Working with interpreters: The challenges of introducing Option Grid patient decision aids

Envisioning Shared Decision Making: A Reflection for the Next Decade

Despite the evolving evidence in favor of shared decision making (SDM) and of decades-long calls for its adoption, SDM remains uncommon in routine care. Reflecting on this lack of progress, we sought to reimagine the future of SDM and the path to take us there. In late 2017, a multidisciplinary and international group of six researchers were challenged by a senior SDM scholar to envision the future and, based on a provocatively critical view of the present, to write letters to themselves from the year 2028. Letters were exchanged and discussed electronically. The group then met in person to discuss the letters. Since the letters painted a dystopian picture, they triggered questions about the nature of SDM, who should benefit from SDM, how to measure its contribution to care, and what new ways can be invented to design and test interventions to implement SDM in routine care. Through contrasting the purposefully generated dystopias with an ideal future for SDM, we generated reflections on a research agenda for SDM. These reflections hinged on recognizing SDM's contributing to care, that is, as a way to advance the problematic human situation of patients. These focused on three distinct yet complimentary contributors to SDM: 1) the process of making decisions, 2) humanistic communication, and 3) fit-to-care of the resulting decision. The group then concluded that to move SDM from envisioned to routine practice, and to ensure it reaches all, particularly persons rendered vulnerable by current forms of health care, a substantial investment in implementation research is necessary. Perhaps the discussion of these reflections can contribute to a path forward that will improve the likelihood of the future we dream for SDM.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

PRACTICAL IMPLICATIONS

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

"What would you recommend doctor?"-Discourse analysis of a moment of dissonance when sharing decisions in clinical consultations

BACKGROUND

Proven benefits of Shared Decision Making (SDM) include improved patient knowledge, involvement and confidence in making decisions. Although widely advocated in policy, SDM is still not widely implemented in practice. A common patient-reported barrier is feeling that "doctor knows best"; thus, patients often defer decisions to the clinician.

OBJECTIVE

To examine the nature of the discourse when patients ask clinicians for a treatment recommendation during consultations when treatment decisions are being shared and to examine clinicians' strategies used in response.

DESIGN, SETTING AND PARTICIPANTS

Theme-orientated discourse analysis was performed on eight audio-recordings of breast cancer diagnostic consultations in which patients or their partners attempted to defer treatment decisions to the clinician. Clinicians were trained in SDM.

RESULTS

Tension was evident in a number of consultations when treatment recommendations were requested. Clinicians responded to recommendation requests by explaining why the decision was being shared (personal nature of the decision, individual preferences and equivalent survival outcomes of treatment options). There was only one instance where a clinician gave a treatment recommendation.

DISCUSSION AND CONCLUSIONS

Strategies for clinicians to facilitate SDM when patients seem to defer decisional responsibility include being clear about why the decision is being shared, acknowledging that this is difficult and making patients feel supported. When patients seek guidance, clinicians can provide a recommendation if grounded in an understanding of the patient's values.

Patient involvement and institutional logics: A discussion paper

The research into patient involvement is seldom concerned with the significance of cultural and structural factors. In this discussion paper, we illustrate our considerations on some of the challenges in implementing the ideal of patient involvement by showing how such factors take part in shaping the ways in which the intentions to involve patients are converted to practical interventions. The aim was to contribute to the approach dealing with contextual and structural factors of significance for patient involvement. With the idea of "institutional logics," borrowed from the Danish scholar, Erik Riiskjaer, we first demonstrate, with examples from our own research, how patient involvement is interpreted differently within the different logics. Then, we show how the different interpretations of patient involvement meet and conflict in mutual competition as the ideals are sought to be converted to practical interventions. At last, we argue that an adequate theoretical model for the development in the future health care system should be expanded with a "patient logic."

Not Missing the Opportunity: Improving Depression Screening and Follow-Up in a Multicultural Community

BACKGROUND

Screening for depression and documenting follow-up is a National Quality Forum-endorsed measure. Yet only seven states report depression screening and follow-up, making it the fourth-least-reported measure on the Medicaid Adult Core Set. In 2016 a multicultural health center found that only 9.1% of clients were screened and followed up for depression. This quality improvement project was conducted to increase the efficacy of Screening, Brief Intervention, and Referral to Treatment (SBIRT) for depression to 75% for screen-positive clients.

METHODS

Four Plan-Do-Study-Act (PDSA) cycles in a 90-day period focused on depression screening, patient engagement, population health management, and team building were used. The package of interventions-use of written standardized Patient Health Questionnaire (PHQ) screening tools in six languages, the Option Grid™ for clients with positive PHQ screens, a "right care" tracking log for those clients, and team meetings and in-services to support capacity building-were operationalized using a point-of-care notebook that created a physical reminder and trigger for the use of the intervention tools. Surveys, charts, and registry data were analyzed to evaluate the population health impact of the interventions.

RESULTS

Provision of evidence-based care increased to 71.4%, and adherence to follow-up increased from 33.3% to 60.0%. Screening in the client's preferred language increased the rate to 85.2%, identifying a positive PHQ incidence of 45.5%.

CONCLUSION

Rapid-cycle improvement with a population health focus demonstrated improved depression screening and follow-up within a multicultural community health center. Outcomes were attributed to team engagement and the use of standardized tools. These processes can be applied to other primary care settings.

Patients' views on the use of an Option Grid for knee osteoarthritis in physiotherapy clinical encounters: An interview study

Background

Patient decision support tools have been developed as a means of providing accurate and accessible information in order for patients to make informed decisions about their care. Option Grids^™ are a type of decision support tool specifically designed to be used during clinical encounters.

Objective

To explore patients’ views of the Option Grid encounter tool used in clinical consultations with physiotherapists, in comparison with usual care, within a patient population who are likely to be disadvantaged by age and low health literacy.

Methods

Semi‐structured interviews with 72 patients (36 who had been given an Option Grid in their consultation and 36 who had not). Thematic analysis explored patients’ understanding of treatment options, perceptions of involvement, and readability and utility of the Option Grid.

Results

Interviews suggested that the Option Grid facilitated more detailed discussion about the risks and benefits of a wider range of treatment options for osteoarthritis of the knee. Participants indicated that the Option Grid was clear and aided their understanding of a structured progression of the options as their condition advanced, although it was not clear whether the Option Grid facilitated greater engagement in shared decision making.

Discussion and conclusion

The Option Grid for osteoarthritis of the knee was well received by patient participants who reported that it helped them to understand their options, and made the notion of choice explicit. Use of Option Grids should be considered within routine consultations.

Shared Decision Making in Immigrant Patients

Communication is at the core of shared decision making, and communication difficulties are therefore barriers to using shared decision making in clinical practice. In clinical encounters with immigrant patients from culturally and linguistically diverse backgrounds, a number of communication challenges arise, which can be obstacles to the implementation of shared decision making. Here, we discuss some of these challenges, possible solutions and research required to address identified knowledge gaps.