Veterans' decision-making preferences and perceived involvement in care for chronic heart failure

A scoping review into the explanations for differences in the degrees of shared decision making experienced by patients

OBJECTIVES

In order to improve the degree of shared decision making (SDM) experienced by patients, it is necessary to gain insight into the explanations for the differences in these degrees.

METHODS

A scoping review of the literature on the explanations for differences in the degree of SDM experienced by patients was conducted. We assessed 21,329 references. Ultimately, 308 studies were included. The explanations were divided into micro, meso, and macro levels.

RESULTS

The explanations are mainly related to the micro level. They include explanations related to the patient and healthcare professionals, the relationship between the patient and the physician, and the involvement of the patient's relatives. On the macro level, explanations are related to restrictions within the healthcare system such as time constraints, and adequate information about treatment options. On the meso level, explanations are related to the continuity of care and the involvement of other healthcare professionals.

CONCLUSIONS

SDM is not an isolated process between the physician and patient. Explanations are connected to the macro, meso, and micro levels.

PRACTICE IMPLICATIONS

This scoping review suggests that there could be more focus on explanations related to the macro and meso levels, and on how explanations at different levels are interrelated.

Perspectives of hospitalized heart failure patients: preferred and perceived participation roles in treatment decisions

Shared decision-making (SDM) is a pivotal process in seeking optimal individual treatment and incorporating clinical evidence and patients' autonomous preferences. However, patients' actual attitudes toward participation in decision-making for state-of-the-art heart failure (HF) treatment remain unclear. We conducted a questionnaire-based survey distributed by nurses and physicians specializing in HF care to assess patients' preferred and perceived participation roles in treatment decision-making during the index hospitalization, rated on five scales (from extremely passive to purely autonomous attitudes). Simultaneously, we investigated the important factors underlying treatment decision-making from the perspective of hospitalized HF patients. Of the 202 patients who were approached by our multidisciplinary HF team between 2017 and 2020, 166 (82.2%) completed the survey. Logistic regression analyses were conducted to identify the clinical determinants of patients who reported that they left all decisions to physicians (i.e., extremely passive attitude). Of the 166 participants (male 67.5%, median age 73 years), 32.5% preferred an extremely passive attitude, while 61.4% reported that they actually chose an extremely passive attitude. A sole determinant of choosing an extremely passive decision-making role was lower educational status (odds ratio: 2.11, 95% confidence interval 1.11-4.00). The most important factor underlying the decision-making was "Physician recommendation" (89.2%). Notably, less than 50% considered "In alignment with my values and preferences" as an important factor underlying treatment decision-making. The majority of HF patients reported that they chose an extremely passive approach, and patients prioritized physician recommendation over their own values and preferences.

A Prospective Cohort Study of Medical Decision-Making Roles and Their Associations with Patient Characteristics and Patient-Reported Outcomes among Patients with Heart Failure

OBJECTIVE

Among patients with heart failure (HF), we examined 1) the evolution of patient involvement in decision making over 2 y, 2) the association of patient characteristics with decision-making roles, and 3) the association of decision-making roles with distress, spiritual well-being, and quality of physician communication.

METHODS

We administered the survey every 4 mo over 24 mo to patients with New York Heart Association class 3/4 symptoms recruited from inpatient clinics. The decision-making roles were categorized as no patient involvement, physician/family-led, joint (with family and/or physicians), patient-led, or patient-alone decision making. The associations between patient characteristics and decision-making roles were assessed using a mixed-effects ordered logistic regression, whereas those between patient outcomes and decision-making roles were investigated using mixed-effects linear regressions.

RESULTS

Of the 557 patients invited, 251 participated in the study. The most common roles in decision making at baseline assessment were "no involvement" (27.53%) and "patient-alone decision making" (25.10%). The proportions of different decision-making roles did not change over 2 y (P = 0.37). Older age (odds ratio [OR] = 0.97; P = 0.003) and being married (OR = 0.63; P = 0.035) were associated with lower involvement in decision making. Chinese ethnicity (OR = 1.91; P = 0.003), higher education (OR = 1.87; P = 0.003), awareness of terminal condition (OR = 2.00; P < 0.001), and adequate self-care confidence (OR = 1.74; P < 0.001) were associated with greater involvement. Compared with no patient involvement, joint (β = -0.58; P = 0.026) and patient-led (β = -0.59; P = 0.014) decision making were associated with lower distress, while family/physician-led (β = 4.37; P = 0.001), joint (β = 3.86; P < 0.001), patient-led (β = 3.46; P < 0.001), and patient-alone (β = 3.99; P < 0.001) decision making were associated with better spiritual well-being.

CONCLUSION

A substantial proportion of patients was not involved in decision making. Patients should be encouraged to participate in decision making since it is associated with lower distress and better spiritual well-being.

HIGHLIGHTS

The level of involvement in medical decision making did not change over time among patients with heart failure. A substantial proportion of patients were not involved in decision making throughout the 24-mo study period.Patients' involvement in decision making varied by age, ethnicity, education level, marital status, awareness of the terminal condition, and confidence in self-care.Compared with no patient involvement in decision making, joint and patient-led decision making were associated with lower distress, and any level of patient involvement in decision making was associated with better spiritual well-being.

Use of the Self- and Family Management Framework in quantitative studies

BACKGROUND

The Self- and Family Management Framework (SFMF) identifies factors and outcomes of patient and family management of chronic illness. In a previous citation analysis, we reported the frequency and nature of use of the SFMF.

PURPOSE

We conducted a sub-analysis of quantitative articles in the citation analysis to examine testing of relationships depicted in the SFMF.

METHODS

We analyzed study purposes, independent and dependent variables, study implications, and text that referred to the SFMF in 40 articles.

FINDINGS

The SFMF has been used largely to explore factors affecting SFM behaviors, focusing on patient versus family self-management. Independent variables included all categories of facilitators/barriers specified in the SFMF. Dependent variables included all SFMF components (Facilitators/Barriers, Processes, Proximal and Distal Outcomes). Racial/ethnic diversity was limited among study participants. Study implications pertained mostly to psychosocial outcomes. Most studies referred to the SFMF generally.

DISCUSSION

Findings will contribute to revision of the SFMF.

Preferred Role in Health Care Decision Making Over Time in Patients With Heart Failure: My Decision or My Doctor's Decision?

BACKGROUND

Understanding patients' preferred role in decision making can improve patient-centered care. This study aimed to determine change and the predictors of change in preferred decision-making roles over time in patients with heart failure.

METHODS AND RESULTS

During the CASA (Collaborative Care to Alleviate Symptoms and Adjust to Illness) trial, patients' preferred roles in decision making were measured using the Control Preferences Scale (range 1-5; higher = less active; n = 312) at 4 timepoints over 1 year. The effect of the CASA intervention on preferred decision-making roles was tested using generalized linear mixed models. Whether preferences changed over time in the whole population was determined using linear regression. Demographic and health-related factors were examined as predictors of change using multiple linear regression. At baseline, most participants preferred active (score 1-2, 37.2%) or collaborative (score 3, 44.9%) roles. The CASA intervention did not influence preferred decision-making roles (P > 0.1). Preferences significantly changed over 1 year (P < 0.01), becoming more active (82.1%, 84.2%, 89.0%, 90.1% active/collaborative at each timepoint). Among all models and covariates, there were no significant predictors of change (P > 0.1).

CONCLUSIONS

Patients' preferred roles in decision making change over time, but changes are not well predicted. Clinicians should frequently and directly communicate with patients about their preferred decision-making roles.

Health Literacy and Patient Participation in Shared Decision-Making in Orthopedic Surgery

The influence of health literacy on involvement in decision-making in orthopedic surgery has not been analyzed and could inform processes to engage patients. The goal of this study was to determine the relationship between health literacy and the patient's preferred involvement in decision-making. We conducted a cross-sectional observational study of patients presenting to a multispecialty orthopedic clinic. Patients completed the Literacy in Musculoskeletal Problems (LiMP) survey to evaluate their health literacy and the Control Preferences Scale (CPS) survey to evaluate their preferred level of involvement in decision-making. Statistical analysis was performed with Pearson's correlation and multivariable logistic regression. Thirty-seven percent of patients had limited health literacy (LiMP score <6). Forty-eight percent of patients preferred to share decision-making with their physician equally (CPS score=3), whereas 38% preferred to have a more active role in decision-making (CPS score≤2). There was no statistically significant correlation between health literacy and patient preference for involvement in decision-making (r=0.130; P=.150). Among patients with orthopedic conditions, there is no significant relationship between health literacy and preferred involvement in decision-making. Results from studies in other specialties that suggest that limited health literacy is associated with a preference for less involvement in decision-making are not generalizable to orthopedic surgery. Efforts to engage patients to be informed and participatory in decision-making through the use of decision aids and preference elicitation tools should be directed toward variation in preference for involvement in decision-making, but not toward patient health literacy. [Orthopedics. 2022;45(4):227-232.].

Use of the self- and family management framework and implications for further development

BACKGROUND

The Self- and Family Management Framework (SFMF) was created in 2006 and revised in 2015 to guide research on self- and family management of chronic conditions. There has been no review of use of the SFMF.

PURPOSE

We reviewed articles citing the SFMF to identify the frequency and nature of use.

METHOD

We conducted a citation analysis, searching Web of Science, Scopus, and Google Scholar databases and extracted key data from identified articles.

FINDINGS

Of 126 articles, 84(66%) cited the 2006 SFMF, 37(29%) cited the 2015 SFMF, and 6(5%) cited both. The SFMF was used most to inform study design. Users noted strengths (e.g., considers family context) and limitations (e.g., non-specification of patient- family caregiver synergies) of the framework.

DISCUSSION

The SFMF has been used broadly to guide research on self- and family management of chronic conditions. Findings will inform development of a third version of the SFMF.

A grounded theory study: Exploring health care professionals decision making when managing end stage heart failure care

AIM

To explore how healthcare professionals in an acute medical setting make decisions when managing the care of patients diagnosed with end stage heart failure, and how these decisions impact directly on the patient's end of life experience.

DESIGN

A constructivist grounded theory approach was adopted.

METHOD

A purposive sample was used to recruit participants that included 16 registered nurses, 15 doctors and 16 patients. Data were collected using semi-structured interviews and focus groups over a 12-month period of fieldwork concluding in 2017. The interviews were recorded and transcribed and the data were analysed using constant comparison and QSR NVivo.

FINDINGS

Four theoretical categories emerged from the data to explain how healthcare professionals and patients negotiated the process of decision making when considering end of life care. These were: signposting symptoms, organizing care, being informed and recognizing dying. The themes revolved around a core category 'a vicious cycle of heart failure care'.

CONCLUSION

Healthcare professionals need to engage in informed decision making with patients to break this 'vicious cycle of care' by identifying key stages in the terminal phase of heart failure and correctly signposting the patient to the most suitable healthcare care professional for intervention.

IMPACT

This study provides a theoretical framework to explain a 'vicious cycle of care' for patients diagnosed with end stage heart failure. This theory grounded in data demonstrates the need for both acute and primary care to design an integrative end of life care pathway for heart failure patients which addresses the need for early shared decision making between the healthcare professional, family and the patient when it comes to end of life conversations.

Causality Orientations and Supportive/Controlled Environment: Understanding Their Influence on Basic Needs, Motivation for Health and Emotions in French Hospitalized Older Adults

Objectives

From a self-determination theory perspective, the purpose of this cross sectional study was to better understand how to motivate hospitalized older adults’ behaviors and test an integrative model of the role of causality orientations and a supportive/controlled environment on basic need satisfaction, motivation for health oriented physical activity, positive and negative affective states, depressive symptoms, apathy, and boredom.

Methods

Older adults (N = 146; M_age = 81.27 years, SD = 7.75, 74.7% female) in French hospital units completed self-report questionnaires and socio-demographic data were also collected.

Results

Partial least squares path modeling results showed that participants’ autonomy orientation positively associated with the perception of a supportive environment was related to need satisfaction, autonomous motivation for health-oriented physical activity, and high scores on positive affective states. Conversely, participants’ impersonal orientation positively associated with the perception of a controlled environment was related to undermining need satisfaction, controlled motivation for health-oriented physical activity, and amotivation, and high scores on both negative affective states, and boredom.

Conclusion

The present results indicate that taking into account personality factors in hospital units can be useful and health professionals should take an interest both in the patients’ causality orientations and the supportive nature of the environment in order to understand better how to motivate patients’ behaviors. The present study points to the need to focus on all motivational dynamics which allow patients’ need satisfaction.

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.

Person-Centred Care in Patients with Acute Coronary Syndrome: Cost-Effectiveness Analysis Alongside a Randomised Controlled Trial

BACKGROUND

Costs associated with an ACS incident are most pronounced in the acute phase but are also considerably long after the initial hospitalisation, partly due to considerable productivity losses, which constitute a substantial part of the economic burden of the disease. Studies suggest that person-centred care may improve health-related quality of life and reduce the costs associated with the disease.

OBJECTIVE

The aim of this study was to calculate the cost-effectiveness of a person-centred care intervention compared with usual care in patients with acute coronary syndrome (ACS), in a Swedish setting.

METHODS

Primary data from a randomised controlled trial of a person-centred intervention in patients with ACS was used. The person-centred intervention involved co-creation of a health plan between the patient and healthcare professionals, based on the patient's narrative. Thereafter, goals for the recovery period were set and followed-up continuously throughout the intervention. The clinical data, collected during the randomised controlled trial, was complemented with data from national health registers and the Swedish Social Insurance Agency. The study was conducted at two hospitals situated in a Swedish municipality. Patients were enrolled between June 2011 and February 2014 (192 patients were included in this study; 89 in the intervention group and 103 in the control group). Incremental cost-effectiveness ratios were calculated separately for the age groups < 65 years and ≥ 65 years in order to account for the age of retirement in Sweden. The cost-effectiveness ratios were calculated using health-related quality of life (EQ-5D) and costs associated with healthcare and pharmaceutical utilisation, and productivity losses.

RESULTS

Treatment effects and costs differed between those below and those above the age of 65 years. The base-case calculations showed that person-centred care was more effective and less costly compared with usual care for patients under 65 years of age, while usual care was more effective and less costly in the older age group. Probabilistic sensitivity analyses resulted in a 90% likelihood that person-centred care is cost-effective compared with usual care for patients with ACS under the age of 65 years.

CONCLUSIONS

Person-centred care was found to be cost-effective compared with usual care for patients with acute coronary syndrome under the age of 65 years. This clinical trial is registered at Researchweb (ID 65791).

Association of Decision-making with Patients' Perceptions of Care and Knowledge during Longitudinal Pulmonary Nodule Surveillance

RATIONALE

Patient participation in medical decision-making is widely advocated, but outcomes are inconsistent.

OBJECTIVES

We examined the associations between medical decision-making roles, and patients' perceptions of their care and knowledge while undergoing pulmonary nodule surveillance.

METHODS

The study setting was an academically affiliated Veterans Affairs hospital network in which 121 participants had 319 decision-making encounters. The Control Preferences Scale was used to assess patients' decision-making roles. Associations between decision-making, including role concordance (i.e., agreement between patients' preferred and actual roles), shared decision-making (SDM), and perceptions of care and knowledge, were assessed using logistic regression and generalized estimating equations.

RESULTS

Participants had a preferred role in 98% of encounters, and most desired an active role (shared or patient controlled). For some encounters (36%), patients did not report their actual decision-making role, because they did not know what their role was. Role concordance and SDM occurred in 56% and 26% of encounters, respectively. Role concordance was associated with greater satisfaction with medical care (adjusted odds ratio [Adj-OR], 5.39; 95% confidence interval [CI], 1.68-17.26), higher quality of patient-reported care (Adj-OR, 2.86; 95% CI, 1.31-6.27), and more disagreement that care could be better (Adj-OR, 2.16; 95% CI, 1.12-4.16). Role concordance was not associated with improved pulmonary nodule knowledge with respect to lung cancer risk (Adj-OR, 1.12; 95% CI, 0.63-2.00) or nodule information received (Adj-OR, 1.13; 95% CI, 0.31-4.13). SDM was not associated with perceptions of care or knowledge.

CONCLUSIONS

Among patients undergoing longitudinal nodule surveillance, a majority had a preference for having active roles in decision-making. Interestingly, during some encounters, patients did not know what their role was or that a decision was being made. Role concordance was associated with greater patient-reported satisfaction and quality of medical care, but not with improved knowledge. Patient participation in decision-making may influence perceptions of care; however, clinicians may need to focus on other communication strategies or domains to improve patient knowledge and health outcomes.

Predicting the preferences for involvement in medical decision making among patients with mental disorders

BACKGROUND

The involvement of patients in medical decision making has been investigated widely in somatic diseases. However, little is known about the preferences for involvement and variables that could predict these preferences in patients with mental disorders.

OBJECTIVE

This study aims to determine what roles mentally ill patients actually want to assume when making medical decisions and to identify the variables that could predict this role, including patients' self-efficacy.

METHOD

Demographic and clinical data of 798 patients with mental disorders from three psychotherapeutic units in Germany were elicited using self-report questionnaires. Control preference was measured using the Control Preferences Scale, and patients' perceived self-efficacy was assessed using the Self-Efficacy Scale. Bivariate and multivariate regression analyses were conducted to investigate the associations between patient variables and control preference.

RESULTS

Most patients preferred a collaborative role (57.5%), followed by a semi passive (21.2%), a partly autonomous (16.2%), an autonomous (2.8%) and a fully passive (2.3%) role when making medical decisions. Age, sex, diagnosis, employment status, medical pretreatment and perceived self-efficacy were associated with the preference for involvement in the multivariate logistic model.

CONCLUSION

Our results confirm the preferences for involvement in medical decisions of mentally ill patients. We reconfirmed previous findings that older patients prefer a shared role over an autonomous role and that subjects with a high qualification prefer a more autonomous role over a shared role. The knowledge about predictors may help strengthen treatment effectiveness because matching the preferred and actual role preferences has been shown to improve clinical outcome.

Making patient values visible in healthcare: a systematic review of tools to assess patient treatment priorities and preferences in the context of multimorbidity

OBJECTIVES

To identify studies of existing instruments available for clinicians to record overall patient preferences and priorities for care, suitable for use in routine primary care practice in patients with multimorbidity. To examine the data for all identified tools with respect to validity, acceptability and effect on health outcomes.

DESIGN

Systematic Review.

DATA SOURCES

MEDLINE, EMBASE and Cochrane databases, each with a predefined search strategy.

ELIGIBILITY CRITERIA

Citations were included if they reported a tool used to record patient priorities or preferences for treatment, and quantitative or qualitative results following administration of the tool.

RESULTS

Our search identified 189 potential studies of which 6 original studies and 2 discussion papers were included after screening for relevance. 5 of 6 studies (83%) were of cross-sectional design and of moderate quality. All studies reported on the usability of a tool in order to elicit patient preferences. No studies reported on changes to patient-specific healthcare outcomes as a consequence of recording preferences and priorities. 1 of 6 studies reported on eliciting patient preference in the context of multimorbidity. No studies incorporated patient preferences into an electronic medical record.

CONCLUSIONS

Given the importance of eliciting patient priorities and preferences in providing patient-centred care in the context of multimorbidity and polypharmacy, we found surprisingly few relevant tools. Some aspects of the tools used for single-disease contexts may also be useful in the context of multimorbidity. There is an urgent need to develop ways to make patient priorities explicitly visible in the clinical record and medical decision-making and to test the effect on patient-relevant outcomes.

Association between Internet use and decision-making preference in older adults

BACKGROUND

Easy access to health-related information on the Internet has the potential to empower patients in making health-related decisions. However, little is known regarding the association between Internet use and decision-making preference in older adults. The aim of the study is to evaluate the association between Internet use and decision-making preference in older adults.

METHOD

The study analyzed cross-sectional data from 1,945 participants of the National Health and Aging Trends Study.

RESULTS

Older adults who used the Internet had greater odds of active decision-making preference (OR 1.75, 95%CI 1.22-2.52, p=0.002) compared to older adults who did not use the Internet. Similarly, older adults, who searched the Internet for health-related information, had higher odds of active decision-making preference (OR 2.16, 95%CI 1.14-4.09, p=0.019) compared to their counterparts.

CONCLUSION

Internet use was found to be associated with active decision-making preference in older adults. Similarly, health-related Internet use was positively associated with decision-making involvement in older adults.

"Doctor, Make My Decisions": Decision Control Preferences, Advance Care Planning, and Satisfaction With Communication Among Diverse Older Adults

CONTEXT

Culturally diverse older adults may prefer varying control over medical decisions. Decision control preferences (DCPs) may profoundly affect advance care planning (ACP) and communication.

OBJECTIVES

To determine the DCPs of diverse, older adults and whether DCPs are associated with participant characteristics, ACP, and communication satisfaction.

METHODS

A total of 146 participants were recruited from clinics and senior centers in San Francisco. We assessed DCPs using the control preferences scale: doctor makes all decisions (low), shares with doctor (medium), makes own decisions (high). We assessed associations between DCPs and demographics; prior advance directives; ability to make in-the-moment goals of care decisions; self-efficacy, readiness, and prior asked questions; and satisfaction with patient-doctor communication (on a five-point Likert scale), using Chi-square and Kruskal-Wallis analysis of variance.

RESULTS

Mean age was 71 ± 10 years, 53% were non-white, 47% completed an advance directive, and 70% made goals of care decisions. Of the sample, 18% had low DCPs, 33% medium, and 49% high. Older age was the only characteristic associated with DCPs (low: 75 ± 11 years, medium: 69 ± 10 years, high: 70 ± 9 years, P = 0.003). DCPs were not associated with ACP, in-the-moment decisions, or communication satisfaction. Readiness was the only question-asking behavior associated (low: 3.8 ± 1.2, medium: 4.1 ± 1.2, high: 4.3 ± 1.2, P = 0.05).

CONCLUSION

Nearly one-fifth of diverse, older adults want doctors to make their medical decisions. Older age and lower readiness to ask questions were the only demographic variables significantly associated with low DCPs. Yet, older adults with low DCPs still engaged in ACP, asked questions, and reported communication satisfaction. Clinicians can encourage ACP and questions for all patients, but should assess DCPs to provide the desired amount of decision support.

Decision Making Among Persons Living With Heart Failure

BACKGROUND

Persons with heart failure (HF) are required to make decisions on a daily basis related to their declining health and make urgent decisions during acute illness exacerbations. However, little is known about the types of decisions patients make.

OBJECTIVE

The aims of this study were to critically evaluate the current quantitative literature related to decision making among persons with HF and identify research gaps in HF decision-making research.

METHODS

A systematic search of literature about decisions persons with HF make was conducted using PubMed, CINAHL, and PsychINFO databases. The following inclusion criteria were used: sample composed of at least 50% HF participants, concrete decisions were made, and a quantitative study design was used. Two authors performed title, abstract, and full-text reviews independently to identify eligible articles.

RESULTS

Twelve quantitative articles were included. Study samples were predominately older, white, male, and married. Two-thirds of the articles focused on decisions related to the end-of-life topics (ie, resuscitation decisions, advanced care planning). The other one-third focused on decisions about care seeking, participant's involvement in treatment decisions during their last clinic visit, and self-care behaviors.

CONCLUSIONS

Within the HF literature, the term decision is often ill-defined or not defined. Limitations in methodological rigor limit definitive conclusions about HF decision making. Future studies should consider strengthening study rigor and examining other decision topics such as inclusion of family in making decisions as HF progresses. Research rigorously examining HF decision making is needed to develop interventions to support persons with HF.

The Association of Patient Chronic Disease Burden and Self-Management Requirements With Shared Decision Making in Primary Care Visits

BACKGROUND

Shared decision making (SDM) is associated with positive health outcomes and may be particularly relevant for patients with chronic disease.

OBJECTIVES

To investigate whether (1) patients with chronic diseases, particularly those requiring self-management, are more likely to engage in SDM behaviors than patients without chronic diseases and (2) patients with chronic diseases are more likely to have their physicians engage them in SDM.

DESIGN

A cross-sectional study of patients who were enrolled in a randomized controlled trial to improve patient-physician communication.

PARTICIPANTS

Adult patients with hypertension at community health clinics in Baltimore, Maryland.

APPROACH

We used multivariable regression models to examine the associations of the following predictor variables: (1) chronic disease burden and (2) diseases requiring self-management with the following outcome variables measuring SDM components: (1) patient information sharing, (2) patient decision making, and (3) physician SDM facilitation.

KEY RESULTS

Patients with greater chronic disease burden and more diseases requiring self-management reported more information sharing (β = .07, P = .03 and β = .12, P = .046, respectively) and decision making (β = .06, P = .02 and β = .21, P < .001) as did patients who reported poor general health. Physician facilitation of SDM was not associated with chronic disease burden or with diseases requiring self-management but was associated with higher patient income.

CONCLUSIONS

Patients with chronic diseases, particularly those requiring self-management, may be more likely to engage in SDM behaviors, but physicians may not be more likely to engage such patients in SDM. Targeting patients with chronic disease for SDM may improve health outcomes among the chronically ill, particularly among vulnerable patients (eg, minorities, low-income patients) who suffer disproportionately from such conditions.

Factors affecting the physician-patient relationship of older veterans with inadequate health literacy: an observational study

BACKGROUND

In Taiwan, older veterans typically match the characteristics of a high prevalence of inadequate health literacy, which is a major barrier to effective communication in delivering proper health care. A good physician-patient relationship increases patients' trust and willingness to communicate, so an awareness of the factors that influence this relationship could improve it over time and enhance patients' health.

AIM

To explore factors related to the physician-patient relationship among older veterans with inadequate health literacy in Taiwan.

DESIGN AND SETTING

Observational study in veterans' homes.

METHOD

Data were collected using self-report questionnaires in face-to-face interviews. Patients with a Test of Functional Health Literacy in Adults score <60 (defined as inadequate health literacy) were recruited. Demographic characteristics, the Geriatric Depression Scale-Short Form, Multidimensional Health Locus of Control, and Perceived Involvement in Care Scales were used to identify related factors. Multiple regression and bootstrapping were used for data analyses.

RESULTS

A total of 256 older individuals were defined as having inadequate health literacy. Patients' perceived involvement in health care partially mediated the relationship between Health Locus of Control and the physician-patient relationship. Perceived Involvement in Care, depression score, and Health Locus of Control were predictors of the physician-patient relationship.

CONCLUSION

Older patients with inadequate health literacy had difficulty becoming actively involved in health care. The GP is in an ideal position to become a key person in helping such patients become involved in health care, and appropriately treating their depression may improve the physician-patient relationship.

Participation of very old adults in health care decisions

BACKGROUND

Some elderly people receive tests or interventions from which they have low likelihood of benefit or for which the goal is not aligned with their values. Engaging these patients in the decision process is one potential approach to improve the individualization of care. Yet some clinicians perceive and some survey data suggest that older adults prefer not to participate in the decision-making process. Those preferences, however, may be formed based on an experience in which factors, such as communication issues, were barriers to participation. Our goal was to shed light on the experience of very old adults in health care decision making from their own point of view to deepen our understanding of their potentially modifiable barriers to participation.

DESIGN

and

METHODS

Semistructured interviews of participants aged 80 and older (n = 29, 59% women and 21% black) were analyzed using the constant comparative method in a grounded theory approach to describe decision making in clinic visits from the patient's perspective.

RESULTS

The average age was 84 years (range, 80-93); each described an average of 6.4 decision episodes. Active participation was highly variable among subjects. Marked differences in participation across participants and by type of decision--surgery, medications, diagnostic procedures, routine testing for preventive care--highlighted barriers to greater participation. The most common potentially modifiable barriers were the perception that there were no options to consider, low patient activation, and communication issues.

CONCLUSIONS

The experience of very old adults highlights potentially modifiable barriers to greater participation in decision making. To bring very old patients into the decision process, clinicians must modify interviewing skills and spend additional time eliciting their values, goals, and preferences.

Too complex and time-consuming to fit in! Physicians' experiences of elderly patients and their participation in medical decision making: a grounded theory study

OBJECTIVE

To explore physicians' thoughts and considerations of participation in medical decision making by hospitalised elderly patients.

DESIGN

A qualitative study using focus group interviews with physicians interpreted with grounded theory and completed with a questionnaire.

SETTING AND PARTICIPANTS

The setting was three different hospitals in two counties in Sweden. Five focus groups were conducted with physicians (n=30) in medical departments, with experience of care of elderly patients.

RESULTS

Physicians expressed frustration at not being able to give good care to elderly patients with multimorbidity, including letting them participate in medical decision making. Two main categories were found: 'being challenged' by this patient group and 'being a small part of the healthcare production machine'. Both categories were explained by the core category 'lacking in time'. The reasons for the feeling of 'being challenged' were explained by the subcategories 'having a feeling of incompetence', 'having to take relatives into consideration' and 'having to take cognitive decline into account'. The reasons for the feeling of 'being a small part of the healthcare production machine' were explained by the subcategories 'at the mercy of routines' and 'inadequate remuneration system', both of which do not favour elderly patients with multimorbidity.

CONCLUSIONS

Physicians find that elderly patients with multimorbidity lead to frustration by giving them a feeling of professional inadequacy, as they are unable to prioritise this common and rapidly growing patient group and enable them to participate in medical decision making. The reason for this feeling is explained by lack of time, competence, holistic view, appropriate routines and proper remuneration systems for treating these patients.

Are elderly people with co-morbidities involved adequately in medical decision making when hospitalised? A cross-sectional survey

BACKGROUND

Medical decision making has long been in focus, but little is known of the preferences and conditions for elderly people with co-morbidities to participate in medical decision making. The main objective of the present study was to investigate the preferred and the actual degree of control, i.e. the role elderly people with co-morbidities wish to assume and actually had with regard to information and participation in medical decision making during their last stay in hospital.This study was a cross-sectional survey including three Swedish hospitals with acute admittance. The participants were patients aged 75 years and above with three or more diagnoses according to the International Classification of Diseases (ICD-10) and three or more hospitalisations during the last year.

METHODS

We used a questionnaire combined with a telephone interview, using the Control Preference Scale to measure each participant's preferred and actual role in medical decision making during their last stay in hospital. Additional questions were asked about barriers to participation in decision making and preferred information seeking role. The results are presented with descriptive statistics with kappa weights.

RESULTS

Of the 297 elderly patients identified, 52.5% responded (n = 156, 46.5% male). Mean age was 83.1 years. Of the respondents, 42 of 153 patients said that they were not asked for their opinion (i.e. no shared decision making). Among the other 111 patients, 49 had their exact preferred level of participation, 37 had less participation than they would have preferred, and 23 had more responsibility than they would have preferred. Kappa statistics showed a moderate agreement between preferred and actual role (κw = 0.57; 95% CI: 0.45-0.69). Most patients wanted to be given more information without having to ask. There was no correlation between age, gender, or education and preferred role. 35% of the patients agreed that they experienced some of the various barriers to decision making that they were asked about: 1) the severity of their illness, 2) doctors with different treatment strategies, 3) difficulty understanding the medical information, and 4) difficulty understanding doctors who did not speak the patient's own language.

CONCLUSIONS

Physicians are not fully responsive to patient preferences regarding either the degree of communication or the patient's participation in decision making. Barriers to participation can be a problem, and should be taken into account more often when dealing with hospitalised elderly people.

End-of-life care conversations with heart failure patients: a systematic literature review and narrative synthesis

BACKGROUND

Current models of end-of-life care (EOLC) have been largely developed for cancer and may not meet the needs of heart failure patients.

AIM

To review the literature concerning conversations about EOLC between patients with heart failure and healthcare professionals, with respect to the prevalence of conversations; patients' and practitioners' preferences for their timing and content; and the facilitators and blockers to conversations.

DESIGN OF STUDY

Systematic literature review and narrative synthesis.

METHOD

Searches of Medline, PsycINFO and CINAHL databases from January 1987 to April 2010 were conducted, with citation and journal hand searches. Studies of adult patients with heart failure and/or their health professionals concerning discussions of EOLC were included: discussion and opinion pieces were excluded. Extracted data were analysed using NVivo, with a narrative synthesis of emergent themes.

RESULTS

Conversations focus largely on disease management; EOLC is rarely discussed. Some patients would welcome such conversations, but many do not realise the seriousness of their condition or do not wish to discuss end-of-life issues. Clinicians are unsure how to discuss the uncertain prognosis and risk of sudden death; fearing causing premature alarm and destroying hope, they wait for cues from patients before raising EOLC issues. Consequently, the conversations rarely take place.

CONCLUSION

Prognostic uncertainty and high risk of sudden death lead to EOLC conversations being commonly avoided. The implications for policy and practice are discussed: such conversations can be supportive if expressed as 'hoping for the best but preparing for the worst'.

Preferences and perceived involvement in treatment decision making among Chinese patients with chronic hepatitis

OBJECTIVES

The objectives of this study were to measure the preferences for and perceived involvement in treatment decision making among Chinese patients with chronic hepatitis and to explore the factors that may influence patients' preferences. The study also aimed to analyze patients' satisfaction with decision and information provision and their relationships with the decisional role.

METHODS

Semistructured interviews were performed with 178 chronic hepatitis patients. The Control Preferences Scale was translated into Chinese from English and adopted to measure patients' preferred and perceived decisional role. Patients' satisfaction with decision and information provision was also investigated by a 5-point Likert-type scale.

RESULTS

Patients with chronic hepatitis in the study generally preferred a collaborative role (45%) or passive role (44%); only 11% of patients preferred an active role in treatment decision making. The agreement between patients' perceived and preferred role was not perfect (Bowker's S = 33.8, P < 0.001). Age and education level were significantly associated with patients' preferences: Younger, better educated patients tended to prefer more active roles. A total of 54% of patients felt satisfied with treatment decisions, whereas 39% of patients felt satisfied with information provision. Patients' levels of satisfaction with their treatment decisions were correlated not only with the perceived role itself but also with its agreement with the preferred role. Patients' satisfaction with information provision was significantly correlated with patients' preferred role. Moreover, there was a significant correlation between patients' satisfaction with the treatment decision and information provision.

CONCLUSIONS

Patients' preferences for participation in treatment decision making should be considered seriously by doctors during the encounter. Health providers should make a greater effort to improve doctor-patient communication and decrease the mismatch between patients' perceived and preferred decisional role.

Primary care patient and provider preferences for diabetes care managers

PURPOSE

The collaborative care model, using care managers, has been shown to be effective in achieving sustained treatment outcomes in chronic disease management. Little effort has been made to find out patient preferences for chronic disease care, hence, we conducted a study aimed at identifying these.

METHODS

A 20-item questionnaire, asking for patients' and providers' preferences and perceptions, was mailed out to 1000 randomly selected patients in Olmsted County, Minnesota, identified through a diabetes registry to have type 2 diabetes mellitus, a prototypical prevalent chronic disease. Surveys were also sent to 42 primary care providers.

RESULTS

There were 254 (25.4%) patient responders and 28 (66%) provider responders. The majority of patients (>70%) and providers (89%) expressed willingness to have various aspects of diabetes care managed by a care manager. Although 75% of providers would be comfortable expanding the care manager role to other chronic diseases, only 39.5% of patient responders would be willing to see a care manager for other chronic problems. Longer length of time from initial diagnosis of diabetes was associated with decreased patient likelihood to work with a care manager.

CONCLUSION

Despite study limitations, such as the lack of validated measures to assess perceptions related to care management, our results suggest that patients and providers are willing to collaborate with a care manager and that both groups have similar role expectations of a care manager.

Patient's preferences for health scenarios associated with hepatitis C and its treatment

BACKGROUND AND AIM

Antiviral therapy with peg-interferon and ribavirin induces sustained virus eradication in 40%-80% of patients with chronic hepatitis C virus (HCV). We investigated patient views on their involvement in therapeutic decision making and on the desirability of disease and treatment-related outcomes.

METHODS

The control preferences and visual analog scales were administered in a pencil and paper format to a series of 45 patients in order to assess their decisional role, preferences for scenarios of HCV disease and antiviral treatment, and estimates of success required to recommend treatment.

RESULTS

The preferred decisional role of patients was passive in 26 (58%), collaborative in 12 (27%) and active in 7 (15%). Median preference scores ranged from 0.30 to 0.90 for scenarios of disease, from 0.05 to 0.80 for side effects and from 25% to 100% for estimates of benefit to recommend treatment.

CONCLUSIONS

Our patients prefer to defer to the doctor the final decision in starting therapy in a context of shared decision making. Reported preferences for HCV scenarios are in the range discussed in the literature. The wide variability in the values attributed to side effects by patients with chronic hepatitis C as well as in expected probabilities of successful treatment suggests a need for decision analysis tailored to the individual patient.