The long way of implementing patient-centered care and shared decision making in Germany

Patient experiences and needs in cancer care- results from a nationwide cross-sectional study in Germany

BACKGROUND

Patient-centredness has become a central quality indicator for oncology care. Elements include shared decision-making, patient navigation and integration of psychosocial care, which impact patient-reported and clinical outcomes. Despite efforts to promote patient-centred care in Germany in recent decades, implementation remains fragmented. Further, research on patient experiences with cancer care and its determinants is limited. Therefore, this study examines which patient- and facility-specific factors are associated with patient-centred quality care delivery.

METHODS

A cross-sectional study was conducted among 1,121 cancer patients in acute treatment, rehabilitation, and aftercare for different cancer entities across Germany. A participatory developed questionnaire was used. Outcome measures were the quality of physician-patient interaction and provision of psychosocial care during acute care. Predictors comprised patient-specific characteristics and treatment facility-specific factors. Multiple linear regression and multivariate binary logistic regression analyses were performed. In addition, a content analysis of open-ended comments on the patients' overall cancer care needs was applied.

RESULTS

Multiple linear regression analysis showed recent diagnosis (β=-0.12, p = < 0.001), being male (β=-0.11, p = 0.003), and having a preference for passive decision-making (β=-0.10, p = 0.001) to be significantly associated with higher interaction quality, but not age, education and health insurance type. An overall low impact of patient characteristics on interaction quality was revealed (adj. R2 = 0.03). Binary logistic regression analysis demonstrated the availability of central contact persons (OR = 3.10, p < 0.001) followed by recent diagnosis (p < 0.001), having breast cancer (p < 0.001) and being female (OR = 1.68, p < 0.05) to significantly predict offering psycho-oncological counselling to patients in acute care facilities. The availability of peer support visiting services (OR = 7.17, p < 0.001) and central contact persons (OR = 1.87, p < 0.001) in the care facility, breast cancer diagnosis (p < 0.001) and a higher level of education (p < 0.05) significantly increased the odds of patients receiving information about peer support in the treatment facility. Despite relatively satisfactory quality of physician-patient interactions in cancer care (M = 3.5 (± 1.1)), many patients expressed that better patient-centred communication and coordinated, comprehensive cancer care are needed.

CONCLUSION

The findings reflect effective developments and improvements in cancer care and suggest that patients' social characteristics are less decisive for delivering patient-centred quality care than systemic factors surrounding the care facilities. They can serve to inform oncology care in Germany.

Assessment of relevance and actual implementation of person-centeredness in healthcare and social support services for women with unintended pregnancy in Germany (CarePreg): results of expert workshops

INTRODUCTION

Person-centeredness is a key principle in the German healthcare system. However, access to high-quality care for women with unintended pregnancy is limited due to social stigma and legal restrictions. There is little research on the adoption of person-centeredness in care for women with unintended pregnancy. The aim of this study was to analyze relevance and actual implementation of dimensions of person-centeredness in psycho-social and medical abortion care from the view of abortion care providers.

METHODS

Counselors and gynecologist working in psycho-social or medical abortion care participated in one of two digital workshops. Discussions were semi-structured based on the 16 dimensions of an integrative model of person-centeredness, audio-recorded and transcribed verbatim. During qualitative content analysis, deductive categories based on the integrative model of person-centeredness were applied and inductive categories were developed. Additionally, participants rated relevance and actual implementation of the dimensions in an online survey.

RESULTS

The 18 workshop participants most intensively discussed the dimensions "access to care", "person-centered characteristics of healthcare providers" and "personally tailored information". Four additional categories on a macro level ("stigmatization of women with unintended pregnancy", "stigmatization of healthcare providers", "political and legal aspects" and "corona pandemic") were identified. Most dimensions were rated as highly relevant but implementation status was described as rather low.

CONCLUSIONS

In Germany, high quality person-centered care for women with unintended pregnancy is insufficiently implemented through limited access to information, a lack of abortion care providers, and stigmatization. There is a need for changes in health care structures to enable nationwide person-centered care for women with unintended pregnancy. Those changes include a more easy access to evidence-based information and person-centered abortion care, more education on abortion care for healthcare providers, integration of topics of abortion care in medical schools and promotion of de-stigmatizing actions to enable abortions as part of the general healthcare.

Effects of a shared decision-making implementation programme on patient-centred communication in oncology-Secondary analysis of a randomised controlled trial

BACKGROUND

There is a need for better implementation of patient-centred (PC) communication and shared decision-making (SDM) in routine cancer care.

OBJECTIVE

The aim of this study was to assess whether a programme to implement SDM in oncology had effects on PC communication in clinical encounters.

DESIGN

This study constitutes a secondary analysis of data derived from an implementation trial applying a stepped wedge design that, among other strategies, incorporated training and coaching to enhance the PC communication skills of physicians.

SETTING AND PARTICIPANTS

We analysed audio recordings of clinical encounters collected in three departments of a comprehensive cancer centre in Germany before and after rolling out the implementation programme.

MAIN VARIABLES STUDIED

We assessed the PC communication skills of physicians.

MAIN OUTCOME MEASURES

Each recording was rated by two researchers using the German version of the Four Habits Coding Scheme (4HCS), an observer-based measure of PC communication. Interrater reliability of the outcome measure was acceptable but moderate. Demographic data of patients participating in audio recordings were analysed.

METHODS

Data were analysed using descriptive statistics and linear mixed-effects models.

RESULTS

In total, 146 encounters, 74 before and 72 after implementation, were evaluated. The mean age of patients was 57.1 years (SD = 13.8), 70.3% were female, the largest portion of patients had medium formal education (32.4%) and were (self-) employed (37.8%). No statistically significant effect of the implementation programme on the physicians' PC communication skills was found.

DISCUSSION

The results indicate that the investigated programme to implement SDM in oncology, including training and coaching, had no effects on PC communication in clinical encounters. These results are in contrast to other studies that report the effects of specific training or coaching on PC communication. Reasons for the lack of effect include the short duration of our training compared to other studies, limited reliability and moderate interrater reliability of the 4HCS scale, limited reach of the intervention programme as well as the inclusion of physicians regardless of their exposure to the interventions.

CONCLUSION

Further research is needed to develop implementation strategies that improve physicians' PC communication skills.

PATIENT CONTRIBUTION

Data on patients and clinical encounters with patients and physicians were analysed. There was no other patient or public involvement.

Informed Consent for Psychotherapy: The Moderating Role of Therapeutic Alliance, Prior Knowledge and Autonomous Motivation on Decision-Making and Treatment Expectation

BACKGROUND

Informed consent is an ethical prerequisite for psychotherapy. There are no routinely used standardized strategies for obtaining informed consent. A new optimized informed consent consultation (OIC) strengthened treatment-relevant aspects. It remains unclear which factors influence the OIC efficacy regarding clinical and decision-related outcomes.

METHODS

N = 122 adults were included in a randomized controlled online trial. Participants received an information brochure on psychotherapy (TAU; n = 61) or OIC + TAU (n = 61). The main and interaction effects of group allocation, therapeutic alliance, prior knowledge about psychotherapy and treatment motivation on treatment expectations, decisional conflict and capacity to consent were tested. Floodlight analyses were conducted for significant interactions.

RESULTS

Large interaction effects were shown between treatment motivation and group allocation on treatment expectations (β = -0.53) and between prior knowledge and group assignment on capacity to consent (β = 0.68). The interaction between treatment motivation and group allocation was significant up to a motivation score of 5.54 (range: 1-7). The interaction between prior knowledge and group assignment was significant up to a knowledge score of 14.38 (range: 5-20).

CONCLUSION

Moderator analyses indicated varying efficacy degrees for the OIC regarding decisional outcomes and expectation. Especially patients with little treatment motivation or low prior knowledge benefited from optimized information about the efficacy and possible side effects of psychotherapy.

TRIAL REGISTRATION

PsychArchives (https://doi.org/10.23668/psycharchives.4929): 17.06.2021.

Shared decision making in recurrent ovarian cancer: Implementation of patient decision aids across three departments of oncology in Denmark

Objective

Patients with relapsed ovarian cancer are offered multiple treatment options. To match treatment with the individual patient's life situation and preferences, healthcare professionals can apply shared decision making (SDM) including patient decision aids (PtDAs).This study aimed to evaluate the implementation of two different PtDAs in consultations with patients suffering from relapsed ovarian cancer.

Methods

We analyzed the following data before and after implementation of the PtDAs: 1) observed SDM using the OPTION instrument, 2) physician treatment recommendations, and 3) patients' and physicians' evaluations of SDM in consultations using the CollaboRATE, SDM-Q-9, and SDM-Q-Doc.

Results

Significant improvement in observed SDM was found after the implementation (p = 0.002). Improvement of SDM was detected in consultations conducted by physicians reporting more than two hours of SDM-training (p < 0.001), but not when physicians reported less than two hours of SDM-training.No before/after differences in treatment recommendations and in patients' and physicians' evaluations were found.

Conclusion

Implementation of PtDAs improved the level of observed SDM. Training of physicians in SDM is necessary for improved SDM practice.

Innovation

Discussing oncological treatment options with the use of PtDAs is not standard practice in Denmark. The present study is one of the first Danish studies focusing on how to implement SDM and PtDAs in oncological consultations.

Diffusion of person-centred care within 27 European countries – interviews with managers, officials, and researchers at the micro, meso, and macro levels

Purpose

This study aimed to describe facilitators and barriers in terms of regulation and financing of healthcare due to the implementation and use of person-centred care (PCC).

Design/methodology/approach

A qualitative design was adopted, using interviews at three different levels: micro = hospital ward, meso = hospital management, and macro = national board/research. Inclusion criteria were staff working in healthcare as first line managers, hospital managers, and officials/researchers on national healthcare systems, such as Bismarck, Beveridge, and mixed/out-of-pocket models, to obtain a European perspective.

Findings

Countries, such as Great Britain and Scandinavia (Beveridge tax-based health systems), were inclined to implement and use person-centred care. The relative freedom of a market (Bismarck/mixed models) did not seem to nurture demand for PCC. In countries with an autocratic culture, that is, a high-power distance, such as Mediterranean countries, PCC was regarded as foreign and not applicable. Another reason for difficulties with PCC was the tendency for corruption to hinder equity and promote inertia in the healthcare system.

Research limitations/implications

The sample of two to three participants divided into the micro, meso, and macro level for each included country was problematic to find due to contacts at national level, a bureaucratic way of working. Some information got caught in the system, and why data collection was inefficient and ran out of time. Therefore, a variation in participants at different levels (micro, meso, and macro) in different countries occurred. In addition, only 27 out of the 49 European countries were included, therefore, conclusions regarding healthcare system are limited.

Practical implications

Support at the managerial level, together with patient rights supported by European countries' laws, facilitated the diffusion of PCC.

Originality/value

Fragmented health systems divided by separate policy documents or managerial roadmaps hindered local or regional policies and made it difficult to implement innovation as PCC. Therefore, support at the managerial level, together with patient rights supported by European countries' laws, facilitated the diffusion of PCC.

Development and evaluation of a website with patients experiences of multiple sclerosis: a mixed methods study

BACKGROUND

A variety of management options (e.g., disease-modifying therapy, lifestyle interventions, rehabilitation) are available for persons with relapsing-remitting multiple sclerosis (MS). Besides coping with the diagnosis, persons with MS have to make complex decisions, e.g., regarding disease-modifying therapies. In addition to factual information, reports of patient experiences may support other patients in their decision-making. Therefore, we developed a website presenting patient experiences illustrated by video, audio and text files. This study aimed to test the acceptability and usability of a website with patient experiences with MS.

METHODS

A mixed-methods approach was applied. A total of 69 participants visited the German "Patient Experiences with MS (PExMS)" website and among them, 50 persons with MS and 6 experts completed an online survey. In total, 18 participants took part in telephone interviews or focus groups. Data from the survey were analysed using descriptive statistics. Qualitative data were analysed using thematic analysis.

RESULTS

Both quantitative and qualitative responses suggest that the PExMS website was viewed positively by patients and experts. 94% of persons with MS agreed that the information was comprehensible and reliable. 54% felt encouraged to share their health problems with others after having studied the website. 74% claimed to use the website if they had to make a decision regarding their health. Qualitative responses deduced from the website fell into 5 key themes: (1) web design, appearance, and functionality, (2) content, (3) usability, (4) satisfaction, and (5) loyalty. The search for persons of similar age and with comparable experiences was a major driving force to navigate the website. The material on the website was perceived as diverse, covering both positive and negative experiences in daily living with MS. All participants greatly appreciated having access to other people's experiences online and judged the material on the website as particularly helpful in decision-making for disease-modifying therapies.

CONCLUSIONS

The findings suggest that the PExMS website might have the potential to be a useful source of audio-visual information for persons with MS. Given the lack of websites available to patients with experiential information, health care professionals may be encouraged to routinely inform patients about this website at regular appointments.

A scattered landscape: assessment of the evidence base for 71 patient decision aids developed in a hospital setting

Background

Recent publications reveal shortcomings in evidence review and summarization methods for patient decision aids. In the large-scale “Share to Care (S2C)” Shared Decision Making (SDM) project at the University Hospital Kiel, Germany, one of 4 SDM interventions was to develop up to 80 decision aids for patients. Best available evidence on the treatments’ impact on patient-relevant outcomes was systematically appraised to feed this information into the decision aids. Aims of this paper were to (1) describe how PtDAs are developed and how S2C evidence reviews for each PtDA are conducted, (2) appraise the quality of the best available evidence identified and (3) identify challenges associated with identified evidence.

Methods

The quality of the identified evidence was assessed based on GRADE quality criteria and categorized into high-, moderate-, low-, very low-quality evidence. Evidence appraisal was conducted across all outcomes assessed in an evidence review and for specific groups of outcomes, namely mortality, morbidity, quality of life, and treatment harms. Challenges in evidence interpretation and summarization resulting from the characteristics of decision aids and the type and quality of evidence are identified and discussed.

Results

Evidence reviews assessed on average 25 systematic reviews/guidelines/studies and took about 3 months to be completed. Despite rigorous review processes, nearly 70% of outcome-specific information derived for decision aids was based on low-quality and mostly on non-directly comparative evidence. Evidence on quality of life and harms was often not provided or not in sufficient form/detail. Challenges in evidence interpretation for use in decision aids resulted from, e.g., a lack of directly comparative evidence or the existence of very heterogeneous evidence for the diverse treatments being compared.

Conclusions

Evidence reviews in this project were carefully conducted and summarized. However, the evidence identified for our decision aids was indeed a “scattered landscape” and often poor quality. Facing a high prevalence of low-quality, non-directly comparative evidence for treatment alternatives doesn’t mean it is not necessary to choose an evidence-based approach to inform patients. While there is an urgent need for high quality comparative trials, best available evidence nevertheless has to be appraised and transparently communicated to patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01777-x.

Optimizing Patient Information Material for a New Psycho-Oncological Care Program Using a Participatory Health Research Approach in Germany

High-quality patient information material (PIM) is essential for patients´ informed decision-making, and its quality may influence a care program's acceptance. In the new psycho-oncological care program, isPO, the initial PIM was developed top-down and required optimization. In this paper, we report on the process and experiences of optimizing PIM's quality bottom-up by applying a Participatory Health Research (PHR) approach. Cancer-patient representatives of the national peer-support group contributed as co-researchers as part of the optimization team. A mixed-methods design was chosen. First, the quality of the initially utilized PIM was assessed with the newly designed user-friendly instrument UPIM-Check. Next, three Participatory Action Research loops were conducted, including cancers survivors and isPO service providers. The initial isPO PIM's were assed to be of low quality, limited usability and incomplete. Bottom-up generated optimization suggestions led to the improvement of two initially used PIMs (leaflet, patient information folder) and the design of two new PIMs (poster, study information overview). The optimized PIM facilitates isPO service providers' care provision and helps newly diagnosed cancer patients in understanding and accepting the new program. PIM optimization benefited from applying PHR. The patient representatives' contribution and active patient engagement were central for quality assessment and designing needs-driven, mature and complete PIM.

Evaluation of a multilevel implementation program for timeout and shared decision making in breast cancer care: a mixed methods study among 11 hospital teams

OBJECTIVE

Evaluation of a multilevel implementation program on shared decision making (SDM) for breast cancer clinicians.

METHODS

The program was based on the 'Measurement Instrument for Determinants of Innovations-model' (MIDI). Key factors for effective implementation were included. Eleven breast cancer teams selected from two geographical areas participated; first six surgery teams and second five systemic therapy teams. A mixed method evaluation was carried out at the end of each period: Descriptive statistics were used for surveys and thematic content analysis for semi-structured interviews.

RESULTS

Twenty-eight clinicians returned the questionnaire (42%). Clinicians (96%) endorse that SDM is relevant to breast cancer care. The program supported adoption of SDM in their practice. Limited financial means, time constraints and concurrent activities were frequently reported barriers. Interviews (n = 21) showed that using a 4-step SDM model - when reinforced by practical examples, handy cards, feedback and training - helped to internalize SDM theory. Clinicians experienced positive results for their patients and themselves. Task re-assignment and flexible outpatient planning reinforce sustainable change. Patient involvement was valued.

CONCLUSION

Our program supported breast cancer clinicians to adopt SDM.

PRACTICE IMPLICATIONS

To implement SDM, multilevel approaches are needed that reinforce intrinsic motivation by demonstrating benefits for patients and clinicians.

Professionals’ beliefs in patient involvement for hospital safety

ABSTRACT Objectives: to analyze the beliefs of health care professionals about the benefits of patient involvement in care during hospitalization. Methods: a descriptive, exploratory, qualitative study was conducted with 87 health professionals from a teaching hospital. Semi-structured interviews were conducted between December 2019 and January 2020 - data was submitted to content analysis and interpreted in light of Rosenstock’s Model of Beliefs in Health. Results: participants included nursing technicians, nurses, doctors, and other professionals. The categories “Professionals’ beliefs about patient involvement in care”, “Practices of patient involvement in care” and “Factors favoring patient involvement in hospital care” emerged. The perception of professionals revealed the influence of patient involvement in care outcomes and benefits for the safety of care. Final Considerations: involving the patient in care is associated with the healthcare professional’s belief in the benefits of this practice for reducing incidents.

Evaluation of a program for routine implementation of shared decision-making in cancer care: results of a stepped wedge cluster randomized trial

BACKGROUND

Shared decision-making (SDM) is preferred by many patients in cancer care. However, despite scientific evidence and promotion by health policy makers, SDM implementation in routine health care lags behind. This study aimed to evaluate an empirically and theoretically grounded implementation program for SDM in cancer care.

METHODS

In a stepped wedge design, three departments of a comprehensive cancer center sequentially received the implementation program in a randomized order. It included six components: training for health care professionals (HCPs), individual coaching for physicians, patient activation intervention, patient information material/decision aids, revision of quality management documents, and reflection on multidisciplinary team meetings (MDTMs). Outcome evaluation comprised four measurement waves. The primary endpoint was patient-reported SDM uptake using the 9-item Shared Decision Making Questionnaire. Several secondary implementation outcomes were assessed. A mixed-methods process evaluation was conducted to evaluate reach and fidelity. Data were analyzed using mixed linear models, qualitative content analysis, and descriptive statistics.

RESULTS

A total of 2,128 patient questionnaires, 559 questionnaires from 408 HCPs, 132 audio recordings of clinical encounters, and 842 case discussions from 66 MDTMs were evaluated. There was no statistically significant improvement in the primary endpoint SDM uptake. Patients in the intervention condition were more likely to experience shared or patient-lead decision-making than in the control condition (d=0.24). HCPs in the intervention condition reported more knowledge about SDM than in the control condition (d = 0.50). In MDTMs the quality of psycho-social information was lower in the intervention than in the control condition (d = - 0.48). Further secondary outcomes did not differ statistically significantly between conditions. All components were implemented in all departments, but reach was limited (e.g., training of 44% of eligible HCPs) and several adaptations occurred (e.g., reduced dose of coaching).

CONCLUSIONS

The process evaluation provides possible explanations for the lack of statistically significant effects in the primary and most of the secondary outcomes. Low reach and adaptations, particularly in dose, may explain the results. Other or more intensive approaches are needed for successful department-wide implementation of SDM in routine cancer care. Further research is needed to understand factors influencing implementation of SDM in cancer care.

TRIAL REGISTRATION

clinicaltrials.gov, NCT03393351 , registered 8 January 2018.

[How does a patient-centered, future-oriented medical curriculum look like? The patients' view]

AIM OF THE STUDY

Medical training in Germany is in a state of flux. Medical education must be adapted to fit the changing health care needs of future societies. This study aims to gain the patients' perspective on the education of medical students to improve future curricula.

METHODOLOGY

Using a semi-structured interview guide, 17 interviews were conducted with patients undergoing inpatient (N=9) or outpatient (N=8) medical treatment. The interviews were subjected to computer-assisted analysis guided by Grounded Theory.

RESULTS

480 codings were condensed into seven main categories: Science Fiction Medicine, Society and the Patient, Professional Environment and Health Care System, Medical Curriculum and Continuing Education, Value System and Motivation, Psychosocial Competence and Medical Professional Competence. The largest main categories are Psychosocial Competence (114 codings) and Professional Environment and Health Care System (105 codings).

CONCLUSION

There is a need for psychosocial education in addition to medical knowledge. A future-focused curriculum should entail practice-oriented education to ensure the training of motivated physicians who possess strengthened digital skills and act on ethical principles and values. Assessment of the patients' perspective should play a crucial role in medical education research.

Adapting the patient and physician versions of the 9-item shared decision making questionnaire for other healthcare providers in Japan

BACKGROUND

In Japan, the number of older people with various health problems and difficulties in living is increasing. In order to practice patient-centered care for them, not only medical professionals but also multidisciplinary teams including care professionals and patients need to practice shared decision making (SDM) in the context of long-term care. For this reason, a measure of SDM in consultations with healthcare professionals (HCPs) other than physicians is needed. Therefore, this study aimed at adapting the patient and physician versions of the 9-item Shared Decision Making Questionnaire (SDM-Q-9, SDM-Q-Doc) for consultations with HCPs other than physicians in Japan.

METHODS

A pair of SDM measures that can be used by HCPs other than physicians, "Care SDM-Questionnaire for care receivers (SDM-C-patient)" and "Care SDM-Questionnaire for care providers (SDM-C-provider)" were prepared based on the Japanese versions of the SDM-Q-9 and SDM-Q-Doc. The internal consistency and conceptual structure of these measures were tested by secondary analysis of data from 496 participants from a workshop on SDM for different HCPs. Measurement invariance were tested by multigroup confirmatory factor analysis (CFA) for the patient (SDM-C-patient and SDM-Q-9) and provider (SDM-C-provider vs. SDM-Q-Doc) versions.

RESULTS

Both the Japanese SDM-C-patient and SDM-C-provider demonstrated high internal consistencies (Cronbach's α coefficient was 0.90 and McDonald's ω coefficient was 0.90 for both measures). CFA showed one-factor structures for both measures and original measures for physicians. Moreover, multigroup CFA showed configural and metric invariance between the novel care measures and original physician's measures.

CONCLUSIONS

Thus, the novel SDM measures for care providers in Japan as well as the original physician's measures could be used in training setting. As these measures were tested only in a training setting, their reliability and validity as new measures for care should be tested in a clinical setting in future.

Patient-centeredness in the multimorbid elderly: a focus group study

Background

 Patient-centeredness (PC) aims to adapt health care to the individual needs and preferences of patients. An existing integrative model of PC comprises several dimensions of PC which have not yet been investigated from the patients’ perspective. Older patients with multimorbidity represent a target group for patient-centered care, as their care needs are particularly complex and should be addressed individually. We aimed to assess the perspective that older patients with multimorbidity have of patient-centered care and to examine the transferability of the integrative model of PC to this specific population.

Method

We performed 4 guided focus group interviews with a total of 20 older individuals with multimorbidity. The focus group interviews were audio-recorded and transcribed verbatim. Patients’ statements were content-analyzed applying an a priori designed system of categories that included the dimensions of PC from the integrative model and the additional category ‘prognosis and life expectancy’, which had emerged from an initial literature search on aspects of PC specific to the multimorbid elderly.

Results

The new category ‘prognosis and life expectancy’ was confirmed and expanded to ‘individual care needs related to aging and chronic disesase’. All dimensions of our integrative PC model were confirmed for older patients with multimorbidity. Among these, we found that eight dimensions (individual care needs related to aging and chronic disease, biopsychosocial perspective, clinician-patient communication, essential characteristics of the clinician, clinician-patient-relationship, involvement of family and friends, coordination and continuity of care, access to care) were complemented by aspects specific to this target population.

Conclusions

The integrative PC model is applicable to the population of older patients with multimorbidity. For a population-specific adaptation, it might be complemented by the dimension ‘individual care needs in aging and chronic disease’, in conjunction with age-specific aspects within existing dimensions. Together with corresponding results from a Delphi survey, our adapted PC model will serve as the basis for a subsequent systematic review of instruments measuring PC in older patients with multimorbidity.

Trial registration

PROSPERO (https://www.crd.york.ac.uk/prospero; CRD42018084057; 2018/02/01), German Clinical Trials Register (www.drks.de; DRKS00013309; 2018/01/23).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02448-8.

Adoption of the concept of person-centred care into discourse in Europe: a systematic literature review

PURPOSE

This study aims to describe how person-centred care, as a concept, has been adopted into discourse in 23 European countries in relation to their healthcare systems (Beveridge, Bismarck, out of pocket).

DESIGN/METHODOLOGY/APPROACH

A literature review inspired by the SPICE model, using both scientific studies (CINHAL, Medline, Scopus) and grey literature (Google), was conducted. A total of 1,194 documents from CINHAL (n = 139), Medline (n = 245), Scopus (n = 493) and Google (n = 317) were analysed for content and scope of person-centred care in each country. Countries were grouped based on healthcare systems.

FINDINGS

Results from descriptive statistics (percentage, range) revealed that person-centred care was most common in the United Kingdom (n = 481, 40.3%), Sweden (n = 231, 19.3%), the Netherlands (n = 80, 6.7%), Northern Ireland (n = 79, 6.6%) and Norway (n = 61, 5.1%) compared with Poland (0.6%), Hungary (0.5%), Greece (0.4%), Latvia (0.4%) and Serbia (0%). Based on healthcare systems, seven out of ten countries with the Beveridge model used person-centred care backed by scientific literature (n = 999), as opposed to the Bismarck model, which was mostly supported by grey literature (n = 190).

PRACTICAL IMPLICATIONS

Adoption of the concept of person-centred care into discourse requires a systematic approach at the national (politicians), regional (guidelines) and local (specific healthcare settings) levels visualised by decision-making to establish a well-integrated phenomenon in Europe.

SOCIAL IMPLICATIONS

Evidence-based knowledge as well as national regulations regarding person-centred care are important tools to motivate the adoption of person-centred care in clinical practice. This could be expressed by decision-making at the macro (law, mission) level, which guides the meso (policies) and micro (routines) levels to adopt the scope and content of person-centred care in clinical practice. However, healthcare systems (Beveridge, Bismarck and out-of-pocket) have different structures and missions owing to ethical approaches. The quality of healthcare supported by evidence-based knowledge enables the establishment of a well-integrated phenomenon in European healthcare.

ORIGINALITY/VALUE

Our findings clarify those countries using the Beveridge healthcare model rank higher on accepting/adopting the concept of person-centered care in discourse. To adopt the concept of person-centred care in discourse requires a systematic approach at all levels in the organisation-from the national (politicians) and regional (guideline) to the local (specific healthcare settings) levels of healthcare.

Patient-Centeredness in Older Adults With Multimorbidity: Results of an Online Expert Delphi Study

BACKGROUND AND OBJECTIVES

Older adults suffering from multimorbidity represent a priority target group for patient-centeredness (PC). We aimed to investigate the transferability of an existing integrated model of PC comprising 15 dimensions on the care of older adults with multimorbidity from an expert perspective.

RESEARCH DESIGN AND METHODS

A total of 242 experts were invited to participate in a 2-round online Delphi study. In round 1, they were asked to (a) individually rate relevance and clarity of the dimensions, (b) add missing dimensions, and (c) prioritize the dimensions. In round 2, experts received results of round 1 and were asked to rerate their ratings.

RESULTS

Forty-eight experts participated in round 1 and 39 in round 2. Ten dimensions were rated as sufficiently relevant and clear, including one new dimension ("prognosis and life expectancy, burden of treatment"). Four dimensions were rated as relevant but insufficiently clear. One dimension failed to reach our validation threshold on both criteria. The 5 dimensions rated as most important were: "patient as a unique person," "clinician-patient communication," "patient involvement in care," "physical, cognitive, and emotional support," and "involvement of family and friends."

DISCUSSION AND IMPLICATIONS

The experts' ratings were higher regarding relevance than regarding clarity, which emphasizes the still existing conceptual uncertainty of PC. Our results give further directions regarding the operationalization of PC in older adults with multimorbidity, which is essential for its implementation in routine care. Further refined using focus groups with geriatric patients, our adapted model serves as a basis for a systematic review of assessment instruments.

Implementation of patient-centred care: which system-level determinants matter from a decision maker's perspective? Results from a qualitative interview study across various health and social care organisations

OBJECTIVES

The healthcare system is characterised by a high degree of complexity and involves various actors at different institutional levels and in different care contexts. To implement patient-centred care (PCC) successfully, a multidimensional consideration of influencing factors is required. Our qualitative study aims to identify system-level determinants of PCC implementation from the perspective of different health and social care organisations (HSCOs).

DESIGN

A qualitative study using n=20 semistructured face-to-face interviews with n=24 participants was carried out between August 2017 and May 2018. Interview data were analysed based on concepts of qualitative content analysis using an inductive and deductive approach.

SETTING AND PARTICIPANTS

Interviews were conducted with clinical and managerial decision makers from multiple HSCOs in the model region of Cologne, Germany. Participants were recruited via networks of practice partners and cold calling.

RESULTS

This study identified various determinants on the system level that are associated with PCC implementation. Decision makers described external regulations as generating an economically controlled alignment of the healthcare system. The availability and qualification of staff resources and patient-related incentives of financial resources were identified as an eminent requirement for providers to deliver PCC. Participants considered the strict separation of financing and delivery of healthcare into inpatient and outpatient sectors to be a barrier to PCC. Interorganisational collaboration and information exchange were identified as facilitators of PCC, as they enable continuous patient care cycles.

CONCLUSION

The results showed the necessity of enforcing paradigm changes at the system level from disease-centredness to patient-centredness while aligning policy and reimbursement decisions directly with patient needs and values. A systematic, long-term planned strategy that extends across all organisations is lacking, rather each organisation seeks its own possibilities to implement PCC activities under external restrictions.Trial registration numberDRKS00011925.

The role of different nephrology experts in informed shared decision-making for renal replacement therapy

BACKGROUND

Interprofessional teams and peer support are being increasingly considered in informed shared decision-making. In Germany, there appear to be deficits in the implementation of informed shared decision-making in the choice of renal replacement therapy, such as the lack of collaboration in interprofessional teams and the absence of structured peer support programmes for patients with chronic kidney disease.

OBJECTIVE

To explore nephrologists' and nurses' perspectives regarding their involvement in shared decision-making when choosing renal replacement therapy.

DESIGN

Guideline-based, problem-centred interviews were used.

PARTICIPANTS

A total of 20 nephrologists and 15 nurses were recruited from 21 dialysis units all over Germany.

APPROACH

Interviews were audio-recorded and transcribed. They were analysed thematically using structuring and summary content analysis, supported by the qualitative data analysis software MAXQDA 12.

RESULTS

The most important findings were the late or missing participation of nurses in the informed shared decision-making process and the unstructured peer support. Along with time and financial factors, these aspects were seen as barriers to shared decision-making with patients who are often overwhelmed by the diagnosis. Furthermore, informed shared decision-making has been insufficiently considered in professional education and training.

CONCLUSION

Shared decision-making in the choice of renal replacement therapy is particularly challenging due to the patients' high disease burden. The greater incorporation of informed shared decision-making in education and training as well as the consistent involvement of nursing staff and structured peer counselling already in the predialysis phase with adequate reimbursement can address the identified hurdles.

What do patients expect? Assessing patient-centredness from the patients' perspective: an interview study

OBJECTIVE

Although there has been much conceptual work on patient-centredness (PC), patients' perspectives on PC were neglected. In a previous study, participating patients rated the relevance of 16 dimensions of an integrative model of PC as high to very high. However, it remained unclear which specific behaviours described in the dimensions were considered most relevant. Thus, the aim of the current study was to further explore which of the specific behaviours described in the model are especially relevant for the high ratings in the previous study.

METHODS AND DESIGN

We conducted semistructured interviews with 20 patients with chronic diseases (16 females, 4 males, mean age: 52 years). Patients answered questions regarding their experiences in the German healthcare system and how optimal healthcare would look like from their perspective. Furthermore, patients were asked to reflect on the most important aspects which they had mentioned in the interview before. Data were analysed via content analysis.

RESULTS

Participants addressed many different aspects of PC, but mostly focused on three major themes: (1) time appropriate access to care, (2) competence, empathy and being taken seriously by HCPs, (3) HCPs' individual consideration of each patient's situation (eg, wishes and needs). Minor themes were: (1) taking a holistic perspective of the patient, (2) patient-centred communication, (3) integration of multidisciplinary treatment elements, (4) transparency regarding waiting time and (5) reduction of unequal access to care.

CONCLUSION

This study enriches the construct of PC by depicting essential aspects of PC from the patients' perspective. The results allow prioritising strategies to implement patient-centred care. Thus, this study helps to pursue the ultimate goal of fostering patient-centred healthcare delivery in Germany.

Hospital practices for the implementation of patient partnership in a multi-national European region

BACKGROUND

The extent to which patients are involved in their care can be influenced by hospital policies and interventions. Nevertheless, the implementation of patient participation and involvement (PPI) at the organisational (meso) level has rarely been assessed systematically. The aim of this study was to assess the occurrence of PPI practises in hospitals in Belgium, France, Germany and Luxembourg and to analyze if, and to what extent, the hospital vision and the presence of a patient committee influence the implementation of PPI practises.

METHODS

A cross-sectional study was carried out using an online questionnaire in hospitals in the border regions of the four countries. The data were analyzed for differences between regions and the maturity of PPI development.

RESULTS

Full responses were obtained from 64 hospitals. A wide range of practices were observed, the degree of maturity was mixed. A majority of hospitals promoted patient partnership in the hospital's philosophy of care statement. However, the implementation of specific interventions for PPI was not found uniformly and differences could be observed between the countries.

CONCLUSIONS

Hospitals in the region seem to be motivated to include patients more fully, however, implementation of PPI interventions seems incomplete and only partially integrated into the general functioning of the hospitals. The implementation of the concept seems to be more mature in the francophone part of the region perhaps due, in part, to a more favourable political context.

Translation and psychometric evaluation of the German version of the IcanSDM measure - a cross-sectional study among healthcare professionals

Background

Shared decision-making (SDM) between patients and healthcare professionals (HCPs) is a key component of patient-centred care. To implement SDM in clinical practice and to evaluate its effects, it is helpful to know about HCPs’ perception of SDM barriers. The measure IcanSDM was developed in Canada and assesses the perception of SDM barriers. To our knowledge, no equivalent measure exists in German. Therefore, the aim of this study was to translate and adapt the IcanSDM measure to be used by a German speaking population and evaluate its psychometric properties.

Methods

This is a cross-sectional psychometric study based on a secondary analysis of baseline data from a SDM implementation study. The original 8-item IcanSDM was translated into German using a team translation protocol. We assessed comprehensibility via cognitive interviews with n = 11 HCPs. Based on results of cognitive interviews, the translated IcanSDM version was revised. Two hundred forty-two HCPs filled out the measure. Psychometric analysis included acceptance (completion rate), item characteristics (response distribution, skewness, item difficulties, corrected item-total correlations, inter-item correlations), factorial structure (confirmatory factor analysis (CFA), model fit), and internal consistency (Cronbach’s α).

Results

We translated and adapted the German IcanSDM successfully except for item 8, which had to be revised after the cognitive interviews. Completion rate was 98%. Skewness of the items ranged between −.797 and 1.25, item difficulties ranged between 21.63 and 70.85, corrected item-total-correlations ranged between .200 and .475, inter-item correlations ranged between .005 and .412. Different models based on CFA results did not provide a valid factorial structure. Cronbach’s α ranged between .563 and .651 for different factor models.

Conclusion

We provide the first German measure for assessing perception of SDM barriers by HCPs. The German IcanSDM is a brief measure with good acceptance. However, we found unsatisfying psychometric properties, which were comparable to results of the original scale. In a next step, the IcanSDM should be further developed and modified and predictive validity should be evaluated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06430-3.

Between competence and warmth: the remaining place of the physician in the era of artificial intelligence

Competence and warmth are two essential dimensions of patient care. During the twentieth century, the industrial revolution in data collection, with the increasing use of machines and the division of labor that led to the development of many subspecialities, increased the overall competence of physicians at the expense of the warmth dimension. The spread of patient-centered care principles aimed to rebalance the two dimensions. In the twenty-first century, the industrial revolution in data processing with the emergence of algorithmic decision-making systems based on artificial intelligence is likely to disrupt further this balance. Competence will no longer be the prerogative of physicians, but a dimension to be shared between physicians and autonomous algorithmic decision-making systems, by contrast to warmth which should remain a human attribute. In this comment, we discuss the extent to which competence and warmth can remain the core dimensions of physician care in the era of artificial intelligence.

Older and Wiser? The Need to Reexamine the Impact of Health Professionals Age and Experience on Competency-Based Practices

INTRODUCTION

Delivery of healthcare services makes up a complex system and it requires providers to be competent and to be able to integrate each of the institute of medicine's (IOM) 5 core competencies into practice. However, healthcare providers are challenged with the task to be able to understand and apply the IOM core competencies into practice.

OBJECTIVE

The purpose of the study was to examine the factors that influence health professional's likelihood of accomplishing the IOM core competencies.

METHODS

A cross-sectional study design was used to administer a validated online survey to health providers. This survey was distributed to physicians, nursing professionals, specialists, and allied healthcare professionals. The final sample included 3,940 participants who completed the survey.

RESULTS

The study findings show that younger health professionals more consistently practice daily competencies than their older counterparts, especially in the use of evidence-based practice, informatics, and working in interdisciplinary teams. Less experienced health professionals more consistently applied quality improvement methods but less consistently used evidence-based practice compared to their more experienced counterparts.

CONCLUSION

There is a need to understand how health professionals' age and experience impact their engagement with IOM's core competencies. This study highlights the need for educational resources on the competencies to be tailored to health providers' age and experience.

Beyond Known Barriers-Assessing Physician Perspectives and Attitudes Toward Introducing Open Health Records in Germany: Qualitative Study

Background

Giving patients access to their medical records (ie, open health records) can support doctor-patient communication and patient-centered care and can improve quality of care, patients’ health literacy, self-care, and treatment adherence. In Germany, patients are entitled by law to have access to their medical records. However, in practice doing so remains an exception in Germany. So far, research has been focused on organizational implementation barriers. Little is known about physicians’ attitudes and perspectives toward opening records in German primary care.

Objective

This qualitative study aims to provide a better understanding of physicians’ attitudes toward opening records in primary care in Germany. To expand the knowledge base that future implementation programs could draw from, this study focuses on professional self-conception as an influencing factor regarding the approval for open health records. Perspectives of practicing primary care physicians and advanced medical students were explored.

Methods

Data were collected through semistructured guide-based interviews with general practitioners (GPs) and advanced medical students. Participants were asked to share their perspectives on open health records in German general practices, as well as perceived implications, their expectations for future medical records, and the conditions for a potential implementation. Data were pseudonymized, audiotaped, and transcribed verbatim. Themes and subthemes were identified through thematic analysis.

Results

Barriers and potential advantages were reported by 7 GPs and 7 medical students (N=14). The following barriers were identified: (1) data security, (2) increased workload, (3) costs, (4) the patients’ limited capabilities, and (5) the physicians’ concerns. The following advantages were reported: (1) patient education and empowerment, (2) positive impact on the practice, and (3) improved quality of care. GPs’ professional self-conception influenced their approval for open records: GPs considered their aspiration for professional autonomy and freedom from external control to be threatened and their knowledge-based support of patients to be obstructed by open records. Medical students emphasized the chance to achieve shared decision making through open records and expected the implementation to be realistic in the near future. GPs were more hesitant and voiced a strong resistance toward sharing notes on perceptions that go beyond clinical data. Reliable technical conditions, the participants’ consent, and a joint development of the implementation project to meet the GPs’ interests were requested.

Conclusions

Open health record concepts can be seen as a chance to increase transparency in health care. For a potential future implementation in Germany, thorough consideration regarding the compatibility of GPs’ professional values would be warranted. However, the medical students’ positive attitude provides an optimistic perspective. Further research and a broad support from decision makers would be crucial to establish open records in Germany.

Making shared decision-making (SDM) a reality: protocol of a large-scale long-term SDM implementation programme at a Northern German University Hospital

INTRODUCTION

Shared decision-making (SDM) is not yet widely used when making decisions in German hospitals. Making SDM a reality is a complex task. It involves training healthcare professionals in SDM communication and enabling patients to actively participate in communication, in addition to providing sound, easy to understand information on treatment alternatives in the form of evidence-based patient decision aids (EbPDAs). This project funded by the German Innovation Fund aims at designing, implementing and evaluating a multicomponent, large-scale and integrative SDM programme-called SHARE TO CARE (S2C)-at all clinical departments of a University Hospital Campus in Northern Germany within a 4-year time period.

METHODS AND ANALYSIS

S2C tackles the aforementioned components of SDM: (1) training physicians in SDM communication, (2) activating and empowering patients, (3) developing EbPDAs in the most common/relevant diseases and (4) training other healthcare professionals in SDM coaching. S2C is designed together with patients and providers. The physicians' training programme entails an online and an in situ training module. The decision coach training is based on a similar but less comprehensive approach. The development of online EbPDAs follows the International Patient Decision Aid Standards and includes written, graphical and video-based information. Validated outcomes of SDM implementation are measured in a preintervention and postintervention evaluation design. Process evaluation accompanies programme implementation. Health economic impact of the intervention is investigated using a propensity-score-matched approach based on potentially preference-sensitive hospital decisions.

ETHICS AND DISSEMINATION

Ethics committee review approval has been obtained from Medical Ethics Committee of the Medical Faculty of the Christian-Albrechts-University Kiel. Project information and results will be disseminated at conferences, on project-hosted websites at University Hospital Medical Center Schleswig Holstein and by S2C as well as in peer-reviewed and professional journals.

[DNVF Memorandum Health Services Research in Oncology]

Health services research in oncology deals with all situations which cancer patients face. It looks at the different phases of care, i. e. prevention / early detection, prehabilitation, diagnostics, therapy, rehabilitation and palliative care as well as the various actors, including those affected, the carers and self-help. It deals with healthy people (e. g. in the context of prevention / early detection), patients and cancer survivors. Due to the nature of cancer and the existing care structures, there are a number of specific contents for health services research in oncology compared to general health services research while the methods remain essentially identical. This memorandum describes the subject, illustrates the care structures and identifies areas of health services research in oncology. This memorandum has been prepared by the Oncology Section of the German Network for Health Services Research and is the result of intensive discussions.

Translation and psychometric evaluation of the German version of the Organisational Readiness for Implementing Change measure (ORIC): a cross-sectional study

OBJECTIVES

To translate the Organisational Readiness for Implementing Change measure into German and assess its psychometric properties.

DESIGN

Cross-sectional psychometric study based on secondary analysis of baseline data from a shared decision-making implementation study.

SETTING

Three departments within one academic cancer centre in Hamburg, Germany.

PARTICIPANTS

For comprehensibility assessment of the translated ORIC version, we conducted cognitive interviews with healthcare professionals (HCPs, n=11). Afterwards, HCPs (n=230) filled out the measure.

PRIMARY AND SECONDARY OUTCOME MEASURES

The original English version of the ORIC was translated into German using a team translation protocol. Based on comprehensibility assessment via cognitive interviews with HCPs, the translated version was revised. We analysed acceptance (completion rate), factorial structure (exploratory factor analysis (EFA), confirmatory factor analysis (CFA), model fit), item characteristics (item difficulties, corrected item-total correlations, inter-item correlations) and internal consistency (Cronbach's α).

RESULTS

Translation and cognitive testing of the German ORIC was successful except for item 10, which showed low comprehensibility as part of content validity in cognitive interviews. Completion rate was >97%. EFA and CFA provided a one-factorial structure. Item difficulties ranged between 55.98 and 65.32, corrected item-total-correlation ranged between 0.665 and 0.774, inter-item correlations ranged between 0.434 and 0.723 and Cronbach's α was 0.93.

CONCLUSIONS

The German ORIC is a reliable measure with high completion rates and satisfying psychometric properties. A one-factorial structure of the German ORIC was confirmed. Item 10 showed limited comprehensibility and therefore reduces content validity of the measure. The German ORIC can be used to analyse organisational readiness for change as a precursor for implementation success of various interventions.

User participation and shared decision-making in adolescent mental healthcare: a qualitative study of healthcare professionals' perspectives

BACKGROUND

Most mental health problems occur in adolescence. There is increasing recognition of user participation and shared decision-making in adolescents' mental healthcare. However, research in this field of clinical practice is still sparse. The objective of this study was to explore healthcare professionals' perspectives on user participation, and opportunities for shared decision-making in Child and Adolescent Mental Health Service (CAMHS) inpatient units.

METHODS

Healthcare professionals at CAMHS inpatient units participated in three focus group interviews. Fifteen participants with experience with user participation and shared decision-making were recruited from five hospitals in Norway.

RESULTS

Five themes emerged: (1) involvement before admission; (2) sufficient time to feel safe; (3) individualized therapy; (4) access to meetings where decisions are made; and (5) changing professionals' attitudes and practices.

CONCLUSION

User participation and shared decision-making require changes in workplace culture, and routines that allow for individualized mental health services that are adapted to adolescents' needs. This calls for a flexible approach that challenges clinical pathways and short-stay hospital policies. The results of this study may inform further work on strengthening user participation and the implementation of shared decision-making.Trial registration Norwegian Regional Committees for Medical and Health Research Ethics, reference number 2017/1195.

Assessing the relevance and implementation of patient-centredness from the patients' perspective in Germany: results of a Delphi study

OBJECTIVE

Patient-centredness (PC) has particularly grown in relevance in health services research as well as in politics and there has been much research on its conceptualisation. However, conceptual work neglected the patients' perspective. Thus, it remains unclear which dimensions of PC matter most to patients. This study aims to assess relevance and current degree of implementation of PC from the perspective of chronically ill patients in Germany.

METHODS

We conducted a Delphi study. Patients were recruited throughout Germany using community-based strategies (eg, newspapers and support groups). In round 1, patients rated relevance and implementation of 15 dimensions of PC anonymously. In round 2, patients received results of round 1 and were asked to re-rate their own results. Participants had to have at least one of the following chronic diseases: cancer, cardiovascular disease, mental disorder or musculoskeletal disorder. Furthermore, patients had to be at least 18 years old and had to give informed consent prior to participation.

RESULTS

226 patients participated in round 1, and 214 patients in round 2. In both rounds, all 15 dimensions were rated highly relevant, but currently insufficiently implemented. Most relevant dimensions included 'patient safety', 'access to care' and 'patient information'. Due to small sizes of subsamples between chronic disease groups, differences could not be computed. For the other subgroups (eg, single disease vs multi-morbidity), there were no major differences.

CONCLUSION

This is one of the first studies assessing PC from patients' perspective in Germany. We showed that patients consider every dimension of PC relevant, but currently not well implemented. Our results can be used to foster PC healthcare delivery and to develop patient-reported experience measures to assess PC of healthcare in Germany.

[Shared decision making in breast care centres in North Rhine-Westphalia: results of a 10-year trend analysis]

BACKGROUND

Although shared decision making (SDM) has been gaining importance in German health services for some time now, the state of its implementation is still unknown. The aim of this study was to provide a valid trend analysis for SDM in breast care centres in the German federal state of North Rhine-Westphalia (NRW) for a period of 10 years.

METHODS

As part of an annual patient survey in breast care centres in NRW, two subscales of the Perceived Involvement in Care Scales (PICS) were used and analysed in multi-level models.

RESULTS

Data from nearly 40,000 patients could be analysed with consistently high response rates. In the observation period from 2006 to 2015 doctor facilitation and patient involvement increased on a scale from 1 to 4 of 3.1 to 3.4 and 2.6 to 2.8, respectively.

CONCLUSIONS

Despite the slight increases in the 10-year observation period a stable trend cannot be assumed. However, this study might be useful as a baseline for other studies on SDM implementation.

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.

[Digital health literacy in Germany - requested, but not supported? Results of the empirical study TK-DiSK]

In Germany, the digital transformation is considered the key to "growth and prosperity". Beyond the debate on the required technical conditions, digital health literacy is seen as a prerequisite for a democratic and patient oriented digitization of the health system. The study "TK-DiSK: digital - self-determined - competent" aimed at examining the perspectives and status of stakeholders in the German health system and of further developing the concept of digital health literacy. Document analysis, surveys and interviews revealed a paradox about digital health literacy: though it is generally seen as a "highly relevant' issue, there is hardly any substantial discussion of it. Interviewed experts did not share a common understanding of its content, disagreed on ways of promoting it, and disputed the agencies to be held responsible for ensuring digital health literacy. Focus groups with patients clearly showed that the facilitation of patient autonomy is a central aspect for their assessment of digital health technologies. This article develops a timely definition of digital health literacy and argues for a comprehensive and targeted promotion addressing individuals as well as organizations.

Perceived diabetes risk and related determinants in individuals with high actual diabetes risk: results from a nationwide population-based survey

Objective

The purpose of this study was first, to examine perceived diabetes risk compared with actual diabetes risk in the general population and second, to investigate which factors determine whether persons at increased actual risk also perceive themselves at elevated risk.

Research design and methods

The study comprised adults (aged 18-97 years) without known diabetes from a nationwide survey on diabetes-related knowledge and information needs in Germany in 2017. Actual diabetes risk was calculated by an established risk score estimating the 5-year probability of developing type 2 diabetes and was compared with perceived risk of getting diabetes over the next 5 years (response options: 'almost no risk', 'slight risk', 'moderate risk', 'high risk'; n = 2327). Among adults with an increased actual diabetes risk (n=639), determinants of perceived risk were investigated using multivariable logistic regression analysis.

Results

Across groups with a 'low' (<2%), 'still low' (2% to<5%), 'elevated' (5% to <10%), and 'high' (≥10%) actual diabetes risk, a proportion of 89.0%, 84.5%, 79.3%, and 78.9%, respectively, perceived their diabetes risk as almost absent or slight. Among those with an increased (elevated/high) actual risk, independent determinants of an increased (moderate/high) perceived risk included younger age (OR 0.92 (95% CI 0.88 to 0.96) per year), family history of diabetes (2.10 (1.06-4.16)), and being informed about an increased diabetes risk by a physician (3.27 (1.51-7.07)), but none of further diabetes risk factors, healthcare behaviors or beliefs about diabetes.

Conclusions

Across categories of actual diabetes risk, perceived diabetes risk was low, even if actual diabetes risk was high. For effective strategies of primary diabetes prevention, attention should be directed to risk communication at the population level as well as in primary care practice.

[Parents as co-producers in the healthcare system: Individual perspectives and consequences for educational concepts]

INTRODUCTION AND OBJECTIVES

In selected healthcare sectors and settings, patients and their relatives are now regarded as co-producers of the healthcare system. This is associated with modified patient roles and new relationship models. Physiotherapists also have to face them by including educational interventions into their traditional scope of practice. However, corresponding intervention concepts for physiotherapy do not yet exist. Therefore, the aim of this contribution is to initiate an empirically supported concept development.

METHODS

As part of a qualitative empirical study, interviews were conducted with 15 parents of children with life-limiting diseases in four federal states of Germany and then evaluated using the reconstruction method of the documentary method according to Bohnsack. The parents' experiences with the assumption of physiotherapeutic care were used as input for first reflections on an instructive intervention concept with reference to relevant learning theory approaches.

RESULTS

In the course of the data evaluation, three divergent orientations (parent types) were identified. Parent type A (autonomy) acts largely autonomously and requires only occasional support. Parent type B (understanding) and C (relief) need more intensive support. While parent type B requires education in order to satisfy their pronounced need for knowledge, parent type C generally questions why they should have to carry out physiotherapeutic task and delegates responsibility back to the professional help system.

DISCUSSION

Physiotherapeutic instruction should take into account the different types of parents with regard to the provision of care. Parents who are motivated to engage in learning processes would like to a) focus on central physiotherapeutic measures, b) be instructed face-to-face and c) be recognized as experts for their child and their situation.

CONCLUSION

Supplemented by the perspective of professionals, insights into the parents' perspective can serve as the basis for empirical impact analysis. The empirically validated intervention concepts for instructive action must be integrated into existing educational, training and further education courses in order to ensure systematic dissemination of knowledge into physiotherapy. In addition, a debate on professional policy must be launched in order to secure instructive action more strongly in the physiotherapeutic repertoire.

Implementation of patient-centred care: which organisational determinants matter from decision maker's perspective? Results from a qualitative interview study across various health and social care organisations

OBJECTIVES

Health and social care systems, organisations and providers are under pressure to organise care around patients' needs with constrained resources. To implement patient-centred care (PCC) successfully, barriers must be addressed. Up to now, there has been a lack of comprehensive investigations on possible determinants of PCC across various health and social care organisations (HSCOs). Our qualitative study examines determinants of PCC implementation from decision makers' perspectives across diverse HSCOs.

DESIGN

Qualitative study of n=24 participants in n=20 semistructured face-to-face interviews conducted from August 2017 to May 2018.

SETTING AND PARTICIPANTS

Decision makers were recruited from multiple HSCOs in the region of the city of Cologne, Germany, based on a maximum variation sampling strategy varying by HSCOs types.

OUTCOMES

The qualitative interviews were analysed using an inductive and deductive approach according to qualitative content analysis. The Consolidated Framework for Implementation Research was used to conceptualise determinants of PCC.

RESULTS

Decision makers identified similar determinants facilitating or obstructing the implementation of PCC in their organisational contexts. Several determinants at the HSCO's inner setting and the individual level (eg, communication among staff and well-being of employees) were identified as crucial to overcome constrained financial, human and material resources in order to deliver PCC.

CONCLUSIONS

The results can help to foster the implementation of PCC in various HSCOs contexts. We identified possible starting points for initiating the tailoring of interventions and implementation strategies and the redesign of HSCOs towards more patient-centredness.

Communicating prognosis to women with early breast cancer - overview of prediction tools and the development and pilot testing of a decision aid

Background

Shared decision-making in oncology requires information on individual prognosis. This comprises cancer prognosis as well as competing risks of dying due to age and comorbidities. Decision aids usually do not provide such information on competing risks. We conducted an overview on clinical prediction tools for early breast cancer and developed and pilot-tested a decision aid (DA) addressing individual prognosis using additional chemotherapy in early, hormone receptor-positive breast cancer as an example.

Methods

Systematic literature search on clinical prediction tools for the effects of drug treatment on survival of breast cancer. The DA was developed following criteria for evidence-based patient information and International Patient Decision Aids Standards. We included data on the influence of age and comorbidities on overall prognosis. The DA was pilot-tested in focus groups. Comprehension was additionally evaluated through an online survey with women in breast cancer self-help groups.

Results

We identified three prediction tools: Adjuvant!Online, PREDICT and CancerMath. All tools consider age and tumor characteristics. Adjuvant!Online considers comorbidities, CancerMath displays age-dependent non-cancer mortality. Harm due to therapy is not reported.

Twenty women participated in focus groups piloting the DA until data saturation was achieved. A total of 102 women consented to participate in the online survey, of which 86 completed the survey. The rate of correct responses was 90.5% and ranged between 84 and 95% for individual questions.

Conclusions

None of the clinical prediction tools fulfilled the requirements to provide women with all the necessary information for informed decision-making. Information on individual prognosis was well understood and can be included in patient decision aids.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3988-2) contains supplementary material, which is available to authorized users.

Adaptation and qualitative evaluation of encounter decision aids in breast cancer care

Purpose

Shared decision-making is currently not widely implemented in breast cancer care. Encounter decision aids support shared decision-making by helping patients and physicians compare treatment options. So far, little was known about adaptation needs for translated encounter decision aids, and encounter decision aids for breast cancer treatments were not available in Germany. This study aimed to adapt and evaluate the implementation of two encounter decision aids on breast cancer treatments in routine care.

Methods

We conducted a multi-phase qualitative study: (1) translation of two breast cancer Option Grid™ decision aids; comparison to national clinical standards; cognitive interviews to test patients’ understanding; (2) focus groups to assess acceptability; (3) testing in routine care using participant observation. Data were analysed using qualitative content analysis.

Results

Physicians and patients reacted positively to the idea of encounter decision aids, and reported being interested in using them; patients were most receptive. Several adaptation cycles were necessary. Uncertainty about feasibility of using encounter decision aids in clinical settings was the main physician-reported barrier. During real-world testing (N = 77 encounters), physicians used encounter decision aids in one-third of potentially relevant encounters. However, they did not use the encounter decision aids to stimulate dialogue, which is contrary to their original scope and purpose.

Conclusions

The idea of using encounter decision aids was welcomed, but more by patients than by physicians. Adaptation was a complex process and required resources. Clinicians did not follow suggested strategies for using encounter decision aids. Our study indicates that production of encounter decision aids alone will not lead to successful implementation, and has to be accompanied by training of health care providers.

Electronic supplementary material

The online version of this article (10.1007/s00404-018-5035-7) contains supplementary material, which is available to authorized users.

Patient and Provider Perspectives on a Decision Aid for Familial Hypercholesterolemia

Familial Hypercholesterolemia (FH) is an inherited disorder associated with increased cardiovascular risk that requires patients to make multiple impactful decisions regarding the management of their condition. Patient decision aids (PDAs) can facilitate shared decision-making (SDM) and enable patients to make choices that are concordant with their goals and values. To inform the development of a PDA for patients with FH, we employed a qualitative inductive approach and focus group discussions with patients, physicians, and genetic counselors. We explored and analyzed the perceptions and understanding of these stakeholders related to a PDA for FH and identified important concepts to include in the PDA. Categories emerging from focus group discussions included: (a) perceptions of a PDA related to FH; (b) discussion about the content of a PDA related to FH; and (c) SDM. In general, stakeholders were in favor of developing tools which can inform and individualize discussion about genetic testing and treatment options for FH. Physicians valued a tool that facilitates knowledge transfer to FH patients. Patients desired a tool to help them understand the genetic aspects of and treatment options related to FH. Genetic counselors emphasized the inclusion of visual aids to support discussion with patients. Potential barriers to and facilitators of PDA implementation were identified. The input of various stakeholders will inform the development of a prototype tool that will be iteratively tested before implementation in the clinical setting.

Assessment of patient centredness through patient-reported experience measures (ASPIRED): protocol of a mixed-methods study

INTRODUCTION

The impact of patient centredness (PC) in healthcare has grown over the years. However, conceptualisations of PC are heterogeneous. Existing patient-reported measures of PC have shown inconsistencies and shortcomings. This impedes the comparison of results across studies. To foster PC, it is important to know which dimensions matter most to patients and to be able to measure its current extent from the patients' perspective. This study aims (1) to assess relevance of dimensions of PC from the patients' perspective, (2) to develop and psychometrically test a core set of patient-reported experience measures (PREMs) assessing PC and (3) to investigate the feasibility of implementation of this core set in routine healthcare.

METHODS AND ANALYSIS

A mixed-methods approach will be used. In phase 1, 200 patients will assess the relevance of the dimensions of PC in a Delphi study using a plain language description. In phase 2, the core set of PREMs will be developed through literature reviews, focus groups, key informant interviews and content validity ratings. The core set will be tested psychometrically in a cross-sectional study with 2000 inpatient and outpatients with different chronic conditions (ie, cancer, cardiovascular diseases, mental disorders and musculoskeletal disorders). In phase 3, the feasibility of implementation of the core set will be assessed through semistructured interviews with healthcare practitioners after piloting in routine care. Furthermore, an expert workshop will be held on how to foster implementation.

ETHICS AND DISSEMINATION

The study will be carried out in accordance to the latest version of the Helsinki Declaration of the World Medical Association and principles of good scientific practice. The study was approved by the Ethics Committee of the Medical Association Hamburg, Germany (study ID: PV5724). The study results will be disseminated in scientific journals and through collaboration partners and plain language press releases.

Valuing health-related quality of life: systematic variation in health perception

BACKGROUND

Population-based value sets are widely used to transform health states into utilities, but may deviate from actual patient experience. Whether this occurs in a systematic way can be analyzed, in a first step, for respondents who do not report problems on the five domains of the EQ-5D-5L instrument in population studies.

METHODS

EQ-5D-5L results from three annual cross-sectional surveys (2012, 2013, and 2014) were filtered for participants who reported being problem-free. Continuous visual analog scale (VAS) scores, ranging from 0 (worst imaginable health) to 100 (best imaginable health) were then used to measure their actual health perception and to compare results with the proposed EQ-5D-5L value. A multiple linear regression model was used to identify possible risk factors for low VAS scores.

RESULTS

Some 3739 (61.5%) participants reported being problem-free. Their mean age was 41.1 years and mean VAS score was 91.9. Age and BMI were significantly associated with lower VAS scores. Age groups from 50 years onwards reported VAS means of 90.0 and below. Female gender and low education also had small but significant negative effects on patient experience. The presence of BMI class III as well as diabetes had the greatest negative effect on VAS results (- 9.0 and - 8.4) and reached the range of minimally important differences. Heart disease (- 6.2) and musculoskeletal disease (- 3.4) also had strong negative effects. The 25th percentile of VAS scores in our sample was 90.0, and the 50th percentile was 95.0.

CONCLUSIONS

For some groups in population studies, especially older people with high BMI and those affected by specific diseases, no problems on all five domains of the EQ-5D-5L fails to reflect the respondents' health perception as measured by the VAS.

Evaluation of a program for routine implementation of shared decision-making in cancer care: study protocol of a stepped wedge cluster randomized trial

BACKGROUND

Shared decision-making (SDM) has become increasingly important in health care. However, despite scientific evidence, effective implementation strategies, and a prominent position on the health policy agenda, SDM is not widely implemented in routine practice so far. Therefore, we developed a program for routine implementation of SDM in oncology by conducting an analysis of the current state and a needs assessment in a pilot study based on the Consolidated Framework for Implementation Research (CFIR). Based on these results, the main aim of our current study is to evaluate the process and outcome of this theoretically and empirically grounded multicomponent implementation program designed to foster SDM in routine cancer care.

METHODS

We use a stepped wedge design, a variant of the cluster randomized controlled trial. The intervention to be implemented is SDM. Three participating clinics of one comprehensive cancer center will be randomized and receive the multicomponent SDM implementation program in a time-delayed sequence. The program consists of the following strategies: (a) SDM training for health care professionals, (b) individual coaching for physicians, (c) patient activation strategy, (d) provision of patient information material and decision aids, (e) revision of the clinics' quality management documents, and (f) critical reflection of current organization of multidisciplinary team meetings. We will conduct a mixed methods outcome and process evaluation. The outcome evaluation will consist of four measurement points. The primary outcome is adoption of SDM, measured by the 9-item Shared Decision Making Questionnaire. A range of other implementation outcomes will be assessed (i.e., acceptability, readiness for implementing change, appropriateness, penetration). The implementation process will be evaluated using stakeholder interviews and field notes. This will allow adapting interventions if necessary.

DISCUSSION

This study is the first large study on routine implementation of SDM conducted in German cancer care. We expect to foster implementation of SDM at the enrolled clinics. Insights gained from this study, using a theoretically and empirically grounded approach, can inform other SDM implementation studies and health policy developments, both nationally and internationally.

TRIAL REGISTRATION

clinicaltrials.gov, NCT03393351 . Registered 8 January 2018.

Implementation of shared decision-making in oncology: development and pilot study of a nurse-led decision-coaching programme for women with ductal carcinoma in situ

Background

To implement informed shared decision-making (ISDM) in breast care centres, we developed and piloted an inter-professional complex intervention.

Methods

We developed an intervention consisting of three components: an evidence-based patient decision aid (DA) for women with ductal carcinoma in situ, a decision-coaching led by specialised nurses (breast care nurses and oncology nurses) and structured physician encounters.

In order to enable professionals to gain ISDM competencies, we developed and tested a curriculum-based training programme for specialised nurses and a workshop for physicians. After successful testing of the components, we conducted a pilot study to test the feasibility of the entire revised intervention in two breast care centres. Here the acceptance of the intervention by women and professionals, the applicability to the breast care centres’ procedures, women’s knowledge, patient involvement in treatment decision-making assessed with the MAPPIN’SDM-observer instrument MAPPIN’O_dyad, and barriers to and facilitators of the implementation were taken into consideration. We used questionnaires, structured verbal and written feedback and video recordings. Qualitative data were analysed descriptively, and mean values and ranges of quantitative data were calculated.

Results

To test the DA, focus groups and individual interviews were conducted with 27 women. Six expert reviews were obtained. The components of the nurse training were tested with 18 specialised nurses and 19 health science students. The development and piloting of the components were successful. The pilot test of the entire intervention included seven patients. In general, the intervention is applicable. Patients attained adequate knowledge (range of correct answers: 9–11 of 11). On average, a basic level of patient involvement in treatment decision-making was observed for nurses and patient–nurse dyads (M(MAPPIN-O_dyad): 2.15 and M(MAPPIN-O_nurse): 1.90). Relevant barriers were identified; physicians barely tolerated women’s preferences that were not in line with the medical recommendation. Classifying women as inappropriate for ISDM due to age or education led physicians to neglect eligible women during the recruitment phase.

Conclusion

Decision-coaching is feasible. Nevertheless, there are some indications that structural changes are needed for long-term implementation. We are currently evaluating the intervention in a cluster randomised controlled trial in 16 breast care centres.

Electronic supplementary material

The online version of this article (10.1186/s12911-017-0548-8) contains supplementary material, which is available to authorized users.