Option Grids: Shared decision making made easier

Objective

To describe the exploratory use of short decision support tools for patients, called Option Grids. Option Grids are summary tables, using one side of paper to enable rapid comparisons of options, using questions that patients frequently ask (FAQs) and designed for face-to-face clinical encounters. To date, most evidence about ‘patient decision aids’ has been based on tools with high content levels, designed for patients to use independently, either before or after visits.

Methods

We studied the use of Option Grids in a quality improvement project, collecting field notes and conducting interviews with clinical teams.

Results

In the ‘Making Good Decisions in Collaboration’ (MAGIC) program, clinicians found that using Option Grids made it easier to explain the existence of options and reported a ‘handover’ effect, where patient involvement in decision making was enhanced.

Conclusion

Option Grids made options more visible and clinicians found it easier to undertake shared decision making when these tools were available. Used in a collaborative way, they enhance patients’ confidence and voice, increasing their involvement in collaborative dialogs.

Practice implications

Further work to confirm these preliminary findings is required, to measure processes and to assess whether these tools have similar impact in other clinical settings.     

Using a ‘talk’ model of shared decision making to propose an observation-based measure: Observer OPTION

Objective

To propose a revised Observer OPTION measure of shared decision making.

Methods

We analyzed published models to identify the core components of a parsimonious conceptual framework of shared decision making. By using this framework, we developed a revised measure combining data from an observational study of clinical practice in Canada with our experience of using Observer OPTION^{12 Item}.

Results

Our conceptual framework for shared decision making composed of justifying deliberative work, followed by the steps of describing options, information exchange, preference elicitation, and preference integration. By excluding items in Observer OPTION^{12 Item} that were seldom observed or not aligned to a robust construct, we propose Observer OPTION^{5 Item}.

Conclusion

Although widely used, Observer OPTION^{12 Item} did not give sufficient attention to preference elicitation and integration, and included items that were not specific to a core construct of shared decision making. We attempted to remedy these shortcomings by proposing a shorter, more focused measure.

Practice implications

Observer OPTION^{5 Item} requires evaluation; we hope that it will be useful as both a research tool and as a formative measure of clinical practice.     

“Many miles to go …”: a systematic review of the implementation of patient decision support interventions into routine clinical practice

Background

Two decades of research has established the positive effect of using patient-targeted decision support interventions: patients gain knowledge, greater understanding of probabilities and increased confidence in decisions. Yet, despite their efficacy, the effectiveness of these decision support interventions in routine practice has yet to be established; widespread adoption has not occurred. The aim of this review was to search for and analyze the findings of published peer-reviewed studies that investigated the success levels of strategies or methods where attempts were made to implement patient-targeted decision support interventions into routine clinical settings.

Methods

An electronic search strategy was devised and adapted for the following databases: ASSIA, CINAHL, Embase, HMIC, Medline, Medline-in-process, OpenSIGLE, PsycINFO, Scopus, Social Services Abstracts, and the Web of Science. In addition, we used snowballing techniques. Studies were included after dual independent assessment.

Results

After assessment, 5322 abstracts yielded 51 articles for consideration. After examining full-texts, 17 studies were included and subjected to data extraction. The approach used in all studies was one where clinicians and their staff used a referral model, asking eligible patients to use decision support. The results point to significant challenges to the implementation of patient decision support using this model, including indifference on the part of health care professionals. This indifference stemmed from a reported lack of confidence in the content of decision support interventions and concern about disruption to established workflows, ultimately contributing to organizational inertia regarding their adoption.

Conclusions

It seems too early to make firm recommendations about how best to implement patient decision support into routine practice because approaches that use a ‘referral model’ consistently report difficulties. We sense that the underlying issues that militate against the use of patient decision support and, more generally, limit the adoption of shared decision making, are under-investigated and under-specified. Future reports from implementation studies could be improved by following guidelines, for example the SQUIRE proposals, and by adopting methods that would be able to go beyond the ‘barriers’ and ‘facilitators’ approach to understand more about the nature of professional and organizational resistance to these tools. The lack of incentives that reward the use of these interventions needs to be considered as a significant impediment.

     

A classification model of patient engagement methods and assessment of their feasibility in real-world settings

Objective

Examine existing reviews of patient engagement methods to propose a model where the focus is on engaging patients in clinical workflows, and to assess the feasibility of advocated patient engagement methods.

Methods

A literature search of reviews of patient engagement methods was conducted. Included reviews were peer-reviewed, written in English, and focused on methods that targeted patients or patient–provider dyads. Methods were categorized to propose a conceptual model. The feasibility of methods was assessed using an adapted rating system.

Results

We observed that we could categorize patient engagement methods based on information provision, patient activation, and patient–provider collaboration. Methods could be divided by high and low feasibility, predicated on the extent of extra work required by the patient or clinical system. Methods that have good fit with existing workflows and that require proportional amounts of work by patients are likely to be the most feasible.

Conclusion

Implementation of patient engagement methods is likely to depend on finding a “sweet-spot” where demands required by patients generate improved knowledge and motivate active participation.

Practice implications

Attention should be given to those interventions and methods that advocate feasibility with patients, providers, and organizational workflows.     

The effect of different cardiovascular risk presentation formats on intentions,understanding and emotional affect: a randomised controlled trial using a web-based risk formatter (protocol)

Background  

The future risk of heart disease can be predicted with increasing precision. However, more research is needed into how this risk is conveyed and presented. The aim of this study is to compare the effects of presenting cardiovascular risk in different formats on individuals' intention to change behaviour to reduce risk, understanding of risk information and emotional affect.     

Transplantation for cystic fibrosis: outcome following early liver transplantation

BACKGROUND AND AIM: Life expectancy in patients with cystic fibrosis (CF) has recently improved due to numerous factors, including a multidisciplinary approach to their management. Prolonged survival may have led to an increasing impact of liver disease on the prognosis of CF patients. The aim of this study was to assess the role of liver transplantation in patients with CF. METHODS: The factors influencing outcome in 24 patients (15 adults and nine children) with CF who have received single liver transplantation, triple heart-lung-liver transplantation (tx) or died while being assessed for triple grafting, were analyzed. RESULTS: Median age at tx in single liver recipients (13 years) was lower than in triple graft recipients (21 years) and those who died (23 years). All patients who received single liver tx made an excellent recovery, including significant improvement of their respiratory function (mean forced vital capacity (FVC) increased from 61% before transplantation to 82% of expected, 6-9 months after tx). Four out of five patients who received triple tx died (0-2 months) after operation. On the basis of our retrospective review, we propose modifications to an existing scoring system for liver tx assessment in CF by scoring additional points for elevated white blood count, bilirubin, and impaired pulmonary function. These changes will need to be evaluated prospectively to confirm their predictive value. CONCLUSIONS: Liver transplantation is effective therapy in young patients with cystic fibrosis, portal hypertension and hepatic dysfunction, and is indicated before a critical stage of deteriorating lung function is reached. In patients with both end-stage liver and lung disease, triple tx has a poor prognosis. Pre-emptive liver tx in younger patients with CF not only has a better outcome but improves lung function.     

Improving patient adherence to lifestyle advice (IMPALA): a cluster-randomised controlled trial on the implementation of a nurse-led intervention for cardiovascular risk management in primary care (protocol)

Background  

Many patients at high risk of cardiovascular diseases are managed and monitored in general practice. Recommendations for cardiovascular risk management, including lifestyle change, are clearly described in the Dutch national guideline. Although lifestyle interventions, such as advice on diet, physical exercise, smoking and alcohol, have moderate, but potentially relevant effects in these patients, adherence to lifestyle advice in general practice is not optimal. The IMPALA study intends to improve adherence to lifestyle advice by involving patients in decision making on cardiovascular prevention by nurse-led clinics. The aim of this paper is to describe the design and methods of a study to evaluate an intervention aimed at involving patients in cardiovascular risk management.