Completing the third person's perspective on patients’ involvement in medical decision-making: approaching the full picture

Shared Decision-Making and Cardiovascular Health: A Scientific Statement From the American Heart Association

Shared decision-making is increasingly embraced in health care and recommended in cardiovascular guidelines. Patient involvement in health care decisions, patient-clinician communication, and models of patient-centered care are critical to improve health outcomes and to promote equity, but formal models and evaluation in cardiovascular care are nascent. Shared decision-making promotes equity by involving clinicians and patients, sharing the best available evidence, and recognizing the needs, values, and experiences of individuals and their families when faced with the task of making decisions. Broad endorsement of shared decision-making as a critical component of high-quality, value-based care has raised our awareness, although uptake in clinical practice remains suboptimal for a range of patient, clinician, and system issues. Strategies effective in promoting shared decision-making include educating clinicians on communication techniques, engaging multidisciplinary medical teams, incorporating trained decision coaches, and using tools (ie, patient decision aids) at appropriate literacy and numeracy levels to support patients in their cardiovascular decisions. This scientific statement shines a light on the limited but growing body of evidence of the impact of shared decision-making on cardiovascular outcomes and the potential of shared decision-making as a driver of health equity so that everyone has just opportunities. Multilevel solutions must align to address challenges in policies and reimbursement, system-level leadership and infrastructure, clinician training, access to decision aids, and patient engagement to fully support patients and clinicians to engage in the shared decision-making process and to drive equity and improvement in cardiovascular outcomes.

Observer Ratings of Shared Decision Making Do Not Match Patient Reports: An Observational Study in 5 Family Medicine Practices

BACKGROUND

Measuring shared decision making (SDM) in clinical practice is important to improve the quality of health care. Measurement can be done by trained observers and by people participating in the clinical encounter, namely, patients. This study aimed to describe the correlations between patients' and observers' ratings of SDM using 2 validated and 2 nonvalidated SDM measures in clinical consultations.

METHODS

In this cross-sectional study, we recruited 238 complete dyads of health professionals and patients in 5 university-affiliated family medicine clinics in Canada. Participants completed self-administered questionnaires before and after audio-recorded medical consultations. Observers rated the occurrence of SDM during medical consultations using both the validated OPTION-5 (the 5-item "observing patient involvement" score) and binary questions on risk communication and values clarification (RCVC-observer). Patients rated SDM using both the 9-item Shared Decision-Making Questionnaire (SDM-Q9) and binary questions on risk communication and values clarification (RCVC-patient).

RESULTS

Agreement was low between observers' and patients' ratings of SDM using validated OPTION-5 and SDM-Q9, respectively (ρ = 0.07; P = 0.38). Observers' ratings using RCVC-observer were correlated to patients' ratings using either SDM-Q9 (r_pb = -0.16; P = 0.01) or RCVC-patients (r_pb = 0.24; P = 0.03). Observers' OPTION-5 scores and patients' ratings using RCVC-questions were moderately correlated (r_φ = 0.33; P = 0.04).

CONCLUSION

There was moderate to no alignment between observers' and patients' ratings of SDM using both validated and nonvalidated measures. This lack of strong correlation emphasizes that observer and patient perspectives are not interchangeable. When assessing the presence, absence, or extent of SDM, it is important to clearly state whose perspectives are reflected.

Do Shared Decision-Making Measures Reflect Key Elements of Shared Decision Making? A Content Review of Coding Schemes

Background. There is a growing need for valid shared decision-making (SDM) measures. We aimed to determine whether the items of extant SDM observer-based coding schemes assess the 4 key elements of SDM. Methods. Items of SDM coding schemes were extracted and categorized. Except for the 4 key elements of SDM (fostering choice awareness, informing about options, discussing patient preferences, and making a decision), (sub)categories were created inductively. Two researchers categorized items independently and in duplicate. Results. Five of 12 coding schemes assessed all 4 SDM elements. Seven schemes did not measure “fostering choice awareness,” and 3 did not measure “discussing patient preferences.” Seventy of 194 items (36%) could not be classified into one of the key SDM elements. Items assessing key SDM elements most often assessed “informing about options” (n = 57/124, 46%). Conclusion. Extant SDM coding schemes often do not assess all key SDM elements and have a strong focus on information provision while other crucial elements of SDM are underrepresented. Caution is therefore needed in reporting and interpreting the resulting SDM scores.

Evaluation of a shared decision-making communication skills training for physicians treating patients with asthma: a mixed methods study using simulated patients

Background

Shared decision-making (SDM) is a key principle in asthma management, but continues to be poorly implemented in routine care. This study aimed to evaluate the impact of a SDM communication skills training for physicians treating patients with asthma on the SDM behaviors of physicians, and to analyze physician views on the training.

Methods

A mixed methods study with a partially mixed sequential equal status design was conducted to evaluate a 12 h SDM communication skills training for physicians treating patients with asthma. It included a short introductory talk, videotaped consultations with simulated asthma patients, video analysis in small group sessions, individual feedback, short presentations, group discussions, and practical exercises. The quantitative evaluation phase consisted of a before (t0) after (t1) comparison of SDM performance using the observer-rated OPTION⁵, the physician questionnaire SDM-Q-Doc, and the patient questionnaire SDM-Q-9, using dependent t-tests. The qualitative evaluation phase (t2) consisted of a content analysis of audiotaped and transcribed interviews.

Results

Initially, 29 physicians participated in the study, 27 physicians provided quantitative data, and 22 physicians provided qualitative data for analysis. Quantitative results showed significantly improved performance in SDM following the training (t1) when compared with performance in SDM before the training (t0) (OPTION⁵: t (26) = − 5.16; p < 0.001) (SDM-Q-Doc: t (26) = − 4.39; p < 0.001) (SDM-Q-9: t (26) = − 5.86; p < 0.001). The qualitative evaluation showed that most physicians experienced a change in attitude and behavior after the training, and positively appraised the training program. Physicians considered simulated patient consultations, including feedback and video analysis, beneficial and suggested the future use of real patient consultations.

Conclusion

The SDM communication skills training for physicians treating patients with asthma has potential to improve SDM performance, but would benefit from using real patient consultations.

Strategies to evaluate healthcare provider trainings in shared decision-making (SDM): a systematic review of evaluation studies

DESIGN AND OBJECTIVES

We performed a systematic review of studies evaluating healthcare provider (HCP) trainings in shared decision-making (SDM) to analyse their evaluation strategies.

SETTING AND PARTICIPANTS

HCP trainings in SDM from all healthcare settings.

METHODS

We searched scientific databases (Medline, PsycInfo, CINAHL), performed reference and citation tracking, contacted experts in the field and scanned the Canadian inventory of SDM training programmes for healthcare professionals. We included articles reporting data of summative evaluations of HCP trainings in SDM. Two reviewers screened records, assessed full-text articles, performed data extraction and assessed study quality with the integrated quality criteria for review of multiple study designs (ICROMS) tool. Analysis of evaluation strategies included data source use, use of unpublished or published measures and coverage of Kirkpatrick's evaluation levels. An evaluation framework based on Kirkpatrick's evaluation levels and the Quadruple Aim framework was used to categorise identified evaluation outcomes.

RESULTS

Out of 7234 records, we included 41 articles reporting on 30 studies: cluster-randomised (n=8) and randomised (n=9) controlled trials, controlled (n=1) and non-controlled (n=7) before-after studies, mixed-methods (n=1), qualitative (n=1) and post-test (n=3) studies. Most studies were conducted in the USA (n=9), Germany (n=8) or Canada (n=7) and evaluated physician trainings (n=25). Eleven articles met ICROMS quality criteria. Almost all studies (n=27) employed HCP-reported outcomes for training evaluation and most (n=19) additionally used patient-reported (n=12), observer-rated (n=10), standardised patient-reported (n=2) outcomes or training process and healthcare data (n=10). Most studies employed a mix of unpublished and published measures (n=17) and covered two (n=12) or three (n=10) Kirkpatrick's levels. Identified evaluation outcomes covered all categories of the proposed framework.

CONCLUSIONS

Strategies to evaluate HCP trainings in SDM varied largely. The proposed evaluation framework maybe useful to structure future evaluation studies, but international agreement on a core set of outcomes is needed to improve evidence.

PROSPERO REGISTRATION NUMBER

CRD42016041623.

Shared decision-making in older patients with colorectal or pancreatic cancer: Determinants of patients' and observers' perceptions

OBJECTIVE

To identify determinants of older patients' perceptions of involvement in decision-making on colorectal (CRC) or pancreatic cancer (PC) treatment, and to compare these with determinants of observers' perceptions.

METHODS

Patients' perceptions of involvement were constructed by the 9-item SDM questionnaire (SDM-Q-9) and a Visual Analogue Scale for Involvement (VAS-I). Observers' perceptions were constructed by the OPTION5, OPTION12, and MAPPIN'SDM. Convergent validities were calculated between the patient-sided and observer instruments using Spearman's correlation coefficient. Linear regression was used to identify determinants per criterion.

RESULTS

58 CRC and 22 PC patients were included (mean age: 71.8 ± 5.2 years, 45.0% female). No significant correlations were found between the patient-sided and observer instruments. Patients' impression of involvement was influenced by patient characteristics such as quality of life and satisfaction, while observers' perceptions mainly referred to encounter characteristics such as the mean duration of consultations and general communication skills.

CONCLUSION

Due to evident differences in determinants, older CRC/PC patients' and observers' perceptions of involvement should both be collected in evaluating the quality of medical decision-making.

PRACTICE IMPLICATIONS

General communication skills should be integrated in SDM training interventions. New SDM measurement tools for patients are needed to sufficiently discriminate between the constructs of involvement and satisfaction.

The quality of instruments to assess the process of shared decision making: A systematic review

OBJECTIVE

To inventory instruments assessing the process of shared decision making and appraise their measurement quality, taking into account the methodological quality of their validation studies.

METHODS

In a systematic review we searched seven databases (PubMed, Embase, Emcare, Cochrane, PsycINFO, Web of Science, Academic Search Premier) for studies investigating instruments measuring the process of shared decision making. Per identified instrument, we assessed the level of evidence separately for 10 measurement properties following a three-step procedure: 1) appraisal of the methodological quality using the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist, 2) appraisal of the psychometric quality of the measurement property using three possible quality scores, 3) best-evidence synthesis based on the number of studies, their methodological and psychometrical quality, and the direction and consistency of the results. The study protocol was registered at PROSPERO: CRD42015023397.

RESULTS

We included 51 articles describing the development and/or evaluation of 40 shared decision-making process instruments: 16 patient questionnaires, 4 provider questionnaires, 18 coding schemes and 2 instruments measuring multiple perspectives. There is an overall lack of evidence for their measurement quality, either because validation is missing or methods are poor. The best-evidence synthesis indicated positive results for a major part of instruments for content validity (50%) and structural validity (53%) if these were evaluated, but negative results for a major part of instruments when inter-rater reliability (47%) and hypotheses testing (59%) were evaluated.

CONCLUSIONS

Due to the lack of evidence on measurement quality, the choice for the most appropriate instrument can best be based on the instrument's content and characteristics such as the perspective that they assess. We recommend refinement and validation of existing instruments, and the use of COSMIN-guidelines to help guarantee high-quality evaluations.

Training doctors briefly and in situ to involve their patients in making medical decisions-Preliminary testing of a newly developed module

OBJECTIVE

To carry out preliminary evaluation of a training module for doctors to enhance their ability to involve their patients in medical decision making. The training refers to the shared decision-making (SDM) communication concept.

METHODS

The training module includes a comprehensive manual, a corresponding video tutorial with communication examples and a 15-minute face-to-face feedback session based on an SDM analysis of a consultation recording provided by the trainee. Ten trainees (four neurologists, three dentists, and three general practitioners) participating in the pretest each recorded four clinical consultations (total sample: N=40) and received three training components. After the training, doctors provided feedback on the module's feasibility in a questionnaire. Communication performance of doctors, patients and doctor-patient dyads was assessed by trained observers and self-assessed by doctors and patients using the MAPPIN'SDM approach. Training effects were determined using Wilcoxon signed-rank tests comparing baseline values with post-intervention performance as assessed in the fourth consultations.

RESULTS

The face-to-face training sessions were short and feasible with regard to clinical reality. Participants considered the training supportive for acquiring SDM skills and recommended more emphasis on the face-to-face feedback. Communication improved according to observers rating doctors (P=.05) and doctor-patient dyads (P=.07) and to doctors' own judgements (P=.02). No improvement was observed in patients' SDM behaviour (P=.11); accordingly, patients' judgements did not indicate improvement (P=.14).

CONCLUSIONS

The training is designed to meet clinicians' needs. Improvement of risk communication after training encourages optimization according to doctors' feedback. Following this study, the efficacy of the training is now being examined in a randomized controlled trial.

Validation of the Norwegian version of MAPPIN'SDM, an observation-based instrument to measure shared decision-making in clinical encounters

OBJECTIVE

To validate the Norwegian version of MAPPIN'SDM observer scales with regard to reliability, accuracy and the extent to which the scales include the essentials of the shared decision-making concept.

METHODS

Three MAPPIN'SDM scales, focusing on the skills of doctor, patient and dyad, were applied to audiovisual records of 35 decision sequences. Inter-rater reliabilities were determined based on kappa coefficients. Sensitivities and specificities were calculated with regard to an expert reference standard. Convergent validities were calculated with the OPTION₅ scale. MAPPIN'SDM was qualitatively compared to OPTION5 using Makoul & Clayman's Integrative Model structure.

RESULTS

Inter-rater reliabilities were high on average over 11 items in each of three observer scales (MAPPIN_doctor=0.77, MAPPIN_patient=0.82, MAPPIN_dyad=0.77). Patient involvement was detected accurately (MAPPIN_dyad: mean sensitivity/specificity 93/91%). Comparison with OPTION₅ showed weak to moderate correlation (Spearman's ρ/p-value: MAPPIN_doctor:=0.44/0.009, MAPPIN_patient: 0.38/0.024, MAPPIN_dyad 0.40/0.016) and little content overlap.

CONCLUSION

MAPPIN'SDM_norge is capable of assessing SDM highly reliably and accurately. Divergence from OPTION₅ reflects explicit disagreement regarding the concept's assumptions.

PRACTICE IMPLICATIONS

MAPPIN'SDM_norge is ready for use in Norway. In-depth debate on the SDM concept's essentials is urgently needed.

Evaluating the quality of shared decision making during the patient-carer encounter: a systematic review of tools

BACKGROUND

The concept of shared decision making (SDM) has been developing in many countries since the 1990s. The main challenge of SDM, based on the principles of respect for the person's autonomy, is to improve patients' participation, should they so wish, in decisions concerning their personal health. To our knowledge, there is only one SDM evaluation tool validated in metropolitan French that does not measure the entire SDM construct. The aim of this review was to identify existing and validated SDM measurement tools to determine which of them could be adapted in French to cover all the dimensions of SDM.

METHODS

A systematic literature review was conducted based on articles found in the PubMed and PsycINFO bibliographic databases and published between 2010 and 2014. Studies were included if the main goal of the article was the development and psychometric validation of an SDM measurement tool, not specific to any given disease or situation, in English, French and Spanish. We used the nine essential elements of the Makoul and Clayman's integrative model to describe the different existing tools.

RESULTS

Nineteen studies were included. Seven new tools had been published since Scholl's previous review in 2011. We observed a recent spread of the multi-appraiser approach, which combines points of view of patients, healthcare professionals and sometimes external observers. Several models were used for the development of the seven newly identified tools. None of the identified tools assessed the nine elements of the Makoul's model. Three of these elements, however, were systematically measured in each of the new tools: "defining/explaining the problem", "patient values/preferences", and "checking/clarifying understanding".

CONCLUSIONS

We identified several potentially interesting tools for the French context which could cover the whole elements of Makoul's model. The next step will be the development of a French-language instrument based on these tools.

Development of a decision guide to support the elderly in decision making about location of care: an iterative, user-centered design

PLAIN ENGLISH SUMMARY

For the elderly to get the care and services they need, they may need to make the difficult decision about staying in their home or moving to another home. Many other people may be involved in their care too (friends, family and healthcare providers), and can support them in making the decision. We asked informal caregivers of elderly people to help us develop a decision guide to support them and their loved ones in making this decision. This guide will be used by health providers in home care who are trained to help people make decisions. The guide is in French and English. To design and test this decision guide we involved elderly people, their caregivers and health administrators. We first asked them what they needed for making the decision, and then designed a first version of the guide. Then we asked them to look at it and give feedback, which was used to make the final version. We then used scientific criteria to check its content and the language used. The final decision guide was acceptable to the caregivers, their elderly loved ones, and the health administrators. The guide is currently being evaluated in a large research project with home care teams in the province of Quebec.

ABSTRACT

Background As they grow older, many elderly people are faced with the difficult and preference-sensitive decision about staying in their home or moving to a residence better adapted to their evolving care needs. We aimed to develop an English and French decision aid (DA) for elderly people facing this decision, and to involve end-users in all phases of the development process. Methods A three-cycle design with involvement of end-users in Quebec. End-users were elderly people (n = 4) caregivers of the elderly (n = 5), health administrators involved in home-care service delivery or policy (n = 6) and an interprofessional research team (n = 19). Cycle 1: Decisional needs assessment and development of the first prototype based on existing tools and input from end-users; overview of reviews examining the impact of location of care on elderly people's health outcomes. Cycle 2: Usability testing with end-users, adaptation of prototype. Cycle 3: Refinement of the prototype with a linguist, graphic designer and end-users. The final prototype underwent readability testing and an International Patient Decision Aids (IPDAS) criteria compatibility assessment to verify minimal requirements for decision aids and was tested for usability by the elderly. ResultsCycle 1: We used the Ottawa Personal Decision Guide to design a first prototype. As the overview of reviews did not find definitive evidence regarding optimal locations of care for elderly people, we were not able to add evidence-based advantages and disadvantages to the guide. Cycle 2: Overall, the caregivers and health administrators who evaluated the prototype (n = 10) were positive. In response to their suggestions, we deleted some elements (overview of pros, cons, and consequences of the options) that were necessary to qualify the tool as a DA and renamed it a "decision guide". Cycle 3: We developed French and English versions of the guide, readable at a primary school level. The elderly judged the guide as acceptable. Conclusion We developed a decision guide to support elderly people and their caregivers in decision making about location of care. This paper is one of few to report on a fully collaborative approach to decision guide development that involves end-users at every stage (caregivers and health administrators early on, the frail elderly in the final stages). The guide is currently being evaluated in a cluster randomized trial. Trial registration: NCT02244359.

Shared decision making: Concepts, evidence, and practice

OBJECTIVE

Shared decision-making (SDM) is advocated as the model for decision-making in preference-sensitive decisions. In this paper we sketch the history of the concept of SDM, evidence on the occurrence of the steps in daily practice, and provide a clinical audience with communication strategies to support the steps involved. Finally, we discuss ways to improve the implementation of SDM.

RESULTS

The plea for SDM originated almost simultaneously in medical ethics and health services research. Four steps can be distinguished: (1) the professional informs the patient that a decision is to be made and that the patient's opinion is important; (2) the professional explains the options and their pros and cons; (3) the professional and the patient discuss the patient's preferences and the professional supports the patient in deliberation; (4) the professional and patient discuss the patient's wish to make the decision, they make or defer the decision, and discuss follow-up. In practice these steps are seen to occur to a limited extent.

DISCUSSION

Knowledge and awareness among both professionals and patients as well as tools and skills training are needed for SDM to become widely implemented.

PRACTICE IMPLICATIONS

Professionals may use the steps and accompanying communication strategies to implement SDM.

Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument

BACKGROUND

We have no clear overview of the extent to which health-care providers involve patients in the decision-making process during consultations. The Observing Patient Involvement in Decision Making instrument (OPTION) was designed to assess this.

OBJECTIVE

To systematically review studies that used the OPTION instrument to observe the extent to which health-care providers involve patients in decision making across a range of clinical contexts, including different health professions and lengths of consultation.

SEARCH STRATEGY

We conducted online literature searches in multiple databases (2001-12) and gathered further data through networking.

INCLUSION CRITERIA

(i) OPTION scores as reported outcomes and (ii) health-care providers and patients as study participants. For analysis, we only included studies using the revised scale.

DATA EXTRACTION

Extracted data included: (i) study and participant characteristics and (ii) OPTION outcomes (scores, statistical associations and reported psychometric results). We also assessed the quality of OPTION outcomes reporting.

MAIN RESULTS

We found 33 eligible studies, 29 of which used the revised scale. Overall, we found low levels of patient-involving behaviours: in cases where no intervention was used to implement shared decision making (SDM), the mean OPTION score was 23 ± 14 (0-100 scale). When assessed, the variables most consistently associated with higher OPTION scores were interventions to implement SDM (n = 8/9) and duration of consultations (n = 8/15).

CONCLUSIONS

Whatever the clinical context, few health-care providers consistently attempt to facilitate patient involvement, and even fewer adjust care to patient preferences. However, both SDM interventions and longer consultations could improve this.

Of blind men and elephants: suggesting SDM-MASS as a compound measure for shared decision making integrating patient, physician and observer views

OBJECTIVE

Shared decision making (SDM) between patient and physician is an interpersonal process. Most SDM measures use the view of one party (patient, physician or observer) as a proxy to capture this process although these views typically diverge. This study suggests the compound measure SDM(MASS) (SDM Meeting its concept's ASSumptions) integrating these three perspectives in one single index.

METHODS

SDM(MASS) was derived theoretically and compared empirically to unilateral perspectives of patients, physicians and observers by application to a data set of 10 physicians (40 consultations) receiving an SDM training.

RESULTS

The constituting parts of SDM(MASS) were highly reliable (Cronbach's alpha .94; interrater reliability .74-.87). Unilateral appraisal of training effects was divergent. SDM(MASS) revealed no effect.

CONCLUSION

SDM(MASS) combines noteworthy information about SDM processes from different viewpoints and thereby delivers plausible assessments. It could overcome immanent shortcomings of unilateral approaches. However, it is a complex measure needing further validation.

MAPPIN'SDM--the multifocal approach to sharing in shared decision making

BACKGROUND

The wide scale permeation of health care by the shared decision making concept (SDM) reflects its relevance and advanced stage of development. An increasing number of studies evaluating the efficacy of SDM use instruments based on various sub-constructs administered from different viewpoints. However, as the concept has never been captured in operable core definition it is quite difficult to link these parts of evidence. This study aims at investigating interrelations of SDM indicators administered from different perspectives.

METHOD

A comprehensive inventory was developed mapping judgements from different perspectives (observer, doctor, patient) and constructs (behavior, perception) referring to three units (doctor, patient, doctor-patient-dyad) and an identical set of SDM-indicators. The inventory adopted the existing approaches, but added additional observer foci (patient and doctor-patient-dyad) and relevant indicators hitherto neglected by existing instruments. The complete inventory comprising a doctor-patient-questionnaire and an observer-instrument was applied to 40 decision consultations from 10 physicians from different medical fields. Convergent validities were calculated on the basis of Pearson correlation coefficients.

RESULTS

Reliabilities for all scales were high to excellent. No correlations were found between observer and patients or physicians neither for means nor for single items. Judgements of doctors and patients were moderately related. Correlations between the observer scales and within the subjective perspectives were high. Inter-perspective agreement was not related to SDM performance or patient activity.

CONCLUSION

The study demonstrates the contribution to involvement made by each of the relevant perspectives and emphasizes the need for an inter-subjective approach regarding SDM measurement.