Instruments to assess the perception of physicians in the decision-making process of specific clinical encounters: a systematic review

Shared decision-making performance of general practice residents: an observational study combining observer, resident, and patient perspectives

BACKGROUND

Shared decision making (SDM) is considered fundamental to person-centred care. However, applying SDM may be a challenge for residents in general practice, since it is a complex competence that requires the integration of knowledge and skills from several competency domains.

OBJECTIVE

To support learning of SDM during medical residency, we aimed to gain insight in Dutch residents' observed and perceived SDM performance in general practice.

METHODS

We evaluated residents' SDM performance from an observer, resident, and patient perspective. Consultations of first- and third-year residents were recorded. Trained observers used the validated Observing Patient Involvement (OPTION5) scale to assess observed SDM performance of residents in 98 actual recorded consultations. Perceived SDM performance was evaluated by residents and patients completing validated SDM questionnaires, supplemented with questions about (the context of) the consultation and perceived relevance of SDM immediately after the consultation. The data were analysed using descriptive statistics (mean, SD, minimums, and maximums) and explorative bivariate analyses.

RESULTS

The residents' observed mean SDM performance was 19.1 (range, 0-100, SD = 10.9), mean resident self-reported SDM performance was 56.9 (range, 0-100, SD = 18.5), and mean patient-reported SDM performance was 73.3 (range, 0-100, SD = 26.8). We found a significant and positive correlation between observed SDM performance and residents' perceived relevance of SDM for the consultation (t = 4.571, P ≤ 0.001) and the duration of the consultation (r = 0.390, P ≤ 0.001).

CONCLUSIONS

This study showed that there is room for increasing awareness of the potential incongruence between observed and perceived SDM performance during medical residency, in order to facilitate the implementation of SDM in clinical practice.

Development and validation of the provider assessed quality of consultations with language interpretation scale (PQC-LI)

OBJECTIVE

With the growing immigrant communities in the western world, there is an urgent need to address language barriers to care, and health disparities as a whole. Studies on limited English proficiency patients (LEP) have focused on patient perspectives of office visits, however little is known about health care provider perspectives of medical visits using interpretive services. We aimed to develop a pragmatic brief questionnaire for assessing providers' views of the quality of communication in outpatient visits with patients with LEP. The questionnaire was validated in a cross-sectional study (n = 99) using principal component analyses (PCA) with oblimin rotation. Internal consistency was analyzed using Cronbach's alpha.

RESULTS

Based on theory and literature, a seven-item scale was developed that captures two relevant concepts: (1) Provider - patient interaction during the consultation and (2) perceived quality of translation. The questionnaire was used to assess 99 LEP consultations and demonstrated good feasibility in a clinical setting. PCA revealed the two theory-based components with good factor loadings and internal consistency of α = 0.77. These preliminary results indicate that the questionnaire provides medical professionals with a validated tool to evaluate LEP patient encounters. Further confirmatory validation of the Provider-assessed Quality of Consultations with Language Interpretation (PQC-LI) in larger samples is warranted.

The work of having a chronic condition: development and psychometric evaluation of the distribution of co-care activities (DoCCA) scale

BACKGROUND

Chronic care involves multiple activities that can be performed by individuals and healthcare staff as well as by other actors and artifacts, such as eHealth services. Thus, chronic care management can be viewed as a system where the individual interacts with people and eHealth services performing activities to maintain or improve health and functioning, called co-care. Yet, the system perspective is not reflected in concepts such as person-centered care and shared decision making. This limits the understanding of individuals' global experience of chronic care management and subsequently the ability to optimize chronic care. The aim of this study was threefold: (1) to propose a theory-based operationalization of co-care for chronic care management, (2) to develop a scale to measure co-care as a distributed system of activities, and (3) to evaluate the scale's psychometric properties. With the theory of distributed cognition as a theoretical underpinning, co-care was operationalized along three dimensions: experience of activities, needs support, and goal orientation.

METHODS

Informed by the literature on patient experiences and work psychology, a scale denoted Distribution of Co-Care Activities (DoCCA) was developed with the three conceptualized dimensions, the activities dimension consisting of three sub-factors: demands, unnecessary tasks, and role clarity. It was tested with 113 primary care patients with chronic conditions in Sweden at two time points.

RESULTS

A confirmatory factor analysis showed support for a second-order model with the three conceptualized dimensions, with activities further divided into the three sub-factors. Cronbach's alpha values indicated a good to excellent reliability of the subscales, and correlations across time points with panel data indicated satisfactory test-retest reliability. Convergent, concurrent and predictive validity of the scale were, overall, satisfactory.

CONCLUSIONS

The psychometric evaluation supports a model consisting of activities (demands, unnecessary tasks, and role clarity), needs support and goal orientation that can be reliably measured with the DoCCA scale. The scale provides a way to assess chronic care management as a system, considering the perspective of the individuals with the chronic condition and how they perceive the work that must be done, across situations, either by themselves or through healthcare, eHealth, or other means.

Cesarean Delivery and Gender of Delivering Physicians: A Systematic Review and Meta-analysis

OBJECTIVE

To assess the association of the gender of the delivering physician and the odds of performing cesarean delivery.

DATA SOURCES

CINAHL, ClinicalTrials.gov, Cochrane Library, PubMed, Scopus and Web of Science from the first year of records through May 2020.

METHODS OF STUDY SELECTION

We included studies that reported odds ratios (OR), or data allowing the calculation of ORs, for cesarean delivery performed by female and male delivering physicians. We also included studies that reported the preference of physicians for performing cesarean deliveries.

TABULATION, INTEGRATION, AND RESULTS

Independent data extraction was carried out by at least two researchers. Standard inverse-variance random effects meta-analysis was used to generate overall ORs. Finally, in two separate meta-analyses, we analyzed 15 studies containing clinical data for 1,269,625 births, and 11 studies containing data for the preference for delivery mode of 4,911 obstetricians. Both the crude and adjusted odds of a cesarean delivery were lower for those performed by female physicians (crude OR 0.75, 95% CI 0.68-0.84, τ=0.029, adjusted OR 0.74, 95% CI 0.65-0.85, τ=0.031). We also found that female physicians had a lower preference for cesarean delivery in both crude and adjusted analysis (crude OR 0.59, 95% CI 0.36-0.96, I=77%, adjusted OR 0.58, 95% CI 0.40-0.84, I=67%).

CONCLUSION

Female physicians are less likely to perform cesarean delivery and less likely to prefer it. This was observed across different health systems and populations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42020158442.

Measuring clinical uncertainty and equipoise by applying the agreement study methodology to patient management decisions

Background

Clinical uncertainty and equipoise are vague notions that play important roles in contemporary problems of medical care and research, including the design and conduct of pragmatic trials. Our goal was to show how the reliability study methods normally used to assess diagnostic tests can be applied to particular management decisions to measure the degree of uncertainty and equipoise regarding the use of rival management options.

Methods

We first use thrombectomy in acute stroke as an illustrative example of the method we propose. We then review, item by item, how the various design elements of diagnostic reliability studies can be modified in order to measure clinical uncertainty.

Results

The thrombectomy example shows sufficient disagreement and uncertainty to warrant the conduct of additional randomized trials. The general method we propose is that a sufficient number of diverse individual cases sharing a similar clinical problem and covering a wide spectrum of clinical presentations be assembled into a portfolio that is submitted to a variety of clinicians who routinely manage patients with the clinical problem.

Discussion

Clinicians are asked to independently choose one of the predefined management options, which are selected from those that would be compared within a randomized trial that would address the clinical dilemma. Intra-rater agreement can be assessed at a later time with a second evaluation. Various professional judgments concerning individual patients can then be compared and analyzed using kappa statistics or similar methods. Interpretation of results can be facilitated by providing examples or by translating the results into clinically meaningful summary sentences.

Conclusions

Measuring the uncertainty regarding management options for clinical problems may reveal substantial disagreement, provide an empirical foundation for the notion of equipoise, and inform or facilitate the design/conduct of clinical trials to address the clinical dilemma.

Measuring shared decision-making and collaborative goal setting in community rehabilitation: a focused ethnography using cross-sectional surveys in Canada

OBJECTIVE

To describe and measure the shared decision-making (SDM) experience, including goal-setting experiences, from the perspective of patients and providers in diverse community-rehabilitation settings.

DESIGN

Prospective, longitudinal surveys.

SETTING

13 primary level-of-care community-rehabilitation sites in diverse areas varying in geography, patient population and provider discipline341 adult, English-speaking patient-participants, and 66 provider-participants.

MEASURES

Alberta Shared decision-maKing Measurement Instrument (dyadic tool measuring SDM), WatLX (outpatient rehabilitation experience) and demographic questionnaire. Survey packages distributed at two timepoints (T0=recruitment; T1=3 months later).

RESULTS

We found that among 341 patient-provider dyads, 26.4% agreed that the appointment at recruitment involved high-quality SDM. Patient perceptions of goal-setting suggested that 19.6% of patients did not set a goal for their care, and only 11.4% set goals in functional language that tied directly to an activity/role/responsibility that was meaningful to their life. Better SDM was clinically associated with higher total family income (p=0.045).

CONCLUSIONS

These findings provide evidence for the importance of SDM and goal setting in community rehabilitation. Among patients, lower ratings of SDM corresponded with less recognition of their preferences. Actionable strategies include supporting financially vulnerable patients in realising SDM through training of providers to make extra space for such patients to share their preferences and better preparing patients to articulate their preferences. We recommend more research into strategies that advance highly functional goal setting with patients, and that lessen survey ceiling effects.

Patient Satisfaction With Decision Making Does Not Correlate With Patient Centeredness of Surgeons

BACKGROUND

High-quality decision making is important in patient-centered care. Although patient involvement in decision making varies widely, most patients desire to share in decision making. The Press-Ganey Patient Satisfaction survey includes questions that measure patients' perceptions of their providers' efforts to involve them in decision making (PGDM). We hypothesized that higher PGDM scores would correlate with higher scores on a validated measure of patient centeredness.

MATERIALS AND METHODS

Surgical providers at a university hospital who routinely receive Press-Ganey scores received a survey that included the Patient-Practitioner Orientation Scale (PPOS), a validated tool that measures the provider's orientation toward patient centeredness on a continuous six-point scale: score ≥5 = high, 4.57-5 = moderate, and <4.57 = low and includes nine-item "caring" or "sharing" subscales. We compared PPOS scores to PGDM scores, averaged from April 2015 to January 2016.

RESULTS

Eighty-six of 112 (75%) of surgical providers responded to the survey. Fifty-two (46%) had PGDM scores available and 26% achieved a perfect score on the PGDM. The overall PPOS scores were low, with a mean of 4.2 (SD = 0.5). The PPOS was not correlated with the PGDM, correlation coefficient (rs) = -0.07 (CI: -0.34-0.21, P = 0.63). Similarly, the two subscales of the PPOS did not correlate with the PGDM with rs = -0.15 (CI: -0.41-0.13, P = 0.29) for "caring" and rs = -0.04 (CI: -0.31-0.23, P = 0.76) for "sharing".

CONCLUSIONS

Although surgical providers scored low in patient centeredness using the PPOS, over one-quarter (26%) of them rank in the top 1% on the PGDM. No correlation was found between providers' patient centeredness and their patients' perceptions of efforts to include them in decision making.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICE IMPLICATIONS

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

Development of a "Patient Rights" Subscale to Measure Informed Decision-Making Within the Dyadic Decisional Conflict Scale for Obstetric Care

BACKGROUND AND PURPOSE

A modified Dyadic Decisional Conflict Scale (D-DCS) and new Patient Rights subscale to measure perceptions of informed decision-making regarding use of epidural analgesia during childbirth are tested.

METHODS

Thirty-five primiparous women and 52 providers from three hospitals tested the modified instrument. Cronbach's α coefficient assessed reliability. Mokken scale, principal components, and correlation analyses assessed unidimensionality of subscales.

RESULTS

Internal reliability was demonstrated for the D-DCS-Patient (Cronbach's α = 0.846) and D-DCS-Provider (α = 0.888). Further analyses suggest the Patient Rightssubscale has potential to make a unique contribution to the D-DCS.

CONCLUSIONS

The modified D-DCS and Patient Rights subscale allow for a more comprehensive study of informed healthcare decision-making that includes legal and ethical elements, which may aid development of targeted interventions to improve decision-making.

Assessment of attitudes and targeted educational needs for refugee care providers in a Ugandan hospital

OBJECTIVES

To evaluate medical trainees' attitudes toward refugee patients in a refugee host country, and to identify educational needs.

METHODS

A 54-question cross-sectional questionnaire was administered to a convenience sample of 81 post-graduate medical trainees at Mbarara Regional Referral Hospital, Uganda, in 2016. Descriptive statistics on medical trainees' attitudes and educational needs regarding care for refugees were calculated. One-way ANOVA was used to assess relationships between an attitude scale and respondent characteristics. Reliability and validity of the survey items and attitude scale were assessed using Cronbach's alpha, item-to-scale correlation, and factor analysis.

RESULTS

The mean score on the attitude scale of 2.8 (SD=1.7) indicated positive attitudes toward refugees. All respondents had contact with refugees, and 89% (n=72) reported a need for further training. Many specifically indicated the need for training in use of translators, support personnel, and behavioral health.  Cronbach's alpha values of greater than 0.7 indicated good internal consistency. Item-to-scale correlation and factor analysis validate the use of an attitude scale. ANOVA showed no significant difference between mean attitude scores in gender (F_(1,77)=0.11, p=0.7367), country of origin (F_(1.78) =0.53, p=0.8723), or year of study (F_{(4,74) =}0.31, p=0.8273).

CONCLUSIONS

Medical trainees in Uganda report positive attitudes toward refugees and a need for additional education in refugee care in multiple specific areas. This study piloted the use of an attitude scale for refugee healthcare providers with promising validity and reliability. Use of these questions could inform curriculum development in refugee host countries.

Timing of Intubation in Acute Respiratory Failure Associated With Sepsis: A Mixed Methods Study

OBJECTIVE

To analyze bedside clinicians' perspectives regarding the decision process to optimize timing of intubation in sepsis-associated acute respiratory failure.

PARTICIPANTS AND METHODS

This mixed methods study was conducted from March 1, 2015, through June 30, 2016. Using qualitative research methods, factors that influenced variability in the decision to intubate were organized into categories and used to build a theoretical explanatory model grounded in current practice variance. All coding schemes were independently reviewed for accuracy and consistency. Themes and findings were then refined with member checking by feedback from individuals and from an anonymous questionnaire until saturation was achieved.

RESULTS

The practice of intubation varied according to 3 domains: (1) patient factors included the nature of the acute illness, comorbidities, clinical presentation, severity, trajectory, and values and preferences; (2) clinician factors included background, training, experience, and practice style; and (3) system factors included workload, policies and protocols, hierarchy, communications, culture, and team dynamics. In different contexts, intubation was considered early (elective), just in time (urgent), or late (rescue). The initial assessment, initial decision, and reassessment mattered.

CONCLUSION

Recognizing that the variability in both the decision to intubate and its timing depends on many factors, and not on clinical criteria alone, should render the clinician more attentive to the eventual progression of the acute respiratory failure.

Validation of SDM-Q-Doc Questionnaire to measure shared decision-making physician's perspective in oncology practice

OBJECTIVE

The aim of this study was to analyze the psychometric properties of the Shared Decision-Making Questionnaire-Physician version (SDM-Q-Doc) in a sample of medical oncologists who provide adjuvant treatment to patients with non-metastatic resected cancer and the correlations between the total SDM-Q-Doc score and physician satisfaction with the information provided.

METHODS

Prospective, observational and multicenter study in which 32 medical oncologists and 520 patients were recruited. The psychometric properties, dimensionality, and factor structure of the SDM-Q-Doc were assessed.

RESULTS

Exploratory factor analyses suggested that the most likely solution was two-dimensional, with two correlated factors: one factor regarding information and another one about treatment. Confirmatory factor analysis based on cross-validation showed that the fitted two-dimensional solution provided the best fit to the data. Reliability analyses revealed good accuracy for the derived scores, both total and sub-scale, with estimates ranging from 0.81 to 0.89. The results revealed significant correlations between the total SDM-Q-Doc score and physician satisfaction with the information provided (p < 0.01); between information sub-scale scores (factor 1) and satisfaction (p < 0.01), and between treatment sub-scale scores (factor 2) and satisfaction (p < 0.01). Medical oncologists of older age and those with more years of experience showed more interest in the patient preferences (p = 0.026 and p = 0.020, respectively). Patient age negatively correlated with SDM information (p < 0.01) and physicians appear to provide more information to young patients.

CONCLUSION

SDM-Q-Doc showed good psychometric properties and could be a helpful tool that examines physician's perspective of SDM and as an indicator of quality and satisfaction in patients with cancer.

Tracing the decision-making process of physicians with a Decision Process Matrix

Background

Decision-making processes in a medical setting are complex, dynamic and under time pressure, often with serious consequences for a patient’s condition.

Objective

The principal aim of the present study was to trace and map the individual diagnostic process of real medical cases using a Decision Process Matrix [DPM]).

Methods

The naturalistic decision-making process of 11 residents and a total of 55 medical cases were recorded in an emergency department, and a DPM was drawn up according to a semi-structured technique following four steps: 1) observing and recording relevant information throughout the entire diagnostic process, 2) assessing options in terms of suspected diagnoses, 3) drawing up an initial version of the DPM, and 4) verifying the DPM, while adding the confidence ratings.

Results

The DPM comprised an average of 3.2 suspected diagnoses and 7.9 information units (cues). The following three-phase pattern could be observed: option generation, option verification, and final diagnosis determination. Residents strove for the highest possible level of confidence before making the final diagnoses (in two-thirds of the medical cases with a rating of practically certain) or excluding suspected diagnoses (with practically impossible in half of the cases).

Discussion

The following challenges have to be addressed in the future: real-time capturing of emerging suspected diagnoses in the memory of the physician, definition of meaningful information units, and a more contemporary measurement of confidence.

Conclusions

DPM is a useful tool for tracing real and individual diagnostic processes. The methodological approach with DPM allows further investigations into the underlying cognitive diagnostic processes on a theoretical level and improvement of individual clinical reasoning skills in practice.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The clinical decision analysis using decision tree

The clinical decision analysis (CDA) has used to overcome complexity and uncertainty in medical problems. The CDA is a tool allowing decision-makers to apply evidence-based medicine to make objective clinical decisions when faced with complex situations. The usefulness and limitation including six steps in conducting CDA were reviewed. The application of CDA results should be done under shared decision with patients' value.

Validation of the Spanish version of the 9-item Shared Decision-Making Questionnaire

OBJECTIVE

To translate and assess the psychometric properties of the 9-item Shared Decision-Making Questionnaire (SDM-Q-9) for measuring patients' perceptions of how clinicians' performance fits the SDM process.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Data were collected in primary care health centres. Patients suffering from chronic diseases and facing a medical decision were included in the study.

MEASUREMENTS

The original German SDM-Q-9 was translated to Spanish using the process of cross-cultural adaptation of self-reported measures as the methodological model for Spanish translation. Reliability (internal consistency) and construct validity [exploratory (EFA) and confirmatory factor analysis (CFA)] were assessed.

RESULTS

The final Spanish version of the SDM-Q-9 was tested in a primary care sample of 540 patients. The SDM-Q-9 presented adequate reliability and acceptable validity. Internal consistency yielded a Cronbach's alpha of 0.885 for the whole scale. EFA showed a two-factorial solution, and for the CFA, the best solution was obtained with a one-dimensional factor with the item 1 excluded, which produced the best indexes of fit.

DISCUSSION AND CONCLUSIONS

The Spanish version of the SDM-Q-9 showed adequate reliability and acceptable validity parameters among primary care patients. The SDM-Q-9 is suitable for use in Spain and other Spanish-speaking countries with similarly organized health-care systems. The use of the SDM-Q-9 may contribute to the evaluation of SDM process from the patient's perspective.

Shared decision-making behaviours in health professionals: a systematic review of studies based on the Theory of Planned Behaviour

Background

Shared decision making (SDM) requires health professionals to change their practice. Socio‐cognitive theories, such as the Theory of Planned Behaviour (TPB), provide the needed theoretical underpinnings for designing behaviour change interventions.

Objective

We systematically reviewed studies that used the TPB to assess SDM behaviours in health professionals to explore how theory is being used to explain influences on SDM intentions and/or behaviours, and which construct is identified as most influential.

Search strategy

We searched PsycINFO, MEDLINE, EMBASE, CINAHL, Index to theses, Proquest dissertations and Current Contents for all years up to April 2012.

Inclusion criteria

We included all studies in French or English that used the TPB and related socio‐cognitive theories to assess SDM behavioural intentions or behaviours in health professionals. We used Makoul & Clayman's integrative SDM model to identify SDM behaviours.

Data extraction and synthesis

We extracted study characteristics, nature of the socio‐cognitive theory, SDM behaviour, and theory‐based determinants of the SDM behavioural intention or behaviour. We computed simple frequency counts.

Main results

Of 12 388 titles, we assessed 136 full‐text articles for eligibility. We kept 20 eligible studies, all published in English between 1996 and 2012. Studies were conducted in Canada (n = 8), the USA (n = 6), the Netherlands (n = 3), the United Kingdom (n = 2) and Australia (n = 1). The determinant most frequently and significantly associated with intention was the subjective norm (n = 15/21 analyses).

Discussion

There was great variance in the way socio‐cognitive theories predicted SDM intention and/or behaviour, but frequency of significance indicated that subjective norm was most influential.

Participation of very old adults in health care decisions

BACKGROUND

Some elderly people receive tests or interventions from which they have low likelihood of benefit or for which the goal is not aligned with their values. Engaging these patients in the decision process is one potential approach to improve the individualization of care. Yet some clinicians perceive and some survey data suggest that older adults prefer not to participate in the decision-making process. Those preferences, however, may be formed based on an experience in which factors, such as communication issues, were barriers to participation. Our goal was to shed light on the experience of very old adults in health care decision making from their own point of view to deepen our understanding of their potentially modifiable barriers to participation.

DESIGN

and

METHODS

Semistructured interviews of participants aged 80 and older (n = 29, 59% women and 21% black) were analyzed using the constant comparative method in a grounded theory approach to describe decision making in clinic visits from the patient's perspective.

RESULTS

The average age was 84 years (range, 80-93); each described an average of 6.4 decision episodes. Active participation was highly variable among subjects. Marked differences in participation across participants and by type of decision--surgery, medications, diagnostic procedures, routine testing for preventive care--highlighted barriers to greater participation. The most common potentially modifiable barriers were the perception that there were no options to consider, low patient activation, and communication issues.

CONCLUSIONS

The experience of very old adults highlights potentially modifiable barriers to greater participation in decision making. To bring very old patients into the decision process, clinicians must modify interviewing skills and spend additional time eliciting their values, goals, and preferences.

Patient preference for involvement, experienced involvement, decisional conflict, and satisfaction with physician: a structural equation model test

Background

A comprehensive model of the relationships among different shared decision-making related constructs and their effects on patient-relevant outcomes is largely missing. Objective of our study was the development of a model linking decision-making in medical encounters to an intermediate and a long-term endpoint. The following hypotheses were tested: physicians are more likely to involve patients who have a preference for participation and are willing to take responsibility in the medical decision-making process, increased patient involvement decreases decisional conflict, and lower decisional conflict favourably influences patient satisfaction with the physician.

Methods

This model was tested in a German primary care sample (N = 1,913). Psychometrically tested instruments were administered to assess the following: patients’ preference for being involved in medical decision-making, patients’ experienced involvement in medical decision-making, decisional conflict, and satisfaction with the primary care provider. Structural equation modelling was used to explore multiple associations. The model was tested and adjusted in a development sub-sample and cross-validated in a confirmatory sample. Demographic and clinical characteristics were accounted for as possible confounders.

Results

Local and global indexes suggested an acceptable fit between the theoretical model and the data. Increased patient involvement was strongly associated with decreased decisional conflict (standardised regression coefficient Β = −.73). Both high experienced involvement (Β = .34) and low decisional conflict (B = -.28) predicted higher satisfaction with the physician. Patients’ preference for involvement was negatively associated with the experienced involvement (B = −.24).

Conclusion

Altogether, our model could be largely corroborated by the collected empirical data except the unexpected negative association between preference for involvement and experienced involvement. Future research on the associations among different SDM-related constructs should incorporate longitudinal studies in order to strengthen the hypothesis of causal associations.

Clinician-patient agreement about the work disability problem of patients having persistent pain: why it matters

BACKGROUND

Studies from different fields documenting the differences between clinicians' and workers' representations have not elucidated where the differences exist or how they can be resolved.

PURPOSE

To define and describe scenarios depicting the differences between clinical judgment, workers' representations about their disability and clinicians' interpretations of these representations.

METHODS

A multiple case-study design was used. Semi-structured prospective interviews were conducted at four points in time, with five clinicians managing 12 cases of workers having persistent pain and participating in an evidence-based work rehabilitation program.

RESULTS

Four scenarios depicting differences in representations were found, but not all the differences necessarily had a negative impact on the program outcomes. For the clinicians, clear identification of the problem was important to allow for the use of concrete, pragmatic strategies. For the workers, congruence between the proposed strategy and their representations was crucial.

CONCLUSION

During rehabilitation, the objectives must be acceptable to both parties or the proposed strategy must, at least, make sense to the patient.

Development and psychometric properties of a five-language multiperspective instrument to assess clinical decision making style in the treatment of people with severe mental illness (CDMS)

BACKGROUND

The aim of this study was to develop and evaluate psychometric properties of the Clinical Decision Making Style (CDMS) scale which measures general preferences for decision making as well as preferences regarding the provision of information to the patient from the perspectives of people with severe mental illness and staff.

METHODS

A participatory approach was chosen for instrument development which followed 10 sequential steps proposed in a current guideline of good practice for the translation and cultural adaptation of measures. Following item analysis, reliability, validity, and long-term stability of the CDMS were examined using Spearman correlations in a sample of 588 people with severe mental illness and 213 mental health professionals in 6 European countries (Germany, UK, Italy, Denmark, Hungary, and Switzerland).

RESULTS

In both patient and staff versions, the two CDMS subscales "Participation in Decision Making" and "Information" reliably measure distinct characteristics of decision making. Validity could be demonstrated to some extent, but needs further investigation.

CONCLUSIONS

Together with two other five-language patient- and staff-rated measures developed in the CEDAR study (ISRCTN75841675) - "Clinical Decision Making in Routine Care" and "Clinical Decision Making Involvement and Satisfaction" - the CDMS allows empirical investigation of the complex relation between clinical decision making and outcome in the treatment of people with severe mental illness across Europe.

Comparing the nine-item Shared Decision-Making Questionnaire to the OPTION Scale - an attempt to establish convergent validity

BACKGROUND

While there has been a clear move towards shared decision-making (SDM) in the last few years, the measurement of SDM-related constructs remains challenging. There has been a call for further psychometric testing of known scales, especially regarding validity aspects.

OBJECTIVE

To test convergent validity of the nine-item Shared Decision-Making Questionnaire (SDM-Q-9) by comparing it to the OPTION Scale.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Data were collected in outpatient care practices. Patients suffering from chronic diseases and facing a medical decision were included in the study.

METHODS

Consultations were evaluated using the OPTION Scale. Patients completed the SDM-Q-9 after the consultation. First, the internal consistency of both scales and the inter-rater reliability of the OPTION Scale were calculated. To analyse the convergent validity of the SDM-Q-9, correlation between the patient (SDM-Q-9) and expert ratings (OPTION Scale) was calculated.

RESULTS

A total of 21 physicians provided analysable data of consultations with 63 patients. Analyses revealed good internal consistency of the SDM-Q-9 and limited internal consistency of the OPTION Scale. Inter-rater reliability of the latter was less than optimal. Association between the total scores of both instruments was weak with a Spearman correlation of r = 0.19 and did not reach statistical significance.

DISCUSSION

By the use of the OPTION Scale convergent validity of the SDM-Q-9 could not be established. Several possible explanations for this result are discussed.

CONCLUSION

This study shows that the measurement of SDM remains challenging.

Decision Support for Patients

Providing a patient with decision support involves helping that person to choose among two or more elective health care options. “Values Clarification” and “Preference Elicitation” are integral to the full decision-support process. During values clarification, the patient and clinician gain insight into the importance that the patient ascribes to the options’ positive and negative characteristics. During preference elicitation, the patient identifies which options are, overall, personally most favored (and, by corollary, which are least favored). This article identifies the roles that values clarification/preference elicitation (VC/PE) play in the full process of patients’ decision support, outlines various approaches to fostering VC/PE, and poses some fundamental and applied research questions about VC/PE. It also argues that, in order to proceed to answer the posed research questions, investigators in the field of patients’ decision support require a systematic set of criteria for comparing the performance of different VC/PE techniques.

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

OBJECTIVE

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

STUDY DESIGN AND SETTING

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

RESULTS

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

CONCLUSION

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

Barriers for an effective communication around clinical decision making: an analysis of the gaps between doctors' and patients' point of view

BACKGROUND

There are doubts on whether patients feel that they have sufficient information for actively participating in clinical decisions.

OBJECTIVE

To describe the type of information that patients receive. To determine whether patients consider this information sufficient, and whether it contributes or not to improve clinical safety. To identify the barriers for patient participation in clinical decision making.

STUDY DESIGN

Cross-sectional study with 764 patients and 327 physicians.

STUDY SETTING AND PARTICIPANTS

Fourteen health centres belonging to three primary care districts and three hospitals in Spain.

PRINCIPAL FINDINGS

Just 35.1% (268) (95% CI 32.2, 39.1%) of patients preferred to have the last word in clinical decisions. Age (39 vs. 62%, P < 0.001) and severity of illness (38 vs. 46%, P = 0.002) increased the tendency to take a passive role. In 85.1% (650) (95% CI 83.3, 88.3%) of the cases, patients reported having received sufficient information. Lack of consultation time (29.6%, 95% CI 25.8, 32.5%) and patients' use of Internet or other sources (19.2%, 95% CI 16.4, 22.2%) were identified as new obstacles to doctor-patient communication by the patients. Only 19.6% (64) (95% CI 15.4, 24.2%) of doctors considered that they could intervene to involve patients in the decisions.

DISCUSSIONS AND CONCLUSIONS

The majority of patients prefer the decisions to be made by their doctor, especially those with more severe illnesses, and older patients. Patients are not normally informed about medication interactions, precautions and foreseeable complications. The information provided by general practitioners does not seem to contribute enough to the patient involvement in clinical safety.

Development and psychometric properties of the Shared Decision Making Questionnaire--physician version (SDM-Q-Doc)

OBJECTIVE

To develop and psychometrically test a brief instrument for assessing the physician's perspective of the shared decision-making process in clinical encounters.

METHODS

We adapted the 9-item Shared Decision Making Questionnaire (SDM-Q-9) for patients to generate a new version for physicians (SDM-Q-Doc). The physician version was tested in clinical encounters between 29 physicians and 324 patients in German outpatient care contexts. Analyses of the extent to which the instrument was accepted, the reliability of the instrument, and the factorial structure of the scale were performed.

RESULTS

Physicians showed a high level of acceptance toward the SDM-Q-Doc. Item discrimination parameters were above .4 for all but one item. An analysis of internal consistency yielded a Cronbach's α of .88. Factor analysis confirmed a one-dimensional structure.

CONCLUSION

The results of this study suggest that the SDM-Q-Doc is a well-accepted and reliable instrument for assessing the physician's perspective during SDM processes in clinical encounters. To our knowledge, the SDM-Q-Doc is the first psychometrically tested scale available for assessing the physician's perspective.

PRACTICE IMPLICATIONS

The SDM-Q-Doc can be used in studies that analyze the effectiveness of the implementation of SDM and as a quality indicator in quality assurance programs and health service assessments.

Patients' and observers' perceptions of involvement differ. Validation study on inter-relating measures for shared decision making

Objective

Patient involvement into medical decisions as conceived in the shared decision making method (SDM) is essential in evidence based medicine. However, it is not conclusively evident how best to define, realize and evaluate involvement to enable patients making informed choices. We aimed at investigating the ability of four measures to indicate patient involvement. While use and reporting of these instruments might imply wide overlap regarding the addressed constructs this assumption seems questionable with respect to the diversity of the perspectives from which the assessments are administered.

Methods

The study investigated a nested cohort (N = 79) of a randomized trial evaluating a patient decision aid on immunotherapy for multiple sclerosis. Convergent validities were calculated between observer ratings of videotaped physician-patient consultations (OPTION) and patients' perceptions of the communication (Shared Decision Making Questionnaire, Control Preference Scale & Decisional Conflict Scale).

Results

OPTION reliability was high to excellent. Communication performance was low according to OPTION and high according to the three patient administered measures. No correlations were found between observer and patient judges, neither for means nor for single items. Patient report measures showed some moderate correlations.

Conclusion

Existing SDM measures do not refer to a single construct. A gold standard is missing to decide whether any of these measures has the potential to indicate patient involvement.

Practice Implications

Pronounced heterogeneity of the underpinning constructs implies difficulties regarding the interpretation of existing evidence on the efficacy of SDM. Consideration of communication theory and basic definitions of SDM would recommend an inter-subjective focus of measurement.

Trial Registration

Controlled-Trials.com ISRCTN25267500.

The impact of physicians' reactions to uncertainty on patients' decision satisfaction

RATIONALE

Patients' and physicians' response to uncertainty may affect decision outcomes. The purpose of this study was to explore the impact of patients' and physicians' reactions to uncertainty on patients' satisfaction with breast health decisions.

METHODS

Seventy-five women facing breast cancer prevention or treatment decisions and five surgeons were recruited from a breast health centre. Patients' and physicians' anxiety from uncertainty was assessed using the Physicians' Reactions to Uncertainty Scale; wording was slightly modified for patients to ensure the scale was applicable. Patients' decision satisfaction was assessed 1-2 weeks after their appointment. A mixed-effects logistic regression model was used to assess associations between patients' and providers' anxiety from uncertainty and patients' decision satisfaction. A provider-specific random effects term was included in the model to account for correlation among patients treated by the same provider.

RESULTS

Patients' decision satisfaction was associated with physicians' anxiety from uncertainty (beta = 0.92, P < 0.01), but not with patients' anxiety from uncertainty (beta = -0.18, P > 0.27).

CONCLUSIONS

This study suggests that physicians' reactions to uncertainty may have an effect on decision satisfaction in patients. More research is needed to confirm this relationship and to determine how to help patient-provider dyads to manage the uncertainty that is inherent in most cancer decisions.

Pitfalls in the statistical examination and interpretation of the correspondence between physician and patient satisfaction ratings and their relevance for shared decision making research

Background

The correspondence of satisfaction ratings between physicians and patients can be assessed on different dimensions. One may examine whether they differ between the two groups or focus on measures of association or agreement. The aim of our study was to evaluate methodological difficulties in calculating the correspondence between patient and physician satisfaction ratings and to show the relevance for shared decision making research.

Methods

We utilised a structured tool for cardiovascular prevention (arriba™) in a pragmatic cluster-randomised controlled trial. Correspondence between patient and physician satisfaction ratings after individual primary care consultations was assessed using the Patient Participation Scale (PPS). We used the Wilcoxon signed-rank test, the marginal homogeneity test, Kendall's tau-b, weighted kappa, percentage of agreement, and the Bland-Altman method to measure differences, associations, and agreement between physicians and patients.

Results

Statistical measures signal large differences between patient and physician satisfaction ratings with more favourable ratings provided by patients and a low correspondence regardless of group allocation. Closer examination of the raw data revealed a high ceiling effect of satisfaction ratings and only slight disagreement regarding the distributions of differences between physicians' and patients' ratings.

Conclusions

Traditional statistical measures of association and agreement are not able to capture a clinically relevant appreciation of the physician-patient relationship by both parties in skewed satisfaction ratings. Only the Bland-Altman method for assessing agreement augmented by bar charts of differences was able to indicate this.

Trial registration

ISRCTN: ISRCT71348772

Reliability and validity of the German version of the OPTION scale

OBJECTIVE

To examine the psychometric properties of the German version of the 'observing patient involvement' scale (OPTION) by analysing video recordings of primary care consultations dealing with counselling in cardiovascular prevention.

DESIGN

Cross-sectional assessment of physician-patient interaction by two rater pairs and two experts in shared decision making (SDM).

SETTING

Primary care.

PARTICIPANTS

Fifteen general practitioners provided 40 videographed consultations.

MEASUREMENTS

Video ratings using the OPTION instrument.

RESULTS

Mean differences on item level between the four raters were quite large. Most items were skewed towards minimal levels of shared decision making. Measures of inter-rater association showed low to moderate associations on item level and high associations on total score level. Cronbach-α of the whole scale based on the data of all four raters is 0.90 and therefore on a high level. An oblique factor analysis revealed two factors, but both factors were highly correlated so we can confirm a one-dimensional structure of the instrument. ROC analyses between the rater total scores and dichotomized expert ratings (SDM yes/no) revealed a good discriminability of the OPTION total score. Physicians with more expertise in shared decision making received higher OPTION ratings.

CONCLUSIONS

The German version of the OPTION scale is reliable at total score level. Some items need further revision in the direction of more concrete, observable behaviour. We were only able to perform a quasi-validation of the scale. Validity issues need further research efforts.

Dyadic OPTION: Measuring perceptions of shared decision-making in practice

BACKGROUND

Current models of the medical consultation emphasize shared decision-making (SDM), whereby the expertise of both the doctor and the patient are recognised and seen to equally contribute to the consultation. The evidence regarding the desirability and effectiveness of the SDM approach is often conflicting. It is proposed that the conflicts are due to the nature of assessment, with current assessments from the perspective of an outside observer.

AIMS

To empirically assess perceived involvement in the medical consultation using the dyadic OPTION instrument.

METHOD

36 simulated medical consultations were organised between general practitioners and standardized- patients, using the observer OPTION and the newly developed dyadic OPTION instruments.

RESULTS

SDM behaviours observed in the consultations were seen to depend on both members of the doctor and patient dyad, rather than each in isolation. Thus a dyadic approach to measurement is supported.

CONCLUSIONS

This current study highlights the necessity for a dyadic approach to assessment and introduces a novel research instrument: the dyadic OPTION instrument.

Fostering shared decision making by occupational therapists and workers involved in accidents resulting in persistent musculoskeletal disorders: a study protocol

BACKGROUND

From many empirical and theoretical points of view, the implementation of shared decision making (SDM) in work rehabilitation for pain due to a musculoskeletal disorder (MSD) is justified but typically the SDM model applies to a one on one encounter between a healthcare provider and a patient and not to an interdisciplinary team.

OBJECTIVES

To adapt and implement an SDM program adapted to the realities of work rehabilitation for pain associated with a MSD. More specific objectives are to adapt an SDM program applicable to existing rehabilitation programs, and to evaluate the extent of implementation of the SDM program in four rehabilitation centres.

METHOD

For objective one, we will use a mixed perspective combining a theory-based development program/intervention and a user-based perspective. The users are the occupational therapists (OTs) and clinical coordinators. The strategies for developing an SDM program will include consulting the scientific literature and group consensus with clinicians-experts. A sample of convenience of eight OTs, four clinical coordinators and four psychologists all of whom have been working full-time in MSD rehabilitation for more than two years will be recruited from four collaborating rehabilitation centres. For objective two, using the same criteria as for objective one, we will first train eight OTs in SDM. Second, using a descriptive design, the extent to which the SDM program has been implemented will be assessed through observations of the SDM process. The observation data will be triangulated with the dyadic working alliance questionnaire, and findings from a final individual interview with each OT. A total of five patients per trained OT will be recruited, for a total of 40 patients. Patients will be eligible if they have a work-related disability for more than 12 weeks due to musculoskeletal pain and plan to start their work rehabilitation programs.

DISCUSSION

This study will be the first evaluation of the program and it is expected that improvements will be made prior to a broader-scale implementation. The ultimate aim is to improve the quality of decision making, patients' quality of life, and reduce the duration of their work-related disability by improving the services offered during the rehabilitation process.

Satisfaction of patients and primary care physicians with shared decision making

Satisfaction with treatment is regarded as an important outcome measure, but its suitability has not been thoroughly investigated in the context of shared decision making (SDM). The authors evaluated whether both patients' and physicians' satisfaction ratings differ between an intervention group and a control group within a structured tool for cardiovascular prevention (ARRIBA-Herz). In a pragmatic, cluster-randomized, controlled trial, 44 family physicians in the intervention group consecutively recruited 550 patients whereas 47 physicians in the control group included 582 patients. Main findings were high satisfaction ratings independent of group allocation in patients and physicians. Significant differences had only negligible effect sizes. Compared to global satisfaction ratings, the effects of the shared decision-making process are better measured by a more concrete approach representing different steps of this process. Further research should refine behaviorally oriented questionnaires that measure SDM and a version for physicians should also be created.

Turning signals into meaning--'shared decision making' meets communication theory

Shared decision making (SDM) is being increasingly challenged for promoting an innovative role model while adhering to an archaic approach to patient-clinician communication, both in clinical practice and the research field. Too often, SDM has been studied at the individual level, which ignores the interpersonal system between patients and physicians. We aimed to encourage debate by reflecting on the essentials of SDM in terms of epistemology. We operationalized the SDM core concept of information exchange in terms of social systems theory. An epistemological analysis of the term information refers to its inherent process character. Exchange of information thereby becomes synonymous with social sense construction, indicating that, rather than just being a vehicle, the act of communication itself is the information. We plead for the adoption of existing dyadic analytical methods such as those offered by the interpersonal paradigm. Implications of an updated concept of information for the use of SDM-evaluation methods, for SDM-goal setting, and for clinical practice of SDM are described.

Feasibility of a randomised trial of a continuing medical education program in shared decision-making on the use of antibiotics for acute respiratory infections in primary care: the DECISION+ pilot trial

Background

The misuse and limited effectiveness of antibiotics for acute respiratory infections (ARIs) are well documented, and current approaches targeting physicians or patients to improve appropriate use have had limited effect. Shared decision-making could be a promising strategy to improve appropriate antibiotic use for ARIs, but very little is known about its implementation processes and outcomes in clinical settings. In this matter, pilot studies have played a key role in health science research over the past years in providing information for the planning, justification, and/or refinement of larger studies. The objective of our study was to assess the feasibility and acceptability of the study design, procedures, and intervention of the DECISION+ program, a continuing medical education program in shared decision-making among family physicians and their patients on the optimal use of antibiotics for treating ARIs in primary care.

Methods

A pilot clustered randomised trial was conducted. Family medicine groups (FMGs) were randomly assigned, to either the DECISION+ program, which included three 3-hour workshops over a four- to six-month period, or a control group that had a delayed exposure to the program.

Results

Among 21 FMGs contacted, 5 (24%) agreed to participate in the pilot study. A total of 39 family physicians (18 in the two experimental and 21 in the three control FMGs) and their 544 patients consulting for an ARI were recruited. The proportion of recruited family physicians who participated in all three workshops was 46% (50% for the experimental group and 43% for the control group), and the overall mean level of satisfaction regarding the workshops was 94%.

Conclusions

This trial, while aiming to demonstrate the feasibility and acceptability of conducting a larger study, has identified important opportunities for improving the design of a definitive trial. This pilot trial is informative for researchers and clinicians interested in designing and/or conducting studies with FMGs regarding training of physicians in shared decision-making.

Trial Registration

Clinicaltrials.Gov NCT00354315

Assessing enablement in clinical practice: a systematic review of available instruments

RATIONALE, AIMS AND OBJECTIVES

Enablement is an intervention by which the health care provider recognizes, promotes and enhances patients' ability to control their health and life. An abundant health literature suggests that enablement is associated with good outcomes. In this review, we aimed at identifying and comparing instruments that assess enablement in the health care context.

METHOD

We conducted a systematic literature review using Medline, Embase, Cochrane, Cinahl and PsycINFO databases, 1980 through March 2009, with specific search strategy for each database. Citations were included if they reported: (1) development and/or validation of an instrument; (2) evaluation of enablement in a health care context; and (3) quantitative results following administration of the instrument. The quality of each main retained citation was assessed using a modified version of the Standards for Reporting of Diagnostic Accuracy.

RESULTS

Of 3135 citations identified, 53 were retrieved for detailed evaluation. Four articles were included. Two instruments were found: the Patient Empowerment Scale (PES) and the Empowering Speech Practices Scale (ESPS). Both instruments assessed enablement in hospital setting, one from the inpatient's perspective (PES) and the other from both perspectives (ESPS).

CONCLUSION

Two instruments assess enablement in hospital setting. No instrument is currently available to assess enablement in an ambulatory care context.

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

Shared decision-making (SDM) has the potential to overcome outdated social role models in the health care system. The concept, however, adheres to archaic epistemological assumptions as can be inferred from the rudimentary stage of the measurement methods used and from the information monopoly that the physician still holds in this concept. Advantages of an up-to-date model of knowledge for understanding and operationalising SDM are outlined. To this purpose, essential definitions of the concept are reflected in terms of epistemology. Accordingly, information emerges through a process of social construction. Likewise, interpersonal relations do not represent a static condition; rather, they develop anew with each interaction. Therefore, constructs suitable to focus on dyadic interaction processes can be used as indicators of sharing in SDM. Theories and methods of the interpersonal paradigm are advocated.

The 9-item Shared Decision Making Questionnaire (SDM-Q-9). Development and psychometric properties in a primary care sample

OBJECTIVE

To develop and psychometrically test a brief patient-report instrument for measuring Shared Decision Making (SDM) in clinical encounters.

METHODS

We revised an existing instrument (Shared Decision Making Questionnaire; SDM-Q), including the generation of new items and changing the response format. A 9-item version (SDM-Q-9) was developed and tested in a German primary care sample of 2351 patients via face validity ratings, investigation of acceptance, as well as factor and reliability analysis. Findings were cross-validated in a randomly selected subsample.

RESULTS

The SDM-Q-9 showed face validity and high acceptance. Factor analysis revealed a clearly one-dimensional nature of the underlying construct. Both item difficulties and discrimination indices proved to be appropriate. Internal consistency yielded a Cronbach's alpha of 0.938 in the test sample.

CONCLUSION

The SDM-Q-9 is a reliable and well accepted instrument. Generalizability of the findings is limited by the elderly sample living in rural areas of Germany. While the current results are promising, further testing of criterion validity and administration in other populations is necessary.

PRACTICE IMPLICATIONS

The SDM-Q-9 can be used in studies investigating the effectiveness of interventions aimed at the implementation of SDM and as a quality indicator in health services assessments.

Developing a dyadic OPTION scale to measure perceptions of shared decision making

OBJECTIVE

Our aim was to develop a measurement which enables research into the interdependent nature of clinical encounters. The prime objective was to develop an instrument capable of assessing the extent to which patients have been involved in (shared) decision making from two viewpoints-that of the patient and the clinician.

METHODS

To develop an initial 'dyadic OPTION' instrument, the twelve original third-person items were drafted in passive, first person plural forms. Using this version initially, three rounds of cognitive debriefing interviews were held. These were audio-recorded and analysed at the end of each round and the results used to revise the dyadic OPTION scale.

RESULTS

It was possible to modify the observer OPTION instrument into an instrument for completion by both clinicians and patients after a dyadic interaction. Cognitive debriefing revealed five areas of interpretative difficulty. Each item of the observer OPTION scale underwent modification in order to develop a dyadic version of the scale.

CONCLUSIONS

The dyadic OPTION scale is acceptable and comprehensible by both clinicians and public respondents. Cognitive debriefing adapted and refined an existing scale and provided confidence that the core constructs of the scale (perceived involvement in decisions making) were understood.

PRACTICE IMPLICATIONS

Further validation of the dyadic OPTION scale is required prior to its use in research settings.

Interpersonal perception in the context of doctor-patient relationships: a dyadic analysis of doctor-patient communication

Doctor-patient communication is an interpersonal process and essential to relationship-centered care. However, in many studies, doctors and patients are studied as if living in separate worlds. This study assessed whether: 1) doctors' perception of their communication skills is congruent with their patients' perception; and 2) patients of a specific doctor agree with each other about their doctor's communication skills. A cross-sectional study was conducted in three provinces in Canada with 91 doctors and their 1749 patients. Doctors and patients independently completed questions on the doctor's communication skills (content and process) after a consultation. Multilevel modeling provided an estimate of the patient and doctor variance components at both the dyad-level and the doctor-level. We computed correlations between patients' and doctors' perceptions at both levels to assess how congruent they were. Consensus among patients of a specific doctor was assessed using intraclass correlation coefficient (ICC). The mean score of the rating of doctor's skills according to patients was 4.58, and according to doctors was 4.37. The dyad-level variance for the patient was .38 and for the doctor was .06. The doctor-level variance for the patient ratings was .01 and for the doctor ratings, .18. The correlation between both the patients' and the doctors' skills' ratings scores at the dyad-level was weak. At the doctor-level, the correlation was not statistically significant. The ICC for patients' ratings was .03 and for the doctors' ratings .76. Overall, this study suggests that doctors and their patients have a very different perspective of the doctors' communication skills occurring during routine clinical encounters.

Establishing patient decision aids in primary care: update on the knowledge base

In recent years, many industrialised countries have moved forward initiatives to reinforce their primary healthcare sector. At the same time, there has been an increased emphasis on the engagement of patients as partners in their care. Consequently, the process by which patients are engaged to share their preferences and become involved in healthcare decisions is changing and pushing the needs for a new kind of knowledge tools, namely patients decision aids. We argue that for shared decision making to be adopted in primary care practices, patient decision aids will need to be embedded in routine clinical care. Subsequently, the objectives of this paper are twofold: to briefly review the knowledge base regarding the implementation of shared decision making in clinical practice and to identify the gaps in knowledge that will need to be addressed for the effective implementation of shared decision making in clinical practice to occur.

Users' perspectives of barriers and facilitators to implementing EHR in Canada: a study protocol

Background

In Canada, federal, provincial, and territorial governments are developing an ambitious project to implement an interoperable electronic health record (EHR). Benefits for patients, healthcare professionals, organizations, and the public in general are expected. However, adoption of an interoperable EHR remains an important issue because many previous EHR projects have failed due to the lack of integration into practices and organizations. Furthermore, perceptions of the EHR vary between end-user groups, adding to the complexity of implementing this technology. Our aim is to produce a comprehensive synthesis of actual knowledge on the barriers and facilitators influencing the adoption of an interoperable EHR among its various users and beneficiaries.

Methods

First, we will conduct a comprehensive review of the scientific literature and other published documentation on the barriers and facilitators to the implementation of the EHR. Standardized literature search and data extraction methods will be used. Studies' quality and relevance to inform decisions on EHR implementation will be assessed. For each group of EHR users identified, barriers and facilitators will be categorized and compiled using narrative synthesis and meta-analytical techniques. The principal factors identified for each group of EHR users will then be validated for its applicability to various Canadian contexts through a two-round Delphi study, involving representatives from each end-user groups. Continuous exchanges with decision makers and periodic knowledge transfer activities are planned to facilitate the dissemination and utilization of research results in policies regarding the implementation of EHR in the Canadian healthcare system.

Discussion

Given the imminence of an interoperable EHR in Canada, knowledge and evidence are urgently needed to prepare this major shift in our healthcare system and to oversee the factors that could affect its adoption and integration by all its potential users. This synthesis will be the first to systematically summarize the barriers and facilitators to EHR adoption perceived by different groups and to consider the local contexts in order to ensure the applicability of this knowledge to the particular realities of various Canadian jurisdictions. This comprehensive and rigorous strategy could be replicated in other settings.

EXACKTE(2): exploiting the clinical consultation as a knowledge transfer and exchange environment: a study protocol

Background

While the evidence suggests that the way physicians provide information to patients is crucial in helping patients decide upon a course of action, the field of knowledge translation and exchange (KTE) is silent about how the physician and the patient influence each other during clinical interactions and decision-making. Consequently, based on a novel relationship-centered model, EXACKTE² (EXploiting the clinicAl Consultation as a Knowledge Transfer and Exchange Environment), this study proposes to assess how patients and physicians influence each other in consultations.

Methods

We will employ a cross-sectional study design involving 300 pairs of patients and family physicians from two primary care practice-based research networks. The consultation between patient and physician will be audio-taped and transcribed. Following the consultation, patients and physicians will complete a set of questionnaires based on the EXACKTE² model. All questionnaires will be similar for patients and physicians. These questionnaires will assess the key concepts of our proposed model based on the essential elements of shared decision-making (SDM): definition and explanation of problem; presentation of options; discussion of pros and cons; clarification of patient values and preferences; discussion of patient ability and self-efficacy; presentation of doctor knowledge and recommendation; and checking and clarifying understanding. Patients will be contacted by phone two weeks later and asked to complete questionnaires on decisional regret and quality of life. The analysis will be conducted to compare the key concepts in the EXACKTE² model between patients and physicians. It will also allow the assessment of how patients and physicians influence each other in consultations.

Discussion

Our proposed model, EXACKTE², is aimed at advancing the science of KTE based on a relationship process when decision-making has to take place. It fosters a new KTE paradigm by putting forward a relationship-centered perspective and has the potential to reveal unknown mechanisms that underline effective KTE in clinical contexts. This will result in better understanding of the mechanisms that may promote a new generation of knowledge transfer strategies.

Appraisal of primary outcome measures used in trials of patient decision support

OBJECTIVE

To appraise instruments used as primary outcome measures in trials measuring the effectiveness of patient decision support interventions.

METHODS

Primary outcome measures were identified in trials of patient decision aids included in the 2003 Cochrane Review. Instruments were appraised for: use in calculating sample size, appropriateness, reliability, validity, responsiveness, precision, interpretability, acceptability, and feasibility.

RESULTS

Of the 35 trials, there were 35 unique primary outcome measures and 8 instruments were appraised. Actual or preferred choice was the primary outcome measure in 18 trials. Two instruments met at least 6 of 8 appraisal criteria: Control Preference Scale (n=2 trials) and Decisional Conflict Scale (n=5 trials). The Decision Conflict Scale was used to calculate sample size in 4 trials.

CONCLUSION

Decision was the most consistent outcome measure. Most publications provided inadequate detail for appraising the instruments. Four instruments (Decisional Conflict, Control Preferences, Genetic Testing Knowledge Questionnaire, and McBride's Satisfaction with Decision) measured one or more International Patient Decision Aid Standards criteria for evaluating effectiveness.

PRACTICE IMPLICATIONS

Selecting relevant and high quality outcome measures remains challenging and is an important area for further research in the field of shared decision making.