Fostering Choice Awareness for Shared Decision Making: A Secondary Analysis of Video-Recorded Clinical Encounters.
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SUBMITTER: Kunneman M
PROVIDER: S-EPMC6124329 | biostudies-literature | 2018 Mar
REPOSITORIES: biostudies-literature
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Fostering Choice Awareness for Shared Decision Making: A Secondary Analysis of Video-Recorded Clinical Encounters.
Kunneman Marleen M Branda Megan E ME Hargraves Ian I Pieterse Arwen H AH Montori Victor M VM
Mayo Clinic proceedings. Innovations, quality & outcomes 20180201 1
<h4>Objective</h4>To assess the extent to which (1) clinicians, using or not using conversation aids, foster choice awareness during clinical encounters and (2) fostering choice awareness, with or without conversation aids, is associated with greater patient involvement in shared decision making (SDM).<h4>Patients and methods</h4>We randomly selected 100 video-recorded encounters, stratified by topic and study arm, from a database of 10 clinical trials of SDM interventions in 7 clinical contexts ...[more]
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Project description:BackgroundShared decision-making, in which physicians and patients openly explore beliefs, exchange information, and reach explicit closure, may represent optimal physician-patient communication. There are currently no universally accepted methods to assess medical students' competence in shared decision-making.ObjectiveTo characterize medical students' shared decision-making with standardized patients (SPs) and determine if students' use of shared decision-making correlates with SP ratings of their communication.DesignRetrospective study of medical students' performance with four SPs.ParticipantsSixty fourth-year medical students.MeasurementsObjective blinded coding of shared decision-making quantified as decision moments (exploration/articulation of perspective, information sharing, explicit closure for a particular decision); SP scoring of communication skills using a validated checklist.ResultsOf 779 decision moments generated in 240 encounters, 312 (40%) met criteria for shared decision-making. All students engaged in shared decision-making in at least two of the four cases, although in two cases 5% and 12% of students engaged in no shared decision-making. The most commonly discussed decision moment topics were medications (n?=?98, 31%), follow-up visits (71, 23%), and diagnostic testing (44, 14%). Correlations between the number of decision moments in a case and students' communication scores were low (rho?=?0.07 to 0.37).ConclusionsAlthough all students engaged in some shared decision-making, particularly regarding medical interventions, there was no correlation between shared decision-making and overall communication competence rated by the SPs. These findings suggest that SP ratings of students' communication skill cannot be used to infer students' use of shared decision-making. Tools to determine students' skill in shared decision-making are needed.
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Project description:Purpose At the end of life, communication is a key factor for good care. However, in clinical practice, it is difficult to adequately discuss end-of-life care. In order to understand and analyze how decision-making related to life-sustaining treatment (LST) is performed, the shared decision-making (SDM) behaviors of physicians were investigated. Methods A questionnaire was designed after reviewing the literature on attitudes toward SDM or decision-making related to LST. A final item was added after consulting experts. The survey was completed by internal medicine residents and hematologists/medical oncologists who treat terminal cancer patients. Results In total, 202 respondents completed the questionnaire, and 88.6% said that the decision to continue or end LST is usually a result of SDM since they believed that sufficient explanation is provided to patients and caregivers, patients and caregivers make their own decisions according to their values, and there is sufficient time for patients and caregivers to make a decision. Expected satisfaction with the decision-making process was the highest for caregivers (57.4%), followed by physicians (49.5%) and patients (41.1%). In total, 38.1% of respondents said that SDM was adequately practiced when making decisions related to LST. The most common reason for inadequate SDM was time pressure (89.6%). Conclusion Although most physicians answered that they practiced SDM when making decisions regarding LST, satisfactory SDM is rarely practiced in the clinical field. A model for the proper implementation of SDM is needed, and additional studies must be conducted to develop an SDM model in collaboration with other academic organizations.
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Project description:BackgroundPatients with kidney failure experience a complex decision on dialysis modality performed either at home or in hospital. The options have different levels of impact on their physical and psychological condition and social life. The purpose of this study was to evaluate the implementation of an intervention designed to achieve shared decision-making for dialysis choice. Specific objectives were: 1) to measure decision quality as indicated by patients' knowledge, readiness and achieved preferences; and 2) to determine if patients experienced shared decision-making.MethodA mixed methods descriptive study was conducted using both questionnaires and semi-structured interviews. Eligible participants were adults with kidney failure considering dialysis modality. The intervention, based on the Three-Talk model, consisted of a patient decision aid and decision coaching meetings provided by trained dialysis coordinators. The intervention was delivered to 349 patients as part of their clinical pathway of care. After the intervention, 148 participants completed the Shared Decision-Making Questionnaire and the Decision Quality Measurement, and 29 participants were interviewed. Concordance between knowledge, decision and preference was calculated to measure decision quality. Interview transcripts were analysed qualitatively.ResultsThe participants obtained a mean score for shared decision-making of 86 out of 100. There was no significant difference between those choosing home- or hospital-based treatment (97 versus 83; p = 0.627). The participants obtained a knowledge score of 82% and a readiness score of 86%. Those choosing home-based treatment had higher knowledge score than those choosing hospital-based treatment (84% versus 75%; p = 0.006) but no significant difference on the readiness score (87% versus 84%; p = 0.908). Considering the chosen option and the knowledge score, 83% of the participants achieved a high-quality decision. No significant difference was found for decision quality between those choosing home- or hospital-based treatment (83% versus 83%; p = 0.935). Interview data informed the interpretation of these results.ConclusionsAlthough there was no control group, over 80% of participants exposed to the intervention and responded to the surveys experienced shared decision-making and reached a high-quality decision. Both participants who chose home- and hospital-based treatment experienced the intervention as shared decision-making and made a high-quality decision. Qualitative findings supported the quantitative results.Trial registrationThe full trial protocol is available at ClinicalTrials. Gov ( NCT03868800 ). The study has been registered retrospectively.
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Project description:BackgroundDespite widespread use, there are few studies evaluating the consumer Choosing Wisely questions.MethodsWe evaluated the impact of the Choosing Wisely questions on consumers' decision-making outcomes. Adults living in Australia were presented with a hypothetical low-value care scenario. Using a 2×2×2 between-subjects factorial design, they were randomized to either the Choosing Wisely questions ("Questions"), a shared decision-making (SDM) preparation video ("Video"), both interventions, or control (no intervention). Primary outcomes were 1) self-efficacy to ask questions and be involved in decision-making and 2) intention to engage in SDM.ResultsA total of 1,439 participants (45.6% with "inadequate" health literacy) were eligible and included in the analysis. Intention to engage in SDM was higher in people randomized to the Video (mean difference [MD] = 0.24 [scale 0-6], 95% confidence interval [CI]: 0.14, 0.35), Questions (MD = 0.12, 95% CI: 0.01, 0.22), and both interventions (MD = 0.33, 95% CI: 0.23-0.44, P < 0.001, d = 0.28) compared with control. Combining interventions had a greater impact than presenting the Questions alone (MD = 0.22, 95% CI: 0.11, 0.32; P < 0.001). Those who received the Video or both interventions reported lower intention to follow the low-value treatment plan without further questioning (all P < 0.05) and more positive attitudes toward SDM (all P < 0.05) compared with control. Intervention acceptability was high in all study arms (>80%), but proactive access was low (1.7%-20.8%). Compared with control, participants who received one or both interventions asked more questions that mapped to the Choosing Wisely questions (all P < .001). There were no main effects of either intervention on self-efficacy or knowledge.ConclusionsThe Choosing Wisely questions and a video to promote SDM may improve intention to engage in SDM and support patients in identifying questions that align with the Choosing Wisely campaign (with some additional benefits of the video intervention).Trial registrationANZCTR376477.HighlightsWe conducted a randomized controlled trial online with adults living in Australia to test the effectiveness of the consumer Choosing Wisely questions and a shared decision-making (SDM) preparation video.Both interventions improved intention to engage in SDM and supported participants to identify questions that align with the Choosing Wisely campaign.There were some additional benefits of the Video intervention in reducing willingness to accept low-value treatment for low-back pain without asking questions; however, neither intervention changed participants' self-efficacy to ask questions and be involved in decision-making nor affected perceptions of preparedness to engage in SDM or knowledge of rights to be involved in health care decision-making.The simple, low-cost nature of the interventions may make them appropriate for implementation within a suite of approaches to address low-value care at a population level.
| S-EPMC10422858 | biostudies-literature
Project description:ObjectiveTo investigate the impact of cost conversations occurring with or without the use of encounter shared decision-making (SDM) tools in medication adherence.Patients and methodsUsing a coding scheme that included the occurrence and characteristics of cost conversation, we analyzed a randomly selected sample of 169 video recordings of clinical encounters. These videos were obtained during the conduct of practice-based randomized clinical trials comparing care with and without SDM tools for patients with diabetes, osteoporosis, and depression. Medication adherence was described in 2 ways: as a binary (yes/no) outcome, in which the patient met at least 80% adherence, or as a continuous variable, which was the percent of days that the patient adhered to their medication. The secondary analysis took place in 2018 from trials that ran between 2007 and 2015.ResultsMost patients were White (155, 93.4%), educated (104, 63.4% completed college), middle-aged (mean age, 58 years), female (104, 61.5%), and from diabetes (86, 50.9%), depression (43, 25.4%), and osteoporosis (40, 23.7%) trials. Cost conversations occurred in 119 clinical encounters (70%) and were more frequent in those encounters in which SDM tools were used (P=.03). Furthermore, 97 (57.4%) of the participants reported more than 80% medication adherence and 70.3±29.34 percentage of days with adherent medication of 70 days. In the multiple regression model, the only factor associated with adherence (binary or continuous) was the condition of the trial in which people participated. For the participants who had cost conversations, the use of an SDM tool, their sex, the nature of cost conversation (direct or indirect), the nature of cost concerns (treatment or patient issue), and the clinician-offered strategies (yes or no) were not associated with adherence.ConclusionIn this videographic analysis of SDM practice-based clinical trials, cost conversations were not associated with the general measures of medication adherence. Future studies should assess whether a tailored cost conversation intervention would impact the cost-related nonadherence among patients.
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Project description:ImportanceAlopecia areata (AA) is an autoimmune disorder of hair loss with a complex and evolving treatment landscape, making it an ideal setting for shared decision-making (SDM) between patients and physicians. Given the varying efficacy, experience, and risks of treatments for AA, we sought to evaluate patient preferences for SDM and the association of SDM with decisional regret.ObjectiveTo evaluate patient preferences for SDM and the association of SDM with decisional regret.Design, setting, and participantsA cross-sectional online survey using the validated SDMQ9 scale for shared decision-making and Decisional Regret Scale (DRS) was distributed using the National Alopecia Areata Foundation (NAAF) with the aim of assessing (1) patient preferences in SDM when making treatment decisions, (2) how patients perceived the last decision to have been made, (3) which components of SDM were incorporated into the last decision, and (4) decisional regret related to their last treatment decision. The survey was distributed from July 12, 2021, to August 2, 2021, and data analysis occurred from October 2021 to March 2022.Main outcomes and measuresPrimary outcomes included (1) patient preferences in incorporation of SDM, (2) how patients made their most recent treatment decision, (3) which components of SDM were incorporated into their most recent treatment decision measured with the validated SDMQ9, and (4) an assessment of decisional regret in relation to SDM components and the most recent treatment modality used by the patient as measured by the validated DRS.ResultsOf 1387 individuals who initiated the survey, 1074 completed it and were included in the analysis (77.4% completion rate). Overall, 917 respondents were women (85.4%). There were 5 American Indian or Alaska Native respondents (0.5%), 33 were Asian (3.1%), 112 Black or African American (10.4%), 836 White (77.8%), and 36 were multiracial (3.4%) or other (36 [3.4%]). The mean age (SD) was 49.3 (15.4) years. Most respondents preferred making the final treatment decision themselves after considering their physician's opinion (503 [46.8%]). Of those who preferred to make treatment decisions using SDM, most made the last AA treatment decision with their physician (596 [55%]; 95% CI, 53%-58%; P < .001). The components of SDM implemented by the patients' dermatologists most identified were the physician "explained the advantages and disadvantages of treatment options" (472 [44%]), and the physician "asked me which treatment option I prefer" (494 [45.9%]). Incorporation of SDM by physicians was generally associated with decreased decisional regret (all ORs with 95% CIs greater than 1.1; P < .01). The treatments associated with the lowest decisional regret were Janus kinase (JAK) inhibitors, followed by biologics, and deciding not to treat; whereas, the highest decisional regret was reported with anthralin and minoxidil.Conclusions and relevanceThe findings of this cross-sectional survey study suggest that patients with AA prefer to make treatment decisions with their dermatologist using SDM. When SDM is used, patients report less decisional regret, indicating that SDM may help improve the patient-reported quality of treatment decisions. Newer, more efficacious therapies such as JAK inhibitors may be related to lower decisional regret. Future studies should seek to devise solutions to implement SDM as the AA treatment landscape continues to evolve.
| S-EPMC9386608 | biostudies-literature
Project description:BackgroundEliciting patient concerns and listening carefully to them contributes to patient-centered care. Yet, clinicians often fail to elicit the patient's agenda and, when they do, they interrupt the patient's discourse.ObjectiveWe aimed to describe the extent to which patients' concerns are elicited across different clinical settings and how shared decision-making tools impact agenda elicitation.Design and participantsWe performed a secondary analysis of a random sample of 112 clinical encounters recorded during trials testing the efficacy of shared decision-making tools.Main measuresTwo reviewers, working independently, characterized the elicitation of the patient agenda and the time to interruption or to complete statement; we analyzed the distribution of agenda elicitation according to setting and use of shared decision-making tools.Key resultsClinicians elicited the patient's agenda in 40 of 112 (36%) encounters. Agendas were elicited more often in primary care (30/61 encounters, 49%) than in specialty care (10/51 encounters, 20%); p?=?.058. Shared decision-making tools did not affect the likelihood of eliciting the patient's agenda (34 vs. 37% in encounters with and without these tools; p?=?.09). In 27 of the 40 (67%) encounters in which clinicians elicited patient concerns, the clinician interrupted the patient after a median of 11 seconds (interquartile range 7-22; range 3 to 234 s). Uninterrupted patients took a median of 6 s (interquartile range 3-19; range 2 to 108 s) to state their concern.ConclusionsClinicians seldom elicit the patient's agenda; when they do, they interrupt patients sooner than previously reported. Physicians in specialty care elicited the patient's agenda less often compared to physicians in primary care. Failure to elicit the patient's agenda reduces the chance that clinicians will orient the priorities of a clinical encounter toward specific aspects that matter to each patient.
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Project description:Shared decision-making (SDM) provides patient-centered care. However, the limited consultation time was the main factor hindering the application. Patient education is crucial in the process of SDM. The use of visual aids as health education materials is an effective way to improve patients' health literacy and medication adherence. This study aimed to determine the effectiveness of the clinician-created educational video of acne, accessed by patients during the waiting time, including knowledge level and satisfaction. This study was conducted in dermatology outpatient clinics and collected patient responses through electronic devices. During the waiting time, patients with acne would read educational pamphlets and complete the test first. Then, a clinician-created 8-minute educational video, as a patient decision aid (PDA), was accessed by patients using their own mobile smart devices, followed by a test and questionnaire about the satisfaction of the pamphlet and video. We enrolled 50 patients with acne, including 33 males and 17 females. The mean age is 25.55 ± 6.27 years old, ranging from 15 to 47 years old. About the patients' knowledge, the test score improved significantly after watching the video (P < .001). The same findings were observed in the subgroup analysis of gender and different age groups. A higher proportion of patients preferred the educational video over the pamphlet in both genders and different age groups. All patients agreed with the video helped them to understand the educational information and impressed them more than reading pamphlets. The application of clinician-created educational videos in patient education seems to be an efficient solution to implement SDM in the daily clinical work. Besides, we could remind patients to watch the video anytime when they were not sure about the treatment choices, side effects, or the precautions of medications.
| S-EPMC9269380 | biostudies-literature
Project description:ObjectiveTo analyse women's stated preferences for establishing the relative importance of each attribute of shared decision-making (SDM) and their willingness to pay (WTP) for more participatory care in breast cancer screening programmes (BCSP).DesignA discrete choice experiment was designed with 12 questions (choice tasks). It included three attributes: 'How the information is obtained', regarding benefits and harms; whether there is a 'Dialogue for scheduled mammography' between the healthcare professional and the woman; and, 'Who makes the decision', regarding participation in BCSP. Data were obtained using a survey that included 12 choice tasks, 1 question on WTP and 7 socioeconomic-related questions. The analysis was performed using conditional mixed-effect logit regression and stratification according to WTP.SettingData collection related to BCSP was conducted between June and November 2021 in Catalonia, Spain.ParticipantsSixty-five women aged between 50 and 60.Main outcome measuresWomen's perceived utility of each attribute, trade-off on these attributes and WTP for SDM in BCSP.ResultThe only significant attribute was 'Who makes the decision'. The decision made alone (coefficient=2.879; 95% CI=2.297 to 3.461) and the decision made together with a healthcare professional (2.375; 95% CI=1.573 to 3.177) were the options preferred by women. The former contributes 21% more utility than the latter. Moreover, 52.3% of the women stated a WTP of €10 or more for SDM. Women's preferences regarding attributes did not influence their WTP.ConclusionsThe participant women refused a current paternalistic model and preferred either SDM or informed decision-making in BCSP.
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Project description:Introduction. An important goal of palliative care is improving the quality of life of patients and their partners/families. To attain this goal, requirements and preferences of patients need to be discussed, preferably through shared decision making (SDM). This enhances patient autonomy and patient-centeredness, requiring active participation by patients. This is demanding for palliative patients, and even more so for patients with limited health literacy (LHL). This study aimed to examine SDM in practice and assess health care professionals' perspectives on their own SDM. Methods. An explanatory sequential mixed methods design was used. Video recordings were gathered cross-sectionally of palliative care consultations with LHL patients (n = 36) conducted by specialized palliative care clinicians and professionals integrating a palliative approach. The consultations were observed for SDM using the OPTION5 instrument. Potential determinants of SDM were examined using multilevel analysis. Sequentially, stimulated recall interviews were conducted assessing the perspectives of professionals on their SDM (n = 19). Interviews were examined using deductive thematic content analysis. Results. The average SDM score in practice was moderate, varying greatly between professionals, as shown by the multilevel analysis and by varying degrees of perceived patient involvement in SDM mentioned in the interviews. To improve this, professionals recommended 1) continuously discussing all options with patients, 2) allowing time for patients to talk, and 3) using strategic timing for involving patients in SDM. Discussion. The implementation of SDM for people with LHL in palliative care varies in quality and needs improvement. SDM needs to be enhanced in this care domain because decisions are complex and demanding for LHL patients. Future research is needed that focuses on supporting strategies for comprehensible SDM, best practices, and organizational adaptations.
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