common long-term complications of type 2 diabetes mellitus: diabetic neuropathy, diabetic retinopathy, and diabetic foot infection requiring transmetatarsal amputation. Using VAS, SG, and TTO, we collected metadata, such as time spent on each assessment and the entire assessment process. We evaluated usability with an adaptation of the System Usability Scale survey and understandability. We evaluated impact on knowledge gained through knowledge assessments about these complications before and after use of The Gambler. Results. Overall satisfaction with The Gambler was high, 4.02 on a 5-point scale. Usability rated highly at 84.93 on a normalized scale between 0 and 100. Knowledge scores increased significantly following use of The Gambler from pretest mean of 68% to posttest mean of 76% (P < 0.01). Average time using the software: ∼7½ minutes. Conclusions. The Gambler is an easy to use and understand computer-based tool for utility assessment. It is feasible to use within clinical encounters to support shared decision making, and it has unique features that make it a powerful tool for investigators interested in research on health utilities.

OpenNotes and shared decision making: a growing practice in clinical transparency and how it can support patient-centered care

Objective

Prior studies suggest inviting patients to read their visit notes (OpenNotes) has important benefits for patient engagement. We utilized survey data to investigate our hypothesis that patients who read more notes would report greater shared decision making (SDM).

Materials and Methods

Our survey focused on the safety and quality implications of OpenNotes. 24 722 patients at an urban healthcare organization were invited to complete the survey, which included an item assessing the number of notes read and the CollaboRATE scale to measure SDM. We used log-binomial regression to estimate the relative probability of top CollaboRATE scores across number of notes read while controlling for several covariates.

Results

6913 patients responded (28% response rate). Patients reading 4+ clinical notes in the past 12 months were 17% more likely to have top CollaboRATE scores when compared to patients who had not read a note in the previous 12 months (RR: 1.17, 95%CI: 1.04-1.32).

Discussion

There is a clear relationship between what SDM requires and the transparency OpenNotes provides. Access to clinicians' notes can support the SDM model, which relies on efficient information exchange between clinicians and well-informed patients.

Conclusion

Our study showed evidence of a relationship between note reading and perceived SDM. Implementation of SDM is likely to expand, given its association with improved patient satisfaction, adherence, and medical decision making. Findings from this study highlight OpenNotes as a policy that institutions can implement as a facilitator of SDM and a manifestation of their commitment to patient autonomy and transparency.

Patients' perspectives on care pathways and informed shared decision making in the transition between psychiatric hospitalization and the community

RATIONALE, AIMS, AND OBJECTIVES

Patients with mental health problems experience numerous transitions into and out of hospital. This study explores former patients' views of pathways in transition between district psychiatric hospital centres (DPCs) and community mental health services.

METHOD

A descriptive qualitative design was chosen. Three focus group interviews with a total of 10 informants from five different communities were conducted. Interviews were transcribed and analysed thematically where themes describe promoting or inhibitory factors to the transition phase.

RESULTS

The informants shared their experiences on issues promoting and preventing successful care pathways in mental health. Four main paired themes were identified: (a) patient participation/activation/empowerment versus paternalism and institutionalization, (b) patient-centred care versus care interpreted as humiliation, (c) interprofessional collaboration or teamwork versus unsafe patient pathways in mental health services, and (d) sustainable integrated care versus fragmented, noncollaborative care.

CONCLUSIONS

Shared decision making was reported more precisely as informed shared decision making. Shared information between all parties involved in care pathways is key.

What do patients and health care professionals view as important attributes in radiotherapy decisions? Input for a breast cancer patient decision aid

Background and aim

There is increased attention for shared decision making (SDM) when deciding on radiotherapy for selected patients with Stage 0–2 breast cancer. This study aimed to explore patients' and health care professionals’ experiences, decisional attributes and needs as input for the development of a patient decision aid to facilitate SDM.

Methods

Qualitative semi-structured interviews were held with fifteen breast cancer patients, being confronted with a radiotherapy decision one month to eight years earlier. Another fifteen interviews were held with professionals specialized in breast cancer care. Interviews were transcribed verbatim and independently coded by two researchers, who agreed upon relevant issues.

Results

Most patients made their decision by weighing the advantages of radiotherapy, i.e. comparing the decrease in recurrence risk with and without radiotherapy, and disadvantages, i.e. possible side effects. Patients and professionals agreed that recurrence risks should be communicated, but not on how to deal with uncertainty. There was wide variation in which, and how, side effects were explained by professionals. The most common side effects mentioned by both patients and professionals were skin toxicity, fatigue and breast deformity.

Conclusion

Patients and professionals appeared to agree on what type of attributes should be communicated during SDM on radiotherapy, but how this should be done is up for discussion. To ensure the patient's voice these attributes and needs need to be incorporated in the risk communication and value elicitation part of the patient decision aid. The format in which the attributes are communicated should be critically evaluated.

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Patients and professionals agree on most important attributes.

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These attributes need to be used in a patient decision aid.

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There is unwarranted inter doctor variation in informing about side effects.

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Professionals differ in opinion how to inform patients about epistemic uncertainties.

Invoking death: How oncologists discuss a deadly outcome

Existing sociological research documents patient and physician reticence to discuss death in the context of a patient's end of life. This study offers a new approach to analyzing how death gets discussed in medical interaction. Using a corpus of 90 video-recorded oncology visits and conversation analytic (CA) methods, this analysis reveals that when existing parameters are expanded to look at mentions of death outside of the end-of-life context, physicians do discuss death with their patients. Specifically, the most frequent way physicians invoke death is in a persuasive context during treatment recommendation discussions. When patients demonstrate active or passive resistance to a recommendation, physicians invoke the possibility of the patient's death to push back against this resistance and lobby for treatment. Occasionally, physicians invoke death in instances where resistance is anticipated but never actualized. Similarly, death invocations function for treatment advocacy. Ultimately, this study concludes that physicians in these data invoke death to leverage their professional authority for particular treatment outcomes.

Patient Perspectives on Decision Making for Carpal Tunnel Syndrome

PURPOSE

Interventions that improve a patient's understanding of the problem and their options might reduce surgeon-to-surgeon variation, activate healthier patient behaviors and mindset, and optimize stewardship of resources while improving quality of care. Patients with carpal tunnel syndrome (CTS) have more uncertainty about which course of action to take (so-called decision conflict) than hand surgeons. We studied patient preferences regarding shared decision making (SDM) for different parts of the treatment for CTS. We assessed the following hypotheses: (1) Younger age does not correlate with a preference for greater involvement in decisions; (2) Demographic and socioeconomic factors are not independently associated with (A) preferences for decision making (separated into preoperative, operative, postoperative, and the full SDM scale) and (B) the Control Preference Scale; (3) the SDM scale does not correlate with the Control Preference Scale.

METHODS

We prospectively invited 113 new and postoperative patients with CTS to participate in the study. We recorded their demographics and they completed the SDM scale and the Control Preference Scale.

RESULTS

The full SDM scale and all subsets showed a patient preference toward sharing the decisions for treatment with the surgeon with a moderate tendency toward patients wanting more surgeon involvement in decision making. On multivariable analysis, having commercial insurance compared with Medicare was independently associated with a preference for less surgeon involvement (ie, higher SDM scores) in decision making (regression coefficient, 0.60; 95% confidence interval, 0.03-1.2).

CONCLUSIONS

Patients with CTS generally prefer to share decisions with their surgeon with a tendency for more surgeon involvement especially in the operative and postoperative period.

CLINICAL RELEVANCE

Decision aids and preference elicitation tools used to ensure diagnostic and treatment decisions for CTS that are aligned with patient preferences are needed. Future studies might address the routine use of these tools on patient outcomes.

A prospective cohort study of shared decision making in lung cancer diagnostics: Impact of using a patient decision aid

OBJECTIVE

The objective of this study was to describe the impact on patient-reported outcomes of introducing Shared Decision Making (SDM) and a Patient Decision Aid (PtDA) in the initial process of lung cancer diagnostics.

METHODS

We conducted a prospective cohort study, where a control cohort was consulted according to usual clinical practice. After introducing SDM through a PtDA and training of the staff, the SDM cohort was enrolled in the study. All patients completed four questionnaires: the Decisional Conflict Scale (DCS) before and after the consultation, the CollaboRATE scale after the consultation, and the Decision Regret Scale (DRS).

RESULTS

Patients exposed to SDM and a PtDA had significantly improved DCS scores after the consultation compared to the control group (a difference of 10.26, p = 0.0128) and significantly lower DRS scores (a difference of 8.98, p = 0.0197). Of the 82 control patients and 52 SDM patients 29% and 54%, respectively, gave the maximum score on the CollaboRATE scale (Pearson's chi² 8.0946, p = 0.004).

CONCLUSION

The use of SDM and a PtDA had significant positive impact on patient-reported outcomes.

PRACTICE IMPLICATIONS

Our results may encourage the increased uptake of SDM in the initial process of lung cancer diagnostics.

Treatment Recommendations in Oncology Visits: Implications for Patient Agency and Physician Authority

Although oncology is a major site for clinician‒patient treatment negotiation requiring a careful balance of potentially competing viewpoints, little is known about how clinicians promote their treatment recommendations to patients and what the manner of promotion tells us about the oncologist‒patient relationship. Utilizing an already-established schema of coding treatment recommendations, I draw on 61 treatment recommendations to examine treatment decision-making in oncology. This paper investigates how physicians balance asserting their authority while at the same time attending to patient agency and involvement in decision-making. Taking this one step further, this paper explores how physicians negotiate decision-making with patients given that they occupy a liminal state between obligations to policy imperatives and commitments to their professional knowledge and technical expertise. How do they do this, and what accounts for this? To answer these questions, this paper analyzes the ways in which physicians present treatment recommendations and the treatment contexts in which they are made.

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.

Goal-Based Shared Decision-Making: Developing an Integrated Model

Objective:

Definitions of shared decision-making (SDM) have largely neglected to consider goal setting as an explicit component. Applying SDM to people with multiple long-term conditions requires attention to goal setting. We propose an integrated model, which shows how goal setting, at 3 levels, can be integrated into the 3-talk SDM model.

Method:

The model was developed by integrating 2 published models.

Results:

An integrated, goal-based SDM model is proposed and applied to a patient with multiple, complex, long-term clinical conditions to illustrate the use of a visualization tool called a Goal Board. A Goal Board prioritizes collaborative goals and aligns goals with interventional options.

Conclusion:

The model provides an approach to achieve person-centered decision-making by not only eliciting and prioritizing goals but also by aligning prioritized goals and interventions.

Practice Implications:

Further research is required to evaluate the utility of the proposed model.

Shared decision-making for delivery mode: An OPTION scale observer-based evaluation

OBJECTIVE

Shared decision-making (SDM) may help to reduce the rate of Cesarean Delivery (CD). The aim of the study was to evaluate the extent to which pregnant women are involved in SDM about the mode of delivery, applying the Italian version of the OPTION¹² scale to obstetric consultations.

METHODS

Fifty-eight outpatient consultations were rated; statistical associations between OPTION¹² scores and sociodemographic data of both patient and physicians were determined.

RESULTS

The OPTION¹² total scores showed a skewed distribution in the lower range of total scores. Total scores in a percentage basis ranged from 0 to 69, with a mean of 21.2 (±19.84) and a median of 13.5. Mean and median scores for all the 12 OPTION¹² items never reached the minimum skill level.

CONCLUSION

A low level of patient involvement in deciding between a CD and a Vaginal Delivery (VD) was demonstrated. Interventions aiming at educating obstetricians as well as the adoption of decision aids are requested.

PRACTICE IMPLICATIONS

The OPTION¹² scale may prove useful for testing the extent of pregnant women's involvement in deciding between CD and VD. The awareness of a low patient involvement seems mandatory to improve SDM and may lead to medico-legal protection.

The Patient's Perspective on Shared Decision-Making in Advanced Parkinson's Disease: A Cross-Sectional Survey Study

Background: Choosing between deep brain stimulation (DBS), Levodopa-Carbidopa intestinal gel (LCIG), or continuous subcutaneous Apomorphine infusion (CSAI) in advanced Parkinson's disease is a complex decision. It is paramount to combine evidence with the professional's expertise and the patient's preferences. The patient's preferences can be elicited and integrated into the treatment choice through shared decision-making (SDM).

Objective: In this cross-sectional survey study we explored patient's involvement in decision-making and identified facilitators and barriers for shared decision-making (SDM) in advanced Parkinson from the patient's perspective.

Methods: We invited 180 Dutch persons with Parkinson who started DBS, LCIG, or CSAI in the previous 3 years to complete a questionnaire. Questions covered three topics; (1) preferred and experienced roles in the decision process for an advanced treatment, (2) information needs to make a decision and actually received information, and (3) factors that had positively or negatively influenced shared decision-making (SDM).

Results: One hundred and twenty one participants completed the questionnaire. The large majority preferred to be involved in the decision-making (93%), and most respondents had experienced an active role (85%). In about half of the respondents (47%), their preferred role did not match their experienced role; 28% had a more active role than they would have preferred. Although 77% perceived to be fully informed at the time of decision, only 41% stated they knew all three therapeutic options. Participants identified the most important facilitators for shared decision-making (SDM) at the patient's level (i.e., perceiving the decision to be his own choice), at the neurologist's level (i.e., having expertise on all treatment options, and taking time for the decision), and within the professional-patient relationship (i.e., trust and having an open discussion). The main barriers for shared decision-making (SDM) existed at the patient's level (i.e., perceiving there is no choice), neurologist's level (own treatment preference), and organizational level (i.e., no research available that compares treatments, multiple professionals involved, and lack of consultation time).

Conclusions: Patients want to be involved and feel involved when choosing an advanced treatment, but often do not know all treatment options. Implementation of true patient involvement needs personalized information provision on all treatment options and improvement on how this information is communicated.

Patient decision aids: a content analysis based on a decision tree structure

INTRODUCTION

This paper presents the preliminary results of a decision-tree analysis of Patient Decision Aids (PDA). PDAs are online or offline tools used to structure health information, elicit relevant values and emphasize the decision as a process, in ways that help patients make more informed health decisions individually or with relevant others.

METHOD

Twenty PDAs are randomly selected from the International Patient Decision Aids Standards (IPDAS) ( https://decisionaid.ohri.ca/AZlist.html ) approved list. An evaluation tool is built bottom-up and top-down and results are described in terms of communicating uncertainty, completeness of the decision tree, ambiguous or misleading phrasing, overall strategies suggested within personal stories.

RESULTS

Twelve of the analyzed PDAs had branches of the decision tree which were not discussed in the tool and 6 had logically ambiguous phrasing. Many tools included dichotomous options, when the option range was wider. Several options were clustered within the "Do not take/Do not do" option and thus the PDA failed to provide all comparisons necessary to make a decision. Some tools employ expressions that do not differentiate between lack of information and known negative effects. Other tools provide unequal amounts or non-comparable bits of information about the options.

CONCLUSION

These results indicate a very loose range of interpretations of what constitutes an option, a treatment, and a treatment option. It thus emphasizes a gap between theory and practice in the evaluation of PDAs. Future developments of PDA evaluation tools should keep track of missing decision tree branches, accurate communication of uncertainty, ambiguity, and lack of knowledge and consider using measures for evaluating the completeness of the option spectrum at an agreed period in time.

Perceptions and observations of shared decision making during pediatric otolaryngology surgical consultations

Objective

Increased parental involvement in the decision-making process when considering elective surgeries for their children, termed shared decision-making (SDM), may lead to positive outcomes. The objective of this study was to describe perceived and observed levels of SDM during pediatric otolaryngology consultations.

Methods

One hundred and seventeen parents and their children undergoing elective surgical consultations were prospectively enrolled. The visits were videotaped and coded using the Observing Patient Involvement (OPTION) scale. Following the encounter, all participants completed a questionnaire that measured perceived levels of SDM (SDM-Q-9). Surgeons also completed a similar questionnaire (SDM-Q-Doc). Spearman’s correlation coefficient was determined to measure the associations between observed and perceived levels of SDM.

Results

The overall OPTION scores were low (median score of 14 out of 48) and not significantly correlated with perceived levels of SDM (SDM-Q-9, p = 0.415; SDM-Q-Doc, p = 0.236), surgery type (p = 0.197), or patient demographic factors. The OPTION scores were positively correlated with consultation length (p < 0.001). There was great variability in the level to which each OPTION items were observed during the consultation (not present in any visits to present in 96.6% of the visits).

Conclusions

Observed levels of SDM were consistently low, but higher levels were observed when the surgeon spent more time during the consultation. Observed levels of SDM did not match perceived levels of SDM, which were consistently rated higher by both caregivers and surgeons.

Goal setting is insufficiently recognised as an essential part of shared decision-making in the complex care of older patients: a framework analysis

BACKGROUND

Multimorbidity poses a challenge for decision-making processes and requires that more attention is paid to patient goals, preferences and needs; however, goal setting is not yet widely recognised as a core aspect of the shared decision-making (SDM) approach. This study aims to analyse clinician perceptions of the concept of goal setting within the context of SDM with older patients with multimorbidity.

METHODS

Semi-structured interviews with general practitioners (GPs) and clinical geriatricians (CGs) were analysed using a framework analysis. The integrative model of SDM was used to develop a categorisation matrix, including goal setting as an additional component.

RESULTS

Sixteen of the 33 clinicians mentioned explicit Goal setting as an integrated component of their definition of SDM, which was comparable to the number of clinicians who listed Patient values and preferences (n = 16), Doctor knowledge and recommendations (n = 19) and Make or explicitly defer a decision (n = 19), elements which are commonly considered to be important aspects of SDM. The other 17 clinicians (6 CGs and 11 GPs) did not mention Goal setting as an explicit component of SDM. Our analysis revealed two potential reasons for this observation. Besides the use of other terminology, part of clinicians viewed collaborative goal setting and SDM as separate but related processes.

CONCLUSIONS

Our study on clinician perspectives highlighted goal setting as component of a SDM approach and could therefore be considered supportive of recent theoretical insights that SDM models that lack an explicit goal-setting component appear to be deficient and overlook an important aspect of engaging patients in decision-making, particularly for patients with complex multimorbidities. We therefore call for the further development of a comprehensive SDM approach for older patients with multimorbidity to include explicit and unequivocal goal setting elements to sufficiently meet the expectations and needs of clinicians and their patients.

Facets of shared decision-making on drug treatment for adults with an eating disorder

Shared decision-making (SDM) means that clinicians and the patient make decisions about the treatment together. Regarding drug treatment in eating disorders (EDs), such decisions may include psychopharmacological treatment for the ED itself, medications for potential co-morbid psychiatric disorders, pharmacological strategies to alleviate the health consequences of an ED, or 'pro re nata' (PRN) medication which is given in acute care when required. Decisions regarding drug treatment in EDs should be specific in terms of the active pharmacological substance, its dose, its route of administration, and the duration of treatment. Decisions should be made with regard to the specific health risks of patients with EDs and the entire treatment approach, and should take alternative measures, additional therapies, and specific combinations of therapies into account. The differences in the expectations of patients, carers, and clinicians towards drug treatment, the lack of specific suggestions in clinical practice guidelines, and the lack of approved psychopharmacological treatment options make SDM necessary, but also a challenge. However, SDM may be limited due to the patient's impaired insight or limited capacity due to the ED. Thus, the legal framework must be taken into consideration.

Implementation and Use of a Client-Facing Web-Based Shared Decision-Making System (MyCHOIS-CommonGround) in Two Specialty Mental Health Clinics

Electronic shared-decision making programs may provide an assistive technology to support physician-patient communication. This mixed methods study examined use of a web-based shared decision-making program (MyCHOIS-CommonGround) by individuals receiving specialty mental health services, and identified qualitative factors influencing adoption during the first 18 months of implementation in two Medicaid mental health clinics. T-tests and χ2 analyses were conducted to assess differences in patient use between sites. Approximately 80% of patients in both clinics created a MyCHOIS-CommonGround user profile, but marked differences emerged between clinics in patients completing shared decision-making reports (79% vs. 28%, χ2(1) = 109.92, p < .01) and average number of reports (7.20 vs. 3.60, t = - 3.64, p < .01). Results suggest high penetration of computer-based programs in specialty mental health services is possible, but clinic implementation factors can influence patient use including leadership commitment, peer staff funding to support the program, and implementation strategy, most notably integration of the program within routine clinical workflow.

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.

The impact and utility of encounter patient decision aids: Systematic review, meta-analysis and narrative synthesis

OBJECTIVE

To determine the effect of encounter patient decision aids (PDAs) as evaluated in randomized controlled trials (RCTs) and conduct a narrative synthesis of non-randomized studies assessing feasibility, utility and their integration into clinical workflows.

METHODS

Databases were systematically searched for RCTs of encounter PDAs to enable the conduct of a meta-analysis. We used a framework analysis approach to conduct a narrative synthesis of non-randomized studies.

RESULTS

We included 23 RCTs and 30 non-randomized studies. Encounter PDAs significantly increased knowledge (SMD = 0.42; 95% CI 0.30, 0.55), lowered decisional conflict (SMD= -0.33; 95% CI -0.56, -0.09), increased observational-based assessment of shared decision making (SMD = 0.94; 95% CI 0.40, 1.48) and satisfaction with the decision-making process (OR = 1.78; 95% CI 1.19, 2.66) without increasing visit durations (SMD= -0.06; 95% CI -0.29, 0.16). The narrative synthesis showed that encounter tools have high utility for patients and clinicians, yet important barriers to implementation exist (i.e. time constraints) at the clinical and organizational level.

CONCLUSION

Encounter PDAs have a positive impact on patient-clinician collaboration, despite facing implementation barriers.

PRACTICAL IMPLICATIONS

The potential utility of encounter PDAs requires addressing the systemic and structural barriers that prevent adoption in clinical practice.

Supporting self-management after traumatic brain injury: Codesign and evaluation of a new intervention across a trauma pathway

Background

Supported self‐management (SSM) is a recognized approach for people with long‐term conditions but, despite the prevalence of unmet needs, little is known about its role for people with traumatic brain injury (TBI).

Objectives

To codesign an SSM intervention with people with TBI and evaluate feasibility of implementation through multidisciplinary staff across a trauma pathway.

Setting and participants

People who had previously been admitted to a Major Trauma Centre following TBI and family members participated in a series of codesign activities. Staff attended SSM workshops and used the intervention with patients in acute and rehabilitation settings.

Methods

We used Normalization Process Theory constructs to guide and interpret implementation. Knowledge, beliefs and confidence of staff in SSM were assessed through pre‐ and post‐training questionnaires, and staff, patients' and families' experiences were explored through semi‐structured interviews. Qualitative data were analysed thematically, and clinical measures were mapped against a matched sample.

Results

Codesigned resources were created and used within an SSM approach for which 110 staff participated in training. Evaluation demonstrated significant differences in staff SSM confidence and skills, following training. Qualitative evaluation revealed adoption by staff, and patients' and families' experiences of using the resources. Challenges included reaching staff across complex pathways to achieve collective implementation.

Conclusion

This is the first project to demonstrate feasibility of SSM for people after TBI starting in an acute trauma setting. Through an open approach to codesign with a marginalized group, the SSM resources were valued by them and held meaning and relevance for staff.

Shared decision-making in orthodontics: Are we there yet?

Shared decision-making (SDM) is the process of making decisions ‘with’ rather than ‘about’ patients. This review outlines key stages of SDM, discusses some of the main barriers to SDM and identifies areas where further evidence is needed to support full integration of SDM into orthodontics.

Shared decision-making experienced by Canadians facing health care decisions: a Web-based survey

BACKGROUND

Despite health policy that promotes shared decision-making, it is not yet the norm in clinical practice. We aimed to assess how much shared decision-making Canadians experienced in health-related decisions in 2017.

METHODS

We conducted a cross-sectional online survey in January 2018 with a Web-based panel of Canadians representing all 10 provinces. We assessed their involvement in health-related decisions made with a health care professional over the previous year by asking about 1) discussion of choice of treatment or care plan, 2) presentation of advantages and disadvantages, 3) exploration of ideas and preferences, 4) discussion of preferred option and 5) match between preferred and actual level of participation. We computed an average shared decision-making score (range 1 [never] to 5 [always]). We presented characteristics of participants and responses using descriptive statistics and explored variations across sociodemographic factors, jurisdictions, geographical areas and care settings (home care or not) using multivariate weighted regressions.

RESULTS

Of the 1591 participants surveyed, 1010 (63.5%) reported receiving health care in the previous 12 months. The mean of the average shared decision-making score was 2.25/5 (standard deviation [SD] 1.16). After weighting, 42.8% of respondents reported that their health care professional often or always mentioned that they had a choice of treatment or care plan, 45.4% reported that advantages and disadvantages were often or always presented, 38.8% reported that they were often or always asked for their ideas or preferences, 40.2% reported that they were often or always asked about their preferred option, and 54.1% stated that their level of participation in decision-making often or always matched their preferred level of participation. Increasing age, rural setting, living in the province of Quebec and not being white significantly decreased the level of shared decision-making experienced. Older respondents (age ≥ 65 yr) receiving home care reported the least shared decision-making (mean score 1.7 [SD 0.5]).

INTERPRETATION

Canadians in all 10 provinces experienced a low degree of shared decision-making in 2017, with variations across sociodemographic factors, jurisdictions, care settings and geographical areas. Further efforts to foster implementation of shared decision-making are needed and should take these variations into account.

Measuring shared decision-making in the pediatric outpatient setting: Psychometric performance of the SDM-Q-9 and CollaboRATE among English and Spanish speaking parents in the US Midwest

OBJECTIVE

Shared decision-making (SDM) measures have never been assessed for validity and feasibility in pediatric outpatient settings. We compared psychometric performance of parent adaptations of a well-established measure (SDM-Q-9) to a newer measure focusing on provider effort in facilitating SDM (CollaboRATE) in two clinics.

METHODS

English (n = 955) and Spanish (n = 58) speaking parents of children ages 1-5 years with symptoms of acute respiratory tract infections (ARTI) completed post-visit SDM-Q-9, CollaboRATE, satisfaction items (visit, provider communication, and study participation), and qualitative feedback.

RESULTS

Parents felt CollaboRATE was more comprehensible and relevant than SDM-Q-9, which refers to decision-making actions difficult to define in ARTI visits. Among English-speakers, both measures showed high internal consistency (α = 0.91, α = 0.97). SDM-Q-9 reliability was strong (split-half, r = 0.83) and CollaboRATE weak-to-moderate (two-week test-retest, ρ = 0.41-0.66). Convergent validity with communication and visit satisfaction was poor for SDM-Q-9 (r=0.38, r=0.34) but higher for CollaboRATE (r=0.59, r = 0.52). Both showed divergent validity with study participation satisfaction (r=0.08, r=0.13). Spanish versions demonstrated similar results.

CONCLUSIONS

Parent preference and correlations with satisfaction support CollaboRATE over SDM-Q-9, however psychometrics were borderline acceptable.

PRACTICE IMPLICATIONS

Tools like CollaboRATE that focus on provider effort appear more appropriate for routine pediatric visits where SDM outcomes may be difficult to identify, yet additional validation research is needed.

Partnerships to Improve Shared Decision Making for Patients with Hypertension - Health Equity Implications

Shared decision making (SDM) has increasingly become appreciated as a method to enhance patient involvement in health care decisions, patient-provider communication, and patient-centered care. Compared with cancer, the literature on SDM for hypertension is more limited. This is notable because hypertension is the leading risk factor for cardiovascular disease and both conditions disproportionately affect certain subgroups of patients. However, SDM holds promise for improving health equity by better engaging patients in their health care. For example, many reasonable options exist for treating uncomplicated stage-1 hypertension. These options include medication and/or lifestyle changes such as healthy eating, physical activity, and weight management. Deciding on "the best" plan of action for hypertension management can be challenging because patients have different goals and preferences for treatment. As hypertension management may be considered a preference-sensitive decision, adherence to treatment plans may be greater if those plans are concordant with patient preferences. SDM can be implemented in a broad array of care contexts, from patient-provider dyads to interprofessional collaborations. In this article, we argue that SDM has the potential to advance health equity and improve clinical care. We also propose a process to evaluate whether SDM has occurred and suggest future directions for research.

[Shared decision-making in acute psychiatric medicine : Contraindication or a challenge?]

BACKGROUND

The concept of shared decision-making (SDM) has existed since the 1990s in multiple fields of somatic medicine but has only been poorly applied in psychiatric clinical routine despite broad acceptance and promising outcomes in clinical studies on its positive effects.

MATERIALS AND METHODS

The concept itself and its practicability in mental health are carefully assessed and strategies for its future implementation in psychiatric medicine are presented in this article. Ongoing clinical studies probing some of those strategies are further outlined.

RESULTS AND DISCUSSION

On top of the ubiquitous shortage of time in clinical routine, psychiatrists report their concern about patients' limited abilities in sharing decisions and their own fear of potentially harmful decisions resulting from a shared process. Misinterpretation of shared decision-making restricting the health care professional to rather an informed choice scenario and their own adhesion to the traditional paternalistic decision-making approach further add to SDM's underutilization. Those hurdles could be overcome by communication skill workshops for all mental health care professionals, including nursing personnels, psychologists, social workers and physicians, as well as the use of decision aids and training courses for patients to motivate and empower them in sharing decisions with the medical staff. By this, the patient-centered treatment approach demanded by guidelines, carers and users could be further facilitated in psychiatric clinical routine.

Evaluation of a Computer-Based Decision Aid for Promoting Informed Prostate Cancer Screening Decisions Among African American Men: iDecide

PURPOSE

To evaluate the effects of iDecide on prostate cancer knowledge, informed decision-making self-efficacy, technology use self-efficacy, and intention to engage in informed decision-making among African American men.

DESIGN

One-group, pretest/posttest.

SETTING

Community settings in South Carolina.

PARTICIPANTS

African American men, ages 40 years +, without a prior prostate cancer diagnosis (n = 354).

INTERVENTION

iDecide, an embodied conversational agent-led, computer-based prostate cancer screening decision aid.

MEASURES

Prostate cancer knowledge, informed decision-making self-efficacy, technology use self-efficacy, and intention to engage in informed decision-making.

ANALYSIS

Descriptive statistics, paired t tests, general linear modeling, Spearman correlations.

RESULTS

On average, participants experienced significant improvements in their prostate cancer knowledge ( P ≤ .001), informed decision-making self-efficacy ( P ≤ .001), and technology use self-efficacy ( P ≤ .001), postintervention. Additionally, 67% of participants reported an intention to engage in informed decision-making.

CONCLUSION

Given the significant improvements across all measures, this research demonstrates that embodied conversational agent-led decision aids can be used to enhance the capacity for making informed prostate cancer screening decisions among African American men and increase their technology use self-efficacy. One critical limitation of this study is that most men had received prostate cancer screening prior to engaging in our intervention, so the implications of this intervention may be different for men who do not have a history of screening. Additionally, actual engagement in informed decision-making postintervention was not assessed.

Barriers and facilitators of pediatric shared decision-making: a systematic review

BACKGROUND

Shared decision-making (SDM) is rarely implemented in pediatric practice. Pediatric health decision-making differs from that of adult practice. Yet, little is known about the factors that influence the implementation of pediatric shared decision-making (SDM). We synthesized pediatric SDM barriers and facilitators from the perspectives of healthcare providers (HCP), parents, children, and observers (i.e., persons who evaluated the SDM process, but were not directly involved).

METHODS

We conducted a systematic review guided by the Ottawa Model of Research Use (OMRU). We searched MEDLINE, EMBASE, Cochrane Library, CINAHL, PubMed, and PsycINFO (inception to March 2017) and included studies that reported clinical pediatric SDM barriers and/or facilitators from the perspective of HCPs, parents, children, and/or observers. We considered all or no comparison groups and included all study designs reporting original data. Content analysis was used to synthesize barriers and facilitators and categorized them according to the OMRU levels (i.e., decision, innovation, adopters, relational, and environment) and participant types (i.e., HCP, parents, children, and observers). We used the Mixed Methods Appraisal Tool to appraise study quality.

RESULTS

Of 20,008 identified citations, 79 were included. At each OMRU level, the most frequent barriers were features of the options (decision), poor quality information (innovation), parent/child emotional state (adopter), power relations (relational), and insufficient time (environment). The most frequent facilitators were low stake decisions (decision), good quality information (innovation), agreement with SDM (adopter), trust and respect (relational), and SDM tools/resources (environment). Across participant types, the most frequent barriers were insufficient time (HCPs), features of the options (parents), power imbalances (children), and HCP skill for SDM (observers). The most frequent facilitators were good quality information (HCP) and agreement with SDM (parents and children). There was no consistent facilitator category for observers. Overall, study quality was moderate with quantitative studies having the highest ratings and mixed-method studies having the lowest ratings.

CONCLUSIONS

Numerous diverse and interrelated factors influence SDM use in pediatric clinical practice. Our findings can be used to identify potential pediatric SDM barriers and facilitators, guide context-specific barrier and facilitator assessments, and inform interventions for implementing SDM in pediatric practice.

TRIAL REGISTRATION

PROSPERO CRD42015020527.

A novel anesthesiologist-led multidisciplinary model for evaluating high-risk surgical patients at a comprehensive cancer center

The objective of this retrospective analysis was to describe the development and implementation of an anesthesiologist-led multidisciplinary committee to evaluate high-risk surgical patients in order to improve surgical appropriateness. The study was conducted in an anesthesia preoperative evaluation clinic at an academic comprehensive cancer center. One hundred sixty-seven high-risk surgical patients with cancer-related diagnoses were evaluated and discussed at a High-Risk Committee (HRC) meeting to determine surgical appropriateness and optimize perioperative care. The HRC is an anesthesiologist-led model for multidisciplinary review of high-risk patients developed at Roswell Park Comprehensive Cancer Center. The group of high-risk patients in which surgery was not performed had, on average, a greater percentage of hypertension, smoking history, dyspnea, heart failure, chronic obstructive pulmonary disease, diabetes, renal failure, and sleep apnea than the group in whom surgery was performed. Only one of 107 high-risk patients who had surgery died within the first 30 days after surgery. A smaller percentage of patients died in the group that had surgery versus the group in which surgery was canceled. For all patients discussed by the HRC, the mortality was less than 2% within the first 30 days after the HRC.

Post-training Shared Decision Making Barriers and Facilitators for Pediatric Healthcare Providers: A Mixed-Methods Study

OBJECTIVE

To assess barriers to and facilitators of shared decision making (SDM) for pediatric healthcare providers (HCPs) after they have been trained in SDM.

METHODS

A mixed methods study using triangulation of data sources. Pediatric HCPs with SDM training who worked at a Canadian tertiary care pediatric hospital were eligible. Participants completed a validated SDM barriers survey (n = 60) and a semi-structured interview (n = 11). We calculated descriptive statistics. Univariate and multivariable ordinary least squares linear regression models determined predictors of HCPs' intention to use SDM. Interviews were audiotaped and transcribed verbatim. We analyzed qualitative data using deductive and inductive content analyses and organized categories according to the Ottawa Model of Research Use.

RESULTS

Intention to use SDM was high (mean score = 5.6/7, SD = 0.78) and positively correlated with SDM use (RR = 1.46, 95% CI 1.18-1.81). However, 52% of survey respondents reported not using SDM after training. HCPs identified factors influencing SDM at the levels of innovation, adopter, environment, and training. Insufficient time (barrier) and buy-in and agreement with SDM (facilitators) were most commonly cited. To improve SDM use, HCPs want a more team-based approach to SDM training, continuing education, and implementation.

CONCLUSIONS

Despite training and positive intentions, many HCPs report not subsequently using SDM and identified numerous post-training barriers to its use. To overcome SDM barriers and improve uptake, HCPs recommend creating a socially supportive environment through a team-based approach to SDM training and implementation. These findings can inform SDM training and implementation interventions at pediatric health care centers.

Barriers and facilitators to shared decision making in child and youth mental health: clinician perspectives using the Theoretical Domains Framework

Shared decision making (SDM) is increasingly being suggested as an integral part of mental health provision. Yet, there is little research on what clinicians believe the barriers and facilitators around practice to be. At the same time, there is also increasing recognition of a theory-practice gap within the field, with calls for more pragmatic uses of theory to inform and improve clinical practice. Using the Theoretical Domains Framework (TDF), a comprehensive, theoretical-led framework, underpinned by 33 behaviour change theories and 128 constructs, clinician perceived barriers and facilitators to SDM are investigated. The sample comprised of 15 clinicians across two sites in England, who took part in qualitative semi-structured interviews and focus groups. Transcripts were analysed using a deductive thematic analysis, and themes were coded under each theoretical domain. Overall, 21 barriers and facilitators for SDM in child and youth mental health were identified across ten domains of the TDF. Under capability, barriers and facilitators were found for knowledge, skills, memory/attention/decision making processes, and behavioural regulation. For opportunity, barriers and facilitators were found for social influences, as well as environmental context and resources. Finally, for motivation, domains covered included: beliefs about consequences, beliefs about capabilities, emotions, and professional role and identity. Findings suggest that a range of barriers and facilitators affect clinicians' abilities to engage in SDM with young people and parents. Interventions which target different domains related to capability, opportunity and motivation should be developed to better facilitate young people and their families in care and treatment decisions.

Validation of CollaboRATE and SURE - two short questionnaires to measure shared decision making during CPAP initiation

Adherence to continuous positive airway pressure (CPAP) treatment tends to be low. Brief validated instruments focusing on shared decision making have not been used in a CPAP context. The aim was to investigate factorial structure, categorical functioning of the response scale and differential item functioning across sub-populations of the CollaboRATE and Sure questionnaires among patients with obstructive sleep apnea (OSA) before CPAP treatment is initiated. A prospective design, including 193 objectively diagnosed (polygraphy) OSA patients (68% men, 59.7 years, SD 11.5) from two CPAP clinics was used. Data were collected with the following questionnaires; Sure, CollaboRATE, Attitudes to CPAP Inventory, Epworth sleepiness scale, minimal insomnia symptoms scale, and hospital anxiety and depression scale. Objective CPAP use was collected after 6 months; 49% demonstrated decisional conflict on SURE and 51% scored low levels of shared decision making on CollaboRATE. Unidimensionality was found for both CollaboRATE (one factor explaining 57.4%) and SURE (one factor explaining 53.7%), as well as local independence. Differential item functioning showed both to be invariant across both male and female patients. Internal consistency (Cronbach's alpha 0.83) and composite reliability (0.89) were good. Latent class analyses showed that patients with low decisional conflict and high shared decision making were more adherent to CPAP treatment. CollaboRATE and SURE provided good validity and reliability scores to measure shared decision making and decisional conflict in relation to CPAP treatment. The questionnaires can be used by healthcare personnel as a tool to simplify the assessment of shared decision making.

Much to do with nothing: microsimulation study on time management in primary care

OBJECTIVE

To investigate the credibility of claims that general practitioners lack time for shared decision making and preventive care.

DESIGN

Monte Carlo microsimulation study.

SETTING

Primary care, United States.

PARTICIPANTS

Sample of general practitioners (n=1000) representative of annual work hours and patient panel size (n=2000 patients) in the US, derived from the National Health and Nutrition Examination Survey.

MAIN OUTCOME MEASURES

The primary outcome was the time needed to deliver shared decision making for highly recommended preventive interventions in relation to time available for preventive care-the prevention-time-space-deficit (ie, time-space needed by doctor exceeding the time-space available).

RESULTS

On average, general practitioners have 29 minutes each workday to discuss preventive care services (just over two minutes for each clinic visit) with patients, but they need about 6.1 hours to complete shared decision making for preventive care. 100% of the study sample experienced a prevention-time-space-deficit (mean deficit 5.6 h/day) even given conservative (ie, absurdly wishful) time estimates for shared decision making. However, this time deficit could be easily overcome by reducing personal time and shifting gains to work tasks. For example, general practitioners could reduce the frequency of bathroom breaks to every other day and skip time with older children who don't like them much anyway.

CONCLUSIONS

This study confirms a widely held suspicion that general practitioners waste valuable time on "personal care" activities. Primary care overlords, once informed about the extent of this vast reservoir of personal time, can start testing methods to "persuade" general practitioners to reallocate more personal time toward bulging clinical demands.

Exploring the experiences of staff working at an opiate assisted treatment clinic: An interpretive descriptive study

There have been many advances in harm reduction over the past three decades. One of the newest approaches is the provision of medical grade heroin to people with opiate addiction, known as opiate assisted treatment (OAT). There is one clinic in North America which provides this service. The goal of this study was to uncover how clinic staff provide care to those who attend this clinic, their perspectives on how the clinic program impacted them and their patients, and their opinions about the program itself. This was a qualitative study with an interpretive descriptive methodology underpinned by critical social theory. Convenience sampling yielded 22 participants - 18 nurses, two social workers and two peer support workers. Thematic analysis was undertaken to identify recurring, converging and contradictory patterns of interaction, key concepts and emerging themes. The study location was the OAT clinic located in the downtown eastside of Vancouver, BC. The findings were organized around the following six themes: from chaos to stability, it's not all roses, a little preparation would be good, putting the patient at the centre, the stigma hasn't gone away, and the clinic is life transforming. Taken together, these themes indicate the complexities of working in this environment. The findings can guide clinic staff, including nurses, in how they provide care to patients with addiction problems and also provide direction for policy makers on harm reduction planning. CONTRIBUTION OF THE PAPER: What is already known about the topic? What does this paper add?

Creating a Pathway for Multidisciplinary Shared Decision-Making to Improve Communication During Preoperative Assessment

Shared decision-making (SDM) is essential for high-quality surgical care. Barriers to SDM exist in clinical practice but there is evidence these obstacles can be overcome. SDM requires clinician and patient engagement. Though patients may indicate understanding, deficits in decision making may persist based on language, age, or educational barriers. Multidisciplinary decision-making before surgery is an opportunity for anesthesiologists and other perioperative professionals to improve surgical care. The authors present an example of a successfully implemented pathway for high-risk surgical patients at a tertiary care center, leveraging the preoperative anesthesia evaluation.

Accelerating implementation of shared decision-making in the Netherlands: An exploratory investigation

OBJECTIVE

To prioritize strategies to implement shared decision-making (SDM) in daily practice, resulting in an agenda for a nationwide approach.

METHODS

This was a qualitative, exploratory investigation involving: Interviews (N = 43) to elicit perceived barriers to and facilitators of change, focus group discussions (N = 51) to develop an implementation strategy, and re-affirmation through written feedback (n = 19). Professionals, patients, researchers and policymakers from different healthcare sectors participated. Determinants for change were addressed at four implementation levels: (1) the concept of SDM, (2) clinician and/or patient, (3) organizational context and (4) socio-political context.

RESULTS

Following the identification of perceived barriers, four strategies were proposed to scale up SDM: 1) stimulating intrinsic motivation among clinicians via an integrated programmatic approach, 2) training and implementation in routine practice, 3) stimulating the empowerment of patients, 4) creating an enabling socio-political context.

CONCLUSION

Clinicians mentioned that applying SDM makes their job more rewarding and indicated that implementation in daily practice needs ground-up redesign. The challenge is to effectively influence the behavior of clinicians and patients alike, and adapt clinical pathways to facilitate the exploration of patient values.

PRACTICE IMPLICATIONS

Stakeholders should connect nationwide initiatives to pool information, and make the healthcare system supportive of implementing SDM.

Primary health care decision making in pre-dialysis chronic kidney disease

OBJECTIVES

This qualitative descriptive study explored the primary health care decisions of a group of 12 Australians in Stages 3B to 5 with chronic kidney disease in the preservation of kidney health.

METHODS

Questioning within the qualitative interviews focused on gaining an understanding of the participants' perceptions of their kidney health and the decisions made as a consequence of their interaction within the Australian primary health care system.

RESULTS

Participants were dependent on their General Practitioner to recognise their symptoms, make the correct diagnosis and authorise the correct referral for specialist nephrology care. Three pathways in this process were identified: 'easy'; 'difficult' and 'protracted'. Clinician failure to correctly attribute symptoms to chronic kidney disease influenced the 'difficult' pathway, while failure to adequately communicate kidney health status influenced the 'protracted' pathway. Use of the language of 'recovery', 'stability' and 'protection' held meaning to the participants in gaining an understanding of their kidney health.

DISCUSSION

Identifying pathways to diagnosis and referral can raise awareness of the challenges kidney health consumers face in their participation within the primary health care arena. Using consumer meaningful language improves the capacity of these consumers to engage in their own primary health care agenda.

Are publicly available internet resources enabling women to make informed fertility preservation decisions before starting cancer treatment: an environmental scan?

Background

To identify publicly available internet resources and assess their likelihood to support women making informed decisions about, and between, fertility preservation procedures before starting their cancer treatment.

Methods

A survey of publically available internet resources utilising an environmental scan method. Inclusion criteria were applied to hits from searches of three data sources (November 2015; repeated June 2017): Google (Chrome) for patient resources; repositories for clinical guidelines and projects; distribution email lists to contact patient decision aid experts. The Data Extraction Sheet applied to eligible resources elicited: resource characteristics; informed and shared decision making components; engagement health services.

Results

Four thousand eight hundred fifty one records were identified; 24 patient resources and 0 clinical guidelines met scan inclusion criteria. Most resources aimed to inform women with cancer about fertility preservation procedures and infertility treatment options, but not decision making between options. There was a lack of consistency about how health conditions, decision problems and treatment options were described, and resources were difficult to understand.

Conclusions

Unless developed as part of a patient decision aid project, resources did not include components to support proactively women’s fertility preservation decisions. Current guidelines help people deliver information relevant to treatment options within a single disease pathway; we identified five additional components for patient decision aid checklists to support more effectively people’s treatment decision making across health pathways, linking current with future health problems.

Electronic supplementary material

The online version of this article (10.1186/s12911-018-0698-3) contains supplementary material, which is available to authorized users.

Shared decision making embedded in the undergraduate medical curriculum: A scoping review

OBJECTIVE

Shared decision making (SDM) training is shown to be effective and is increasingly embedded in continuing medical education. There is little evidence, however, about undergraduate medical education for SDM. The aim of this scoping review was to identify existing SDM training embedded in the undergraduate medical curriculum and analyze their impact.

METHODS

The authors systematically searched the extant literature for peer reviewed articles, hand searched key journals and reference lists of key articles, and contacted relevant stakeholders as part of a key informant analysis.

RESULTS

Included in the qualitative synthesis were 12 studies evaluating 11 SDM courses in medical education across six countries. Most courses integrated SDM training in clinical clerkship and varied in length from one to seven hours. The majority of studies assessed course impact on students' skills in SDM. Most studies suggested that students' skills and confidence in SDM significantly increased post-training, but three studies reported no significant improvement in SDM. Ten courses continue to be taught routinely.

CONCLUSION

Overall, studies suggested a positive impact on medical students' skills, confidence, and attitudes regarding SDM. Embedding SDM training in undergraduate medical education may be a practical and effective solution for current barriers to the widespread adoption of SDM.

Improving Shared Decision Making Between Patients and Clinicians: Design and Development of a Virtual Patient Simulation Tool

BACKGROUND

Shared decision making (SDM) involves the formation of a collaborative partnership between the patient and clinician combining both of their expertise in order to benefit decision making. In order for clinicians to be able to carry out this skilled task, they require practice. Virtual reality, in the form of a virtual patient, could offer a potential method of facilitating this.

OBJECTIVE

The objective of this study was to create a virtual patient that simulated a primary care consultation, affording the opportunity to practice SDM. A second aim was to involve patients in the design of a virtual patient simulation and report the process of the design.

METHODS

We employed a multistep design process drawing on patient and expert involvement.

RESULTS

A virtual patient, following a narrative style, was built, which allows a user to practice and receive feedback; both clinical and communication skills are required for the simulation. The patient group provided multiple insights, which the academic team had overlooked. They pertained mostly to issues concerning the patient experience.

CONCLUSIONS

It is possible to design a virtual patient that allows a learner to practice their ability to conduct SDM. Patient input into the design of virtual patient simulations can be a worthwhile activity.

Patients' participation during treatment and care of breast cancer - a possibility and an imperative

PURPOSE

To explore how patients experience participation during treatment and care for breast cancer related to their understanding.

METHOD

Semi-structured individual interviews with 16 women diagnosed with breast cancer. Interpretative qualitative content analysis was performed.

RESULTS

Three main themes describe patient participation. Theme 1 Respectful and personal encounters illustrates how the treatment from health care staff contributed to feelings of being "seen" as a human, a basis for participation. Theme 2 Part-owner in decision making describes the women's varied wishes of participating in treatment decisions. Theme 3 Striving to manage treatment, care and self-care concerns the need to manage self-care for well-being.

CONCLUSIONS

Patient participation is both a possibility and an imperative. Patients must be recognized as unique human beings with varying needs of participation. Shared learning and understanding in dialogue with health care staff is a prerequisite. A novel approach where patients and health care staff are both partners and participants is presented.

PRACTICAL IMPLICATION

The results call for an initiation of training programs supporting pedagogical competence in staff and patients' learning in breast cancer care. Access to health care in the outpatient and the hospital settings is needed long term after treatment to support patient participation.

The Most Important Therapy Outcomes for School-Aged Children Who Stutter: An Exploratory Study

PURPOSE

The aim of this article was to identify what school-aged children who stutter consider to be the most important outcomes from therapy.

METHOD

A Delphi approach was employed for the study. Eighteen participants aged 9-13 years completed a survey, generating 90 statements that would constitute successful therapy outcomes. After categorization and reduction, 79 statements were sent to participants in a second survey to seek consensus on their importance. Fifteen participants aged 8-14 years completed this second survey. Statements with the highest median ratings and smallest standard deviations were retained.

RESULTS

Twenty-one statements were retained after analysis. These reflected hopes for affective and behavioral change in the young person and in other people after therapy. Important outcomes included, but are not limited to, increased fluency, greater independence, increased confidence at school, others knowing how to support the individual, and communication situations feeling easier.

CONCLUSIONS

Participants identified a range of outcomes that were important to achieve as a result of speech and language therapy. The findings suggest a need for a more holistic view of what is meant by successful therapy, incorporating improvements in the ability to communicate and participate in daily situations. The findings suggest that an integrated or holistic approach to intervention would be required to achieve these goals and should include significant others from the child's environment. The important statements identified in this study could be used to inform the content of therapy and to evaluate change over time.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.7144205.

US-based cross-sectional survey of clinicians' knowledge and attitudes about shared decision-making across healthcare professions and specialties

OBJECTIVE

In this study, we aim to compare shared decision-making (SDM) knowledge and attitudes between US-based physician assistants (PAs), nurse practitioners (NPs) and physicians across surgical and family medicine specialties.

SETTING

We administered a cross-sectional, web-based survey between 20 September 2017 and 1 November 2017.

PARTICIPANTS

272 US-based NPs, PA and physicians completed the survey. 250 physicians were sent a generic email invitation to participate, of whom 100 completed the survey. 3300 NPs and PAs were invited, among whom 172 completed the survey. Individuals who met the following exclusion criteria were excluded from participation: (1) lack of English proficiency; (2) area of practice other than family medicine or surgery; (3) licensure other than physician, PA or NP; (4) practicing in a country other than the US.

RESULTS

We found few substantial differences in SDM knowledge and attitudes across clinician types, revealing positive attitudes across the sample paired with low to moderate knowledge. Family medicine professionals (PAs) were most knowledgeable on several items. Very few respondents (3%; 95% CI 1.5% to 6.2%) favoured a paternalistic approach to decision-making.

CONCLUSIONS

Recent policy-level promotion of SDM may have influenced positive clinician attitudes towards SDM. Positive attitudes despite limited knowledge warrant SDM training across occupations and specialties, while encouraging all clinicians to promote SDM. Given positive attitudes and similar knowledge across clinician types, we recommend that SDM is not confined to the patient-physician dyad but instead advocated among other health professionals.

A Study to Assess the Feasibility of Implementing a Web-Based Decision Aid for Birth after Cesarean to Increase Opportunities for Shared Decision Making in Ethnically Diverse Settings

INTRODUCTION

Decision aids are central to shared decision making and are recommended for value-sensitive pregnancy decisions, such as birth after cesarean. However, effective strategies for widespread decision aid implementation, with interactive web-based platforms, are lacking. This study tested the feasibility and acceptability of implementing a Health Insurance Portability and Accountability Act-secure, web-based decision aid to support shared decision making about birth choices after cesarean, within urban, ethnically diverse outpatient settings.

METHODS

A before-and-after design was used to assess feasibility and acceptability for decision aid implementation. Measures included women's knowledge, decisional conflict, birth preferences, birth outcomes, decision aid use, decision aid acceptability ratings (content, features, and functions), and views on how the decision aid supported shared decision making.

RESULTS

Of the 68 women who participated, most were black (46.2%) or Hispanic (35.4%). Their knowledge scores increased by 2.58 points out of 15 (P < .001; d = 0.87), and decisional conflict score reduced by 0.45 points out of 5 points (P < .001; d = 0.69). Forty-four women (65.9%) attempted a vaginal birth after cesarean, of whom 29 (65.7%) succeeded. Women rated decision aid content, features, and functions as good or excellent. Most indicated they would recommend it to others. Health care providers recommended additional strategies to simplify decision aid access and integration into routine care.

DISCUSSION

Implementing web-based decision aids within ethnically diverse practice settings is potentially feasible and worthwhile. However, strategies are needed to improve women's access and to encourage timely decision aid usage to prepare them for decision discussions with health care providers. Sustained implementation will require seamless integration into clinic workflow, which could include health care provider tools (counselling guides) embedded within the electronic health record, along with continuing education to support and engage health care providers in their use.

Connecting patient experience, leadership, and the importance of involvement, information, and empathy in the care process

To improve health outcomes, restore trust, and create a safe and healing environment for patients, the health system needs to shift from being disease, system, and provider focused to being patient centred. Drawing from a patient story, this article focuses on three aspects of the care process that have a significant impact on patient experience: involvement in care, information about treatment and care, and empathy and respect. It will also provide recommendations for leaders in how to become more patient centred and aligned to the LEADS competency framework.

Needs of parents and professionals to improve shared decision-making in interprofessional maternity care practice: A qualitative study

BACKGROUND

Shared decision-making (SDM) is a critical but challenging component of high quality maternity care. In co-creation with parents and professionals, we are developing an intervention to improve SDM. As a first step we aimed to explore the experiences and needs of parents and professionals regarding shared decision-making in interprofessional antenatal, natal, and postnatal care.

METHODS

We organized 11 focus groups in the Netherlands in November and December 2016. Parents, primary care midwives, hospital-based midwives, obstetricians, obstetric nurses, and maternity care assistants participated.

RESULTS

Parents and professionals recognized the SDM steps of introducing a decision (choice talk) and discussing options (option talk), but most parents did not seem to discuss preferences and weigh options with professionals before making their final decision (decision talk). Barriers to SDM were often related to interprofessional collaboration, while good communication skills of parents and professionals facilitated SDM. An intervention to improve SDM would need to: (a) increase awareness and offer insight into the SDM process and roles and responsibilities of parents and professionals, (b) develop good communication skills, and (c) encourage interprofessional collaboration. The preferred design of the intervention was online, interactive, and practical.

CONCLUSIONS

Parents and professionals will benefit from an intervention designed to improve SDM. A practical e-learning for all maternity care providers and e-health information for parents seems most appropriate. Key elements for the e-learning are raising awareness of the roles and responsibilities of parents and professionals, developing good communication skills and encouraging interprofessional collaboration. This requires a variety of educational strategies.