[Shared decision-making and communication theory: grounding the tango]

A case for preference-sensitive decision timelines to aid shared decision-making in intensive care: need and possible application

In the intensive care unit, it can be challenging to determine which interventions align with the patients' preferences since patients are often incapacitated and other sources, such as advance directives and surrogate input, are integral. Managing treatment decisions in this context requires a process of shared decision-making and a keen awareness of the preference-sensitive instances over the course of treatment. The present paper examines the need for the development of preference-sensitive decision timelines, and, taking aneurysmal subarachnoid hemorrhage as a use case, proposes a model of one such timeline to illustrate their potential form and value. First, the paper draws on an overview of relevant literature to demonstrate the need for better guidance to (a) aid clinicians in determining when to elicit patient preference, (b) support the drafting of advance directives, and (c) prepare surrogates for their role representing the will of an incapacitated patient in clinical decision-making. This first section emphasizes that highlighting when patient (or surrogate) input is necessary can contribute valuably to shared decision-making, especially in the context of intensive care, and can support advance care planning. As an illustration, the paper offers a model preference-sensitive decision timeline-whose generation was informed by existing guidelines and a series of interviews with patients, surrogates, and neuro-intensive care clinicians-for a use case of aneurysmal subarachnoid hemorrhage. In the last section, the paper offers reflections on how such timelines could be integrated into digital tools to aid shared decision-making.

Integrating patient perspectives in medical decision-making: a qualitative interview study examining potentials within the rare disease information exchange process in practice

BACKGROUND

Many European countries have recently implemented national rare disease plans. Although the network is strengthening, especially on the macro and meso levels, patients still go a long way through healthcare systems, with many health professionals involved and scarce evidence to gather. Specifically, patient involvement in the form of shared decision-making can offer further potential to increase healthcare systems' efficiency on a micro level. Therefore, we examine the implementation of the shared decision-making concept thus far, and explore whether efficiency potentials exist-which are particularly relevant within the rare disease field-and how they can be triggered.

METHODS

Our empirical evidence comes from 101 interviews conducted from March to September 2014 in Germany; 55 patients, 13 family members, and 33 health professionals participated in a qualitative interview study. Transcripts were analyzed using a directed qualitative content analysis.

RESULTS

The interviews indicate that the decision-making process is increasingly relevant in practice. In comparison, however, the shared decision-making agreement itself was rarely reported. A majority of interactions are dominated by individual, informed decision-making, followed by paternalistic approaches. The patient-physician relationship was characterized by a distorted trust-building process, which is affected by not only dependencies due to the diseases' severity and chronic course, but an often-reported stigmatization of patients as stimulants. Moreover, participation was high due to a pronounced engagement of those affected, diminishing as patients' strength vanish during their odyssey through health care systems. The particular roles of "expert patients" or "lay experts" in the rare disease field were revealed, with further potential in integrating the gathered information.

CONCLUSIONS

The study reveals the named efficiency potentials, which are unique for rare diseases and make the further integration of shared decision-making very attractive, facilitating diagnostics and disease management. It is noteworthy that integrating shared decision-making in the rare disease field does not only require strengthening the position of patients but also that of physicians. Efforts can be made to further integrate the concept within political frameworks to trigger the identified potential and assess the health-economic impact.

Dyadic validity of the Decisional Conflict Scale: common patient/physician measures of patient uncertainty were identified

OBJECTIVES

We aimed to assess the dyadic validity of the Decisional Conflict Scale (DCS) for assessing shared decision making in clinical consultations. We applied dyadic criteria, which consider the patient and physician as an interactive dyad instead of as independent individuals, to identify common patient/physician measures of patient uncertainty.

STUDY DESIGN AND SETTING

Patients and their physicians, participating in a randomized clustered trial, completed separately an adapted version of the DCS with five subscales. We performed factor analysis on the full DCS and each subscale independently. We defined a measure as dyadic when measurement invariance across patients and physicians was supported.

RESULTS

We analyzed 332 paired responses (physicians with adults or with parents and children) at study entry and 339 at exit. Factor analysis showed that the full DCS is not a valid dyadic measure. However, independent analysis of each subscale showed measurement invariance for values clarity, support, and effective decision (comparative fit index range, 0.93-1; root mean square error of approximation range, 0-0.07; and P-value > 0.05).

CONCLUSION

Application of our dyadic validation criterion indicated that the full DCS cannot be considered a dyadic measure. However, three of its subscales, values clarity, support and effective decision, are valid dyadic measures.

Shared decision-making in antihypertensive therapy: a cluster randomised controlled trial

Background

Hypertension is one of the key factors causing cardiovascular diseases. A substantial proportion of treated hypertensive patients do not reach recommended target blood pressure values. Shared decision making (SDM) is to enhance the active role of patients. As until now there exists little information on the effects of SDM training in antihypertensive therapy, we tested the effect of an SDM training programme for general practitioners (GPs). Our hypotheses are that this SDM training (1) enhances the participation of patients and (2) leads to an enhanced decrease in blood pressure (BP) values, compared to patients receiving usual care without prior SDM training for GPs.

Methods

The study was conducted as a cluster randomised controlled trial (cRCT) with GP practices in Southwest Germany. Each GP practice included patients with treated but uncontrolled hypertension and/or with relevant comorbidity. After baseline assessment (T0) GP practices were randomly allocated into an intervention and a control arm. GPs of the intervention group took part in the SDM training. GPs of the control group treated their patients as usual. The intervention was blinded to the patients. Primary endpoints on patient level were (1) change of patients’ perceived participation (SDM-Q-9) and (2) change of systolic BP (24h-mean). Secondary endpoints were changes of (1) diastolic BP (24h-mean), (2) patients’ knowledge about hypertension, (3) adherence (MARS-D), and (4) cardiovascular risk score (CVR).

Results

In total 1357 patients from 36 general practices were screened for blood pressure control by ambulatory blood pressure monitoring (ABPM). Thereof 1120 patients remained in the study because of uncontrolled (but treated) hypertension and/or a relevant comorbidity. At T0 the intervention group involved 17 GP practices with 552 patients and the control group 19 GP practices with 568 patients. The effectiveness analysis could not demonstrate a significant or relevant effect of the SDM training on any of the endpoints.

Conclusion

The study hypothesis that the SDM training enhanced patients’ perceived participation and lowered their BP could not be confirmed. Further research is needed to examine the impact of patient participation on the treatment of hypertension in primary care.

Trial registration

German Clinical Trials Register (DRKS): DRKS00000125

Some but not all dyadic measures in shared decision making research have satisfactory psychometric properties

OBJECTIVE

To assess the psychometric properties of dyadic measures for shared decision making (SDM) research.

STUDY DESIGN AND SETTING

We conducted an observational cross-sectional study in 17 primary care clinics with physician-patient dyads. We used seven subscales to measure six elements of SDM: (1) defining the problem, presenting options, and discussing pros and cons; (2) clarifying the patient's values and preferences; (3) discussing the patient's self-efficacy; (4) drawing on the doctor's knowledge; (5) verifying the patient's understanding; and (6) assessing the patient's uncertainty. We assessed the reliability and invariance of the factorial structure and considered a measure to be dyadic if the factorial structure of the patient version was similar to that of the physician version and if there was equality of loading (no significant chi-square).

RESULTS

We analyzed data for 264 physicians and 269 patients. All measures except one showed adequate reliability (Cronbach alpha, 0.70-0.93) and factorial validity (root mean square error of approximation, 0.000-0.06). However, we found only four measures to be dyadic (P>0.05): the values clarification subscale, perceived behavioral subscale, information-verifying subscale, and uncertainty subscale.

CONCLUSION

The subscales for values clarification, perceived behavioral control, information verifying, and uncertainty are appropriate dyadic measures for SDM research and can be used to derive dyadic indices.