A prospective cohort study of shared decision making in lung cancer diagnostics: Impact of using a patient decision aid

ObjectiveThe objective of this study was to describe the impact on patient-reported outcomes of introducing Shared Decision Making (SDM) and a Patient Decision Aid (PtDA) in the initial process of lung cancer diagnostics.MethodsWe conducted a prospective cohort study, where a control cohort was consulted according to usual clinical practice. After introducing SDM through a PtDA and training of the staff, the SDM cohort was enrolled in the study. All patients completed four questionnaires: the Decisional Conflict Scale (DCS) before and after the consultation, the CollaboRATE scale after the consultation, and the Decision Regret Scale (DRS).ResultsPatients exposed to SDM and a PtDA had significantly improved DCS scores after the consultation compared to the control group (a difference of 10.26, p = 0.0128) and significantly lower DRS scores (a difference of 8.98, p = 0.0197). Of the 82 control patients and 52 SDM patients 29% and 54%, respectively, gave the maximum score on the CollaboRATE scale (Pearson’s chi² 8.0946, p = 0.004).ConclusionThe use of SDM and a PtDA had significant positive impact on patient-reported outcomes.Practice implicationsOur results may encourage the increased uptake of SDM in the initial process of lung cancer diagnostics.     

Keeping the patient in the center: Common challenges in the practice of shared decision making

Objective

To examine situations where shared decision making (SDM) in practice does not achieve the goal of a patient-centered decision.

Decision making in depression: differences in decisional conflict between healthy and depressed individuals

This study investigated differences in the emergence of decisional conflict in healthy and depressed participants. The two groups of interest were questioned about their experience of decisional conflict and ongoing thoughts and impressions during decision making. As predicted, depressed participants experienced more decisional conflict than healthy participants. Furthermore, the diverse processes hypothesis was supported: In healthy participants, preoccupation with the task was the only predictor of decisional conflict. In depressed participants, decisional conflict was predicted by a combination of depression‐related processes (e.g., low self‐efficacy, lack of concentration, rumination, etc.). This research reduces the gap between the relevance of the symptom of indecisiveness (e.g., for diagnostic purposes) and the lack of knowledge in this realm of psychopathology. Copyright © 2009 John Wiley & Sons, Ltd. Key Practitioner Message:

• Depressed inpatients report more every day decisional conflict than healthy people. Practitioners should be aware of this symptom of depression that has not received much attention in research and practice yet.
• Beyond this quantitative difference, there is also a qualitative difference between the decisional conflict experienced by depressed and healthy individuals: While healthy individuals' decisional conflict revolves around a thorough consideration of the decision task, depressed individuals' decisional conflict seems to be characterized by an inward focus of attention. They engage in an evaluation of their personal resources and competences as a decision maker.
• Improving self‐efficacy and reducing feelings of helplessness related to decision making should alleviate decisional conflict in depressed people. These means may thus constitute a powerful intervention to reduce every day stress for patients and enhance recovery from depression.
• This research highlights the detrimental effects of self‐focused thinking in depression. Decision making seems to be another task that is negatively affected by this type of depressogenic thinking. Interventions tackling depressive rumination appear beneficial in the light of this study.

     

Twelve myths about shared decision making

Objective

As shared decision makes increasing headway in healthcare policy, it is under more scrutiny. We sought to identify and dispel the most prevalent myths about shared decision making.

Methods

In 20 years in the shared decision making field one of the author has repeatedly heard mention of the same barriers to scaling up shared decision making across the healthcare spectrum. We conducted a selective literature review relating to shared decision making to further investigate these commonly perceived barriers and to seek evidence supporting their existence or not.

Results

Beliefs about barriers to scaling up shared decision making represent a wide range of historical, cultural, financial and scientific concerns. We found little evidence to support twelve of the most common beliefs about barriers to scaling up shared decision making, and indeed found evidence to the contrary.

Conclusion

Our selective review of the literature suggests that twelve of the most commonly perceived barriers to scaling up shared decision making across the healthcare spectrum should be termed myths as they can be dispelled by evidence.

Practice implications

Our review confirms that the current debate about shared decision making must not deter policy makers and clinicians from pursuing its scaling up across the healthcare continuum.     

General practitioners' views on shared decision making: a qualitative analysis

Despite rhetoric about increasing partnership in the consultation, shared decision making (SDM) is not necessarily happening in practice. As patient involvement in decision making cannot be achieved without general practitioners’ (GPs) co-operation, attention to their concerns is essential. Previous research has used simulated patients to explore this area. Here, data from consultations and interviews with patients and GPs were used in focus group discussions enabling GPs to ground their views of the practical application of SDM in their own and other participants’ real life practice. The following ideas were discussed; what constitutes SDM in practice, negotiation about treatment, perceptions of patients’ viewpoints and perceived barriers to SDM. Agreement with SDM in theory may not translate into practice. The process outlined is being developed in order to establish whether the techniques could provide a supportive environment in which GPs can make changes to their practice to increase patient participation.     

Measuring critical deficits in shared decision making before elective surgery

Objective

Identifying patient factors correlated with specific needs in preoperative decision making is of clinical and ethical importance. We examined patterns and predictors of deficiencies in informed surgical consent and shared decision-making in preoperative patients.

Methods

Validated measures were used to survey 1034 preoperative patients in the preoperative clinic after signed informed consent. Principal component analysis defined correlated groupings of factors. Multivariable analysis assessed patient factors associated with resultant groupings.

Results

13% of patients exhibited deficits in their informed consent process; 33% exhibited other types of deficits. Informed consent deficits included not knowing the procedure being performed or risks and benefits. Other deficits included not having addressed patient values, preferences and goals. Non-English language and lower educational level were factors correlated with higher risk for deficits.

Conclusion

Deficits exist in over a third of patients undergoing preoperative decision-making. Sociodemographic factors such as language and educational level identified particularly vulnerable groups at risk for having an incomplete, and possibly ineffective, decision-making process.

Practice implications

Interventions to identify vulnerable groups and address patient centered surgical decision making in the pre-operative setting are needed. Focused interventions to address the needs of at-risk patients have potential to improve the surgical decision-making process and reduce disparities.     

An integrative model of shared decision making in medical encounters

OBJECTIVE: Given the fluidity with which the term shared decision making (SDM) is used in teaching, assessment and research, we conducted a focused and systematic review of articles that specifically address SDM to determine the range of conceptual definitions. METHODS: In April 2005, we ran a Pubmed (Medline) search to identify articles published through 31 December 2003 with the words shared decision making in the title or abstract. The search yielded 681 citations, 342 of which were about SDM in the context of physician-patient encounters and published in English. We read and reviewed the full text of all 342 articles, and got any non-redundant references to SDM, which yielded an additional 76 articles. RESULTS: Of the 418 articles examined, 161 (38.5%) had a conceptual definition of SDM. We identified 31 separate concepts used to explicate SDM, but only "patient values/preferences" (67.1%) and "options" (50.9%) appeared in more than half the 161 definitions. Relatively few articles explicitly recognized and integrated previous work. CONCLUSION: Our review reveals that there is no shared definition of SDM. We propose a definition that integrates the extant literature base and outlines essential elements that must be present for patients and providers to engage in the process of SDM. PRACTICE IMPLICATIONS: The integrative definition of SDM is intended to provide a useful foundation for describing and operationalizing SDM in further research.     

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.     

Developing CollaboRATE: A fast and frugal patient-reported measure of shared decision making in clinical encounters

Objective

Measuring the process of shared decision making is a challenge, which constitutes a barrier to research and implementation. The aim of the study was to report the development of CollaboRATE, brief patient-reported measure of shared decision making.

Methods

We used the following stages: (1) item formulation; (2) cognitive interviews; (3) item refinement; and (4) pilot testing of final items. Participants were over 18 years old, recruited from the public areas of the Dartmouth-Hitchcock Medical Center.

Results

The key finding of this study is that developing a brief patient-reported measure of shared decision making requires a move away from terms such as ‘decisions’, ‘options’ and ‘preferences’. Although technically correct, these terms act as barriers. They are often unfamiliar, and they also implicitly assume that patients are willing to take active roles in decision making; whereas patients are often unaware that decisions are required, or have taken place, never mind feel that they could or should have participated in them.

Conclusion

These methods have allowed us to develop a brief, patient-reported measure of shared decision making that is highly accessible to intended users.

Practice implications

The potential strength of the CollaboRATE will be the ability for completion in less than 30 s, and across a range of routine settings.     

Understanding patient perceptions of shared decision making

Objective

This study aims to develop a conceptual model of patient-defined SDM, and understand what leads patients to label a specific, decision-making process as shared.

Methods

Qualitative interviews were conducted with 23 primary care patients following a recent appointment. Patients were asked about the meaning of SDM and about specific decisions that they labeled as shared. Interviews were coded using qualitative content analysis.

Results

Patients’ conceptual definition of SDM included four components of an interactive exchange prior to making the decision: both doctor and patient share information, both are open-minded and respectful, patient self-advocacy, and a personalized physician recommendation. Additionally, a long-term trusting relationship helps foster SDM. In contrast, when asked about a specific decision labeled as shared, patients described a range of interactions with the only commonality being that the two parties came to a mutually agreed-upon decision.

Conclusion

There is no one-size-fits all process that leads patients to label a decision as shared. Rather, the outcome of “agreement” may be more important than the actual decision-making process for patients to label a decision as shared.

Practice implications

Studies are needed to better understand how longitudinal communication between patient and physicians and patient self-advocacy behaviors affect patient perceptions of SDM.     

Humanistic communication in the evaluation of shared decision making: A systematic review

Objective

To assess the extent to which evaluations of shared decision making (SDM) assess the extent and quality of humanistic communication (i.e., respect, compassion, empathy).

Psychiatric patients' attitudes towards concordance and shared decision making

Objectives

To assess psychiatric outpatients’ attitudes towards concordance and shared decision making in a psychiatric setting and to evaluate the role that self-perceived knowledge and beliefs about psychiatric medicines play in those attitudes.

Methods

The Leeds Attitude to Concordance Scale (LATCon) was tested on a sample of 435 psychiatric outpatients. Principal Component Analysis was used to assess the structure of LATCon items. Regression analysis on LATCon scores was performed with sociodemographics, Belief about Medicines Questionnaire (BMQ) subscales, self-perceived knowledge, perceived psychiatrist behaviour and current medications as predictor variables.

Results

The LATCon scale showed a good factorial validity, with a monofactorial structure and high internal consistency. Psychiatric outpatients tended to be in agreement with the concept of concordance, but they did not share some relevant aspects of the construct. Cognitive representations of psychiatric medications, assessed by the BMQ subscales, significantly predicted scores on the LATCon scale.

Conclusion

Psychiatric outpatients show a considerable desire to participate in decision making about their treatment. The Spanish version of the LATCon Scale seems to be a valid instrument.

Practice implications

Psychiatrists must consider their patients’ desire to participate in treatment decisions and explore how patients’ views about psychiatric medications influence their attitudes towards concordance.     

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.     

Educational programs to teach shared decision making to medical trainees: A systematic review

ObjectiveShared decision-making (SDM) is a process of collaboration between patients and clinicians. An increasing number of educational programs to teach SDM have been developed. We aimed to summarize and evaluate the body of evidence assessing the outcomes of these programs.MethodsWe conducted a systematic review of studies that aimed to teach SDM to medical trainees. Reviewers worked independently and in duplicate to select studies, extract data and evaluate the risk of bias.ResultsEighteen studies were included. Most studies focused on residents/fellows (61 %) and combined a didactic component with a practical experience (50 % used a standardized patient). Overall, participants reported satisfaction with the courses. The effects on knowledge, attitudes/confidence and comfort with SDM were small; no clear improvement on SDM skills was noted. Evaluation of clinical behavior and outcomes was limited (3/18 studies). Studies had moderate risk of bias.ConclusionVery low quality evidence suggests that educational programs for teaching SDM to medical trainees are viewed as satisfactory and have a small impact on knowledge and comfort with SDM. Their impact on clinical skills, behaviors and patient outcomes is less clear.Practical implicationsIntegration of formal and systematic outcomes evaluation (effects on behavior/clinical practice) should be part of future programs.     

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

Objective

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

Methods

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

Results

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

Conclusions

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

Practice implications

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

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.     

Development and field testing of a decision support tool to facilitate shared decision making in contraceptive counseling

ObjectiveWe developed and formatively evaluated a tablet-based decision support tool for use by women prior to a contraceptive counseling visit to help them engage in shared decision making regarding method selection.MethodsDrawing upon formative work around women’s preferences for contraceptive counseling and conceptual understanding of health care decision making, we iteratively developed a storyboard and then digital prototypes, based on best practices for decision support tool development. Pilot testing using both quantitative and qualitative data and cognitive testing was conducted. We obtained feedback from patient and provider advisory groups throughout the development process.ResultsNinety-six percent of women who used the tool in pilot testing reported that it helped them choose a method, and qualitative interviews indicated acceptability of the tool’s content and presentation. Compared to the control group, women who used the tool demonstrated trends toward increased likelihood of complete satisfaction with their method. Participant responses to cognitive testing were used in tool refinement.ConclusionOur decision support tool appears acceptable to women in the family planning setting.Practice implicationsFormative evaluation of the tool supports its utility among patients making contraceptive decisions, which can be further evaluated in a randomized controlled trial.