Factors associated with level of shared decision making in Malaysian primary care consultations

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.

Patients’ and physicians’ gender and perspective on shared decision-making: A cross-sectional study from Dubai

Background

Delivering patient-centered care is a declared objective of many health delivery systems globally, especially in an era of value-based health care. It entails the active engagement of the patients in healthcare decisions related to their health, also known as shared decision making (SDM). Little is known about the role of gender in shaping the perspective of patients on their opportunity for engaging in SDM in the Arabian Gulf Region. The aim of this study is to investigate the role of gender in shaping patients’ perspectives toward their opportunity for SDM in Dubai, UAE.

Methods

This study utilized a cross-sectional survey consisting of sociodemographic questions and the 9-item Shared Decision-Making Questionnaire (SDM-Q-9). A total of 50 physicians (25 females and 25 males), practicing at a large private healthcare delivery network in Dubai, were recruited using convenience sampling. Ten patients of every recruited physician (5 male and 5 female) were surveyed (i.e., a total of 500 patients). Statistical analysis assessed the differences in patients’ perceptions of physician SDM attitude scores by physicians’ and patients’ gender using independent t-test, ANOVA-test, and Chi-square analyses.

Findings

A total of 50 physicians and 500 patients (250 male patients and 250 female patients) participated in this study. The odd of patients agreement was significantly lower for male physicians, compared to their female counterparts, on the following elements of SDM: the doctor precisely explaining the advantages and disadvantages of the treatment (OR = 0.55, 95%CI: 0.34–0.88, p = 0.012); the doctor helping them understand the information (OR = 0.47, 95%CI: 0.23–0.97, p = 0.038), the doctor asking about preferred treatment option (OR = 0.52, 95%CI: 0.35–0.77, p = 0.001), and the doctor thoroughly weighting the different treatment options (OR = 0.60, 95%CI: 0.41–0.90, p = 0.013). No significant associations were observed between patients’ gender and their perception of their opportunity for SDM. Likewise, no significant associations were observed between the same or different physician-patient gender and patients’ perception of physicians’ SDM attitudes. Statistically significant associations were observed between physician-patient gender and preferred treatment option for patients (p = 0.012).

Conclusion

Study findings suggest that while there were no differences in patients’ perspective on SDM by the gender of patients, significant differences were observed by the gender of physicians. Female physicians, compared to their male counterparts, were more engaged in SDM, with both male and female patients. Male physician-female patient dyad received the lowest scores on SDM. This could be explained by the cultural, social, and religious sensitivities that infiltrate the physician-patient relationship in the Arab contexts. Despite the multi-cultural nature of the country, some female patients may still experience some discomfort in opening up and in discussion preferences with male physicians. For physicians, striking the right balance between assertiveness and SDM is necessary within the cultural context, especially among male providers. Offering targeted learning and development programs on the importance and practice of SDM is also necessary to ensure equitable opportunity for engagement in SDM for all patients irrespective of the gender of their provider.

Exploring motivations and resistances for implementing shared decision-making in clinical practice: A systematic review based on a structure-process-outcome model

OBJECTIVE

Shared decision-making (SDM) as a multicollaborative approach is vital for facilitating patient-centred care. Considering the limited clinical practice, we attempted to synthesize the motivations and resistances, and investigate their mutual relationships for advancing the implementation of SDM.

METHODS

A comprehensive systematic review using Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines was performed. 'Shared decision making' was searched as the mesh term through PubMed, Web of Science and EBSCO from 2000 to 2021, and the quality of literature was appraised using the QualSyst Tool. Motivations and resistances were categorized based on content analysis and the 'structure-process-outcome' model.

RESULTS

From 8319 potential citations, 105 were included, comprising 53 qualitative studies (the average quality score is 0.92) and 52 quantitative studies (the average quality score is 0.95). A total of 42 categories of factors were identified into 11 themes and further grouped into three dimensions: structure, process and outcome. The structure dimension comprised six themes (71.43%), the process dimension contained four themes (11.01%) and the outcome dimension covered only one theme. Across all categories, decision-making time and patients' decision preparedness in the process dimension were the most reported, followed by physicians' communication skills and health care environment in the structure dimension. Analysis of implementation of SDM among various types of diseases showed that more influencing factors were extracted from chronic diseases and unspecified disease decisions.

CONCLUSIONS

The major determinants for the implementation of SDM are focused on the structural dimension, which challenges the health systems of both developed and low- and middle-income countries. Furthermore, we consider it important to understand more about the interactions among the factors to take integrated measures to address the problems and to ensure the effectiveness of implementing SDM.

PATIENT OR PUBLIC CONTRIBUTION

Patients, healthcare professionals and other stakeholders articulated their perspectives on the implementation of SDM actively, and these were adopted and analysed in this study. However, the above-mentioned individuals were not directly involved in the process of this study. Protocol was registered on PROSPERO (CRD42021259309).

Insights into Delivering Cross-Cultural Medical Education in the UK and Malaysia

Newcastle University UK operates an international campus, NUMed, in Malaysia. NUMed delivers the same medical degree programme as in the UK, within a different cultural context. In this paper, medical education faculty and NUMed graduates with experience working in both the UK and Malaysia provide insights into cross-cultural diversity in approaches to learning. Observations from small and large group teaching and approaches to assessment are discussed in relation to students' cultural backgrounds including previous learning experiences and English language abilities. We provide practice points for educators preparing a diverse range of students to work in global healthcare settings.

Relationships among Antecedents, Processes, and Outcomes for Shared Decision Making: A Cross-Sectional Survey of Patients with Lumbar Degenerative Disease

BACKGROUND

Among musculoskeletal disorders, lumbar degenerative disease (LDD) is the leading cause of total disability-adjusted life years globally. Clinical guidelines for LDD describe multiple treatment options in which shared decision making becomes appropriate.

OBJECTIVES

To explore the relationships among measures of decision antecedents, process, and outcomes in patients with LDD.

METHODS

Patients with LDD were recruited from outpatient clinics in a teaching hospital in Taiwan and administered surveys to collect measures of decision antecedents, processes, and outcomes. Multiple linear regression was conducted to assess the association between decision antecedents and the decision making process. Hierarchical linear regression was conducted to assess the relationships among decision antecedents, the decision making process, and decision outcomes.

RESULTS

A total of 132 patients (mean age, 61 years) completed the survey. After adjustment for personal factors, 2 decision antecedents (namely, decision making self-efficacy and readiness) significantly predicted patients' experiences of engaging in shared decision making (SDM). Decision making readiness and process were associated with fewer decisional conflicts and greater decision satisfaction.

LIMITATIONS

Models derived from cross-sectional surveys cannot establish causal relationships among decision antecedents, decision making processes, and decision outcomes.

CONCLUSIONS

Our results support the SDM framework, which proposes relationships among decision antecedents, the decision making process, and decision outcomes.

Clinician Factors Rather Than Patient Factors Affect Discussion of Treatment Options

BACKGROUND

Shared decision-making aims to combine what matters most to a patient with clinician expertise to develop a personalized health strategy. It is a dialogue between patient and clinician in which preferences are expressed, misconceptions reoriented, and available options are considered. To improve patient involvement, it would help to know more about specific barriers and facilitators of patient-clinician communication. Health literacy, the ability to obtain, process, and understand health information, may affect patient participation in decision-making. If the patient is quiet, deferential, and asks few questions, the clinician may assume a more paternalistic style. A patient with greater agency and engagement could be the catalyst for shared decisions.

QUESTIONS/PURPOSES

We assessed (1) whether effective clinician communication and effort is related to patient health literacy, and (2) if there are other factors associated with effective clinician communication and effort.

METHODS

We combined a prospective, cross-sectional cohort of 86 audio-recorded visits of adult patients seeking specialist hand care for a new problem at an urban community hospital in the Netherlands with a cohort of 72 audio-recorded hand surgery visits from a tertiary hospital in the United States collected for a prior study. The American cohort represents a secondary use of data from a set of patients from a separate study using audio-recorded visits and administering similar questionnaires that assessed different endpoints. In both cohorts, adult patients seeking specialist hand care for a new problem were screened. In total, 165 patients were initially screened, of which 96% (158) participated. Eight percent (13) of visits were excluded since the final diagnosis remained unclear, 8% (12) since it was not the first consultation for the current problem, 5% (8) in which only one treatment option was available, and < 1% (1) since there was a language barrier. A total of 123 patients were analyzed, 68 from the Netherlands and 55 from the United States. The Newest Vital Sign (NVS) health literacy test, validated in both English and Dutch, measures the ability to use health information and is based on a nutrition label from an ice cream container. It was used to assess patient health literacy on a scale ranging from 0 (low) to 6 (high). The 5-item Observing Patient Involvement (OPTION5) instrument is commonly used to assess the quality of patient-clinician discussion of options. Scores may be influenced by clinician effort to involve patients in decision-making as well as patient engagement and agency. Each item is scored from 0 (no effort) to 4 (maximum effort), with a total maximum score of 20. Two independent raters reached agreement (kappa value 0.8; strong agreement), after which all recordings were scored by one investigator. Visit duration and patient questions were assessed using the audio recordings. Patients had a median (interquartile range) age of 54 (38 to 66) years, 50% were men, 89% were white, 66% had a nontraumatic diagnosis, median (IRQ) years of education was 16 (12 to 18) years, and median (IQR) health literacy score was 5 (2 to 6). Median (IQR) visit duration was 9 (7 to 12) minutes. Cohorts did not differ in important ways. The number of visits per clinician ranged from 14 to 29, and the mean overall communication effectiveness and effort score for the visits was low (8.5 ± 4.2 points of 20 points). A multivariate linear regression model was used to assess factors associated with communication effectiveness and effort.

RESULTS

There was no correlation between health literacy and clinician communication effectiveness and effort (r = 0.087 [95% CI -0.09 to 0.26]; p = 0.34), nor was there a difference in means (SD) when categorizing health literacy as inadequate (7.8 ± 3.8 points) and adequate (8.9 ± 4.5 points; mean difference 1.0 [95% CI -2.6 to 0.54]; p = 0.20). After controlling for potential confounding variables such as gender, patient questions, and health literacy, we found that longer visit duration (per 1 minute increase: r2 = 0.31 [95% CI -0.14 to 0.48]; p < 0.001), clinician 3 (compared with clinician 1: OR 33 [95% CI 4.8 to 229]; p < 0.001) and clinician 5 (compared with clinician 1: OR 11 [95% CI 1.5 to 80]; p = < 0.02) were independently associated with more effective communication and effort, whereas clinician 6 was associated with less effective communication and effort (compared with clinician 1: OR 0.08 [95% CI 0.01 to 0.75]; p = 0.03). Clinicians' communication strategies (the clinician variable on its own) accounted for 29% of the variation in communication effectiveness and effort, longer visit duration accounted for 11%, and the full model accounted for 47% of the variation (p < 0.001).

CONCLUSION

The finding that the overall low mean communication effectiveness and effort differed between clinicians and was not influenced by patient factors including health literacy suggests clinicians may benefit from training that moves them away from a teaching or lecturing style where patients receive rote directives regarding their health. Clinicians can learn to adapt their communication to specific patient values and needs using a guiding rather than directing communication style (motivational interviewing).Level of Evidence Level II, prognostic study.