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Barton JL, Kunneman M, Hargraves I, LeBlanc A, Brito JP, Scholl I, Montori VM. Envisioning Shared Decision Making: A Reflection for the Next Decade. MDM Policy Pract 2020; 5:2381468320963781. [PMID: 35187247 PMCID: PMC8855401 DOI: 10.1177/2381468320963781] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/14/2020] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Jennifer L. Barton
- Oregon Health & Science University, Portland, Oregon
- VA Portland Health Care System, Portland, Oregon
| | - Marleen Kunneman
- Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Ian Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Annie LeBlanc
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Department of Family and Emergency Medicine, Faculty of Medicine, and Research Center on Healthcare and Social Services in Primary Care, Laval University, Quebec City, Quebec
| | - Juan P. Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Division of Diabetes, Endocrinology, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Isabelle Scholl
- Institut und Poliklinik für Medizinische Psychologie, Hamburg, Germany
| | - Victor M. Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
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Scalia P, Durand MA, Berkowitz JL, Ramesh NP, Faber MJ, Kremer JAM, Elwyn G. The impact and utility of encounter patient decision aids: Systematic review, meta-analysis and narrative synthesis. PATIENT EDUCATION AND COUNSELING 2019; 102:817-841. [PMID: 30612829 DOI: 10.1016/j.pec.2018.12.020] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/23/2018] [Accepted: 12/18/2018] [Indexed: 06/09/2023]
Abstract
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.
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Affiliation(s)
- Peter Scalia
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Marie-Anne Durand
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Julia L Berkowitz
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Nithya P Ramesh
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Marjan J Faber
- Radboud university medical center, Scientific Institute for Quality of Healthcare, PO Box 9101, Nijmegen, 6500, HB, the Netherlands.
| | - Jan A M Kremer
- Radboud university medical center, Scientific Institute for Quality of Healthcare, PO Box 9101, Nijmegen, 6500, HB, the Netherlands.
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, One Medical Center Drive, Lebanon, NH, 03756, USA.
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Sherlock R, Wood F, Joseph-Williams N, Williams D, Hyam J, Sweetland H, McGarrigle H, Edwards A. "What would you recommend doctor?"-Discourse analysis of a moment of dissonance when sharing decisions in clinical consultations. Health Expect 2019; 22:547-554. [PMID: 30916446 PMCID: PMC6543150 DOI: 10.1111/hex.12881] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 01/31/2019] [Accepted: 03/01/2019] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Rebecca Sherlock
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Fiona Wood
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Denitza Williams
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Joanna Hyam
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | | | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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Beedholm K, Frederiksen K. Patient involvement and institutional logics: A discussion paper. Nurs Philos 2018; 20:e12234. [PMID: 30592122 DOI: 10.1111/nup.12234] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 11/26/2018] [Accepted: 11/26/2018] [Indexed: 11/30/2022]
Abstract
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."
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Affiliation(s)
- Kirsten Beedholm
- Department of Public Health, Section for Nursing, Aarhus University, Aarhus C, Denmark
| | - Kirsten Frederiksen
- Department of Public Health, Section for Nursing, Aarhus University, Aarhus C, Denmark
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Schaeffer AM, Jolles D. Not Missing the Opportunity: Improving Depression Screening and Follow-Up in a Multicultural Community. Jt Comm J Qual Patient Saf 2018; 45:31-39. [PMID: 30139563 DOI: 10.1016/j.jcjq.2018.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 05/31/2018] [Accepted: 06/01/2018] [Indexed: 10/28/2022]
Abstract
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.
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Scalia P, Elwyn G, Barr P, Song J, Zisman-Ilani Y, Lesniak M, Mullin S, Kurek K, Bushell M, Durand MA. Exploring the use of Option Grid™ patient decision aids in a sample of clinics in Poland. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2018; 134:1-8. [DOI: 10.1016/j.zefq.2018.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 04/11/2018] [Accepted: 04/27/2018] [Indexed: 10/16/2022]
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Kinsey K, Firth J, Elwyn G, Edwards A, Brain K, Marrin K, Nye A, Wood F. Patients' views on the use of an Option Grid for knee osteoarthritis in physiotherapy clinical encounters: An interview study. Health Expect 2017; 20:1302-1310. [PMID: 28779512 PMCID: PMC5689238 DOI: 10.1111/hex.12570] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2017] [Indexed: 12/01/2022] Open
Abstract
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.
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Affiliation(s)
| | - Jill Firth
- Pennine MSK Partnership Ltd, Greater Manchester, UK
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth, NH, USA
| | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Katherine Brain
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Katy Marrin
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Alan Nye
- Pennine MSK Partnership Ltd, Greater Manchester, UK
| | - Fiona Wood
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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Abstract
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.
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Affiliation(s)
- Claudia C Dobler
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | | | - Michael R Gionfriddo
- Center for Pharmacy Innovation and Outcomes, Geisinger Health System, Forty Fort, Pennsylvania
| | - Juan Pablo Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
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