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

Unravelling clinicians' shared decision-making adoption: a qualitative exploration through the lens of diffusion of innovations theory

OBJECTIVES

This study uses the diffusion of innovations (DOI) theory to comprehensively understand the adoption of shared decision-making (SDM) in clinical practice, specifically focusing on the 'knowledge' and 'persuasion' stages within DOI. We aim to understand the challenges and dynamics associated with SDM adoption, offering insights for more patient-centred decision-making in healthcare.

DESIGN

This qualitative study employs a modified framework analysis approach, integrating ethnographic and interview data from prior research, along with additional interviews. The framework used is based on the DOI theory.

STUDY SETTING AND PARTICIPANTS

This study was conducted in the obstetrics and gynaecology department of a tertiary teaching hospital in the Eastern region of the Netherlands. It included interviews with 20 participants, including gynaecologists, obstetrics registrars and junior doctors currently practising in the department. Additionally, data from prior research conducted within the same department were incorporated, ensuring the maintenance of contextual consistency.

RESULTS

Findings reveal a complex interplay between SDM's benefits and challenges. Clinicians value SDM for upholding patient autonomy and enhancing medical practice, viewing it as valuable for medical decision-making. Decision aids are seen as advantageous in supporting treatment decisions. Challenges include compatibility issues between patient and clinician preferences, perceptions of SDM as time-consuming and difficult and limitations imposed by the rapid pace of healthcare and its swift decisions. Additionally, perceived complexity varies by situation, influenced by colleagues' attitudes, with limited trialability and sparsely observed instances of SDM.

CONCLUSIONS

Clinicians' decision to adopt or reject SDM is multifaceted, shaped by beliefs, cognitive processes and contextual challenges. Cognitive dissonance is critical as clinicians reconcile their existing practices with the adoption of SDM. Practical strategies such as practice assessments, open discussions about SDM's utility and reflective practice through professional development initiatives empower clinicians to make the best informed decision to adopt or reject SDM.

Patients' experiences of shared decision-making in nursing care: A qualitative study

AIM

To explore patients' experiences of shared decision-making, in nursing care during their stay in a healthcare institution.

DESIGN

This study employed a qualitative descriptive design.

METHODS

Twenty participants were interviewed from two rehabilitation centres, a nephrology ward of a hospital, and a rehabilitation ward of a long-term care facility. A constant comparative method was used for the inductive analysis.

RESULTS

The main theme was 'feeling seen and understood', in the context of person-centred care, which served as the unifying thread across five themes. The five themes included the importance of a positive nurse-patient relationship as a foundation for shared decision-making. Next, patients experienced collaboration, and this was influenced by verbal and non-verbal communication. Another theme was that patients often felt overwhelmed during their stay, affecting shared decision-making. The fourth theme was that many decisions were not made through the shared decision-making process but were still perceived as satisfactory. The final theme highlighted patients' perspectives on their role in decision-making and influencing factors.

CONCLUSION

Patients describe how feeling seen and understood is a prerequisite for shared decision-making as a part of person-centred care. For nurses, this implies that they should focus on aspects such as building a good relationship and acknowledgement of patients' feelings and circumstances, next to empowering patients to feel knowledgeable and valued. This way patient's motivation to participate in shared decision-making will be enhanced.

REPORTING METHOD

Following the EQUATOR guidelines, reporting was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ).

PATIENT OR PUBLIC CONTRIBUTION

Patients were involved in the study through interviews during the research process and member checks during analysis.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Before initiating shared decision-making processes, prioritise making the patient feel seen and understood. Be mindful that patients often feel overwhelmed during their stay. Use a person-centred approach to make patients feel knowledgeable-this empowers them for shared decision-making.

IMPACT

Research on patients' experiences of shared decision-making in nursing care is limited, yet crucial for understanding patients' needs in shared decision-making. This study highlights patients' perceptions that shared decision-making is best facilitated within the nurse-patient relationship by nurses who primarily focus on ensuring that patients feel acknowledged and understood.

Current level of shared decision-making in hepatobiliary surgical oncology (SAPACHA)

BACKGROUND

Shared decision-making (SDM) may improve patient autonomy and health outcomes. This study assessed the level of SDM at both ends of the spectrum of hepatobiliary surgery to identify needs and opportunities for improvement.

METHODS

A mixed-methods study was performed. Consultations regarding surgery for perihilar cholangiocarcinoma (pCCA) or hepatocellular adenoma (HCA) were prospectively included between September 2020 and December 2022. The level of patient involvement in treatment decision-making was assessed objectively by analysis of audio-recorded consultations using the OPTION-5 instrument. The perceived level of SDM was appreciated by patients (SDM-Q-9) and surgeons (SDM-Q-doc) through questionnaires. Higher scores indicated higher levels of SDM. Outcomes were compared between patient groups and two focus groups were held.

RESULTS

Ten pCCA- and nine HCA-patients were included in the quantitative part of the study. Median OPTION-5, SDM-Q-9 and SDM-Q-doc scores were 35% (IQR: 25-45%), 86% (IQR: 76-96%), and 73% (IQR: 71-78%), respectively. SDM-Q-9 scores among HCA-patients (79% [IQR: 71-82%]) were significantly lower than in pCCA-patients (96% [IQR: 93-100%], p < 0.001). In focus groups, patients reported a lack of information, support, and expressed positive attitudes towards decision support tools (DSTs).

CONCLUSION

Patient involvement and information provision among HPB-surgical patients show room for improvement, particularly for HCA-patients. DSTs may be helpful for this purpose.

Is it fun or is it hard? Studying physician-related attributes of shared decision-making by ranking case vignettes

Objective

This study investigated provider-related attributes of shared decision-making (SDM). It studied how physicians rank SDM cases compared to other cases, taking 'job satisfaction' and 'complexity' as ranking criteria.

Methods

Ten vignettes representing three cases of SDM, three cases dealing with patients' emotions and four with technical problems were designed to conduct a modified ordinal preference elicitation study. Gynaecologists and trainees ranked the vignettes for 'job satisfaction' or 'complexity'. Results were analysed by comparing the top three and down three ranked cases for each type of case using exact p-values obtained with custom-made randomisation tests.

Results

Participants experienced more satisfaction significantly from performing technical cases than cases dealing with emotions or SDM. Moreover, technical cases were perceived as less complex than those dealing with emotions. However, results were inconclusive about whether gynaecologists find SDM complex.

Conclusion

Findings suggest gynaecologists experience lower satisfaction with SDM tasks, possibly due to them falling outside their comfort zone. Integrating SDM into daily routines and promoting culture change favouring dealing with non-technical problems might help mitigate issues in SDM implementation.

Innovation

Our novel study assesses SDM in the context of task appraisal, illuminating the psychology of health professionals and providing valuable insights for implementation science.

Assessing the impact of patient-involvement healthcare strategies on patients, providers, and the healthcare system: A systematic review

BACKGROUND

Patient involvement has become an important and lively field of research, yet existing findings are fragmented and often contested. Without a synthesis of the research field, these findings are of limited use to scholars, healthcare providers, or policy-makers.

OBJECTIVE

Examine the body of knowledge on patient involvement to determine what is known, contested, and unknown about benefits, risks, and effective implementation strategies.

PATIENT INVOLVEMENT

Patients were not involved.

METHODS

Systematic literature review of 99 journal articles using a conceptual model integrating three levels: health systems, health providers, and patients. We extracted individual research findings and organized them into the structure of our model to provide a holistic picture of patient involvement.

RESULTS

The review highlights overlaps and conflicts between various patient involvement approaches. Our results show benefits for individual patients and the health system as a whole. At the provider level, however, we identified clear barriers to patient involvement.

DISCUSSION

Patient involvement requires collaboration among health systems, healthcare providers, and patients. We showed that increasing patient responsibility and health literacy requires policy-maker interventions. This includes incentives for patient education by providers, adapting medical education curricula, and building a database of reliable health information and decision support for patients. Furthermore, policies supporting a common infrastructure for digital health data and managed patient data exchange will foster provider collaboration.

PRACTICAL VALUE

Our review shows how an approach integrating health systems, healthcare providers, and patients can make patient involvement more effective than isolated interventions. Such systematic patient involvement is likely to improve population health literacy and healthcare quality.

Shared decision-making and the duration of medical consultations: A systematic review and meta-analysis

OBJECTIVE

1) determine whether increased levels of Shared Decision-Making (SDM) affect consultation duration, 2) investigate the intervention characteristics involved.

METHODS

MEDLINE, EMBASE, CINAHL and Cochrane library were systematically searched for experimental and cross-sectional studies up to December 2021. A best-evidence synthesis was performed, and interventions characteristics that increased at least one SDM-outcome, were pooled and descriptively analyzed.

RESULTS

Sixty-three studies were selected: 28 randomized clinical trials, 8 quasi-experimental studies, and 27 cross-sectional studies. Overall, pooling of data was not possible due to substantial heterogeneity. No differences in consultation duration were found more often than increased or decreased durations. . Consultation times (minutes:seconds) were significantly increased only among interventions that: 1) targeted clinicians only (Mean Difference [MD] 1:30, 95% Confidence Interval [CI] 0:24-2:37); 2) were performed in primary care (MD 2:05, 95%CI 0:11-3:59; 3) used a group format (MD 2:25, 95%CI 0:45-4:05); 4) were not theory-based (MD 4:01, 95%CI 0:38-7:23).

CONCLUSION

Applying SDM does not necessarily require longer consultation durations. Theory-based, multilevel implementation approaches possibly lower the risk of increasing consultation durations.

PRACTICE IMPLICATIONS

The commonly heard concern that time hinders SDM implementation can be contradicted, but implementation demands multifaceted approaches and space for training and adapting work processes.

What helps the successful implementation of digital decision aids supporting shared decision-making in cardiovascular diseases? A systematic review

Aims

Although digital decision aids (DAs) have been developed to improve shared decision-making (SDM), also in the cardiovascular realm, its implementation seems challenging. This study aims to systematically review the predictors of successful implementation of digital DAs for cardiovascular diseases.

Methods and results

Searches were conducted in MEDLINE, Embase, PsycInfo, CINAHL, and the Cochrane Library from inception to November 2021. Two reviewers independently assessed study eligibility and risk of bias. Data were extracted by using a predefined list of variables. Five good-quality studies were included, involving data of 215 patients and 235 clinicians. Studies focused on DAs for coronary artery disease, atrial fibrillation, and end-stage heart failure patients. Clinicians reported DA content, its effectivity, and a lack of knowledge on SDM and DA use as implementation barriers. Patients reported preference for another format, the way clinicians used the DA and anxiety for the upcoming intervention as barriers. In addition, barriers were related to the timing and Information and Communication Technology (ICT) integration of the DA, the limited duration of a consultation, a lack of communication among the team members, and maintaining the hospital's number of treatments. Clinicians' positive attitude towards preference elicitation and implementation of DAs in existing structures were reported as facilitators.

Conclusion

To improve digital DA use in cardiovascular diseases, the optimum timing of the DA, training healthcare professionals in SDM and DA usage, and integrating DAs into existing ICT structures need special effort. Current evidence, albeit limited, already offers advice on how to improve DA implementation in cardiovascular medicine.

Effects and Working Mechanisms of a Multilevel Implementation Program for Applying Shared Decision-Making while Discussing Systemic Treatment in Breast Cancer

Background: Enhancing the application of shared decision-making (SDM) is critical for integrating patient preferences in breast cancer treatment choices. We investigated the effect of an adapted multilevel SDM implementation program in breast cancer care. Methods: Breast cancer patients qualifying for (neo)adjuvant systemic treatment were included in a multicenter before−after study. Consultations were audio recorded between June 2018 and July 2019 and analyzed using the five-item Observing Patient Involvement in Decision-Making (OPTION-5) instrument to score SDM application by clinicians. The Shared Decision-Making Questionnaire (SDM-Q-9) was used to rate patients’ perceived SDM level. Consultation duration, decision types, number of options discussed and consultations per patient were monitored. Regression analysis was used to investigate the correlated variables and program components. Results: Mean OPTION-5 scores increased from 33.9 (n = 63) before implementation to 54.3 (n = 49) after implementation (p < 0.001). The SDM-Q-9 scores did not change: 91.1 (n = 51) at baseline versus 88.9 (n = 23) after implementation (p = 0.81). Without increasing consultation time, clinicians discussed more options after implementation. The regression analysis showed that exposure to the implementation program, redistribution of tasks and discussing feedback from consultations was associated with a higher level of SDM. Conclusion: The multilevel program helped clinicians achieve clinically relevant improvement in SDM, especially when it is tailored to (individuals in) teams and includes (e-)training, discussing feedback on consultations and redistribution of tasks.

Translating knowledge into practice for communication skills training for health care professionals

Despite the evidence that person-centred communication underpins all that we do in our interactions with patients, caregivers and team members, the knowledge about the implementation of systematic communication skills training is still in its infancy. This position paper describes some of the main contextual facilitators for translating knowledge about communication skills training for health care professionals (HCP) and recommends ways to guide practical implementation. Based on the literature that has been published over the last two decades, it seems evident that communication skills training programs should be underpinned by clinician self-reflection, be experiential, and focused on behaviour change and implementation of new skills into practice. The programs should be delivered by trainers possessing an understanding of communication micro skills, the skills and confidence to observe interactions, and coach learners through the rehearsal of alternative approaches. Communication skills programs should be flexible to adapt to individual learners, local needs, and circumstances. Interventions should not be limited to the empowerment of individual HCP but should be a part of the organisational quality assurance framework, e.g., by including communication skills in clinical audits. Implementation science frameworks may provide tools to align programs to the context and to address the determinants important for a sustained implementation process. Programs need to be embedded as 'core business', otherwise the culture change will be elusive and sustainability under threat if they are only dependent on provisional funding.

Shared decision-making in advanced kidney disease: a scoping review

OBJECTIVES

To provide a comprehensive overview of interventions that support shared decision-making (SDM) for treatment modality decisions in advanced kidney disease (AKD). To provide summarised information on their content, use and reported results. To provide an overview of interventions currently under development or investigation.

DESIGN

The JBI methodology for scoping reviews was followed. This review conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist.

DATA SOURCES

MEDLINE, Embase, Web of Science, Cochrane Library, Emcare, PsycINFO, PROSPERO and Academic Search Premier for peer-reviewed literature. Other online databases (eg, clinicaltrials.gov, OpenGrey) for grey literature.

ELIGIBILITY FOR INCLUSION

Records in English with a study population of patients >18 years of age with an estimated glomerular filtration rate <30 mL/min/1.73 m2. Records had to be on the subject of SDM, or explicitly mention that the intervention reported on could be used to support SDM for treatment modality decisions in AKD.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened and selected records for data extraction. Interventions were categorised as prognostic tools (PTs), educational programmes (EPs), patient decision aids (PtDAs) or multicomponent initiatives (MIs). Interventions were subsequently categorised based on the decisions they were developed to support.

RESULTS

One hundred forty-five interventions were identified in a total of 158 included records: 52 PTs, 51 EPs, 29 PtDAs and 13 MIs. Sixteen (n=16, 11%) were novel interventions currently under investigation. Forty-six (n=46, 35.7%) were reported to have been implemented in clinical practice. Sixty-seven (n=67, 51.9%) were evaluated for their effects on outcomes in the intended users.

CONCLUSION

There is no conclusive evidence on which intervention is the most efficacious in supporting SDM for treatment modality decisions in AKD. There is a lot of variation in selected outcomes, and the body of evidence is largely based on observational research. In addition, the effects of these interventions on SDM are under-reported.

Patients' preferred and perceived decision-making roles, and observed patient involvement in videotaped encounters with medical specialists

OBJECTIVE

To assess how patients prefer and perceive medical decision making, which factors are associated with their preferred and perceived decision-making roles, and whether observed involvement reflects patients' perceived role.

METHODS

We asked 781 patients visiting a medical specialist from 18 different disciplines to indicate their preferred and perceived decision-making roles. Patient involvement in videotaped consultations was assessed with the OPTION5 instrument.

RESULTS

Most patients preferred and perceived decision making as shared (SDM; 58% and 43%, respectively), followed by paternalistic (26% and 38%), and informative (16% and 15%). A large minority (n = 103, 21%) of patients preferring shared or informative decision making (n = 482) experienced paternalistic decision making. Mean (SD) OPTION5 scores were highest in consultations which patients perceived as informative (26.0 (19.7)), followed by shared (19.1 (17.2)) and lowest in paternalistic decision making (11.8 (13.4) p < 0.001).

CONCLUSIONS

Most patients want to be involved in decision making. Patients perceive that the physician makes the decision more often than they prefer, and perceive more involvement in the decision than objective assessment by an independent researcher shows.

PRACTICE IMPLICATIONS

A clearer understanding of patients' medical decision-making experiences is needed to optimize physician SDM training programmes and patient awareness campaigns.

Shared decision making, patient-centered communication and patient satisfaction - A cross-sectional analysis

OBJECTIVES

The integration of shared decision making (SDM) and patient-centered communication (PCC) is needed to actively involve patients in decision making. This study examined the relationship between shared decision making and patient-centered communication.

METHODS

In 82 videotaped hospital outpatient consultations by 41 medical specialists from 18 disciplines, we assessed the extent of shared decision making by the OPTION⁵ score and patient-centered communication by the Four Habits Coding Scheme (4HCS), and analyzed the occurrence of a high versus low degree (above or below median) of SDM and/or PCC, and its relation to patient satisfaction scores.

RESULTS

In comparison to earlier studies, we observed comparable 4HCS scores and relatively low OPTION⁵ scores. The correlation between the two was weak (r = 0.29, p = 0.009). In 38% of consultations, we observed a combination of high SDM and low PCC scores or vice versa. The combination of a high SDM and high PCC, which was observed in 23% of consultations, was associated with significantly higher patient satisfaction scores.

CONCLUSION

Shared decision making and patient-centered communication are not synonymous and do not always co-exist.

PRACTICE IMPLICATIONS

The value of integrated training of shared decision making and patient-centered communication should be further explored.

Shared decision-making in the Netherlands: Progress is made, but not for all. Time to become inclusive to patients

Dutch initiatives targeting shared decision-making (SDM) are still growing, supported by the government, the Federation of Patients' Organisations, professional bodies and healthcare insurers. The large majority of patients prefers the SDM model. The Dutch are working hard to realise improvement in the application of SDM in daily clinical practice, resulting in glimpses of success with objectified improvement on observed behavior. Nevertheless, the culture shift is still ongoing. Large-scale uptake of SDM behavior is still a challenge. We haven't yet fully reached the patients' needs, given disappointing research data on patients' experiences and professional behavior. In all Dutch implementation projects, early adopters, believers or higher-educated persons have been overrepresented, while patients with limited health literacy have been underrepresented. This is a huge problem as 25% of the Dutch adult population have limited health literacy. To further enhance SDM there are issues to be addressed: We need to make physicians conscious about their limited application of SDM in daily practice, especially regarding preference and decision talk. We need to reward clinicians for the extra work that comes with SDM. We need to be inclusive to patients with limited health literacy, who are less often actually involved in decision-making and at the same time more likely to regret their chosen treatment compared to patients with higher health literacy.

Providing antibiotics to immigrants: a qualitative study of general practitioners' and pharmacists' experiences

BACKGROUND

If healthcare professionals perceive that patients strongly expect to be prescribed antibiotics, inappropriate prescriptions may result. As it is unknown whether this happens more often with certain patient groups, we explored whether general practitioners (GPs) and pharmacists perceived such expectations when they provided antibiotics to immigrant patients.

METHODS

Ten GPs and five pharmacists from Rotterdam, the Netherlands, were interviewed on the basis of a semi-structured topic guide. Atlas.ti software was then used to conduct a thematic analysis.

RESULTS

GPs felt that immigrant patients, especially those who had arrived recently, were more likely to expect to receive antibiotics than native Dutch patients. However, these expectations had decreased over the last years and did not always lead immigrants to exert pressure on them. Except for language barriers, the factors reported by GPs to influence their antibiotic prescribing behaviour were unrelated to patients' immigrant background. If there was a language barrier, GPs experienced greater diagnostic uncertainty and needed additional time to obtain and communicate correct information. To overcome language barriers, they often used point-of-care testing to convince patients that antibiotics were unnecessary. Although pharmacists rarely experienced problems dispensing antibiotics to immigrants, they and GPs both struggled to find effective ways of overcoming language barriers, and stressed the need for multi-language support materials.

CONCLUSION

While pharmacists rarely experience any problems providing antibiotics to immigrants, GPs regularly face language barriers with immigrant patients, which complicate the diagnostic process and communicating information in the limited available time. This sometimes leads antibiotics to be prescribed inappropriately.

Structurally collecting patient feedback on trainee skills: A pilot study in Obstetrics and Gynaecology

OBJECTIVE

This pilot study tested a tool that collects patient feedback on trainees' skills in shared decision-making (SDM) and general consultation. It also examined trainees' views on SDM and patient feedback, exploring potential skills improvement through reflexive practice.

METHODS

Patients were asked to rate trainees after consultation in a six-itemed questionnaire. The questionnaire included 'CollaboRATE' (a validated tool to test SDM), the 'Net Promoter Score' and two open-ended questions. Questionnaire results were described quantitatively and tested for differences. Results were presented to trainees at three intervals. Trainees were interviewed afterwards. Interview transcripts were thematically analysed.

RESULTS

Eleven trainees in Obstetrics and Gynaecology participated. Out of 1651 sent questionnaires 399 were returned (response rate 24%). Questionnaire results showed no differences when comparing trainees or group scores over time. Interview results were thematically analysed using the reflexivity framework. Trainees were able to reflect on their SDM skills. They valued receiving patient feedback, yet were able to formulate few learning points from it.

CONCLUSION

Although skills improvement was not evident, patient feedback still has potential benefits.

PRACTICE IMPLICATIONS

Patient feedback should be combined with facilitated reflections at timely intervals to reinforce behaviour change. Supervisors play an important role in facilitating reflections with trainees.

Asking the right questions: towards a person-centered conception of shared decision-making regarding treatment of advanced chronic kidney disease in older patients

An increasing number of older patients have to decide on a treatment plan for advanced chronic kidney disease (CKD), involving dialysis or conservative care. Shared decision-making (SDM) is recommended as the model for decision-making in such preference-sensitive decisions. The aim of SDM is to come to decisions that are consistent with the patient’s values and preferences and made by the patient and healthcare professional working together. In clinical practice, however, SDM appears to be not yet routine and needs further implementation. A shift from a biomedical to a person-centered conception might help to make the process more shared. Shared should, therefore, be interpreted as two persons bringing two perspectives to the table, that both need to be explored during the decision-making process. Starting from the patient’s perspective will enable to determine the mutual goals of care first and, subsequently, determine the best way for achieving those goals. To perform such SDM, the healthcare professional needs to become a skilled companion, being part of the patient’s relational context, and start asking the right questions about what matters to the patient as person. In this article, we describe the need for a person-centered conception of SDM for the setting of older patients with advanced CKD.

Why do medical residents prefer paternalistic decision making? An interview study

BACKGROUND

Although shared decision making is championed as the preferred model for patient care by patient organizations, researchers and medical professionals, its application in daily practice remains limited. We previously showed that residents more often prefer paternalistic decision making than their supervisors. Because both the views of residents on the decision-making process in medical consultations and the reasons for their 'paternalism preference' are unknown, this study explored residents' views on the decision-making process in medical encounters and the factors affecting it.

METHODS

We interviewed 12 residents from various specialties at a large Dutch teaching hospital in 2019-2020, exploring how they involved patients in decisions. All participating residents provided written informed consent. Data analysis occurred concurrently with data collection in an iterative process informing adaptations to the interview topic guide when deemed necessary. Constant comparative analysis was used to develop themes. We ceased data collection when information sufficiency was achieved.

RESULTS

Participants described how active engagement of patients in discussing options and decision making was influenced by contextual factors (patient characteristics, logistical factors such as available time, and supervisors' recommendations) and by limitations in their medical and shared decision-making knowledge. The residents' decision-making behavior appeared strongly affected by their conviction that they are responsible for arriving at the correct diagnosis and providing the best evidence-based treatment. They described shared decision making as the process of patients consenting with physician-recommended treatment or patients choosing their preferred option when no best evidence-based option was available.

CONCLUSIONS

Residents' decision making appears to be affected by contextual factors, their medical knowledge, their knowledge about SDM, and by their beliefs and convictions about their professional responsibilities as a doctor, ensuring that patients receive the best possible evidence-based treatment. They confuse SDM with acquiring informed consent with the physician's treatment recommendations and with letting patients decide which treatment they prefer in case no evidence based guideline recommendation is available. Teaching SDM to residents should not only include skills training, but also target residents' perceptions and convictions regarding their role in the decision-making process in consultations.

Evaluation of a multilevel implementation program for timeout and shared decision making in breast cancer care: a mixed methods study among 11 hospital teams

OBJECTIVE

Evaluation of a multilevel implementation program on shared decision making (SDM) for breast cancer clinicians.

METHODS

The program was based on the 'Measurement Instrument for Determinants of Innovations-model' (MIDI). Key factors for effective implementation were included. Eleven breast cancer teams selected from two geographical areas participated; first six surgery teams and second five systemic therapy teams. A mixed method evaluation was carried out at the end of each period: Descriptive statistics were used for surveys and thematic content analysis for semi-structured interviews.

RESULTS

Twenty-eight clinicians returned the questionnaire (42%). Clinicians (96%) endorse that SDM is relevant to breast cancer care. The program supported adoption of SDM in their practice. Limited financial means, time constraints and concurrent activities were frequently reported barriers. Interviews (n = 21) showed that using a 4-step SDM model - when reinforced by practical examples, handy cards, feedback and training - helped to internalize SDM theory. Clinicians experienced positive results for their patients and themselves. Task re-assignment and flexible outpatient planning reinforce sustainable change. Patient involvement was valued.

CONCLUSION

Our program supported breast cancer clinicians to adopt SDM.

PRACTICE IMPLICATIONS

To implement SDM, multilevel approaches are needed that reinforce intrinsic motivation by demonstrating benefits for patients and clinicians.

Effectiveness of individual feedback and coaching on shared decision-making consultations in oncology care: Study protocol for a randomized clinical trial (Preprint)

Background

Shared decision-making (SDM) is particularly important in oncology as many treatments involve serious side effects, and treatment decisions involve a trade-off between benefits and risks. However, the implementation of SDM in oncology care is challenging, and clinicians state that it is difficult to apply SDM in their actual workplace. Training clinicians is known to be an effective means of improving SDM but is considered time consuming.

Objective

This study aims to address the effectiveness of an individual SDM training program using the concept of deliberate practice.

Methods

This multicenter, single-blinded randomized clinical trial will be performed at 12 Dutch hospitals. Clinicians involved in decisions with oncology patients will be invited to participate in the study and allocated to the control or intervention group. All clinicians will record 3 decision-making processes with 3 different oncology patients. Clinicians in the intervention group will receive the following SDM intervention: completing e-learning, reflecting on feedback reports, performing a self-assessment and defining 1 to 3 personal learning questions, and participating in face-to-face coaching. Clinicians in the control group will not receive the SDM intervention until the end of the study. The primary outcome will be the extent to which clinicians involve their patients in the decision-making process, as scored using the Observing Patient Involvement–5 instrument. As secondary outcomes, patients will rate their perceived involvement in decision-making, and the duration of the consultations will be registered. All participating clinicians and their patients will receive information about the study and complete an informed consent form beforehand.

Results

This trial was retrospectively registered on August 03, 2021. Approval for the study was obtained from the ethical review board (medical research ethics committee Delft and Leiden, the Netherlands [N20.170]). Recruitment and data collection procedures are ongoing and are expected to be completed by July 2022; we plan to complete data analyses by December 2022. As of February 2022, a total of 12 hospitals have been recruited to participate in the study, and 30 clinicians have started the SDM training program.

Conclusions

This theory-based and blended approach will increase our knowledge of effective and feasible training methods for clinicians in the field of SDM. The intervention will be tailored to the context of individual clinicians and will target the knowledge, attitude, and skills of clinicians. The patients will also be involved in the design and implementation of the study.

Trial Registration

Netherlands Trial Registry NL9647; https://www.trialregister.nl/trial/9647

International Registered Report Identifier (IRRID)

DERR1-10.2196/35543

Patients' views of shared decision making in inflammatory bowel disease: a survey in China

Background

Recently, decision-making process has become increasingly complex. But there is limited information on Chinese patients’ views of shared decision making (SDM) in inflammatory bowel disease (IBD). This questionnaire investigation aimed to understand Chinese patients’ perspectives and expectations of SDM in IBD and analyze the possible factors that influence their views.

Methods

An online survey was conducted from July 19th to 24th, 2020. A total of 1118 patients completed the survey.

Results

One-third of patients were dissatisfied with the current decision-making model, and the satisfaction of inpatients was lower than that of outpatients. 84% of patients preferred to participate in SDM, who were young and had a high education level, high income, commercial insurance, strong learning ability and knowledge of SDM. Most of those who did not want to participate (72%) were worried about the cost. The kind of medicine (948, 84.8%), surgical indications (505, 45.2%) and operation methods (482, 43.1%) were the topics that patients thought most require SDM. Side effects of medicine (837, 74.9%), costs of therapy (675, 60.4%), and surgical risks (563, 50.4%) were considered to be the most influential factors for SDM. 52.7% of all patients hoped experts in different disciplines would participate in SDM. The most desirable amount of time for discussion was 30 to 60 min (562/1118, 50.3%), that were associated with the cost of SDM.

Conclusion

We can meet the needs of patients by reducing costs and strengthening online patient education and exploring a model suitable for Chinese IBD patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01702-8.

Barriers and facilitators to shared decision-making in hospitals from policy to practice: a systematic review

Background

Involving patients in their healthcare using shared decision-making (SDM) is promoted through policy and research, yet its implementation in routine practice remains slow. Research into SDM has stemmed from primary and secondary care contexts, and research into the implementation of SDM in tertiary care settings has not been systematically reviewed. Furthermore, perspectives on SDM beyond those of patients and their treating clinicians may add insights into the implementation of SDM. This systematic review aimed to review literature exploring barriers and facilitators to implementing SDM in hospital settings from multiple stakeholder perspectives.

Methods

The search strategy focused on peer-reviewed qualitative studies with the primary aim of identifying barriers and facilitators to implementing SDM in hospital (tertiary care) settings. Studies from the perspective of patients, clinicians, health service administrators, and decision makers, government policy makers, and other stakeholders (for example researchers) were eligible for inclusion. Reported qualitative results were mapped to the Theoretical Domains Framework (TDF) to identify behavioural barriers and facilitators to SDM.

Results

Titles and abstracts of 8724 articles were screened and 520 were reviewed in full text. Fourteen articles met inclusion criteria. Most studies (n = 12) were conducted in the last four years; only four reported perspectives in addition to the patient-clinician dyad. In mapping results to the TDF, the dominant themes were Environmental Context and Resources, Social/Professional Role and Identity, Knowledge and Skills, and Beliefs about Capabilities. A wide range of barriers and facilitators across individual, organisational, and system levels were reported. Barriers specific to the hospital setting included noisy and busy ward environments and a lack of private spaces in which to conduct SDM conversations.

Conclusions

SDM implementation research in hospital settings appears to be a young field. Future research should build on studies examining perspectives beyond the clinician-patient dyad and further consider the role of organisational- and system-level factors. Organisations wishing to implement SDM in hospital settings should also consider factors specific to tertiary care settings in addition to addressing their organisational and individual SDM needs.

Trial Registration

The protocol for the review is registered on the Open Science Framework and can be found at https://osf.io/da645/, DOI 10.17605/OSF.IO/DA645.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01142-y.

Learning shared decision-making in clinical practice

OBJECTIVE

To explore how shared decision-making (SDM) is learned in clinical practice according to professionals and patients.

METHODS

Focus group and individual interviews with interns (n = 9), residents (n = 12), senior physicians (n = 13), and (former) patients and relatives (n = 13) in fertility care and intensive care.

RESULTS

Patients and professionals identified barriers and drivers for SDM related to patient, caregiver, and context. Participants agreed: the nuances of SDM are learned in practice, not during undergraduate medical education. Through observing and copying from other professionals, interns and residents describe building their personal "repertoire" of SDM skills, knowledge, and attitude. Professionals indicated it was helpful to see many different examples - both good and bad - of physicians in action.

CONCLUSION

Learning SDM is a complicated task for both students and professionals in healthcare. Relevant factors are the involvement of patients, the role of informal learning processes and role models, and the importance of reflective practice.

PRACTICE IMPLICATIONS

Learning SDM in practice requires 1) measures to lessen pressures on a meso and macro level that hinder SDM in practice, 2) inventive and precise training and education and paying explicit attention to informal learning processes in clinical practice and learning through role models.

Effect of a multilevel implementation programme on shared decision-making in breast cancer care

BACKGROUND

Women with newly diagnosed breast cancer face multiple treatment options. Involving them in a shared decision-making (SDM) process is essential. The aim of this study was to evaluate whether a multilevel implementation programme enhanced the level of SDM behaviour of clinicians observed in consultations.

METHODS

This before-after study was conducted in six Dutch hospitals. Patients with breast cancer who were facing a decision on surgery or neoadjuvant systemic treatment between April 2016 and September 2017 were included, and provided informed consent. Audio recordings of consultations made before and after implementation were analysed using the five-item Observing Patient Involvement in Decision-Making (OPTION-5) instrument to assess whether clinicians adopted new behaviour needed for applying SDM. Patients scored their perceived level of SDM, using the nine-item Shared Decision-Making Questionnaire (SDM-Q-9). Hospital, duration of the consultation(s), age, and number of consultations per patient that might influence OPTION-5 scores were investigated using linear regression analysis.

RESULTS

Consultations of 139 patients were audiotaped, including 80 before and 59 after implementation. Mean (s.d.) OPTION-5 scores, expressed on a 0-100 scale, increased from 38.3 (15.0) at baseline to 53.2 (14.8) 1 year after implementation (mean difference (MD) 14.9, 95 per cent c.i. 9.9 to 19.9). SDM-Q-9 scores of 105 patients (75.5 per cent) (72 before and 33 after implementation) were high and showed no significant changes (91.3 versus 87.6; MD -3.7, -9.3 to 1.9). The implementation programme had an association with OPTION-5 scores (β = 14.2, P < 0.001), hospital (β = 2.2, P = 0.002), and consultation time (β = 0.2, P < 0.001).

CONCLUSION

A multilevel implementation programme supporting SDM in breast cancer care increased the adoption of SDM behaviour of clinicians in consultations.

What Works in Implementing Patient Decision Aids in Routine Clinical Settings? A Rapid Realist Review and Update from the International Patient Decision Aid Standards Collaboration

BACKGROUND

Decades of effectiveness research has established the benefits of using patient decision aids (PtDAs), yet broad clinical implementation has not yet occurred. Evidence to date is mainly derived from highly controlled settings; if clinicians and health care organizations are expected to embed PtDAs as a means to support person-centered care, we need to better understand what this might look like outside of a research setting.

AIM

This review was conducted in response to the IPDAS Collaboration's evidence update process, which informs their published standards for PtDA quality and effectiveness. The aim was to develop context-specific program theories that explain why and how PtDAs are successfully implemented in routine healthcare settings.

METHODS

Rapid realist review methodology was used to identify articles that could contribute to theory development. We engaged key experts and stakeholders to identify key sources; this was supplemented by electronic database (Medline and CINAHL), gray literature, and forward/backward search strategies. Initial theories were refined to develop realist context-mechanism-outcome configurations, and these were mapped to the Consolidated Framework for Implementation Research.

RESULTS

We developed 8 refined theories, using data from 23 implementation studies (29 articles), to describe the mechanisms by which PtDAs become successfully implemented into routine clinical settings. Recommended implementation strategies derived from the program theory include 1) co-production of PtDA content and processes (or local adaptation), 2) training the entire team, 3) preparing and prompting patients to engage, 4) senior-level buy-in, and 5) measuring to improve.

CONCLUSIONS

We recommend key strategies that organizations and individuals intending to embed PtDAs routinely can use as a practical guide. Further work is needed to understand the importance of context in the success of different implementation studies.

Association between Physicians' Perception of Shared Decision Making with Antibiotic Prescribing Behavior in Primary Care in Hubei, China: A Cross-Sectional Study

Shared decision-making (SDM) has been advocated as one effective strategy for improving physician–patient relationships and optimizing clinical outcomes. Our study aimed to measure physicians’ perception of SDM and establish the relationship between physicians’ perception of SDM and prescribing behavior in patients with upper respiratory tract infections. One cross-sectional study was conducted in Hubei Province from December 2019 to January 2020. The SDM questionnaire and prescription data of 2018 from electronic health records data were matched for each physician in this study. Multilevel modeling was applied to explore the relationship between physicians’ perception of SDM and antibiotic prescribing in primary care. Analyses were statistically controlled for demographic characteristics of the physicians and patients. Physicians’ positive perception of SDM had small but statistically significant effects on lower prescribing of antibiotics in the patient group aged over 40 years (odds ratio (OR) < 1; p < 0.05). Moreover, female physicians (OR = 0.71; p = 0.007) with higher educational levels (bachelor’s degree and above; OR = 0.71; p = 0.024) were significantly associated with the prescribing of less antibiotics (p < 0.05). A more positive perception of SDM was demonstrated as one significant predictor of less prescribing of antibiotics in the patient group over 40 years. There may be a promising focus of implementing SDM strategies targeting physician–patient communication in primary care.

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 use of PROMs and shared decision-making in medical encounters with patients: An opportunity to deliver value-based health care to patients

BACKGROUND

The recent emphasis on value-based health care (VBHC) is thought to provide new opportunities for shared decision-making (SDM) in the Netherlands, especially when using patient-reported outcome measures (PROMs) in routine medical encounters. It is still largely unclear about how PROMs could be linked to SDM and what we expect from clinicians in this respect.

AIM

To describe approaches and lessons learned in the fields of SDM and VBHC implementation that converge in using PROMs in medical encounters.

APPROACH

Based on input from three Dutch forerunner case examples and available evidence about SDM and VBHC, we describe barriers and facilitators regarding the use of PROMs and SDM in the medical encounter. Barriers and facilitators were structured according to a conversational model that included monitoring and managing, team talk, option talk, choice talk, and decision talk. Key lessons learned and recommendations were synthesized.

RESULTS

The use of individual, N = 1 PROMs scores in the medical encounter has been largely achieved in the forerunner projects. Conversation on monitoring and managing is relatively well implemented, and option talk to some extent, unlike team talk, and decision talk. Aggregated PROMs information describing outcomes of treatment options seemed to be scarcely used. Experienced barriers largely corresponded to what is known from the literature, eg, perceived lack of time and lack of tools summarizing the options. Some concerns were identified about increasing health care consumption as a result of using PROMs and SDM in the medical encounter.

CONCLUSION

Successful implementation of SDM within VBHC initiatives may not be self-evident, even though individual, N = 1 PROMs scores are being used in the medical encounter. Education and staff resources on meso and macro levels may facilitate the more time-consuming SDM aspects. It seems fruitful to especially target team talk and choice talk in redesigning clinical pathways.

Shared decision making: Physicians' preferred role, usual role and their perception of its key components

OBJECTIVE

To investigate physicians' preferred and usual roles in decision making in medical consultations, and their perception of shared decision making (SDM).

METHODS

A cross-sectional survey of 785 physicians in a large Dutch general teaching hospital was undertaken in June 2018, assessing their preferred and usual decision making roles (Control Preference Scale), and their view on SDM key components (SDMQ9 questionnaire).

RESULTS

Most physicians (n = 232, 58%) preferred SDM, but more often performed paternalistic decision making (n = 121, 31%) in daily practice than they preferred (n = 80, 20%, p < 0.0001), most commonly because they judged the patient to be incapable of participating in decision making. Most physicians preferring SDM presented different options for treatment (n = 213, 92%) with their advantages and disadvantages (n = 209, 90%) but fewer made clear that a decision had to be made (n = 104, 45%) or explored the patient's wish how to be involved in decision making (n = 80, 34%).

CONCLUSION

Although most physicians prefer SDM, they often revert to a paternalistic approach and tend to limit SDM to discussing treatment options.

PRACTICE IMPLICATION

Teaching physicians in SDM should include raising awareness about discussing the decision process itself and help physicians to counter their tendency to revert to paternalistic decision making in daily practice.

Improvement of shared decision making in integrated stroke care: a before and after evaluation using a questionnaire survey

BACKGROUND

Shared decision making (SDM) is at the core of policy measures for making healthcare person-centred. However, the context-sensitive nature of the challenges in integrated stroke care calls for research to facilitate its implementation. This before and after evaluation study identifies factors for implementation and concludes with key recommendations for adoption.

METHODS

Data were collected at the start and end of an implementation programme in five stroke services (December 2017 to July 2018). The SDM implementation programme consisted of training for healthcare professionals (HCPs), tailored support, development of decision aids and a social map of local stroke care. Participating HCPs were included in the evaluation study: A questionnaire was sent to 25 HCPs at baseline, followed by 11 in-depth interviews. Data analysis was based on theoretical models for implementation and 51 statements were formulated as a result. Finally, all HCPs were asked to validate and to quantify these statements and to formulate recommendations for further adoption.

RESULTS

The majority of respondents said that training of all HCPs is essential. Feedback on consultation and peer observation are considered to help improve performance. In addition, HCPs stated that SDM should also be embedded in multidisciplinary meetings, whereas implementation in the organisation could be facilitated by appointed ambassadors. Time was not seen as an inhibiting factor. According to HCPs, negotiating patients' treatment decisions improves adherence to therapy. Despite possible cognitive or communications issues, all are convinced patients with stroke can be involved in a SDM-process. Relatives play an important role too in the further adoption of SDM. HCPs provided eight recommendations for adoption of SDM in integrated stroke care.

CONCLUSIONS

HCPs in our study indicated it is feasible to implement SDM in integrated stroke care and several well-known implementation activities could improve SDM in stroke care. Special attention should be given to the following activities: (1) the appointment of knowledge brokers, (2) agreements between HCPs on roles and responsibilities for specific decision points in the integrated stroke care chain and (3) the timely investigation of patient's preferences in the care process - preferably before starting treatment through discussions in a multidisciplinary meeting.

Using PROMs during routine medical consultations: The perspectives of people with Parkinson's disease and their health professionals

BACKGROUND

The use of patient-reported outcomes measures (PROMs), such as quality of life or symptoms like pain or fatigue, is increasingly embraced within patient-centred care and shared decision making.

OBJECTIVES

To investigate: (a) how patients and health professionals think about using PROMs during routine medical consultations; (b) for which purpose(s), patients and health professionals want to use PROMs during those consultations; and (c) how patients interpret PROMs information presented in various formats. People with Parkinson's disease and their health professionals served as case example.

METHODS

We performed semi-structured interviews with patients (N = 13) and professionals (N = 7 neurologists; N = 7 physiotherapists). We also used a survey in which patients (N = 115) were shown six figures displaying different information types. Presentation formats of this information varied (line/bar graphs). Interpretation by patients, perceived usefulness of information, attitude towards using information during routine medical consultations and (hypothetical) decisions were assessed.

FINDINGS

Patients and professionals were generally positive about using PROMs during medical consultations. Professionals stressed the opportunity to monitor changes in individual PROMs over time. Patients were primarily positive about aggregated PROMs to make treatment decisions. This information was also most often interpreted correctly, especially when presented through a line graph (90.1% correct). Professionals thought patients should take the initiative in discussing PROMs, whereas patients thought professionals should do so.

CONCLUSION/DISCUSSION

When used in routine medical consultations, PROMs seem to have potential to support shared decision making and facilitate patient-professional communication. However, training seems needed for both patients and professionals to facilitate actual discussion and proper interpretation.

The Mixed-Method 5W2D Approach for Health System Stakeholders Analysis in Quality of Care: An Application to the Moroccan Context

(1) Background: Quality of care (QC) is not only about satisfying patients, but also about satisfying the various health system stakeholders (HSS). This makes it a complex and difficult objective to achieve. This study aims at proposing a methodological framework for identifying HSS, prioritizing them in QC, and analyzing their interrelationships. (2) Methods: The proposed framework is the mixed-method 5W2D approach, which uses a combination of three basic methods: the 5W questioning technique (What, Who, Why, Where, and When), the Delphi method, and the Decision making trial and evaluation laboratory (DEMATEL) technique. It consists of three interdependent phases. First of all, a preliminary list of HSS is established based on a systematic literature review, which is then projected and adapted to the national context using the 5W questioning technique. Secondly, the identified HSS are classified in order according to their influence and impact on QC by employing Delphi method. Thirdly, the interrelationships between HSS are determined and analyzed by applying DEMATEL technique. An application of 5W2D is conducted in the Moroccan context as its health system involves a wide range of stakeholders. (3) Results: Results defined 17 groups of HSS, whose prioritization led to three groups that are at the core of the health system: patients and their families, health personnel, and government. Roles and expectations of these groups regarding QC are divergent and contradictory, which require making trade-offs. The findings of this study intend to guide the development of inclusive strategies and policies that involve key stakeholders for QC assessment and improvement.