Shared decision-making--transferring research into practice: the Analytic Hierarchy Process (AHP)

Objective

To illustrate how the Analytic Hierarchy Process (AHP) can be used to promote shared decision-making and enhance clinician–patient communication.

Methods

Tutorial review.

Results

The AHP promotes shared decision-making by creating a framework that is used to define the decision, summarize the information available, prioritize information needs, elicit preferences and values, and foster meaningful communication among decision stakeholders.

Conclusions

The AHP and related multi-criteria methods have the potential for improving the quality of clinical decisions and overcoming current barriers to implementing shared decision-making in busy clinical settings. Further research is needed to determine the best way to implement these tools and to determine their effectiveness.

Practice implications

Many clinical decisions involve preference-based trade-offs between competing risks and benefits. The AHP is a well-developed method that provides a practical approach for improving patient–provider communication, clinical decision-making, and the quality of patient care in these situations.     

Shared decision-making about colorectal cancer screening: A conceptual framework to guide research

Objective

To develop a conceptual framework to guide research on shared decision-making about colorectal cancer (CRC) screening among persons at average risk and their providers.

Methods

Based upon a comprehensive review of empirical literature and relevant theories, a conceptual framework was developed that incorporated patient characteristics, cultural beliefs, provider/health care system variables, health belief/knowledge/stage of adoption variables, and shared decision-making between patients and providers that may predict behavior. Relationships among concepts in the framework, shared decision-making process and outcomes, and CRC screening behavior were proposed. Directions for future research were presented.

Results

Many of the concepts in the proposed framework have been examined in prior research. However, these elements have not been combined previously to explain shared decision-making about CRC screening.

Conclusion

Research is needed to test the proposed relationships and hypotheses and to refine the framework.

Practice Implications

Findings from future research guided by the proposed framework may inform clinical practice to facilitate shared decision-making about CRC screening.     

Developing a model of decision-making about complementary therapy use for patients with cancer: A qualitative study

Objective

To improve our understanding of patient participation in health care consultations and decision-making by exploring a consultation that lies at the interface between mainstream care and complementary therapies.

Methods

Thirty-four holistic consultations were observed at centres offering complementary therapies for cancer, followed by interviews with patients and focus groups with professionals.

Results

A model of decision-making about complementary therapy use emerged from the data: ‘Advice: Assessor led decision’, ‘Confirmation: Joint decision’, ‘Access: Patient-led decision’ and ‘Informed: Patient-led decision’. Decision-making style was contingent on identifiable communication strategies in the preceding information-sharing and discussion phases of the consultation.

Conclusion

This study confirms the importance of gauging patients’ preferences for level of participation in decision-making. Models of consultations are generally based on the assumption that a greater degree of patient participation is a good thing that access to information and decision-making power is sought by all patients. Data from this study suggest that, in this context at least, this is not necessarily the case. The study also stresses the dynamic nature of the consultation, in which roles are fluid rather than fixed.

Practice implications

Insight were gained into professionals’ communication strategies and patients’ role preferences in decision-making, which may be applicable more widely.     

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.     

Inconsistencies in patient perceptions and observer ratings of shared decision making: The case of colorectal cancer screening

Objective

To compare patient-reported and observer-rated shared decision making (SDM) use for colorectal cancer (CRC) screening and evaluate patient, physician and patient-reported relational communication factors associated with patient-reported use of shared CRC screening decisions.

Methods

Study physicians are salaried primary care providers. Patients are insured, aged 50–80 and due for CRC screening. Audio-recordings from 363 primary care visits were observer-coded for elements of SDM. A post-visit patient survey assessed patient-reported decision-making processes and relational communication during visit. Association of patient-reported SDM with observer-rated elements of SDM, as well as patient, physician and relational communication factors were evaluated using generalized estimating equations.

Results

70% of patients preferred SDM for preventive health decisions, 47% of patients reported use of a SDM process, and only one of the screening discussions included all four elements of SDM per observer ratings. Patient report of SDM use was not associated with observer-rated elements of SDM, but was significantly associated with female physician gender and patient-reported relational communication.

Conclusion

Inconsistencies exist between patient reports and observer ratings of SDM for CRC screening.

Practice implications

Future studies are needed to understand whether SDM that is patient-reported, observer-rated or both are associated with informed and value-concordant CRC screening decisions.     

Treatment decision-making in the medical encounter: Comparing the attitudes of French surgeons and their patients in breast cancer care

Objectives

To explore attitudes of French surgeons and their patients towards treatment decision-making (TDM) in the medical encounter.

Methods

Surgeons involved in early stage breast cancer and their patients treated in a French cancer care network received a cross-sectional survey questionnaire containing examples of four different approaches to TDM: paternalistic, “some sharing”, informed TDM and, shared TDM.

Results

Surgeons’ interaction styles were clearly distributed among paternalistic, shared and mixed. The paternalistic approach seemed to be associated with private rather than public practice and with less professional experience. Patients reported a rather low level of participation in TDM, varying by socio-demographic characteristics. One third of patients were dissatisfied with the way their treatment decision had been made.

Conclusion

Most surgeons reported adopting the “some sharing” approach. However, one patient out of three reported that they would have liked to participate more in the TDM process.

Practice implications

Surgeons need to ask patients what their preferences for involvement in TDM are and then think about ways to accommodate both their own and patients’ preferences regarding the TDM process to be used in each encounter. In addition, decision aids could be offered to surgeons to help them discuss treatment options with their patients.     

Shared decision-making in ongoing outpatient psychiatric treatment

Objective

Research on patient involvement in decision-making in psychiatry has focused on first encounters. This study investigated what decisions are made, level of patient involvement and factors influencing patient involvement in ongoing outpatient visits.

Methods

72 visits conducted by 20 psychiatrists were video recorded. Patients had a diagnosis of depression or schizophrenia.

Results

On average, there was one medication related and one other decision per visit. Some psychiatrists involved patients more in decisions, as did female psychiatrists. Involvement was lower when patients had more negative symptoms.

Conclusion

Involvement in decision-making appears to be influenced by the individual psychiatrist and specific symptoms but not visit length.

Practice implications

It is noteworthy that patient involvement is not influenced by length of the visit given that this would be a barrier in busy clinical practice. The next step would be to identify the communication patterns of psychiatrists who involve patients more in decision-making.     

Adaptive Conjoint Analysis as individual preference assessment tool: Feasibility through the internet and reliability of preferences

Objective

Patient values are not routinely assessed in clinical practice. Adaptive Conjoint Analysis (ACA) is increasingly applied in studies assessing treatment preferences, and could provide a means to routinely assess individual patients’ treatment preferences.

Methods

An ACA-questionnaire was administered three times (7–10 days apart) to 98 long-term rectal cancer survivors either on a portable computer or through internet, to assess whether (a) responses differ according to administration mode, (b) relative importances of rectal cancer treatment outcomes (survival, local control, incontinence, sexual problems) consolidate over time, (c) ACA-outcomes are sufficiently reliable (ICC) for use in individual decision-making. We also evaluated patients’ acceptance of ACA.

Results

Mode did not affect ACA-completion or evaluation. Importance scores did not consolidate over time. ICCs were poor for sexual problems and fair for the other outcomes, and were at least equal or higher from first to second retest. Most participants valued completing the ACA-questionnaire and learning their results.

Conclusion

Values did not show consolidation over time. ACA-derived preferences should not determine which treatment patients should choose.

Practice implications

Findings extend ACA-validation studies to the health care setting and suggest that ACA-questionnaires might be appreciated as adjuncts to treatment decision-making in newly diagnosed patients.     

‘I beg your pardon?’ Nurses’ experiences in facilitating doctors’ learning process – An interview study

Objective

Working alongside specialized palliative care nurses brings about learning opportunities for general practitioners. The views of these nurses toward their role as facilitator of learning is unknown. The aim of this study is to clarify the views and preferences of these nurses toward their role as facilitator of physicians’ learning.

Methods

Qualitative study based on semi-structured interviews. We interviewed 21 palliative care nurses in Belgium who were trained in the role of learning facilitator. Data were analyzed using Grounded Theory principles.

Results

First all interviewees shared the conviction that patient care is their core business. Secondly two core themes were defined: nurses’ preferences toward sharing knowledge and their balancing between patient care and team care. Combining these themes yielded a typology of nurses’ behavioral style: the clinical expert-style, the buddy-style, the coach-style and the mediator-style.

Conclusions

Palliative care nurses’ interpretation of the role as facilitator of general practitioners’ learning diverges according to personal characteristics and preferences.

Practice implications

Asking clinical expert nurses to become a facilitator of other professional's learning requires personal mentoring during this transition. Nurses’ preferences toward practice behavior should be taken into account.     

Counseling women with early pregnancy failure: utilizing evidence, preserving preference

Objectives

To apply principles of shared decision-making to EPF management counseling. To present a patient treatment priority checklist developed from review of available literature on patient priorities for EPF management.

Methods

Review of evidence for patient preferences; personal, emotional, physical and clinical factors that may influence patient priorities for EPF management; and the clinical factors, resources, and provider bias that may influence current practice.

Results

Women have strong and diverse preferences for EPF management and report higher satisfaction when treated according to these preferences. However, estimates of actual treatment patterns suggest that current practice does not reflect the evidence for safety and acceptability of all options, or patient preferences. Multiple practice barriers and biases exist that may be influencing provider counseling about options for EPF management.

Conclusion

Choosing management for EPF is a preference-sensitive decision. A patientcentered approach to EPF management should incorporate counseling about all treatment options.

Practice implications

Providers can integrate a counseling model into EPF management practice that utilizes principles of shared decision-making and an organized method for eliciting patient preferences, priorities, and concerns about treatment options.     

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.     

Whole mind and shared mind in clinical decision-making

Objective

To review the theory, research evidence and ethical implications regarding “whole mind” and “shared mind” in clinical practice in the context of chronic and serious illnesses.

Methods

Selective critical review of the intersection of classical and naturalistic decision-making theories, cognitive neuroscience, communication research and ethics as they apply to decision-making and autonomy.

Results

Decision-making involves analytic thinking as well as affect and intuition (“whole mind”) and sharing cognitive and affective schemas of two or more individuals (“shared mind”). Social relationships can help processing of complex information that otherwise would overwhelm individuals’ cognitive capacities.

Conclusions

Medical decision-making research, teaching and practice should consider both analytic and non-analytic cognitive processes. Further, research should consider that decisions emerge not only from the individual perspectives of patients, their families and clinicians, but also the perspectives that emerge from the interactions among them. Social interactions have the potential to enhance individual autonomy, as well as to promote relational autonomy based on shared frames of reference.

Practice implications

Shared mind has the potential to result in wiser decisions, greater autonomy and self-determination; yet, clinicians and patients should be vigilant for the potential of hierarchical relationships to foster coercion or silencing of the patient's voice.     

Modeling patient-centered communication: Oncologist relational communication and patient communication involvement in breast cancer adjuvant therapy decision-making

Objective

Relational communication refers to those messages communicators naturally express that carry meaning about the type and quality of relationship they share. It is expected that patients of oncologists who express positive relational communication will be more communicatively involved in their office visits, and regret their decision for adjuvant therapy following surgery less.

Methods

One hundred eighty (180) audio-recorded discussions between oncologists (n = 40) and early stage (I–III) breast cancer patients were coded with the Siminoff Communication Content and Affect Program (SCCAP). The data were used to test the relationships between patient demographics, oncologist relational communication, patient communication involvement and self-reported patient decision regret.

Results

After controlling for clinician clusters, oncologists’ verbal (i.e., confirming messages) and nonverbal (i.e., direct and inclusive speech) relational communication is indirectly associated with lower patient decision regret via the mediating effect of greater patient communication involvement.

Conclusion

Clinician relational communication provides an influential affective climate for decision-making that appears to have important effects on patients’ decision confidence.

Practice implications

Clinicians should recognize the potential of their own relational messages to facilitate patients’ communication involvement in decision-making during cancer care.     

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.     

Physician communication styles in initial consultations for hematological cancer

Objective

To characterize practices in subspecialist physicians’ communication styles, and their potential effects on shared decision-making, in second-opinion consultations.

Methods

Theme-oriented discourse analysis of 20 second-opinion consultations with subspecialist hematologist-oncologists.

Results

Physicians frequently “broadcasted” information about the disease, treatment options, relevant research, and prognostic information in extended, often-uninterrupted monologs. Their communicative styles had one of two implications: conveying options without offering specific recommendations, or recommending one without incorporating patients’ goals and values into the decision. Some physicians, however, used techniques that encouraged patient participation.

Conclusions

Broadcasting may be a suboptimal method of conveying complex treatment information in order to support shared decision-making. Interventions could teach techniques that encourage patient participation.

Practice implications

Techniques such as open-ended questions, affirmations of patients’ expressions, and pauses to check for patient understanding can mitigate the effects of broadcasting and could be used to promote shared decision-making in information-dense subspecialist consultations.     

Discrepancies between adolescents’ attributed relevance and experiences regarding communication are associated with poorer client participation and learning processes in psychosocial care

Objective

To examine adolescents’ attributed relevance and experiences regarding communication, and whether discrepancies in these are associated with clients’ participation and learning processes in psychosocial care.

Methods

Adolescents receiving psychosocial care (n = 211) completed measures of communication in three domains: affective communication, information provision, and shared decision-making. Participation involved clients’ attendance and adherence (professional-reported). Learning processes involved clients’ improved understanding and improved confidence (client and professional-reported).

Results

Important but less often experienced affective communication was associated with low adherence (odds ratio, 95% confidence interval: 2.8, 1.1–6.8), less improvement in understanding (3.7, 1.5–9.0), and less improvement in confidence (4.5, 1.8–11.6). If information provision or shared decision-making was important but less often experienced, adolescents were more likely to demonstrate less improvement in understanding (3.1, 1.1–8.5; 4.2, 1.7–10.8). The combination “less important but experienced” only had an effect regarding affective communication; these adolescents were more likely to demonstrate less improvement in confidence (6.0, 2.3–15.4).

Conclusion

Discrepancies between attributed relevance and experiences frequently occur. These discrepancies negatively affect adolescents’ participation and their learning processes, although the pattern differs across communication domains.

Practice implications

Care professionals should pay considerable attention to their clients’ communication preferences and adapt their communication style when necessary.     

Patient-health care provider communication among patients with newly diagnosed prostate cancer: Findings from a population-based survey

Objective

To examine the multidimensional concept of patient-health care provider (HCP) communication, its effects on patient satisfaction with oncology care services, and related racial differences.

Methods

The current analysis draws from a population-based survey sample of 1011 African American and 1034 Caucasian American men with newly diagnosed prostate cancer. The variables of satisfaction with health care services, interpersonal treatment, contextual knowledge of the patient, and prostate cancer communication were analyzed using multiple-group structural equation modeling.

Results

Regardless of race, patient-HCP communication was related positively to interpersonal treatment by the HCP, HCP's contextual knowledge of the patient, and prostate cancer communication. More positive patient-HCP communication was related to more satisfaction with health care services. Racial differences were significant in the relationships between patient-HCP communication and prostate cancer communication.

Conclusion

Content and interpersonal relationships are important aspects of patient-HCP communication and affect patient satisfaction with oncologic care for prostate cancer.

Practice implications

HCPs need to integrate the transfer of information with emotional support and interpersonal connection when they communicate with men with newly diagnosed prostate cancer.     

The validity of education and guidance for clinical communication in cancer care: Evidence-based practice will depend on practice-based evidence

Objective

The validity of clinical communication skills education and guidance for cancer care is sometimes portrayed as self-evident. This view needs re-examination in light of critiques of the concept of communication skills.

Methods

We critically examine principles that steer communication teaching and guidance in cancer care and draw on research that can inform the next generation of development in this field.

Results

Unlike other areas of clinical skills, communication is highly contested. Any instance of communication is open to multiple interpretations; expert principles of communication are imprecise and often contradictory. The concept of communication skills will constrain development, because of its implication that universal, expert-defined components of communication are the building blocks of clinical relationships. Research on communication in practice indicates insights that could enrich future education and guidance.

Conclusions

Communication experts have more to learn from practitioners and patients than is commonly appreciated. Inductive, qualitative research should incorporate patient and practitioner perspectives as well as observations of communication.

Practice implications

Solutions to communication dilemmas might be found in detailed study of communication in practice, rather than in current expert principles. Incorporating such evidence will help to ensure the continued authority of communication curricula and guidance as evidence-based and patient-centred.