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.     

The many “Disguises” of patient-centered communication: Problems of conceptualization and measurement

ObjectiveTo critically examine different approaches to the measurement of patient-centered communication.MethodsProvides a critique of 7 different measures of patient-centered communication with respect to differences in their assumptions about what constitutes patient-centeredness and in their approaches to measurement.ResultsThe measures differed significantly with regard to whether the measure captured behavior (what the interactants did) or judgment (how well the behavior was performed), focused on the individual clinician or on the interaction as a whole, and on who makes the assessment (participant or observer). A multidimensional framework for developing patient-centered communication measures is presented that encompasses the patient’s perspective and participation, the biopsychosocial context of the patient’s health, the clinician-patient relationship, quality of information-exchange, shared understanding, and shared, evidence-based decision-making.ConclusionsThe state of measurement of the patient-centered communication construct lacks coherence, in part because current measures were developed either void of a conceptual framework or from very different theoretical perspectives.Practice implicationsAssessment of patients’ experiences with quality of communication in medical encounters should drill down into specific domains of patient-centeredness.     

Opportunities and limitations of shared decision making in multidisciplinary tumor conferences with patient participation – A qualitative interview study with providers

ObjectiveThe aim of this study was to examine opportunities and limitations of shared decision making in multidisciplinary tumor conferences with patient participation from the providers’ perspective in breast and gynecological cancer centers.MethodsSemi-structured guideline-based expert interviews were conducted with providers from breast and gynecological cancer centers with and without patient participation in multidisciplinary tumor conferences. Interviews were transcribed, anonymized and analyzed using qualitative content analysis.ResultsThe providers (n = 30) reported that some process steps of shared decision making can be implemented in limited form and under certain conditions in multidisciplinary tumor conferences with patient participation. Above all, patients can potentially ask questions and contribute individual additional information and their preferences.ConclusionThis study contributes first insights into the implementation of shared decision making in multidisciplinary tumor conferences with patient participation. From the providers’ perspective, the implementation of shared decision making seems difficult under the current circumstances. Further studies, using patient experiences, participative observations or interventional designs, are required.Practice ImplicationsDespite the limited implementation of shared decision making in tumor conferences, patient participation can be advantageous as it can allow patients to ask questions and contribute individual additional information as well as their preferences.     

Prostate-specific health-related quality of life and patient-physician communication — A 3.5-year follow-up

ObjectiveThe aim of this study is to examine associations between prostate-specific health-related quality of life (HRQOL) and aspects of patient-physician communication in localized prostate cancer treatment.MethodsData of patients with localized prostate cancer were collected at 6-month intervals over a 3.5-year period within a prospective, observational study (HAROW). Data collection comprised D’Amico risk categories, the Charlson Comorbidity Index, patient-physician communication (information, shared decision making, support, devotion), and prostate-specific HRQOL (incontinence aid, urinary symptoms, bowel symptoms, hormonal treatment-related symptoms, sexual functioning, sexual activity). Data of N = 1722 patients undergoing radical prostatectomy were analyzed by longitudinal multilevel analysis.ResultsThe mean patient age was 65 years; 31% had a low risk and 38% an intermediate risk of cancer growth and spread; 73% had a Charlson Comorbidity Index of 0. Significant associations were found between prostate-specific HRQOL and shared decision making, support and devotion. Patient information was not significantly associated with aspects of prostate-specific HRQOL.ConclusionPatient reported long term outcomes are associated with aspects of patient-physician communication in prostate cancer patients. Patients feeling involved by their urologists experience less side effects of (surgical) treatment.Practice implicationsSpecial communication training programmes should be developed and implemented for urologists.     

A longitudinal study of third-year medical students’ communication competence,communication anxiety,and attitudes toward patient-centered care

ObjectiveWe investigated changes in medical students’ communication competence and communication anxiety during their third year of training when they are immersed in formative clinical experiences that shape their patient-centered care and communication skills.MethodsWe invited 282 students to complete a longitudinal, four-phase online survey during their third-year. Our response rate was 62.8% at Phase I (n = 177), 34.0% at Phase II (n = 96), 37.9% at Phase III (n = 107), and 48.9% at Phase IV (n = 138). Measures included communication competence, communication anxiety, and patient-centered attitudes and orientation. We employed hierarchical linear modeling to analyze the data.ResultsStudents’ communication competence and anxiety improved over time. Female students reported greater communication anxiety and less competence related to information giving. At each phase, patient-centered attitudes significantly predicted communication competence and communication anxiety.ConclusionStudents’ competence and anxiety regarding communication during medical encounters improve during their third year and are significantly influenced by their attitudes and orientation towards patient-centered care and communication.Practice implicationsSchools should integrate curriculum that fosters positive attitudes toward patient-centered communication and provides opportunities to practice complex communication skills, which may increase competence and recognition that patient-centered communication is an important clinical skill.     

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.

Dumping the information bucket: A qualitative study of clinicians caring for patients with early stage non-small cell lung cancer

ObjectiveTo evaluate the quality of patient-clinician communication and shared decision making (SDM) when two disparate treatments for early stage non-small cell lung cancer (NSCLC) are discussed.MethodsWe conducted a qualitative study to evaluate the experiences of 20 clinicians caring for patients with clinical Stage I NSCLC prior to treatment, focusing on communication practices. We used directed content analysis and a patient-centered communication theoretical model to guide understanding of communication strategies.ResultsAll clinicians expressed the importance of providing information, especially for mitigating patient worry, despite recognition that patients recall only a small amount of the information given. When patients expressed distress, clinicians exhibited empathy but preferred to provide more information in order to address patient concerns. Most clinicians reported practicing SDM, however, they also reported not clearly eliciting patient preferences and values, a key part of SDM.ConclusionCommunication with patients about treatment options for early stage NSCLC primary includes information giving. We found that only a few communication domains associated with SDM occurred regularly, and SDM may not be necessary in this clinical context.Practice implicationsClinicians may need to incorporate nurse navigators or more written materials for effectively discussing potentially equivalent treatment options with their patients.     

Communicating to promote informed decisions in the context of early pregnancy loss

ObjectiveTo evaluate residents’ ability to engage standardized patients in informed decision making during a pregnancy loss scenario.MethodsForty patient encounters between interns and standardized patients were coded to assess informed decision-making practices, exploration of unexpressed concerns, and support provision.ResultsInterns engaged in minimum informed decision making but did not address all of the communicative elements necessary for informed decisions, and most elements were only partially addressed. Patients in this study did not receive information about all management options, their concerns were not addressed, and there was limited support communicated for their decision.ConclusionThis study offers an initial assessment of a communicative approach to evaluate and improve decision making during early pregnancy loss. A comprehensive approach to making informed decisions must include discussion of all management options, exploration of patient preferences and concerns, and support for the patient’s decision.Practice implicationsPhysicians could benefit from communication skills training to communicate more effectively with patients to help them make more informed decisions.     

Implementation,participation and satisfaction rates of a web-based decision support tool for patients with metastatic colorectal cancer

ObjectiveTo examine implementation and patients’ and providers’ participation and satisfaction of a newly developed decision support tool (DST) for patients with metastatic colorectal cancer (mCRC) in palliative setting.MethodsOur DST consisted of a consultation sheet and web-based tailored information for mCRC treatment options. We conducted an implementation trajectory in 11 Dutch hospitals and evaluated implementation, participation and satisfaction rates.ResultsImplementation rates fluctuated between 3 and 72 handed out (median:23) consultation sheets per hospital with patients’ login rates between 36% and 83% (median:57%). The majority of patients (68%) had (intermediate)-high participation scores. The median time spent using the DST was 38 min (IQR:18–56) and was highest for questions concerning patients’ perspective (5 min). Seventy-six% of patients were (very) satisfied. The provider DST rating was 7.8 (scale 1–10) and participation ranged between 25 and 100%. Remaining implementation thresholds included providers’ treatment preferences, resistance against shared decision-making and (over)confidence in shared decision-making concepts already in use.ConclusionWe implemented a DST with sufficient patient and oncologist satisfaction and high patient participation, but participation differed considerably between hospitals suggesting unequal adoption of our tool.Practice implicationsRequirements for structural implementation are to overcome remaining thresholds and increase awareness for additional decision support.     

Agreement of physician and patient ratings of communication in medical encounters: A systematic review and meta-analysis of interrater agreement

ObjectiveTo determine the agreement of physician and patient ratings of communication in medical face-to-face consultations.MethodsA systematic search of twelve databases was conducted. Studies investigating agreement between physician and patient ratings of communication in medical face-to-face encounters and reporting interrater agreement were included. Methodological quality was assessed, and study characteristics and physician-patient agreement were narratively summarized. Meta-analysis was conducted for a subsample of the included studies investigating shared decision making.ResultsOf the 17 included studies, ten studies did not demonstrate any correspondence between physician and patient ratings. The remaining seven studies revealed poor to fair absolute agreement (κ between .13 and .42; κ_w between .31 and .49; 95% CI 0.13 – 0.76) and poor to moderate consistency (r = .17 and .06; r_polyc between .39 and .63; p < .05). Meta-analysis of six studies yielded small association (r_polyc = .15).ConclusionPhysicians and patients evaluate communication differently and at best, only slightly agree in their ratings, indicating that the construct of communication is not measurable in a stable manner.Practice implicationsDecision makers and researchers should be aware that they assess different aspects of communication, depending on the perspective examined.PROSPERO registration number: CRD42019120065     

Relationship of patient-centered communication and cancer risk information avoidance: A social cognitive perspective

ObjectiveWe examined the relationship between patient-centered communication and cancer risk information avoidance and estimated the mediating role of self-efficacy in this relationship.MethodsUsing nationally representative cross-sectional data from the U.S. Health Information National Trends Survey (N = 2033), this study aims to provide a comprehensive understanding of the relationship between patient-centered communication and cancer risk information avoidance via correlation analysis, stepwise regression models, and mediation analysis.ResultsPatient-centered communication was significantly negatively associated with cancer risk information avoidance (β= −0.09, p < 0.01) after controlling for gender, income, education, and cancer risk perception. Self-efficacy fully mediated the relationship of patient-centered communication with cancer risk information avoidance.ConclusionPatient-centered communication can improve patients’ self-efficacy, thereby preventing them from avoiding cancer risk information.Practice implicationsThe negative relationship between patient-centered communication and cancer risk information avoidance substantiates that improving patient-centered communication is a promising approach to support caregivers in their activities, reduce patients’ subjective cancer burden, and even improve their health. To address cancer-related issues, policymakers can consider interventions from the external environment and internal personal cognition perspectives.     

Randomized trial of a question prompt list to increase patient active participation during interactions with black patients and their oncologists

ObjectiveCommunication during racially-discordant interactions is often of poor quality and may contribute to racial treatment disparities. We evaluated an intervention designed to increase patient active participation and other communication-related outcomes during interactions between Black patients and non-Black oncologists.MethodsParticipants were 18 non-Black medical oncologists and 114 Black patients at two cancer hospitals in Detroit, Michigan, USA. Before a clinic visit to discuss treatment, patients were randomly assigned to usual care or to one of two question prompt list (QPL) formats: booklet (QPL-Only), or booklet and communication coach (QPL-plus-Coach). Patient-oncologist interactions were video recorded. Patients reported perceptions of the intervention, oncologist communication, role in treatment decisions, and trust in the oncologist. Observers assessed interaction length, patient active participation, and oncologist communication.ResultsThe intervention was viewed positively and did not increase interaction length. The QPL-only format increased patient active participation; the QPL-plus-Coach format decreased patient perceptions of oncologist communication. No other significant effects were found.ConclusionThis QPL booklet is acceptable and increases patient active participation in racially-discordant oncology interactions. Future research should investigate whether adding physician-focused interventions might improve other outcomes.Practice implicationsThis QPL booklet is acceptable and can improve patient active participation in racially-discordant oncology interactions.     

What perceptions do patients have of decision making (DM)? Toward an integrative patient-centered care model. A qualitative study using focus-group interviews

Objective

To understand patients’ perceptions of decision making and identify relationships among decision-making models.

Methods

This qualitative study was made up of four focus group interviews (elderly persons, users of health support groups, students, and rural inhabitants). Participants were asked to report their perceptions of decision making in three written clinical scenarios (hypertension, breast cancer, prostate cancer). The analysis was based on the principles of grounded theory.

Results

Most patients perceived decision making as shared decision making, a deliberative question–response interaction with the physician that allowed patients to be experts in obtaining clearer information, participating in the care process, and negotiating compromises with physician preferences. Requesting second opinions allowed patients to maintain control, even within the paternalistic model preferred by elderly persons. Facilitating factors (trust, qualitative non-verbal communication, time to think) and obstacles (serious/emergency situations, perceived inadequate scientific competence, problems making requests, fear of knowing) were also part of shared decision making.

Conclusion and practice implications

In the global concept of patient-centered care, shared decision making can be flexible and can integrate paternalistic and informative models. Physicians’ expertise should be associated with biomedical and relational skills through listening to, informing, and advising patients, and by supporting patients’ choices.     

Missed opportunity? Caregiver participation in the clinical encounter. A videographic analysis

Objective

Although the assistance of caregivers is critical to patients undertaking self-care, little is known about their participation in visits and involvement in decision making. We sought to examine this caregiver participation in shared decision making through videographic analysis.

Methods

We identified video recordings from outpatient visits in which a healthcare professional, patient, and caregiver participated, drawn from five practice-based randomized trials testing the efficacy of decision aids vs. usual care. Two reviewers, working independently, coded videos to explore caregiver engagement in the clinical encounter, clinician facilitation of that engagement, and the influence of decision aids in the engagement process.

Results

In most of the 37 videos coded, caregivers’ participation was self-triggered. We saw no impact of the use of decision aids on caregiver participation. Clinicians did not address the caregivers’ preferred level of involvement in decision making in any of the video recorded encounters analyzed.

Conclusion

In this analysis, most clinicians did not engage caregivers in outpatient visits for chronic care. While the use of decision aids improves communication between patient and clinician, they do not appear to affect caregiver involvement during consultations.

Practice implications

Research on the comparative effectiveness of ways to engage caregivers to optimize patient-important outcomes, including enhancing the shared decision making process is necessary.     

How well do healthcare professionals know of the priorities of their older patients regarding treatment outcomes?

ObjectivesFor shared decision making, it is crucial to identify patients’ priorities regarding health outcomes. Our aim was to study whether healthcare professionals know these priorities.MethodsIn this cross-sectional study we included older patients who had to make a treatment decision, their general practitioners (GPs) and their medical specialists. Agreement between the patients’ main health outcome as prioritised by using the Outcome Prioritization Tool (OPT) and the perception of the same outcome by their healthcare professionals.ResultsEighty-seven patients were included. Median age was 76 years, 87.4% of patients presented with malignant disease. The majority prioritised maintaining independence (51.7%), followed by extending life (27.6%). The agreement between patients and healthcare professionals was low (GPs 41.7%, kappa 0.067, p = 0.39), medical specialists 40.3%, kappa 0.074, p = 0.33). Positively related to agreement was patient’s age > 75, and a longer relation with their patients (for GPs), and the patient having no partner (for medical specialist). Having a malignant disease, dependent living and functional deficits were negatively related to agreement.ConclusionsHealthcare professionals have poor perceptions of their patients’ priorities.Practice implicationsTo realise patient-centered care, it is crucial to discuss priorities explicitly with all patients.     

The role of weight bias and role-modeling in medical students’ patient-centered communication with higher weight standardized patients

ObjectivePatients with obesity may experience less patient-centered care. We assessed whether medical students’ implicit/explicit weight-related attitudes and perceptions of normative attitudes are associated with patient-centered care for patients with obesity.MethodsThird and fourth year medical students (N = 111) at one medical school completed a survey and participated in a patient care scenario with a standardized patient with obesity. Encounters were coded for patient-centered behavior. Predictors of patient-centered behaviors were assessed.ResultsStudent perceptions that negative attitudes about patients with obesity are normative in medical school were significantly associated with poorer patient-centered behaviors, including lower attentiveness (b=?0.19, p = 0.01), friendliness (b=?0.28, p < 0.001), responsiveness (b=?0.21, p = 0.002), respectfulness (b=?0.17, p = 0.003), interactivity (b=?0.22, p = 0.003), likelihood of being recommended by observers (b=?0.34, p < 0.001), and patient-centeredness index scores (b=?0.16, p = 0.002). Student reported faculty role-modeling of discrimination against patients with obesity predicted lower friendliness (b=?0.16, p = 0.03), recommendation likelihood (b=?0.22, p = 0.04), and patient-centeredness index score (b=?0.12, p = 0.03).ConclusionsNegative normative attitudes and behaviors regarding obesity in the medical school environment may adversely influence the quality of patient-centered behaviors provided to patients with obesity.Practice implicationsEfforts to improve patient-centered communication quality among medical trainees may benefit from intervention to improve group normative attitudes about patients with obesity.     

Evaluating provider communication in pediatric chronic kidney disease care using a global coding system

ObjectiveAmong adolescents and young adults (AYAs) with chronic illness, effective provider communication is essential for patient-centered care during a sensitive developmental period. However, communication in chronic illness care for AYAs is not well studied. Our objectives were to describe the provider communication skills in pediatric chronic kidney disease (CKD) care visits; and determine if communication skills differ by AYA characteristics.MethodsWe adapted a global consultation rating system for pediatric subspecialty care using audiotaped clinic encounters of 18 pediatric nephrologists with 99 AYAs (age M(SD) = 14.9(2.6)) with CKD stages 1–5 and 96 caregivers. We hypothesized that provider communication skills would differ by AYA characteristics (age, gender, and race).ResultsThe strongest provider skills included initiating the session and developing rapport; lowest rated skills were asking patient’s perspective and checking understanding. Communication scores did not consistently differ by AYA age or race, but were rated higher with female AYAs in several domains (ps<0.05).ConclusionsPediatric providers generally had adequate or good communication scores with AYAs, but improvement in certain skills, particularly with male AYAs, may further support patient-centered care.Practice implicationsTo achieve consistent, patient-centered communication with AYAs, an observation-based global assessment may identify areas for provider improvement.     

Shared decision making: Physicians’ preferred role,usual role and their perception of its key components

ObjectiveTo investigate physicians’ preferred and usual roles in decision making in medical consultations, and their perception of shared decision making (SDM).MethodsA cross-sectional survey of 785 physicians in a large Dutch general teaching hospital was undertaken in June 2018, assessing their preferred and usual decision making roles (Control Preference Scale), and their view on SDM key components (SDMQ9 questionnaire).ResultsMost physicians (n = 232, 58%) preferred SDM, but more often performed paternalistic decision making (n = 121, 31%) in daily practice than they preferred (n = 80, 20%, p < 0.0001), most commonly because they judged the patient to be incapable of participating in decision making. Most physicians preferring SDM presented different options for treatment (n = 213, 92%) with their advantages and disadvantages (n = 209, 90%) but fewer made clear that a decision had to be made (n = 104, 45%) or explored the patient’s wish how to be involved in decision making (n = 80, 34%).ConclusionAlthough most physicians prefer SDM, they often revert to a paternalistic approach and tend to limit SDM to discussing treatment options.Practice implicationTeaching physicians in SDM should include raising awareness about discussing the decision process itself and help physicians to counter their tendency to revert to paternalistic decision making in daily practice.