Establishing patient decision aids in primary care: update on the knowledge base

Do Upper Extremity Trauma Patients Have Different Preferences for Shared Decision-making Than Patients With Nontraumatic Conditions?

BACKGROUND

Shared decision-making is a combination of expertise, available scientific evidence, and the preferences of the patient and surgeon. Some surgeons contend that patients are less capable of participating in decisions about traumatic conditions than nontraumatic conditions.

QUESTIONS/PURPOSES

(1) Do patients with nontraumatic conditions have different preferences for shared decision-making when compared with those who sustained acute trauma? (2) Do disability, symptoms of depression, and self-efficacy correlate with preference for shared decision-making?

METHODS

In this prospective, comparative trial, we evaluated a total of 133 patients presenting to the outpatient practices of two university-based hand surgeons with traumatic or nontraumatic hand and upper extremity illnesses or conditions. Each patient completed questionnaires measuring their preferred role in healthcare decision-making (Control Preferences Scale [CPS]), symptoms of depression (Patients' Health Questionnaire), and pain self-efficacy (confidence that one can achieve one's goals despite pain; measured using the Pain Self-efficacy Questionnaire). Patients also completed a short version of the Disabilities of the Arm, Shoulder, and Hand questionnaire and an ordinal rating of pain intensity.

RESULTS

There was no difference in decision-making preferences between patients with traumatic (CPS: 3 ± 2) and nontraumatic conditions (CPS: 3 ± 1 mean difference = 0.2 [95% confidence interval, -0.4 to 0.7], p = 0.78) with most patients (95 versus 38) preferring shared decision-making. More educated patients preferred a more active role in decision-making (beta = -0.1, r = 0.08, p = 0.001); however, differences in levels of disability, pain and function, depression, and pain-related self-efficacy were not associated with differences in patients' preferences in terms of shared decision-making.

CONCLUSIONS

Patients who sustained trauma have on average the same preference for shared decision-making compared with patients who sustained no trauma. Now that we know the findings of this study, clinicians might be motivated to share their expertise about the treatment options, potential outcomes, benefits, and harms with the patient and to discuss their preference as well in a semiacute setting, resulting in a shared decision.

"Many miles to go …": a systematic review of the implementation of patient decision support interventions into routine clinical practice

BACKGROUND

Two decades of research has established the positive effect of using patient-targeted decision support interventions: patients gain knowledge, greater understanding of probabilities and increased confidence in decisions. Yet, despite their efficacy, the effectiveness of these decision support interventions in routine practice has yet to be established; widespread adoption has not occurred. The aim of this review was to search for and analyze the findings of published peer-reviewed studies that investigated the success levels of strategies or methods where attempts were made to implement patient-targeted decision support interventions into routine clinical settings.

METHODS

An electronic search strategy was devised and adapted for the following databases: ASSIA, CINAHL, Embase, HMIC, Medline, Medline-in-process, OpenSIGLE, PsycINFO, Scopus, Social Services Abstracts, and the Web of Science. In addition, we used snowballing techniques. Studies were included after dual independent assessment.

RESULTS

After assessment, 5322 abstracts yielded 51 articles for consideration. After examining full-texts, 17 studies were included and subjected to data extraction. The approach used in all studies was one where clinicians and their staff used a referral model, asking eligible patients to use decision support. The results point to significant challenges to the implementation of patient decision support using this model, including indifference on the part of health care professionals. This indifference stemmed from a reported lack of confidence in the content of decision support interventions and concern about disruption to established workflows, ultimately contributing to organizational inertia regarding their adoption.

CONCLUSIONS

It seems too early to make firm recommendations about how best to implement patient decision support into routine practice because approaches that use a 'referral model' consistently report difficulties. We sense that the underlying issues that militate against the use of patient decision support and, more generally, limit the adoption of shared decision making, are under-investigated and under-specified. Future reports from implementation studies could be improved by following guidelines, for example the SQUIRE proposals, and by adopting methods that would be able to go beyond the 'barriers' and 'facilitators' approach to understand more about the nature of professional and organizational resistance to these tools. The lack of incentives that reward the use of these interventions needs to be considered as a significant impediment.

Perceptions of shared decision making and decision aids among rural primary care clinicians

BACKGROUND

Shared decision making (SDM) and decision aids (DAs) increase patients' involvement in health care decisions and enhance satisfaction with their choices. Studies of SDM and DAs have primarily occurred in academic centers and large health systems, but most primary care is delivered in smaller practices, and over 20% of Americans live in rural areas, where poverty, disease prevalence, and limited access to care may increase the need for SDM and DAs.

OBJECTIVE

To explore perceptions and practices of rural primary care clinicians regarding SDM and DAs.

DESIGN

Cross-sectional survey. Setting and Participants Primary care clinicians affiliated with the Oregon Rural Practice-based Research Network.

RESULTS

Surveys were returned by 181 of 231 eligible participants (78%); 174 could be analyzed. Two-thirds of participants were physicians, 84% practiced family medicine, and 55% were male. Sixty-five percent of respondents were unfamiliar with the term shared decision making, but following definition, 97% reported that they found the approach useful for conditions with multiple treatment options. Over 90% of clinicians perceived helping patients make decisions regarding chronic pain and health behavior change as moderate/hard in difficulty. Although 69% of respondents preferred that patients play an equal role in making decisions, they estimate that this happens only 35% of the time. Time was reported as the largest barrier to engaging in SDM (63%). Respondents were receptive to using DAs to facilitate SDM in print- (95%) or web-based formats (72%), and topic preference varied by clinician specialty and decision difficulty.

CONCLUSIONS

Rural clinicians recognized the value of SDM and were receptive to using DAs in multiple formats. Integration of DAs to facilitate SDM in routine patient care may require addressing practice operation and reimbursement.

Barriers and facilitators to routine distribution of patient decision support interventions: a preliminary study in community-based primary care settings

BACKGROUND

A growing body of literature documents the value of decision support interventions (DESIs) in facilitating patient participation in preference sensitive decision making, but little is known about their implementation in routine care.

OBJECTIVE

This study explored barriers and facilitators to prescribing DESIs in primary care.

SETTING AND PARTICIPANTS

Four community-based primary care practices across Los Angeles County serving diverse low and middle income populations participated.

DESIGN

The first phase focused on implementing DESI prescribing into routine care. Weekly academic detailing visits served to identify barriers to DESI prescribing, generate ethnographic field notes and record DESI prescriptions. The second phase explored the impact of a financial incentive on DESI prescribing. At the project's conclusion, each physician completed an in-depth interview.

RESULTS

The four practices prescribed an average of 6.5 DESIs a month (range 3.6-9.2) during Phase I. The financial incentive increased DESI prescribing by 71% to 11.1 per month (range 3.5-21.4). The estimated percentages of patients who viewed the DESI were 37.9 and 43.9% during Phases I and II, respectively. Qualitative data suggest that physician buy-in with the project goal was crucial to DESI distribution success. Competing demands and time pressures were persistent barriers. The effects of the financial incentive were mixed.

CONCLUSIONS

This study confirmed the importance of physician engagement when implementing DESIs and found mixed effects for providing financial incentives. The relatively low rate of DESI viewing suggests further research on increasing patient uptake of these interventions in routine practice is necessary.