The effects of a shared decision-making intervention in primary care of depression: a cluster-randomized controlled trial

Experiences of Clients and Professionals with the Recovery Oriented Intake

The Recovery Oriented Intake (ROI) integrates recovery principles from the start of treatment, and involves peer experts, unlike the intake as usual (IAU). This study compared experiences with ROI and IAU among 127 clients and 391 professionals, consisting of practitioners and peer experts. Intake's quality, measured with questionnaires, showed no differences in experiences between ROI and IAU clients. However, practitioners experienced ROI as more recovery-oriented than IAU. The ROI Fidelity Check (RFC) revealed that clients' RFC-scores, but not practitioners', predicted their valuation of intake's quality. This underscores the need for (re)training and peer supervision for professionals to ensure adherence to ROI's principles. Discrepancies between clients' and professionals' experiences at the start of treatment are consistent with literature on working alliance and Shared Decision Making (SDM). Differences between ROI and IAU professionals may stem from heightened awareness of recovery principles due to training and the presence of peer experts during intake.

Using decision support tools for treatment decision making about antidepressants in outpatient psychiatric consultations

OBJECTIVE

To examine the use of decision support tools in decision making about antidepressants during conversations between patients with major depressive disorder (MDD) and their psychiatrists.

METHODS

Theme-oriented discourse analysis of two psychiatric consultation groups: control (n = 17) and intervention (n = 16). In the control group, only a doctor's conversation guide was used; in the intervention group, the conversation guide and a patient decision aid (PDA) were used.

RESULTS

Psychiatrists mainly dominated conversations in both consultation groups. They were less likely to elicit patient treatment-related perspectives in the intervention group as they focused more on delivering the information than obtaining patient perspectives. However, using PDA in the intervention group slightly encouraged patients to participate in decisional talk.

CONCLUSION

The decision support tools did promote SDM performance. Using the conversation guide in both consultation groups encouraged the elicitation of patient perspectives, which helped the psychiatrists in tailoring their recommendations of options based on patient preferences and concerns. Using the PDA in the intervention group created space for treatment discussion and fostered active collaboration in treatment decision making.

PRACTICE IMPLICATIONS

Our findings have implications for SDM communication skills training and critical reflection on SDM practice.

Analysis and mapping the research landscape on patient-centred care in the context of chronic disease management

RATIONALE

Patient-centred care has emerged as a transformative approach in managing chronic diseases, aiming to actively involve patients in their healthcare decisions.

AIMS AND OBJECTIVES

This study was conducted to analyse and map the research landscape on patient-centred care in the context of chronic disease management.

METHODS

This study used Scopus to retrieve the relevant articles. The analysis focused on the growth pattern, highly cited articles, randomised clinical trials, patients and providers perspectives, facilitators and barriers, frequent author keywords, emerging topics, and prolific countries and journals in the field.

RESULTS

In total, 926 research articles met the inclusion criteria. There was a notable increase in the number of publications over time. Cancer had the highest number of articles (n = 379, 40.9%), followed by diabetes mellitus, and mental health and psychiatric conditions. Studies on patient-centred care in diabetic patients received the highest number of citations. The results identified 52 randomised controlled trials that covered four major themes: patient-centred care for diabetes management, shared decision-making in mental health and primary care, shared decision-making in cancer care, and economic evaluation and cost-effectiveness. The study identified 51 studies that examined the impact of tools such as computer-based systems, decision aids, smartphone apps, and online tools to improve patient-centred outcomes. A map of author keywords showed that renal dialysis, HIV, and atrial fibrillation were the most recent topics in the field. Researchers from the United States contributed to more than half of the retrieved publications. The top active journals included "Patient Education and Counselling" and "Health Expectations".

CONCLUSION

This study provides valuable insights into the research landscape of patient-centred care within the context of chronic diseases. The current study provided a comprehensive overview of the research landscape on patient-centred care, which can empower patients by raising their awareness about clinical experiences and outcomes.

A systematic review of shared decision making training programs for general practitioners

BACKGROUND

Shared decision making (SDM) has been presented as the preferred approach for decisions where there is more than one acceptable option and has been identified a priority feature of high-quality patient-centered care. Considering the foundation of trust between general practitioners (GPs) and patients and the variety of diseases in primary care, the primary care context can be viewed as roots of SDM. GPs are requesting training programs to improve their SDM skills leading to a more patient-centered care approach. Because of the high number of training programs available, it is important to overview these training interventions specifically for primary care and to explore how these training programs are evaluated.

METHODS

This review was reported in accordance with the PRISMA guideline. Eight different databases were used in December 2022 and updated in September 2023. Risk of bias was assessed using ICROMS. Training effectiveness was analyzed using the Kirkpatrick evaluation model and categorized according to training format (online, live or blended learning).

RESULTS

We identified 29 different SDM training programs for GPs. SDM training has a moderate impact on patient (SMD 0.53 95% CI 0.15-0.90) and observer reported SDM skills (SMD 0.59 95%CI 0.21-0.97). For blended training programs, we found a high impact for quality of life (SMD 1.20 95% CI -0.38-2.78) and patient reported SDM skills (SMD 2.89 95%CI -0.55-6.32).

CONCLUSION

SDM training improves patient and observer reported SDM skills in GPs. Blended learning as learning format for SDM appears to show better effects on learning outcomes than online or live learning formats. This suggests that teaching facilities designing SDM training may want to prioritize blended learning formats. More homogeneity in SDM measurement scales and evaluation approaches and direct comparisons of different types of educational formats are needed to develop the most appropriate and effective SDM training format.

TRIAL REGISTRATION

PROSPERO: A systematic review of shared-decision making training programs in a primary care setting. PROSPERO 2023 CRD42023393385 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023393385 .

The Effects of Patient Preference on Clinical Outcome, Satisfaction and Adherence Within the Treatment of Anxiety and Depression: A Meta-Analysis

BACKGROUND

Taking patient preference into consideration has received increased attention in the last decades. We conducted a meta-analysis to estimate the effects of patient preference on clinical outcome, satisfaction and adherence regarding treatment of depression and anxiety.

METHODS

Pubmed, Embase, PsycINFO and Scopus were searched for (cluster) randomized controlled trials. Twenty-six randomized controlled clinical trials were included, comprising 3670 participants, examining the effect of patient preference regarding treatment of anxiety and depression on clinical outcome, satisfaction and/or adherence.

RESULTS

No effect of patient preference was found on clinical outcome [d = 0.06, 95% CI = (-0.03, 0.15), p = 0.16, n = 23 studies]. A small effect of patient preference was found on treatment satisfaction [d = 0.33, 95% CI = (0.08, 0.59), p = 0.01, n = 6 studies] and on treatment adherence [OR = 1.55, 95% CI = (1.28, 1.87), p < 0.001, n = 22 studies].

LIMITATIONS

Patient preference is a heterogeneous concept, future studies should strive to equalize operationalization of preference. Subgroup analyses within this study should be interpreted with caution because the amount of studies per analysed subgroup was generally low. Most studies included in this meta-analysis focused on patients with depression. The small number of studies (n = 6) on satisfaction, prevents us from drawing firm conclusions.

CONCLUSIONS

While this meta-analysis did not find a positive effect of considering patient preference on clinical outcome, it was associated with slightly better treatment satisfaction and adherence. Accommodating preference of patients with anxiety and depression can improve treatment.

TRIAL REGISTRATION

PROSPERO: CRD42020172556.

Associations Between Patient Comfort with a Primary Care Provider and Three Measures of Behavioral Health Services Utilization

BACKGROUND

Behavioral health services (BHS) can help improve and treat mental and emotional health problems. Yet, attitudinal and/or structural barriers often prevent individuals from accessing and benefiting from these services. Positive provider-patient interactions in healthcare, encompassing patient comfort with a primary care provider (PCP), which is often enhanced by shared decision-making, may mitigate the stigma associated with seeing a mental health professional; this may improve BHS utilization among patients who need these services. However, few studies have examined how patient comfort with a PCP, often through shared decision-making, may influence patients' BHS utilization in the real world. This study sought to address this gap in practice.

METHOD

Multivariable regression analyses, using weighted data from an internet panel survey of Los Angeles County adults (n = 749), were carried out to examine the associations between patient comfort with a PCP and three measures of BHS utilization. Subsequent analyses were conducted to explore the extent to which shared decision-making moderated these associations.

RESULTS

Participants who reported an intermediate or high comfort level with a provider had higher odds of reporting that they were likely to see (aOR = 2.10 and 3.84, respectively) and get advice (aOR = 2.75 and 4.76, respectively) from a mental health professional compared to participants who reported a low comfort level. Although shared decision-making influenced participants' likelihood of seeing and getting advice from a mental health professional, it was not a statistically significant moderator in these associations.

CONCLUSION

Building stronger relationships with patients may improve BHS utilization, a provider practice that is likely underutilized.

Shifting Perspectives on the Challenges of Shared Decision Making in Mental Health Care

Although shared decision making (SDM) has become the most preferable way in doctor-patient communication, it is not fully implemented in mental health care likely due to the complex nature of psychiatric syndromes and treatments. In this review we provide a systematic overview of all perceived and reported barriers to SDM in the literature, acknowledging field-specific challenges, and offering perspectives to promote its wider use. We conducted a systematic search of the wider literature in different databases and included all publications mentioning specified barriers to SDM in psychiatric care. Relevant data and opinions were categorised into micro-, meso- and macro-level themes and put into clinical perspective. We derived 20 barriers to SDM from 100 studies and reports. Eight were on micro-level care delivery, seven involved meso-level issues, five concerned macro-level themes. The multitude of perceived and actual barriers to SDM underline the challenges its implementation poses in mental health care, some of which can be resolved while others are inherent to the nature of the care, with its long-term relationships, complex dynamics, and social consequences, all requiring a flexible approach. We present four perspectives to help change views on the potential of SDM in mental health care.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017.

OBJECTIVES

To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach.

SEARCH METHODS

We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022.

SELECTION CRITERIA

We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence.

MAIN RESULTS

This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015.

AUTHORS' CONCLUSIONS

Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.

A scoping review into the explanations for differences in the degrees of shared decision making experienced by patients

OBJECTIVES

In order to improve the degree of shared decision making (SDM) experienced by patients, it is necessary to gain insight into the explanations for the differences in these degrees.

METHODS

A scoping review of the literature on the explanations for differences in the degree of SDM experienced by patients was conducted. We assessed 21,329 references. Ultimately, 308 studies were included. The explanations were divided into micro, meso, and macro levels.

RESULTS

The explanations are mainly related to the micro level. They include explanations related to the patient and healthcare professionals, the relationship between the patient and the physician, and the involvement of the patient's relatives. On the macro level, explanations are related to restrictions within the healthcare system such as time constraints, and adequate information about treatment options. On the meso level, explanations are related to the continuity of care and the involvement of other healthcare professionals.

CONCLUSIONS

SDM is not an isolated process between the physician and patient. Explanations are connected to the macro, meso, and micro levels.

PRACTICE IMPLICATIONS

This scoping review suggests that there could be more focus on explanations related to the macro and meso levels, and on how explanations at different levels are interrelated.

Utilising patient-reported outcomes for goal-directed therapy of hip fracture patients: a sequential controlled trial

BACKGROUND

Hip fracture patients (HFPs) frequently have multiple underlying conditions, necessitating that agreed-upon goals take these complications into consideration. Communication regarding goals between medical-personnel and patients is not always effective. Patient-reported outcomes (PROs) can outline personal goals and help promote quality health care in HFPs. Few studies have been published on this topic. The study's aim was to outline the process of using PROs for goal-directed therapy among HFPs.

METHODS

This sequential controlled trial was conducted among HFPs from two medical centres. The control and the intervention group received integrative rehabilitation. PROs were measured in both groups using the SF36 questionnaire three times postsurgery: 24-48 hours, 2 weeks and 3 months. During the first round of questioning, only the intervention group was asked 'what matters most to you?' during the rehabilitative process. Accordingly, agreed-upon goals that were determined by the SF36's eight topics and were incorporated into the HFP's rehabilitative process. A Likert scale of 1-5, '1' indicating no-achievement and '5' full-achievement, was used to assess the goal achievement 4-6 months post-fracture.

RESULTS

84 HFPs participated in the study: 40 and 44 in the intervention and control group, respectively. In both groups, PROs declined after the HF, then improved somewhat 3 months later, but did not return to prefracture scores. Among the intervention group, 39% reached their specific goals (Likert level 5). Patients who achieved their goals had better PROs in comparison to others. The intervention group indicated PROs helped them articulate their desires and introduced them to new areas of care.

CONCLUSIONS

Shifting from asking 'what's the matter?' to 'what matters most to you?' can improve the understanding of HFPs' own priorities, promote quality outcomes and enhance patient-centred care. Using PROs as a guide for goal-directed therapy can create a more inclusive process that includes the patients' most important health determinants and needs.

Transition readiness of youth with co-occurring chronic health and mental health conditions: A mixed methods study

BACKGROUND

A large proportion of youth with chronic conditions have mental health comorbidities. However, the effect of these comorbidities on paediatric-adult transition readiness, and the relevance of widely used tools for measuring transition readiness, are unknown.

OBJECTIVE

The objectives of this study were to describe and explore the transition readiness of youth with co-occurring chronic health and mental health conditions using a combination of quantitative data obtained from participants completing the Transition Readiness Assessment Questionnaire (TRAQ) and qualitative data.

DESIGN AND PARTICIPANTS

A three-phase sequential explanatory mixed methods design was employed, with the qualitative strand taking priority. First, the TRAQ scores (range 1-5) of youth with co-occurring conditions (n = 61) enroled in a multisite randomized controlled trial were measured, followed by qualitative interviews with a sample of youth (n = 9) to explain the quantitative results. Results from both strands were then integrated, yielding comprehensive insights.

RESULTS

Median TRAQ scores ranged from 2.86 on the appointment keeping subscale to 5.00 on the talking with providers subscale. The qualitative results uncovered the complexities faced by this group concerning the impact of a mental health comorbidity on transition readiness and self-management skills across TRAQ domains. The integrated findings identified a diverse and highly individualized set of strengths and challenges amongst this group that did not align with overarching patterns as measured by the TRAQ.

CONCLUSIONS

This mixed methods study generated novel understandings about how youth with co-occurring conditions develop competencies related to self-care, self-advocacy and self-management in preparation for paediatric-adult service transitions. Results demonstrated the assessment of transition readiness using a generic scale does not address the nuanced and complex needs of youth with co-occurring chronic health and mental health conditions. Our findings suggest tailoring transition readiness practices for this group based on youths' own goals, symptoms, coping mechanisms and resources.

PATIENT OR PUBLIC INVOLVEMENT

This study was conducted in collaboration with five young adult research partners (YARP) with lived experience transitioning from paediatric to adult health/mental health services. The YARP's contributions across study phases ensured the perspectives of young people were centred throughout data collection, analysis, interpretation and presentation of findings. All five YARP co-authored this manuscript.

Improving the Therapeutic Relationship When Prescribing Antidepressants: A Pilot Study

Studies indicate that the quality of the doctor-patient relationship moderates the effect of pharmacotherapy. To enhance the quality of the therapeutic relationship in the pharmacotherapy of depression, we developed a brief manual with interactive materials for residents in psychiatry and their patients. In a pilot study at a psychiatric university hospital's outpatient department, we compared patient-centered treatment parameters of a first patient group treated as usual and a second patient group treated using the manual. The study had no influence on the choice of medication. In the manual group, patient satisfaction with the doctor-patient relationship increased significantly at the three-month follow-up. Depression parameters declined in both groups, without group differences. Continuation of antidepressant medication at six months was higher in the manual group. In conclusion, a simple intervention using written materials for doctors prescribing antidepressants improved doctors' and patients' satisfaction with treatment.

Inclusion of person-centred care in UK postgraduate medical education curricula: Interviews and documentary analysis

BACKGROUND

Person-centred care (PCC) involves placing people at the centre of their healthcare decision making to ensure it meets their needs, values, and personal circumstances. Increasingly, PCC is promoted in healthcare policy and guidance, but little is known about how this is embedded in postgraduate medical training. The aim of this research was to understand how PCC is embedded in UK postgraduate medical training and explore factors influencing inclusion of PCC in curricula content.

METHODS

To explore this, we interviewed senior professionals with key roles in the curricula from four UK Royal Colleges (Psychiatrists; Physicians; Surgeons; and GPs) and used framework analysis on interviews and relevant curricula documents to identify themes.

RESULTS

Legislation and professional/educational guidance influenced inclusion. PCC definitions and terminology differed and placement within curricula was variable. Royal Colleges defined the curriculum and provided training to ensure competence, but local deaneries independently implemented the curriculum. Trainer engagement was greater than trainee buy in. Quality assurance focused on feedback from trainers and trainees rather than patients, and patient and public involvement in curriculum development, teaching, and assessment was limited.

CONCLUSIONS

There is a need for cross-organisation collaboration to develop a PCC competence framework that defines the skills and level of competence required at different points in training, with clarity around the differences between undergraduate and postgraduate requirements. Greater auditing and quality assurance of programme delivery would help identify successful practices to share within and across Royal Colleges, while still maintaining the flexibility of local provision. Engagement with patients and the public in this work can only strengthen provision.

Comparison of analog and digital patient decision aids for the treatment of depression: a scoping review

Introduction

Patient decision aids (PDAs) are important tools to empower patients and integrate their preferences and values in the decision-making process. Even though patients with mental health problems have a strong interest in being more involved in decision making about their treatment, research has mainly focused on PDAs for somatic conditions. In this scoping review, we focus on patients suffering from depression and the role of PDAs for this patient group. The review offers an overview of digital and analog PDAs, their advantages and disadvantages as well as recommendations for further research and development.

Methods

A systematic search of the existing literature guided by the Cochrane Handbook for Systematic Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - extension for scoping reviews (PRISMA-ScR) was conducted. Three electronic literature databases with the appropriate thematic focus were searched (PubMed, PsycInfo, and Web of Science). The search strategy used controlled and natural language to search for the key concepts decision aids and depression. The articles were selected in a two-step process guided by predefined inclusion and exclusion criteria. We narratively synthetized information extracted from 40 research articles.

Results

We included 40 articles in our review. Our review revealed that there is more focus on digital PDAs in research than in clinical practice. Digitalization can enhance the benefits of PDAs by developing tools that are more efficient, interactive, and personalized. The main disadvantages of both types of PDAs for the treatment of depression are related to time, dissemination, and capacity building for the health care providers. Digital PDAs need to be regularly updated, effective strategies for their dissemination and acceptance need to be identified, and clinicians need sufficient training on how to use digital PDAs. There is more research needed to study which forms of PDAs are most appropriate for various patient groups (e.g., older adults, or patients with comorbidities), and to identify the most effective ways of PDAs' integration in the clinical workflow. The findings from our review could be well aligned with the International Patient Decision Aids Standards.

Discussion

More research is needed regarding effective strategies for the implementation of digital PDAs into the clinical workflow, ethical issues raised by the digital format, and opportunities of tailoring PDAs for diverse patient groups.

Understanding the Physical Health Problems of People with Psychotic Disorders Using Digital Storytelling

People with psychotic disorders struggle to be heard and express concerns beyond their mental health, especially concerns related to the side effects of treatment. Using digital storytelling, this study aimed to uncover and expose the underlying systems that oppress people with psychotic disorders from meeting their physical health needs. The stories revealed two themes: body as a contested site and biological entity with society, and (in)visible patient and paternalism. Spivak's theory of subalternity provided the theoretical basis for a critical analysis and discussion of the experiences. More research is required to highlight the power relations and structures that lead to health disparity in psychiatry.

Design of a real-world, prospective, longitudinal, observational study to compare vortioxetine with other standard of care antidepressant treatments in patients with major depressive disorder: a PatientsLikeMe survey

BACKGROUND

Major depressive disorder (MDD) is a recurrent psychiatric condition that presents challenges in responding to treatment and achieving long-term remission. To improve outcomes, a shared decision-making treatment approach with patient and healthcare practitioner (HCP) engagement is vital. PatientsLikeMe (PLM), a peer community of patients, provides information on MDD, symptoms, and treatment through forums and resources, helping patients stay engaged in their treatment journey. Data on PLM can be harnessed to gain insights into patient perspectives on MDD symptom management, medication switches, and treatment goals and measures.

METHODS

This ongoing, decentralized, longitudinal, observational, prospective study is being conducted using the PLM platform in two parts, enrolling up to 500 patients with MDD in the United States aged ≥ 18 years to compare vortioxetine with other monotherapy antidepressants. The first qualitative component consists of a webinar and discussion forum with PLM community members with MDD, followed by a pilot for functionality testing to improve the study flow and questions in the quantitative survey. The quantitative component follows on the PLM platform, utilizing patient-reported assessments, over a 24-week period. Three surveys will be conducted at baseline and weeks 12 and 24 to collect data on patient global impression of improvement, depression severity, cognitive function, quality of life (QoL) and well-being, medication satisfaction, emotional blunting, symptoms of anhedonia and resilience, as well as goal attainment. Quantitative results will be compared between groups. The qualitative component is complete; patient recruitment is underway for the quantitative component, with results expected in late 2023.

DISCUSSION

These results will help HCPs understand patient perspectives on the effectiveness of vortioxetine versus other monotherapy antidepressants in alleviating symptoms of MDD and improvements in QoL. Data from the PLM platform will support a patient goal-based treatment approach, as results can be shared by patients with their HCPs, providing them with insights on patient-centric goals, treatment management and adherence, as well as allowing them to observe changes in patient-related outcomes scores. Findings from the study will also help to optimize the PLM platform to build scalable solutions and connectivity within the community to better serve patients with MDD.

Shared decision making with schizophrenic patients: a randomized controlled clinical trial with booster sessions (DECIDE Study)

BACKGROUND

The treatment of schizophrenia requires a prolonged, multidimensional intervention that includes antipsychotic drugs. Treatment adherence is essential to effectively control the disorder. Shared decision-making (SDM) is a strategy, supported by numerous practical and ethical arguments, that seeks to involve patients in the therapeutic process to improve treatment adherence and satisfaction. The use of this model in mental health has been limited for many intrinsic and extrinsic reasons. The results of clinical trials conducted to date have largely been disappointing, potential due to study design-related limitations.

AIM/QUESTION

To evaluate the efficacy, in terms of treatment adherence and improvement in clinical variables, such as severity of symptoms, days of hospitalization or insight, of a carefully timed SDM model initiated immediately prior to hospital discharge in patients with schizophrenia.

METHODS

Single-blind, randomized clinical trial in an acute psychiatric care unit within the Andalusian Health Department to compare SDM (experimental group) to treatment as usual (TAU; control group) in a sample of patients hospitalized for an acute episode of schizophrenia or schizoaffective disorder. The study was performed between January 2014 and June 2017. The experimental group participated in SDM sessions prior to discharge with regular booster sessions over the one-year follow-up. The health care team responsible for SDM was predisposed to concordance (LatCon II scale) and received specific training in SDM. A hierarchical multiple linear regression analysis was performed to evaluate the factors independently associated with adherence, controlling for sociodemographic, clinical, and admission-related variables. Variables were assessed at admission, discharge and at 3, 6 and 12 months after discharge during the one year follow up. BARS, DAI, WAI-S, COMRADE and PANSS were used to evaluate adherence, attitude to treatment, therapeutic alliance, satisfaction and confidence with decision and clinical status, respectively.

RESULTS

A total of 227 schizophrenic patients hospitalized with acute decompensation were evaluated; of these, 102 met all inclusion criteria and were included in the study. Most patients (95%) had prior experience with antipsychotics and most (82%) had experienced related side effects. Despite randomization, psychopathologic severity was greater in the experimental group, with a mean (SD) PANSS score of 104.08 (80) vs. 93.45 (20.30) (p < 0.05). The final regression model to explain adherence was significant (adjusted R2 = 0.384; F [df= 6] = 4.386; p < 0.001), with a direct, significant and independent association with SDM mediated by the number of booster sessions.

DISCUSSION

Shared decision making with booster sessions appears to increase treatment adherence in patients with severe mental disorders.

IMPLICATION ON PRACTICE

Ethical, practical, and clinical reasons support the use of strategies designed promote the use of long-term, shared decision-making in psychiatric patients, especially in schizophrenia spectrum disorder.

Measurement of person-centred consultation skills among healthcare practitioners: a systematic review of reviews of validation studies

BACKGROUND

Person-centred care is integral to high-quality health service provision, though concepts vary and the literature is complex. Validated instruments that measure person-centred practitioner skills, and behaviours within consultations, are needed for many reasons, including in training programmes. We aimed to provide a high-level synthesis of what was expected to be a large and diverse literature through a systematic review of existing reviews of validation studies a of instruments that measure person-centred practitioner skills and behaviours in consultations. The objectives were to undertake a critical appraisal of these reviews, and to summarise the available validated instruments and the evidence underpinning them.

METHODS

A systematic search of Medline, EMBASE, PsycINFO and CINAHL was conducted in September 2020. Systematic reviews of validation studies of instruments measuring individual practitioner person-centred consultation skills or behaviours which report measurement properties were included. Review quality was assessed with the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses. Details of the reviews, the included validation studies, and the instruments themselves are tabulated, including psychometric data, and a narrative overview of the reviews is provided.

RESULTS

Four reviews were eligible for inclusion. These used different conceptualisations of person-centredness and targeted distinct, sometimes mutually exclusive, practitioners and settings. The four reviews included 68 unique validation studies examining 42 instruments, but with very few overlaps. The critical appraisal shows there is a need for improvements in the design of reviews in this area. The instruments included within these reviews have not been subject to extensive validation study.

DISCUSSION

There are many instruments available which measure person-centred skills in healthcare practitioners and this study offers a guide to what is available to researchers and research users. The most relevant and promising instruments that have already been developed, or items within them, should be further studied rigorously. Validation study of existing material is needed, not the development of new measures.

Development and pilot of the Alcohol and Depression Decision-Aid for Psychological Treatments (ADDAPT)

Purpose

Evidence is lacking as to the superiority of dual-focused versus single-focused approaches in treating depression and alcohol use comorbidity. Different people may also value the different features of treatment options differently, necessitating a decision-support tool. This study aims to test the acceptability, feasibility, safety and potential usefulness of the Alcohol and Depression Decision-Aid for Psychological Treatments (ADDAPT).

Design/methodology/approach

ADDAPT was developed according to International Patient Decision-Aid Standards and in consultation with potential end users. Adults with depression and alcohol use comorbidity, who were considering/recently considered psychological treatments, were recruited via online advertisements. After clicking on the study URL, participants accessed the ADDAPT e-book and completed validated and purpose-designed questionnaires.

Findings

Of the 24 participants, most would recommend ADDAPT to others (79.2% agree) and endorsed it as easy-to-use (75%), useful in decision-making (79.2%), presenting balanced (87.5%), up-to-date (91.7%), easy-to-understand (79.2%) and trustworthy information (83.3%), which did not provoke anxiety (i.e. safety; 75%). Post-use, participants felt well prepared to decide on treatment (M = 3.48/5) and demonstrated good treatment knowledge (M = 65.83%). All but one participant indicated a treatment choice supported by best available evidence, and decisional conflict scores except for the uncertainty subscale were below the threshold for decisional delay (all M < 37.5/100).

Originality/value

ADDAPT is the first decision-aid of its kind, with pilot findings supporting its acceptability, feasibility, safety and potential usefulness for improving decision-making quality among people considering psychological treatment options for depression and alcohol use comorbidity.

The effects of a ‘COVID Nurse Assistant’ application on patient satisfaction in COVID isolation rooms

Introduction: The COVID-19 pandemic has caused a major shift in the healthcare delivery system. With the limited personal protection equipment and a nursing service shortage caused ineffective nursing care delivered to COVID-19 patients. Wearing full personal protective equipment (PPE) hinders nurse-patients communication and inhibiting the achievement of treatment goals. This study aims to examine the effect of a ‘COVID Nurse Assistant’ (CNA) application on patient satisfaction in COVID-19 isolation rooms. Design and Methods: This was a comparative study with an experimental and control group design. The participants were patients confirmed positive with COVID-19 receiving care in an isolation room for at least three days and were fully conscious. The intervention used was accessing health information related to COVID-19 through a mobile-friendly application namely-‘COVID Nurse Assistant’. The instrument used was the Patient Satisfaction Questionnaire (PSQ-18) translated into Bahasa Indonesia. In addition, an independent t-Test was used to perform statistical analysis. Results and Discussions: A total 158 respondents completed the online survey among of 219 eligible patients (72% response rate). The score in the general and financial satisfaction sub-scales reported by patients in the experimental group were significantly different from the control with p-values of 0.032 and 0.018 respectively. However, other subscales were not significantly different between the two groups. Conclusions: The implementation of the CNA online application has noteworthy implications on patient satisfaction. However, further studies examining similar system in different clinical areas would provide better information for the optimal use of technology in patient education.  

Shared decision-making and the duration of medical consultations: A systematic review and meta-analysis

OBJECTIVE

1) determine whether increased levels of Shared Decision-Making (SDM) affect consultation duration, 2) investigate the intervention characteristics involved.

METHODS

MEDLINE, EMBASE, CINAHL and Cochrane library were systematically searched for experimental and cross-sectional studies up to December 2021. A best-evidence synthesis was performed, and interventions characteristics that increased at least one SDM-outcome, were pooled and descriptively analyzed.

RESULTS

Sixty-three studies were selected: 28 randomized clinical trials, 8 quasi-experimental studies, and 27 cross-sectional studies. Overall, pooling of data was not possible due to substantial heterogeneity. No differences in consultation duration were found more often than increased or decreased durations. . Consultation times (minutes:seconds) were significantly increased only among interventions that: 1) targeted clinicians only (Mean Difference [MD] 1:30, 95% Confidence Interval [CI] 0:24-2:37); 2) were performed in primary care (MD 2:05, 95%CI 0:11-3:59; 3) used a group format (MD 2:25, 95%CI 0:45-4:05); 4) were not theory-based (MD 4:01, 95%CI 0:38-7:23).

CONCLUSION

Applying SDM does not necessarily require longer consultation durations. Theory-based, multilevel implementation approaches possibly lower the risk of increasing consultation durations.

PRACTICE IMPLICATIONS

The commonly heard concern that time hinders SDM implementation can be contradicted, but implementation demands multifaceted approaches and space for training and adapting work processes.

Improving Patient-Centered Care for Veterans With Treatment-Resistant Depression Using Shared Decision-Making Tools

INTRODUCTION

Treatment-resistant depression (TRD) exists when patient depression continues without remission or reduction despite treatment. There are no standardized guidelines for identifying TRD, but one failed antidepressant treatment at an adequate dose and duration can constitute TRD, especially in cases of severe depression or suicidality. TRD rates for depressed patients average approximately 50% to 60% of the general population. These numbers are higher in the military population and are often complicated by comorbidities.

AIM

Chart audits revealed 68% of psychiatric clinic outpatient veterans met criteria for TRD. Only 25% of patients were being treated adequately for TRD, and 0% were offered other options for treatment. This project aimed to improve patient-centered TRD care at a veteran's hospital to 80% within 90 days.

METHODS

This quality improvement project was implemented using plan-do-study-act (PDSA) cycles. Interventions were tested over four rapid-cycle phases with improvements for screening, handouts, surveys, and team meetings over 8 weeks. Four core interventions were followed throughout the project: screening for TRD, right-care case management tracking, patient engagement with shared decision-making (SDM), and team engagement.

RESULTS

Starting from a baseline right-care score of 25%, the project attained an overall mean of 99.6% representing improved patient-centered TRD care and surpassing the 80% goal defined in the aim.

CONCLUSION

Overall TRD care was improved using SDM options and inter-clinic teamwork and communication.

Effectiveness of Shared Decision-making Training Programs for Health Care Professionals Using Reflexivity Strategies: Secondary Analysis of a Systematic Review

BACKGROUND

Shared decision-making (SDM) leads to better health care processes through collaboration between health care professionals and patients. Training is recognized as a promising intervention to foster SDM by health care professionals. However, the most effective training type is still unclear. Reflexivity is an exercise that leads health care professionals to question their own values to better consider patient values and support patients while least influencing their decisions. Training that uses reflexivity strategies could motivate them to engage in SDM and be more open to diversity.

OBJECTIVE

In this secondary analysis of a 2018 Cochrane review of interventions for improving SDM by health care professionals, we aimed to identify SDM training programs that included reflexivity strategies and were assessed as effective. In addition, we aimed to explore whether further factors can be associated with or enhance their effectiveness.

METHODS

From the Cochrane review, we first extracted training programs targeting health care professionals. Second, we developed a grid to help identify training programs that used reflexivity strategies. Third, those identified were further categorized according to the type of strategy used. At each step, we identified the proportion of programs that were classified as effective by the Cochrane review (2018) so that we could compare their effectiveness. In addition, we wanted to see whether effectiveness was similar between programs using peer-to-peer group learning and those with an interprofessional orientation. Finally, the Cochrane review selected programs that were evaluated using patient-reported or observer-reported outcome measurements. We examined which of these measurements was most often used in effective training programs.

RESULTS

Of the 31 training programs extracted, 24 (77%) were interactive, among which 10 (42%) were considered effective. Of these 31 programs, 7 (23%) were unidirectional, among which 1 (14%) was considered effective. Of the 24 interactive programs, 7 (29%) included reflexivity strategies. Of the 7 training programs with reflexivity strategies, 5 (71%) used a peer-to-peer group learning strategy, among which 3 (60%) were effective; the other 2 (29%) used a self-appraisal individual learning strategy, neither of which was effective. Of the 31 training programs extracted, 5 (16%) programs had an interprofessional orientation, among which 3 (60%) were effective; the remaining 26 (84%) of the 31 programs were without interprofessional orientation, among which 8 (31%) were effective. Finally, 12 (39%) of 31 programs used observer-based measurements, among which more than half (7/12, 58%) were effective.

CONCLUSIONS

Our study is the first to evaluate the effectiveness of SDM training programs that include reflexivity strategies. Its conclusions open avenues for enriching future SDM training programs with reflexivity strategies. The grid developed to identify training programs that used reflexivity strategies, when further tested and validated, can guide future assessments of reflexivity components in SDM training.

Shared decision-making interventions for people with mental health conditions

BACKGROUND

One person in every four will suffer from a diagnosable mental health condition during their life. Such conditions can have a devastating impact on the lives of the individual and their family, as well as society.  International healthcare policy makers have increasingly advocated and enshrined partnership models of mental health care. Shared decision-making (SDM) is one such partnership approach. Shared decision-making is a form of service user-provider communication where both parties are acknowledged to bring expertise to the process and work in partnership to make a decision.  This review assesses whether SDM interventions improve a range of outcomes. This is the first update of this Cochrane Review, first published in 2010.

OBJECTIVES

To assess the effects of SDM interventions for people of all ages with mental health conditions, directed at people with mental health conditions, carers, or healthcare professionals, on a range of outcomes including: clinical outcomes, participation/involvement in decision-making process (observations on the process of SDM; user-reported, SDM-specific outcomes of encounters), recovery, satisfaction, knowledge, treatment/medication continuation, health service outcomes, and adverse outcomes.

SEARCH METHODS

We ran searches in January 2020 in CENTRAL, MEDLINE, Embase, and PsycINFO (2009 to January 2020). We also searched trial registers and the bibliographies of relevant papers, and contacted authors of included studies.  We updated the searches in February 2022. When we identified studies as potentially relevant, we labelled these as studies awaiting classification.

SELECTION CRITERIA

Randomised controlled trials (RCTs), including cluster-randomised controlled trials, of SDM interventions in people with mental health conditions (by Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD) criteria).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

This updated review included 13 new studies, for a total of 15 RCTs. Most participants were adults with severe mental illnesses such as schizophrenia, depression, and bipolar disorder, in higher-income countries. None of the studies included children or adolescents.  Primary outcomes We are uncertain whether SDM interventions improve clinical outcomes, such as psychiatric symptoms, depression, anxiety, and readmission, compared with control due to very low-certainty evidence. For readmission, we conducted subgroup analysis between studies that used usual care and those that used cognitive training in the control group. There were no subgroup differences. Regarding participation (by the person with the mental health condition) or level of involvement in the decision-making process, we are uncertain if SDM interventions improve observations on the process of SDM compared with no intervention due to very low-certainty evidence. On the other hand, SDM interventions may improve SDM-specific user-reported outcomes from encounters immediately after intervention compared with no intervention (standardised mean difference (SMD) 0.63, 95% confidence interval (CI) 0.26 to 1.01; 3 studies, 534 participants; low-certainty evidence). However, there was insufficient evidence for sustained participation or involvement in the decision-making processes. Secondary outcomes We are uncertain whether SDM interventions improve recovery compared with no intervention due to very low-certainty evidence. We are uncertain if SDM interventions improve users' overall satisfaction. However, one study (241 participants) showed that SDM interventions probably improve some aspects of users' satisfaction with received information compared with no intervention: information given was rated as helpful (risk ratio (RR) 1.33, 95% CI 1.08 to 1.65); participants expressed a strong desire to receive information this way for other treatment decisions (RR 1.35, 95% CI 1.08 to 1.68); and strongly recommended the information be shared with others in this way (RR 1.32, 95% CI 1.11 to 1.58). The evidence was of moderate certainty for these outcomes. However, this same study reported there may be little or no effect on amount or clarity of information, while another small study reported there may be little or no change in carer satisfaction with the SDM intervention. The effects of healthcare professional satisfaction were mixed: SDM interventions may have little or no effect on healthcare professional satisfaction when measured continuously, but probably improve healthcare professional satisfaction when assessed categorically. We are uncertain whether SDM interventions improve knowledge, treatment continuation assessed through clinic visits, medication continuation, carer participation, and the relationship between users and healthcare professionals because of very low-certainty evidence. Regarding length of consultation, SDM interventions probably have little or no effect compared with no intervention (SDM 0.09, 95% CI -0.24 to 0.41; 2 studies, 282 participants; moderate-certainty evidence). On the other hand, we are uncertain whether SDM interventions improve length of hospital stay due to very low-certainty evidence. There were no adverse effects on health outcomes and no other adverse events reported.

AUTHORS' CONCLUSIONS

This review update suggests that people exposed to SDM interventions may perceive greater levels of involvement immediately after an encounter compared with those in control groups. Moreover, SDM interventions probably have little or no effect on the length of consultations.  Overall we found that most evidence was of low or very low certainty, meaning there is a generally low level of certainty about the effects of SDM interventions based on the studies assembled thus far. There is a need for further research in this area.

Impact of clinical decision-making participation and satisfaction on outcomes in mental health practice: results from the CEDAR European longitudinal study

The present study aimed to assess: (1) whether a more active involvement of patients is associated with an improvement of clinical symptoms, global functioning, and quality-of-life; and (2) how patients' satisfaction with clinical decisions can lead to better outcome after 1 year. Data were collected as part of the study 'Clinical decision-making and outcome in routine care for people with severe mental illness (CEDAR)', a longitudinal observational study, funded by the European Commission and carried out in six European countries. Patients' inclusion criteria were: (a) aged between 18 and 60 years; (b) diagnosis of a severe mental illness of any kind according to the Threshold Assessment Grid (TAG) ≥ 5 and duration of illness ≥ 2 years; (c) expected contact with the local mental health service during the 12-month observation period; (d) adequate skills in the language of the host countries; and (e) the ability to provide written informed consent. The clinical decision-making styles of clinicians and the patient satisfaction with decisions were assessed using the Clinical Decision Making Style and the Clinical Decision Making Involvement and Satisfaction scales, respectively. Patients were assessed at baseline and 1 year after the recruitment. The sample consisted of 588 patients with severe mental illness, mainly female, with a mean age of 41.69 (±10.74) and a mean duration of illness of 12.5 (±9.27) years. The majority of patients were diagnosed with psychotic (45.75%) or affective disorders (34.01%). At baseline, a shared CDM style was preferred by 70.6% of clinicians and about 40% of patients indicated a high level of satisfaction with the decision and 31% a medium level of satisfaction. Higher participation in clinical decisions was associated with improved social functioning and quality-of-life, and reduced interpersonal conflicts, sense of loneliness, feelings of inadequacy, and withdrawal in friendships after 1 year (p < 0.05). Moreover, a higher satisfaction with decisions was associated with a better quality-of-life (p < 0.0001), reduced symptom severity (p < 0.0001), and a significantly lower illness burden associated with symptoms of distress (p < 0.0001), interpersonal difficulties (p < 0.0001), and problems in social roles (p < 0.05). Our findings clearly show that a higher involvement in and satisfaction of patients with clinical decision-making was associated with better outcomes. More efforts have to be made to increase the involvement of patients in clinical decision-making in routine care settings.

Development of a model for shared care between general practice and mental healthcare: a protocol for a co-production study

INTRODUCTION

Mental health illness represents one of the greatest health burdens in the world. It is well documented that treatment of these illnesses could be optimised through strengthened collaboration between general practice and specialised mental healthcare services (shared care). Furthermore, involvement of users in the design of new interventions to strengthen end-user value and sustainability is key. Therefore, the aim of this study is to develop a shared care intervention in co-production with users.

METHODS AND ANALYSIS

The study will take place at psychiatric outpatient clinics in Denmark.The project is described in four sequential steps, each informing and leading into the next: a systematic review (step 1) will be followed by an exploratory study investigating how stakeholders (general practitioners, mental healthcare staff and patients) perceive existing treatment and collaboration between general practice and mental health services. Steps 1 and 2 will inform and qualify the intervention that will be developed in step 3 as a co-creation study. Step 4 will assess the intervention in a feasibility study. Step 4 will be designed as a non-randomised intervention study with a control group with preassessments and postassessments. In total, 240 patients will be recruited. Questionnaires will be administered to the participants at their first visit to an outpatient clinic and again after 3 months. The primary outcome will be patients' self-reported mental health status (Short Form Health Survey, SF-36) and recovery (revised Recovery Assessment Scale, RAS-R). Recruitment will take place from June 2023 to May 2024.

ETHICS AND DISSEMINATION

The project is approved by the ethics committee (REG-016-2022). Informed consent based on written and verbal information about the aims, purpose and use of the study and the data collection will be obtained from all participants. The study findings will be published in peer-reviewed journals and presented at national and international conferences. The study is registered at ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT05172375.

PROSPERO REGISTRATION NUMBER

287989.

Quality of Late-Life Depression Information on the Internet: Website Evaluation Study

BACKGROUND

The internet can increase the accessibility of mental health information and improve the mental health literacy of older adults. The quality of mental health information on the internet can be inaccurate or biased, leading to misinformation.

OBJECTIVE

This study aims to evaluate the quality, usability, and readability of websites providing information concerning depression in later life.

METHODS

Websites were identified through a Google search and evaluated by assessing quality (DISCERN), usability (Patient Education Materials Assessment Tool), and readability (Simple Measure of Gobbledygook).

RESULTS

The overall quality of late-life depression websites (N=19) was adequate, and the usability and readability were poor. No significant relationship was found between the quality and readability of the websites.

CONCLUSIONS

The websites can be improved by enhancing information quality, usability, and readability related to late-life depression. The use of high-quality websites may improve mental health literacy and shared treatment decision-making for older adults.

Development and acceptability of a decision aid for major depressive disorder considering discontinuation of antidepressant treatment after remission

Aim

While evidence‐based antidepressant treatment is available for major depressive disorder, standard approaches for discontinuation of antidepressants after remission have not yet been established. Decision aids are structured clinical tools that facilitate shared decision‐making between patients and healthcare providers. This study aimed to describe the development process and acceptability of decision aids for major depressive disorder following discontinuation of antidepressant treatment after remission.

Methods

We systematically developed a decision aids according to the International Patient Decision Aid Standards. First, a decision aids prototype was created using the results of a systematic review and meta‐analysis previously conducted to identify the consequences of continuing and discontinuing antidepressant treatment. Second, a mixed‐methods questionnaire (alpha acceptability testing) was administered to patients and healthcare providers to improve the decision aids prototype and develop it into a final version acceptable for clinical settings.

Results

Our decision aids consisted of a description of major depressive disorder, the option to continue or discontinue antidepressant treatment, the advantages and disadvantages of each option, the consequences of each option, and value clarification exercises for each option. The patients (n = 22) reported that the decision aids had acceptable language (91%), adequate information (91%), and a well‐balanced presentation (95%). Healthcare providers (n = 20) provided favorable feedback. The final decision aids fulfilled all six International Patient Decision Aid Standards qualifying criteria.

Conclusion

We successfully developed a decision aids for discontinuation of antidepressant treatment after remission, which could be used during the shared decision‐making process. Further studies are needed to verify the effects of using the decision aids during the shared decision‐making process.

Writing Notes, Thinking About People

In 2021, a research group led by Jenny Park published a qualitative study of 600 medical encounter notes written by 138 physicians.² The researchers found some language that conveyed positive regard, was clearly informative, and effective, while also discovering at least 5 ways in which doctors expressed negative feelings toward their patients. Their paper highlights phrases that convey incredulity ("he claims that nicotine patches don't work for him"), disapproval, stereotyping, and the extent to which providers find patients difficult. They also note diction that emphasizes physician authority and unilateral opposed to shared decision making ("She was told to discontinue…" or "I have instructed him to…"). In their paper, Park's group cautions that, although in and of itself, positive or negative language may not be harmful in the care of individuals, at least 1 study has shown that where dismissive language is used, physicians are less likely to adhere to appropriate guidelines.³.

Evaluation of a decision aid for the treatment of depression among college students

Objective: Depression, and its treatment, is a concern among college students. Research indicates decision aids (DA) improve patients' treatment knowledge, decision making, and decisional conflict; however, it is unknown whether they are helpful for disseminating depression treatment information to college students. This study evaluated a DA for depression and its impact on college students' knowledge and treatment decision making. Methods: College students (N = 144) completed questionnaires pre-, post-, and at 1-month follow-up after reviewing an evidence-based DA for depression. Results: Participants rated the DA as highly acceptable and useful, and their knowledge increased at post-treatment and follow-up. However, treatment option presentation order influenced decision making. Conclusions: This DA is a useful and acceptable decision-making tool, and increased knowledge of depression and its treatment among college students. This study proposes a novel tool for educating college students about depression treatment, furthering our understanding of factors influencing treatment preferences.

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

OBJECTIVE

Ready 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.

METHODS

A 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.

RESULTS

Compared 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.

CONCLUSION

The interprofessional group training can improve HCPs' SDM-competencies.

PRACTICE IMPLICATIONS

Addressing 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.

Antidepressant decision aid for major depressive disorder patients (ADAM): Development and pilot testing

OBJECTIVES

This study aimed to develop and assess the effectiveness of an encounter decision aid for Malaysian patients with MDD to support treatment decision-making during the consultation.

METHODS

The decision aid prototype was developed following a literature review and six focus groups. Alpha testing assessed its comprehensibility, acceptability, usability and desirability through user-centered cognitive interviews. Beta-testing evaluated preliminary evidence on its efficacy using the SDM Scale and PDMS. Feasibility was assessed by timing the consultation.

RESULTS

The alpha testing demonstrated that the decision aid was patient-oriented, comprehensible, comprehensive, concise and objective with an appealing design. Beta-testing indicated that PtDA significantly increased patients satisfaction with SDM from patients' [83.32 (13.92) vs 85.76 (13.80); p < 0.05] and physicians' [81.07 (10.09) vs 86.36 (10.10); p < 0.05] perspectives and prepared the patients for decision making from the patients' [PDMS patients: 84.10 (12.69)] and physicians' [PDMS physicians: 83.78 (16.62)] perspectives as well. There was no change in the consultation time between the control and the intervention groups.

CONCLUSIONS

We developed an antidepressant PtDA for Malaysian patients with MDD that increases patients' involvement in shared decision making and enhances their preparedness for decision making.

PRACTICE IMPLICATIONS

Using the PtDA can support collaborative decision-making in routine clinical practice without extending the consultation time.

Are shared decision making studies well enough described to be replicated? Secondary analysis of a Cochrane systematic review

Background

Interventions to change health professionals’ behaviour are often difficult to replicate. Incomplete reporting is a key reason and a source of waste in health research. We aimed to assess the reporting of shared decision making (SDM) interventions.

Methods

We extracted data from a 2017 Cochrane systematic review whose aim was to determine the effectiveness of interventions to increase the use of SDM by healthcare professionals. In a secondary analysis, we used the 12 items of the Template for Intervention Description and Replication (TIDieR) checklist to analyze quantitative data. We used a conceptual framework for implementation fidelity to analyze qualitative data, which added details to various TIDieR items (e.g. under “what materials?” we also reported on ease of access to materials). We used SAS 9.4 for all analyses.

Results

Of the 87 studies included in the 2017 Cochrane review, 83 were randomized trials, three were non-randomized trials, and one was a controlled before-and-after study. Items most completely reported were: “brief name” (87/87, 100%), “why” (rationale) (86/87, 99%), and “what” (procedures) (81/87, 93%). The least completely reported items (under 50%) were “materials” (29/87, 33%), “who” (23/87, 26%), and “when and how much” (18/87, 21%), as well as the conditional items: “tailoring” (8/87, 9%), “modifications” (3/87, 4%), and “how well (actual)” (i.e. delivered as planned?) (3/87, 3%). Interventions targeting patients were better reported than those targeting health professionals or both patients and health professionals, e.g. 84% of patient-targeted intervention studies reported “How”, (delivery modes), vs. 67% for those targeting health professionals and 32% for those targeting both. We also reported qualitative analyses for most items. Overall reporting of items for all interventions was 41.5%.

Conclusions

Reporting on all groups or components of SDM interventions was incomplete in most SDM studies published up to 2017. Our results provide guidance for authors on what elements need better reporting to improve the replicability of their SDM interventions.

Effects of decision aids for depression treatment in adults: systematic review

AIM AND METHOD

To determine the effect on decisional-related and clinical outcomes of decision aids for depression treatment in adults in randomised clinical trials. In January 2019, a systematic search was conducted in five databases. Study selection and data extraction were performed in duplicate. Meta-analyses were performed, and standardised and weighted mean differences were calculated, with corresponding 95% confidence intervals. The certainty of the evidence was evaluated with GRADE methodology.

RESULTS

Six randomised clinical trials were included. The pooled estimates showed that decision aids for depression treatment had a beneficial effect on patients' decisional conflict, patient knowledge and information exchange between patient and health professional. However, no statistically significant effect was found for doctor facilitation, treatment adherence or depressive symptoms. The certainty of the evidence was very low for all outcomes.

CLINICAL IMPLICATIONS

Using decision aids to choose treatment in patients with depression may have a a beneficial effect on decisional-related outcomes, but it may not translate into an improvement in clinical outcomes.

Resident and informal caregiver involvement in medication-related decision-making and the medicines' pathway in nursing homes: experiences and perceived opportunities of healthcare professionals

BACKGROUND

Person-centered care has been shown to be beneficial for nursing home residents. The know-how and attitude of healthcare professionals, however, can make its implementation difficult. Also, research on person-centered care with regard to medication decision-making and the medicines' pathway in nursing homes is lacking. This study aimed to provide an understanding of healthcare professionals' attitudes and perspectives on current resident and informal caregiver involvement in medication decision-making and the medicines' pathway in nursing homes.

METHODS

A qualitative, explorative study using semi-structured interviews with a sample of 25 healthcare professionals from four different nursing homes was performed. Interview transcripts were analyzed by means of an inductive thematic framework.

RESULTS

Three overarching domains were identified: 1) features of, 2) drivers and barriers for, and 3) perceived consequences of resident and informal caregiver involvement in medication decision-making and the medicines' pathway. Involvement was mainly initiated by residents and informal caregivers themselves, pointing towards information and participation needs among both groups. Nevertheless, actions of healthcare professionals towards resident and informal caregiver involvement were mainly reactive and fragmentary. Their actions were influenced by the perception of residents and informal caregivers' desire and capabilities to be involved, the perception of their own professional role, but also by organizational factors such as the nursing home's philosophy. Furthermore, organizational concerns tempered the motivation to provide residents and informal caregivers with more medication-related responsibilities.

CONCLUSIONS

Resident and informal caregiver involvement in medication decision-making and the medicines' pathway remains limited in nursing homes. Information and participation needs of residents and informal caregivers were not fully acknowledged by healthcare professionals. As such, we can conclude that there is a need for initiatives, both on an individual and on an organizational level, to create and improve awareness on opportunities to improve resident and informal caregiver involvement in medication decision-making and the medicines' pathway.

Empowering Patients in the Therapeutic Decision-Making Process: A Glance Into Behçet's Syndrome

Behçet's syndrome (BS) represents a challenging condition, characterized by a variable spectrum of disease profile and associated with a significant limitation of the daily activities as well as a potential negative impact on relationships and psychological status. Considering also the complexity of the therapeutic management of BS, that often includes biological off-label treatments, the participation in the therapeutic decision-making process of the BS patients is essential to ensure the integration of the care process into the life of the patient. For this reason, the empowerment of BS patients represents a crucial need and the present work is aimed at fully exploring all the potential variables implicated in the BS patient empowerment, also highlighting major points to consider and concrete actions to be planned in the immediate future in order to implement a pragmatic facilitation of the patients' empowerment.

Value of Patient-Centered Glycemic Control in Patients with Type 2 Diabetes

PURPOSE OF REVIEW

Present the value of a person-centered approach in diabetes management and review current evidence supporting its practice.

RECENT FINDINGS

Early evidence from glycemic control trials in diabetes resulted in most practice guidelines adopting a glucose-centric intensive approach for management of the disease, consistently relying on HbA1c as a marker of metabolic control and success. This paradigm has been recently dispelled by new evidence that shows that intensive glycemic control does not provide a significant benefit regarding patient-important microvascular and macrovascular hard outcomes when compared to moderate glycemic targets. The goals of diabetes therapy are to reduce the risks of acute and chronic complications and increase quality of life while incurring least burden of treatment and disruption to the patient's life. A person-centered approach to diabetes management is achieved through shared decision making, integration of evidence-based care and patient´s needs, values and preferences, and minimally disruptive approaches to diabetes care and at the same time offer practical guidance to clinicians and patients on achieving this type of care.

Mental health professionals' perceived barriers and enablers to shared decision-making in risk assessment and risk management: a qualitative systematic review

BACKGROUND

Risk assessment and risk management are fundamental processes in the delivery of safe and effective mental health care, yet studies have shown that service users are often not directly involved or are unaware that an assessment has taken place. Shared decision-making in mental health systems is supported by research and advocated in policy. This systematic review (PROSPERO: CRD42016050457) aimed to explore the perceived barriers and enablers to implementing shared decision-making in risk assessment and risk management from mental health professionals' perspectives.

METHODS

PRISMA guidelines were followed in the conduct and reporting of this review. Medline, CINAHL, EMBASE, PsycINFO, AMED and Internurse were systematically searched from inception to December 2019. Data were mapped directly into the Theoretical Domains Framework (TDF), a psychological framework that includes 14 domains relevant to behaviour change. Thematic synthesis was used to identify potential barriers and enablers within each domain. Data were then matched to the three components of the COM-B model: Capability, Opportunity, and Motivation.

RESULTS

Twenty studies met the eligibility criteria. The findings of this review indicate that shared decision-making is not a concept commonly used in mental health services when exploring processes of risk assessment and risk management. The key barriers identified were 'power and best interest' (social influences) and 'my professional role and responsibility' (social/professional role and identity). Key enablers were 'therapeutic relationship' (social influences) and 'value collaboration' (reinforcement). The salient barriers, enablers and linked TDF domains matched COM-B components 'opportunity' and 'motivation'.

CONCLUSION

The review highlights the need for further empirical research to better understand current practice and mental health professionals' experiences and attitudes towards shared decision-making in risk assessment and risk management.

A Systematic Review of Shared Decision-Making Interventions for Service Users With Serious Mental Illnesses: State of the Science and Future Directions

OBJECTIVE

Shared decision making (SDM) is a health communication model that may be particularly appealing to service users with serious mental illnesses, who often want to be involved in making decisions about their mental health care. The purpose of this systematic review was to describe and evaluate participant, intervention, methodological, and outcome characteristics of SDM intervention studies conducted within this population.

METHODS

Systematic searches of the literature through April 2020 were conducted and supplemented by hand searching of reference lists of identified studies. A total of 53 independent studies of SDM interventions that were conducted with service users with serious mental illnesses and that included a quantitative or qualitative measure of the intervention were included in the review. Data were independently extracted by at least two authors.

RESULTS

Most studies were conducted with middle-age, male, White individuals from Western countries. Interventions fell into the following categories: decision support tools only, multicomponent interventions involving decision support tools, multicomponent interventions not involving decision support tools, and shared care planning and preference elicitation interventions. Most studies were randomized controlled trials with sufficient sample sizes. Outcomes assessed were diverse, spanning decision-making constructs, clinical and functional, treatment engagement or adherence, and other constructs.

CONCLUSIONS

Findings suggest important future directions for research, including the need to evaluate the impact of SDM in special populations (e.g., young adults and racial-ethnic minority groups); to expand interventions to a broader array of decisions, users, and contexts; and to establish consensus measures to assess intervention effectiveness.

The impact of shared decision-making on the treatment of anxiety and depressive disorders: systematic review

Background

Shared decision-making encourages patients to explore treatment options/choices in collaboration with their healthcare provider, inclusive of the best available evidence and the patient's values/preferences. Several effective treatments exist for people with anxiety and/or depressive disorders; shared decision-making may be particularly useful in this context.

Aims

To investigate whether shared decision-making enhances clinical outcomes in adults with anxiety and/or depressive disorders.

Method

A systematic review was conducted. Five electronic health databases were searched from database inception until August 2019, in addition to reference lists of included studies. Prospective controlled studies of shared decision-making in adults (aged 18–64 years) diagnosed with an anxiety and/or depressive disorder were included. Two reviewers independently conducted each stage of the review process.

Results

Six randomised controlled trials (N = 1834 participants) were included. Patient satisfaction improved in four studies. Patients were more likely to receive adequate treatment for depression in three studies. Anxiety symptoms decreased in one study. Patient involvement in decision-making increased in three studies. Because of the lack of blinded interventions and outcome assessment, the included studies were at moderate risk of bias. The certainty of evidence ranged from low to moderate, per GRADE criteria.

Conclusions

Shared decision-making shows promise for enhancing quality-of-care outcomes such as patient satisfaction, without increasing consultation time, but appears unlikely to improve symptoms of depression. However, it appears to be understudied in patients with anxiety disorders. Heterogeneity regarding definition and measurement of shared decision-making posed challenges for interpreting the results. More research is recommended to advance the field.

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

OBJECTIVE

To 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.

METHODS

A 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.

RESULTS

The 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.

CONCLUSION

SDM intervention improved SDM self-efficacy and reduced conflict in patients with LDDs.

PRACTICE IMPLICATIONS

Clinicians can integrate DAs and decision coaching in SDM conversations. SDM intervention seems to engage patients in decision-making, especially those without family involvement.

NICE shared decision making guidelines and mental health: challenges for research, practice and implementation

The National Institute for Health and Care Excellence (NICE) initiated an ambitious effort to develop the first shared decision making guidelines. The purpose of this commentary is to identify three main concerns pertaining to the new published guidelines for shared decision making research, practice, implementation and cultural differences in mental health.

The impact of shared decision making on time consumption and clinical decisions. A prospective cohort study

OBJECTIVE

Concerns of increased time consumption and of the impact on clinical decisions may restrain doctors from shared decision making (SDM). This paper evaluates consultation length and decisions made when using an in-consult patient decision aid (PtDA).

METHODS

This prospective cohort study compared an unexposed cohort with a cohort exposed to SDM and a PtDA in two preference-sensitive decision situations: invasive lung cancer diagnostics and adjuvant treatment for early breast cancer. Outcome measures were consultation length and decisions made.

RESULTS

The study included 261 consultations, 115 were in the SDM-exposed cohort. Consultations were inconsiderably longer in the SDM cohort; 2 min, 11 s (p = 0.2217) for lung cancer diagnostics and 3 min, 57 s (p = 0.1128) for adjuvant breast cancer treatment. In lung cancer diagnostics, consultation length became more uniform and decisions tended to become conservative after introduction of SDM. For adjuvant breast cancer, slightly more patients in the SDM cohort chose to decline treatment.

CONCLUSION

Shared decision making did not take significantly longer time and led to slightly more conservative decisions.

PRACTICE IMPLICATIONS

SDM may be implemented without considerable impact on consultation length. The impact on clinical decisions depends mainly on the clinical situation.

Predictors of preference for cognitive-behavioral therapy (CBT) and yoga interventions among older adults

The purpose of this study was to examine factors that influence a person's choice of cognitive-behavioral therapy (CBT) or yoga, the stability of these preferences, and the impact of preference on engagement and process measures. We conducted a randomized preference trial of CBT and yoga in 500 adults ≥60 years with symptoms of worry. Participants reported their intervention preference, strength of preference, and factors impacting preference. Engagement in the intervention (session completion and dropout rates) was assessed. Process measures included satisfaction with the intervention, therapeutic alliance, and intervention expectancy. Neither intervention preference (48% and 52% chose CBT and yoga, respectively) nor strength of preference differed significantly between the two preference trial groups. Intervention expectancies at baseline among those in the preference trial were approximately 4.5 units (40-point scale) higher for their preferred intervention (p < .0001 within each group). A principal component analysis of factors influencing preference identified three constructs. Using logistic regression, components focused on attitudes about CBT or yoga were predictive of ultimate preference (odds ratio = 11.5, 95% C.I.6.3-21.0 per 1SD difference in component 1 for choosing CBT; odds ratio = 7.8, 95% CI4.3-13.9 per 1SD difference in component 2 for choosing yoga). There were no significant differences between the randomized and preference trials on intervention adherence, completion of assessments, intervention satisfaction, or working alliance. Receiving a preferred treatment had no significant effects on intervention outcomes through participant engagement or process measures. When options are limited, providers may have confidence in offering the most readily available non-pharmacological treatments.

A Case Report of College Students' Rating of a Shared Decision-Making Tool for Taking Antidepression Medication

Forty-nine students enrolled at a medium size public university volunteered to review an interactive decision-making tool constructed to present the pros and cons of taking antidepression medication. The tool is built according to guidelines for shared decision-making with 7 educational sections followed by 4 queries on expectations about antidepressants, 3 key knowledge questions, and determination of readiness to take action. The most frequently cited reason for the content being helpful was improved understanding (78%) followed by increased personal confidence (37%) and helped me take action (14%). The most frequently cited reason for the content not being more helpful was already known information (74%) followed by not enough information (12%). The range of personal preferences underscores the complexity of motivations in responding to depressive symptoms. The prevalence of depression in the college population with a range of treatment options, limitations on resources, and new challenges mounted with the pandemic for campus life recommends further study of such tools.

Development of a novel gout treatment patient decision aid by patient and physician: A qualitative research study

BACKGROUND

Gout treatment is not optimized globally, often due to therapeutic inertia by physicians or poor adherence to urate-lowering medications by patients. A patient decision aid (PDA) to facilitate shared decision making (SDM) in gout treatment may overcome these physician-patient barriers.

OBJECTIVE

The study explored the views of physicians and patients on a novel locally designed gout treatment PDA prototype.

DESIGN

Qualitative descriptive design was used to gather data from in-depth-interviews (IDI) and focus group discussions (FGD). Data analysis was via thematic analysis. Emergent themes shaped a revised version of the PDA.

SETTING AND PARTICIPANTS

Adult Asian patients with recent acute gout exacerbations and local Primary Care Physicians (PCP) in Singapore were purposefully chosen. 15 patients with gout and 11 PCPs participated across three IDIs and six FGDs, with the investigators exploring their views of a prototype gout treatment PDA.

RESULTS

Patients and physicians generally concurred with the content and design of the PDA prototype. However, while patients preferred fewer treatment details, the PCPs desired more information. Patients preferred the display of statistics, while PCPs felt that numbers were not relevant to patients. The latter were hesitant to include treatment options that were unavailable in primary care. Both stakeholders indicated that they would use the PDA during a consultation. PCPs would need further training in SDM, given a lack of understanding of it.

CONCLUSION AND PATIENT CONTRIBUTION

Patients will be the prime users of the PDA. While their views differed partially from the physicians, both have jointly developed the novel gout treatment PDA.

Inclusion of person-centred care in medical and nursing undergraduate curricula in the UK: Interviews and documentary analysis

OBJECTIVE

We aimed to understand how person-centred care (PCC) is represented in UK professional standards for undergraduate medical/nursing education and explored how these are reflected in programme provision.

METHODS

We identified PCC components in medical (GMC) and nursing (NMC) professional standards and university curricula documents provided. We also identified themes from interviews with high-level informants for medical/nursing undergraduate programmes using framework analysis.

RESULTS

The GMC appears to promote a more paternalistic model of care with discrete PCC components in specific sections and the NMC a more collaborative model with PCC distributed throughout. These differences persisted into education delivery. Medical educators perceived greater barriers to inclusion of PCC than nursing educators; however, both consistently identified cultural and organisational attributes. Clarity was lacking regarding PCC definition, how to teach/assess PCC, and competence expectations.

CONCLUSION

Development of a PCC skills competence framework would increase consistency and support teaching and assessment in undergraduate curricula. Further research to understand the perspectives of healthcare professionals involved in placements would help inform PCC teaching recommendations.

PRACTICE IMPLICATIONS

High-level support from senior HEI leaders; multi-disciplinary approaches to curricula development, teaching, and assessment; and greater inclusion of service users would ensure higher quality PCC education for undergraduate students.

Skills-based intervention to enhance collaborative decision-making: systematic adaptation and open trial protocol for veterans with psychosis

Background

Collaborative decision-making is an innovative decision-making approach that assigns equal power and responsibility to patients and providers. Most veterans with serious mental illnesses like schizophrenia want a greater role in treatment decisions, but there are no interventions targeted for this population. A skills-based intervention is promising because it is well-aligned with the recovery model, uses similar mechanisms as other evidence-based interventions in this population, and generalizes across decisional contexts while empowering veterans to decide when to initiate collaborative decision-making. Collaborative Decision Skills Training (CDST) was developed in a civilian serious mental illness sample and may fill this gap but needs to undergo a systematic adaptation process to ensure fit for veterans.

Methods

In aim 1, the IM Adapt systematic process will be used to adapt CDST for veterans with serious mental illness. Veterans and Veteran’s Affairs (VA) staff will join an Adaptation Resource Team and complete qualitative interviews to identify how elements of CDST or service delivery may need to be adapted to optimize its effectiveness or viability for veterans and the VA context. During aim 2, an open trial will be conducted with veterans in a VA Psychosocial Rehabilitation and Recovery Center (PRRC) to assess additional adaptations, feasibility, and initial evidence of effectiveness.

Discussion

This study will be the first to evaluate a collaborative decision-making intervention among veterans with serious mental illness. It will also contribute to the field’s understanding of perceptions of collaborative decision-making among veterans with serious mental illness and VA clinicians, and result in a service delivery manual that may be used to understand adaptation needs generally in VA PRRCs.

Trial registration

ClinicalTrials.gov Identifier: NCT04324944

Construction of a patient decision aid for the treatment of uncomplicated urinary tract infection in primary care

Background

Uncomplicated urinary tract infection (uUTI) is very common among women in primary care. The risk of developing pyelonephritis remains low after uUTI, nonetheless, empiric antibiotic therapy is frequently prescribed for symptomatic purposes. This may lead to adverse effects and antibiotic resistance. Furthermore, patients may express the will to limit the use of antibiotics. Some European countries recommend discussing a delayed prescription with the patient and developing a shared decision. The aim of this study is to create a patient decision aid (PtDA) used in primary care settings to make a shared decision between practitioners and women about whether or not to treat uUTI with antibiotics.

Methods

We followed the steps recommended by the International Patient Decision Aids Standards, with a scoping phase, a design phase (including focus groups and literature review), and an alpha-testing phase. A steering group, made of patients and physicians, met throughout the study to develop a prototype PtDA.

Results

The information included in the PtDA is the definition of uUTI, information on the options, their benefits, risks, and consequences, based on a review of the literature. The results of the focus group made possible to determine the patient’s values and preferences to consider in decision-making, including: the discomfort felt, the impact on daily life, patients’ perceptions of antibiotics, and the position relative to the risk of adverse effect. The choices in presentation, organisation and design are the result of the work of the steering group, improved by feedback from alpha testing. We confirmed the need for shared decision-making and the equipoise in this situation.

Conclusions

We developed a PtDA to be used in primary care for sharing decision on the use of antibiotic in uUTI. It needs to be validated in a beta-testing phase, with complementary advice from peers, and then tested in a clinical study comparing its use with the systematic prescription approach.