Effectiveness of a computerized decision aid in primary care on decision making and quality of life in menorrhagia: results of the MENTIP randomized controlled trial.

BACKGROUND: Computerized decision aids have the potential to increase patient involvement in the decision-making process. However, most published evidence concerning the effectiveness of decision aids is from secondary care. AIM: To evaluate whether the addition of a computerized decision aid to written information improves decision making in women consulting their general practitioner with menorrhagia compared with written information alone. DESIGN: of study. Randomized controlled trial. SETTING: Nineteen general practices in the North of England. METHOD: One hundred forty-nine women presenting with menorrhagia were randomized to receive written information and access to a computerized decision aid or written information alone. Outcomes were assessed using postal questionnaires. These were scores on the Decisional Conflict Scale and State-Trait Anxiety Inventory anxiety scale at 2 weeks and the Menorrhagia Specific Utility quality-of-life scale, knowledge about menorrhagia, and anxiety and process measures at 6 months. RESULTS: Two weeks after the intervention, there was significantly less decisional conflict in the intervention group (adjusted difference = -16.6; 95% confidence interval [CI] = -21.5 to -11.7; P < 0.001). At 6 months, the intervention group showed better knowledge about menorrhagia (adjusted difference = 9.3 ; 95% CI = 1.9 to 16.6; P = 0.014) and menorrhagia quality of life (adjusted difference = 10.9; 95% CI = 0.9 to 21.0; P = 0.033). There was no difference in anxiety scores at either 2 weeks or 6 months. CONCLUSIONS: A computerized decision aid, used outside of the primary care consultation, is effective in increasing patient involvement in decision making in primary care.     

患者对手术的知情同意权

患者对手术相关信息具有广泛"知情"的权利,而不仅仅限于现行<手术同意书>所列内容.取得患者"同意"而签订的免责条款,不具有法律效力.在某些特定条件下,患者的知情同意权会受到不同程度的限制.     

Patients' awareness of their rights in a developing country

AIM: To determine the awareness of a regulation on patients' rights passed in 1998 in Turkey. METHODS: All hospitalized patients in the internal medicine and general surgery wards in three large hospitals during the study period were eligible for the study, which was performed in 2001 in the Denizli province, Turkey. The study group consisted of 166 patients. Data were collected during face-to-face interviews using a questionnaire. RESULTS: Only 9% of patients were aware of the regulation about patients' rights. Most patients were given equal access to health care (91%), benefitted from the capabilities of their selected healthcare institutions (86.7%), and their privacy was protected (86.1%). Those patients who stated that they had not received care in accordance with their rights identified the shortcomings as not receiving written (95.2%) or verbal (53%) information from healthcare professionals, and the failure of healthcare personnel to introduce themselves (75.3%). On most occasions, the patients stated that they were not able to request services as stated in the PRR from healthcare professionals. CONCLUSION: Few patients knew about the regulation on patients' rights, indicating a need for extensive education of patients and healthcare professionals.     

The role of doctor's opinion in shared decision making: what does shared decision making really mean when considering invasive medical procedures?1

OBJECTIVE: The goal of this study was to gain understanding about patients' perspectives on decision making in the context of invasive medical interventions and whether patients' decision-making preferences influenced the type of information they desired to be provided by physicians. DESIGN: Questionnaire study of consecutive patients in a university-based general medicine clinic. INTERVENTIONS: Patients were presented with a randomized list of three types of information that physicians could provide (risk, benefit and physician's opinion on whether they should undergo the procedure). Patients were asked whether they preferred patient-based, physician-based, or shared decision making and then were asked to select which one or combination of these three information types was most important to them in their own decision making. Patients were also asked to self-report on how many invasive procedures they had undergone in their own lives. PARTICIPANTS: A total of 202 consecutive patients (mean age = 65.1 years, SD = 12.3, range 28-88; mean education 13.3 years, SD 2.9, range 2-23). MAIN OUTCOME MEASURES: Patient reports. RESULTS: Of the 202 patients, two patients reported no decision-making preference. These two patients were excluded from the analysis. Of the 200 remaining patients, 62.5% (125/200) preferred shared, 22.5%(45/200) preferred physician-based, and 15.5% (31/200) preferred patient-based decision making. More than half of all subjects chose physician opinion as the most important type of information for decision making. Older patients (odds ratio 1.028; confidence interval 1.003-1.053) were more likely to have ranked the doctor's opinion as the most important in their decision making for invasive medical interventions. CONCLUSIONS: Although most patients want to share decision making with their physicians regarding invasive procedures, the majority of these patients report relying on the doctor's opinion on whether to undergo the procedure as the most important information in their own decision making.     

Respected as a Client,Cared for as a Patient: Evidence of Heuristic Decision-Making from Yelp Reviews of Obstetrician-Gynecologists

ABSTRACT

Previous literature has demonstrated a gap between what health care consumers say they want to know about their physicians and the publicly available information the health care industry provides. This systematic analysis of Yelp reviews from the 25 most populous U.S. metropolitan areas is predicated on the assumptions that patients who post online physician reviews include information they would find useful when choosing a physician, and that this information represents an ecologically valid sample for making inferences regarding patients’ decision making process. Obstetrician gynecologists are twice as likely to be reviewed as other physicians, but this is, to our knowledge, the first study examining online reviews of obstetrician-gynecologists specifically. This study contributes to the literature on medical decision making, demonstrating that the physician choice decision is made using a heuristic tallying model, in which only two, nearly equally weighted parameters are meaningful: patient (which, within the reviews, incorporates physician interpersonal manner and physician knowledge and skills) and office management. Yelp reviews of obstetrician-gynecologists follow patterns previously established in scholarship: ratings are bimodal, and approximately two-thirds are positive. In the absence of objective, user-friendly physician-level information, patients will turn to review sites like Yelp when choosing physicians. Rather than resisting this trend, physicians and hospital systems would be better served by working with review sites, or creating their own, to emphasize aspects of the experience patients are qualified to evaluate: the physician’s interpersonal manner and office management.     

The therapeutic partnership: legal and ethical aspects of consumer health information

Patients' rights to information in the UK are based on a mixture of statute (including legislation on access to medical records) and case law (principally revolving around the issue of informed consent). These rights are set out in the Patient's Charter, which is itself a mixture of rights based on legislation and those enforced by management practice. Failure to provide adequate information to a patient could expose a medical practitioner to action for negligence or battery. Negligent information-giving could also expose consumer health information services to damages, for which the best defence is a high standard of professional competence and adequate professional indemnity insurance. Sharing information about the risks and benefits of treatment to enable truly informed decision making and consent by the patient is a key element of an ethical relationship between care giver and consumer--the therapeutic partnership.     

Improving patient care through patient-family education programs

The author's purpose of this study was to investigate patients' beliefs about the effectiveness of a patient education program. The authors interviewed general medicine and cardiac patients and their families at a large teaching hospital. They asked participants to describe the kind of information the hospital provided about patients' illnesses, pain management, and self-care following discharge and asked participants if they were satisfied with the information provided. The findings revealed that cardiac patients had greater access to information about their illnesses than general medicine patients. Overall, patients received verbal communication from doctors and nurses about their condition. All of the patients relied on pharmacological interventions for managing their pain and were unclear about how to manage their care following discharge. The authors describe recommendations for developing a written patient education curriculum, including information that addresses pain management options and discharge protocols.     

Participation in medical decision making: the patients' perspective.

PURPOSE: Variability in reports of patients' preferences to participate in decision making may be due in part to a lack of understanding about how patients conceptualize their participation. The authors sought to learn more about how patients view their involvement in decisions related to their health care. METHODS: The authors conducted individual interviews to allow patients to frame the decision-making process from their own perspective. The constant comparative-method approach to analysis was employed to ensure that the analysts defined the codes in a consistent manner. RESULTS: Twenty-six persons were interviewed. The main themes discussed by the participants reflecting how they viewed their involvement in medical decision making are the following: 1) decision making is often an ongoing process in which patient participation may change over time, 2) decision making is performed within an extended social context, 3) the decisions patients report being involved in are often distinct from those traditionally studied (choice of treatment or screening strategies), 4) patient involvement in decision making occurs in response to physicians' recommendations, and 5) patients make choices in the context of their specific illness perceptions. CONCLUSIONS: Participants in this study view their participation in decision making as including ideas distinct from those traditionally discussed by researchers. These findings suggest that the variability in patient participation noted in previous studies may be due in part to limitations in study design.     

"It's my body': does patient involvement in decision making reduce decisional conflict?

OBJECTIVE: This study explores how much people with HIV/AIDS wanted and how much they actually perceived being involved in the decision to take or not to take antiretroviral treatment (ART). The congruence between desired and perceived decisional involvement was also related to decisional conflict. METHOD: Cross-sectional (N = 79), the Control Preferences Scale assessed patients' preferred versus perceived role in treatment decision making. The Decisional Conflict Scale measured patients' perceived difficulties in decision making. RESULTS: Although a minority of patients (32%) perceived their role as shared decision making, the majority (59%) preferred shared decision making. Some did not desire shared decision making, with 28% preferring to decide on their own versus 13% wanting their physicians to decide for them. Overall, 58% did not feel they had achieved their desired role in decision making (half of whom perceived more control and the other half less control than preferred). Participants declining ART felt more pressure to decide alone compared with those taking ART (P < 0.01). Decisional conflict was expressed by 53% and was highest when physicians unilaterally made decisions about ART for patients who preferred shared decision making (P < 0.001). CONCLUSIONS: In this study, most physicians do not meet their patients' desired roles in decision making. One-third of people taking ART feel less involved than they desire. More critically, half of those declining ART feel pressured to decide alone, suggesting that physicians should remain involved in the decision to reject treatment, as this requires careful monitoring and periodical revisiting. Because lack of shared decision making is related to decisional conflict, physicians may reduce decisional conflict by meeting patients' desires for shared decision making.     

Clinical decision making and the provision of information in PEG feeding: an exploration of patients and their carers' perceptions

Background:  Government health care policy encourages a culture of patient choice and involvement in decision making, although the complexities and challenges involved in fully engaging patients in clinical decision making can be perceived as barriers to effective communication between the professional and patient. The present study aimed to explore the patients and their carers perceptions of the adequacy of the information provided and their subsequent involvement in the decision making process for percutaneous endoscopic gastrostomy (PEG) tube insertion.
Methods:  The study used purposive sampling. A cross-sectional qualitative design was utilised using semi-structured interviews, which were tape recorded. Sixteen patients and 27 carers were interviewed. The interviews were then transcribed verbatim and data analysis was undertaken using thematic analysis.
Results:  Only four patients and 11 carers reported having a choice in the decision for PEG placement, with only four patients and 10 carers, respectively, reporting they received sufficient information regarding the PEG. Poor communication, lack of information and inappropriate information, attitudes of health care professionals and exclusion were key themes for patients.
Conclusions:  Clinicians should develop interdisciplinary and participative practices to agree shared treatment goals and evaluate patient experiences. Consideration should also be given to the use of decision making models; in our opinion, the development of such a model, which supports interdisciplinary and participative approaches to decision making, is urgently required.     

Ethical decision making by family physicians

One hundred thirty-one Illinois family physicians, 53 general practitioners, and 65 general internists responded to a survey on medical ethics. From these data emerged a profile of the family physicians and an identification of the ethical problems they encounter most frequently in their practice: (1) issues about contraception, (2) pain control, (3) telling the patient the truth, (4) sexual issues, (5) informed consent, (6) confidentiality, (7) controlling patients' behavior with medication, (8) sterilization, (9) professional etiquette, (10) patients' rights, and (11) peer review.     

Informing and involving patients to improve the quality of medical decisions

Good-quality care requires that procedures, treatments, and tests be not only medically appropriate, but also desired by informed patients. Current evidence shows that most medical decisions are made by physicians with little input from patients. This article describes issues surrounding informed patient decision making and the steps necessary to improve the way decisions are made. Creating incentives for providers and health care organizations to inform patients and incorporate patients' goals into decisions is critical. Patient surveys are needed to monitor the quality of decision making. Health information technology can help by collecting information from patients about their symptoms, how well they understand their options, and what is important to them, and sharing that information with providers. We review public and private developments that could facilitate the development of tools and methods to improve patient-centered care.     

Development of a model to guide decision making in amyotrophic lateral sclerosis multidisciplinary care

Background

Patients with amyotrophic lateral sclerosis (ALS) face numerous decisions for symptom management and quality of life. Models of decision making in chronic disease and cancer care are insufficient for the complex and changing needs of patients with ALS .

Objective

The aim was to examine the question: how can decision making that is both effective and patient‐centred be enacted in ALS multidisciplinary care?

Setting and participants

Fifty‐four respondents (32 health professionals, 14 patients and eight carers) from two specialized ALS multidisciplinary clinics participated in semi‐structured interviews. Interviews were transcribed, coded and analysed thematically.

Results

Comparison of stakeholder perspectives revealed six key themes of ALS decision making. These were the decision‐making process; patient‐centred focus; timing and planning; information sources; engagement with specialized ALS services; and access to non‐specialized services. A model, embedded in the specialized ALS multidisciplinary clinic, was derived to guide patient decision making. The model is cyclic, with four stages: ‘Participant Engagement’; ‘Option Information’; ‘Option Deliberation’; and ‘Decision Implementation’.

Discussion

Effective and patient‐centred decision making is enhanced by the structure of the specialized ALS clinic, which promotes patients'' symptom management and quality of life goals. However, patient and carer engagement in ALS decision making is tested by the dynamic nature of ALS, and patient and family distress. Our model optimizes patient‐centred decision making, by incorporating patients'' cyclic decision‐making patterns and facilitating carer inclusion in decision processes.

Conclusions

The model captures the complexities of patient‐centred decision making in ALS. The framework can assist patients and carers, health professionals, researchers and policymakers in this challenging disease environment.     

Bringing social structure back into clinical decision making

Although research in the past twenty years has resulted in an increasingly sophisticated understanding of clinical decision making processes, the dominant approach in this area of inquiry remains limited. Most studies emphasize normative models of how decisions ought to be made, others attempt to describe physicians' thinking, but few take the social context of decision making systematically into account. Research models typically assume that physicians are autonomous professionals practicing in socially insular clinical settings--an approach that is consistent with classic formulations of the social structure of medical practice, but they ignore 30 years of sociological research on research on patient-physician relationships and major historical changes in the structure of medical practice. Eisenberg's still timely advice to students of clinical decision making--that they need to describe decision making in the context of 'sociologic influences' (including patient, physician and practice setting characteristics)--is expanded in the present discussion. Recent studies are reviewed, highlighting important dimensions of social structure impinging on physicians' decision making. Findings indicate that the process of clinical decision making is likely influenced by patients' age, gender, socioeconomic status, and race, physicians' professional training and experience, as well as by larger structural features of organized clinical settings. Our review of these studies on the social context of clinical decision making, however, reveals major methodological limitations including those inherently imposed by secondary data analysis, normative approaches, written case vignettes, small, non-random samples and the inadequate control of confounding influences. We present a feasible, alternative research strategy, built on a factorial experimental design. Illustrative findings indicate how complex social structural influence on clinical decision making may be disentangled in an unconfounded manner.     

Patients' perceptions of physicians communication and outcomes of the accrual to trial process

The purpose of this study was to examine the relations among patients' perceptions of their physicians' communicative behavior during the informed consent interview, the patient's feeling of being confirmed by the physician and satisfied with care delivered by the physician, and the patient's decision to participate in a clinical trial or not. Respondents included 130 cancer patients who were eligible for a clinical trial and who had recently discussed trial participation with their physicians. Results indicated that a linear combination of the variables physician affiliative style, physician dominant or controlling style, patient satisfaction, patient confirmation, patient preference for decision making, patient desire for information, and patient age discriminate between patients who agree to participate in clinical trials and patients who refuse to participate. Physicians' affiliative communicative behaviors and patient satisfaction were clearly important to patients who agreed to participate. Motivations for patients who declined to participate in trials were less clear. Implications for physicians who offer clinical trials to their patients are that specific communication skills may enhance their patients' satisfaction and may help increase enrollment in clinical trials.     

Patient involvement in clinical decision making: the effect of GP attitude on patient satisfaction

OBJECTIVE: This study investigates general practitioners' (GPs) and patients' attitudes to shared decision making, and how these attitudes affect patient satisfaction. BACKGROUND: Sharing of information and decisions in the consultation is largely accepted as the ideal in general practice. Studies show that most patients prefer to be involved in decision making and shared decision making is associated with patient satisfaction, although preferences vary. Still we know little about how the interaction of GP and patients' attitudes affects patient satisfaction. One such study was conducted in the USA, but comparative studies are lacking. DESIGN: Questionnaire survey distributed through GPs. SETTING AND PARTICIPANTS: The results are based on the combined questionnaires of 41 GPs and 829 of their patients in the urban municipality of Bergen in the western part of Norway. Main variables studied The data were collected using a nine-item survey instrument constructed to measure attitudes towards patient involvement in medical consultations. The patients were also asked to rate their satisfaction with their GP. RESULTS AND CONCLUSIONS: The patients had a strong preference for shared decision making. The GPs also generally preferred shared decision making, but to a lesser degree than the patients, which is the opposite of the findings of the US study. There was a positive effect of the GP's attitude towards shared decision making on patient satisfaction, but no significant effect of congruence of attitudes between patient and GP on patient satisfaction. The suggested explanation is that GPs that are positive to sharing decisions are more responsive to patients' needs and therefore satisfy patients even when the patient's attitude differs from the GPs' attitude. Hence, although some patients do prefer a passive role, it is important to promote positive attitudes towards patient involvement in medical consultations.