Shared decision making in the United States: policy and implementation activity on multiple fronts

A qualitative study of the experiences and perceptions of older patients and relatives prior to cardiac surgery

BACKGROUND

Shared decision-making plays an important role in ensuring value-based healthcare in cardiac surgery. However, the personal situations of patients in cardiac care have not been widely explored, and thus, little is known about the decision-making experiences of patients and their relatives before surgery.

OBJECTIVE

To explore the perceptions of patients indicated for cardiac surgery and their relatives during the decision-making process, as well as their experiences of a conversation aimed at achieving shared decision-making in the treatment trajectory.

METHODS

The data were collected through semi-structured in-depth interviews with patients aged ≥70 years who were indicated for cardiac surgery and their relatives until theme saturation. Both inductive and deductive analysis were conducted based on the principles of reflexive thematic analysis.

RESULTS

Interviews with 16 patients and 10 relatives provided in-depth insights into the experiences of patients and their relatives in terms of a shared decision-making process prior to surgery. Overall, 15 subthemes were identified, and these were divided into three themes. In general, the patients' experiences and perceptions were influenced by their (1) general daily functioning. The relatives were more concerned about (2) social expectations and (3) existential uncertainty.

CONCLUSIONS

Patients eligible for cardiac surgery and their families have unique experiences and perceptions during the process of shared decision-making. The subthemes emerging from this study, such as the overestimation of potential medical outcomes by patients and their relatives, who experience fear about the current health situation of their loved one, require careful attention from healthcare professionals during decision-making conversations.

Patients ' perspectives on bone replacement materials in a German university hospital setting

BACKGROUND

The challenges in developing new bone replacement materials and procedures reside not solely in technological innovation and advancement, but also in a broader patient therapy acceptance. Therefore, there is a need to assess patients' perspectives on the materials and approaches in use as well as the ones being developed to better steer future progress in the field.

METHODS

A self-initiating cross-sectional questionnaire aimed at people seeking treatment at the university hospital environment of Charité Berlin was formulated. The survey contained 15 close-ended questions directed toward the participant's epidemiological profile, willingness, acceptance, and agreement to receive different bone replacement materials, as well as, worries about the post-surgical consequences that can arise post bone replacement surgery. Descriptive and categorical analysis was performed to compare the observed number of subjects, their profile and each related response (Pearson's chi-square test or Fischer's test, p < 0.05).

RESULTS

A total of 198 people engaged with the questionnaire, most of them Millennials. Overall patients trusted scientifically developed biomaterials designed for bone replacement, as demonstrated by their willingness to participate in a clinical trial, their acceptance of alloplastic materials, and the none/few worries about the presence of permanent implants. The data revealed the preferences of patients towards autologous sources of cells and blood to be used with a biomaterial. The data have also shown that both generation and education influenced willingness to participate in a clinical trial and acceptance of alloplastic materials, as well as, worries about the presence of permanent implants and agreement to receive a material with pooled blood and cells.

CONCLUSION

Patients were open to the implantation of biomaterials for bone replacement, with a preference toward autologous sources of blood and/or tissue. Moreover, patients are concerned about strategies based on permanent implants, which indicates a need for resorbable materials. The knowledge gained in this study supports the development of new bone biomaterials.

Surgical Informed Consent: A Scoping Review of Physician-facing Decision Support Tools

Objectives

Physician-facing decision support tools facilitate shared decision-making (SDM) during informed consent, but it is unclear whether they are comprehensive in the domains they measure. In this scoping review, we aimed to (1) identify the physician-facing tools used during SDM; (2) assess the patient-centered domains measured by these tools; (3) determine whether tools are available for older adults and for use in various settings (elective vs. emergent); and (4) characterize domains future tools should measure.

Methods

Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews, Embase, Medline, and Web of Science were queried for articles published between January 2000 and September 2022. Articles meeting inclusion criteria underwent title and abstract review. Eligible studies underwent data abstraction by two reviewers.

Results

Of 4365 articles identified, 160 were eligible. Tools to aid in surgical SDM focus on elective procedures (79%) and the outpatient setting (71%). Few tools are designed for older adults (5%) or for nonelective procedures (9%). Risk calculators were most common, followed by risk indices, prognostic nomograms, and communication tools. Of the domains measured, prognosis was more commonly measured (85%), followed by alternatives (28%), patient goals (36%), and expectations (46%). Most tools represented only one domain (prognosis, 33.1%) and only 6.7% represented all four domains.

Conclusions and Implications

Tools to aid in the surgical SDM process measure short-term prognosis more often than patient-centered domains such as long-term prognosis, patient goals, and expectations. Further research should focus on communication tools, the needs of older patients, and use in diverse settings.

'What you suggest is not what I expected': How pre-consultation expectations affect shared decision-making in patients with low back pain

OBJECTIVE

Existing studies on shared decision-making (SDM) have hardly taken into consideration that patients could have independently developed expectations prior to their consultation with a healthcare provider, nor have studies explored how such expectations affect SDM. Therefore, we explore how pre-consultation expectations affect SDM in patients with low back pain.

METHODS

We performed a qualitative study through telephone interviews with 10 patients and seven care professionals (physicians, nurse, physician assistants) and 63 in-person observations of patient-physician consultations in an outpatient clinic in the Netherlands. Transcripts were analyzed through an open coding process.

RESULTS

A discrepancy existed between what patients expected and what care professionals could offer. Professionals perceived they had to undertake additional efforts to address patients' 'unrealistic' expectations while attempting SDM. Patients, in turn, were often dissatisfied with the outcomes of the SDM encounter, as they believed their own expectations were not reflected in the final decision.

CONCLUSION

Unaddressed pre-consultation expectations form a barrier to constructive SDM encounters.

PRACTICAL IMPLICATIONS

Patients' pre-consultation expectations need to be explored during the SDM encounter. To achieve decisions that are truly shared by care professionals and patients, patients' pre-consultation expectations should be better incorporated into SDM models and education.

A valued voice: A qualitative analysis of parental decision-making preferences in emergent paediatric surgery

INTRODUCTION

Shared decision-making, with an emphasis on patient autonomy, is often advised in healthcare decision-making. However, this may be difficult to implement in emergent settings. We have previously demonstrated that when considering emergent operations for their children, parents prefer surgeon guidance as opposed to shared decision-making. Here, we interviewed parents of paediatric patients who had undergone emergent operations to better understand parental decision-making preferences.

METHODS

Parents of paediatric patients who underwent surgery over the past 5 years at a University-based, tertiary children's hospital for cancer, an emergent operation while in the neonatal intensive care unit (NICU) or extracorporeal membrane oxygenation (ECMO) were invited to complete a 60-min semi-structured interview. Interviews were digitally recorded and transcribed verbatim. Thematic content analysis was performed via deductive and inductive analysis. An iterative approach to thematic sampling/data analysis was used.

RESULTS

Thematic saturation was achieved after 12 interviews (4 cancer, 5 NICU and 3 ECMO). Five common themes were identified: (1) recommendations from surgeons are valuable; (2) 'lifesaving mode': parents felt there were no decisions to be made; (3) effective ways of obtaining information about treatment; (4) shared decision-making as a 'dialogue' or 'discussion' and (5) parents as a 'valued voice' to advocate for their children.

CONCLUSIONS

When engaging in decision-making regarding emergent surgical procedures for their children, parents value a surgeon's recommendation. Parents felt that discussion or dialogue with surgeons defined shared decision-making, and they believed that the opportunity to ask questions gave them a 'valued voice', even when they felt there were no decisions to be made.

PATIENT OR PUBLIC CONTRIBUTION

For this study, we interviewed parents of paediatric patients who had undergone emergent operations to better understand parental decision-making preferences. Parents thus provided all the data for the study.

Shared Decision-making in the U.S.: Evidence exists, but implementation science must now inform policy for real change to occur

Shared decision making (SDM) is defined as an approach in which clinicians and patients share the best available evidence when faced with the task of making decisions, and in which patients are supported to consider options to achieve informed preferences [1]. Over the past decade, SDM has been increasingly recognized as a component of value-based care in the US. There is greater acceptance overall that SDM is a key strategy for achieving patient-centered care, enhancing patient safety, and achieving the triple aim of better health, better care, and lower costs [2]. Essential elements of SDM include recognizing and acknowledging that a decision is required; knowing and understanding the best available evidence on risks and benefits; and incorporating the patient's values and preferences into the decision [3]. This paper provides an update of our previous review of SDM in the US published in 2017. We describe changes in healthcare policies to support SDM at the federal and state levels, the integration of SDM into clinical practice, and the role of implementation science to advance SDM. Finally, we discuss potential next steps to inform policies for SDM and facilitate uptake of SDM in clinical practice.

Decision coaching for people making healthcare decisions

BACKGROUND

Decision coaching is non-directive support delivered by a healthcare provider to help patients prepare to actively participate in making a health decision. 'Healthcare providers' are considered to be all people who are engaged in actions whose primary intent is to protect and improve health (e.g. nurses, doctors, pharmacists, social workers, health support workers such as peer health workers). Little is known about the effectiveness of decision coaching.

OBJECTIVES

To determine the effects of decision coaching (I) for people facing healthcare decisions for themselves or a family member (P) compared to (C) usual care or evidence-based intervention only, on outcomes (O) related to preparation for decision making, decisional needs and potential adverse effects.

SEARCH METHODS

We searched the Cochrane Library (Wiley), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (Ebsco), Nursing and Allied Health Source (ProQuest), and Web of Science from database inception to June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) where the intervention was provided to adults or children preparing to make a treatment or screening healthcare decision for themselves or a family member. Decision coaching was defined as: a) delivered individually by a healthcare provider who is trained or using a protocol; and b) providing non-directive support and preparing an adult or child to participate in a healthcare decision. Comparisons included usual care or an alternate intervention. There were no language restrictions.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations, assessed risk of bias, and extracted data on characteristics of the intervention(s) and outcomes. Any disagreements were resolved by discussion to reach consensus. We used the standardised mean difference (SMD) with 95% confidence intervals (CI) as the measures of treatment effect and, where possible, synthesised results using a random-effects model. If more than one study measured the same outcome using different tools, we used a random-effects model to calculate the standardised mean difference (SMD) and 95% CI. We presented outcomes in summary of findings tables and applied GRADE methods to rate the certainty of the evidence.

MAIN RESULTS

Out of 12,984 citations screened, we included 28 studies of decision coaching interventions alone or in combination with evidence-based information, involving 5509 adult participants (aged 18 to 85 years; 64% female, 52% white, 33% African-American/Black; 68% post-secondary education). The studies evaluated decision coaching used for a range of healthcare decisions (e.g. treatment decisions for cancer, menopause, mental illness, advancing kidney disease; screening decisions for cancer, genetic testing). Four of the 28 studies included three comparator arms.  For decision coaching compared with usual care (n = 4 studies), we are uncertain if decision coaching compared with usual care improves any outcomes (i.e. preparation for decision making, decision self-confidence, knowledge, decision regret, anxiety) as the certainty of the evidence was very low.  For decision coaching compared with evidence-based information only (n = 4 studies), there is low certainty-evidence that participants exposed to decision coaching may have little or no change in knowledge (SMD -0.23, 95% CI: -0.50 to 0.04; 3 studies, 406 participants). There is low certainty-evidence that participants exposed to decision coaching may have little or no change in anxiety, compared with evidence-based information. We are uncertain if decision coaching compared with evidence-based information improves other outcomes (i.e. decision self-confidence, feeling uninformed) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with usual care (n = 17 studies), there is low certainty-evidence that participants may have improved knowledge (SMD 9.3, 95% CI: 6.6 to 12.1; 5 studies, 1073 participants). We are uncertain if decision coaching plus evidence-based information compared with usual care improves other outcomes (i.e. preparation for decision making, decision self-confidence, feeling uninformed, unclear values, feeling unsupported, decision regret, anxiety) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with evidence-based information only (n = 7 studies), we are uncertain if decision coaching plus evidence-based information compared with evidence-based information only improves any outcomes (i.e. feeling uninformed, unclear values, feeling unsupported, knowledge, anxiety) as the certainty of the evidence was very low.

AUTHORS' CONCLUSIONS

Decision coaching may improve participants' knowledge when used with evidence-based information. Our findings do not indicate any significant adverse effects (e.g. decision regret, anxiety) with the use of decision coaching. It is not possible to establish strong conclusions for other outcomes. It is unclear if decision coaching always needs to be paired with evidence-informed information. Further research is needed to establish the effectiveness of decision coaching for a broader range of outcomes.

Ignorance is Not Bliss: The Case for Comprehensive Reproductive Counseling for Women with Chronic Kidney Disease

The bioethics literature has paid little attention to matters of informed reproductive decision-making among women of childbearing age who have chronic kidney disease (CKD), including women who are on dialysis or women who have had a kidney transplant. Women with CKD receive inconsistent and, sometimes, inadequate reproductive counseling, particularly with respect to information about pursuing pregnancy. We identify four factors that might contribute to inadequate and inconsistent reproductive counseling. We argue that women with CKD should receive comprehensive reproductive counseling, including information about the possibility of pursuing pregnancy, and that more rigorous research on pregnancy in women with CKD, including women on dialysis or who have received a kidney transplant, is warranted to improve informed reproductive decision making in this population.

Healthy or not? The impact of conflicting health-related information on attentional resources

Despite its ubiquity, little is known about the impact of exposure to conflicting health information on cognitive efficiency. We hypothesized that it would reduce attentional capacity, as evidenced by (1) increased response errors during the Attention Network Test (ANT), (2) decreased efficiency of each ANT system (alerting, orienting, execute control), and (3) increased self-reported workload, (4) nutritional confusion and (5) nutritional backlash. A sample of 184 online participants were assigned randomly to read an article containing either congruent or conflicting health information. Subsequently, they completed the ANT and self-report measures of workload, nutritional confusion, and backlash at nutritional recommendations and research. Participants in the conflicting health information condition made more errors, had overall slower reaction times, and reported greater workload, nutritional confusion, and backlash. No differences were found for individual ANT systems. These findings suggest that exposure to conflicting health information can degrade attentional mechanisms responsible for accurate and prompt responding to incoming information.

Conceptual understanding and applicability of shared decision-making in psychiatric care: An integrative review

WHAT IS KNOWN ON THE SUBJECT?: Shared decision-making is a concept originating in the medical field, and it is ideally based on a trustful relationship between the patient and the health professionals involved. Shared decision-making shows potential to strengthen patient autonomy and encourages patients to become involved in decisions regarding their treatment. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: A universal concept and understanding of shared decision-making with relevance specifically to psychiatric clinical practice could not be identified in the analysed literature. Shared decision-making refers to a process, and how and whether the patient wishes to participate in the decision-making process should be clarified from the very beginning. On the basis of this synthesizing review, a process model for psychiatric practice was specified and illustrated to help lead health professionals, patients and other supporters through the decision-making process. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The process of shared decision-making should be made visible to all persons involved, and it should be stated at the beginning that a decision must be made. Decisions regarding treatment are usually not limited to a single consultation. A collaborative approach including multiple health professionals and other supporters, such as peer workers and family members, is required. Psychiatric nurses could support patients during the process of decision-making and provide additional information, if requested.

ABSTRACT

INTRODUCTION: Patient involvement in decisions regarding treatment has increasingly been supported in health care, and therefore, shared decision-making (SDM), as an informative and participative approach, is promoted in the scientific literature.

AIM

To review the current state of research regarding the conceptual understanding and implementation of SDM in psychiatric clinical practice.

METHOD

An integrative review that included empirical, theoretical and conceptual research published between 1997 and 2019 was conducted. For this, five health-related databases were searched.

RESULTS

Fourteen articles were included in the synthesis. No universal conceptual understanding of SDM regarding psychiatric care could be identified, although several articles highlighted the link with other concepts, such as autonomy and patient-centeredness. Furthermore, four additional key themes with relevance for the successful implementation of SDM in clinical practice were determined.

DISCUSSION

SDM refers to a process and is usually not limited to a single consultation. SDM shows the potential to enhance patient-centred and recovery-oriented care. A collaborative approach including multiple health professionals, peer workers and family members is required.

IMPLICATIONS FOR PRACTICE

The process of SDM should be made visible for all parties involved. Nurses in particular could play a key role by collecting information regarding patient's preferences and by providing support.

Assessment of Parental Choice Predisposition for Tonsillectomy in Children

Importance

The decision to proceed with tonsillectomy to treat pediatric obstructive sleep-disordered breathing (OSDB) often falls on individual families. Despite emphasis on shared decision-making between parents and surgeons about tonsillectomy for OSDB, the extent to which parents have already decided about surgery prior to the child's consultation is not known.

Objective

To identify predictors of parent choice predisposition for surgical treatment of OSDB with tonsillectomy and describe its association with parent-clinician communication.

Design, Setting, and Participants

Observational cohort study conducted at 3 outpatient clinical sites (urban-based outpatient center, suburban off-site outpatient center, and community-based medical center) associated with a large academic center. A total of 149 parents of children undergoing their initial otolaryngology consultation for OSDB were identified through clinic scheduling records and deemed eligible for participation in this study. Of the 149 parents, a volunteer sample of 64 parents (42.9%) agreed to participate and have their consultation audiorecorded. Of these 64 participants, 12 parents were excluded because their child had previously been evaluated for OSDB by a specialist.

Main Outcomes and Measures

The primary outcomes and measures were treatment choice predisposition scale (a measure of the strength of a patient's treatment decision prior to entering a medical consultation), parent communication behaviors coded in consultation audiorecordings (substantive questions asked, introduced medical jargon, expression of treatment preference, and scores on the OSDB and Adenotonsillectomy Knowledge Scale for parents).

Results

A total of 52 parent participants were included in the final analysis. Most parent participants were female (n = 48; 92%); 50% (n = 26) of parents were non-Hispanic White, 37% (n = 19) were Black, 10% (n = 5) were Hispanic/Latino, and 4% (n = 2) self-reported race/ethnicity as "Other." Mean (range) choice predisposition was 6.84 (2-10), with 22 parents (42%) more predisposed to choose tonsillectomy. Parents more predisposed to choose tonsillectomy used more medical jargon during the consultation (odds ratio [OR], 3.95; 95% CI, 1.16-15.15) and were less likely to ask questions (OR, 0.22; 95% CI, 0.05-0.87). Parental predictors of greater predisposition toward choosing surgery were White race (OR, 7.31; 95% CI, 1.77-39.33) and prior evaluation by a pediatrician for OSDB (OR, 6.10; 95% CI, 1.44-33.34).

Conclusions and Relevance

In this cohort study of parents of children with OSDB, many parents were predisposed to choose treatment with tonsillectomy prior to initial surgical consultation, which may lessen engagement and influence 2-way communication. In this cohort, greater predisposition for tonsillectomy was observed in non-Hispanic White parents and parents of patients who had been previously evaluated by a pediatrician for OSDB. Understanding parent choice predisposition for surgery may promote improved communication and parental engagement during surgical consultations. It may also help direct education about sleep and tonsillectomy to nonsurgical forums.

Continuing professional education of Iranian healthcare professionals in shared decision-making: lessons learned

Background

In this study, we sought to assess healthcare professionals’ acceptance of and satisfaction with a shared decision making (SDM) educational workshop, its impact on their intention to use SDM, and their perceived facilitators and barriers to the implementation of SDM in clinical settings in Iran.

Methods

We conducted an observational quantitative study that involved measurements before, during, and immediately after the educational intervention at stake. We invited healthcare professionals affiliated with Tabriz University of Medical Sciences, East Azerbaijan, Iran, to attend a half-day workshop on SDM in December 2016. Decisions about prenatal screening and knee replacement surgery was used as clinical vignettes. We provided a patient decision aid on prenatal screening that complied with the International Patient Decision Aids Standards and used illustrate videos. Participants completed a sociodemographic questionnaire and a questionnaire to assess their familiarity with SDM, a questionnaire based on theoretical domains framework to assess their intention to implement SDM, a questionnaire about their perceived facilitators and barriers of implementing SDM in their clinical practice, continuous professional development reaction questionnaire, and workshop evaluation. Quantitative data was analyzed descriptively and with multiple linear regression.

Results

Among the 60 healthcare professionals invited, 41 participated (68%). Twenty-three were female (57%), 18 were specialized in family and emergency medicine, or community and preventive medicine (43%), nine were surgeons (22%), and 14 (35%) were other types of specialists. Participants’ mean age was 37.51 ± 8.64 years with 8.09 ± 7.8 years of clinical experience. Prior to the workshop, their familiarity with SDM was 3.10 ± 2.82 out of 9. After the workshop, their belief that practicing SDM would be beneficial and useful (beliefs about consequences) (beta = 0.67, 95% CI 0.27, 1.06) and beliefs about capability of using SDM (beta = 0.32, 95% CI -0.08, 0.72) had the strongest influence on their intention of practicing SDM. Participants perceived the main facilitator and barrier to perform SDM were training and high patient load, respectively.

Conclusions

Participants thought the workshop was a good way to learn SDM and that they would be able to use what they had learned in their clinical practice. Future studies need to study the level of intention of participants in longer term and evaluate the impact of cultural differences on practicing SDM and its implementation in both western and non-western countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06233-6.

High-risk surgery among older adults: Not-quite shared decision-making

BACKGROUND

Shared decision-making is critical to optimal patient-centered care. For elective operations, when there is sufficient time for deliberate discussion, little is known about how surgeons navigate decision-making and how surgeons align care with patient preferences. In this context, we sought to explore surgeons' approaches to decision-making for adults ≥65 years at high-risk of postoperative complications or death.

METHODS

We conducted semistructured in-depth interviews with 46 practicing surgeons across Michigan. Transcripts were iteratively analyzed through steps informed by inductive thematic analysis.

RESULTS

Four major themes emerged characterizing how surgeons approach high-risk surgical decision-making for older adults: (1) risk assessment was defined as the process used by surgeons to identify and analyze factors that may negatively impact outcome; (2) expectations and goals described the process of surgeons engaging with patients and families to discuss potential outcomes and desired objectives; (3) external and internal motivating factors outlined extrinsic dynamics (eg, quality metrics, referrals) and intrinsic drivers (eg, surgeons' personal experiences) that influenced high-risk decision-making; and (4) decision-making approaches and challenges encompassed the roles of patients and surgeons and obstacles to engaging in a true shared decision-making process.

CONCLUSION

Although shared decision-making is strongly recommended, we found that surgeons who perform high-risk operations among older adults predominantly focused on assessing risk and setting expectations with patients and families rather than inviting them to actively participate in the decision-making process. Surgeons also reported influences on decision-making from quality metrics, referrals, and personal experiences. Patient involvement, however, was seldom discussed suggesting that surgeons may not be engaging in true shared decision-making when benefits should be weighed against a high likelihood of harm.

Discrepancies in decision making preferences between parents and surgeons in pediatric surgery

BACKGROUND

Little data exists regarding decision-making preferences for parents and surgeons in pediatric surgery. Here we investigate whether parents and surgeons have similar decision-making preferences as well as which factors influence those preferences. Specifically, we compare parents' and surgeons' assessments of the urgency and complexity of pediatric surgical scenarios and the impact of their assessments on decision-making preferences.

METHODS

A survey was emailed to parents of patients evaluated in a university-based pediatric surgery clinic and surgeons belonging to the American Pediatric Surgical Association. The survey asked respondents to rate 6 clinical vignettes for urgency, complexity, and desired level of surgeon guidance using the Controlled Preferences Scale (CPS).

RESULTS

Regarding urgency, parents were more likely than surgeons to rate scenarios as emergent when cancer was involved (parents: 68.8% cancer vs. 29.5% non-cancer, p < .001; surgeons: 19.2% cancer vs. 25.4% non-cancer, p = .051). Parents and surgeons were more likely to rate a scenario as emergent when a baby was involved (parents: 45.2% baby vs. 36.2% child, p = .001; surgeons: 28.0% baby vs. 14.0% child, p < .001). Regarding decision-making preferences, parents and surgeons had similar CPS scores (2.56 vs. 2.72, respectively). Multivariable analysis showed parents preferred more surgeon guidance when scenarios involved a baby (OR 1.22; 95% CI 1.08-1.37; p < 0.01) or a cancer diagnosis (OR 1.29; 95% CI 1.11-1.49; p < 0.01), and that both parents and surgeons preferred more surgeon guidance when a scenario was considered emergent (parents: OR 1.81; 95% CI 1.37-2.38, p < 0.001; surgeons: OR 2.48 95% CI 1.76-3.49, p < 0.001).

CONCLUSIONS

When a pediatric patient is a baby or has cancer, parents are more likely then surgeons to perceive the clinical situation to be emergent, and both parents and surgeons prefer more surgeon guidance in decision-making when a clinical scenario is considered emergent. More research is needed to understand how parents' decision-making preferences depend on clinical context.

The impact of a physician's recommendation and gender on informed decision making: A randomized controlled study in a simulated decision situation

Objective

This study examined the influence of physicians’ recommendations and gender on the decision‐making process in a preference‐sensitive situation.

Methods

N = 201 participants were put in a hypothetical scenario in which they suffered from a rupture of the anterior cruciate ligament (ACL). They received general information on two equally successful treatment options for this injury (surgery vs physiotherapy) and answered questions regarding their treatment preference, certainty and satisfaction regarding their decision and attitude towards the treatment options. Then, participants watched a video that differed regarding physician's recommendation (surgery vs physiotherapy) and physician's gender (female vs male voice and picture). Afterwards, they indicated again their treatment preference, certainty, satisfaction and attitude, as well as the physician's professional and social competence.

Results

Participants changed their treatment preferences in the direction of the physician's recommendation (P < .001). Decision certainty (P < .001) and satisfaction (P < .001) increased more strongly if the physician's recommendation was congruent with the participant's prior attitude than if the recommendation was contrary to the participant's prior attitude. Finally, participants’ attitudes towards the recommended treatment became more positive (surgery recommendation: P < .001; physiotherapy recommendation: P < .001). We found no influence of the physician's gender on participants’ decisions, attitudes, or competence assessments.

Conclusion

This research indicates that physicians should be careful with recommendations when aiming for shared decisions, as they might influence patients even if the patients have been made aware that they should take their personal preferences into account. This could be particularly problematic if the recommendation is not in line with the patient's preferences.

A Complicated Case of Vaccine Refusal

Parents in the United States have a legal right to refuse vaccination for their children. There are, however, special circumstances under which the state may compel vaccination against parental wishes. In this Ethics Rounds article, we present the case of a young boy with sickle cell disease who was partially vaccinated against encapsulated bacteria and the ethics of whether to compel complete vaccination before splenectomy.

Shared decision making in surgery: a scoping review of patient and surgeon preferences

Background

Many suggest that shared decision-making (SDM) is the most effective approach to clinical counseling. It is unclear if this applies to surgical decision-making-especially regarding urgent, highly-morbid operations. In this scoping review, we identify articles that address patient and surgeon preferences toward SDM in surgery.

Methods

We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) to develop our protocol. Medline, EMBASE, and Cochrane databases were searched from inception through 11.2017. Title/abstract review identified peer-reviewed, empirical articles that addressed patient/surgeon preferences toward SDM in surgery. Identified articles underwent full review by two independent investigators. We addressed the following questions: (1) What is known from existing empirical evidence about patients’ and/or surgeons’ surgical decision-making preferences? (2) Why might patients and/or surgeons prefer SDM? (3) Does acuity of intervention impact surgical decision-making preferences? Outcome measures included study methods, surgical specialty, diagnosis, study location/setting, type/number of subjects, acuity of intervention, surgeon/patient decision-making preferences, and factors associated with favoring SDM. Data was analyzed in Microsoft Excel.

Results

20,359 articles were identified with 4988 duplicates, yielding 15,371 articles for title/abstract review. 74 articles were included in final analysis. 68% of articles discussed oncologic decision-making. 46% of these focused on breast cancer. 92% of articles included patients, 22% included surgeons. 75% of articles found surgeons favored SDM, 25% demonstrated surgeons favored surgeon guidance. 54% of articles demonstrated patients favored SDM, 35% showed patients favored surgeon guidance, 11% showed patients preferred independent decision-making. The most common factors for patients favoring SDM included female gender, higher education, and younger age. For surgeons, the most common factors for favoring SDM included limited evidence for a given treatment plan, multiple treatment options, and impact on patient lifestyle. No articles evaluated decision-making preferences in an emergent setting.

Conclusions

There has been limited evaluation of patient and surgeon preferences toward SDM in surgical decision-making. Generally, patients and surgeons expressed preference toward SDM. None of the articles evaluated decision-making preferences in an emergent setting, so assessment of the impact of acuity on decision-making preferences is limited. Extension of research to complex, emergent clinical settings is needed.

A Web-Based Decision Aid (myAID) to Enhance Quality of Life, Empowerment, Decision Making, and Disease Control for Patients With Ulcerative Colitis: Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

Patients with ulcerative colitis (UC) often face complex treatment decisions. Although shared decision making (SDM) is considered important, tools to facilitate this are currently lacking for UC. A recent pilot study of a novel Web-based decision aid (DA), my Actively Informed Decision (myAID), has suggested its acceptability and feasibility for informing treatment decisions and facilitating SDM in clinical practice.

OBJECTIVE

This paper describes the study protocol of the myAID study to assess the clinical impact of systematic implementation of myAID in routine UC management.

METHODS

The myAID study is a multicenter, cluster randomized controlled trial (CRCT) involving 22 Australian sites that will assess the clinical efficacy of routine use of myAID (intervention) against usual care without access to myAID (control) for UC patients. Participating sites (clusters) will be randomly allocated in a 1:1 ratio between the 2 arms. Patients making a new treatment decision beyond 5-aminosalicylate agents will be eligible to participate. Patients allocated to the intervention arm will view myAID at the time of recruitment and have free access to it throughout the study period. The effect of the myAID intervention will be assessed using the results of serial Web-based questionnaires and fecal calprotectin at baseline, 2 months, 6 months, and 12 months. A Web-based questionnaire within 2-4 weeks of referral will determine early change in quality of decision making and anxiety (both arms) and intervention acceptability (intervention arm only).

RESULTS

Study recruitment and funding began in October 2016, and recruitment will continue through 2020, for a minimum of 300 study participants at baseline at the current projection. The primary outcome will be health-related quality of life (Assessment of Quality of Life-8D), and secondary outcomes will include patient empowerment, quality of decision making, anxiety, work productivity and activity impairment, and disease activity. In addition, we aim to determine the predictors of UC treatment decisions and outcomes and the cost-effectiveness of implementing myAID in routine practice. Feedback obtained about myAID will be used to determine areas for improvement and barriers to its implementation. Completion of data collection and publication of study results are anticipated in 2021.

CONCLUSIONS

myAID is a novel Web-based DA designed to facilitate SDM in UC management. The results of this CRCT will contribute new evidence to the literature in comparing outcomes between patients who routinely access such decision support intervention versus those who do not, across multiple large inflammatory bowel disease centers as well as community-based private practices in Australia.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry ACTRN12617001246370 http://anzctr.org.au/Trial/ Registration/TrialReview.aspx?ACTRN=12617001246370.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/15994.

What is "shared" in shared decision-making? Philosophical perspectives, epistemic justice, and implications for health professions education

BACKGROUND

Drawing from the philosophical work of Hans-Georg Gadamer and the perspectives of theorists Mikhail Bakhtin and Kenneth Burke, the aim of this paper is to critically reflect on the meaning of the word "shared."

METHOD

The authors draw on the concept of epistemic justice, which they argue permeates the clinical encounter, to discuss how various forms of, and claims to, knowledge may influence the attainement of shared decision-making in health care contexts. The specific objectives are twofold: first, the authors draw key concepts from key Gadamerian, Burkean, and Bakhtinian philosophical perspectives to consider shared decision-making in relation to two types of epistemic injustice: testimonial and hermeneutic epistemic injustice. Second, building on philosopher Paulo Freire's critical pedagogy, the authors emphasize that major changes in educational structures and systems are required to promote the critical reflexivity required to address issues of epistemic justice, in the broader pursuit of authentic shared decision-making.

RESULTS

They propose three main areas of focus for helath professions education: (a) changes in content (moving from a focus on biomedical knowledge to more content on social sciences) and methods of teaching (more dialogue and the creation of moments of dissonance); (b) a re-examination of teachers' role in promoting epistemic justice; and (c) inclusion of patients as partners.

CONCLUSIONS

Without major transformation in what, how, and with whom we teach, future clinicians may be unprepared to enact shared decision-making in a manner that does justice to the various ways of knowing.

Surgeons' Views on Shared Decision-Making

PURPOSE

Shared decision-making (SDM) has a significant role in surgical encounters, where decisions are influenced by both clinician and patient preferences. Herein, we sought to explore surgeons' practices and beliefs about SDM.

METHODS

We performed a qualitative study consisting of semi-structured individual interviews with 18 surgeons from private practice and academic surgery practices in Baltimore, Maryland. We purposively sampled participants to maximize diversity of practice type (academic vs private), surgical specialty, gender, and experience level. Interview topics included benefits and challenges to patient involvement in decision-making, communicating uncertainty to patients, and use of decision aids. Interviews were audio-recorded and transcribed. Transcripts were analyzed using content analysis to identify themes.

RESULTS

Surgeons were supportive of patients being involved in decision-making, particularly in cases with uncertainty about treatment options. However, surgeons identified SDM as being more appropriate for patients whom surgeons perceived as interested in decision-making involvement and for decisions in which surgeons did not have strong preferences. Additionally, surgeons reported typically presenting only a subset of available options, remaining confident in their ability to filter less suitable options based on intuitive risk assessments. Surgeons differed in their approach to making recommendations, with some guiding patients towards what they saw as the correct or optimal decision while others sought to maintain neutrality and support of the patients' chosen decision.

CONCLUSIONS

Many surgeons do not believe SDM is universally optimal for every surgical decision. They instead use assessments of patient disposition or potential clinical uncertainty to guide their perceived appropriateness of using SDM.

The duality of option-listing in cancer care

OBJECTIVE

Listing more than one option for treatment, termed "option-listing" (OL) is one way to facilitate shared decision-making. We seek to evaluate how oncologists do option-listing in clinical encounters across disease contexts.

METHOD

We coded and transcribed 90 video-recorded interactions between 5 oncologist participants and a convenience sample of 82 patients at 2 large clinics in the western U.S. We used conversation analytic (CA) methods to examine patterns of behavior when oncologists provided more than one treatment option to patients.

RESULTS

In early-stage disease, OL provides patients with options while at the same time constraining those options through expression of physician bias. This effect disappears when cancer is at an advanced stage. In this context, OL is presented without physician preference and demonstrates recission of medical authority.

CONCLUSION

In early-stage contexts, OL functions as a way for physicians to array available options to patients while also communicating their expertise. In advanced-stage contexts, OL functions as a way to minimize treatment options and highlight dwindling possibilities.

PRACTICE IMPLICATIONS

OL is one way to implement shared decision-making, but it can also be used to facilitate a realization that treatment choices are diminishing and disease is progressing beyond a cure.

Musculoskeletal pain stakeholder engagement and partnership development: determining patient-centered research priorities

BACKGROUND

Musculoskeletal (MSK) pain is a global public health problem with increased societal burden. Increased attention has focused toward patient and other stakeholder perspectives when determining future MSK pain research priorities, however infrastructure and capacity building within the community are needed for individuals and organizations to participate in patient-centered outcomes research. The purpose of this manuscript is to describe our collaborative experiences with several MSK pain stakeholders and processes to identify a top priority research topic.

METHODS

Lunch meetings and formalized workshops were used to develop infrastructure for engaging patients and other stakeholders with early capacity building for partners to identify MSK pain research ideas based on their personal experiences. Additional capacity building and engagement through literature searching further prepared partners to contribute informed decisions about MSK pain research topics and subsequent selection of an important research question.

RESULTS

Several key deliverables (e.g., Governance Document, Communication Plan) were developed and completed over the course of this project to provide partnership structure. Other key deliverables included a list of preliminary comparative effectiveness research ideas (n = 8) and selection of shared decision making for MSK pain as the top priority research topic with patient partners identifying pain self-efficacy as an important outcome domain.

CONCLUSIONS

Our patient partners provided the catalyst for identifying shared decision making as a high priority research topic based on a wide spectrum of stakeholder perspectives and unique experiences. Patient partners were primarily identified using a single rehabilitation health system and clinician partners were heavily weighted by physical therapists which may have introduced selection bias.

OpenNotes and shared decision making: a growing practice in clinical transparency and how it can support patient-centered care

Objective

Prior studies suggest inviting patients to read their visit notes (OpenNotes) has important benefits for patient engagement. We utilized survey data to investigate our hypothesis that patients who read more notes would report greater shared decision making (SDM).

Materials and Methods

Our survey focused on the safety and quality implications of OpenNotes. 24 722 patients at an urban healthcare organization were invited to complete the survey, which included an item assessing the number of notes read and the CollaboRATE scale to measure SDM. We used log-binomial regression to estimate the relative probability of top CollaboRATE scores across number of notes read while controlling for several covariates.

Results

6913 patients responded (28% response rate). Patients reading 4+ clinical notes in the past 12 months were 17% more likely to have top CollaboRATE scores when compared to patients who had not read a note in the previous 12 months (RR: 1.17, 95%CI: 1.04-1.32).

Discussion

There is a clear relationship between what SDM requires and the transparency OpenNotes provides. Access to clinicians' notes can support the SDM model, which relies on efficient information exchange between clinicians and well-informed patients.

Conclusion

Our study showed evidence of a relationship between note reading and perceived SDM. Implementation of SDM is likely to expand, given its association with improved patient satisfaction, adherence, and medical decision making. Findings from this study highlight OpenNotes as a policy that institutions can implement as a facilitator of SDM and a manifestation of their commitment to patient autonomy and transparency.

Perceptions of shared decision making among health care professionals

RATIONALE AND AIMS

Scholars have progressively promoted shared decision making (SDM) as an optimal model of treatment decision making in clinical practice. Nevertheless, it is unclear whether health care professionals (a) understand SDM well, (b) believe that SDM is helpful in their daily practice, and (c) are willing to practice SDM during their daily activities. These are crucial research topics; however, such research is still limited. The aim of this study was to apply the knowledge-attitude-behavior (KAB) model to probe health care professionals' perceptions of SDM.

METHODS

A questionnaire was delivered to health care professionals working in various hospitals in southern Taiwan from 9 November 2018 to 8 January 2019. In addition to KAB constructs, this study explored the barriers to SDM practice and willingness to practice SDM among health care professionals. Predictive variables were subjected to multiple linear regression analysis to investigate health care professionals' views of SDM.

RESULTS

Valid respondents numbered 400, including physicians, pharmacists, nurses, and other health care professionals. The characteristics of these health care professionals significantly affected the mean scores of the KAB model. A correlation analyses indicated that the KAB constructs were positively correlated with each other. The top three barriers reported were lack of time (57.50%), lack of knowledge (38.25%), and difficulty of developing patient decision aids (37.75%). Respondents who were willing to practice SDM opined that SDM can provide the best health care for patients (81.62%), can maintain and improve individual clinical expertise (77.38%), and can meet patient and social expectations (48.40%).

CONCLUSIONS

Continuous emphasis on education regarding SDM and continuous promotion of a positive attitude of SDM acceptance can influence the behaviour of practicing SDM among health care professionals. Further study is required to assess the SDM practices of various health care professionals in different settings.

A descriptive model of shared decision making derived from routine implementation in clinical practice ('Implement-SDM'): Qualitative study

OBJECTIVE

Research is needed to understand how Shared Decision-Making (SDM) is enacted in routine clinical settings. We aimed to 1) describe the process of SDM between clinicians and patients; 2) examine how well the SDM process compares to a prescriptive model of SDM, and 3) propose a descriptive model based on observed SDM in routine practice.

METHODS

Patients with chronic kidney disease and early stage breast cancer were recruited consecutively via Cardiff and Vale University Health Board (UK) teams. Consultations were audio-recorded, transcribed and thematically analysed.

RESULTS

Seventy-six consultations were observed: 26 pre-dialysis consultations and two consultations each for 25 breast cancer patients. Key stages of the 'Three Talk Model' were observed. However, we also observed more elements and greater complexity: a distinct preparation phase; tailored and evolving integrative option conversation; patients and clinicians developing 'informed preferences'; distributed and multi-stage decisions; and a more open-ended planning discussion. Use of decision aids was limited.

CONCLUSION

A more complex picture was observed compared with previous portrayals in current theoretical models.

PRACTICE IIMPLICATIONS

The model can provide a basis for future training and initiatives to promote SDM, and tackle the gap between what is advocated in policy, but rarely achieved in practice.

Minority patient preferences, barriers, and facilitators for shared decision-making with health care providers in the USA: A systematic review

OBJECTIVES

This systematic review of contemporary literature sought to better understand racial and ethnic minority patients' shared decision-making (SDM) preferences, challenges and facilitators.

METHODS

Data sources were PubMed, CINAHL, Embase, Google Scholar, PsycINFO, Sociological Abstracts, and Web of Science databases for publications between 2011 and 2016. Publications were included if they studied SDM during the clinical encounter for minority adults in clinical care in the United States. We conducted a narrative, descriptive synthesis of each study.

RESULTS

From over 5000 publications identified through the search strategy, 18 met eligibility criteria following an abstract and full text (n = 685) review in Covidence. Studies focused on SDM in developing treatment plans (n = 10), and were conducted in primary care (n = 6) or hospital/health system settings (n = 6). Patients' decision preferences ranged from physician-driven altogether or initially, to patient-driven style. A comprehensive list of SDM facilitators and barriers was developed.

CONCLUSION

Despite strong policy and research SDM support to increase patient communication and a growing published literature, results suggest lack of representation of minority populations in contemporary literature.

PRACTICE IMPLICATIONS

Provider training may be needed to facilitate patient-provider transition from a passive toward a more active SDM engagement over time while confidence, trust and rapport is established.

An integrated knowledge translation approach to develop a shared decision-making strategy for use by Inuit in cancer care: a qualitative study

Background

In relation to the general Canadian population, Inuit face increased cancer risks and barriers to health services use. In shared decision-making (sdm), health care providers and patients make health care decisions together. Enhanced participation in cancer care decisions is a need for Inuit. Integrated knowledge translation (kt) supports the development of research evidence that is likely to be patient-centred and applied in practice.

Objective

Using an integrated kt approach, we set out to promote the use of sdm by Inuit in cancer care.

Methods

An integrated kt study involving researchers with a Steering Committee of cancer care system partners who support Inuit in cancer care ("the team") consisted of 2 theory-driven phases:■ using consensus-building methods to tailor a previously developed sdm strategy and developing training in the sdm strategy; and■ training community support workers (csws) in the sdm strategy and testing the sdm strategy with community members.

Results

The team developed a sdm strategy that included a workshop and a booklet with 6 questions for use by csws with patients. The sdm strategy (training and booklet) was finalized based on feedback from 5 urban-based Inuit csws who were recruited and trained in using the strategy. Trained csws were matched with 8 community members, and use of the sdm strategy was assessed during interviews, reported as 6 themes. Participants found the sdm strategy to be useful and feasible for use.

Conclusions

An integrated kt approach of structured research processes with partners developed a sdm strategy for use by Inuit in cancer care. Further work is needed to test the sdm strategy.

Measuring shared decision-making in the pediatric outpatient setting: Psychometric performance of the SDM-Q-9 and CollaboRATE among English and Spanish speaking parents in the US Midwest

OBJECTIVE

Shared decision-making (SDM) measures have never been assessed for validity and feasibility in pediatric outpatient settings. We compared psychometric performance of parent adaptations of a well-established measure (SDM-Q-9) to a newer measure focusing on provider effort in facilitating SDM (CollaboRATE) in two clinics.

METHODS

English (n = 955) and Spanish (n = 58) speaking parents of children ages 1-5 years with symptoms of acute respiratory tract infections (ARTI) completed post-visit SDM-Q-9, CollaboRATE, satisfaction items (visit, provider communication, and study participation), and qualitative feedback.

RESULTS

Parents felt CollaboRATE was more comprehensible and relevant than SDM-Q-9, which refers to decision-making actions difficult to define in ARTI visits. Among English-speakers, both measures showed high internal consistency (α = 0.91, α = 0.97). SDM-Q-9 reliability was strong (split-half, r = 0.83) and CollaboRATE weak-to-moderate (two-week test-retest, ρ = 0.41-0.66). Convergent validity with communication and visit satisfaction was poor for SDM-Q-9 (r=0.38, r=0.34) but higher for CollaboRATE (r=0.59, r = 0.52). Both showed divergent validity with study participation satisfaction (r=0.08, r=0.13). Spanish versions demonstrated similar results.

CONCLUSIONS

Parent preference and correlations with satisfaction support CollaboRATE over SDM-Q-9, however psychometrics were borderline acceptable.

PRACTICE IMPLICATIONS

Tools like CollaboRATE that focus on provider effort appear more appropriate for routine pediatric visits where SDM outcomes may be difficult to identify, yet additional validation research is needed.

Beginning with high value care in mind: A scoping review and toolkit to support the content, delivery, measurement, and sustainment of high value care

OBJECTIVE

To create a shared vision for the content, delivery, measurement, and sustainment of patient-centered high value care.

METHODS

We performed a scoping review and translated findings into toolkit for system leaders. For our scoping review, we searched Medline, 2005-November 2015, for literature on patient-centered care (PCC) and its relationship to a high value care change model. We supplemented searches with key author, Google Scholar, and key website searches. One author reviewed all titles, abstracts, and articles for inclusion; another reviewed a random 20%. To develop our toolkit, we translated evidence into simple, actionable briefs on key topics and added resources. We then iteratively circulated briefs and the overall toolkit to potential users, making updates as needed.

RESULTS

In our scoping review, we found multiple interventions and measures to support the components of PCC and our change model. We found little on the overall effects of PCC or how PCC creates value. Potential users reported our toolkit was simple, understandable, thorough, timely, and likely to be globally useful.

CONCLUSIONS

Considerable evidence supports patient-centered high value care and a toolkit garnered enthusiasm.

PRACTICE IMPLICATIONS

The toolkit is ready for use, but needs comparison to other approaches.

Utilizing a 3S (strategies, source and setting) approach to understand the patient's preferences when addressing medication non-adherence in patients with diabetes: a focus group study in a primary outpatient clinic

OBJECTIVE

Non-adherence with diabetes medicines is a challenge. Approximately 54% of patients are non-adherent with their diabetes medicines. The objective of this study was to understand patients' preferences when addressing non-adherence based on the 3S approach-strategies (what approaches can be used in addressing non-adherence), settings (when and where should the intervention happen) and sources (who should provide the intervention).

DESIGN

A focus group research design was used.

SETTING

A primary outpatient clinic from an integrated healthcare system in the USA.

PARTICIPANTS

Patients who were non-adherent with diabetes medicines.

DATA COLLECTION

The focus group guide was based on the Medication Adherence Reasons Scale, which has 19 reasons identified for non-adherence. For each item in the scale, patients were asked for strategies that can be used in addressing that issue, the setting in which the interventions should be provided and the source to provide the interventions.

DATA ANALYSIS

Open coding and content analysis.

RESULTS

Two focus groups, each group having seven patients, were conducted. The major strategies identified were patient education, self-responsibility of patients, family support, reminders and societal support. The key educational needs were dealing with side effects and learning to use insulin properly, and a need for different learning styles when offering education. For the source, the major ones were physicians and pharmacists, having a continuous dialogue about the disease and medicines, and individuality in managing the disease. Respondents also recommended using a peer support group. For the setting, the patients preferred continuity of patient education throughout the disease.

CONCLUSION

The 3S approach was able to elicit several recommendations from patients to improve their adherence with diabetes medicines. Educational strategies were identified as the foremost approach coming from physicians and pharmacists throughout their disease journey, in addition to peer support.

Does maternity care decision-making conform to shared decision- making standards for repeat cesarean and labor induction after suspected macrosomia?

BACKGROUND

In a national United States survey, we investigated whether crucial shared decision-making standards were met for 2 common maternity care decisions.

METHODS

Secondary analysis of Listening to Mothers III. A sequence of validated questions concerning shared decision-making was adapted to 2 maternity care decisions: to induce labor or wait for spontaneous onset of labor among women who were told their baby may be "getting quite large" (N = 349); and for women with 1 or 2 prior cesareans (N = 393), the decision to have a repeat cesarean.

RESULTS

Almost half (N = 163; 47%) of women who were told their baby might be large reported engaging in a discussion concerning possible labor induction vs waiting for labor, while a large majority (N = 321; 82%) of women with a prior cesarean discussed the option of a repeat cesarean or a planned vaginal birth after cesarean (VBAC). Women who engaged in discussions received disproportionate information about having the interventions and were more likely to experience the interventions (68% induction, 87% repeat cesarean) than women who did not. After adjustment, women who reported that their provider recommended scheduling a repeat cesarean were 14 times more likely to give birth via cesarean compared with those whose providers recommended planning VBAC (AOR 14.2; 95% CI: 3.2, 63.0).

CONCLUSION

Our findings suggest that, for the decisions in question, established standards of shared decision-making are not being reliably implemented in maternity care despite opportunities to do so. Provider recommendations and the disproportionate conveyance of reasons for an intervention appear to be related to higher levels of intervention.

Do surgeons and patients/parents value shared decision-making in pediatric surgery? A systematic review

BACKGROUND

Shared decision-making (SDM) is touted as the preferred approach to clinical counseling. However, few data exist regarding whether patients prefer SDM over surgeon-guided discussions for complex surgical decision-making. Even fewer data exist regarding surgeon preferences. Such issues may be especially pronounced in pediatric surgery given the complex decision-making triad between patients/parents and surgeons. The objective of this systematic review was to evaluate patient/parent and surgeon attitudes toward SDM in pediatric surgery.

METHODS

A systematic review of English language articles in Medline, EMBASE, and Cochrane databases was performed. Inclusion and exclusion criteria were predefined. Text screening and data abstraction were performed by two investigators.

RESULTS

Seven thousand five hundred eighty-four articles were screened. Title/abstract review excluded 7544 articles, and full-text review excluded four articles. Thirty-six articles were identified as addressing patient/parent or surgeon preferences toward SDM in pediatric surgery. Subspecialties included Otolaryngology (33%), General Surgery (30%), Plastics (14%), Cardiac (11%), Urology (8%), Neurosurgery (6%), Orthopedics (6%), and Gynecology (3%). Most studies (94%) evaluated elective/nonurgent procedures. The majority (97%) concentrated on patient/parent preferences, whereas only 22% addressed surgeon preferences. Eleven percent of studies found that surgeons favored SDM, and 73% demonstrated that patients/parents favored SDM.

CONCLUSIONS

Despite recommendations that SDM is the preferred approach to clinical counseling, our systematic literature review shows that few studies evaluate patient/parent and surgeon attitudes toward SDM in pediatric surgery. Of these studies, very few focus on complex, urgent/emergent decision-making. Further research is needed to understand whether patients/parents, as well as surgeons, may prefer a more surgeon-guided approach to decision-making, especially when surgery is complex or taking place in urgent/emergent settings.

An Innovative Shared Decision-Making Curriculum for Internal Medicine Residents: Findings From the University of Pittsburgh Medical Center

PURPOSE

Shared decision making (SDM) is a core competency in health policy and guidelines. Most U.S. internal medicine residencies lack an SDM education curriculum. A standardized patient (SP)-based curriculum teaching key concepts and skills of SDM was developed.

METHOD

This curriculum consisted of an innovative seven-step SDM model and a skills-focused SP case, integrated into the ambulatory rotation for senior medicine residents at the University of Pittsburgh Medical Center in 2015. Evaluation consisted of pre/postcurriculum surveys assessing residents' knowledge of and attitudes toward SDM. Skills development was assessed via pre/postcurricular audio recordings of clinical decision making.

RESULTS

Thirty-six residents completed the curriculum (survey participation rate 88%). There was significant improvement in residents' knowledge (median score pre 75%, post 100%, P < .01); confidence (median composite score pre 2.87, post 3.0, P < .01, where 1 = not confident/important, 4 = very confident/important); and importance of SDM (median composite score pre 3.14, post 3.5, P < .01). Forty-four clinical recordings (31 pre, 13 post) were assessed using the Observing Patient Involvement in Decision-Making scale. Improvement in use of SDM skills was seen among all residents (mean increase 1.84 points, P = .27). When data were stratified post hoc by U.S. versus international medical graduates, there was significant improvement in total score (mean increase of 5.15 points, P = .01) among U.S. graduates only.

CONCLUSIONS

SDM is teachable, and this skill-based curricular intervention resulted in improvement in senior medicine residents' knowledge of, attitudes toward, and demonstration of SDM skills.

Evidence-Based Medicine in Otolaryngology, Part 8: Shared Decision Making—Impact, Incentives, and Instruments

In our previous installment, we introduced shared decision making (SDM) as a collaborative process in which patients, families, and clinicians develop a mutually optimized treatment plan when more than 1 reasonable treatment option exists. In this subsequent installment of our Evidence-Based Medicine in Otolaryngology Series, we expand on the topic of SDM, including the related current state of clinical decision making, the impact of SDM on health care utilization and patient satisfaction, the potential role of system and society changes, the experience with SDM as it relates to race and ethnicity, existing financial incentives, and the validated instruments that assess the extent to which SDM occurs.

Evidence-Based Medicine in Otolaryngology Part 7: Introduction to Shared Decision Making

Shared decision making (SDM) is a collaborative process in which patients, families, and clinicians develop a mutually agreed upon treatment plan when more than one reasonable treatment option exists. This cooperative engagement fosters improvements in patient satisfaction, disease management, and outcomes and also has the capacity to promote evidence-based care. Thus, this seventh installment of our Evidence-Based Medicine in Otolaryngology series focuses on SDM. We introduce SDM, including its potential to reduce decisional conflict and decisional regret, when it should be used, its potential benefits, barriers to implementation, and its role in the management of chronic disease and otolaryngological conditions.

Involving citizens in priority setting for public health research: Implementation in infection research

BACKGROUND

Public sources fund the majority of UK infection research, but citizens currently have no formal role in resource allocation. To explore the feasibility and willingness of citizens to engage in strategic decision making, we developed and tested a practical tool to capture public priorities for research.

METHOD

A scenario including six infection themes for funding was developed to assess citizen priorities for research funding. This was tested over two days at a university public festival. Votes were cast anonymously along with rationale for selection. The scenario was then implemented during a three-hour focus group exploring views on engagement in strategic decisions and in-depth evaluation of the tool.

RESULTS

188/491(38%) prioritized funding research into drug-resistant infections followed by emerging infections(18%). Results were similar between both days. Focus groups contained a total of 20 citizens with an equal gender split, range of ethnicities and ages ranging from 18 to >70 years. The tool was perceived as clear with participants able to make informed comparisons. Rationale for funding choices provided by voters and focus group participants are grouped into three major themes: (i) Information processing; (ii) Knowledge of the problem; (iii) Responsibility; and a unique theme within the focus groups (iv) The potential role of citizens in decision making. Divergent perceptions of relevance and confidence of "non-experts" as decision makers were expressed.

CONCLUSION

Voting scenarios can be used to collect, en-masse, citizens' choices and rationale for research priorities. Ensuring adequate levels of citizen information and confidence is important to allow deployment in other formats.

Qualitative systematic review of barriers and facilitators to patient-involved antipsychotic prescribing

BACKGROUND

Despite policy and practice mandates for patient involvement, people with serious mental illness often feel marginalised in decisions about antipsychotic medication. Aims To examine stakeholder perspectives of barriers and facilitators to involving people with serious mental illness in antipsychotic prescribing decisions.

METHOD

Systematic thematic synthesis.

RESULTS

Synthesis of 29 studies identified the following key influences on involvement: patient's capability, desire and expectation for involvement, organisational context, and the consultation setting and processes.

CONCLUSIONS

Optimal patient involvement in antipsychotic decisions demands that individual and contextual barriers are addressed. There was divergence in perceived barriers to involvement identified by patients and prescribers. For example, patients felt that lack of time in consultations was a barrier to involvement, something seldom raised by prescribers, who identified organisational barriers. Patients must understand their rights to involvement and the value of their expertise. Organisational initiatives should mandate prescriber responsibility to overcome barriers to involvement. Declaration of interest None.

Development of a Framework Based on Reflective MCDA to Support Patient-Clinician Shared Decision-Making: The Case of the Management of Gastroenteropancreatic Neuroendocrine Tumors (GEP-NET) in the United States

Introduction

Well- or moderately differentiated gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are often slow-growing, and some patients with unresectable, asymptomatic, non-functioning tumors may face the choice between watchful waiting (WW), or somatostatin analogues (SSA) to delay progression. We developed a comprehensive multi-criteria decision analysis (MCDA) framework to help patients and physicians clarify their values and preferences, consider each decision criterion, and support communication and shared decision-making.

Methods

The framework was adapted from a generic MCDA framework (EVIDEM) with patient and clinician input. During a workshop, patients and clinicians expressed their individual values and preferences (criteria weights) and, on the basis of two scenarios (treatment vs WW; SSA-1 [lanreotide] vs SSA-2 [octreotide]) with evidence from a literature review, expressed how consideration of each criterion would impact their decision in favor of either option (score), and shared their knowledge and insights verbally and in writing.

Results

The framework included benefit-risk criteria and modulating factors, such as disease severity, quality of evidence, costs, and constraints. Overall and progression-free survival being most important, criteria weights ranged widely, highlighting variations in individual values and the need to share them. Scoring and considering each criterion prompted a rich exchange of perspectives and uncovered individual assumptions and interpretations. At the group level, type of benefit, disease severity, effectiveness, and quality of evidence favored treatment; cost aspects favored WW (scenario 1). For scenario 2, most criteria did not favor either option.

Conclusions

Patients and clinicians consider many aspects in decision-making. The MCDA framework provided a common interpretive frame to structure this complexity, support individual reflection, and share perspectives.

Funding

Ipsen Pharma.

Electronic supplementary material

The online version of this article (10.1007/s12325-017-0653-1) contains supplementary material, which is available to authorized users.

Shared decision-making at the end of life: A focus group study exploring the perceptions and experiences of multi-disciplinary healthcare professionals working in the home setting

BACKGROUND

Globally recommended in healthcare policy, Shared Decision-Making is also central to international policy promoting community palliative care. Yet realities of implementation by multi-disciplinary healthcare professionals who provide end-of-life care in the home are unclear.

AIM

To explore multi-disciplinary healthcare professionals' perceptions and experiences of Shared Decision-Making at end of life in the home.

DESIGN

Qualitative design using focus groups, transcribed verbatim and analysed thematically.

SETTING/PARTICIPANTS

A total of 43 participants, from multi-disciplinary community-based services in one region of the United Kingdom, were recruited.

RESULTS

While the rhetoric of Shared Decision-Making was recognised, its implementation was impacted by several interconnecting factors, including (1) conceptual confusion regarding Shared Decision-Making, (2) uncertainty in the process and (3) organisational factors which impeded Shared Decision-Making.

CONCLUSION

Multiple interacting factors influence implementation of Shared Decision-Making by professionals working in complex community settings at the end of life. Moving from rhetoric to reality requires future work exploring the realities of Shared Decision-Making practice at individual, process and systems levels.

Exploring differences in the use of the statin choice decision aid and diabetes medication choice decision aid in primary care

Background

Shared decision making is essential to patient centered care, but can be difficult for busy clinicians to implement into practice. Tools have been developed to aid in shared decision making and embedded in electronic medical records (EMRs) to facilitate use. This study was undertaken to explore the patterns of use and barriers and facilitators to use of two decision aids, the Statin Choice Decision Aid (SCDA) and the Diabetes Medication Choice Decision Aid (DMCDA), in primary care practices where the decision aids are embedded in the EMR.

Methods

A survey exploring factors that influenced use of each decision aid was sent to eligible primary care clinicians affiliated with the Mayo Clinic in Rochester, MN. Survey data was collected and clinician use of each decision aid via links from the EMR was tracked.

Results

The survey response rate was 40% (105/262). Log file data indicated 51% of clinicians used the SCDA and 9% of clinicians used the DMCDA. Reasons for lack of use included lack of knowledge of the EMR link, not finding the decision aids helpful, and time constraints. Survey responses indicated that use of the tool as intended was low, with many clinicians only discussing decision aid topics that they found relevant.

Conclusion

Although guidelines for both the treatment of blood cholesterol with a statin and for the treatment of hyperglycemia in type 2 diabetes recommend shared decision making, tools that facilitate shared decision making are not routinely used even when embedded in the EMR. Even when decision aids are used, their use may not reflect patient centered care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-017-0514-5) contains supplementary material, which is available to authorized users.

Conflicting health information: a critical research need

Conflicting health information is increasing in amount and visibility, as evidenced most recently by the controversy surrounding the risks and benefits of childhood vaccinations. The mechanisms through which conflicting information affects individuals are poorly understood; thus, we are unprepared to help people process conflicting information when making important health decisions. In this viewpoint article, we describe this problem, summarize insights from the existing literature on the prevalence and effects of conflicting health information, and identify important knowledge gaps. We propose a working definition of conflicting health information and describe a conceptual typology to guide future research in this area. The typology classifies conflicting information according to four fundamental dimensions: the substantive issue under conflict, the number of conflicting sources (multiplicity), the degree of evidence heterogeneity and the degree of temporal inconsistency.

Use of the Diabetes Medication Choice Decision Aid in patients with type 2 diabetes in Greece: a cluster randomised trial

OBJECTIVE

To assess the efficacy of the Diabetes Medication Choice Decision Aid among patients with type 2 diabetes in Greece.

DESIGN

Open-label cluster randomised controlled trial.

SETTING

Primary and secondary care practices across Greece.

PARTICIPANTS

5 sites allocated to the decision aid (n=101 patients) and 4 sites to control (n=103 patients).

INTERVENTION

Clinicians and patients in the intervention arm used a decision aid, based on outcomes that both consider important when choosing among antihyperglycaemic medications. Patients in the control arm received usual care.

OUTCOME MEASURES

The primary outcome was patient's level of decisional comfort after the initial clinical encounter. Secondary outcomes included patient's knowledge about type 2 diabetes and medications, and patient's and clinician's satisfaction. Adherence to prescribed antihyperglycaemic medication and change in glycated haemoglobin were assessed at 24 weeks.

RESULTS

Patients in both arms had similar scores in overall decisional comfort (mean difference between the usual care and decision aid arms -6.9, 95% CI -21.5 to 7.7) and its subscales. Patients' knowledge was high in both arms (mean difference 2.3%, 95% CI -15.7% to 20.4%). Patients and clinicians in both groups were equally satisfied with the decision-making. No significant difference in medication adherence and glycaemic control was found across arms. Clinicians found the decision aid useful and reported that its integration in their daily routine was easy.

CONCLUSIONS

The decision aid was implemented and positively received in the clinical setting in Greece, in line with the patient-centred approach endorsed by current guidelines. However, this trial yielded imprecise results in terms of patient outcomes. Further research is needed to investigate the interaction between the patient and the clinician in order to clarify the association between the use of decision aids and implementation of shared decision-making.

TRIAL REGISTRATION NUMBER

NCT01861756. Pre-results.

Shared decision-making for people living with dementia in extended care settings: protocol for a systematic review

INTRODUCTION

Approximately 450 000 people in the UK are living in care homes, 70% of whom are thought to have dementia or significant memory problems. This means that they may need support with day-to-day decisions about their health and care. Shared decision-making interventions can have a positive impact on patient outcomes. They recognise an individual's rights to make decisions about their care or treatment and support person-centred approaches to care delivery.

METHODS

A systematic review of studies designed to assess, implement, measure and/or explore shared decision-making with cognitively impaired adults in (or transferrable to) an extended care setting, with a view to answering the research question: How can people living with dementia and cognitive impairment be included in day-to-day decisions about their health and care in extended care settings? The systematic review will be started in May 2016. Studies are excluded that focus on advance decision-making. The search strategy is limited to a 20-year timeframe and English language and includes electronic databases; CINAHL, PubMed, the Cochrane Library, NICE Evidence, OpenGrey, Autism Data, Google Scholar, Scopus and MedicinesComplete.

ETHICS AND DISSEMINATION

Ethical approval not required. Planned dissemination routes for protocol and systematic review through conference presentations, peer-reviewed journals and research networks including the East of England CLAHRC, INTERDEM, and the National Care Homes Research and Development Forum.

DISCUSSION

The review will explore how shared decision-making is characterised and constructed in extended care settings for people living with cognitive impairment and their staff and family carers, in relation to their preferences and desires, the roles people play, facilitators, barriers, risk and benefits. The findings will inform an intervention study facilitating shared decision-making for people living with dementia in care homes and have the potential to inform future policy and practice.

TRIAL REGISTRATION NUMBER

CRD42016035919.

Training health professionals in shared decision making: Update of an international environmental scan

OBJECTIVE

To update an environmental scan of training programs in SDM for health professionals.

METHODS

We searched two systematic reviews for SDM training programs targeting health professionals produced from 2011 to 2015, and also in Google and social networks. With a standardized data extraction sheet, one reviewer extracted program characteristics. All completed extraction forms were validated by a second reviewer.

RESULTS

We found 94 new eligible programs in four new countries and two new languages, for a total of 148 programs produced from 1996 to 2015-an increase of 174% in four years. The largest percentage appeared since 2012 (45.27%). Of the 94 newprograms, 42.55% targeted licensed health professionals (n=40), 8.51% targeted pre-licensure (n=8), 28.72% targeted both (n=27), 20.21% did not specify (n=19), and 5.32% targeted also patients (n=5). Only 23.40% of the new programs were reported as evaluated, and 21.28% had published evaluations.

CONCLUSIONS

Production of SDM training programs is growing fast worldwide. Like the original scan, this update indicates that SDM training programs still vary widely. Most still focus on the single provider/patient dyad and few are evaluated.

PRACTICE IMPLICATIONS

This update highlights the need to adapt training programs to interprofessional practice and to evaluate them.

Shared decision making in endocrinology: present and future directions

In medicine and endocrinology, there are few clinical circumstances in which clinicians can accurately predict what is best for their patients. As a result, patients and clinicians frequently have to make decisions about which there is uncertainty. Uncertainty results from limitations in the research evidence, unclear patient preferences, or an inability to predict how treatments will fit into patients' daily lives. The work that patients and clinicians do together to address the patient's situation and engage in a deliberative dialogue about reasonable treatment options is often called shared decision making. Decision aids are evidence-based tools that facilitate this process. Shared decision making is a patient-centred approach in which clinicians share information about the benefits, harms, and burden of different reasonable diagnostic and treatment options, and patients explain what matters to them in view of their particular values, preferences, and personal context. Beyond the ethical argument in support of this approach, decision aids have been shown to improve patients' knowledge about the available options, accuracy of risk estimates, and decisional comfort. Decision aids also promote patient participation in the decision-making process. Despite accumulating evidence from clinical trials, policy support, and expert recommendations in endocrinology practice guidelines, shared decision making is still not routinely implemented in endocrine practice. Additional work is needed to enrich the number of available tools and to implement them in practice workflows. Also, although the evidence from randomised controlled trials favours the use of this shared decision making in other settings, populations, and illnesses, the effect of this approach has been studied in a few endocrine disorders. Future pragmatic trials are needed to explore the effect and feasibility of shared decision making implementation into routine endocrinology and primary care practice. With the available evidence, however, endocrinologists can now start to practice shared decision making, partner with their patients, and use their expertise to formulate treatment plans that reflect patient preferences and are more likely to fit into the context of patients' lives. In this Personal View, we describe shared decision making, the evidence behind the approach, and why and how both endocrinologists and their patients could benefit from this approach.

Shared Decision Making and Choice for Elective Surgical Care: A Systematic Review

OBJECTIVE

Shared decision making (SDM), an integrative patient-provider communication process emphasizing discussion of scientific evidence and patient/family values, may improve quality care delivery, promote evidence-based practice, and reduce overuse of surgical care. Little is known, however, regarding SDM in elective surgical practice. The purpose of this systematic review is to synthesize findings of studies evaluating use and outcomes of SDM in elective surgery.

DATA SOURCES

PubMed, Cochrane CENTRAL, EMBASE, CINAHL, and SCOPUS electronic databases.

REVIEW METHODS

We searched for English-language studies (January 1, 1990, to August 9, 2015) evaluating use of SDM in elective surgical care where choice for surgery could be ascertained. Identified studies were independently screened by 2 reviewers in stages of title/abstract and full-text review. We abstracted data related to population, study design, clinical dilemma, use of SDM, outcomes, treatment choice, and bias.

RESULTS

Of 10,929 identified articles, 24 met inclusion criteria. The most common area studied was spine (7 of 24), followed by joint (5 of 24) and gynecologic surgery (4 of 24). Twenty studies used decision aids or support tools, including modalities that were multimedia/video (13 of 20), written (3 of 20), or personal coaching (4 of 20). Effect of SDM on preference for surgery was mixed across studies, showing a decrease in surgery (9 of 24), no difference (8 of 24), or an increase (1 of 24). SDM tended to improve decision quality (3 of 3) as well as knowledge or preparation (4 of 6) while decreasing decision conflict (4 of 6).

CONCLUSION

SDM reduces decision conflict and improves decision quality for patients making choices about elective surgery. While net findings show that SDM may influence patients to choose surgery less often, the impact of SDM on surgical utilization cannot be clearly ascertained.

Deliberative democracy in health care: current challenges and future prospects

BACKGROUND

There is a vast body of literature on deliberative, participative, or engaged democracy. In the area of health care there is a rapidly expanding literature on deliberative democracy as embodied in various notions of public engagement, shared decision-making (SDM), patient-centered care, and patient/care provider autonomy over the past few decades. It is useful to review such literature to get a sense of the challenges and prospects of introducing deliberative democracy in health care.

OBJECTIVE

This paper reviews the key literature on deliberative democracy and SDM in health care settings with a focus on identifying the main challenges of promoting this approach in health care, and recognizing its progress so far for mapping out its future prospects in the context of advanced countries.

METHOD

Several databases were searched to identify the literature pertinent to the subject of this study. A total of 56 key studies in English were identified and reviewed carefully for indications and evidence of challenges and/or promising avenues of promoting deliberative democracy in health care.

RESULTS

Time pressure, lack of financial motivation, entrenched professional interests, informational imbalance, practical feasibility, cost, diversity of decisions, and contextual factors are noted as the main challenges. As for the prospects, greater clarity on conception of public engagement and policy objectives, real commitment of the authorities to public input, documenting evidence of the effectiveness of public involvement, development of patient decision supports, training of health professionals in SDM, and use of multiple and flexible methods of engagement leadership suited to specific contexts are the main findings in the reviewed literature.

CONCLUSION

Seeking deliberative democracy in health care is both challenging and rewarding. The challenges have been more or less identified. However, its prospects are potentially significant. Such prospects are more likely to materialize if deliberative democracy is pursued more systematically in the broader sociopolitical domains.

Who and when should we screen for prostate cancer? Interviews with key opinion leaders

Prostate cancer screening using prostate-specific antigen (PSA) is highly controversial. In this Q & A, Guest Editors for BMC Medicine's 'Spotlight on Prostate Cancer' article collection, Sigrid Carlsson and Andrew Vickers, invite some of the world's key opinion leaders to discuss who, and when, to screen for prostate cancer. In response to the points of view from the invited experts, the Guest Editors summarize the experts' views and give their own personal opinions on PSA screening.