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Biomedical subjects

G Elwyn

Publications and source records attributed to G Elwyn.

At least 37 records · Page 2Linked to original sources
PubMed2001

Measuring the involvement of patients in shared decision-making: a systematic review of instruments.

We wanted to determine whether research instruments exist which focus on measuring to what extent health professionals involve patients in treatment and management decisions. A systematic search and appraisal of the relevant literature was conducted by electronic searching techniques, snowball sampling and correspondence with field specialists. The instruments had to concentrate on assessing patient involvement in decision-making by observation techniques (either direct or using audio or videotaped data) and contain assessments of the core aspects of 'involvement', namely evidence of patients being involved (explicitly or implicitly) in decision-making processes, a portrayal of options and a decision-making or deferring stage. Eight instruments met the inclusion criteria. But we did not find any instruments that had been specifically designed to measure the concept of 'involving patients' in decisions. The results reveal that little attention has been given to a detailed assessment of the processes of patient involvement in decision-making. The existing instrumentation only includes these concepts as sub-units within broader assessments, and does not allow the construct of patient involvement to be measured accurately. Instruments developed to measure 'patient-centeredness' are unable to provide enough focus on 'involvement' because of their attempt to cover so many dimensions. The concept of patient involvement (shared decision-making; informed collaborative choice) is emerging in the literature and requires an accurate method of assessment.

Decision Making↗
PubMed2001

Shared decision making observed in clinical practice: visual displays of communication sequence and patterns.

UNLABELLED: The aim of the study was to examine the communication strategies of general practitioners attempting to involve patients in treatment or management decisions. This empirical data was then compared with theoretical 'competences' derived for 'shared decision making'. The subjects were four general practitioners, who taped conducted consultations with the specific intent of involving patients in the decision-making process. The consultations were transcribed, coded into skill categorizations and presented as visual display using a specifically devised sequential banding METHOD: The empirical data from these purposively selected consultation from clinicians who are experienced in shared decision making did not match suggested theoretical frameworks. The views of patients about treatment possibilities and their preferred role in decision making were not explored. The interactions were initiated by a problem-defining phase, statements of 'equipoise' consistently appeared and the portrayal of option information was often intermingled with opportunities to allow patients to question and reflect. A decision-making stage occurred consistently after approximately 80% of the total consultation duration and arrangements were consistently made for follow-up and review. Eight of the 10 consultations took more than 11 min - these specific consultations were characterized by significant proportions of time provided for information exchange and patient interaction. The results demonstrate that some theoretical competences are not distinguishable in practice and other stages, not previously described, such as the 'portrayal of equipoise', are observed. The suggested ideal of a shared decision-making interaction will either require more time than currently allocated, or alternative strategies to enable information exchange outside the consultation.

Adult↗
PubMed2001

Consumers' views of quality in the consultation and their relevance to 'shared decision-making' approaches.

BACKGROUND: There is a recognized need to assess the effects of shared decision-making and other communication interventions. However, the outcomes usually assessed for evidence of 'effectiveness' are determined by researchers and have not been based on consumers' views. AIM: This study aimed to identify the important outcomes of consultations for consumers, and to compare with those reported in the current literature. SETTING AND PARTICIPANTS: Forty-seven participants attending six focus group interviews. Most interviews took place in and all were orientated towards the UK primary care setting. METHODS: Focus group study. RESULTS: Many affective outcomes were identified, consistent with the current literature trends. However, many cognitive and behavioural outcomes that are assessed in the current literature were not noted by participants as important. Furthermore, a broader range of outcomes than is evident in the current literature was viewed as important to these participants. CONCLUSIONS: There is a need to revisit the outcomes which are assessed in decision-making and communication research. The outcomes of greatest importance to consumers must be identified and confirmed by new research which is based directly on the views of consumers themselves.

Consumer Behavior↗
PubMed2001

Joining them up: the challenges of organisational change in the professional politic of general practice.

Primary health care in the UK is currently centred around independent contractor organisations (general practices). Although the development of these organisations is considered necessary to improve the quality of health care, no structures exist to support the systematic development necessary to attain this goal. Part of the failure to change clinical processes has been the requirement that general practitioners attend passive educational events for continuing professional development, without reference to organisational or local health priorities. A feasibility study to integrate professional and practice development planning sought to overcome this mismatch. NHS Staff College Wales, as a facilitating organisation in this study, developed a model to assist practices to identify, prioritise and implement developments, interlinked with individuals' professional development. The paper summarises the experiences of facilitators supporting this integrated approach, using Senge's model of the challenges to the successful implementation of change. The role of facilitation in negotiating these challenges is also explored. The paper concludes that the approach is effective in the integration of professional and practice development and offers a useful framework to progress the quality improvement agenda.

Cooperative Behavior↗
PubMed2001

Antibiotics and shared decision-making in primary care.

Antibiotics are often prescribed to patients with respiratory tract infections who are unlikely to benefit. Models of physician-patient interaction may help understanding of this problem and inform the design of communication skills interventions to enhance appropriate prescribing. The 'paternalistic model' of the consultation remains common in the setting of acute respiratory tract infections. However, the four assumptions that could support this model are not valid for most of these patients, because: best treatment is controversial; management is inconsistent; physicians are not in the best position to evaluate trade-offs between management options without understanding patients' perspectives; and many pressures (apart from patients' agendas) intrude into the consultation. One alternative is the 'informed model' of consulting, but this does not take society's interests into account. The 'shared decision-making model', however, provides a framework for addressing both clinicians' and patients' agendas, and could guide the development and evaluation of specific consultation strategies to promote more appropriate use of antibiotics in primary care.

Anti-Bacterial Agents↗
PubMed2001

Understanding risk and lessons for clinical risk communication about treatment preferences.

This paper defines risk and its component elements and describes where clinical practice may be starting from in terms of what is reported in the literature about understanding risks and the information requirements of consumers. It notes briefly how theoretical models in the literature contribute to our understanding by providing a basis from which to summarise current evidence about the effects of healthcare interventions which address risks and risk behaviour. The situations or types of interventions in which risk related interventions are most effective are described, but a significant caveat is noted about the types of outcomes which have been reported in the literature and which are most appropriate to evaluate. The effects of "framing" variations in the information given to consumers and the ethical dilemmas these raise for a debate about "informed choice" in healthcare programmes are discussed. In response to both the practical and ethical dilemmas that arise from the current evidence, some of the areas where attention should be focused in the future are outlined so that both health gain and informed choice might be achieved. These include the use of decision aids, although their implementation is not widespread at present. Lessons from the current literature on how further progress can be made towards improved communication, discussion between professionals and consumers, and enhancing informed choice are discussed.

Communication↗
PubMed2000

Organisational development in general practice: lessons from practice and professional development plans (PPDPs).

BACKGROUND: Improving the quality and effectiveness of clinical practice is becoming a key task within all health services. Primary medical care, as organised in the UK is composed of clinicians who work in independent partnerships (general practices) that collaborate with other health care professionals. Although many practices have successfully introduced innovations, there are no organisational development structures in place that support the evolution of primary medical care towards integrated care processes. Providing incentives for attendance at passive educational events and promoting 'teamwork' without first identifying organisational priorities are interventions that have proved to be ineffective at changing clinical processes. A practice and professional development plan feasibility study was evaluated in Wales and provided the experiential basis for a summary of the lessons learnt on how best to guide organisational development systems for primary medical care. RESULTS: Practice and professional development plans are hybrids produced by the combination of ideas from management (the applied behavioural science of organisational development) and education (self-directed adult learning theories) and, in conceptual terms, address the lack of effectiveness of passive educational strategies by making interventions relevant to identified system wide needs. In the intervention, each practice participated in a series of multidisciplinary workshops (minimum 4) where the process outcome was the production of a practice development plan and a set of personal portfolios, and the final outcome was a realised organisational change. It was apparent during the project that organisational admission to a process of developmental planning needed to be a stepwise process, where initial interest can lead to a fuller understanding, which subsequently develops into motivation and ownership, sufficient to complete the exercise. The advantages of introducing expert external facilitation were clear: evaluations of internal group processes were possible, strategic issues could be raised and explored and financial probity ensured. These areas are much more difficult to examine when only internal stakeholders are engaged in a planning process. CONCLUSIONS: It is not possible to introduce practice and professional development plans (organisational development and organisational learning projects) in a publicly funded health care system without first addressing existing educational and management structures. Existing systems are based on educational credits for attendance and emerging accountability frameworks (criteria checklists) for clinical governance. Moving to systems that are less summative and more formative, and based on the philosophies of continual quality improvement, require changes to be made in the relevant support systems in order achieve policy proposals.

Evidence-Based Medicine↗
PubMed2000

Judging the 'weight of evidence' in systematic reviews: introducing rigour into the qualitative overview stage by assessing Signal and Noise.

The 'weight of evidence' in a topic area can be judged by assessing the 'Signal' from available research publications and tempering the importance attached by the level of 'Noise' (the inverse of methodological quality). This assessment process has validity and reliability and can be applied to the 'qualitative overview' stage of systematic reviews. This enables the important themes and areas of relevance to the research question to be identified. Important findings from individual papers may also be identified providing further information which may not be evident from quantitative analysis. The findings from these more qualitative stages of analysis complement, but do not replace, quantitative analysis.

Data Interpretation, Statistical↗
PubMed2000

Diaries of evidence-based tutors: beyond 'numbers needed to teach'...

Interprofessional evidence-based health care courses have been held throughout the UK over the last few years, modelled on the approach used in McMaster University of using problem-based facilitated small-group formats to achieve the stated goals. Both delegates and tutors have been aware of the tensions which are inherent within these courses between: (a) the variation in learning cultures which is exhibited by the delegates and the effect this has on processes (i.e. the tension between the reductionist approach of bioscience and the more qualitative leanings of the applied and 'caring' disciplines); and (b) the conflict which arises between the goal of 'learning' applied healthcare biostatistics and the ability to leave the course with the skills to teach others. This qualitative study uses tutor-kept diaries to understand some of the tensions apparent to the teaching faculty during a week-long course in Wales, UK.

Evidence-Based Medicine↗
PubMed2000

Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices.

BACKGROUND: Involving patients in healthcare decisions makes a potentially significant and enduring difference to healthcare outcomes. One difficulty (among many) is that the 'involvement' of patients in decisions has been left undefined. It is usually conceptualised as 'patient centredness', which is a broad and variably interpreted concept that is difficult to assess using current tools. This paper attempts to gauge general practitioners' (GPs') attitudes to patient involvement in decision making and their views about the contextual factors, competences, and stages required to achieve shared decisions within consultations. AIM: To explore and understand what constitutes the appropriate involvement of patients in decision making within consultations, to consider previous theory in this field, and to propose a set of competences (skills) and steps that would enable clinical practitioners (generalists) to undertake 'shared decision making' in their clinical environment. METHOD: Qualitative study using focus group interviews of key informants. RESULTS: Experienced GPs with educational roles have positive attitudes to the involvement of patients in decisions, provided the process matches the role individuals wish to play. They perceive some clinical problems as being more suited to a cooperative approach to decision making and conceptualised the existence of professional equipoise towards the existence of legitimate treatment options as an important facilitative factor. A sequence of skills was proposed as follows: 1) implicit or explicit involvement of patients in the decision-making process; 2) explore ideas, fears, and expectations of the problem and possible treatments; 3) portrayal of equipoise and options; 4) identify preferred data format and provide tailor-made information; 5) checking process: understanding of information and reactions (e.g. ideas, fears, and expectations of possible options); 6) acceptance of process and decision making role preference; 7) make, discuss or defer decisions; 8) arrange follow-up. CONCLUSIONS: These clinicians viewed involvement as an implicit ethos that should permeate medical practice, provided that clinicians respect and remain alert to patients' individual preferred roles in decision making. The interpersonal skills and the information requirements needed to successfully share decisions are major challenges to the clinical consultation process in medical practice. The benefits of patient involvement and the skills required to achieve this approach need to be given much higher priority at all levels: at policy, education, and within further professional development strategies.

Attitude of Health Personnel↗
PubMed1999

General practice registrar responses to the use of different risk communication tools in simulated consultations: a focus group study.

OBJECTIVES: To pilot the use of a range of complementary risk communication tools in simulated general practice consultations; to gauge the responses of general practitioners in training to these new consultation aids. DESIGN: Qualitative study based on focus group discussions. SETTING: General practice vocational training schemes in South Wales. PARTICIPANTS: 39 general practice registrars and eight course organisers attended four sessions; three simulated patients attended each time. METHOD: Registrars consulting with simulated patients used verbal or "qualitative" descriptions of risks, then numerical data, and finally graphical presentations of the same data. Responses of doctors and patients were explored by semistructured discussions that had been audiotaped for transcription and analysis. RESULTS: The process of using risk communication tools in simulated consultations was acceptable to general practitioner registrars. Providing doctors with information about risks and benefits of treatment options was generally well received. Both doctors and patients found it helped communication. There were concerns about the lack of available, unbiased, and applicable evidence and a shortage of time in the consultation to discuss treatment options adequately. Graphical presentation of information was often favoured-an approach that also has the potential to save consultation time. CONCLUSIONS: A range of risk communication "tools" with which to discuss treatment options is likely to be more applicable than a single new strategy. These tools should include both absolute and relative risk information formats, presented in an unbiased way. Using risk communication tools in simulated consultations provides a model for training in risk communication for professional groups.

Attitude of Health Personnel↗
PubMed1999

Towards a feasible model for shared decision making: focus group study with general practice registrars.

OBJECTIVES: To explore the views of general practice registrars about involving patients in decisions and to assess the feasibility of using the shared decision making model by means of simulated general practice consultations. DESIGN: Qualitative study based on focus group interviews. SETTING: General practice vocational training schemes in south Wales. PARTICIPANTS: 39 general practice registrars and eight course organisers (acting as observers) attended four sessions; three simulated patients attended each time. METHOD: After an introduction to the principles and suggested stages of shared decision making the registrars conducted and observed a series of consultations about choices of treatment with simulated patients using verbal, numerical, and graphical data formats. Reactions were elicited by using focus group interviews after each consultation and content analysis undertaken. RESULTS: Registrars in general practice report not being trained in the skills required to involve patients in clinical decisions. They had a wide range of opinions about "involving patients in decisions," ranging from protective paternalism ("doctor knows best"), through enlightened self interest (lightening the load), to the potential rewards of a more egalitarian relationship with patients. The work points to three contextual precursors for the process: the availability of reliable information, appropriate timing of the decision making process, and the readiness of patients to accept an active role in their own management. CONCLUSIONS: Sharing decisions entails sharing the uncertainties about the outcomes of medical processes and involves exposing the fact that data are often unavailable or not known; this can cause anxiety to both patient and clinician. Movement towards further patient involvement will depend on both the skills and the attitudes of professionals, and this work shows the steps that need to be taken if further progress is to be made in this direction.

Attitude of Health Personnel↗