Generalized shared decision making approaches and patient problems. Adapting AHRQ’s SHARE Approach for Purposeful SDM

ObjectiveGeneralized shared decision making (SDM) describes the involvement of patients in choosing options. However, there are many situations in which patients and clinicians make decisions together that don’t focus on choosing between options, e.g. problem-solving dialysis and insulin use while traveling. Poor uptake associated with clinicians’ perception that SDM doesn’t apply to clinical situations they face may reflect the lack of adaptation of generalized SDM approaches to patients’ problems. The Purposeful SDM schema published in 2019 identifies problems for which different kinds of SDM are appropriate.MethodsThe U.S. Agency for Healthcare Research and Quality developed SHARE as a generalized SDM approach. We sought to adapt SHARE to the different problems that patients face using a matrix to relate SHARE steps and Purposeful SDM modes and describe changes in generalized concepts and practices of SDM across these modes.ResultsMany SHARE communicative behaviors applied across modes, although the meaning of SDM terms and practices, e.g. patients involved as problem solvers versus experts, varied substantially.ConclusionAspects of SHARE require adaptation to different patient problems.Practice implicationsSDM in education, practice, and tools may be supported by adapting generalized SDM approaches to patients’ problems.     

PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease

ObjectiveDescribe cardiovascular clinicians’ perceptions of Shared Decision Making following use of a decision aid (DA) for stable coronary artery disease (CAD) “PCI Choice”, in a randomized controlled trial.MethodsWe conducted a semi-structured qualitative interview study with cardiologists and physician extenders (n = 13) after using PCI Choice in practice. Interviews were transcribed then coded. Codes were organized into salient themes. Final themes were determined by consensus with all authors.ResultsMost clinicians (70%) had no prior knowledge of SDM or DAs. Mixed views about the role of the DA in the visit were related to misconceptions of how patient education differed from SDM. Qualitative assessment of clinician perceptions generated three themes: 1) Gaps exist in clinician knowledge around SDM; 2) Clinicians are often uncomfortable with modifying baseline practice; and 3) Clinicians express interest in using DAs after initial exposure within a research setting.ConclusionsUse of DAs by clinicians during clinic visits may improve understanding of SDM. Initial use is marked by a reluctance to modify established practice patterns.Practice implicationsAs clinicians explore new approaches to benefit their patients, there is an opportunity for DAs that provide clinician instruction on core elements of SDM to lead to enhanced SDM in clinical practice.     

Shared decision-making among non-physician healthcare professionals: Enhancing patient involvement in women’s reproductive health in community healthcare settings

ObjectiveShared decision-making (SDM) is an important approach to patient-centered care in women’s reproductive healthcare. This study explored SDM experiences and perceptions among non-physician healthcare professionals.MethodsWe completed 20 key-informant interviews with non-physician healthcare professionals (i.e., NP, RN, CNM, doula, pharmacist, chiropractor) living in Indiana (September 2019-May 2020) who provided community-based women’s reproductive healthcare. Interviews were audio-recorded, transcribed, and analyzed using an expanded grounded theory framework. Constant comparative analysis identified emergent themes.ResultsProfessionals noted community-based healthcare required contextualized decision-making approaches. Results identified listening, decisional ownership, and engagement strategies that enhanced SDM involvement. Findings suggested outcome-oriented SDM concepts, including decisional ownership and investigative listening to enhance SDM. Providers redefined ‘challenging’ patients as engaged in their healthcare and discussed ways SDM improved healthcare experience beyond one visit.ConclusionFindings offered insight into actionable and practical strategies for enhancing SDM in community-based women’s reproductive healthcare. The findings offer strategies to improve SDM by addressing barriers and facilitators among professionals. This extends SDM beyond the patient-physician dyad and supports broader application of SDM.Practice implicationsIncorporating professionals’ experiences into SDM concepts can enhance SDM in community-based women’s healthcare practice, offering opportunities to support a culture of SDM across settings.     

Bringing personal perspective elicitation to the heart of shared decision-making: A scoping review

ObjectivesProponents of shared decision-making (SDM) advocate the elicitation of the patient’s perspective. This scoping review explores if, and to what extent, the personal perspectives of patients are elicited during a clinical encounter, as part of a SDM process. We define personal perspective elicitation (PPE) as: the disclosure (either elicited by the clinician or spontaneously expressed by the patient) of information related to the patient’s personal preferences, values and/or context.MethodsA search was conducted in five literature databases from inception dates up to July 2020, to identify empirical studies about SDM (with/without SDM instrument).ResultsThe search identified 4562 abstracts; 263 articles were read in full text, resulting in 99 included studies. Studies reported low levels of PPE. Integration of personal perspectives into the conversation or a future care plan was largely absent. The majority of the discussed content related to physical health, while social and psychological topics were mostly unaddressed.ConclusionsPPE occurs on a very low level in efforts to achieve SDM according to evaluation studies.Practice implicationsPPE is advocated but rarely achieved in SDM evaluation studies. Causes should be identified, followed by designing interventions to improve this aspect of SDM.     

Goal-setting for behavior change in primary care: An exploration and status report

Objective

This paper explores the behavior change method of goal-setting and reviews the literature on goal-setting in primary care for patients with chronic conditions.

Methods

A literature search was conducted resulting in eight articles meeting the criteria of goal-setting interventions in primary care for adults or adolescents with chronic conditions.

Results

Hypotheses are advanced that goal-setting is generally conducted by collaboratively working with patients to set short-term and specific goals, with follow-up to provide feedback to patients. The articles reviewed generally confirmed these hypotheses. This review did not focus on clinical outcomes, but on the processes of engaging patients in goal-setting discussions.

Conclusion

Evidence that goal-setting is superior to other behavior change methods has not been shown. Since goal-setting is being utilized as a behavior change technique in many primary care sites, primary care practices can benefit from information on how best to implement this innovation.

Practice Implications

Generally, clinicians are minimally involved in goal-setting discussions with their patients. Engaging patients in goal-setting can be done with interactive computer programs and non-clinical members of the primary care team.     

Making shared decisions in relation to planned caesarean sections: What are we up to?

ObjectiveTo map the literature in relation to shared decision making (SDM) for planned caesarean section (CS), particularly women’s experiences in receiving the information they need to make informed decisions, their knowledge of the risks and benefits of CS, the experiences and attitudes of clinicians in relation to SDM, and interventions that support women to make informed decisions.MethodsUsing a scoping review methodology, quantitative and qualitative evidence was systematically considered. To identify studies, PubMed, Maternity and Infant Care, MEDLINE, and Web of Science were searched for the period from 2008 to 2018.Results34 studies were included, with 9750 women and 3313 clinicians. Overall women reported limited SDM, and many did not have the information required to make informed decisions. Clinicians generally agreed with SDM, while recognising it often does not occur. Decision aids and educational interventions were viewed positively by women.ConclusionMany women were not actively involved in decision-making. Decision aids show promise as a SDM-enhancing tool. Studies that included clinicians suggest uncertainty regarding SDM, although willingness to engage.Practice implications: Moving from clinician-led decision-making to SDM for CS has potential to improve patient experiences, however this will require considerable clinician training, and implementation of SDM interventions.     

Eliciting patient preferences in shared decision-making (SDM): Comparing conversation analysis and SDM measurements

ObjectiveTo explore how physicians bring up patient preferences, and how it aligns with assessments of shared decision-making.MethodsQualitative conversation analysis of physicians formulating hypotheses about the patient’s treatment preference was compared with quantitative scores on SDM and ‘patient preferences’ using OPTION(5) and MAPPIN’SDM.ResultsPhysicians occasionally formulate hypotheses about patients’ preferences and then present a treatment option on the basis of that (“if you think X + we can do Y”). This practice may promote SDM in that the decisions are treated as contingent on patient preferences. However, the way these hypotheses are formulated, simultaneously constrains the patient’s freedom of choice and exerts a pressure to accept the physician’s recommendation. These opposing effects may in part explain cases where different assessment instruments yield large variations in SDM measures.ConclusionEliciting patient preferences is a complex phenomenon that can be difficult to reduce into an accurate number. Detailed analysis can shed light on how patient preferences are elicited, and its consequences for patient involvement. Comparing CA and SDM measurements can contribute to specifying communicative actions that SDM scores are based on.Practice implicationsOur findings have implications for SDM communication skills training and further development of SDM measurements.     

Physicians’ views and experiences of discussing weight management within routine clinical consultations: A thematic synthesis

ObjectiveTo systematically search and synthesise qualitative studies of physicians’ views and experiences of discussing weight management within a routine consultation.MethodsA systematic search of four electronic databases identified 11,169 articles of which 16 studies met inclusion criteria. Quality was appraised using the Critical Appraisal Skills Programme tool and a thematic synthesis conducted of extracted data.ResultsFour analytical themes were found: (1) physicians’ pessimism about patients’ weight loss success (2) physicians’ feel hopeless and frustrated (3) the dual nature of the physician-patient relationship (4) who should take responsibility for weight management.ConclusionDespite clinical recommendations barriers remain during consultations between physicians and patients about weight management. Many of these barriers are potentially modifiable.Practice implicationsImproving training, providing clearer guidelines and placing a greater emphasis on collaboration within and between clinicians will help reduce barriers for both physicians and patients. In particular, there is an urgent need for more specialised training for physicians about weight management to promote knowledge and skills in behaviour change techniques and ways to broach sensitive topics without damaging patient relationships.     

Efficacy of the doktormitSDM training module in supporting shared decision making − Results from a multicenter double-blind randomized controlled trial

ObjectiveTraining to improve physicians’ shared decision making (SDM) competencies with proven effectiveness and efficiency is rare. This study evaluated the brief in situ training module ‘doktormitSDM’.MethodsIn a multicenter RCT, each physician recorded four consultations, each of which included a diagnostic or treatment decision (N = 152 consultations from seven medical specialties).The doktormitSDM training module included two video-based individual coaching sessions (15 min) at the physicians’ workplaces, supplemented by a manual and a video tutorial.Primary endpoint was the compound measure SDMmass (based on the MAPPIN’SDM system) which incorporates patient and observer perceptions of involvement and doctor-patient concordance on perceived involvement.ResultsSDMmass increased significantly in the intervention group compared to the controls (effect size 0.58; p= 0.05; t-test). This effect tended to persist at follow-up (effect size 0.63; p=0.06). Patients’ perceived involvement increased accordingly (effect sizes 0.9/.58; p=0.01/.07).ConclusionThe doktormitSDM training module is effective and efficient at improving SDM competencies. This is the first SDM training to be evaluated with a compound measure simultaneously considering doctor, patient and observer ratings.Practice implicationsOwing to its very brief form and its reference to the doctors’ own consultation videos, the doktormitSDM training module meets clinicians’ needs and time constraints.     

Ready for SDM- evaluation of an interprofessional training module in shared decision making – A cluster randomized trial

ObjectiveReady for SDM was developed in Norway as a comprehensive modularized curriculum for health care providers (HCP). The current study evaluated the efficacy of one of the modules, a 2-hour interprofessional SDM training designed to enhance SDM competencies.MethodsA cluster randomized controlled trial was conducted with eight District Psychiatric Centres randomized to wait-list control (CG) or intervention group (IG). Participants and trainers were not blinded to their allocation. The IG received a 2-hour didactic and interactive training, using video examples. The primary outcome was the agreement between the participants’ and an expert assessment of patient involvement in a video recorded consultation. The SDM-knowledge score was a secondary outcome.ResultsCompared to the CG (n = 65), the IG (n = 69) judged involvement behavior in a communication example more accurately (mean difference of weighted T, adjusted for age and gender:=?0.098, p = 0.028) and demonstrated better knowledge (mean difference=?0.58; p = 0.014). A sensitivity analysis entering a random effect for cluster turned out not significant.ConclusionThe interprofessional group training can improve HCPs’ SDM-competencies.Practice implicationsAddressing interprofessional teams using SDM communication training could supplement existing SDM training approaches. More research is needed to evaluate the training module’s effects as a component of large-scale implementation of SDM.     

Effectiveness of shared decision-making intervention in patients with lumbar degenerative diseases: A randomized controlled trial

ObjectiveTo evaluate the efficacy of shared decision-making (SDM) intervention among patients with lumbar degenerative diseases (LDDs) in terms of decision self-efficacy, control preferences, SDM process, decision satisfaction, and conflict.MethodsA total of 130 outpatients with LDDs recruited from orthopedic or rehabilitation clinics were randomly assigned to the SDM intervention (n = 67) or comparison (n = 63) groups. Patients in the intervention group received decision aids (DAs) with decision coaching and those in controlled group received standard educational materials from a health educator. The primary outcome was decision self-efficacy, and secondary outcomes were control preference, SDM process, conflict, and satisfaction.ResultsThe SDM intervention significantly improved decision self-efficacy (mean difference [MD] = 7.1, 95% confidence interval [CI]: 1.7–12.5, partial η² = 0.05) and reduced conflict (MD = −7.0, 95% CI: −12.2 to −1.9, partial η² = 0.06), especially in patients without family involvement, compared with the health education group. However, no significant between-group differences were observed in other outcomes.ConclusionSDM intervention improved SDM self-efficacy and reduced conflict in patients with LDDs.Practice ImplicationsClinicians can integrate DAs and decision coaching in SDM conversations. SDM intervention seems to engage patients in decision-making, especially those without family involvement.     

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.     

Healthcare professionals’ behaviour regarding the implementation of shared decision-making in screening programmes: A systematic review

ObjectiveTo explore the barriers to and facilitators of healthcare professionals’ implementation of SDM regarding screening programmes.MethodA systematic review was conducted in PubMed, Cochrane Library, CINHAL, and PsyscInfo. The barriers and facilitators identified were classified into three factors based on their origin: patients, healthcare system performance, and healthcare professionals themselves.ResultsEight studies were selected: seven related to cancer screening. The most significant facilitators were literacy and interest in active participation, both of which have their origins in patients. The most significant barriers identified for the first time in a systematic review were legal conflict, lack of remuneration and lack of flexibility in clinical guidelines in screening programmes.ConclusionThe results of this study show that there are differences between barriers and facilitators for SDM when it is applied in the context of healthy people who perform preventive activities, particularly screening, in contrast to general medical consultation contexts.Practical implicationsThe authors suggest that to advance in the practice of SDM, we need to develop and disseminate training documents. Further, SDM should be incorporated into clinical guidelines. There should be more studies focusing on healthcare professionals’ behaviour within the context of the uncertainty of screening programmes.     

The submissive silence of others: Examining definitions of shared decision making

ObjectiveOur aim was to use critical discourse analysis (CDA) to examine the most widely cited definitions of shared decision making so that we can evaluate how language is used to position participants. Based on our conceptual understanding, we presumed that shared decision making involves acts of communication where processes are collaborative.MethodsWe used a CDA lens to closely examine the phrases, semantics, syntax, implied functions, and the social actions proposed in SDM definition texts. We conducted a systematic search guided by the PRISMA guidelines, to identify the most widely cited definitions of SDM.ResultsA total of 72 studies met our inclusion criteria. While SDM is not consistently defined, it was striking to find that clinicians are constructed as active whereas patients were viewed to be passive participants. The definitions construct SDM to be a gift that the clinician has the power to offer, and the relationship in the definitions appears asymmetric, in which only one party seems to speak.ConclusionsThe SDM definitions examined convey a process characterized by a clinician who speaks, while a patient mostly listens, and is invited to contribute. An alternative definition might be constructed through references to joint activity via sentences in active voice.Practice implicationsClinicians may be influenced by definitions of SDM that reinforce the positionality of active speaker versus passive recipient. Clearer definitions that address the constructs of power and roles may help support the implementation of SDM.     

Is there a duty to recontact in light of new genetic technologies? A systematic review of the literature

PurposeWith rapid advances in genetic technologies, new genetic information becomes available much faster today than just a few years ago. This has raised questions about whether clinicians have a duty to recontact eligible patients when new genetic information becomes available and, if such duties exist, how they might be implemented in practice.MethodsWe report the results of a systematic literature search on the ethical, legal, social (including psychological), and practical issues involved in recontacting former patients who received genetic services. We identified 1,428 articles, of which 61 are covered in this review.ResultsThe empirical evidence available indicates that most but not all patients value being recontacted. A minority of (older) articles conclude that recontacting should be a legal duty. Most authors consider recontacting to be ethically desirable but practically unfeasible. Various solutions to overcome these practical barriers have been proposed, involving efforts of laboratories, clinicians, and patients.ConclusionTo advance the discussion on implementing recontacting in clinical genetics, we suggest focusing on the question of in what situations recontacting might be regarded as good standard of care. To this end, reaching a professional consensus, obtaining more extensive empirical evidence, and developing professional guidelines are important.Genet Med17 8, 668–678.