Is patient involvement possible when decisions involve scarce resources? A qualitative study of decision-making in primary care

'Walking together': How relationships shape physicians' clinical reasoning

INTRODUCTION

The clinical reasoning literature has increasingly considered context as an important influence on physicians' thinking. Physicians' relationships with patients, and their ongoing efforts to maintain these relationships, are important influences on how clinical reasoning is contextualised. The authors sought to understand how physicians' relationships with patients shaped their clinical reasoning.

METHODS

Drawing from constructivist grounded theory, the authors conducted semi-structured interviews with primary care physicians. Participants were asked to reflect on recent challenging clinical experiences, and probing questions were used to explore how participants attended to or leveraged relationships in conjunction with their clinical reasoning. Using constant comparison, three investigators coded transcripts, organising the data into codes and conceptual categories. The research team drew from these codes and categories to develop theory about the phenomenon of interest.

RESULTS

The authors interviewed 15 primary care physicians with a range of experience in practice and identified patient agency as a central influence on participants' clinical reasoning. Participants drew from and managed relationships with patients while attending to patients' agency in three ways. First, participants described how contextualised illness constructions enabled them to individualise their approaches to diagnosis and management. Second, participants managed tensions between enacting their typical approaches to clinical problems and adapting their approaches to foster ongoing relationships with patients. Finally, participants attended to relationships with patients' caregivers, seeing these individuals' contributions as important influences on how their clinical reasoning could be enacted within patients' unique social contexts.

CONCLUSION

Clinical reasoning is influenced in important ways by physicians' efforts to both draw from, and maintain, their relationships with patients and patients' caregivers. Such efforts create tensions between their professional standards of care and their orientations toward patient-centredness. These influences of relationships on physicians' clinical reasoning have important implications for training and clinical practice.

Expectations and Experiences of a Group of Patients Enrolled in an Educational Program for Rheumatoid Arthritis at a Specialized Care Center in Colombia

Introduction

Rheumatoid arthritis is a chronic inflammatory disease diagnosed in a productive stage of life. Patients with RA experience changes in their musculoskeletal system, overall health and quality of life. It has been identified that patients with RA do not have appropriate knowledge about their condition. Educational programs can provide new knowledge, accompaniment, and closer follow-up to improve empowerment and quality of life in patients with RA.

Purpose

To describe rheumatoid arthritis patients' experiences, perceptions, and expectations when enrolling on a multicomponent educational program in a specialized RA setting.

Patients and Methods

A qualitative study was done. Patients with RA who attended a specialized center and enrolled in an educational program participated in two focus groups. The focus group discussions and the interviews were recorded, transcribed verbatim, analyzed, and emerging themes were constructed.

Results

Thirty-one participants were included in the focus groups. The median age was 60 years IQR (54-67), 92% were female. Two relevant categories emerged: first, the experience of being diagnosed with RA. Second, the program's ability to empower participants with knowledge and the possibility of transferring knowledge to other patients with the same condition. In addition, patients gave a high score to the expectations regarding the educational program.

Conclusion

Understanding patients' expectations when enrolling in an educational program allows educators and clinicians to understand their motivations to create tailored programs that can contribute to acquiring empowerment in the educational process and managing their disease. Stakeholders should consider patients' expectations when implementing these interventions for patients with RA to adapt the intervention according to the patient's context and needs, which will directly affect the patient's adherence and lead to better use and allocation of resources for educational activities.

Shared decision making in peri-operative medicine: Miles to go in Indian scenario

Shared Decision Making (SDM) in peri-operative medicine is increasingly encouraged as an ideal model of treatment decision making in the medical encounter. Moreover, it has the potential to improve the quality of the decision-making process for patients and ultimately, patient outcomes. This review focuses on several published literature on SDM in peri-operative medicine, its Implementation, barriers faced by Patient and the Provider, Myths regarding SDM and current scenario of SDM in India. Within the anesthetic community, patient consent is vigorously guided. However, this community suffers from lack of advancements in implementing the patient-focused rather than doctor-focused characteristics of SDM. Out of the several barriers, the most common barrier towards the implementation of SDM is the lack of time from the provider community. Within the anesthesia domain, the consultations discussed directly preceding the surgery do not pursue the customary and highly organized stages of typical outpatient consultations. Under these backgrounds and to be successfully implemented, it becomes imperative to begin the process of SDM pre-operative assessment clinic targeting both the high- and low-risk patients. It is critical to summarise that SDM does not end at the time of anesthesia for the peri-operative healthcare professional, but it gets to carry forward until patient discharge. Therefore, it is carried as the Pinnacle of Patient-Centred Care.

Patient and public involvement facilitators: Could they be the key to the NHS quality improvement agenda?

OBJECTIVE

Research into patient and public involvement (PPI) has not examined in detail patient and public involvement facilitators' (PPIFs) roles and activities. This study analysed PPIFs' roles using qualitative data gathered from three different UK health-care organizations.

DESIGN

Thematic analysis was used to examine cross-sectional data collected using a mixed-methods approach from three organizations: a mental health trust, a community health social enterprise and an acute hospital trust. The data set comprised of 27 interviews and 48 observations.

FINDINGS

Patient and public involvement facilitators roles included the leadership and management of PPI interventions, developing health-care practices and influencing quality improvements (QI). They usually occupied middle-management grades but their PPIF role involved working in isolation or in small teams. They reported facilitating the development and maintenance of relationships between patients and the public, and health-care professionals and service managers. These roles sometimes required them to use conflict resolution skills and involved considerable emotional labour. Integrating information from PPI into service improvement processes was reported to be a challenge for these individuals.

CONCLUSIONS

Patient and public involvement facilitators capture and hold information that can be used in service improvement. However, they work with limited resources and support. Health-care organizations need to offer more practical support to PPIFs in their efforts to improve care quality, particularly by making their role integral to developing QI strategies.

To what degree do patients actively choose their healthcare provider at the point of referral by their GP? A video observation study

BACKGROUND

Many countries in Europe have implemented managed competition and patient choice during the last decade. With the introduction of managed competition, health insurers also became an important stakeholder. They purchase services on behalf of their customers and are allowed to contract healthcare providers selectively. It has, therefore, become increasingly important to take one's insurance into account when choosing a provider. There is little evidence that patients make active choices in the way that policymakers assume they do. This research aims to investigate, firstly, the role of patients in choosing a healthcare provider at the point of referral, then the role of the GP and, finally, the influence of the health insurer/insurance policies within this process.

METHODS

We videotaped a series of everyday consultations between Dutch GPs and their patients during 2015 and 2016. In 117 of these consultations, with 28 GPs, the patient was referred to another healthcare provider. These consultations were coded by three observers using an observation protocol which assessed the role of the patient, GP, and the influence of the health insurer during the referral.

RESULTS

Patients were divided into three groups: patients with little or no input, patients with some input, and those with a lot of input. Just over half of the patients (56%) seemed to have some, or a lot of, input into the choice of a healthcare provider at the point of referral by their GP. In addition, in almost half of the consultations (47%), GPs inquired about their patients' preferences regarding a healthcare provider. Topics regarding the health insurance or insurance policy of a patient were rarely (14%) discussed at the point of referral.

CONCLUSIONS

Just over half of the patients appear to have some, or a lot of, input into their choice of a healthcare provider at the point of referral by their GP. However, the remainder of the patients had little or no input. If more patient choice continues to be an important aim for policy makers, patients should be encouraged to actively choose the healthcare provider who best fits their needs and preferences.

Taking societal cost into clinical consideration: U.S. physicians' views

BACKGROUND

Recent campaigns (e.g., the American Board of Internal Medicine Foundation's Choosing Wisely) reflect the increasing role that physicians are expected to have in stewarding health care resources. We examine whether physicians believe they should pay attention to societal costs or refuse requests for costly interventions with little chance of patient benefit.

METHODS

We conducted a secondary analysis of data from a 2010 national survey of 2016 U.S. physicians sampled from the AMA Physician Masterfile. Criterion measures were agreement or disagreement with two survey items related to costs of care. We also examined whether physicians' practice and religious characteristics were associated with their responses.

RESULTS

The adjusted response rate was 62% (1156/1878). Forty-seven percent of physicians agreed that physicians "should not consider the societal cost of medical care when caring for individual patients," whereas 69% agreed that physicians "should refuse requests from patients or their families for costly interventions that have little chance of benefitting the patient." Physicians in specialties that care for patients at the end of life were more supportive of refusing such costly interventions. We did not find consistent associations between physicians' religiosity and their responses to these items, though those least supportive of taking into account societal cost were disproportionately from Christian affiliations.

CONCLUSION

Physicians were nearly evenly divided regarding whether they should help control societal costs when caring for individual patients, but a strong majority agreed that physicians should refuse costly interventions that have little chance of benefit.

Shared Decision-Making in Growth Hormone Therapy-Implications for Patient Care

Several studies have shown that adherence to growth hormone therapy (GHT) is not optimal. There are several reasons why patients may not fully adhere to their treatment regimen and this may have implications on treatment success, patient outcomes and healthcare spending and resourcing. A change in healthcare practices, from a physician paternalistic to a more patient autonomous approach to healthcare, has encouraged a greater onus on a shared decision-making (SDM) process whereby patients are actively encouraged to participate in their own healthcare decisions. There is growing evidence to suggest that SDM may facilitate patient adherence to GHT. Improved adherence to therapy in this way may consequently positively impact treatment outcomes for patients. Whilst SDM is widely regarded as a healthcare imperative, there is little guidance on how it should be best implemented. Despite this, there are many opportunities for the implementation of SDM during the treatment journey of a patient with a GH-related disorder. Barriers to the successful practice of SDM within the clinic may include poor patient education surrounding their condition and treatment options, limited healthcare professional time, lack of support from clinics to use SDM, and healthcare resourcing restrictions. Here we discuss the opportunities for the implementation of SDM and the barriers that challenge its effective use within the clinic. We also review some of the potential solutions to overcome these challenges that may prove key to effective patient participation in treatment decisions. Encouraging a sense of empowerment for patients will ultimately enhance treatment adherence and improve clinical outcomes in GHT.

Decision making in NICE single technological appraisals: How does NICE incorporate patient perspectives?

CONTEXT

The National Institute for Health and Care Excellence (NICE) has an explicit mandate to include patient and public involvement in the appraisal of medicines to be available for funding on the NHS. NICE involves an appraisal committee who are required to take on board experiential evidence from patient experts alongside population-based evidence on clinical and cost-effectiveness when making a decision whether to fund a drug.

OBJECTIVE

This paper considers how NICE Single Technological Appraisal (STA) committees attempt to incorporate the views of patients in making decisions about funding medicines on the NHS.

METHODS

A prospective design was employed to follow three pharmaceutical products involving three different appraisal committees. Three data collection methods were used: analysis of documentary evidence sent by NICE, non-participant unstructured observations of the open and closed sessions of meetings and qualitative interviews.

SETTINGS AND PARTICIPANTS

Unstructured non-participant observations were carried out at nine STA meetings, and 41 semi-structured interviews were undertaken with committee members from NICE's STA committees, patient experts, analysts from NICE's project team and drug manufacturers.

RESULTS

Our analysis showed how the committees displayed a preference for an ideal-type of patient representative, disagreement among the committee when weighing-up patient statements in the STA process and more pre-preparation support for patient involvement.

CONCLUSIONS

Although NICE has attempted to adopt an approach flexible to patients and carers through formal decision-making arrangements that incorporate patient views, nonetheless, the processes of the STAs can in fact undermine the very evidence collected from patient representatives.

Wasting the doctor's time? A video-elicitation interview study with patients in primary care

Reaching a decision about whether and when to visit the doctor can be a difficult process for the patient. An early visit may cause the doctor to wonder why the patient chose to consult when the disease was self-limiting and symptoms would have settled without medical input. A late visit may cause the doctor to express dismay that the patient waited so long before consulting. In the UK primary care context of constrained resources and government calls for cautious healthcare spending, there is all the more pressure on both doctor and patient to meet only when necessary. A tendency on the part of health professionals to judge patients' decisions to consult as appropriate or not is already described. What is less well explored is the patient's experience of such judgment. Drawing on data from 52 video-elicitation interviews conducted in the English primary care setting, the present paper examines how patients seek to legitimise their decision to consult, and their struggles in doing so. The concern over wasting the doctor's time is expressed repeatedly through patients' narratives. Referring to the sociological literature, the history of 'trivia' in defining the role of general practice is discussed, and current public discourses seeking to assist the patient in developing appropriate consulting behaviour are considered and problematised. Whilst the patient is expected to have sufficient insight to inform timely consulting behaviour, it becomes clear that any attempt on the part of doctor or patient to define legitimate help-seeking is in fact elusive. Despite this, a significant moral dimension to what is deemed appropriate consulting by doctors and patients remains. The notion of candidacy is suggested as a suitable framework and way forward for encompassing these struggles to negotiate eligibility for medical time.

Interprofessional simulation to improve patient participation in transitional care

BACKGROUND

Educating and training healthcare professionals is known to improve the quality of transitional care for older adults. Arranging interprofessional meetings for healthcare professionals might be useful to improve patient participation skills in transitional care.

AIM

To describe the learning activities used in The Meeting Point programme, focusing on patient participation in transitional care, and assess whether they increase healthcare professionals' awareness of and competencies relating to patient participation in the transitional care of older patients.

DESIGN

Data were collected as part of an educational intervention programme, The Meeting Point, including three seminars on 'Patient participation in the transitional care of older patients' and four follow-up meetings. Participants were nurses, care assistants, doctors, physiotherapists, patient coordinators and administrative personnel from hospital, nursing homes and home-based care services.

METHOD

The Meeting Point was organised around four pillars: introduction, teaching session, group work activity and plenary discussion. Qualitative data included log reports, summaries of meetings, notes from group work activities, and reports from participants and from follow-up meetings.

RESULTS

Feedback from participants shows that they were satisfied with meeting healthcare professionals from other units of care. A film scenario was perceived relevant for group work activity and useful in focusing participants' attention to patient participation. Follow-up meetings show that some nursing home wards, the emergency department and one medical ward at the hospital continued with ongoing work to improve quality of care. Efforts included implementation of an observational waiting room with comfortable chairs, planning for discharge in hospital admission, a daily patient flow registration system and motivational interviewing during admission to nursing home.

CONCLUSIONS

The description of the learning activities used at The Meeting Point seminars shows that they were useful to increase awareness of and competencies on patient participation in transitional care.

Patient and public involvement: how much do we spend and what are the benefits?

BACKGROUND AND OBJECTIVES

Patient and public involvement (PPI) is seen as a way of helping to shape health policy and ensure a patient-focused health-care system. While evidence indicates that PPI can improve health-care decision making, it also consumes monetary and non-monetary resources. Given the financial climate, it is important to start thinking about the costs and benefits of PPI and how to evaluate it in economic terms.

DESIGN

We conducted a literature review to assess the potential benefits and costs of involvement and the challenges in carrying out an economic evaluation of PPI.

RESULTS

The benefits of PPI include effects on the design of new projects or services, on NHS governance, on research design and implementation and on citizenship and equity. Economic evaluation of PPI activities is limited. The lack of an appropriate analytical framework, data recording and understanding of the potential costs and benefits of PPI, especially from participants' perspectives, represent serious constraints on the full evaluation of PPI.

CONCLUSIONS

By recognizing the value of PPI, health-care providers and commissioners can embed it more effectively within their organizations. Better knowledge of costs may prompt organizations to effectively plan, execute, evaluate and target resources. This should increase the likelihood of more meaningful activity, avoid tokenism and enhance organizational efficiency and reputation.

How clinical rationing works in practice: A case study of morbid obesity surgery

Difficulties in setting healthcare priorities are encountered throughout the world. There is no agreement on the most appropriate principles or methods for healthcare rationing although there is some consensus that it should be undertaken as systematically and accountably as possible. Although some steps towards achieving accountability have been made at the macro and meso level, at the consultation level rationing remains implicit and poorly understood. Using morbid obesity surgery as a case study, we observed a series of UK National Health Service consultations where rationing was ongoing and conducted in-depth interviews with doctors and patients (2011-2014). A longitudinal approach was taken to research and in total 22 consultations were observed and 78 interviews were undertaken. Sampling was undertaken purposively and theoretically and analyses were undertaken thematically. Clinicians needed to prioritise 55 patients from 450 eligible referrals, but disagreed over the extent to which clinical and financial factors were the driving force behind decision-making. The most prominent rationing technique observed in consultations was rationing by selection, but examples of rationing by delay, by deterrence, and by deflection were also commonplace. Although all clinicians sought to avoid rationing by denial, only six of the 22 patients recruited to the research were known to have been treated at the end of the three-year period. Most clinicians sought to manage rationing implicitly, and only one explained the link between decision-making criteria and financial constraints on care availability. Although existing frameworks for categorising NHS rationing techniques were useful in identifying implicit strategies, in practice these techniques over-lapped substantially and we have proposed a simpler framework for analysing NHS rationing decisions at the consultation level, which includes just three categories - rationing by exclusion, rationing by deterrence, and rationing by delay.

Primary care-led commissioning and public involvement in the English National Health Service. Lessons from the past

Background

Patient and Public involvement (PPI) in health care occupies a central place in Western democracies. In England, this theme has been continuously prominent since the introduction of market reforms in the early 1990s. The health care reforms implemented by the current Coalition Government are making primary care practitioners the main commissioners of health care services in the National Health Service, and a duty is placed on them to involve the public in commissioning decisions and strategies. Since implementation of PPI initiatives in primary care commissioning is not new, we asked how likely it is that the new reforms will make a difference. We scanned the main literature related to primary care-led commissioning and found little evidence of effective PPI thus far. We suggest that unless the scope and intended objectives of PPI are clarified and appropriate resources are devoted to it, PPI will continue to remain empty rhetoric and box ticking.

Aim

To examine the effect of previous PPI initiatives on health care commissioning and draw lessons for future development.

Method

We scanned the literature reporting on previous PPI initiatives in primary care-led commissioning since the introduction of the internal market in 1991. In particular, we looked for specific contexts, methods and outcomes of such initiatives.

Findings

1. PPI in commissioning has been constantly encouraged by policy makers in England. 2. Research shows limited evidence of effective methods and outcomes so far. 3. Constant reconfiguration of health care structures has had a negative impact on PPI. 4. The new structures look hardly better poised to bring about effective public and patient involvement.

Patient and citizen participation in health: the need for improved ethical support

Patient and citizen participation is now regarded as central to the promotion of sustainable health and health care. Involvement efforts create and encounter many diverse ethical challenges that have the potential to enhance or undermine their success. This article examines different expressions of patient and citizen participation and the support health ethics offers. It is contended that despite its prominence and the link between patient empowerment and autonomy, traditional bioethics is insufficient to guide participation efforts. In addition, the turn to a "social paradigm" of ethics in examinations of biotechnologies and public health does not provide an account of values that is commensurable with the pervasive autonomy paradigm. This exacerbates rather than eases tensions for patients and citizens endeavoring to engage with health. Citizen and patient participation must have a significant influence on the way we do health ethics if its potential is to be fulfilled.

Developing a model of decision-making about complementary therapy use for patients with cancer: a qualitative study

OBJECTIVE

To improve our understanding of patient participation in health care consultations and decision-making by exploring a consultation that lies at the interface between mainstream care and complementary therapies.

METHODS

Thirty-four holistic consultations were observed at centres offering complementary therapies for cancer, followed by interviews with patients and focus groups with professionals.

RESULTS

A model of decision-making about complementary therapy use emerged from the data: 'Advice: Assessor led decision', 'Confirmation: Joint decision', 'Access: Patient-led decision' and 'Informed: Patient-led decision'. Decision-making style was contingent on identifiable communication strategies in the preceding information-sharing and discussion phases of the consultation.

CONCLUSION

This study confirms the importance of gauging patients' preferences for level of participation in decision-making. Models of consultations are generally based on the assumption that a greater degree of patient participation is a good thing that access to information and decision-making power is sought by all patients. Data from this study suggest that, in this context at least, this is not necessarily the case. The study also stresses the dynamic nature of the consultation, in which roles are fluid rather than fixed.

PRACTICE IMPLICATIONS

Insight were gained into professionals' communication strategies and patients' role preferences in decision-making, which may be applicable more widely.

Affordability as a discursive accomplishment in a changing National Health Service

Health systems worldwide face the challenges of rationing. The English National Health Service (NHS) was founded on three core principles: universality, comprehensiveness, and free at the point of delivery. Yet patients are increasingly hearing that some treatments are unaffordable on the NHS. We considered affordability as a social accomplishment and sought to explore how those charged with allocating NHS resources achieved this in practice. We undertook a linguistic ethnography to examine the work practices of resource allocation committees in three Primary Care Trusts (PCTs) in England between 2005 and 2012, specifically deliberations over 'individual funding requests' (IFRs)--requests by patients and their doctors for the PCT to support a treatment not routinely funded. We collected and analysed a diverse dataset comprising policy documents, legal judgements, audio recordings, ethnographic field notes and emails from PCT committee meetings, interviews and a focus group with committee members. We found that the fundamental values of universality and comprehensiveness strongly influenced the culture of these NHS organisations, and that in this context, accomplishing affordability was not easy. Four discursive practices served to confer legitimacy on affordability as a guiding value of NHS health care: (1) categorising certain treatments as only eligible for NHS funding if patients could prove 'exceptional' circumstances; (2) representing resource allocation decisions as being not (primarily) about money; (3) indexical labelling of affordability as an ethical principle, and (4) recontextualising legal judgements supporting refusal of NHS treatment on affordability grounds as 'rational'. The overall effect of these discursive practices was that denying treatment to patients became reasonable and rational for an organisation even while it continued to espouse traditional NHS values. We conclude that deliberations about the funding of treatments at the margins of NHS care have powerful consequences both for patients and for redrawing the ideological landscape of NHS care.

Barriers and opportunities of empowerment as applied in diabetes settings: a focus on health care professionals' experiences

This exploratory study examines the opportunities and barriers health care professionals (HCPs) working with diabetes patients face when they try to implement the rhetoric of patient empowerment in practice. A small sample of diabetes HCPs (N=13), from National Health Service (NHS) hospital, walk-in and general practitioner (GP) clinics in South-East England, was interviewed through in-depth semi-structured interviews. Interviews were recorded, transcribed verbatim and analysed thematically. The analysis showed that empowerment was seen as beneficial for patients and HCPs. Time and resources could be moved from successfully empowered patients and focussed on more complex patients, this was termed 'selective empowerment'. The main barriers to empowerment were identified as a lack of resources, time and HCPs trained in empowerment techniques. Empowerment is a popular concept in theory, and presents HCPs with several opportunities but also important barriers in its practical, clinical implementation day-to-day.

Health care professionals' understanding and day-to-day practice of patient empowerment in diabetes; time to pause for thought?

This exploratory study examines what Health Care Professionals (HCPs) working with diabetes patients, understand by the term 'empowerment', their attitudes towards it and whether they believe they practise in ways consistent with empowerment principles. A small sample of diabetes HCPs (N=13), from National Health Service (NHS) hospital, walk-in and General Practitioner (GP) clinics in South-East England, was interviewed. In-depth semi-structured interviews established attitudes towards and use of empowerment in day-to-day practice. Interviews were recorded, transcribed verbatim and analysed thematically. There was no clear specific understanding of what empowerment is and what it involves, although there was broad reporting of factors around education and informed choices. Disagreement was evident about the level of freedom patients should have in making choices - from leading them to the 'right' choice to an acceptance that they may have the right to choose not to be empowered. No consensus emerged on what is successful empowerment and how it is measured. The resistance of some patients to the process of empowerment in its original definition of active partnership in care, was seen as problematic by HCPs. Although empowerment is a popular concept in theory, its practical, clinical implementation day to day, can be problematic.

Marrying contradictions: healthcare professionals perceptions of empowerment in the care of people with Type 2 Diabetes

OBJECTIVE

The aim of the study was to establish how healthcare professionals (HCPs) involved in Type 2 Diabetes (T2D) perceive patient-empowerment. We aimed to identify their understanding of empowerment, and how these inform their day-to-day practice.

METHODS

Employing a qualitative approach, ten interviews with diabetes HCPs in two local Health Trusts were conducted. Data were transcribed verbatim and analysed using framework analysis.

RESULTS

HCPs viewed empowerment as a rejection of the paternalistic approach. Emphasis was given to ways of balancing clinical aims against patients' concerns. Some saw the approach as improving service quality, whereas others saw empowerment as a process of social justice. These were related variably to the expedient use of resources.

CONCLUSION

Models of empowerment, which promote that HCPs bring clinical expertise and patients 'lay' expertise of illness to the medical encounter, are inadequately descriptive of how empowerment approaches are actually engaged with, by HCPs.

PRACTICE IMPLICATIONS

The empowerment approach is construed and utilised in different ways. Clarification of what empowerment entails in practice for HCPs, as well as what HCPs perceive are its multiple aims, is required.

Health systems and sustainability: doctors and consumers differ on threats and solutions

BACKGROUND

Healthcare systems face the problem of insufficient resources to meet the needs of ageing populations and increasing demands for access to new treatments. It is unclear whether doctors and consumers agree on the main challenges to health system sustainability.

METHODOLOGY

We conducted a mail survey of Australian doctors (specialists and general practitioners) and a computer assisted telephone interview (CATI) of consumers to determine their views on contributors to increasing health care costs, rationing of services and involvement in health resource allocation decisions. Differences in responses are reported as odds ratios (OR) and 99% confidence intervals (CI).

RESULTS

Of 2948 doctors, 1139 (38.6%) responded; 533 of 826 consumers responded (64.5% response). Doctors were more concerned than consumers with the effects of an ageing population (OR 3.0; 99% CI 1.7, 5.4), and costs of new drugs and technologies (OR 5.1; CI 3.3, 8.0), but less likely to consider pharmaceutical promotional activities as a cost driver (OR 0.29, CI 0.22, 0.39). Doctors were more likely than consumers to view 'community demand' for new technologies as a major cost driver, (OR 1.6; 1.2, 2.2), but less likely to attribute increased costs to patients failing to take responsibility for their own health (OR 0.35; 0.24, 0.49). Like doctors, the majority of consumers saw a need for public consultation in decisions about funding for new treatments.

CONCLUSIONS

Australian doctors and consumers hold different views on the sustainability of the healthcare system, and a number of key issues relating to costs, cost drivers, roles and responsibilities. Doctors recognise their dual responsibility to patients and society, see an important role for physicians in influencing resource allocation, and acknowledge their lack of skills in assessing treatments of marginal value. Consumers recognise cost pressures on the health system, but express willingness to be involved in health care decision making.

Referral recommendations for osteoarthritis of the knee incorporating patients' preferences

BACKGROUND

GPs have to respond to conflicting policy developments. As gatekeeper they are supposed to manage the growing demand for specialist services and as patient advocate they should be responsive to patients' preferences. We used an innovative approach to develop a referral guideline for patients with chronic knee pain that explicitly incorporates patients' preferences.

METHODS

A guideline development group of 12 members including patients, GPs, orthopaedic surgeons and other health care professionals used formal consensus development informed by systematic evidence reviews. They rated the appropriateness of referral for 108 case scenarios describing patients according to symptom severity, age, body mass, co-morbidity and referral preference. Appropriateness was expressed on scale from 1 ('strongly disagree') to 9 ('strongly agree').

RESULTS

Ratings of referral appropriateness were strongly influenced by symptom severity and patients' referral preferences. The influence of other patient characteristics was small. There was consensus that patients with severe knee symptoms who want to be referred should be referred and that patient with moderate or mild symptoms and strong preference against referral should not be referred. Referral preference had a greater impact on the ratings of referral appropriateness when symptoms were moderate or severe than when symptoms were mild.

CONCLUSIONS

Referral decisions for patients with osteoarthritis of the knee should only be guided by symptom severity and patients' referral preferences. The guideline development group seemed to have given priority to avoiding inefficient resource use in patients with mild symptoms and to respecting patient autonomy in patients with severe symptoms.

The role of ethics committees and ethics consultation in allocation decisions: a 4-stage process

BACKGROUND

Decisions about the allocation and rationing of medical interventions likely occur in all health care systems worldwide. So far very little attention has been given to the question of what role ethics consultation and ethics committees could or should play in questions of allocation at the hospital level.

OBJECTIVES AND METHODS

This article argues for the need for ethics consultation in rationing decisions using empirical data about the status quo and the inherent nature of bedside rationing. Subsequently, it introduces a 4-stage process for establishing and conducting ethics consultation in rationing questions with systematic reference to core elements of procedural justice.

RESULTS

Qualitative and quantitative findings show a significant demand for ethics consultation expressed directly by doctors, as well as additional indirect evidence of such a need as indicated by ethically challenging circumstances of inconsistent and structurally disadvantaging rationing decisions. To address this need, we suggest 4 stages for establishing and conducting ethics consultation in rationing questions we recommend: (1) training, (2) identifying actual scarcity-related problems at clinics, (3) supporting decision-making, and (4) evaluation.

CONCLUSION

This process of ethics consultation regarding rationing decisions would facilitate the achievement of several practical goals: (i) encouragement of an awareness and understanding of ethical problems in bedside rationing, (ii) encouragement of achieving efficiency along with rationing, (iii) reinforcement of consistency in inter- and intraindividual decision-making, (iv) encouragement of explicit reflection and justification of the prioritization criteria taken into consideration, (v) improvement in internal (in-house) and external transparency, and (vi) prevention of the misuse of the corresponding consulting structures.

The Desirability of Being Open About Health Care Rationing Decisions: Findings from a Qualitative Study of Patients and Clinical Professionals

Objective

To understand the views of patients and professionals about how feasible and appropriate it is to make health care rationing decisions openly at the consultation level.

Methods

Thirty-one patients and 21 health care professionals were asked about their experiences of implicit and explicit rationing during in-depth interviews structured around two clinical case studies (morbid obesity and breast cancer). Sampling was undertaken theoretically and data analysis was carried out using constant comparison.

Results

Patients had a broad awareness of health care rationing and nearly all said they wanted to know how financial factors affected the provision of their health care. However, the experience of explicit rationing could be distressing and one patient regretted having been told. Despite a firm commitment to the ideal of being open with patients about rationing, in practice, clinical professionals encountered a number of ethical and practical barriers to making such decisions explicitly, meaning that implicit methods were frequently adopted.

Conclusions

The results suggest that moves in the UK and elsewhere to undertake rationing more explicitly are in line with the preferences of the majority of patients and professionals. However, the potential for distress caused through rationing openly means that further research is needed to understand whether explicitness is always the best approach at the consultation level, and professionals need further training and support to deal with the stressful nature of making rationing decisions openly.

Encounters with unemployment in occupational health care: Nurses' constructions of clients without work

This study explores occupational health nurses' encounters with unemployed clients in Finland. It involved setting up and evaluating a new service, Career Health Care, that resembled occupational health care, except that clients were recruited from among job seekers who were participating in one of three active labour market policy measures: vocational training, subsidised employment in the public sector, or participatory training for entering the labour market. Our main interest focused on nurses' perceptions of the unemployed and their professional practices in the context of Career Health Care. The analysis revealed four overlapping discourses with regard to clients: the client as a casualty of unemployment, the client as unemployed but active, the client as a deviant in the labour market, and the client as a skilled user of the system. Each discourse had implications for professional practice. The risk of negative stereotyping and consequent exclusion from services is discussed here. In conclusion, we stress the complexity of providing health services that can match the increasing diversity of contemporary labour market trajectories.

Decisions about referrals for psychological therapies: a matched-patient qualitative study

BACKGROUND

Psychological therapies are effective treatments for common mental health problems, but access is limited. GPs face difficult decisions as to whom to refer, but little is known about this decision-making process.

AIM

To explore GPs' accounts of decisions to refer, or not refer, patients for psychological therapy.

DESIGN OF STUDY

A qualitative study, using a matched-patient procedure.

SETTING

General practices in two inner London boroughs.

METHOD

In semi-structured interviews, GPs were asked to compare and contrast five matched-patient pairs, consisting of patients who had been referred for psychological therapy paired with patients not referred. The interviews were analysed using a general thematic analysis.

RESULTS

Fourteen GPs discussed 130 matched patients (65 patient pairs). Three main factors distinguished GPs' accounts of the patients they referred compared with the matched patients they did not refer. These factors were: patient initiative in requesting or showing interest in referral; estimated capacity of the patient to benefit from psychological therapy; and the GP's own capacity to help the patient in terms of skills, expertise, and time.

CONCLUSION

GPs gave accounts of themselves acting as rational decision makers, judging how effective they thought a referral would be based on a patient's clinical presentation and motivation, compared with the GPs' own ability to help.

The culture of massage therapy: valued elements and the role of comfort, contact, connection and caring

OBJECTIVE

To explore the attributes of the therapy encounter valued by repeat users of health-related massage therapy.

DESIGN

A qualitative design with telephone focus group methodology was used. A total of 19 repeat users of massage therapy participated in three telephone focus groups where audiotaped semi-structured interviews were conducted.

SETTING

Telephone focus group with massage clients from a range of provincial and urban regions in New Zealand.

MAIN OUTCOME MEASURES

Summary of reported themes of the massage experience. Data were thematically analysed using the general inductive approach.

RESULTS

Six valued elements of the massage encounter (time for care and personal attention, engaging and competent therapist, trust partnership, holism and empowerment, effective touch and enhancing relaxation), four modulators (comfort, contact, connection and caring) and two themes relating to adding experiential value (enjoyment, escapism) characterize the massage therapy culture.

CONCLUSIONS

The culture of massage therapy care incorporates a number of characteristics that are congruent with the complementary and alternative medicine approach to health. In addition, massage specific factors were identified. The humanistic aspects of the therapy encounter valued by clients offer insight into the growing use of massage therapy and the success of massage therapy outcomes.

The role of economic evaluation in the decision-making process of family physicians: design and methods of a qualitative embedded multiple-case study

Background

A considerable amount of resource allocation decisions take place daily at the point of the clinical encounter; especially in primary care, where 80 percent of health problems are managed. Ignoring economic evaluation evidence in individual clinical decision-making may have a broad impact on the efficiency of health services. To date, almost all studies on the use of economic evaluation in decision-making used a quantitative approach, and few investigated decision-making at the clinical level. An important question is whether economic evaluations affect clinical practice. The project is an intervention research study designed to understand the role of economic evaluation in the decision-making process of family physicians (FPs). The contributions of the project will be from the perspective of Pierre Bourdieu's sociological theory.

Methods/design

A qualitative research strategy is proposed. We will conduct an embedded multiple-case study design. Ten case studies will be performed. The FPs will be the unit of analysis. The sampling strategies will be directed towards theoretical generalization. The 10 selected cases will be intended to reflect a diversity of FPs. There will be two embedded units of analysis: FPs (micro-level of analysis) and field of family medicine (macro-level of analysis). The division of the determinants of practice/behaviour into two groups, corresponding to the macro-structural level and the micro-individual level, is the basis for Bourdieu's mode of analysis. The sources of data collection for the micro-level analysis will be 10 life history interviews with FPs, documents and observational evidence. The sources of data collection for the macro-level analysis will be documents and 9 open-ended, focused interviews with key informants from medical associations and academic institutions. The analytic induction approach to data analysis will be used. A list of codes will be generated based on both the original framework and new themes introduced by the participants. We will conduct within-case and cross-case analyses of the data.

Discussion

The question of the role of economic evaluation in FPs' decision-making is of great interest to scientists, health care practitioners, managers and policy-makers, as well as to consultants, industry, and society. It is believed that the proposed research approach will make an original contribution to the development of knowledge, both empirical and theoretical.

Balancing patient preferences and clinical needs: community versus hospital based care for patients with suspected DVT

OBJECTIVE

To establish patients' preferences and willingness to pay (WTP) for different service models for suspected deep vein thrombosis (DVT).

METHODS

We analysed patient responses to a discrete choice experiment (DCE) questionnaire which had been targeted at patients in Leicester, UK. The questionnaire elicited preferences/WTP for attributes of DVT provision including speed of diagnosis; access; continuity of care; and minimizing hospital visits. Additionally we evaluated trade-offs between clinical and service attributes. We analysed responses from 256 patients with suspected DVT (65% response rate).

RESULTS

Respondents are WTP pound 4.82 per extra hour of dedicated DVT service provision; pound 17.12 per hospital visit avoided; pound 115.73 per day's reduction in diagnostic wait; and pound 179.32 for 'much' not 'some' continuity, or pound 56.88 for 'some' not 'lack' of continuity in nursing.

CONCLUSIONS

Research evaluating different DVT service models usually reports on clinical efficacy in centres of excellence. Results show prompt diagnosis is valued by patients and may improve efficacy by reducing unnecessary anticoagulation. However, patients value 'process' measures such as continuity of care also. To ensure optimal provision, clinical benefit measurement ought to be augmented with information on patients' preferences.

Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals' perceptions

OBJECTIVE

To update a systematic review on the barriers and facilitators to implementing shared decision-making in clinical practice as perceived by health professionals.

METHODS

From March to December 2006, PubMed, Embase, CINHAL, PsycINFO, and Dissertation Abstracts were searched. Studies were included if they reported on health professionals' perceived barriers and facilitators to implementing shared decision-making in practice. Quality of the included studies was assessed. Content analysis was performed with a pre-established taxonomy.

RESULTS

Out of 1130 titles, 10 new eligible studies were identified for a total of 38 included studies compared to 28 in the previous version. The vast majority of participants (n=3231) were physicians (89%). The three most often reported barriers were: time constraints (22/38) and lack of applicability due to patient characteristics (18/38) and the clinical situation (16/38). The three most often reported facilitators were: provider motivation (23/38) and positive impact on the clinical process (16/38) and patient outcomes (16/38).

CONCLUSION

This systematic review update confirms the results of the original review.

PRACTICE IMPLICATIONS

Interventions to foster implementation of shared decision-making in clinical practice will need to address a range of factors.

Impact of the model for end-stage liver disease allocation policy on the use of high-risk organs for liver transplantation

BACKGROUND & AIMS

Although priority for liver transplantation is determined by the model for end-stage liver disease (MELD) score, the quality of organs used is subject to physician discretion. We aimed to determine whether implementation of MELD affected the quality of organs transplanted, the type of patients who receive the higher-risk organs, and the impact of these changes on their posttransplant survival.

METHODS

Data were analyzed from the United Network for Organ Sharing of adults who underwent deceased-donor liver transplantation between January 1, 2007, and August 1, 2007 (n = 47,985). Dependent variables included the donor risk index (a continuous variable that measures the risk of graft failure associated with a particular organ) and patient survival after transplantation.

RESULTS

The overall organ quality of transplanted livers has worsened since MELD implementation, with an increase in the donor risk index equivalent to a 4% increased risk of graft failure after adjusting for temporal trends (P < .001). This was accompanied by a shift from using the higher-risk organs in the more urgent patients (in the pre-MELD era) to using the higher-risk organs in the less urgent patients (in the post-MELD era). Posttransplant survival has worsened over time (hazard ratio, 1.017/y; P = .005) among the less urgent patients (MELD scores, <20); mediation analysis suggests this change in survival was caused primarily by changes in organ quality.

CONCLUSIONS

As an unintended consequence of the MELD allocation policy, patients that are least in need of a liver transplant now receive the highest-risk organs. This has reduced posttransplant survival in recent years among patients with low MELD scores.

Bedside rationing by general practitioners: a postal survey in the Danish public healthcare system

BACKGROUND

It is ethically controversial whether medical doctors are morally permitted to ration the care of their patients at the bedside. To explore whether general practitioners in fact do ration in this manner we conducted a study within primary care in the Danish public healthcare system. The purpose of the study was to measure the extent to which general practitioners (GPs) would be willing to factor in cost-quality trade-offs when prescribing medicine, and to discover whether, and if so to what extent, they believe that patients should be informed about this.

METHODS

Postal survey of 600 randomly selected Danish GPs, of which 330 responded to the questionnaire. The Statistical Package for the Social Sciences (SPSS, version 14.0) was used to produce general descriptive statistics. Significance was calculated with the McNemar and the chi-square test. The main outcome measures of the study were twofold: an assessment of the proportion of GPs who, in a mainly hypothetical setting, would consider cost-quality trade-offs relevant to their clinical decision-making given their economic impact on the healthcare system; and a measure of the extent to which they would disclose this information to patients.

RESULTS

In the hypothetical setting 95% of GPs considered cost-quality trade-offs relevant to their clinical decision-making given the economic impact of such trade-offs on the healthcare system. In all 90% stated that this consideration had been relevant in clinical decision-making within the last month. In the hypothetical setting 55% would inform their patients that they considered a cost-quality trade-off relevant to their clinical decisions given the economic impact of such trade-offs on the healthcare system. The most common reason (68%) given for not wanting to inform patients about this matter was the belief that the information would not prove useful to patients. In the hypothetical setting cost-quality trade-offs were considered relevant significantly more often in connection with concerns about costs to the patient (86%) than they were in connection with concerns about costs to the healthcare system (55%; p < 0.001).

CONCLUSION

Although readiness to consider cost-quality trade-offs relevant to clinical decisions is prevalent among GPs in Denmark, only half of GPs would disclose to patients that they consider this relevant to their clinical decision-making. The results of this study raise two important ethical problems. First, under Danish law physicians are required to inform patients about all equal treatments. The fact that only a few GPs would inform their patients about all of the relevant treatments therefore seems to contravene Danish law. Second, it is ethically controversial that physicians act as economic gatekeepers.

How physicians allocate scarce resources at the bedside: a systematic review of qualitative studies

Although rationing of scarce health-care resources is inevitable in clinical practice, there is still limited and scattered information about how physicians perceive and execute this bedside rationing (BSR) and how it can be performed in an ethically fair way. This review gives a systematic overview on physicians' perspectives on influences, strategies, and consequences of health-care rationing. Relevant references as identified by systematically screening major electronic databases and manuscript references were synthesized by thematic analysis. Retrieved studies focused on themes that fell under three major headings: (i) conditions and influences of BSR, (ii) strategies of BSR, and (iii) consequences of BSR. The range of themes indicates that physicians' rationing behavior is highly variable, strongly influenced by context-related factors, and consists mainly of implicit rationing strategies. Torn between patient advocacy and the obligation to contain costs, physicians experience various role conflicts. The development of explicit rationing strategies seems necessary to avoid arbitrary BSR and allow a fair allocation of health-care resources.

Thou shalt versus thou shalt not: a meta-synthesis of GPs' attitudes to clinical practice guidelines

BACKGROUND

GPs' adherence to clinical practice guidelines is variable. Barriers to guideline implementation have been identified but qualitative studies have not been synthesised to explore what underpins these attitudes.

AIM

To explore and synthesise qualitative research on GPs' attitudes to and experiences with clinical practice guidelines.

DESIGN OF STUDY

Systematic review and meta-synthesis of qualitative studies.

METHOD

PubMed, CINAHL, EMBASE, Social Science Citation Index, and Science Citation Index were used as data sources, and independent data extraction was carried out. Discrepancies were resolved by consensus. Initial thematic analysis was conducted, followed by interpretative synthesis.

RESULTS

Seventeen studies met the inclusion criteria. Five were excluded following quality appraisal. Twelve papers were synthesised which reported research in the UK, US, Canada, and the Netherlands, and covered different clinical guideline topics. Six themes were identified: questioning the guidelines, GPs' experience, preserving the doctor-patient relationship, professional responsibility, practical issues, and guideline format. Comparative analysis and synthesis revealed that GPs' reasons for not following guidelines differed according to whether the guideline in question was prescriptive, in that it encouraged a certain type of behaviour or treatment, or proscriptive, in that it discouraged certain treatments or behaviours.

CONCLUSION

Previous analyses of guidelines have focused on professional attitudes and organisational barriers to adherence. This synthesis suggests that the purpose of the guideline, whether its aims are prescriptive or proscriptive, may influence if and how guidelines are received and implemented.

Physicians' intentions and use of three patient decision aids

Background

Decision aids are evidence based tools that assist patients in making informed values-based choices and supplement the patient-clinician interaction. While there is evidence to show that decision aids improve key indicators of patients' decision quality, relatively little is known about physicians' acceptance of decision aids or factors that influence their decision to use them. The purpose of this study was to describe physicians' perceptions of three decision aids, their expressed intent to use them, and their subsequent use of them.

Methods

We conducted a cross-sectional survey of random samples of Canadian respirologists, family physicians, and geriatricians. Three decision aids representing a range of health decisions were evaluated. The survey elicited physicians' opinions on the characteristics of the decision aid and their willingness to use it. Physicians who indicated a strong likelihood of using the decision aid were contacted three months later regarding their actual use of the decision aid.

Results

Of the 580 eligible physicians, 47% (n = 270) returned completed questionnaires. More than 85% of the respondents felt the decision aid was well developed and that it presented the essential information for decision making in an understandable, balanced, and unbiased manner. A majority of respondents (>80%) also felt that the decision aid would guide patients in a logical way, preparing them to participate in decision making and to reach a decision. Fewer physicians (<60%) felt the decision aid would improve the quality of patient visits or be easily implemented into practice and very few (27%) felt that the decision aid would save time. Physicians' intentions to use the decision aid were related to their comfort with offering it to patients, the decision aid topic, and the perceived ease of implementing it into practice. While 54% of the surveyed physicians indicated they would use the decision aid, less than a third followed through with this intention.

Conclusion

Despite strong support for the format, content, and quality of patient decision aids, and physicians' stated intentions to adopt them into clinical practice, most did not use them within three months of completing the survey. There is a wide gap between intention and behaviour. Further research is required to study the determinants of this intention-behaviour gap and to develop interventions aimed at barriers to physicians' use of decision aids.

The meaning of patient involvement and participation in health care consultations: A taxonomy

A number of trends, pressures and policy shifts can be identified that are promoting greater patient involvement in health care delivery through consultations, treatments and continuing care. However, while the literature is growing fast on different methods of involvement, little attention has been given so far to the role which patients themselves wish to play, nor even of the conceptual meanings behind involvement or participation. This article reviews the current models of involvement in health care delivery as derived from studies of professional views of current and potential practice, prior to examining the empirical evidence from a large-scale qualitative study of the views and preferences of citizens, as patients, members of voluntary groups, or neither. Individual domiciliary interviews were carried out with 44 people recruited from GP practices in northern England. These respondents were then included in a second phase of 34 focus groups in 6 different localities in northern and southern England, of which 22 were with individuals unaffiliated to any voluntary/community groups, 6 related to local voluntary/community groups with specific interests in health or health care, and 6 related to groups without such specific interests. A final set of 12 workshops with the same samples helped to confirm emergent themes. The qualitative data enabled a taxonomy of patient-desired involvement to be derived, which is contrasted with professional-determined levels of involvement identified from the literature. Participation is seen as being co-determined by patients and professionals, and occurring only through the reciprocal relationships of dialogue and shared decision-making. Not everyone wanted to be involved and the extent to which involvement was desired depended on the contexts of type and seriousness of illness, various personal characteristics and patients' relationships with professionals. These levels are seen to provide basic building blocks for a more sophisticated understanding of involvement within and between these contexts for use by professionals, managers, policy-makers and researchers.

Primary health care professionals' views on barriers and facilitators to the implementation of the Ottawa Decision Support Framework in practice

OBJECTIVE

To describe primary health care professionals' views on barriers and facilitators for implementing the Ottawa Decision Support Framework (ODSF) in their practice.

METHODS

Thirteen focus groups with 118 primary health care professionals were performed. A taxonomy of barriers and facilitators to implementing clinical practice guidelines was used to content-analyse the following sources: reports from each workshop, field notes from the principal investigator and written materials collected from the participants.

RESULTS

Applicability of the ODSF to the practice population, process outcome expectation, asking patients about their preferred role in decision making, perception that the ODSF was modifiable, time issues, familiarity with the ODSF and its practicability were the most frequently identified both as barriers as well as facilitators. Forgetting about the ODSF, interpretation of evidence, challenge to autonomy and total lack of agreement with using the ODSF in general were identified only as barriers. Asking about values, health professional's outcome expectation, compatibility with the patient-centered approach or the evidence-based approach, ease of understanding and implementation, and ease of communicating the ODSF were identified only as facilitators.

CONCLUSION

These results provide insight on the type of interventions that could be developed in order to implement the ODSF in academic primary care practice.

PRACTICE IMPLICATIONS

Interventions to implement the ODSF in primary care practice will need to address a broad range of factors at the levels of the health professionals, the patients and the health care system.

Patient involvement in clinical decision making: the effect of GP attitude on patient satisfaction

OBJECTIVE

This study investigates general practitioners' (GPs) and patients' attitudes to shared decision making, and how these attitudes affect patient satisfaction.

BACKGROUND

Sharing of information and decisions in the consultation is largely accepted as the ideal in general practice. Studies show that most patients prefer to be involved in decision making and shared decision making is associated with patient satisfaction, although preferences vary. Still we know little about how the interaction of GP and patients' attitudes affects patient satisfaction. One such study was conducted in the USA, but comparative studies are lacking.

DESIGN

Questionnaire survey distributed through GPs.

SETTING AND PARTICIPANTS

The results are based on the combined questionnaires of 41 GPs and 829 of their patients in the urban municipality of Bergen in the western part of Norway. Main variables studied The data were collected using a nine-item survey instrument constructed to measure attitudes towards patient involvement in medical consultations. The patients were also asked to rate their satisfaction with their GP.

RESULTS AND CONCLUSIONS

The patients had a strong preference for shared decision making. The GPs also generally preferred shared decision making, but to a lesser degree than the patients, which is the opposite of the findings of the US study. There was a positive effect of the GP's attitude towards shared decision making on patient satisfaction, but no significant effect of congruence of attitudes between patient and GP on patient satisfaction. The suggested explanation is that GPs that are positive to sharing decisions are more responsive to patients' needs and therefore satisfy patients even when the patient's attitude differs from the GPs' attitude. Hence, although some patients do prefer a passive role, it is important to promote positive attitudes towards patient involvement in medical consultations.

Barriers and facilitators to implementing shared decision-making in clinical practice: a systematic review of health professionals' perceptions

BACKGROUND

Shared decision-making is advocated because of its potential to improve the quality of the decision-making process for patients and ultimately, patient outcomes. However, current evidence suggests that shared decision-making has not yet been widely adopted by health professionals. Therefore, a systematic review was performed on the barriers and facilitators to implementing shared decision-making in clinical practice as perceived by health professionals.

METHODS

Covering the period from 1990 to March 2006, PubMed, Embase, CINHAL, PsycINFO, and Dissertation Abstracts were searched for studies in English or French. The references from included studies also were consulted. Studies were included if they reported on health professionals' perceived barriers and facilitators to implementing shared decision-making in their practices. Shared decision-making was defined as a joint process of decision making between health professionals and patients, or as decision support interventions including decision aids, or as the active participation of patients in decision making. No study design was excluded. Quality of the studies included was assessed independently by two of the authors. Using a pre-established taxonomy of barriers and facilitators to implementing clinical practice guidelines in practice, content analysis was performed.

RESULTS

Thirty-one publications covering 28 unique studies were included. Eleven studies were from the UK, eight from the USA, four from Canada, two from The Netherlands, and one from each of the following countries: France, Mexico, and Australia. Most of the studies used qualitative methods exclusively (18/28). Overall, the vast majority of participants (n = 2784) were physicians (89%). The three most often reported barriers were: time constraints (18/28), lack of applicability due to patient characteristics (12/28), and lack of applicability due to the clinical situation (12/28). The three most often reported facilitators were: provider motivation (15/28), positive impact on the clinical process (11/28), and positive impact on patient outcomes (10/28).

CONCLUSION

This systematic review reveals that interventions to foster implementation of shared decision-making in clinical practice will need to address a broad range of factors. It also reveals that on this subject there is very little known about any health professionals others than physicians. Future studies about implementation of shared decision-making should target a more diverse group of health professionals.

Decision-making in community-based paediatric physiotherapy: a qualitative study of children, parents and practitioners

Approaches to practice based on partnership and shared decision-making with patients are now widely recommended in health and social care settings, but less attention has been given to these recommendations in children's services, and to the decision-making experiences of non-medical practitioners and their patients or clients. This study explored children's, parents' and practitioners' accounts of shared decision-making in the context of community-based physiotherapy services for children with cerebral palsy. Semi-structured interviews were conducted with 11 children with cerebral palsy living in an inner city area of northern England, and with 12 of their parents. Two focus groups were conducted with 10 physiotherapy practitioners. Data were analysed using the constant comparative method. When asked explicitly about decision-making, parents, children and practitioners reported little or no involvement, and each party saw the other as having responsibility for decisions. However, when talking in more concrete terms about their experiences, each party did report some involvement in decision-making. Practitioners' accounts focused on their responsibility for making decisions about resource allocation, and thereby, about the usefulness and intensity of interventions. Parents indicated that these practitioner-led decisions were sometimes in conflict with their aspirations for their child. Parents and children appeared to have most involvement in decisions about the acceptability and implementation of interventions. Children's involvement was more limited than parents'. While parents could legitimately curtail unacceptable interventions, children were mostly restricted to negotiating about how interventions were implemented. In these accounts the involvement of each party varied with the type of issue being decided and decision-making appeared more unilateral than shared. In advocating shared decision-making, greater understanding of its weaknesses as well as its strengths, and greater clarity about the domains that are suitable for a shared decision-making approach and the roles of different parties, would seem a helpful step.

Patient Participation in Medical Consultations

BACKGROUND

Patients vary in their willingness and ability to actively participate in medical consultations. Because more active patient participation contributes to improved health outcomes and quality of care, it is important to understand factors affecting the way patients communicate with healthcare providers.

OBJECTIVES

The objectives of this study were to examine the extent to which patient participation in medical interactions is influenced by 1) the patient's personal characteristics (age, gender, education, ethnicity); 2) the physician's communication style (eg, use of partnership-building and supportive talk); and 3) the clinical setting (eg, the health condition, medical specialty).

RESEARCH DESIGN AND SUBJECTS

The authors conducted a post hoc cross-sectional analysis of 279 physician-patient interactions from 3 clinical sites: 1) primary care patients in Sacramento, California, 2) patients with systemic lupus erythematosus (SLE) from the San Francisco Bay area, and 3) patients with lung cancer from a VA hospital in Texas.

MAIN OUTCOME MEASURES

The outcome measures included the degree to which patients asked questions, were assertive, and expressed concerns and the degree to which physicians used partnership-building and supportive talk (praise, reassurance, empathy) in their consultations.

RESULTS

The majority of active participation behaviors were patient-initiated (84%) rather than prompted by physician partnership-building or supportive talk. Patients who were more active participants received more facilitative communication from physicians, were more educated, and were more likely to be white than of another ethnicity. Women more willingly expressed negative feelings and concerns. There was considerable variability in patient participation across the 3 clinical settings. Female physicians were more likely to use supportive talk than males, and physicians generally used less supportive talk with nonwhite compared with white patients.

CONCLUSIONS

Patient participation in medical encounters depends on a complex interplay of personal, physician, and contextual factors. Although more educated and white patients tended to be more active participants than their counterparts, the strongest predictors of patient participation were situation-specific, namely the clinical setting and the physician's communicative style. Physicians could more effectively facilitate patient involvement by more frequently using partnership-building and supportive communication. Future research should investigate how the nuances of individual clinical settings (eg, the health condition, time allotted for the visit) impose constraints or opportunities for more effective patient involvement in care.

Patient-perceived involvement and satisfaction in Parkinson's disease: Effect on therapy decisions and quality of life

Patient-centered consultation styles are associated with higher patient satisfaction and improved health outcomes in diabetes and hypertension. In outpatient neurology, dissatisfaction with communication relates significantly to noncompliance. We undertook a single-center study in Parkinson's disease (PD) using standardized questionnaires to score patient-perceived involvement in therapy decisions (score 4 = low to 25 = high) and satisfaction with the consultation (score 1 = low to 7 = high). Correlation was tested against health outcomes of Unified Parkinson's Disease Rating Scale (UPDRS) Motor score, activities of daily living (UPDRS 2 and Schwab and England), Parkinson's disease quality of life (PDQ-39), Mini-Mental State Examination (MMSE), and Geriatric Depression Scale (GDS). Of 117 patients enrolled, 107 (91%) fully completed the questionnaires. Mean patient-perceived involvement scored 14.4 (SD, 2.8). Mean satisfaction scored 5.3 (SD 0.7). Higher involvement was associated with increased satisfaction (r = 0.28; P = 0.003), particularly distress relief (r = 0.38; P < 0.0001). Communication scores correlated significantly with compliance intent (r = 0.6; P < 0.0001). There was no correlation between either involvement or satisfaction and UPDRS, Schwab and England, MMSE, or GDS. Quality of life was significantly associated with depression, UPDRS, duration of PD, compliance intent, and satisfaction. The significant positive association between compliance intent and quality of life in the more satisfied patient replicates findings in other disease areas. Due attention to these aspects in delivering care to the PD patient is appropriate.