Using decision aids in community-based primary care: a theory-driven evaluation with ethnically diverse patients

Objective

To assess the effects of informational brochures and video decision aids about cancer screening on patient intention to engage in shared decision-making and its predictors in a racially diverse sample.

Methods

Participants were recruited from 13 community-based primary care practices serving racially and ethnically diverse patients in predominately economically disadvantaged neighborhoods. Participants completed theory-based measures assessing attitudes, perceived social norms, self-efficacy and intentions for working with their physician to make a cancer screening decision after reviewing a brochure or video decision aid, but before seeing the physician. A post-questionnaire assessed screening decisions and participant knowledge.

Results

Participants who reviewed a video decision aid had higher knowledge and were more likely to want to be the primary decision-maker. They reported lower perceived social norms, self-efficacy and intentions to work with their physicians than participants who reviewed a brochure. Participants who decided against cancer screening reported lower intentions to work with their physician in making a decision and were less likely to report having spoken with their physician about screening.

Conclusion

Participants who opted against cancer screening after reviewing a brochure or decision aid were less likely to discuss their decision with their physician. The tendency toward autonomous decision-making was stronger among participants who reviewed a video decision aid.     

Strategies for distributing cancer screening decision aids in primary care

Objective

Decision aids (DAs) have been shown to facilitate shared decision making about cancer screening. However, little data exist on optimal strategies for dissemination. Our objective was to compare different decision aid distribution models.

Methods

Eligible patients received video decision aids for prostate cancer (PSA) or colon cancer screening (CRC) through 4 distribution methods. Outcome measures included DA loans (N), % of eligible patients receiving DA, and patient and provider satisfaction.

Results

Automatically mailing DAs to all age/gender appropriate patients led to near universal receipt by screening-eligible patients, but also led to ineligible patients receiving DAs. Three different elective (non-automatic) strategies led to low rates of receipt. Clinician satisfaction was higher when patients viewed the DA before the visit, and this model facilitated implementation of the screening choice. Regardless of timing or distribution method, patient satisfaction was high.

Conclusions

An automatic DA distribution method is more effective than relying on individual initiative. Enabling patients to view the DA before the visit is preferred.

Practice implications

Systematically offering DAs to all eligible patients before their appointments is the ideal strategy, but may be challenging to implement.     

Video-based patient decision aids: A scoping review

Objective

This study reviews the published literature on the use of video-based decision aids (DA) for patients. The authors describe the areas of medicine in which video-based patient DA have been evaluated, the medical decisions targeted, their reported impact, in which countries studies are being conducted, and publication trends.

Implementing decision and communication aids to facilitate patient-centered care in breast cancer: A case study

Objective

Decision Services (DS) provide support for breast cancer patients at the University of California, San Francisco to help ensure patient-centered care.

Methods

We examined a case study to explore whether our program practices matched our program theory, and what the patient in the case thought was effective and ineffective about our decision support interventions.

Results

The patient relied on a decision aid to educate her husband about her condition; felt that her question list contributed to a productive and efficient consultation with her oncologist; credited an audio-recording with helping her remember to follow-up with a genetic counselor; and reviewed the consultation summary 30 days into treatment in order to reflect on her decision. The patient rated the interventions highly on surveys, and experienced desirable reductions in decisional conflict, and improvements in knowledge. However, the question-prompting intervention was associated with a small decrease in self-efficacy, and the patient criticized the decision aid for omitting mention of a prognostic test.

Conclusion

This case illustrates how decision support interventions can be deployed to promote patient-centered care.

Practice implications

Breast care centers should consider distributing decision aids and assisting patients in listing questions, recording consultations, and obtaining written consultation summaries.     

Implementing decision and communication aids to facilitate patient-centered care in breast cancer: A case study

ObjectiveDecision Services (DS) provide support for breast cancer patients at the University of California, San Francisco to help ensure patient-centered care.MethodsWe examined a case study to explore whether our program practices matched our program theory, and what the patient in the case thought was effective and ineffective about our decision support interventions.ResultsThe patient relied on a decision aid to educate her husband about her condition; felt that her question list contributed to a productive and efficient consultation with her oncologist; credited an audio-recording with helping her remember to follow-up with a genetic counselor; and reviewed the consultation summary 30 days into treatment in order to reflect on her decision. The patient rated the interventions highly on surveys, and experienced desirable reductions in decisional conflict, and improvements in knowledge. However, the question-prompting intervention was associated with a small decrease in self-efficacy, and the patient criticized the decision aid for omitting mention of a prognostic test.ConclusionThis case illustrates how decision support interventions can be deployed to promote patient-centered care.Practice implicationsBreast care centers should consider distributing decision aids and assisting patients in listing questions, recording consultations, and obtaining written consultation summaries.     

Antenatal psychiatric illness and adequacy of prenatal care in an ethnically diverse inner-city obstetric population

Summary Objective: This study assessed the prevalence of antenatal psychiatric illness in low-income, ethnically diverse patients in an urban obstetric clinic and examined associations between positive psychiatric screens and inadequate utilization of prenatal care. Methods: Bilingual research assistants administered the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire and the Mood Disorder Questionnaire to 154 English- and Spanish-speaking pregnant patients attending routine prenatal visits. We assessed associations between patient characteristics, current and past psychiatric diagnoses, and utilization of prenatal care. Results: Forty-five (29%) women screened positive for criteria for current psychiatric disorders with the highest rates for major or minor depression (26%) and anxiety disorders (10%). Inadequate prenatal care utilization was significantly associated with past psychiatric history and domestic abuse in the last year, but not with current psychiatric diagnosis, alcohol abuse, age, primiparity, marital status, receipt of government assistance, or unplanned pregnancy. Even after adjustment for possible confounding risk factors (e.g. past substance abuse, single marital status, unstable housing, education less than high school, and having other children), past psychiatric history was still significantly associated with inadequate prenatal care utilization and delayed initiation of care. Conclusions: A high percentage of disadvantaged pregnant women meet screening criteria for psychiatric disorders when screened during routine prenatal visits. Screening for past psychiatric history in routine prenatal visits could identify patients at risk for inadequate utilization of prenatal care.     

Expanding the reach of decision and communication aids in a breast care center: A quality improvement study

Objective

One academically based breast cancer clinic implements decision and communication aids as part of routine clinical care. This quality improvement study aimed to expand reach of these supportive materials and services with budget-neutral program changes.

Methods

We used program theory and continuous quality improvement to design changes to our program. We calculated reach as the number of new patient visits for which we administered decision and communication aids. We compared reach before and after the program changes.

Results

Program changes included: reassigning program outreach tasks from over-committed to under-utilized personnel; deploying personnel in floating rather than fixed schedules; and creating a waitlist so service delivery was dynamically reallocated from overbooked to underbooked personnel. Before these changes, we reached 208 visitors with decision aids, and 142 visitors with communication aids. Changes were associated with expanded reach, culminating in program year 2008 with the delivery of 936 decision aids and 285 communication aids.

Conclusions

We observed over a fourfold increase in decision aid reach and a twofold increase in communication aid reach. We attribute increases to recent program changes.

Practice implications

This study illustrates how program theory and quality improvement methods can contribute to expanded reach of decision and communication aids.     

Treatment decision making involving patients with dementia in acute care: A scoping review

Objective

To summarize the evidence regarding the factors and processes of treatment decision making involving a person with dementia (PWD) in the acute care setting.

A comprehensive evaluation of IL4 variants in ethnically diverse populations: association of total serum IgE levels and asthma in white subjects

BACKGROUND: The role of variation in the IL4 gene in asthma and allergy susceptibility is controversial. This cytokine is important in IgE isotype switching and the regulation of allergic inflammation; however, published studies have not delineated the specific role of variation in this gene in allergic disorders. OBJECTIVE: We sought to identify single nucleotide polymorphisms (SNPs) in IL4 and to evaluate the association of SNPs and haplotypes with asthma and allergic phenotypes (total serum IgE) in white, African American, and Hispanic asthmatic populations. METHODS: Sixteen individuals were resequenced, and 19 SNPs were identified; 2 novel and 17 SNPs were previously reported. Eleven of the SNPs were used to evaluate association in the 3 groups. RESULTS: Nine polymorphisms were associated with total serum IgE levels in white subjects (.0012 < or = P < or =.034), and 5 of these were also associated with asthma in this population (.010 < or = P < or =.031). Three common haplotypes were observed, and all were associated with either high or low serum IgE levels in white subjects (.00008 < or = P < or =.004). Inspection of the haplotypes revealed that 3017 G/T in intron 2 was the only SNP concordant with serum IgE levels (G allele with lower levels and T allele with higher levels). CONCLUSIONS: After a comprehensive genetic evaluation, our data suggest that the 3017 G/T variant or the haplotype it identifies influences IL4's ability to modulate total serum IgE levels. Inconsistencies with previously reported IL4 associations might be due to population differences in allele frequencies, the extent of linkage disequilibrium with this SNP or haplotype, or both.     

The Statin Choice decision aid in primary care: A randomized trial

Objective

To assess the impact of a decision aid on perceived risk of heart attacks and medication adherence among urban primary care patients with diabetes.

Methods

We randomly allocated 150 patients with diabetes to participate in a usual primary care visit either with or without the Statin Choice tool. Participants completed a questionnaire at baseline and telephone follow-up at 3 and 6 months.

Results

Intervention patients were more likely to accurately perceive their underlying risk for a heart attack without taking a statin (OR: 1.9, CI: 1.0–3.8) and with taking a statin (OR: 1.4, CI: 0.7–2.8); a decline in risk overestimation among patients receiving the decision aid accounts for this finding. There was no difference in statin adherence at 3 or 6 months.

Conclusion

A decision aid about using statins to reduce coronary risk among patients with diabetes improved risk communication, beliefs, and decisional conflict, but did not improve adherence to statins.

Practice implications

Decision aid enhanced communication about the risks and benefits of statins improved patient risk perceptions but did not alter adherence among patients with diabetes.     

Impact of decision aids in a sustained implementation at a breast care center

Objective

We examined the reach and impact of five decision aids (DAs) routinely distributed to breast cancer patients as part of a shared decision making demonstration project.

Methods

From 2005 to 2008, we surveyed patients’ change in knowledge and decisional conflict (DC) before and after their review of DAs. Using bivariate tests, we identified significant predictors of change in knowledge or decisional conflict and entered significant predictors into a multivariate regression model.

Results

We distributed 1553 DAs to 1098 patients and received 549 completed surveys. The DAs were associated with increased knowledge and decreased DC. For knowledge, significant predictors of above-average change included: lower baseline knowledge and viewing the surgery decision aid. For decisional conflict, significant predictors of above-average change included: higher decisional conflict; viewing any of the early-stage cancer DAs; and Hispanic ethnicity.

Conclusions

DAs used in routine care were associated with significant knowledge gains and reductions in decisional conflict. Some subsets of patients (those reporting low baseline knowledge, high DC, or Hispanic ethnicity) may benefit more than others.

Practice implications

Breast cancer patients benefit overall from routine distribution of DAs. Our exploratory findings may be useful in generating hypotheses to identify target populations who would most benefit from reviewing DAs.     

Assessments for measuring patient-centered cultural sensitivity in community-based primary care clinics

OBJECTIVE: To develop and test the reliability of three race/ethnicity-specific forms of the pilot Tucker-Culturally Sensitive Health Care Inventory (T-CUSHCI) for use by patients at community-based primary care centers to evaluate the level of patient-centered cultural sensitivity perceived in the health care that they experience. METHODS: This research involved two studies using independent samples of primary care patients. In study 1, mostly low-income African-American, Hispanic and non-Hispanic white American patients (N=221) rated the importance of specific provider and office staff behaviors and attitudes, and center policies and physical environment characteristics that were earlier identified in previous focus groups as characteristics of patient-centered culturally sensitive healthcare. In study 2, three pilot race/ethnicity-specific T-CUSHCI patient forms were constructed from the items rated as at least important in study 1. Mostly low-income African-American and non-Hispanic white American patients (N=180) provided data to determine the reliability of the T-CUSHCI patient form for their racial/ethnic group. RESULTS: The pilot T-CUSHCI-African-American patient form and the pilot T-CUSHCI-non-Hispanic white American patient form were found to have Cronbach's alpha coefficients ranging from 0.71-0.96 and six-month test-retest and split-half reliabilities ranging from 0.92-0.99. CONCLUSION: The pilot T-CUSHCI patient forms (one each for African Americans, Hispanics and non-Hispanic whites) should be further tested using a national sample of patients. In the interim, these inventory forms can be used as clinical tools to obtain patient feedback for providing "individualized" patient-centered culturally sensitive healthcare.     

Coaching and guidance with patient decision aids: A review of theoretical and empirical evidence

Background

Coaching and guidance are structured approaches that can be used within or alongside patient decision aids (PtDAs) to facilitate the process of decision making. Coaching is provided by an individual, and guidance is embedded within the decision support materials. The purpose of this paper is to: a) present updated definitions of the concepts “coaching” and “guidance”; b) present an updated summary of current theoretical and empirical insights into the roles played by coaching/guidance in the context of PtDAs; and c) highlight emerging issues and research opportunities in this aspect of PtDA design.

Methods

We identified literature published since 2003 on shared decision making theoretical frameworks inclusive of coaching or guidance. We also conducted a sub-analysis of randomized controlled trials included in the 2011 Cochrane Collaboration Review of PtDAs with search results updated to December 2010. The sub-analysis was conducted on the characteristics of coaching and/or guidance included in any trial of PtDAs and trials that allowed the impact of coaching and/or guidance with PtDA to be compared to another intervention or usual care.

Results

Theoretical evidence continues to justify the use of coaching and/or guidance to better support patients in the process of thinking about a decision and in communicating their values/preferences with others. In 98 randomized controlled trials of PtDAs, 11 trials (11.2%) included coaching and 63 trials (64.3%) provided guidance. Compared to usual care, coaching provided alongside a PtDA improved knowledge and decreased mean costs. The impact on some other outcomes (e.g., participation in decision making, satisfaction, option chosen) was more variable, with some trials showing positive effects and other trials reporting no differences. For values-choice agreement, decisional conflict, adherence, and anxiety there were no differences between groups. None of these outcomes were worse when patients were exposed to decision coaching alongside a PtDA. No trials evaluated the effect of guidance provided within PtDAs.

Conclusions

Theoretical evidence continues to justify the use of coaching and/or guidance to better support patients to participate in decision making. However, there are few randomized controlled trials that have compared the effectiveness of coaching used alongside PtDAs to PtDAs without coaching, and no trials have compared the PtDAs with guidance to those without guidance.

     

Motivational interviewing and shared decision making in primary care

Objective

The aim of this study was to assess general practitioners’ (GP) readiness to involve obese patients in therapy decision making and to determine whether they integrate motivational interviewing techniques.

Methods

Fifty-eight preventive Check-up 35 encounters with overweight and obese patients in primary care were audio recorded in 12 GP practices. The use of motivational interviewing techniques was rated with the Behavior Change Counseling Index (BECCI). The involvement in medical decisions was rated with the Observing Patient Involvement Scale (OPTION).

Results

OPTION and BECCI scores were low (means = 0.71 and 1.65), indicating minimal implementation of shared decision making and motivational interviewing in preventive encounters with these patients. GPs used more motivational interviewing for patients with a BMI > 30 kg/m² than for those with a BMI < 30 kg/m². Female GPs had significantly higher shared decision making scores, indicating that they prefer to involve patients in medical decisions. GPs differed significantly in their use of both approaches.

Conclusions

Shared decision making and motivational interviewing, though known to be successful strategies in lifestyle counseling, are rarely used during obesity encounters in our sample of German GPs.

Practice implications

GPs should be sensitized and trained in the application of these methods.     

Prevalence of chronic fatigue and chronic fatigue syndrome in Korea: community-based primary care study

There have been many epidemiological and clinical researches on chronic fatigue (CF) and chronic fatigue syndrome (CFS) since the 1990s, but such studies have been quite limited in Korea. The aim of this study was to investigate the point prevalence of CF and CFS in patients who visited community-based eight primary care clinics in Korea. The study subjects were 1,648 patients aged 18 yr and over who visited one of eight primary care clinics in Korea between the 7th and 17th of May 2001. The physicians determined the status of the subjects through fatigue-related questionnaires, medical history, physical examination, and laboratory tests. The subjects were categorized into no fatigue, prolonged fatigue, CF and then CF were further classified to medically explained CF (Physical CF and Psychological CF) and medically unexplained CF (CFS and idiopathic chronic fatigue). The point prevalence of CF and CFS were 8.4% (95% CI 7.1-9.7%) and 0.6% (95% CI 0.2-1.0%). Medically explained CF was 80.5% of CF, of which 57.1% had psychological causes. The clinical characteristics of CFS were distinguished from explained CF. CF was common but CFS was rare in community-based primary care settings in Korea.