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PubMed2000

Implementing shared decision-making in routine practice: barriers and opportunities.

OBJECTIVE: Determine feasibility of shared decision-making programmes in fee-for-service hospital systems including physicians' offices and in-patient facilities. DESIGN: Survey and participant observation. Data obtained during Phase 1 of a patient outcome study. SETTINGS AND PARTICIPANTS: Three hospitals in Michigan: one 299-bed rural regional hospital, one 650-bed urban community hospital, one 459-bed urban and suburban teaching hospital. All nurses and physicians who agreed to use the programmes participated in the evaluation (n = 34). INTERVENTION: Two shared decision-making(R) (SDP) multimedia programmes: surgical treatment choice for breast cancer and ischaemic heart disease treatment choice. MAIN OUTCOME MEASURES: (1) clinicians' evaluations of programme quality; (2) challenges in hospital settings; and (3) patient referral rates. RESULTS: SDP programmes were judged to be clear, accurate and about the right length and amount of information. Programmes were judged to be informative and appropriate for patients to see before making a decision. Clinicians were neutral about patients' desire to participate in treatment decision-making. Referral volume to SDPs was lower than expected: 24 patients in 7 months across three hospitals. Implementation challenges centred on time pressures in patient care. CONCLUSIONS: Productivity and time pressure in US health care severely constrain shared decision-making programme implementation. Physician referral may not be a reliable mechanism for patient access. Possible innovations include: (1) incorporation into the informed consent process; (2) provider or payer negotiated requirement in the routine hospital procedure to use the SDP as a quality indicator; and (3) payer reimbursement to professional providers who make SDP programmes available to patients.

Journal Article↗
PubMedDate not supplied

Breast cancer risk assessment and prevention: a framework for shared decision-making consultations.

Options for breast cancer prevention, used in combination with screening and surveillance, include lifestyle modifications, chemoprevention with tamoxifen, and prophylactic surgery. Preventive health decisions are often preference driven: patients typically must choose whether to initiate effective treatments that hold the possibility of side effects that can negatively impact quality of life. This situation demands that patients be well informed and have a full understanding of the risks associated with each option. Investigators have developed a comprehensive decision-making framework designed to support breast cancer prevention consultations within a shared decision-making setting. The framework integrates predictive information from current risk models within the context of a woman's general health to appropriately frame breast cancer risk management consultations and outlines the application of available treatments and emerging biomarker information to individual patient decisions. Using an evidence-based approach, specialized risk-benefit projections can be provided in the clinical setting. A more comprehensive individualized risk profile allows for tailored medical management plans and can better prepare patients to make informed decisions. The framework is intended to encourage a shared decision-making approach to prevention consultations, a method for researchers to increase accrual to trials, and to more quickly incorporate new findings into the routine of practice.

Age Factors↗
PubMed2003

Clinical issues in shared decision-making applied to breast cancer.

OBJECTIVES: To assess (1) the clinical issues addressed during the medical encounter; (2) the feasibility of the process of shared decision-making in clinical practice and (3) patients' desires concerning the question of 'who should take the decision in breast cancer treatments?' DESIGN: Qualitative pilot study based on clinical encounters using decision boards and information booklets. SETTING: Centre Léon Bérard, a comprehensive cancer centre in the Rhône-Alpes region of France. PARTICIPANTS: One breast cancer surgeon and 22 breast cancer patients. MAIN OUTCOME MEASURES: Analysis of patients' reactions to a shared decision-making process concerning surgery and chemotherapy, and analysis of its practical feasibility (i.e. duration of the consultations). RESULTS: (1) Twenty-one patients participated in the decision regarding surgery; all chose conservative treatment; 15 patients had their own say about chemotherapy (nine chose no chemotherapy, six chose chemotherapy). (2) Participating in treatment choice generated anxiety for a majority of patients. Some were dissatisfied because they had to make a choice and consequently to give up the other option. Finally, some were uncertain about making the right choice. Nevertheless, most were satisfied with the information given and the possibility of participating to the treatment decision-making process. (3) The total duration of the entire process of shared decision-making is consistent with the time spent with patients with such a severe disease. DISCUSSION/CONCLUSION: Most of the patients expressed their satisfaction regarding the possibility to participate in treatment decision-making, knowing that offering treatment choice is very unusual in France. From this pilot study it appears that shared decision-making is feasible in clinical practice. Nevertheless, a quantitative study based on a large sample of patients is necessary to: (1) confirm this hypothesis, (2) ensure that patients are willing to participate in their treatment decision-making, and (3) measure the potential benefits related to this participation.

Anxiety↗
PubMed2003

Exploring doctor and patient views about risk communication and shared decision-making in the consultation.

BACKGROUND: There have been significant conceptual developments regarding shared decision-making (SDM) and assessments of people's hypothetical preferences for involvement in treatment or care decisions. There are few data on the perceptions of patients and professionals about SDM in actual practice. OBJECTIVE: To explore, from paired doctor-patient interviews, participants' perceptions of SDM in the consultation and the level of consensus between the participants in the consultation process. DESIGN: Qualitative analysis of semi-structured interview data. SETTING AND PARTICIPANTS: Twenty general practitioners received training packages in 'risk communication' (RC) and 'SDM' to use as tools within the consultation. Forty patients with one of four conditions, for which a range of treatment options is available, were selected. Patient/doctor pairs were interviewed separately following consultations at four stages -'baseline' [general practitioner's (GP) usual consultation style], SDM training, RC alone, and both RC and SDM training. Interviews were transcribed and analysed using NVivo software. RESULTS: Risk communication interventions by doctors appeared to result in a greater perception of decisions being made in the consultation. High levels of satisfaction with consultations were evident before application of the interventions and did not change after the interventions. Doctors' and patients' perceptions of the consultations were highly congruent at all phases of the study. CONCLUSION: Shared decision-making and RC approaches were helpful in selected consultations and showed no detrimental effects to patients. However, the use of RC and SDM made only small differences to decision-making in consultations within the population studied. Increasing patient participation may be seen as more ethically justifiable than the traditional paternalistic approach but this needs to be set against the additional training costs incurred.

Adult↗
PubMed2001

Nasogastric tube versus gastrostomy tube for gastric decompression in abdominal surgery: a prospective, randomized trial comparing patients' tube-related inconvenience.

BACKGROUND: Perioperative decompression of the stomach is still a common procedure and can be achieved using either nasogastric tubes (NTs) or gastrostomy tubes (GTs). While both procedures appear to be equally effective, some authors believe that NTs are less convenient for patients than GTs. However, to date, no reliable prospective data are available on this issue. METHODS: We conducted a prospective, randomized trial comparing NTs versus GTs with a total of 110 patients undergoing elective colon surgery. The primary outcome measure was the patient's tube-related inconvenience and pain, assessed in a standardized interview on day 2 after surgery and quantified by means of a visual-analog scale (VAS). A questionnaire including the EORTC QLQ-C30 and additional items regarding retrospective tube-related judgements was administered on the day of discharge and 4 weeks after discharge. Secondary endpoints were the therapy-related morbidity and general complications. RESULTS: When patients were asked which of their drainage tubes (all patients had three or four drainage tubes, such as decompression drains, urinary drains, central venous line) was most inconvenient, 43% (CI 33-53%) in the NT group reported that the NT was most inconvenient, while only 4% (CI 1-10%) of the GT patients judged the GT most inconvenient ( P<0.001, Chi(2) test). This effect was also found in VAS ratings of inconvenience and discomfort ( P<0.01). Also postoperatively (p.o.), NT patients evidenced less preference for their tube system (day 2 p.o.: 71%, CI 61-80%; 4 weeks p.o.: 66%, CI 56-75%) than did GT patients (day 2 p.o.: 94%, CI 88-98%; 4 weeks p.o.: 91% CI 84-96%); again, these differences were statistically significant ( P<0.02; Chi(2) test). No differences between groups emerged regarding global quality of life or conventional clinical outcomes. CONCLUSION: This prospective randomized trial supports the clinical observation that NT causes more subjective inconvenience than GT. In cases when a prolonged postoperative ileus is expected, decisions for a prophylactic decompressing tube system have to weigh up the possibilities of different averse clinical as well as subjective outcomes. It is then preferable to include patients' preferences in the individual decision making process (shared-decision making).

Aged↗
PubMed2005

Shared decision-making in primary care: tailoring the Charles et al. model to fit the context of general practice.

OBJECTIVE: To explore the application of the original Charles et al. model of shared treatment decision-making [Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med 1997;44:681-92; Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med 1999;49:651-61] in the context of general practice, and to determine whether the model needs tailoring for use in this clinical context. METHODS: Conceptual paper, presenting the defining characteristics of general practice compared to the original clinical context for which the model was developed (i.e. life threatening disease with different treatment options), and exploring how the model can be tailored for use in the context of general practice. RESULTS: We identify two areas where the original model requires tailoring: sharing the decision-making around agreeing on an agenda for each consultation; and adapting the information transfer component of the model to acknowledge that doctors may not be the only, or even the main, source of technical information for patients. Finally, we explore the importance of shared decision-making in the context of chronic disease. CONCLUSION: The Charles et al. model can be tailored for use in general practice. PRACTICE IMPLICATIONS: Tailoring the model for use in general practice has implications for research, in terms of identifying the additional physician competencies needed for implementation. Policy makers who wish to promote shared decision-making need to ensure that incentives which prioritize access and health outcomes do not militate against shared decision-making in general practice.

Acute Disease↗
PubMed2006

Shared decision-making in an intercultural context. Barriers in the interaction between physicians and immigrant patients.

OBJECTIVE: The objective of this exploratory paper is to describe several barriers in shared decision-making in an intercultural context. METHODS: Based on the prevailing literature on intercultural communication in medical settings, four conceptual barriers were described. When the conceptual barriers were described, they were compared with the results from semi-structured interviews with purposively selected physicians (n = 18) and immigrant patients (n = 13). Physicians differed in medical discipline (GPs, company doctors, an internist, a cardiologist, a gynaecologist, and an intern) and patients had different ethnic and immigration backgrounds. RESULTS: The following barriers were found: (1) physician and patient may not share the same linguistic background; (2) physician and patient may not share similar values about health and illness; (3) physician and patient may not have similar role expectations; and (4) physician and patient may have prejudices and do not speak to each other in an unbiased manner. CONCLUSION: We conclude that due to these barriers, the transfer of information, the formulation of the diagnosis, and the discussion of treatment options are at stake and the shared decision-making process is impeded. PRACTICE IMPLICATIONS: Improving physician's skills to recognize the communication limitations during shared decision-making as well as improving the skills to deal with the barriers may help to ameliorate shared decision-making in an intercultural setting.

Communication Barriers↗
PubMed2006

A computer-based information-tool for chronic pain patients. Computerized information to support the process of shared decision-making.

OBJECTIVE: Assessment of the use of a computerized information-tool in the context of a shared decision-making process with chronic pain patients. METHODS: In the scope of a prospective and randomized study on shared decision-making with Fibromyalgia patients, a total of 75 patients had access to computer-based information about their illness. Fibromyalgia is a condition of chronic wide-spread pain, belonging to rheumatism, which mainly affects mature female patients. The majority of the patients in our study are female (93%) with an average age of 50 years. The computer-based information-tool provided the patients with detailed information about pathogenesis, typical symptoms, treatment options and prognosis. Six evaluative questions were posed to the participants concerning the assessment of the information presented, the handling of the programme, the need for an introduction to the programme, the quality of the layout and the assessment of the length of time spent in front of the computer and the assessment of the usefulness of such a tool in general practitioners' offices. Furthermore, psychological self-assessment questionnaires were filled out by the participants. RESULTS: The patients highly appreciate the possibility of using computer-based information-tools and endorse the implementation of such tools in general practitioners' offices. CONCLUSION: Computerized information leads to a better understanding of the illness and the treatment options on the part of the patient. PRACTICAL IMPLICATIONS: For further practical use it is crucial to provide an introduction to the handling of a computer to unskilled patients.

Chronic Disease↗
PubMed1999

Is 'shared decision-making' feasible in consultations for upper respiratory tract infections? Assessing the influence of antibiotic expectations using discourse analysis.

OBJECTIVES: To examine the discourse of consultations in which conflict occurs between parents and clinicians about the necessity of antibiotics to treat an upper respiratory tract infection. To appraise the feasibility of shared decision-making in such consultations. DESIGN: A qualitative study using discourse analysis techniques. SETTING: A general practice with 12 500 patients in an urban area of Cardiff, Wales. PARTICIPANTS: Two consultations were purposively selected from a number of audiotaped sessions. The consultations took place during normal clinics in which appointments are booked at 7-minute intervals. The practitioner is known to be interested in involving patients in treatment decisions. METHOD: Discourse analysis was employed to examine the consultation transcripts. This analysis was then compared with the theoretical competencies proposed for 'shared decision-making'. RESULTS: The consultations exhibit less rational strategies than those suggested by the shared decision-making model. Strong parental views are expressed (overtly and covertly) which seem derived from prior experiences of similar illnesses and prescribing behaviours. The clinician responds by emphasizing the 'normality' of upper respiratory tract infections and their recurrence, accompanied by expressions that antibiotic treatment is ineffective in 'viral' illness - the suggested diagnosis. The competencies of 'shared decision-making' are not exhibited. CONCLUSIONS: The current understanding of shared decision-making needs to be developed for those situations where there are dis-agreements due to the strongly held views of the participants. Clinicians have limited strategies in situations where patient treatment preferences are opposed to professional views. Dispelling 'misconceptions' by sharing information and negotiating agreed management plans are recommended. But it seems that communication skills, information content and consultation length have to receive attention if such strategies are to be employed successfully.

Journal Article↗
PubMed2004

Self-reported use of shared decision-making among breast cancer specialists and perceived barriers and facilitators to implementing this approach.

BACKGROUND: Physicians are increasingly urged to practice shared decision-making with their patients. Using a cross-sectional survey, we explored the extent to which Ontario breast cancer specialists report practising shared decision-making with their patients, their comfort level with this approach, and perceived barriers and facilitators to implementation. PARTICIPANTS AND METHODS: All Ontario surgeons and oncologists (radiation and medical) treating women with early-stage breast cancer were eligible for this study. Likert scales were used to measure physicians' comfort level with and self-reported use of different treatment decision-making approaches as well as perceived barriers and facilitators to treatment decision-making with patients. RESULTS: The response rate was 79% for oncologists and 72% for surgeons. More physicians from each specialty (87% of oncologists and 89% of surgeons) expressed high levels of comfort with clinical example 4 (designed to illustrate a shared approach) than with any of the other examples presented (e.g. the informed and paternalistic approach). Similarly, more oncologists and surgeons reported that their usual approach to treatment decision-making was like example 4 than like any other approach presented (56% of oncologists and 69% of surgeons, respectively). Comfort levels with example 4 for oncologists and surgeons were 31% and 20% higher, respectively, than the reported use of this approach. Lack of time and patient anxiety, patient lack of information and/or misinformation, and patient unwillingness or inability to participate were perceived by a substantial minority of both oncologists and surgeons as barriers to patient involvement in treatment decision-making. Key facilitators identified included patients' emotional readiness, support, information and trust in the physician. More research is needed to identify contextual, physician, patient, and interaction factors that will facilitate shared decision-making in the medical encounter and help both parties create an environment conducive to implementing this approach to the extent desired.

Adult↗
PubMed2003

Patient comprehension of information for shared treatment decision making: state of the art and future directions.

How does the way that information is presented potentially influence patients' consent for health treatments, in a shared decision making process? The goal of this paper is to present an overview of selected recent literature concerning patient health information presentation/use for treatment decision making. Recent work with patient populations has begun to extend early cognitive psychological work showing systematic biases in thinking. Key research findings are organized by type of format (probability, graphic, and qualitative/quantitative dimensions). The applied literature on this topic is amenable to only limited integration in regard to key findings, and relatively few novel approaches to improving information comprehension have been described in the health literature. Promising approaches being proposed, developed, and tested are described, such as enhanced-access computerized patient choice modules, "debiasing" techniques, and tailoring of information. Additional theoretical and practical issues are discussed, as well as selected policy implications of current knowledge.

Cognition↗
PubMed2002

Shared treatment decision making in a collectively funded health care system: possible conflicts and some potential solutions.

In recent years there has been a growth in the advocacy of shared decision making (SDM) between clinicians and patients as a way of practicing medicine. Although there is a range of perspectives on what SDM means, in essence it refers to greater involvement of the individual patient in deliberations about appropriate forms of clinical management. The patient's perception of the role of the doctor in SDM is crucial: for it to work successfully, the patient needs to be able to be confident that the doctor is focused on which treatment will generate the greatest benefit for them. However, the doctor also has responsibilities to others, in particular to other patients and potential patients within the collectively funded health care system. This dual responsibility can create a range of dilemmas for the clinician in the context of SDM: Should they inform patients about all effective treatments or just those that the health care system considers cost-effective? Do they risk losing patients from their books if they inform patients about their responsibilities to the health care system? SDM also raises questions about the wider principles of the health care system: Are its equity principles consistent with SDM? Should patients with a strong preference for an effective but non-cost-effective treatment be permitted to pay for it privately? This paper describes the nature of the conflicts that are likely to emerge if SDM diffuses within collectively funded health care systems, and considers a range of policy responses. It argues that the risk of conflict may be reduced by making a clear distinction between clinical guidelines (focusing on effectiveness) and system guidelines (focusing on cost-effectiveness).

Communication↗
PubMed1999

Oversight mechanisms in public managed care programs: from little oversight to negotiations to shared decision-making.

An expanded range of oversight mechanisms is being adopted to hold public human service programs more accountable to funding sources as well as consumers, family members, and providers. Most of these approaches are hierarchical in nature. Some involve negotiated agreements and each is designed to meet certain goals and functions. Each utilizes different forms of decision-making. Stakeholders prefer to be part of a shared decision-making process. Understanding these underlying premises can help to assess the strengths and weaknesses of each method and can suggest how to most effectively utilize combinations of approaches to improve program performance. Whether we will move toward a new paradigm emphasizing participation and collaboration rather than more formal structural approaches is yet undetermined but will greatly affect how programs are monitored and evaluated in the future.

Consumer Advocacy↗
PubMed2004

Clinical practice guidelines to improve shared decision-making about assistive device use in home care: a pilot intervention study.

This study examines whether clinical practice guidelines (CPG) for the introduction of assistive devices (ADs) in home care improve shared decision-making about AD use and modify its social-cognitive correlates. Data were collected in an intervention study with quasi-experimental design. Questionnaires were obtained from 116 home nurses and home care workers and their 140 clients with disabilities. Significant differences between intervention and control group revealed that implementation of CPG improved home nurses' and home care workers' self-reported practice: the number of intervention methods they applied increased, and the methods were applied with increased intensity. Nurses' attitudes towards introducing ADs in a shared decision-making process decreased in both intervention group and control group over time. Clients' reports about caregivers' practice showed a minor concurrence with the reports of the caregivers themselves. The complexity of the CPG and a substantial time investment were reported as the main barriers to involving clients in shared decision-making through the experimental CPG. Nevertheless, CPG hold promise for shared decision-making between formal caregivers and community-dwelling persons with disabilities concerning AD use. The findings suggest that these CPG can structure communication between caregiver and client, and can support caregivers in facilitating clients' self-determination concerning coping with their disabilities.

Activities of Daily Living↗
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↗
PubMed2002

Shared decision-making strategies for early prostate cancer.

Prostate cancer remains one of the most prevalent and least understood of all human malignancies. Pathologic evidence suggests that neoplastic changes of the prostate epithelium begin early in a man's adult life, but do not become clinically evident or relevant until decades later. The natural history of this enigmatic disease is heterogeneous, ranging from a benign and indolent course to one that rapidly progresses, causing significant morbidity and mortality. The divergent aspects of prostate cancer are underscored by vast differences in incidence and mortality statistics, causing consternation among clinicians and patients regarding the relative value of early detection, screening, and treatment strategies. Competing risks and perceived benefits of proposed treatment options including surgery, radiation therapy, hormonal deprivation, watchful waiting, and newer technologies are complex. Given these uncertainties, how should patients integrate these data and what role must physicians play in the process? Here we present a summary of shared decision making for men with localized prostate cancer. We approach this task by using a clinical case scenario to discuss issues relating to incidence and mortality trends, uncertainty regarding natural history, biopsy techniques and concerns, relevant tumor and clinical data, patient information gathering through Web-based resources, as well as support and advocacy groups, outcomes implications, and methods patients use to approach treatment decisions. We present a unified platform for shared decision-making strategies regarding prostate cancer in clinical practice.

Decision Making↗
PubMed2005

Communicating prognosis in the dialysis consent process: a patient-centered, guideline-supported approach.

Recent guidelines recommend shared decision making between patients and nephrologists as the model for dialysis decision making. A key component of this shared decision making is obtaining informed consent. As part of this process, nephrologists have an obligation to inform patients with chronic kidney disease of their prognosis. Ideally, patients themselves should be involved in the decision-making process; however, some patients will not possess decision-making capacity, and others may be unwilling to participate. Determining what to tell patients about prognosis requires tailoring the conversation to the individual patient's preferences. Conversations about prognosis need to occur in a timely fashion so that patients have the opportunity to consider options and make decisions before dialysis is inevitable. Communication strategies are available to assist nephrologists in breaking the bad news of the need for dialysis and its associated burdens. The approach described in this article should help nephrologists discuss prognosis with their patients in a way that is patient centered and in accordance with clinical practice guideline recommendations.

Communication↗
PubMed2001

Sharing decisions in cancer care.

Previous studies have demonstrated that the majority of cancer patients fail to achieve their desired level of participation during treatment decision making. However, it is unclear whether this failure affects patient well-being and satisfaction. Furthermore, whilst shared decision making is currently espoused as the preferred model for doctor patient relations, little empirical evidence exists showing it has beneficial effects for patients. We aimed to evaluate the impact of shared decision making and the achievement of preferred role on patient anxiety, recall of information, and satisfaction. Patients with cancer indicated their preferred level of participation in decision making and preferences for information and emotional support prior to their initial consultation with an oncologist. Anxiety was assessed prior to and immediately after the consultation and recall seven days after the consultation. Anxiety was reassessed at two-weeks post-consultation at which time patients also reported their satisfaction with the consultation and perceived role of participation in treatment decision making. Satisfaction with the information and emotional support received was also evaluated. Of the 233 patients available for analysis, a match between preferred and perceived roles was found for over one-third of patients (34%), with 29% more active and 37% less involved in decision making than preferred. Multivariate analyses demonstrated that role mismatch significantly predicted changes in anxiety levels from pre to immediate postconsultation (p = 0.03). However, irrespective of preferred role in decision making, perceived role, but not role mismatch, significantly and independently predicted satisfaction with both the consultation (p = 0.0005) and the amount of information and emotional support received from the doctor (p = 0.004). Patients who reported a shared role in decision making were most satisfied with the consultation and with the information about treatment and emotional support received. Those who reported that either themselves or the doctor exclusively made the decision were least satisfied. These findings underscore the pre-eminence of the shared decision making model and suggest that encouraging participation may be the safest standard approach. Doctor - as well as patient - based interventions are required to promote patient participation.

Adaptation, Psychological↗