Interventions to support shared decision making for medication therapy in long term conditions: A systematic review

Effect of Shared Decision-Making on Trust in Physicians in the Management of Systemic Lupus Erythematosus: The Trust Measurement for Physicians and Patients With Systemic Lupus Erythematosus Prospective Cohort Study

OBJECTIVE

Few studies have explored whether the involvement of patients in shared decision-making (SDM) is beneficial to the management of systemic lupus erythematosus (SLE). Therefore, this study investigated the relationship between patient participation in SDM and their trust in physicians using data from the Trust Measurement in Physicians and Patients With SLE (TRUMP2-SLE) study.

METHODS

Data regarding the nine-item Japanese version of the Shared Decision-Making Questionnaire (SDM-Q-9) scores, Trust in Physician Scale (TIPS) scores, and Abbreviated Wake Forest Physician Trust Scale (A-WFPTS) scores for interpersonal trust in a physician and trust in the medical profession were collected from patients with SLE who visited the outpatient clinics of five facilities in Japan through a self-administered questionnaire. The relationships among these scores were analyzed by general linear models with cluster-robust variance.

RESULTS

This study included 433 patients with SLE. The median baseline TIPS and A-WFPTS (attending physician version) scores were 82 (73-93) and 80 (70-95), respectively. A higher baseline SDM-Q-9 score was correlated with an increase in the TIPS score at one year (coefficient per 10-point [pt] increase, 0.94 pts, 95% confidence interval [CI] 0.16-1.72). A higher baseline SDM-Q-9 score was correlated with a higher A-WFPTS score for interpersonal trust (coefficient per 10-pt increase, 2.20 pts, 95% CI 1.44-2.96). The baseline SDM-Q-9 score was also correlated with an increase in the general physician version of the A-WFPTS score at one year (coefficient per 10-pt increase, 1.29 pts, 95% CI 0.41-2.18).

CONCLUSION

Engagement of patients with SLE in SDM elevates their trust in the attending physicians and health care providers, potentially enhancing doctor-patient relationships and overall health care trust.

Challenges in Obtaining and Seeking Information Among Breast Cancer Survivors in an Asian Country: a Qualitative Study

Breast cancer survivors on adjuvant endocrine therapy (AET) have distinct information-seeking experience compared to those in the diagnosis and intensive treatment phase. This study aimed to understand the challenges in obtaining and seeking information among Malaysian breast cancer survivors. We conducted semi-structured, one-to-one interviews among patients using AET from two hospitals and a local cancer organization. Interviews were conducted until theme saturation was achieved (N = 25). Interviews were de-identified, transcribed verbatim, and analysed using thematic analysis. To ensure rigor, coding was conducted through regular discussions between two researchers and the findings were shared with several participants after analysis was completed. Three main themes were identified: limitations in the healthcare system, pitfalls of seeking information online, and limited information from local sources. The participants perceived that their information needs were not met by their healthcare providers and sought information on the Internet to complement their information needs. However, they were faced with risks of misinformation, information overload, and unethical promotion of health products. Those with limited English proficiency had difficulties in accessing quality information, and suggested that there should be more content created by local health advocates in local languages, with information that is tailored for local cultures. As the Internet has become an important medium of health education, healthcare providers and patients should be equipped with the skills to share and search for information online. Digital health literacy needs to be incorporated in patient education modules to create a more informed and empowered patient community.

Technology-supported shared decision-making in chronic conditions: A systematic review of randomized controlled trials

OBJECTIVES

To describe the role of patients with a chronic disease, healthcare professionals (HCPs) and technology in shared decision making (SDM) and the use of clinical decision support systems (CDSSs), and to evaluate the effectiveness of SDM and CDSSs interventions.

METHODS

Randomized controlled studies published between 2011 and 2021 were identified and screened independently by two reviewers, followed by data extraction and analysis. SDM elements and interactive styles were identified to shape the roles of patients, HCPs and technology.

RESULTS

Forty-three articles were identified and reported on 21 SDM-studies, 15 CDSS-studies, 2 studies containing both an SDM-tool and a CDSS, and 5 studies with other decision support components. SDM elements were mostly identified in SDM-tools and interactions styles were least common in the other decision support components.

CONCLUSIONS

Patients within the included RCTs mainly received information from SDM-tools and occasionally CDSSs when it concerns treatment strategies. HCPs provide and clarify information using SDM-tools and CDSSs. Technology provides interactions, which can support more active SDM. SDM-tools mostly showed evidence for positive effects on SDM outcomes, while CDSSs mostly demonstrated positive effects on clinical outcomes.

PRACTICE IMPLICATIONS

Technology-supported SDM has potential to optimize SDM when patients, HCPs and technology collaborate well together.

A decision support tool has similar high PrEP uptake and increases early PrEP persistence in adolescent girls and young women in South Africa: results from a randomized controlled trial

INTRODUCTION

African adolescent girls and young women (AGYW) have high rates of HIV acquisition and are a priority population for HIV pre-exposure prophylaxis (PrEP). PrEP implementation has been limited by AGYW's low perceived HIV risk and provider demands. A decision support tool (DST) with information about PrEP could improve clients' risk perception, knowledge about PrEP, informed decision-making and motivation to use PrEP based on their risk, facilitating PrEP delivery in primary healthcare (PHC) clinics.

METHODS

We designed MyPrEP, a client-facing DST about PrEP and HIV prevention, with youth-friendly information and images. The impact of the MyPrEP tool was assessed among HIV-negative women aged 18-25 years presenting to a PHC clinic in Johannesburg, South Africa from March 2019 to 2020. AGYW were randomized by day to the DST or a general health website as the control condition. A clinician blinded to DST versus control allocation provided standard of care counselling about PrEP, offered PrEP, administered a questionnaire and conducted sexually transmitted infection testing. The primary outcome was PrEP initiation and the secondary outcome was PrEP persistence at 1 month, determined by pharmacy dispensation records.

RESULTS

Of 386 AGYW screened, 353 were randomized (DST n = 172, control n = 181) with a median age of 21 years (interquartile range [IQR] 20, 23) and 56% (199/353) attending the clinic for HIV testing, 46% (164/353) using contraception, 15% (53/353) using condoms consistently and 37% (108/353) with a curable sexually transmitted infection. PrEP was initiated by 97% in the DST group and 94% in the control group (OR 1.79; 95% confidence interval, CI = 0.79-1.53), of whom two-thirds planned to continue PrEP until they decided if they liked PrEP. At 1 month, PrEP persistence was 19% in the DST and 10% in the control group (OR 1.97, 95% CI 1.08-3.69). Ninety-nine percent randomized to the DST reported satisfaction with MyPrEP.

CONCLUSIONS

Among AGYW attending a South African PHC clinic, PrEP uptake was >90% with two-fold higher PrEP persistence at 1 month in those randomized to use the MyPrEP DST. Given the need for strategies to support PrEP implementation and improve low PrEP persistence among African AGYW, a PrEP DST warrants further evaluation.

Evaluation of the shared decision-making process scale in cancer screening and medication decisions

OBJECTIVES

Examine reliability and validity of the Shared Decision-Making (SDM) Process scale for cancer screening and medication decisions.

METHODS

Secondary data analysis from 6174 participants who made decisions about cancer screening (breast, colon or prostate) or medication (menopause, depression, hypertension or high cholesterol). Key measures included the SDM Process scale, decisional conflict, decision regret, and decision quality. Construct validity was examined by testing whether higher SDM Process scores were associated with lower regret, lower decisional conflict and higher decision quality. Meta-analyses summarized data across studies. Some studies assessed the scale's reliability.

RESULTS

Average SDM Process scores ranged from 1.2 to 2.5. There was a moderate-to-large, positive association between scores and lack of decisional conflict (cancer screening: d=0.61, CI(0.38, 0.84), p < .001; medications: d=0.36, CI(0.29, 0.44), p < .001). High scores were associated with lower decision regret (cancer screening: d=-0.24, CI(-0.37, -0.11), p < .001; medications: d=-0.30, CI(-0.40,-0.20), p < .001). There was no relationship with decision quality. Retest reliability was acceptable (ICC>0.7) for seven of eight clinical samples.

CONCLUSIONS

The SDM Process scale demonstrated construct validity and retest reliability in cancer screening and medication decisions.

PRACTICE IMPLICATIONS

The validated SDM Process scale is a short, patient reported metric to evaluate the current state of SDM.

Torn between two lovers - on being a psychologist in a university medical centre

Background

Psychology as applied to health and illness has a relatively short history. Nevertheless, that history shows a rapid development of the theoretical models that guide the field over the past 60 years. Core theoretical approaches are concisely reviewed, in the context of Kaplan's paper 'Behavior as the central outcome in health care' (1990), which is used as a model to examine the extent to which these approaches embrace Kaplan's notions.

Advances

Empirical studies from the health psychology domain are used, which demonstrate the gains in terms of quality of life and behavioural outcomes in patients with (chronic) somatic diseases. Over a period of some 60 years, theoretical models and core concepts in psychology as applied to health and illness have evolved from psychosomatic views to neuropsychology, quality of life, patient education, self-management, illness perceptions, patient-reported outcome measures (PROMs), shared decision-making (SDM) and health humanities (HH). The more recent models (SDM, HH) appear to align to a considerable degree with adopting 'behavior as the central outcome an outcome in health care'; shared decision-making and health humanities focus on encouraging patients to make sense of and give meaning to their illness in order to attain optimal psychosocial adjustment.

Conclusions

In addition to 'behavior as the central outcome in health care', a new definition of the concept of health (i.e. 'the ability to adapt and to self-manage' - Huber et al., 2011) seems to favour patients, healthcare providers, society, and health psychology. Incorporating this concept into medical care may be viewed as a challenge for health psychologists - and as a source of continual struggle with strong biomedical forces.

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.

Improving Initial Medication Adherence to cardiovascular disease and diabetes treatments in primary care: Pilot trial of a complex intervention

Introduction

The Initial Medication Adherence (IMA) intervention is a multidisciplinary and shared decision-making intervention to improve initial medication adherence addressed to patients in need of new treatments for cardiovascular diseases and diabetes in primary care (PC). This pilot study aims to evaluate the feasibility and acceptability of the IMA intervention and the feasibility of a cluster-RCT to assess the effectiveness and cost-effectiveness of the intervention.

Methods

A 3-month pilot trial with an embedded process evaluation was conducted in five PC centers in Catalonia (Spain). Electronic health data were descriptively analyzed to test the availability and quality of records of the trial outcomes (initiation, implementation, clinical parameters and use of services). Recruitment and retention rates of professionals were analyzed. Twenty-nine semi-structured interviews with professionals (general practitioners, nurses, and community pharmacists) and patients were conducted to assess the feasibility and acceptability of the intervention. Three discussion groups with a total of fifteen patients were performed to review and redesign the intervention decision aids. Qualitative data were thematically analyzed.

Results

A total of 901 new treatments were prescribed to 604 patients. The proportion of missing data in the electronic health records was up to 30% for use of services and around 70% for clinical parameters 5 months before and after a new prescription. Primary and secondary outcomes were within plausible ranges and outliers were barely detected. The IMA intervention and its implementation strategy were considered feasible and acceptable by pilot-study participants. Low recruitment and retention rates, understanding of shared decision-making by professionals, and format and content of decision aids were the main barriers to the feasibility of the IMA intervention.

Discussion

Involving patients in the decision-making process is crucial to achieving better clinical outcomes. The IMA intervention is feasible and showed good acceptability among professionals and patients. However, we identified barriers and facilitators to implementing the intervention and adapting it to a context affected by the COVID-19 pandemic that should be considered before launching a cluster-RCT. This pilot study identified opportunities for refining the intervention and improving the design of the definitive cluster-RCT to evaluate its effectiveness and cost-effectiveness.

Clinical trial registration

ClinicalTrials.gov, identifier NCT05094986.

Complex multidisciplinary intervention to improve Initial Medication Adherence to cardiovascular disease and diabetes treatments in primary care (the IMA-cRCT study): mixed-methods process evaluation protocol

INTRODUCTION

Medication non-initiation, or primary non-adherence, is a persistent public health problem that increases the risk of adverse clinical outcomes. The initial medication adherence (IMA) intervention is a complex multidisciplinary intervention to improve adherence to cardiovascular and diabetes treatments in primary care by empowering the patient and promoting informed prescriptions based on shared decision-making. This paper presents the development and implementation strategy of the IMA intervention and the process evaluation protocol embedded in a cluster randomised controlled trial (the IMA-cRCT) to understand and interpret the outcomes of the trial and comprehend the extent of implementation and fidelity, the active mechanisms of the IMA intervention and in what context the intervention is implemented and works.

METHODS AND ANALYSIS

We present the protocol for a mixed-methods process evaluation including quantitative and qualitative methods to measure implementation and fidelity and to explore the active mechanisms and the interactions between the intervention, participants and its context. The process evaluation will be conducted in primary care centres and community pharmacies from the IMA-cRCT, and participants include healthcare professionals (general practitioners, nurses and community pharmacists) as well as patients. Quantitative data collection methods include data extraction from the intervention operative records, patient clinical records and participant feedback questionnaires, whereas qualitative data collection involves semistructured interviews, focus groups and field diaries. Quantitative and qualitative data will be analysed separately and triangulated to produce deeper insights and robust results.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Research Ethics Comittee (CEIm) at IDIAP Jordi Gol (codeCEIm 21/051 P). Findings will be disseminated through publications and conferences, as well as presentations to healthcare professionals and stakeholders from healthcare organisations.

TRIAL REGISTRATION NUMBER

NCT05026775.

Shared Decision-Making for Patients Hospitalized with Acute Myocardial Infarction: A Randomized Trial

OBJECTIVE

Adherence to guideline-recommended medications after acute myocardial infarction (AMI) is suboptimal. Patient fidelity to treatment regimens may be related to their knowledge of the risk of death following AMI, the pros and cons of medications, and to their involvement in treatment decisions. Shared decision-making may improve both patients' knowledge and involvement in treatment decisions.

METHODS

In a pilot trial, patients hospitalized with AMI were randomized to the use of the AMI Choice conversation tool or to usual care. AMI Choice includes a pictogram of the patient's estimated risk of mortality at 6 months with and without guideline-recommended medications, ie, aspirin, statins, beta-blockers, and angiotensin-converting enzyme inhibitors. Primary outcomes were patient knowledge and conflict with the decision made assessed via post-encounter surveys. Secondary outcomes were patient involvement in the decision-making process (observer-based OPTION12 scale) and 6-month medication adherence.

RESULTS

Patient knowledge of the expected survival benefit from taking medications was significantly higher (62% vs 16%, p<0.0001) in the AMI Choice group (n = 53) compared to the usual care group (n = 53). Both groups reported similarly low levels of conflict with the decision to start the medications (13 (SD 24.2) vs 16 (SD 22) out of 100; p=0.16). The extent to which clinicians in the AMI Choice group involved their patients in the decision-making process was high (OPTION12 score 53 out of 100, SD 12). Medication adherence at 6-months was relatively high in both groups and not different between groups.

CONCLUSION

The AMI Choice conversation tool improved patients' knowledge of their estimated risk of short-term mortality after an AMI and the pros and cons of treatments to reduce this risk. The effect on patient fidelity to recommended medications of using this SDM tool and of SDM in general should be tested in larger trials enrolling patients at high risk for nonadherence.

TRIAL REGISTRATION NUMBER

NCT00888537.

Long-Term Effectiveness of a Decision Support App (Pink Journey) for Women Considering Breast Reconstruction Surgery: Pilot Randomized Controlled Trial

Background

Various kinds of breast reconstruction (BR) options, including implants and autologous, and surgery techniques, including traditional and endoscope assisted, can be used to perform surgery. All options have their own advantages and disadvantages. Women decide on an option depending on the values and preferences they emphasize. Lacking knowledge about BR or having decision difficulties during the treatment decision process makes women experience more decision regret, psychological distress, and poor body image. Delivering decision support with a values clarification exercise using eHealth approaches would be beneficial for patient outcomes.

Objective

This study aims to examine the effects of a decision support app on decision-making quality and psychological morbidity for women considering BR surgery.

Methods

This randomized controlled trial included women who were over 20 years of age and were newly diagnosed with breast cancer and candidates for mastectomy. Women having an option for breast conservation were excluded. After being referred from the outpatient physician, the women provided consent and completed the baseline assessment. Women allocated to the control group (CG) received usual care and were provided with a pamphlet with information about types of surgery and the advantages and disadvantages of different surgery types. Women allocated to the intervention group (IG) were given the same pamphlet and guided to use the Pink Journey app to support their decision. Then they were also prompted to discuss the opinions with their significant others. Finally, the decision-making process of using the app was printed out for women that they could take home. Decision conflict, anxiety, and depression were measured at baseline. At 1 week after the intervention (T1) and at 1 month (T2), 8 months (T3), and 12 months (T4) after surgery, the women completed decision conflict, decision regret, anxiety, depression, and body image scales. An intention-to-treat analysis was performed.

Results

From February 2018 to July 2019, 96 women were randomly assigned to the CG (n=48) or the IG (n=48). Results revealed that body image distress declined significantly for the IG but increased for the CG. The interaction of time and group also reached significance, indicating a significant decrease in body image distress from baseline in the IG compared with the CG after the 12th month (T4) follow-up (β=–2.25, standard error=1.01, P=.027). However, there was no significant difference in decision conflict (P=.21-.87), decision regret (P=.44-.55), anxiety (P=.26-.33), and depression (P=.20-.75), indicating that the decrease in these outcomes in the IG was not greater than those in the CG.

Conclusions

Although we found no effect on decision conflict, decision regret, anxiety, and depression, a decision aid that combines surgery information and values clarification can help women reduce their body image distress.

Trial Registration

ClinicalTrials.gov NCT04190992; https://clinicaltrials.gov/ct2/show/NCT04190992

Shared decision-making and the implementation of treatment recommendations for depression

OBJECTIVE

This study aimed to examine the relationship between shared decision-making (SDM) and the implementation of treatment recommendations amongst outpatients at a specialist Depression Clinic.

METHODS

A total of 110 adult outpatients in a specialist Depression Clinic in Sydney, Australia, completed an online survey examining their experiences of shared decision-making (SDM) during their psychiatrist consultation and the extent to which they later implemented Depression Clinic treatment recommendations.

RESULTS

The odds of implementing treatment recommendations were over four times higher in patients who reported a high level of SDM in their consultation, compared to those who reported a low level of SDM. Further, three elements of patient-rated SDM were significantly associated with an increased likelihood of implementing depression treatment recommendations. These three elements were: i) being given the opportunity to ask questions or voice concerns; ii) being asked about any problems or side effects from previous treatments; and iii) being involved in deciding their treatment plan.

CONCLUSIONS

SDM was significantly associated with an increased likelihood of implementing psychiatrists' treatment recommendations at a specialist Depression Clinic.

PRACTICE IMPLICATIONS

We recommend that clinicians be informed of the potential benefits of SDM and adopt SDM when developing treatment plans with patients living with depression.

Association Between Patient-Clinician Relationships and Adherence to Antihypertensive Medications Among Black Adults: An Observational Study Design

Background We assessed the associations between patient-clinician relationships (communication and involvement in shared decision-making [SDM]) and adherence to antihypertensive medications. Methods and Results The 2010 to 2017 Medical Expenditure Panel Survey (MEPS) data were analyzed. A retrospective cohort study design was used to create a cohort of prevalent and new users of antihypertensive medications. We defined constructs of patient-clinician communication and involvement in SDM from patient responses to the standard questionnaires about satisfaction and access to care during the first year of surveys. Verified self-reported medication refill information collected during the second year of surveys was used to calculate medication refill adherence; adherence was defined as medication refill adherence ≥80%. Survey-weighted multivariable-adjusted logistic regression models were used to measure the odds ratio (OR) and 95% CI for the association between both patient-clinician constructs and adherence. Our analysis involved 2571 Black adult patients with hypertension (mean age of 58 years; SD, 14 years) who were either persistent (n=1788) or new users (n=783) of antihypertensive medications. Forty-five percent (n=1145) and 43% (n=1016) of the sample reported having high levels of communication and involvement in SDM, respectively. High, versus low, patient-clinician communication (OR, 1.38; 95% CI, 1.14-1.67) and involvement in SDM (OR, 1.32; 95% CI, 1.08-1.61) were both associated with adherence to antihypertensives after adjusting for multiple covariates. These associations persisted among a subgroup of new users of antihypertensive medications. Conclusions Patient-clinician communication and involvement in SDM are important predictors of optimal adherence to antihypertensive medication and should be targeted for improving adherence among Black adults with hypertension.

Identifying research gaps: A review of virtual patient education and self-management

BACKGROUND

Avatars in Virtual Reality (VR) can not only represent humans, but also embody intelligent software agents that communicate with humans, thus enabling a new paradigm of human-machine interaction.

OBJECTIVE

The research agenda proposed in this paper by an interdisciplinary team is motivated by the premise that a conversation with a smart agent avatar in VR means more than giving a face and body to a chatbot. Using the concrete communication task of patient education, this research agenda is rather intended to explore which patterns and practices must be constructed visually, verbally, para- and nonverbally between humans and embodied machines in a counselling context so that humans can integrate counselling by an embodied VR smart agent into their thinking and acting in one way or another.

METHODS

The scientific literature in different bibliographical databases was reviewed. A qualitative narrative approach was applied for analysis.

RESULTS

A research agenda is proposed which investigates how recurring consultations of patients with healthcare professionals are currently conducted and how they could be conducted with an embodied smart agent in immersive VR.

CONCLUSIONS

Interdisciplinary teams consisting of linguists, computer scientists, visual designers and health care professionals are required which need to go beyond a technology-centric solution design approach. Linguists' insights from discourse analysis drive the explorative experiments to identify test and discover what capabilities and attributes the smart agent in VR must have, in order to communicate effectively with a human being.

A Real-Time Artificial Intelligence-Assisted System to Predict Weaning from Ventilator Immediately after Lung Resection Surgery

Assessment of risk before lung resection surgery can provide anesthesiologists with information about whether a patient can be weaned from the ventilator immediately after surgery. However, it is difficult for anesthesiologists to perform a complete integrated risk assessment in a time-limited pre-anesthetic clinic. We retrospectively collected the electronic medical records of 709 patients who underwent lung resection between 1 January 2017 and 31 July 2019. We used the obtained data to construct an artificial intelligence (AI) prediction model with seven supervised machine learning algorithms to predict whether patients could be weaned immediately after lung resection surgery. The AI model with Naïve Bayes Classifier algorithm had the best testing result and was therefore used to develop an application to evaluate risk based on patients' previous medical data, to assist anesthesiologists, and to predict patient outcomes in pre-anesthetic clinics. The individualization and digitalization characteristics of this AI application could improve the effectiveness of risk explanations and physician-patient communication to achieve better patient comprehension.

Interventions to facilitate shared decision-making using decision aids with patients in Primary Health Care: A systematic review

BACKGROUND

Shared decision making (SDM) is a process within the physician-patient relationship applicable to any clinical action, whether diagnostic, therapeutic, or preventive in nature. It has been defined as a process of mutual respect and participation between the doctor and the patient. The aim of this study is to determine the effectiveness of decision aids (DA) in primary care based on changes in adherence to treatments, knowledge, and awareness of the disease, conflict with decisions, and patients' and health professionals' satisfaction with the intervention.

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted in Medline, CINAHL, Embase, the Cochrane Central Register of Controlled Trials, and the NHS Economic Evaluation Database. The inclusion criteria were randomized clinical trials as study design; use of SDM with DA as an intervention; primary care as clinical context; written in English, Spanish, and Portuguese; and published between January 2007 and January 2019. The risk of bias of the included studies in this review was assessed according to the Cochrane Collaboration's tool.

RESULTS

Twenty four studies were selected out of the 201 references initially identified. With the use of DA, the use of antibiotics was reduced in cases of acute respiratory infection and decisional conflict was decreased when dealing with the treatment choice for atrial fibrillation and osteoporosis. The rate of determination of prostate-specific antigen (PSA) in the prostate cancer screening decreased and colorectal cancer screening increased. Both professionals and patients increased their knowledge about depression, type 2 diabetes, and the perception of risk of acute myocardial infarction at 10 years without statins and with statins. The satisfaction was greater with the use of DA in choosing the treatment for depression, in cardiovascular risk management, in the treatment of low back pain, and in the use of statin therapy in diabetes. Blinding of outcomes assessment was the most common bias.

CONCLUSIONS

DA used in primary care are effective to reduce decisional conflict and improve knowledge on the disease and treatment options, awareness of risk, and satisfaction with the decisions made. More studies are needed to assess the impact of shared decision making in primary care.

Satisfaction in parturients receiving epidural analgesia after prenatal shared decision-making intervention: a prospective, before-and-after cohort study

Background

The explanation of epidural analgesia by anesthesiologist would often begin after the parturient is admitted to the hospital. Because of labor pain, the decision of receiving epidural analgesia would often be made by the family members, instead of the parturient herself. We aimed to test whether earlier prenatal shared decision-making (SDM) interventions increase parturient’s comprehension and satisfaction of epidural labor analgesia, compared to conventional explanation after labor pain begun.

Methods

During the 28th week of gestation, we provided the SDM parturient health education as well as a leaflet with quick response codes. Scanning the code would link to education videoclips which explained what epidural analgesia is and its advantages and disadvantages. Original routine practice group parturients received explanation of analgesia after admission for delivery. To measure the satisfaction of labor pain service, the accessibility of information, and the communication with medical staff, we designed a questionnaire with reference to (1) Pregnancy and Maternity Care Patients’ Experiences Questionnaire (PreMaPEQ), (2) Preterm Birth Experience and Satisfaction Scale (P-BESS), and (3) Women’s Views of Birth Labor Satisfaction Questionnaire (WOMBLSQ). The questionnaire was amended after a pretest involving 30 parturients who had received epidural analgesia. Scree test analysis and exploratory factor analysis were performed; then, the questionnaire was revised again. A total of 200 valid questionnaires were collected—100 each from the original routine practice group and the SDM group.

Results

The SDM group reported significantly higher satisfaction with and understanding of epidural analgesia, and a significantly higher satisfaction with the information received, and the quality of pain relief. After SDM intervention, significant increasement of the average satisfaction scores in question “my epidural is effective” (9.10%; mean difference: 0.38; 95% confidence interval, 0.17 ~ 0.59; p < 0.001) and “The effect of epidural is just as what I have expected” (10.41%; mean difference: 0.41; 95% confidence interval, 0.18 ~ 0.64; p < 0.001) was demonstrated.

Conclusions

An earlier prenatal SDM intervention with sufficient information through videoclips increased parturients’ comprehensions and satisfaction of epidural analgesia service.

Trial registration

ISRCTN registry, 14,256,563. Registered April 1st, 2020 (10.1186/ISRCTN14256563).

New galaxies in the universe of shared decision-making and rheumatoid arthritis

PURPOSE OF REVIEW

Implementing shared decision-making (SDM) is a top international priority to improve care for persons living with rheumatoid arthritis. Using SDM tools, such as decision aids improve patients' knowledge and support communication with their clinicians on treatment benefits and risks. Despite calls for SDM in treat-to-target, studies demonstrating effective SDM strategies in rheumatology clinical practice are scarce. Our objective was to identify recent and relevant literature on SDM in rheumatoid arthritis.

RECENT FINDINGS

We found a burgeoning literature on SDM in rheumatoid arthritis that tackles issues of implementation. Studies have evaluated the SDM process within clinical consultations and found that uptake is suboptimal. Trials of newly developed patient decision aids follow high methodological standards, but large-scale implementation is lacking. Innovative SDM strategies, such as shared goals and preference phenotypes may improve implementation of treat-to-target approach. Research and patient engagement are standardizing measures of SDM for clinical uses.

SUMMARY

Uptake of SDM in rheumatoid arthritis holds promise in wider clinicians' and patients' awareness, availability of decision aids, and broader treat-to-target implementation strategies, such as the learning collaborative. Focused attention is needed on facilitating SDM among diverse populations and those at risk of poorer outcomes and barriers to communication.