Shared decision making: the reliability of the OPTION scale in Italy

Shared decision-making in the treatment of adolescents diagnosed with depression: A cross-sectional survey of mental health professionals in China

WHAT IS ALREADY KNOWN?: SDM improves clinical outcomes by increasing attendance and treatment adherence in adolescents diagnosed with depression. SDM could reduce treatment disagreements and enhance consumers' and their families' satisfaction with mental healthcare services. Healthcare professionals are a critical part of SDM. However, MHPs' practices of SDM in the daily management of adolescents diagnosed with depression need to be clarified. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: From the viewpoints of MHPs, SDM was not extensively applied in the daily management of adolescents diagnosed with depression. MHPs who trust their consumers and have received training related to SDM are more likely to practice SDM in the daily management of adolescents diagnosed with depression. The positive preferences for providing information and family involvement in treatment decision-making are facilitators; working in closed inpatient mental health wards and open inpatient mental health wards are hindering factors for MHPs' practices of SDM. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: MHPs should encourage information sharing with consumers and their family members to help them participate in treatment decision-making actively. A trusting and friendly therapeutic relationship with consumers should be maintained in the daily management of adolescents diagnosed with depression. SDM-related training should be encouraged for MHPs to promote widespread SDM.

ABSTRACT

INTRODUCTION: Shared decision-making (SDM) is an ideal model for a therapeutic relationship that can improve health outcomes. Healthcare professionals are a critical part of SDM, and they play an important role in the practices of SDM in the clinical setting. Evidence suggests that adolescents diagnosed with depression can benefit substantially from SDM. However, mental health professionals' (MHPs) practices of SDM for adolescents diagnosed with depression in China are not well-documented.

AIM

This study aimed to investigate the practices of SDM for adolescents diagnosed with depression from the viewpoints of MHPs in China.

METHOD

In this cross-sectional study, we recruited a total of 581 MHPs by convenience sampling. The Shared Decision-Making Questionnaire-Physician Version (SDM-Q-Doc) was used to evaluate the MHPs' practices of SDM for adolescents diagnosed with depression.

RESULTS

The mean SDM-Q-Doc was 80.47 (±16.31). Within the six specific decision-making situations, most MHPs selected non-SDM (52.7%-71.6%). Substantial numbers of respondents believed that MHPs made the final decision, especially with regard to the development (37%) and adjustment of medication regimens (42%). The practice of SDM was predicted by MHPs' preference for providing information, their trust in consumers, preference for family involvement in treatment decision-making, working in an outpatient clinic and receiving SDM training (F = 23.582; p = .000; R2  = .198; adjusted R2  = .189).

DISCUSSION

Although the MHPs' self-rated score of SDM-Q-Doc was high, SDM was not extensively applied in the daily management of adolescents diagnosed with depression. Thus, SDM needs to be further promoted by enhancing SDM-related training for MHPs, thereby actively promoting the involvement of families, facilitating the information sharing for consumers and families, and building an active, trusting consumer-practitioner relationship.

IMPLICATIONS FOR PRACTICE

MHPs should prioritise information sharing with consumers and families, as well as build trusting and friendly therapeutic relationships. Family involvement in treatment decisions should be encouraged when adolescents diagnosed with depression are in need. Actively participating in training related to SDM is also important. Future high-quality evidence is still needed to explore the facilitators and barriers to SDM practices from a tripartite perspective of MHPs, adolescents diagnosed with depression and their families.

Bringing personal perspective elicitation to the heart of shared decision-making: A scoping review

OBJECTIVES

Proponents of shared decision-making (SDM) advocate the elicitation of the patient's perspective. This scoping review explores if, and to what extent, the personal perspectives of patients are elicited during a clinical encounter, as part of a SDM process. We define personal perspective elicitation (PPE) as: the disclosure (either elicited by the clinician or spontaneously expressed by the patient) of information related to the patient's personal preferences, values and/or context.

METHODS

A search was conducted in five literature databases from inception dates up to July 2020, to identify empirical studies about SDM (with/without SDM instrument).

RESULTS

The search identified 4562 abstracts; 263 articles were read in full text, resulting in 99 included studies. Studies reported low levels of PPE. Integration of personal perspectives into the conversation or a future care plan was largely absent. The majority of the discussed content related to physical health, while social and psychological topics were mostly unaddressed.

CONCLUSIONS

PPE occurs on a very low level in efforts to achieve SDM according to evaluation studies.

PRACTICE IMPLICATIONS

PPE is advocated but rarely achieved in SDM evaluation studies. Causes should be identified, followed by designing interventions to improve this aspect of SDM.

Psychometric Properties of the 9-Item Shared Decision-Making Questionnaire (SDM-Q-9): Validation of the Italian Version in a Large Psychiatric Clinical Sample

OBJECTIVE

The nine-item Shared Decision-Making Questionnaire (SDM-Q-9) is one of the most frequently used tools for assessing patients' involvement in medical decision-making, but so far, it not been validated in Italian. We aimed to validate the Italian version of the SDM-Q-9 in a clinical sample of patients suffering from major psychiatric disorders.

METHOD

We involved 307 consecutive patients affected by major psychiatric disorders (including schizophrenia spectrum disorders, affective disorders and eating disorders) in a real-world outpatient clinical setting. Confirmatory Factor Analysis (CFA) was conducted to examine the latent structure of the SDM-Q-9. Cronbach's alpha and correlations between the SDM-Q-9 and the Observing Patient Involvement (OPTION) scale were calculated to measure internal consistency and convergent validity respectively.

RESULTS

The final sample was made up of 289 participants (response rate 94.1%) who completed the assessment. CFA confirmed the unidimensional structure as in the original version (χ2/df= 1.69; CFI= 0.98; TLI= 0.97; RMSEA= 0.05; SRMR= 0.08). Internal consistency of the total scale was Cronbach's α = .86. Regarding construct validity, we found several correlations between the SDM-Q-9 and OPTION scale.

CONCLUSIONS

Our findings suggest that the Italian version of SDM-Q-9 performs well if compared to other languages validated versions, so it is a useful patient-centred measure to assess the involvement in medical decision-making (SDM) of patients from clinical samples from the Italian-speaking population.

Where are we in shared decision-making in Italy? A brief updated review

The aim of this paper is to provide an overview of the current state of the art concerning patient-centred care (PCC), shared decision-making (SDM), and patient involvement in health care in Italy, by updating the previous versions of the review. In the past 5 years some progress has been made towards a higher involvement of patients in their health care and patient-centredness into the national health care system. The updated scoping literature search focused on articles reporting primary data collected in Italy and showed a great increase in the number of publications. Nonetheless, the research efforts are still relatively sporadic compared to other countries especially as for evaluations of interventions and, most notably, they are not driven by a consistent effort to promote SDM and PCC in clinical practice.

The Chinese version of OPTION scale: Is it reliable on measuring the shared decision-making among preoperative conversations

OBJECTIVE

To test the reliability of the Chinese version of the OPTION¹² (OPTION¹²-C) scale; and to evaluate the level of shared decision-making (SDM) in the preoperative conversations for high-risk procedures by using the OPTION¹²-C.

METHODS

Two hundred and ninety-seven conversations were rated. Cronbach's alpha, Pearson's correlation coefficient and intraclass correlation coefficient (ICC) were used to assess the reliability of the OPTION¹²-C. Mean and median were applied to evaluate the scores.

RESULTS

The Cronbach's alpha was 0.603. The Pearson's correlation coefficient of the sub-items ranged from 0.002 to 0.595; the inter-rater ICC was 0.992. The mean and median of the total scores were 9.61 ( ± 3.583) and 9 respectively. 430 family members appeared in the conversations.

CONCLUSION

The reliability of the OPTION¹²-C was acceptable. The SDM behaviors of doctors were only scored at or close to the minimal skill level. High level of family involvement demonstrated the Chinese culture of family- centeredness.

PRACTICE IMPLICATIONS

The OPTION¹²-C was proved to be applicable for testing the extent of SDM. The low level of SDM indicates a need to improve Chinese doctors' communication skills.

Shared decision-making among non-physician healthcare professionals: Enhancing patient involvement in women's reproductive health in community healthcare settings

OBJECTIVE

Shared decision-making (SDM) is an important approach to patient-centered care in women's reproductive healthcare. This study explored SDM experiences and perceptions among non-physician healthcare professionals.

METHODS

We completed 20 key-informant interviews with non-physician healthcare professionals (i.e., NP, RN, CNM, doula, pharmacist, chiropractor) living in Indiana (September 2019-May 2020) who provided community-based women's reproductive healthcare. Interviews were audio-recorded, transcribed, and analyzed using an expanded grounded theory framework. Constant comparative analysis identified emergent themes.

RESULTS

Professionals noted community-based healthcare required contextualized decision-making approaches. Results identified listening, decisional ownership, and engagement strategies that enhanced SDM involvement. Findings suggested outcome-oriented SDM concepts, including decisional ownership and investigative listening to enhance SDM. Providers redefined 'challenging' patients as engaged in their healthcare and discussed ways SDM improved healthcare experience beyond one visit.

CONCLUSION

Findings offered insight into actionable and practical strategies for enhancing SDM in community-based women's reproductive healthcare. The findings offer strategies to improve SDM by addressing barriers and facilitators among professionals. This extends SDM beyond the patient-physician dyad and supports broader application of SDM.

PRACTICE IMPLICATIONS

Incorporating professionals' experiences into SDM concepts can enhance SDM in community-based women's healthcare practice, offering opportunities to support a culture of SDM across settings.

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

OBJECTIVES

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

DESIGN

A cross-sectional, observational study.

SETTING

NHS teaching hospital.

PARTICIPANTS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

The OPTION Scale: Measuring Patients' Perceptions of Shared Decision-Making in the Kingdom of Saudi Arabia

Background

Involving patients in the decision-making process is now widely accepted as appropriate and ethical during consultations, particularly when several options are available. The aim of this study is to measure the patients’ perceptions of shared decision-making practices during clinical encounters in Saudi Arabia.

Methods

This study employs a quantitative cross-sectional design. The OPTION scale was translated to Arabic. The questionnaire’s content validity was assessed using an expert panel review. The questionnaire was then administered to 291 participants through online recruitment.

Results

Participants reported positive perceptions of shared decision-making practices in Saudi Arabia. The lowest perceived shared decision-making scores were from patients who visited the internal medicine department (f = 2.163, P = 0.009). Participants who received care from female physicians reported significantly higher levels of involvement in the shared decision-making process compared to male physicians (t = −2.732, P = 0.007). Although the majority of the participants in the study were from Eastern Province, this province documented the lowest mean perceived decision-making score by the patients compared to other provinces within Saudi Arabia (f = 3.613, P = 0.007). Female participants in the study had a higher shared decision-making score than the male participants (t = −3.644, P < 0.0001).

Conclusion

Generally, the study results confirmed that shared decision-making in the Saudi health system includes significant patient involvement. Interventions that enhance the culture of shared decision-making in Saudi Arabia are necessary to ensure better adherence to treatment plans and thus better health outcomes.

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.

Do Shared Decision-Making Measures Reflect Key Elements of Shared Decision Making? A Content Review of Coding Schemes

Background. There is a growing need for valid shared decision-making (SDM) measures. We aimed to determine whether the items of extant SDM observer-based coding schemes assess the 4 key elements of SDM. Methods. Items of SDM coding schemes were extracted and categorized. Except for the 4 key elements of SDM (fostering choice awareness, informing about options, discussing patient preferences, and making a decision), (sub)categories were created inductively. Two researchers categorized items independently and in duplicate. Results. Five of 12 coding schemes assessed all 4 SDM elements. Seven schemes did not measure “fostering choice awareness,” and 3 did not measure “discussing patient preferences.” Seventy of 194 items (36%) could not be classified into one of the key SDM elements. Items assessing key SDM elements most often assessed “informing about options” (n = 57/124, 46%). Conclusion. Extant SDM coding schemes often do not assess all key SDM elements and have a strong focus on information provision while other crucial elements of SDM are underrepresented. Caution is therefore needed in reporting and interpreting the resulting SDM scores.

[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.

Study protocol of a randomized controlled trial on two new dissemination strategies for a brief, shared-decision-making (SDM) training for oncologists: web-based interactive SDM online-training versus individualized context-based SDM face-to-face training

BACKGROUND

Oncological patients often feel left out of important treatment decisions. However, when physicians engage them in shared decision-making (SDM), patients benefit in many ways and the situation is improved. SDM can effectively be taught to physicians, but participation barriers for SDM physician group trainings are high, making it hard to convince physicians to participate. With this in mind, we aim to develop and evaluate two new dissemination strategies for a brief, SDM training program based upon a proven SDM group-training concept: an individualized context-based SDM face-to-face training (IG I) and a web-based interactive SDM online training (IG II). We aim to analyze which improvements can be achieved by IG I and II compared to a control group (CG) in physician SDM competence and performance as well as the impact on the physician-patient relationship. Furthermore, we analyze differences in satisfaction concerning the two dissemination strategies by means of a training evaluation.

METHODS/DESIGN

We examine - based on a three-armed randomized controlled trial (IG I, IG II, CG) - the effectiveness of two new dissemination strategies for a SDM training program compared to a CG receiving no SDM training (voluntary access to SDM training as an incentive for participation after completion of the study). We aim to include 162 physicians randomized to one of the three arms. There will be two assessment points in time (before intervention: T₀ and post-training: T₁). The main outcome is the SDM competence of physicians as measured by an established observational assessment rating system (OPTION-12) by means of consultations with Standardized Patients. Standardized Patients are individuals trained to act as "real" patients. Secondary outcome measures are the SDM performance (SDM-Q-9) and the Questionnaire on the Quality of Physician-Patient-Interaction (QQPPI) both rated by Standardized Patients as well as the physicians' training evaluation.

DISCUSSION

This trial will assess the effectiveness and acceptability of two new dissemination strategies for a brief, SDM training program for physicians. Opportunities and challenges regarding implementation in daily routines will be discussed.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT02674360 . Prospectively registered on 4 February 2016.

Essential ingredients of engagement when working alongside people after their first episode of psychosis: A qualitative meta-synthesis

AIM

Early intervention services (EISs) for first-episode psychosis (FEP) have been established internationally, however, service disengagement is a recurrent concern resulting in unplanned treatment cessation. The implications of this are far-reaching due to the financial and personal costs associated with untreated symptoms. The aim of this meta-synthesis was to collect, interpret and synthesize qualitative research about how engagement is experienced within EISs for FEP.

METHODS

A systematic search was conducted in PsycINFO, Ovid MEDLINE and Ovid Emcare from date of conception to November 2016. Following initial screening, 91 abstracts and 13 full texts were reviewed for eligibility. Nine studies were then critically appraised using the CASP tool for qualitative studies, data were systematically extracted and results were synthesized using constant comparison and reciprocal translational analysis.

RESULTS

Nine qualitative studies explored engagement with EISs, from the perspectives of service users and their caregivers. No studies were found from the perspectives of clinicians or services. All 9 studies employed an inductive methodology, within an interpretivist epistemology. Five main themes were identified: experiences of finding help; factors promoting engagement; the therapeutic relationship; the role of caregivers in supporting engagement; and factors impacting ongoing engagement.

CONCLUSIONS

There is a critical need to stimulate discussion around this multifaceted phenomenon, including a continued focus on the roles of key stakeholders and clinical models that may further facilitate collaboration in treatment plans and recovery.

Assessing Shared Decision-Making Clinical Behaviors Among Genetic Counsellors

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Spot the difference: shared decision-making and supported decision-making in mental health

Respecting a person’s choices about the mental health services they do or do not use is a mark of quality support, and is often pursued for moral reasons, as a rights imperative and to improve outcomes. Yet, providing information and assistance for people making decisions about the mental health services can be a complex process, and has been approached in various ways. Two prominent approaches to this end are ‘shared decision-making’ and ‘supported decision-making’. This article considers each of these approaches, discussing points of similarity and difference and considering how the two might complement one another. By exploring the contribution that each approach can make, we conclude by proposing how future application of these approaches can account for the broader context of decisions, including support for ongoing decision-making; the multitude of service settings where decision-making occurs; and the diversity in supportive practices required to promote active involvement.

Right choice, right time: Evaluation of an online decision aid for youth depression

BACKGROUND

Appropriate treatment for youth depression is an important public health priority. Shared decision making has been recommended, yet no decision aids exist to facilitate this.

OBJECTIVES

The main objective of this study was to evaluate an online decision aid for youth depression.

DESIGN

An uncontrolled cohort study with pre-decision, immediately post-decision and follow-up measurements.

SETTING AND PARTICIPANTS

Young people (n=66) aged 12-25 years with mild, mild-moderate or moderate-severe depression were recruited from two enhanced primary care services.

INTERVENTION

Online decision aid with evidence communication, preference elicitation and decision support components.

MAIN OUTCOME MEASURES

The main outcome measures were ability to make a decision; whether the decision was in line with clinical practice guidelines, personal preferences and values; decisional conflict; perceived involvement; satisfaction with decision; adherence; and depression scores at follow-up.

RESULTS

After using the decision aid, clients were more likely to make a decision in line with guideline recommendations (93% vs 70%; P=.004), were more able to make a decision (97% vs 79%; P=.022), had significantly reduced decisional conflict (17.8 points lower (95% CI: 13.3-22.9 points lower) on the Decisional Conflict Scale (range 0-100)) and felt involved and satisfied with their decision. At follow-up, clients had significantly reduced depression symptoms (2.7 points lower (95% CI: 1.3-4.0 points lower) on the Patient Health Questionnaire nine-item scale (range 0-27)) and were adherent to 88% (95% CI: 82%-94%) of treatment courses.

DISCUSSION AND CONCLUSIONS

A decision aid for youth depression can help ensure evidence-based, client-centred care, promoting collaboration in this often difficult to engage population.

Exploring the relationships between participatory decision-making, visit duration, and general practitioners' provision of argumentation to support their medical advice: results from a content analysis

OBJECTIVE

General practitioners' medical recommendations are not always accepted by their patients. As patients bring their own beliefs, knowledge, and preferences to the medical encounter, their opinions concerning diagnosis and treatment may deviate from their doctors'. Aiming to convince their patients of the acceptability of their advice, doctors can advance arguments. Few quantitative studies have been conducted focusing on general practitioners' provision of argumentation and little is known about the relationship between the use of argumentation and characteristics of the medical visit, such as (participatory) decision-making and visit duration. This study seeks to explore these relationships.

METHODS

An observational study of seventy, randomly drawn videos of general practice consultations was conducted. A theory-based codebook was developed. Two independent coders analyzed doctors' provision of argumentation, their decision-making style, and the duration of each visit.

RESULTS

General practitioners' provision of argumentation was found to be associated with lengthier visits and a more participatory decision-making style. In addition, visit duration and participatory decision-making appeared associated.

CONCLUSION

These results suggest that the use of argumentation may contribute toward achieving patient-centered care through communication.

PRACTICE IMPLICATIONS

As a result, the findings underscore the potential relevance of developing courses focusing on doctors' argumentation skills.

Making decisions about treatment for young people diagnosed with depressive disorders: a qualitative study of clinicians' experiences

BACKGROUND

The imperative to provide effective treatment for young people diagnosed with depressive disorders is complicated by several factors including the unclear effectiveness of treatment options. Within this context, little is known about how treatment decisions are made for this population.

METHODS

In order to explore the experiences and beliefs of clinicians about treatment decision making for this population, semi-structured, qualitative interviews were conducted with 22 psychiatrists, general practitioners and allied health professionals from health care settings including specialist mental health services and primary health care. Interviews were audio taped, transcribed verbatim and analysed using thematic analysis.

RESULTS

Clinicians largely reported and endorsed a collaborative model of treatment decision making for youth depression, although several exceptions to this approach were also described (e.g., when risk issues were present), highlighting a need to adapt the decision-making style to the characteristics and needs of the client. A differentiation was made between the decision-making processes (e.g., sharing of information) and who makes the decision. Caregiver involvement was seen as optional, especially in situations where no caregivers were involved, but ideal and useful if the caregivers were supportive. Gaps between the type and amount of information clinicians wanted to give their clients and what they actually gave them were reported (e.g., having fact sheets on hand). A broad range of barriers to involving clients and caregivers in decision-making processes were described relating to four levels (client and caregiver, clinician, service and broader levels) and suggestions were given to help overcome these barriers, including up-to-date, accessible and relevant information.

CONCLUSIONS

The current data support a collaborative model of treatment decision making for youth depression which: (1) focuses on the decision-making processes rather than who actually makes the decision; (2) is flexible to the individual needs and characteristics of the client; and (3) where caregiver involvement is optional. Shared decision making interventions and the use of decision aids should be considered for this area.

INvolvement of breast CAncer patients during oncological consultations: a multicentre randomised controlled trial--the INCA study protocol

INTRODUCTION

Studies on patient involvement show that physicians make few attempts to involve their patients who ask few questions if not facilitated. On the other hand, the patients who participate in the decision-making process show greater treatment adherence and have better health outcomes. Different methods to encourage the active participation during oncological consultation have been described; however, similar studies in Italy are lacking. The aims of the present study are to (1) assess the effects of a preconsultation intervention to increase the involvement of breast cancer patients during the consultation, and (2) explore the role of the attending companions in the information exchange during consultation.

METHODS AND ANALYSIS

All female patients with breast cancer who attend the Oncology Out-patient Services for the first time will provide an informed consent to participate in the study. They are randomly assigned to the intervention or to the control group. The intervention consists of the presentation of a list of relevant illness-related questions, called a question prompt sheet. The primary outcome measure of the efficacy of the intervention is the number of questions asked by patients during the consultation. Secondary outcomes are the involvement of the patient by the oncologist; the patient's perceived achievement of her information needs; the patient's satisfaction and ability to cope; the quality of the doctor-patient relationship in terms of patient-centeredness; and the number of questions asked by the patient's companions and their involvement during the consultation. All outcome measures are supposed to significantly increase in the intervention group.

ETHICS AND DISSEMINATION

The study was approved by the local Ethics Committee of the Hospital Trust of Verona. Study findings will be disseminated through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01510964.

Decision-making in multiple sclerosis consultations in Italy: third observer and patient assessments

OBJECTIVE

To assess decision-making in multiple sclerosis (MS) from third observer and patient perspectives.

METHOD

Audio recordings of first-ever consultations with a participating physician (88 outpatients, 10 physicians) at four tertiary MS care clinics in Italy, were rated by a third observer using the Observing Patient Involvement in Shared Decision Making (OPTION) and by patients using the Perceived Involvement in Care Scale (PICS).

RESULTS

Mean patient age was 37.5, 66% were women, 72% had MS, and 28% had possible MS or other disease. Mean PICS subscale scores (range 0 poor, 100 best possible) were 71.9 (SD 24.3) for "physician facilitation" (PICS-F); 74.6 (SD 22.9) for "patient information exchange" (PICS-I); and only 22.5 (SD 16.2) for "patient decision making" (PICS-DM). Mean OPTION total score (0 poor, 100 best possible) was 29.6 (SD 10.3). Poorest OPTION scores were found for items assessing "preferred patient approach to receiving information" and "preferred patient level of involvement." Highest scores were for "clinician drawing attention to identified problem", "indicating need for decision making," and "need to review the decision." Consultation time, woman physician, patient-physician gender concordance and PICS-F were associated with higher OPTION total score; older physician and second opinion consultation were associated with lower OPTION score.

CONCLUSIONS

In line with findings in other settings, our third observer findings indicated limited patient involvement abilities of MS physicians during first consultations. Patient perceptions of physician skills were better than third observers', although they correlated. Consultations with women physicians, and younger physicians, were associated with higher third observer and patient-based scores. Our findings reveal a need to empower Italian MS physicians with better communication and shared decision-making skills, and show in particular that attention to MS patient preferences for reception of information and involvement in health decisions, need to be improved.

The perception of shared medical decision making of expert and lay people: effects of observing a movie clip depicting a medical consultation

OBJECTIVE

To test for differences between experts and lay people in assessment of the degree to which a doctor engaged in a shared decision making (SDM) with a patient using the OPTION scale and a movie clip as stimulus material.

METHODS

A segment of the movie 'Wit', depicting the communication of the diagnosis and the therapy proposed of a cancer, was shown to (a) university students with no knowledge about doctor-patient communication; (b) nurses working in medicine departments; (c) advanced medical students; (d) hospital physicians. The participants were asked to complete the OPTION scale which measures the extent to which physicians involve patients in medical decisions. An analysis of variance was used to compare OPTION scores across the four groups and to compare males and females.

RESULTS

Being female [F(1,190)=11.9; p<.001] and being familiar with medical issues [F(3,190)=11.09; p<.001] were both significantly associated with a negative evaluations of the doctor's ability to involve the patient in the SDM.

CONCLUSION

Lay people and males (including male experts), are less demanding regarding SDM abilities.

PRACTICE IMPLICATIONS

A more systematic use of videos and the OPTION scale as validated outcome measure could be helpful educational strategy for the teaching of SDM.

Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument

BACKGROUND

We have no clear overview of the extent to which health-care providers involve patients in the decision-making process during consultations. The Observing Patient Involvement in Decision Making instrument (OPTION) was designed to assess this.

OBJECTIVE

To systematically review studies that used the OPTION instrument to observe the extent to which health-care providers involve patients in decision making across a range of clinical contexts, including different health professions and lengths of consultation.

SEARCH STRATEGY

We conducted online literature searches in multiple databases (2001-12) and gathered further data through networking.

INCLUSION CRITERIA

(i) OPTION scores as reported outcomes and (ii) health-care providers and patients as study participants. For analysis, we only included studies using the revised scale.

DATA EXTRACTION

Extracted data included: (i) study and participant characteristics and (ii) OPTION outcomes (scores, statistical associations and reported psychometric results). We also assessed the quality of OPTION outcomes reporting.

MAIN RESULTS

We found 33 eligible studies, 29 of which used the revised scale. Overall, we found low levels of patient-involving behaviours: in cases where no intervention was used to implement shared decision making (SDM), the mean OPTION score was 23 ± 14 (0-100 scale). When assessed, the variables most consistently associated with higher OPTION scores were interventions to implement SDM (n = 8/9) and duration of consultations (n = 8/15).

CONCLUSIONS

Whatever the clinical context, few health-care providers consistently attempt to facilitate patient involvement, and even fewer adjust care to patient preferences. However, both SDM interventions and longer consultations could improve this.

The OPTION scale for the assessment of shared decision making (SDM): methodological issues

BACKGROUND

Promoting patient involvement in medical decision making has become a desirable goal in medical consultations. Reliable and valid measures are necessary to evaluate interventions designed to promote shared decision making and to understand determinants and associations. The OPTION ("observing patient involvement") scale is the most prominent observation instrument for assessing the extent to which clinicians actively involve patients in decision making.

OBJECTIVE

This paper discusses psychometric and methodological characteristics of the OPTION scale.

RESULTS

There is little support for the purported unidimensional structure. Although reliabilities are acceptable, results are highly heterogeneous across studies. There is also little evidence concerning validity. In particular, studies mainly failed to support convergent validity. Additional issues pertain to lack of item independence, restriction of range, and failure to consider dyadic aspects.

CONCLUSIONS

Given these findings, a number of methodological and conceptual issues still need to be addressed for the effective measurement of patient involvement. Directions for future research are discussed.

Quality of decision making is related to decision outcome for patients with cardiac arrhythmia

OBJECTIVE

Clinical consultations with patients should be informed by the evidence-based and involve shared decision making (SDM). We aimed to determine the delivery of SDM by clinicians with patients referred for invasive treatment of cardiac electrical disease and to establish whether decisions made corresponded with patient and referring physician expectations.

METHODS

Forty-nine outpatient consultations with two consultant cardiologists in one large tertiary centre were audio-recorded. Demographic data, diagnosis, reasons for referral and decision reached were compared directly with patient and referring physician expectations. The OPTION instrument was used to measure SDM. Patient expectations and satisfaction were elicited.

RESULTS

Quality of SDM was good (mean OPTION score 49%) and there was broad patient satisfaction. While all patients were suitable for invasive treatment, and the majority (80%, n=39) had been explicitly referred for it, only 59% (n=29) opted to proceed. Consultation quality with respect to SDM was significantly greater for patients choosing a less invasive option.

CONCLUSION

These consultations often change expected management. Where decision making in the consultation is of higher quality, patients were more likely to change to a less invasive option.

PRACTICE IMPLICATIONS

Clinicians performing invasive cardiac treatment should be able to demonstrate high quality decision making.

Toward shared decision making: using the OPTION scale to analyze resident-patient consultations in family medicine

PURPOSE

Do residents in family medicine practice share decision making with patients during consultations? This study used a validated scale to score family medicine residents' shared decision-making (SDM) skills in primary care consultations and to determine whether residents' demographic characteristics were correlated with their scores.

METHOD

Between January 2009 and April 2010 at two Canadian academic health centers, the authors recruited unique dyads of patients consulting in primary care and family medicine residents. They recorded, transcribed, and assessed consultations using the Observing Patient Involvement in Decision Making (OPTION) scale, which measures 12 SDM-specific behaviors on a scale of 0% to 100% (high score = better SDM). They calculated descriptive and inferential statistics for the scores.

RESULTS

From 212 eligible residents, the authors recruited 152 unique patient-resident dyads (participation rate = 75%): 68 dyads from 13 clinics in London, Ontario, and 84 from six family medicine units in Quebec City, Quebec. The mean global OPTION score was 24% ± 8%; the mean score for each of the 12 items ranged from 4% to 37%. Five of the 12 behaviors obtained a mean score below "a minimal attempt is made to exhibit the behavior" (i.e., <25%). There was a positive correlation between the score and the duration of the consultation (r = 0.24, P = .003), with longer consultations producing higher scores.

CONCLUSIONS

Participating family medicine residents have not integrated SDM behaviors, which may also pertain to residencies elsewhere. Interventions are required to foster family medicine residents' practice of SDM.

Reliability and validity of the German version of the OPTION scale

OBJECTIVE

To examine the psychometric properties of the German version of the 'observing patient involvement' scale (OPTION) by analysing video recordings of primary care consultations dealing with counselling in cardiovascular prevention.

DESIGN

Cross-sectional assessment of physician-patient interaction by two rater pairs and two experts in shared decision making (SDM).

SETTING

Primary care.

PARTICIPANTS

Fifteen general practitioners provided 40 videographed consultations.

MEASUREMENTS

Video ratings using the OPTION instrument.

RESULTS

Mean differences on item level between the four raters were quite large. Most items were skewed towards minimal levels of shared decision making. Measures of inter-rater association showed low to moderate associations on item level and high associations on total score level. Cronbach-α of the whole scale based on the data of all four raters is 0.90 and therefore on a high level. An oblique factor analysis revealed two factors, but both factors were highly correlated so we can confirm a one-dimensional structure of the instrument. ROC analyses between the rater total scores and dichotomized expert ratings (SDM yes/no) revealed a good discriminability of the OPTION total score. Physicians with more expertise in shared decision making received higher OPTION ratings.

CONCLUSIONS

The German version of the OPTION scale is reliable at total score level. Some items need further revision in the direction of more concrete, observable behaviour. We were only able to perform a quasi-validation of the scale. Validity issues need further research efforts.

How much do family physicians involve pregnant women in decisions about prenatal screening for Down syndrome?

OBJECTIVE

To assess the extent to which family physicians (FPs) involve women in decisions about prenatal screening for Down syndrome.

METHODS

Based on transcripts of consultations between 41 FPs and 128 women, two raters independently assessed clinician's efforts to involve women in decisions about prenatal screening for Down syndrome using the French-language version of OPTION. Descriptive statistics of OPTION scores were calculated. Construct validity was assessed by performing a principal factor analysis and by measuring association with consultation duration and FPs sociodemograhics. Internal consistency was assessed with Cronbach's alpha and inter-rater reliability with the intraclass correlation coefficient.

RESULTS

The overall mean OPTION score was low: 19 +/- 7 (range = 0 [no involvement] to 100 [high involvement]). One factor accounted for 80% of the variance. Both internal consistency and inter-rater reliability were very good (Cronbach's alpha = 0.73; ICC = 0.76). OPTION scores were lower for residents than for licensed FPs (17 +/- 5 vs 21 +/- 4; p = 0.02) and were positively associated with duration of consultation (r = 0.56; p < 0.001).

CONCLUSION

Based on the French-language version of OPTION, which showed satisfactory psychometric properties, FPs studied put minimal efforts to involve women in decisions about prenatal screening for Down syndrome.

The role of physician-patient communication in promoting patient-participatory decision making

CONTEXT

Involving patients in decision making (DM) is being advocated in clinical practice. For it to be operational, some behavioural models have been put forward. Yet, their suitability and implementation in primary care are controversial.

OBJECTIVE

To illustrate: (i) some of the strategies general practitioners use to involve patients in DM and (ii) a type of patient involvement in the context of primary care based on the appropriate use of general communication skills along the physician-patient interaction to promote participation without an extensive exhibition of options.

STRATEGY

Analysis of two real situations of family medicine practice.

CONCLUSION

The quality of the process of involving patients in DM depends mainly on the professional's communicative effort to achieve understanding and rapport rather than on an extensive discussion of possibilities or their prioritization.

[Patient involvement in decision making in primary care clinics: development of a measuring tool]

OBJECTIVES

This work aims to explore to what extent Spanish primary care providers involve patients in decisions and describe the development of a suggested tool for assessing patient involvement in these settings.

DESIGN

Cross-sectional, development of a measurement tool.

SETTING

Primary care clinics.

PARTICIPANTS

Family doctors and residents.

INTERVENTIONS

Based on a review of the literature and the opinions of primary care doctors, a selection was made of items from a previous scale used to measure general communication skills (CICAA-Patient Centred) and new specific items were added to this to measure involvement.

MAIN MEASUREMENTS

The involvement of patients in decision-making was evaluated initially with this tool in 31 different clinical visits and the scale was then reformulated. A pool of 161 interviews was used to complete the process. Some psychometric properties (reliability and internal consistency) were estimated for the different samples and stages of the process.

RESULTS

Some degree of patient involvement was found in just 31 visits. Despite this, only in 18 of these (58%) was there some involvement in a discussion about more than one treatment option. The Cohen's kappa values of the CICAA-Decision scale were between 0.48 and 0.94. Cronbach's alpha was 0.60/0.51. The global Intra-class correlation coefficient was 0.96.

CONCLUSIONS

The levels of patient involvement were lower than expected. A simple question, such as that defined by one item in particular, and the CICAA-D scale, in general, could be useful to assess patient involvement in decision making in primary care.

Nurses' perceptions of factors influencing patient decision support for place of care at the end of life

Although patients have more choices about where to receive care as death approaches, they often need help with decision making. This study identified factors that influence nurses' provision of decision support. A total of 22 nurses, from 3 health networks, participated in semistructured interviews. Overall, nurses held favorable attitudes toward providing decision support for place of care at end of life. Overlap between other professionals' roles and nurses' clinical experience affected nurses' decision support behaviors. Although nurses considered decision support to be part of patient-centered care, they report a lack of skills, confidence, and tools to help them provide it. These findings confirm the need to develop practical postlicensure education strategies and ways to embed patient decision support tools into systems of care.

Audit and feedback using the brief Decision Support Analysis Tool (DSAT-10) to evaluate nurse-standardized patient encounters

OBJECTIVE

To evaluate the brief Decision Support Analysis Tool (DSAT-10) for auditing the quality of nurse-standardized patient encounters, structuring feedback for nurses, and testing instrument reliability.

METHODS

A systematic process was used to develop standardized patient scenarios, pilot-test scenarios, calibrate DSAT-10 coders, analyze taped telephone encounters using DSAT-10, and provide feedback. Inter-rater reliability was calculated using coder agreement, kappa, and intra-class correlation coefficients.

RESULTS

Six scenarios portrayed patients' decisional uncertainty from either: pressure from others (n=2), unclear values (n=2), or inadequate information (n=2). Scenarios were easy to use over the telephone, produced realistic role performance, and were practical for audio-recording interactions. DSAT-10 analysis of 76 nurse-standardized patient encounters revealed nurses' strengths (e.g., information provision) and their limitations (e.g., lack of discussion of values and/or support needs). Scores discriminated between trained and untrained nurses. The kappa coefficient over all items was 0.55 (95% CI: 0.49, 0.61) with higher agreement for encounters involving trained nurses (0.62; 95% CI: 0.43, 0.80).

CONCLUSION

Auditing nurse-standardized patient encounters using DSAT-10 and providing feedback to nurses was feasible. Although DSAT-10 items had adequate inter-rater reliability and discriminated between trained/untrained nurses, some items were problematic.

PRACTICE IMPLICATIONS

Providing feedback on nurse encounters with standardized patients experiencing uncertainty has the potential to enhance nurses' decision support skills.

Involving patients in decisions during psychiatric consultations

BACKGROUND

Patient involvement in the decision-making process is a key element for good clinical practice. Few data are available on patient involvement in psychiatry.

AIMS

To assess in a psychiatric out-patient context how psychiatrists involve patients in therapeutic decisions and to determine the extent to which patient and psychiatrist characteristics contribute to patient involvement.

METHOD

Eighty transcripts from audiotaped first out-patient consultations, conducted by 16 psychiatrists, were rated with the OPTION (observing patient involvement) scale. Interrater reliability indices were obtained for 30 randomly selected interviews. Associations between OPTION scores and some clinical and socio-demographic variables were tested using t-test, ANOVA and Pearson's correlation coefficient where appropriate. The distribution of scores for each psychiatrist was assessed by intracluster correlation coefficients.

RESULTS

Interrater reliability and internal consistency of the OPTION scale in the psychiatric setting were satisfactory. The total score and the ratings for the single OPTION items showed a skewed distribution, with a prevalence of scores in the low range of abilities, corresponding to minimal attempts to involve patients or a minimal skill level.

CONCLUSIONS

The OPTION scale proves to be a reliable instrument to assess patient involvement in a psychiatric setting. Psychiatrists showed poor patient involvement abilities parallel to previous findings in psychiatry and primary care. They need to be encouraged to share treatment decisions with their patients and to apply patient involvement skills. Further research is needed to establish which patient variables and clinical settings in psychiatry are more amenable to shared decisions, and how participation of psychiatric patients in treatment decisions will affect the outcome.

Patient and citizen participation in health care decisions in Italy

In recent years there has been a growing recognition in Western healthcare systems of the importance of considering preferences of patients and the public in tailoring health services and treatment plans. The active collaboration between doctor and patient has recently been encouraged through the shared decision-making model. Aim of the present contribution is to describe the current state of patient and public participation in healthcare in Italy. First, we will briefly outline the organization of the Italian National Health Service; second, we will describe the governmental and institutional initiatives regarding participation; third, some examples of associations and initiatives promoting patient participation will be provided; forth, we will report on research projects on patient participation published in peer-reviewed journals; and finally, we will provide some examples on training activities promoting patient participation. The Italian National Health Plan and many regional and local health authorities in Italy explicitly recognize the importance of patient/citizen participation in healthcare decisions at the macro, meso and micro level of decision-making. However, application of a shared model is still at an early stage in Italy. The reported experiences have yielded positive results and have shown that particular attention should be dedicated to more disadvantaged subgroups of the population, involving patient organisations, enhancing patient/citizen knowledge and adopting approaches that take the specific context into account.