Shared decision-making and outcomes in type 2 diabetes: A systematic review and meta-analysis

ObjectiveType 2 diabetes is a chronic disease which necessitates the development of a therapeutic alliance between patient and provider. This review systematically examines the association between treatment shared decision-making (SDM) and outcomes in diabetes.MethodsA range of bibliographic databases and gray literature sources was searched. Included studies were subjected to dual data extraction and quality assessment. Outcomes were synthesized using meta-analyses where reporting was sufficiently homogenous or alternatively synthesized in narrative fashion.ResultsThe search retrieved 4592 records, which were screened by title, abstract, and full text to identify 16 studies with a range of study designs and populations. We found evidence of an association between SDM and improved decision quality, patient knowledge and patient risk perception. We found little evidence of an association between SDM and glycemic control, patient satisfaction, quality of life, medication adherence or trust in physician.ConclusionsThis work elucidates the potential clinical utility of SDM interventions in the management of Type 2 Diabetes and helps inform future research on the topic.Practice implicationsA more complete understanding of the associations between SDM and outcomes will guide and motivate efforts aimed at improving uptake of the SDM paradigm.     

The association between frailty and medication adherence among community-dwelling older adults with chronic diseases: Medication beliefs acting as mediators

ObjectiveTo explore the association between frailty and medication adherence by modeling medication beliefs (i.e., necessity and concerns) as mediators among community-dwelling older patients.MethodsThis cross-sectional study was conducted among 780 Chinese older patients. Frailty, medication adherence and medication beliefs were assessed using the Comprehensive Frailty Assessment Instrument (CFAI), the 4-item Morisky Medication Adherence Scale (MMAS-4) and the Beliefs about Medicines Questionnaire-Specific (BMQ-Specific), respectively. The PROCESS SPSS Macro version 2.16.3, model 4 was used to test the significance of the indirect effects.ResultsFrailty was associated with high medication necessity (β = 0.091, p = 0.011) and high medication concerns (β = 0.297, p < 0.001). Medication adherence was positively associated with medication necessity (β = 0.129, p = 0.001), and negatively associated with medication concerns (β = −0.203, p < 0.001). Medication necessity and medication concerns attenuated the total effect of frailty on medication adherence by −13.6% and 70.3%, respectivelyConclusionHigh medication concerns among frail older patients inhibit their medication adherence, which cannot be offset by the positive effect of their high medication necessity on medication adherence.Practice implicationsInterventions should target medication beliefs among frail older patients, particularly medication concerns, to efficiently improve their medication adherence.     

Educational intervention for older people with asthma: A randomised controlled trial

ObjectivesTo improve the asthma control and adherence to asthma preventer medication of older people using the Patient Asthma Concerns Tool (PACT) to identify and address unmet needs and patient concerns.MethodsCommunity dwelling adults over 55 years, living in Victoria or New South Wales were recruited into a single-blind, parallel design, randomised-controlled trial comparing person-centred education including device technique, versus written information-only education. Fifty-eight participants randomised to the intervention group and 56 to the control completed participation. Outcome measures: asthma control, adherence to preventer medication, asthma related quality of life, asthma exacerbations and written action plan ownership were assessed at baseline, and 3 and 12 months post intervention.ResultsIntervention participants experienced improvements in asthma control, adherence to asthma preventer medication, reduced exacerbations, improved quality of life and an increase in asthma action plan ownership at 3 and 12 months.ConclusionAsthma outcomes in older people can be significantly improved by delivering tailored education that identifies specific patient concerns and unmet needs.Practical implicationsUse of the PACT to identify patient concerns and unmet needs will assist health professionals to improve the health literacy of patients by addressing gaps in their knowledge and perceptions of asthma control.     

“I think that everybody should be involved”: What informs experiences of shared decision-making in supporting people living with schizophrenia spectrum disorders?

ObjectiveTo identify facilitators and barriers associated with shared decision-making (SDM) in Australians affected by schizophrenia spectrum disorders.MethodsWe surveyed 78 participants with lived experience and held 12 in-depth interviews, including seven carers.ResultsA multiple linear regression model identified two independent variables significantly associated with degree of SDM: Personal Wellbeing Index scores (ß = .32, t = 3.3, p = .001) and treatment satisfaction rating (ß =.46, t = 4.7, p < .001), indicating that higher personal wellbeing and higher treatment satisfaction were significantly related to higher degree of SDM. Two key themes were identified through interview data: a complex pathway to SDM and impacts on wellbeing. Sub-themes included: self and carer characteristics, holistic care, education and knowledge, and power balance. Generally, participants reported a desire for SDM, noting that healthcare professionals inconsistently involve them in treatment decisions.ConclusionSDM is associated with treatment satisfaction and personal wellbeing among people living with schizophrenia spectrum disorders, but can be difficult to implement due to a range of challenges.Practice implicationsThere is a need to improve SDM in this population by decreasing stigma and discrimination, balancing power in consultations, increasing access to holistic treatment, and improving education and knowledge.     

Remote shared decision making through telemedicine: A systematic review of the literature

ObjectivesTo assess the extent to which shared decision making (SDM) can take place in telemedicine (remote SDM).MethodsWe searched Medline, Cochrane, and Scopus from 2010 until August 7th, 2020 for articles on remote SDM in the care of any patient using any technology. We also conducted a search for telemedicine articles citing key reports on SDM outcome measures. Two reviewers independently screened titles and abstracts, reviewed full text eligible studies, and synthesized their content using thematic analysis.ResultsOf the 12 eligible articles, most were European with patients with chronic disease or mental and behavioral health. 8 articles used synchronous remote SDM and 1 used asynchronous remote SDM. Themes related to interactional workability of both telemedicine technologies and SDM emerged, namely access to broadband, digital literacy, and satisfaction with the convenience of remote visits.ConclusionsTelemedicine technologies may foster virtual interactions that support remote SDM, which, in turn, may promote productive patient-clinician interactions and patient-centered care.Practice implicationsDigitally-mediated consultations surged amidst the COVID-19 pandemic. The extent to which SDM frameworks developed for in-person use need any adaptation for remote SDM remains unclear. Investment in innovation, design, implementation, and effectiveness research to advance remote SDM are needed.     

Shared decision making,patient-centered communication and patient satisfaction – A cross-sectional analysis

ObjectivesThe integration of shared decision making (SDM) and patient-centered communication (PCC) is needed to actively involve patients in decision making. This study examined the relationship between shared decision making and patient-centered communication.MethodsIn 82 videotaped hospital outpatient consultations by 41 medical specialists from 18 disciplines, we assessed the extent of shared decision making by the OPTION⁵ score and patient-centered communication by the Four Habits Coding Scheme (4HCS), and analyzed the occurrence of a high versus low degree (above or below median) of SDM and/or PCC, and its relation to patient satisfaction scores.ResultsIn comparison to earlier studies, we observed comparable 4HCS scores and relatively low OPTION⁵ scores. The correlation between the two was weak (r = 0.29, p = 0.009). In 38% of consultations, we observed a combination of high SDM and low PCC scores or vice versa. The combination of a high SDM and high PCC, which was observed in 23% of consultations, was associated with significantly higher patient satisfaction scores.ConclusionShared decision making and patient-centered communication are not synonymous and do not always co-exist.Practice implicationsThe value of integrated training of shared decision making and patient-centered communication should be further explored.     

Co-creating sensible care plans using shared decision making: Patients’ reflections and observations of encounters

ObjectiveTo evaluate how the use of a within-encounter SDM tool (compared to usual care in a randomized trial) contributes to care plans that make sense to patients with atrial fibrillation considering anticoagulation.MethodsIn a planned subgroup of the trial, 123 patients rated post-encounter how much sense their decided-upon care plan made to them and explained why. We explored how sense ratings related to observed patient involvement (OPTION12), patient’s decisional conflict, and adherence to their plan based on pharmacy records. We analyzed patient motives using Burke’s pentad.ResultsPlan sensibility was similarly high in both arms (Usual care n = 62: mean 9.4/10 (SD 1.0) vs SDM tool n = 61: 9.2/10 (SD 1.5); p = .8), significantly and weakly correlated to decisional conflict (rho = ?0.28, p = .002), but not to OPTION12 or adherence. Plans made sense to most patients given their known efficacy, safety and what is involved in implementing them.ConclusionAdding an effective intervention to promote SDM did not affect how much, or why, care plans made sense to patients receiving usual care, nor patient adherence to them.Practice ImplicationsEvaluating the extent to which care plans make sense can improve SDM assessments, particularly when SDM extends beyond selecting from a menu of options.     

Shared decision making for the allergist

ObjectiveShared decision making (SDM) is becoming more commonly appreciated and used in medical practice as a way to empower patients who are facing treatment preference-sensitive conditions, such as allergic rhinitis, atopic dermatitis, food allergy, and persistent asthma. The purpose of this review is to educate the allergy health care provider about how SDM works and provide practical advice and allergist-specific SDM resources.Data SourcesPubMed and online patient decision aid resources.Study SelectionsStudies and reviews relevant to SDM and patient decision aids relevant to the allergy health care provider were selected for discussion.ResultsThere are ethical, practical, economic, and psychological imperatives for the implementation of quality SDM, particularly for chronic diseases. Many benefits and barriers of SDM have been identified and models have been developed to encourage implementation of quality SDM. For the allergy health care provider, SDM for asthma has been shown to improve adherence, outcomes, and patient satisfaction with care. Patient decision aids are useful tools for SDM and have recently been developed for allergen immunotherapy, severe asthma, and atopic dermatitis.ConclusionEffective SDM has been shown to improve adherence and lead to better outcomes. SDM should be universally implemented as a key component of patient-centered health care. Allergy health care providers should work with their patients to reach treatment decisions that align with their values and preferences.     

The experiences of shared decision-making of women who had an induction of labour

ObjectivesThe importance of shared decision-making (SDM) in relation to induction of labour (IOL) is recognised, little is known about women’s experiences of and satisfaction with decision-making and how this can be improved. The aim of this study was to 1) gain insight into women’s experiences of SDM in relation to IOL, 2) understand the factors associated with satisfaction versus dissatisfaction during SDM, and 3) identify recommendations for service improvement.MethodsQualitative semi-structured telephone interviews were conducted with 32 women who had a recent IOL at one of eight public hospitals in Sydney, Australia. An inductive approach to coding and categorisation of themes was used.ResultsWhile women reported varied experiences with SDM, many reported not feeling that they had a choice about IOL, not being presented with the risks and benefits of different birth options, and receiving insufficient information about the IOL process and methods. Satisfaction versus dissatisfaction with SDM appeared more closely related to a woman’s willingness to have an IOL and their willingness to defer decision-making, rather than the process of SDM. Recommendations for improvement included improved SDM practices, access to guidelines and continuity of care.ConclusionThere is a need to improve SDM processes around IOL.Practice implicationsParticular areas for improvement include more comprehensive discussions surrounding the pros and cons of different birth methods and the IOL process. Decision aids and clinician training may assist with SDM.     

Factors associated with level of shared decision making in Malaysian primary care consultations

ObjectiveTo measure the level of shared decision-making (SDM) in primary care consultations in Malaysia, a multicultural, middle-income developing country.MethodsA cross-sectional study was conducted in an urban, public primary care clinic. Convenience sampling was used to recruit participants, and audio-recorded consultations were scored for SDM levels by two independent raters using the OPTION tool. Univariate and multivariate analysis was conducted to determine factors significantly associated with SDM levels.Results199 patients and 31 doctors participated. Mean consultation time was 14.3 min (+ SD 5.75). Patients’ age ranged from 18 to 87 years (median age of 57.5 years). 52.8 % of patients were female, with three main ethnicities (Malay, Chinese, Indian). The mean OPTION score was found to be 7.8 (+ SD 3.31) out of 48. After a multivariate analysis, only patient ethnicity (β= -0.142, p < 0.05) and increased consultation time (β = 0.407, p < 0.01) were associated with higher OPTION scores.ConclusionsPatients in Malaysia experience extremely poor levels of SDM in general practice. Higher scores were associated with increased consultation time and patient ethnicity.Practice implicationsMalaysian general practitioners should aim to develop and practice cultural competency skills to avoid biased SDM practice towards certain ethnicities.     

Decision making about anti-TNF therapy: A pilot trial of a shared decision-making intervention

ObjectiveWe conducted a pre-post pilot trial to determine the feasibility and acceptability of a multi-component intervention (pre-clinic letter, shared decision making cards and follow-up phone call) designed to facilitate SDM in pediatric inflammatory bowel disease (IBD).MethodsWe recruited physicians (n = 11) caring for IBD patients and families (n = 36) expected to discuss anti-tumor necrosis treatment. We measured feasibility and acceptability of the intervention, observed SDM, perceived SDM, decision conflict, and regret. Medical records were used to assess clinical outcomes, time to decision and adherence. We compared all outcomes between the usual care and intervention study arms.ResultsTwo out of three intervention components were feasible. Visit length increased significantly in the intervention arm. Parents and patients rated the intervention as acceptable, as did most physicians. The intervention was associated with a higher-level of observed SDM. There was no difference perceived SDM, decision conflict, regret or quality of life outcomes between arms. Physician global assessment improved over time in the intervention arm.ConclusionsThis pilot trial provides important guidance for developing a larger scale trial of a modified intervention.Practice implicationsOverall, our intervention shows promise in supporting SDM and engaging both parents and patients in pediatric IBD decisions.     

The effectiveness of pharmacist- led discharge medication counselling in the emergency department (ExPLAIN): A pilot quasi-experimental study

ObjectiveTo evaluate the effectiveness of pharmacist-led discharge medication counselling using a structured, multimodal educational strategy with teach-back (intervention) against standard care.MethodsThis was a quasi-experimental study in a public, metropolitan ED. Participants discharged home with new medications were allocated to receive the intervention or standard care using convenience sampling. Participant characteristics (i.e. age, sex, socio-economic status, medications) and health literacy were collected. The outcomes measured were satisfaction with information, ED re-presentation and length of stay.ResultsThere were 51 participants: 14 received intervention, 37 had standard care. Overall, 12% had inadequate health literacy. Group characteristics and health literacy were similar. Participants who received the intervention were significantly reported higher satisfaction with information about their new medications compared to standard care (p = 0.009). Specifically, the intervention was associated with a 98% increase in satisfaction with information relating to side-effects. There were no differences in re-presentation and length of stay.ConclusionPharmacist-led discharge medication counselling incorporating a structured, multimodal educational strategy and teach-back was effective in improving patient satisfaction with medication information in the ED.Practice implicationsA similar intervention could be trialled in other EDs, but outcomes other beyond satisfaction should be considered.     

Inconsistencies in patient perceptions and observer ratings of shared decision making: The case of colorectal cancer screening

Objective

To compare patient-reported and observer-rated shared decision making (SDM) use for colorectal cancer (CRC) screening and evaluate patient, physician and patient-reported relational communication factors associated with patient-reported use of shared CRC screening decisions.

Methods

Study physicians are salaried primary care providers. Patients are insured, aged 50–80 and due for CRC screening. Audio-recordings from 363 primary care visits were observer-coded for elements of SDM. A post-visit patient survey assessed patient-reported decision-making processes and relational communication during visit. Association of patient-reported SDM with observer-rated elements of SDM, as well as patient, physician and relational communication factors were evaluated using generalized estimating equations.

Results

70% of patients preferred SDM for preventive health decisions, 47% of patients reported use of a SDM process, and only one of the screening discussions included all four elements of SDM per observer ratings. Patient report of SDM use was not associated with observer-rated elements of SDM, but was significantly associated with female physician gender and patient-reported relational communication.

Conclusion

Inconsistencies exist between patient reports and observer ratings of SDM for CRC screening.

Practice implications

Future studies are needed to understand whether SDM that is patient-reported, observer-rated or both are associated with informed and value-concordant CRC screening decisions.     

Multiple health literacy dimensions are associated with physicians’ efforts to achieve shared decision-making

ObjectivesShared decision-making (SDM) in health care is widely encouraged. However, for SDM to occur patients need to be able to obtain, understand and apply medical information. Our aim was to assess the relationship between health literacy (HL), numeracy and SDM (using French translations of validated measures).MethodsA cross-sectional survey using a self-administered online questionnaire was proposed to all members of the Seintinelles association. Several scales were used to measure HL (FCCHL and 3HLQ/SILS), numeracy (SNS-3), the SDM process (CollaboRATE) and explore their inter-relationships.ResultsData from 2 299 respondents (96.7% women, 46.1% with a history of cancer) were analysed. All measurement scales showed adequate psychometric properties. Functional HL, communicative HL and numeracy were positively associated with SDM while no significant relation was observed between critical HL and SDM. Furthermore, perceived difficulties in asking physicians’ questions and deprivation were negatively associated with SDM.ConclusionPatient support to reach SDM requires high levels of HL, particularly in the functional and communicative domains. Efforts must be made to improve access and understanding of health information.Practice implicationsBrief self-reported measures could be used to screen for low levels of health literacy, tailor information accordingly and improve patient involvement in healthcare decision-making.     

Effectiveness of shared decision-making intervention in patients with lumbar degenerative diseases: A randomized controlled trial

ObjectiveTo evaluate the efficacy of shared decision-making (SDM) intervention among patients with lumbar degenerative diseases (LDDs) in terms of decision self-efficacy, control preferences, SDM process, decision satisfaction, and conflict.MethodsA total of 130 outpatients with LDDs recruited from orthopedic or rehabilitation clinics were randomly assigned to the SDM intervention (n = 67) or comparison (n = 63) groups. Patients in the intervention group received decision aids (DAs) with decision coaching and those in controlled group received standard educational materials from a health educator. The primary outcome was decision self-efficacy, and secondary outcomes were control preference, SDM process, conflict, and satisfaction.ResultsThe SDM intervention significantly improved decision self-efficacy (mean difference [MD] = 7.1, 95% confidence interval [CI]: 1.7–12.5, partial η² = 0.05) and reduced conflict (MD = −7.0, 95% CI: −12.2 to −1.9, partial η² = 0.06), especially in patients without family involvement, compared with the health education group. However, no significant between-group differences were observed in other outcomes.ConclusionSDM intervention improved SDM self-efficacy and reduced conflict in patients with LDDs.Practice ImplicationsClinicians can integrate DAs and decision coaching in SDM conversations. SDM intervention seems to engage patients in decision-making, especially those without family involvement.     

Patients’ perception of their involvement in shared treatment decision making: Key factors in the treatment of inflammatory bowel disease

Objectives

This study aims to characterize the relationships between the quality of the information given by the physician, the involvement of the patient in shared decision making (SDM), and outcomes in terms of satisfaction and anxiety pertaining to the treatment of inflammatory bowel disease (IBD).

A structural equation model of relationships of health literacy,illness and medication beliefs with medication adherence among patients with chronic obstructive pulmonary disease

ObjectiveTo determine the relative contributions of health literacy (HL) and illness and medication beliefs to medication adherence among older COPD patients and determine the pathways through which they operate.MethodsThe study was conducted using data from a prospective cohort of COPD patients in New York City and Chicago. We used structural equation modeling to examine the pathways linking HL, through medications and illness beliefs, with COPD medication adherence.ResultsOut of 393 older adults with COPD, 123 (31%) had limited HL and 208 (53%) reported low adherence to daily COPD medications. Those with limited HL were more likely to have low medication adherence (p < 0.0001). Medications concerns (p = 0.001) and medication necessity (p = 0.003) demonstrated a mediational role between HL and adherence. However, in the final multivariate model, HL did not have direct effect on medication adherence (p = 0.12) and illness beliefs (p = 0.16) did not demonstrate a mediational role between HL and adherence.ConclusionOur findings suggest that low HL is not a direct predictor of poor medication adherence among COPD patients.Practice implicationsAddressing medication concerns and reinforcing the need for daily COPD medications may be a more effective strategy for increasing adherence in this population.     

Communicating with older adults with long-term conditions about self-management goals: A systematic review and thematic synthesis

ObjectiveTo synthesise a body of fine-grained observational research on communication between healthcare professionals (HCPs), older adults, and carers regarding self-management goals and actions.MethodsWe conducted a systematic review, searching nine electronic databases and the grey literature. Two reviewers independently selected for inclusion following a two-stage process and studies and discrepancies were resolved through consultation with the review team.Results898 records were retrieved, and eight studies were included in the review. Aggregative thematic analysis resulted in 13 categories of communication practices across three decision-making domains: (1) initiating: actions occurring prior to the commitment point; (2) proposing: putting forward a course of action; and (3) committing and closing: committing (or not) to the course of action.ConclusionsDespite an increasing emphasis on the importance of personalised care planning and shared decision-making (SDM) to support older people’s health and wellbeing, HCPs did not consistently practice this approach and, in some cases, worked in opposition to it.Practice implicationsWe encourage HCPs to prepare older adults to engage actively with SDM and the goal setting process by employing patient-centred communication resources. These could assist with identifying different types of goals that are realistic and relevant to patients in daily life.