Implementing shared decision-making in Australia

"We will be the ones bearing the consequences": A qualitative study of barriers and facilitators to shared decision-making in hospital-based maternity care

BACKGROUND

Pregnant women involved in decisions about their care report better health outcomes for themselves and their children. Shared decision-making (SDM) is a priority for health services; however, there is limited research on factors that help and hinder SDM in hospital-based maternity settings. The purpose of this study was to explore barriers and facilitators to SDM in a large tertiary maternity care service from the perspectives of multiple stakeholders.

METHODS

Qualitative semi-structured interviews were undertaken with 39 participants including women, clinicians, health service administrators and decision-makers, and government policymakers. The interview guide and thematic analysis were based on the Theoretical Domains Framework to identify barriers and facilitators to SDM.

RESULTS

Women expect to be included in decisions about their care. Health service administrators and decision-makers, government policymakers, and most clinicians want to include them in decisions. Key barriers to SDM included lack of care continuity, knowledge, and clinician skills, as well as professional role and decision-making factors. Key facilitators pertained to policy and guideline changes, increased knowledge, professional role factors, and social influences.

CONCLUSION

This study revealed common barriers and facilitators to SDM and highlighted the need to consider perspectives outside the patient-clinician dyad. It adds to the limited literature on barriers and facilitators to SDM in hospital care settings. Organizational- and system-wide changes to service delivery are necessary to facilitate SDM. These changes may be enabled by education and training, changes to policies and guidelines to include and support SDM, and adequately timed information provision to enable SDM conversations.

Implementing patient decision aids into general practice clinical decision support systems: Feasibility study in cardiovascular disease prevention

Objective

Patient decision aids (DA) facilitate shared decision making, but implementation remains a challenge. This study tested the feasibility of integrating a cardiovascular disease (CVD) prevention DA into general practice software.

Methods

We developed a desktop computer application (app) to auto-populate a CVD prevention DA from general practice medical records. 4 practices received monthly practice reports from July-Nov 2021, and 2 practices use the app with limited engagement. CVD risk assessment data and app use were monitored.

Results

The proportion of eligible patients with complete CVD risk assessment data ranged from 59 to 94%. Monthly app use ranged from 0 to 285 sessions by 13 individual practice staff including GPs and nurses, with staff using the app an average of 67 sessions during the study period. High users in the 5-month study period continued to use the app for 10 months. Low use was attributed to reduced staff capacity during COVID-19 and technical issues.

Conclusion

High users sustained interest in the app, but additional strategies are required for low users. The study will inform implementation plans for new guidelines.

Innovation

This study showed it is feasible to integrate patient decision aids with Australian general practice software, despite the challenges of COVID-19 at the time of the study.

Should I take aspirin? A qualitative study on the implementation of a decision aid on taking aspirin for bowel cancer prevention

OBJECTIVES

Australian guidelines recommend 50-70 years consider taking aspirin to reduce their bowel cancer risk. We trialled a decision aid in general practice to facilitate the implementation of these guidelines into clinical practice. This publication reports on the qualitative results from the process evaluation of the trial. We aimed to explore general practitioners' (GPs) and their patients' approach to shared decision-making (SDM) about taking aspirin to prevent bowel cancer and how the decision aids were used in practice.

METHODS

Semistructured interviews were conducted with 17 participants who received the decision aid and 12 GPs who participated in the trial between June and November 2021. The interviews were coded inductively, and emerging themes were mapped onto the Revised Programme Theory for SDM.

RESULTS

The study highlighted the dynamics of SDM for taking aspirin to prevent bowel cancer. Some participants discussed the decision aid with their GPs as advised prior to taking aspirin, others either took aspirin or dismissed it outright without discussing it with their GPs. Notably, participants' trust in their GPs, and participants' diverse worldviews played pivotal roles in their decisions. Although the decision aid supported SDM for some, it was not always prioritised in a consultation. This was likely impacted during the trial period as the COVID-19 pandemic was the focus for general practice.

CONCLUSION

In summary, this study illustrated the complexities of SDM through using a decision aid in general practice to implement the guidelines for low-dose aspirin to prevent bowel cancer. While the decision aid prompted some participants to speak to their GPs, they were also heavily influenced by their unwavering trust in the GPs and their different worldviews. In the face of the COVID-19 pandemic, SDM was not highly prioritised. This study provides insights into the implementation of guidelines into clinical practice and highlights the need for ongoing support and prioritisation of cancer prevention in general practice consultations.

TRIAL REGISTRATION NUMBER

ACTRN12620001003965.

Piloting a shared decision-making clinician training intervention in maternity care in Australia: A mixed methods study

PROBLEM

Implementation of woman-centred care in evidence-based maternity practice requires clinicians to be skilled in shared decision-making, yet there is limited training or research into such interventions.

BACKGROUND

Shared decision-making enables women to make informed decisions in partnership with clinicians where there are varied clinical options in relation to indications for and timing of planned birth.

AIM

We aimed to develop a shared decision-making training intervention and evaluate its feasibility and acceptability to midwives and obstetricians.

METHODS

The intervention was co-designed by midwifery and medical clinician-researchers, and a consumer representative. Online training and demonstration videos were distributed to midwives and obstetricians in three Sydney hospitals, followed by two online workshops in 2021 and 2022 where participants practised shared decision-making in roleplaying scenarios tailored to timing of birth. Training was evaluated using post-workshop and post-training surveys and semi-structured qualitative interviews.

FINDINGS

The training workshop format, duration and content were well received. Barriers to the uptake of shared decision-making were time, paternalistic practices and fear of repercussions of centring women in the decision-making process.

DISCUSSION

The intervention enabled midwifery and medical colleagues to learn communication repertoires from each other in woman-centred discussions around timing of birth. Roleplay scenarios enabled participants to observe and provide feedback on their colleagues' shared decision-making practices, while providing a space for collective reflection on ways to promote, and mitigate barriers to, its implementation in practice.

CONCLUSION

Shared decision-making training supports maternity clinicians in developing skills that implement woman-centred care in the timing of planned birth.

Finding Your Way - A shared decision making resource developed by and for Aboriginal people in Australia: Perceived acceptability, usability, and feasibility

BACKGROUND

Finding Your Way is a culturally adapted shared decision making (SDM) resource for Aboriginal (First Nations) people of Australia. It integrates the Eight Ways of Aboriginal Learning (8 Ways) and was created by Aboriginal health workers and community members in New South Wales (NSW), Australia.

OBJECTIVE

To explore the perceived acceptability, usability, and feasibility of Finding Your Way as a SDM resource for Aboriginal people making health and wellbeing decisions.

METHODS

The web-based resources were disseminated using social media, professional networks, publications, and the 'Koori grapevine'. Thirteen 'champions' also promoted the resources. An online questionnaire was available on the website for three months. Framework analysis determined early indications of its acceptability, usability, and feasibility. Web and social media analytics were also analysed. Partnership with and leadership by Aboriginal people was integrated at all phases of the project.

RESULTS

The main landing page was accessed 5219 times by 4259 users. 132 users completed the questionnaire. The non-linear and visual aspects of the resources 'speak to mob' and identified with Aboriginal culture. The inclusion of social and emotional well-being, and the holistic approach were well received by the small number of users who opted to provide feedback. They suggested that non-digital formats and guidance on the resources are required to support use in clinical practice.

CONCLUSION

The 8 Ways enabled the development of a culturally safe SDM resource for Aboriginal people, which was well received by users who took the time to provide feedback after a brief dissemination process. Additional accessible formats, practice guides and training are required to support uptake in clinical practice.

PRACTICE IMPLICATIONS

Finding Your Way could be used to help improve experiences, health literacy, decision making quality and outcomes of healthcare for Aboriginal Australians.

Preferences for deprescribing antihypertensive medications amongst clinicians, carers and people living with dementia: a discrete choice experiment

BACKGROUND

Optimal management of hypertension in people with dementia may involve deprescribing antihypertensives. Understanding differing treatment priorities is important to enable patient-centred care. This study explored preferences for antihypertensive deprescribing amongst people living with dementia, carers and clinicians.

METHODS

Discrete choice experiments (DCEs) are a stated preference survey method, underpinned by economic theory. A DCE was conducted, and respondents completed 12 labelled choice-questions, each presenting a status quo (continuing antihypertensives) and antihypertensive deprescribing option. The questions included six attributes, including pill burden, and event risks for stroke, myocardial infarction, increased blood pressure, cognitive decline, falls.

RESULTS

Overall, 112 respondents (33 carers, 19 people living with dementia, and 60 clinicians) completed the survey. For people with dementia, lower pill burden increased preferences for deprescribing (odds ratio (OR) 1.95, 95% confidence interval (95% CI) 1.08-3.52). Increased stroke risk (for each additional person out of 100 having a stroke) decreased the likelihood of deprescribing for geriatricians (OR 0.71, 95% CI 0.55-0.92) and non-geriatrician clinicians (OR 0.62, 95% CI 0.45-0.86), and carers (OR 0.71, 95% CI 0.58-0.88). Increased myocardial infarction risk decreased preferences for deprescribing for non-geriatricians (OR 0.81, 95% CI 0.69-0.95) and carers (OR 0.84, 95% CI 0.73-0.98). Avoiding cognitive decline increased preferences for deprescribing for geriatricians (OR 1.17, 95% CI 1.03-1.33) and carers (OR 1.27, 95% CI 1.09-1.48). Avoiding falls increased preferences for deprescribing for clinicians (geriatricians (OR 1.20, 95% CI 1.11-1.29); non-geriatricians (OR 1.16, 95% CI 1.07-1.25)). Other attributes did not significantly influence respondent preferences.

CONCLUSIONS

Antihypertensive deprescribing preferences differ amongst people with dementia, carers and clinicians. The study emphasises the importance of shared decision-making within the deprescribing process.

"The Terminology Might Be Ahead of Practice": Embedding Shared Decision Making in Practice-Barriers and Facilitators to Implementation of SDM in the Context of Maternity Care

Background. It is a patient's right to be included in decisions about their health care. Implementing shared decision making (SDM) is important to enable active communication between clinicians and patients. Although health policy makers are increasingly mandating SDM implementation, SDM adoption has been slow. This study explored stakeholders' organizational- and system-level barriers and facilitators to implementing policy mandated SDM in maternity care in Victoria, Australia. Method. Twenty-four semi-structured interviews were conducted with participants including clinicians, health service administrators and decision makers, and government policy makers. Data were mapped to the Theoretical Domains Framework to identify barriers and facilitators to SDM implementation. Results. Factors identified as facilitating SDM implementation included using a whole-of-system approach, providing additional implementation resources, correct documentation facilitated by electronic medical records, and including patient outcomes in measurement. Barriers included health service lack of capacity, unclear policy definitions of SDM, and policy makers' lack of resources to track implementation. Conclusion. This is the first study to our knowledge to explore barriers and facilitators to SDM implementation from the perspective of multiple actors following policy mandating SDM in tertiary health services in Australia. The primary finding was that there are concerns that SDM implementation policy is outpacing practice. Nonclinical staff play a crucial role translating policy to practice. Addressing organizational- and system-level barriers and facilitators to SDM implementation should be a key concern of health policy makers, health services, and staff.

Highlights

New government policies require shared decision making (SDM) implementation in hospitals.There is limited evidence for how to implement SDM in hospital settings.There are concerns SDM implementation policy is outpacing practice.Understanding and capacity for SDM varies considerably among stakeholders.Whole of system approaches and electronic medical records are seen to facilitate SDM.

Advance care plans for vulnerable and disadvantaged adults: systematic review and narrative synthesis

BACKGROUND

Evidence suggests that there is a gap in advance care planning (ACP) completion between vulnerable and disadvantaged populations compared with the general population. This review seeks to identify tools, guidelines or frameworks that have been used to support ACP interventions with vulnerable and disadvantaged adult populations as well as their experiences and outcomes with them. The findings will inform practice in ACP programmes.

METHODS

A systematic search of six databases from 1 January 2010 to 30 March 2022 was conducted to identify original peer-reviewed research that used ACP interventions via tools, guidelines or frameworks with vulnerable and disadvantaged adult populations and reported qualitative findings. A narrative synthesis was conducted.

RESULTS

Eighteen studies met the inclusion criteria. Relatives, caregivers or substitute decision-makers were included in eight studies.

SETTINGS

hospital outpatient clinics (N=7), community settings (N=7), nursing homes (N=2), prison (N=1) and hospital (N=1). A variety of ACP tools, guidelines or frameworks were identified; however, the facilitator's skills and approach in delivering the intervention appeared to be as important as the intervention itself. Participants indicated mixed experiences, some positive, some negative and four themes emerged: uncertainty, trust, culture and decision-making behaviour. The most common descriptors relating to these themes were prognosis uncertainty, poor end-of-life communication and the importance of building trust.

CONCLUSION

The findings indicate that ACP communication could be improved. ACP conversations should incorporate a holistic and personalised approach to optimise efficacy. Facilitators should be equipped with the necessary skills, tools and information needed to assist ACP decision-making.

Assessing the impact of patient-involvement healthcare strategies on patients, providers, and the healthcare system: A systematic review

BACKGROUND

Patient involvement has become an important and lively field of research, yet existing findings are fragmented and often contested. Without a synthesis of the research field, these findings are of limited use to scholars, healthcare providers, or policy-makers.

OBJECTIVE

Examine the body of knowledge on patient involvement to determine what is known, contested, and unknown about benefits, risks, and effective implementation strategies.

PATIENT INVOLVEMENT

Patients were not involved.

METHODS

Systematic literature review of 99 journal articles using a conceptual model integrating three levels: health systems, health providers, and patients. We extracted individual research findings and organized them into the structure of our model to provide a holistic picture of patient involvement.

RESULTS

The review highlights overlaps and conflicts between various patient involvement approaches. Our results show benefits for individual patients and the health system as a whole. At the provider level, however, we identified clear barriers to patient involvement.

DISCUSSION

Patient involvement requires collaboration among health systems, healthcare providers, and patients. We showed that increasing patient responsibility and health literacy requires policy-maker interventions. This includes incentives for patient education by providers, adapting medical education curricula, and building a database of reliable health information and decision support for patients. Furthermore, policies supporting a common infrastructure for digital health data and managed patient data exchange will foster provider collaboration.

PRACTICAL VALUE

Our review shows how an approach integrating health systems, healthcare providers, and patients can make patient involvement more effective than isolated interventions. Such systematic patient involvement is likely to improve population health literacy and healthcare quality.