Commentary: At the Center of Decision Making in Mental Health Services and Interventions Research: Patients,Clinicians, or Relationships?

Wills and Holmes-Rovner (2006) highlight the fact that despite growing interest in the role of patient preferences and shared decision making with clinicians in the general health services research community, relatively little is known about the impact of these preferences and processes on actual decisions, service delivery engagement, or intervention outcomes in the mental health field. This commentary expands on three important points raised in Wills and Holmes-Rovner's article: (a) the need for more and better research on values assessment, (b) contextual factors in the decision-making process, and (c) the measurement of patient preferences regarding their level of involvement in decision making.     

The impact and utility of encounter patient decision aids: Systematic review,meta-analysis and narrative synthesis

Objective

To determine the effect of encounter patient decision aids (PDAs) as evaluated in randomized controlled trials (RCTs) and conduct a narrative synthesis of non-randomized studies assessing feasibility, utility and their integration into clinical workflows.

Use and Evaluation of a CD-ROM-Based Decision Aid for Prostate Cancer Treatment Decisions

The survival advantages associated with different treatments for localized prostate cancer (PCa) continue to be uncertain. We evaluated patients’ use of an interactive CD-ROM-based decision aid designed to improve informed decision making about PCa treatment. Newly diagnosed, early-stage PCa patients who had not made a treatment decision completed a baseline telephone interview (N = 132), were mailed the CD-ROM, and completed a one-month follow-up interview (N = 120; 91%). Compared to non-users (21%), CD-users (79%) preferred to make an independent rather than a shared treatment decision (OR = 3.5, CI 1.2,10.5). The majority of users (63%–90%) responded positively regarding the length and clarity of the information. Further, 76% reported using the CD as much/more than other information sources. A preference for having less decisional control predicted greater satisfaction with the CD (F[7,87] = 4.75, p < .05). Electronic utilization data revealed that the topics most accessed concerned treatment information and that users spent over an hour using the CD (median = 72 minutes). This electronic educational tool was well-accepted by patients and may be particularly useful for patients who desire less control over their treatment decisions and who are less proactive in seeking information on their own.     

Integrating Interventions and Services Research: Progress and Prospects

Although interventions and services research paradigms have distinct historical roots and methodologic traditions, both aim to improve mental health services for adults and youth. This article introduces a series of articles that represent examples of innovative and integrative (i.e., integration of services and interventions research) research efforts. This work involves an integration of the interventions and services research paradigms to address the difficult questions related to improving mental health services in diverse settings. Each of the four articles takes a distinctly different path in bringing together the interventions and services research traditions, with foci ranging from (a) using psychotherapy measurement tools to assess the content of usual care practice in collaboration with providers, (b) adapting randomized clinical trial design to fit nonmental healthcare settings while addressing relevant outcomes, (c) understanding and incorporating patient preferences into treatment research, and (d) identifying organization-level variables relevant to interventions development and implementation. In the introductory article, we provide a brief précis concerning the interventions and services research traditions, highlight how each of the four articles illustrates an innovative integration of interventions and services research, and discuss additional future directions beyond the work introduced in this series.     

Prediction and Postdiction in Clinical Decision Making

An article on "Post Hoc Reasoning in Possible Cases of Child Sexual Abuse: Symptoms of Inconclusive Origin" by Sbraga and O'Donohue (2003 , this issue) illustrates some general guidelines for clinical decision making. Most important in this regard is the fact that psychological assessment data are considerably more dependable for describing what people are like than for predicting how they are likely to behave or postdicting what they are likely to have done or experienced. This commentary reviews the nature of this difference in dependability and some related considerations involving nomothetic and idio-graphic appraisal, heterogeneity and nonspecificity of group characteristics, and markers and probabilities for identifying conditions. Awareness of these considerations can help clinicians and other psychological decision makers avoid unwarranted certainty in offering opinions about the likely occurrence of past or future events.     

自我-他人医疗决策差异研究

目的:考察医疗情境中,自我决策与为他人提供建议是否存在决策偏差,并基于解释水平的理论,解释这种偏差的由来。方法:改编Ficchhoff等使用过的医疗决策问题,分别以正/负框架(2)×自我/他人(2)进行描述。355名临床专业大学生被随机分为四组完成决策任务。结果:社会距离对医疗决策影响显著(χ2=8.636,P=0.003),自我决策与向他人建议相比,被试更倾向短期获益,长期受损的保守方案。框架效应对医疗决策影响显著(χ2=9.804,P=0.002),正性框架相比负性框架,被试更倾向短期受损,长期获益的手术方案。解释水平与框架效应交互作用显著:正性框架中,自我-他人决策差异显著(χ2=12.309,P<0.001),自我决策更倾向手术方案,负性框架中,自我-他人决策无显著差异(χ2=0.706,P=0.401);自我决策中,框架效应不显著(χ2=0.91,P=0.340),向他人建议,框架效应显著(χ2=13.256,P<0.001)。结论:社会距离与框架描述对医疗决策存在影响。     

Text-only and picture conversation aids both supported shared decision making for breast cancer surgery: Analysis from a cluster randomized trial

ObjectivesTo determine if two encounter conversation aids for early-stage breast cancer surgery increased observed and patient-reported shared decision making (SDM) compared with usual care and if observed and patient-reported SDM were associated.MethodsSurgeons in a cluster randomized trial at four cancer centers were randomized to use an Option Grid, Picture Option Grid, or usual care. We used bivariate statistics, linear regression, and multilevel models to evaluate the influence of trial arm, patient socioeconomic status and health literacy on observed SDM (via OPTION-5) and patient-reported SDM (via collaboRATE).ResultsFrom 311 recordings, OPTION-5 scores were 73/100 for Option Grid (n = 40), 56.3/100 for Picture Option Grid (n = 144), and 41.0/100 for usual care (n = 127; p < 0.0001). Top collaboRATE scores were 81.6 % for Option Grid, 80.0 % for Picture Option Grid, and 56.4 % for usual care (p < 0.001). Top collaboRATE scores correlated with an 8.60 point (95 %CI 0.66, 13.7) higher OPTION-5 score (p = 0.008) with no correlation in the multilevel analysis. Patients of lower socioeconomic status had lower OPTION-5 scores before accounting for clustering.ConclusionsBoth conversation aids led to meaningfully higher observed and patient-reported SDM. Observed and patient-reported SDM were not strongly correlated.Practice implicationsHealthcare providers could implement these conversation aids in real-world settings.     

Emergency Decision Making: A Theoretical Analysis of Responses to Disaster Warnings

Abstract

This article presents a theoretical model of emergency decision making that focuses on the decision maker's answers to basic questions evoked by warnings or signs of danger. Effective emergency decisions are most likely to be made, according to the theory, when a vigilant coping pattern is dominant, which requires that the following four mediating conditions are met: 1) awareness of serious risks if no protective action is taken; 2) awareness of serious risks if any of the salient protective actions is taken; 3) moderate or high degree of hope that a search for information and advice will lead to a better (i.e., less risky) solution; and 4) belief that there is sufficient time to search and deliberate before any serious threat will materialize. When one or another of these conditions is not met, a defective coping pattern, such as defensive avoidance or hypervigilance, will be dominant, which generally leads to maladaptive actions. In addition to suggesting new interventions for facilitating adaptive behavior in emergencies, the theoretical model provides a basis for integrating disparate findings from psychological research on the effects of warnings and confrontations with danger.     

大学生心理资本与职业决策自我效能的关系

目的探讨大学生心理资本与职业决策自我效能的关系。方法本研究采用问卷法对354名大学生进行调查研究。结果大学生整体心理资本水平较高;心理资本的不同维度在性别(t=2.43,P0.05)、学历(t=2.22,P0.05)和出生地(t=2.37,P0.05)上有显著差异;心理资本和职业决策自我效能呈显著正相关(r=0.65,P0.01);心理资本有5个维度对职业决策自我效能具有预测力,由高到低依次是:希望(29.3%)、谦虚诚信(8.5%)、乐观向上(3.6%)、回复力(1.5%)和融洽的人际关系(1.2%)。结论大学生职业决策自我效能受心理资本水平的影响。     

International collaboration in shared decision-making: the International Shared Decision Making (ISDM) conference history and prospects

Objective

Analyze the role of collaboration in the International Shared Decision Making organization (ISDM).

Methods

Case study of the seven year history of ISDM as a professional network.

Results

The International Shared Decision Making meeting Conference (ISDM) has held four biennial meetings since its inception in 2001. It is a freestanding professional meeting, with no permanent institutional support and no formal governance structure. In both its history and its prospects, collaboration among attendees has been pivotal to its growth. It both attracts and holds its “members” through the strength of the relationships formed during and between meetings. Exchanges in ISDM are informational, collegial, and indirectly economic.

Conclusion

ISDM's future rests on keeping all three functions healthy. It must maintain a focus on putting the shared decision making work first through becoming a “worknet”. Technologies that promote shared decision making can then be assembled and developed that support transformation of health care.

Practice Implications

Innovative professional organizations need to develop their work through deliberate development of networking techniques to move innovation into practice.     

Involving Children and Adolescents in Medical Decision Making: Developmental and Clinical Considerations

Outlined the issues in informed consent, as well as goals forinvolving children and adolescents in decisions regarding theirown medical treatment. This paper reviews the developmentaland clinical considerations, and provides recommendations, fordetermining particular children's level of involvement. Finally,there are distinct roles for pediatric psychologists in thisprocess, which are described. As medical treatment becomes increasinglysophisticated, there is an obligation for pediatric psychologiststo appreciate the ethical and clinical issues in medical decisionmaking for families.     

What Influences the Implementation of Shared Decision Making: An Umbrella Review

ObjectiveTo provide a cogent summation of the evidence base of the key barriers and facilitators to implementing shared decision making (SDM).MethodsAn umbrella review of existing reviews on SDM was adopted. Databases were searched from 1997 to December 2018. Studies were included if they performed a review of barriers and facilitators to SDM. Results: 7 eligible reviews were identified. The five themes identified were: patient factors, professional factors, environmental factors, relationship factors, and factors related to information provision. Lack of time was the main factor hindering the implementation of SDM. Encouragement and motivation of providers to use SDM was a significant enabler of SDM implementation.ConclusionsThe provision of time and resources are insufficient if not accompanied by efforts to support and motivate providers to use SDM.Practice implicationsHealthcare providers need to be educated on the importance of building a relationship with their patients. To enhance this relationship, physicians may need to improve their interaction skills. They need to be curious and explore their patients' preferences, listen to them and respect their opinions, explain options and outcomes, and encourage them to participate in the decision making.     

A Web-Based Tool to Support Shared Decision Making for People With a Psychotic Disorder: Randomized Controlled Trial and Process Evaluation

Background

Mental health policy makers encourage the development of electronic decision aids to increase patient participation in medical decision making. Evidence is needed to determine whether these decision aids are helpful in clinical practice and whether they lead to increased patient involvement and better outcomes.

Objective

This study reports the outcome of a randomized controlled trial and process evaluation of a Web-based intervention to facilitate shared decision making for people with psychotic disorders.

Methods

The study was carried out in a Dutch mental health institution. Patients were recruited from 2 outpatient teams for patients with psychosis (N=250). Patients in the intervention condition (n=124) were provided an account to access a Web-based information and decision tool aimed to support patients in acquiring an overview of their needs and appropriate treatment options provided by their mental health care organization. Patients were given the opportunity to use the Web-based tool either on their own (at their home computer or at a computer of the service) or with the support of an assistant. Patients in the control group received care as usual (n=126). Half of the patients in the sample were patients experiencing a first episode of psychosis; the other half were patients with a chronic psychosis. Primary outcome was patient-perceived involvement in medical decision making, measured with the Combined Outcome Measure for Risk Communication and Treatment Decision-making Effectiveness (COMRADE). Process evaluation consisted of questionnaire-based surveys, open interviews, and researcher observation.

Results

In all, 73 patients completed the follow-up measurement and were included in the final analysis (response rate 29.2%). More than one-third (48/124, 38.7%) of the patients who were provided access to the Web-based decision aid used it, and most used its full functionality. No differences were found between the intervention and control conditions on perceived involvement in medical decision making (COMRADE satisfaction with communication: F_1,68=0.422, P=.52; COMRADE confidence in decision: F_1,67=0.086, P=.77). In addition, results of the process evaluation suggest that the intervention did not optimally fit in with routine practice of the participating teams.

Conclusions

The development of electronic decision aids to facilitate shared medical decision making is encouraged and many people with a psychotic disorder can work with them. This holds for both first-episode patients and long-term care patients, although the latter group might need more assistance. However, results of this paper could not support the assumption that the use of electronic decision aids increases patient involvement in medical decision making. This may be because of weak implementation of the study protocol and a low response rate.

Trial Registration

Dutch Trial Register (NTR) trial number: 10340; http://www.trialregister.nl/trialreg/admin/rctsearch.asp?Term=10340 (Archived by WebCite at http://www.webcitation.org/6Jj5umAeS).     

Decision aids for patients facing health treatment decisions in Spain: Preliminary results

Objective

This study presents ongoing research aimed at understanding the suitability and impact of various decision aids (DAs) on patients with different chronic conditions in the Spanish National Health System.

Methods

A three-phase process was employed to develop and evaluate DAs for patients with hip or knee osteoarthritis (OA), benign prostatic hyperplasia (BPH), and depression, including: (1) systematic reviews on the effectiveness of shared decision making (SDM) interventions (including DAs); (2) the development of DAs; (3) a pilot study assessing the DAs.

Results

Systematic reviews carried out highlight that there are few studies assessing the effectiveness of DAs for OA, BPH, and depression. The development of DAs and their assessment currently differs for each medical condition. The DAs assessed for OA and BHP are well accepted. In a pilot study with OA patients, the DA produced a significant improvement in the decisional conflict “informed” subscale.

Conclusion

Research on SDM and DAs for different chronic conditions is at a very early stage in Spain. It is not possible to draw any definite conclusions about the effectiveness of DAs for clinical practice.

Practice implications

It is necessary to conduct more high quality studies to evaluate the effects of DAs in the Spanish context.     

Shared Decision Making Guidance Reminders in Practice (SDM-GRIP)

Objective

Develop a system of practice tools and procedures to prompt shared decision making in primary care. SDM-GRIP (Shared Decision Making Guidance Reminders in Practice) was developed for suspected stable coronary artery disease (CAD), prior to the percutaneous coronary intervention (PCI) decision.

Methods

Program evaluation of SDM-GRIP components: Grand Rounds, provider training (communication skills and clinical evidence), decision aid (DA), patient group visit, encounter decision guide (EDG), SDM provider visit.

Results

Participation – Physician training = 73% (21/29); patient group visits = 25% of patients with diagnosis of CAD contacted (43/168). SDM visits = 16% (27/168). Among SDM visit pairs, 82% of responding providers reported using the EDG in SDM encounters. Patients valued the SDM-GRIP program, and wanted to discuss comparative effectiveness information with a cardiologist. SDM visits were routinely reimbursed.

Conclusion

Program elements were well received and logistically feasible. However, recruitment to an extra educational group visit was low. Future implementation will move SDM-GRIP to the point of routine ordering of non-emergent stress tests to retain pre-decision timing of PCI and to improve coordination of care, with SDM tools available across primary care and cardiology.

Practice implications

Guidance prompts and provider training appear feasible. Implementation at stress testing requires further investigation.     

Measuring shared decision making in the consultation: a comparison of the OPTION and Informed Decision Making instruments

OBJECTIVE: To investigate the applied and conceptual relationship between two measures of shared decision making using the OPTION instrument developed in Wales and the Informed Decision Making instrument developed in Seattle, USA using audio-taped consultation data from a UK general practice population. METHODS: Twelve general practitioners were recruited from 6 general practices in the southwest of England. One hundred twenty-three GP-patient consultations were audio-recorded. Audiotapes were sent off to, and rated by, respective experts in the use of the OPTION and the Informed Decision Making instruments. RESULTS: Compared to earlier work using the Informed Decision Making tool, consultations in this sample were shorter, had fewer decisions and tended to have a greater number of elements present. Similar to previous research using the OPTION, values using the OPTION instrument were low with two items, giving the patient opportunities to ask questions and checking patient understanding, exhibiting the most variability. Using a 'key' decision in each consultation as the basis for comparison, the Informed Decision Making score was not related to the overall OPTION score (Spearman's rho=0.14, p=0.13). Both instruments also predicted different 'best' and 'worst' doctors. Using a Bland-Altman plot for assessing agreement, the mean difference between the two measures was 1.11 (CI 0.66-1.56) and the limits of agreement were -3.94 to 6.16. There were several elements between the two instruments that appeared conceptually similar and correlations for these were generally higher. These were: discussing alternatives or options (Spearman's rho=0.35, p=0.0001), discussion of the patient's role in decision making (Spearman's rho=0.23, p=0.012), discussion of the pros/cons of the alternatives (Spearman's rho=0.20, p=0.024) and assessment of the patient's understanding (Spearman's rho=0.19, p=0.03). CONCLUSION: Measures of shared decision making are helpful in identifying those shared decision making skills which may be problematic or difficult to integrate into practice and provide a tool by which the development of skills can be assessed over time. Research may implicitly place undue value on those aspects of shared decision making which are most easily measured. PRACTICE IMPLICATIONS: Shared decision making tools are a useful way of capturing the presence or absence of specific shared decision making skills and changes in skills acquisition over time. However there may be limits in the extent to which the concept of shared decision making can be measured and that more easily measured skills will be emphasised to the detriment of other important shared decision making skills.