1
|
Ubbink DT, Matthijssen M, Lemrini S, van Etten-Jamaludin FS, Bloemers FW. Systematic review of barriers, facilitators, and tools to promote shared decision making in the emergency department. Acad Emerg Med 2024. [PMID: 39180226 DOI: 10.1111/acem.14998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/24/2024] [Accepted: 07/24/2024] [Indexed: 08/26/2024]
Abstract
OBJECTIVE The objective was to systematically review all studies focusing on barriers, facilitators, and tools currently available for shared decision making (SDM) in emergency departments (EDs). BACKGROUND Implementing SDM in EDs seems particularly challenging, considering the fast-paced environment and sometimes life-threatening situations. Over 10 years ago, a previous review revealed only a few patient decision aids (PtDAs) available for EDs. METHODS Literature searches were conducted in MEDLINE, Embase, and Cochrane library, up to November 2023. Observational and interventional studies were included to address barriers or facilitators for SDM or to investigate effects of PtDAs on the level of SDM for patients visiting an ED. RESULTS We screened 1946 studies for eligibility, of which 33 were included. PtDAs studied in EDs address chest pain, syncope, analgesics usage, lumbar puncture, ureterolithiasis, vascular access, concussion/brain bleeding, head-CT choice, coaching for elderly people, and activation of patients with appendicitis. Only the primary outcome was meta-analyzed, showing that PtDAs significantly increased the level of SDM (18.8 on the 100-point OPTION scale; 95% CI 12.5-25.0). PtDAs also tended to increase patient knowledge, decrease decisional conflict and decrease health care services usage, with no obvious effect on overall patient satisfaction. Barriers and facilitators were identified on three levels: (1) patient level-emotions, health literacy, and their own proactivity; (2) clinician level-fear of medicolegal consequences, lack of SDM skills or knowledge, and their ideas about treatment superiority; and (3) system level-time constraints, institutional guidelines, and availability of PtDAs. CONCLUSIONS Circumstances in EDs are generally less favorable for SDM. However, PtDAs for conditions seen in EDs are helpful in overcoming barriers to SDM and are welcomed by patients. Even in EDs, SDM is feasible and supported by an increasing number of tools for patients and physicians.
Collapse
Affiliation(s)
- Dirk T Ubbink
- Department of Surgery, Amsterdam University Medical Center at the University of Amsterdam, Location AMC, Amsterdam, the Netherlands
| | | | - Samia Lemrini
- Faculty of Medicine, University of Amsterdam, Amsterdam, the Netherlands
| | - Faridi S van Etten-Jamaludin
- Amsterdam University Medical Center at the University of Amsterdam, Location AMC, Research Support Medical Library, Amsterdam, the Netherlands
| | - Frank W Bloemers
- Department of Trauma Surgery, Amsterdam University Medical Center at the University of Amsterdam, Location AMC, Amsterdam, the Netherlands
| |
Collapse
|
2
|
Müller MA, Gamondi C, Truchard ER, Sterie AC. Voices of the Future: Junior Physicians' Experiences of Discussing Life-Sustaining Treatments With Hospitalized Patients. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2024; 11:23821205241277334. [PMID: 39246599 PMCID: PMC11378183 DOI: 10.1177/23821205241277334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 08/07/2024] [Indexed: 09/10/2024]
Abstract
OBJECTIVES Life-sustaining treatments (LST) aim to prolong life without reversing the underlying medical condition. Being associated with a high risk of developing unwanted adverse outcomes, decisions about LST are routinely discussed with patients at hospital admission, particularly when it comes to cardiopulmonary resuscitation. Physicians may encounter many challenges when enforcing shared decision-making in this domain. In this study, we map out how junior physicians in Southern Switzerland refer to their experiences when conducting LST discussions with hospitalized patients and their learning strategies related to this. METHODS In this qualitative exploratory study, we conducted semi-directive interviews with junior physicians working at the regional public hospital in Southern Switzerland and analyzed them with an inductive thematic analysis. RESULTS Nine physicians participated. We identified 3 themes: emotional burden, learning strategies and practices for conducting discussions. Participants reported feeling unprepared and often distressed when discussing LST with patients. Factors associated with emotional burden were related to the context and to how physicians developed and managed their emotions. Participants signaled having received insufficient education to prepare for discussing LST. They reported learning to discuss LST essentially through trial and error but particularly appreciated the possibility of mentoring and experiential training. Explanations that physicians gave about LST took into account patients' frequent misconceptions. Physicians reported feeling under pressure to ensure that decisions documented were medically indicated and being more at ease when patients decided by themselves to limit treatments. Communication was deemed as an important skill. CONCLUSIONS Junior physicians experienced conducting LST discussions as challenging and felt caught between advocating for medically relevant decisions and respecting patients' autonomy. Participants reported a substantive emotional burden and feeling unprepared for this task, essentially because of a lack of adequate training. Interventions aiming to ameliorate junior physicians' competency in discussing LST can positively affect their personal experiences and decisional outcomes.
Collapse
Affiliation(s)
- Michael Andreas Müller
- Palliative and Supportivecare Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Claudia Gamondi
- Palliative and Supportivecare Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Eve Rubli Truchard
- Service of Geriatrics and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Chair of Geriatric Palliativecare, Service of Palliative and Supportive Care and Service of Geriatrics and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Anca-Cristina Sterie
- Palliative and Supportivecare Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Chair of Geriatric Palliativecare, Service of Palliative and Supportive Care and Service of Geriatrics and Geriatric Rehabilitation, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
3
|
Blum L, Jarach CM, Ellen ME. Perceptions of shared decision making in gastroenterology and inflammatory bowel disease: A qualitative analysis. PATIENT EDUCATION AND COUNSELING 2023; 115:107877. [PMID: 37437510 DOI: 10.1016/j.pec.2023.107877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVE Shared decision-making (SDM) is the partnership and discussion between clinicians and patients to make an appropriate decision based on scientific evidence and patient preferences. Many benefits are associated with SDM; however, little is known about its awareness or use by inflammatory bowel disease (IBD) clinicians in gastroenterology departments across Israel. This study aims to identify barriers and facilitators in implementing SDM as standard practice to achieve optimal disease management and personalized care for patients with IBD. METHODS Sixteen semi-structured interviews were conducted with IBD clinicians across Israel to identify the barriers and facilitators for SDM use. An interview guide was developed, based on the systematic approach of the Theoretical Domain Framework (TDF). Interview transcripts were coded into theoretical domains to identify factors that may impact SDM. RESULTS Sixteen gastroenterologists from nine different hospitals were interviewed. Common TDF domains that presented as barriers were: knowledge, skills, social/professional role and identity, environmental context and resources, and reinforcement. Most participants had never heard the precise term "shared decision making" and lacked formal training on SDM. CONCLUSION This study identified key barriers and facilitators to SDM in IBD clinics across Israel. Main barriers of SDM include limited or nonexistent training; clinicians were unaware of SDM guidelines or techniques. The main facilitators of SDM were clinicians' social and professional role and identity and their beliefs about the influence of IBD and/or CD. PRACTICE IMPLICATIONS These influencing factors and TDF domains identified provide a basis for developing future interventions to improve the implementation of SDM within IBD management.
Collapse
Affiliation(s)
- Livnat Blum
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel.
| | - Carlotta Micaela Jarach
- Laboratory of Lifestyle Research, Department of Medical Epidemiology, Mario Negri Institute of Pharmacological Research, IRCCS, Italy.
| | - Moriah E Ellen
- Department of Health Policy and Management, Guilford Glazer Faculty of Business and Management and Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel; Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Canada; Israel Implementation Science and Policy Engagement Centre, Ben-Gurion University of the Negev, Israel.
| |
Collapse
|
4
|
Nama N, Hall M, Neuman M, Sullivan E, Bochner R, De Laroche A, Hadvani T, Jain S, Katsogridakis Y, Kim E, Mittal M, Payson A, Prusakowski M, Shastri N, Stephans A, Westphal K, Wilkins V, Tieder J. Risk Prediction After a Brief Resolved Unexplained Event. Hosp Pediatr 2022; 12:772-785. [PMID: 35965279 DOI: 10.1542/hpeds.2022-006637] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Only 4% of brief resolved unexplained events (BRUE) are caused by a serious underlying illness. The American Academy of Pediatrics (AAP) guidelines do not distinguish patients who would benefit from further investigation and hospitalization. We aimed to derive and validate a clinical decision rule for predicting the risk of a serious underlying diagnosis or event recurrence. METHODS We retrospectively identified infants presenting with a BRUE to 15 children's hospitals (2015-2020). We used logistic regression in a split-sample to derive and validate a risk prediction model. RESULTS Of 3283 eligible patients, 565 (17.2%) had a serious underlying diagnosis (n = 150) or a recurrent event (n = 469). The AAP's higher-risk criteria were met in 91.5% (n = 3005) and predicted a serious diagnosis with 95.3% sensitivity, 8.6% specificity, and an area under the curve of 0.52 (95% confidence interval [CI]: 0.47-0.57). A derived model based on age, previous events, and abnormal medical history demonstrated an area under the curve of 0.64 (95%CI: 0.59-0.70). In contrast to the AAP criteria, patients >60 days were more likely to have a serious underlying diagnosis (odds ratio:1.43, 95%CI: 1.03-1.98, P = .03). CONCLUSIONS Most infants presenting with a BRUE do not have a serious underlying pathology requiring prompt diagnosis. We derived 2 models to predict the risk of a serious diagnosis and event recurrence. A decision support tool based on this model may aid clinicians and caregivers in the discussion on the benefit of diagnostic testing and hospitalization (https://www.mdcalc.com/calc/10400/brief-resolved-unexplained-events-2.0-brue-2.0-criteria-infants).
Collapse
Affiliation(s)
- Nassr Nama
- Division of General Pediatrics, Department of Pediatrics, University of British Columbia and BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Mark Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Erin Sullivan
- Department of Pediatrics, University of Washington, Seattle Children's Core for Biomedical Statistics, Seattle, Washington
| | - Risa Bochner
- SUNY Downstate Health Sciences University/New York City Health and Hospitals/Kings County Hospital, New York City, New York
| | - Amy De Laroche
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Teena Hadvani
- Division of Hospital Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Shobhit Jain
- Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Kansas
| | - Yiannis Katsogridakis
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Edward Kim
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
| | - Manoj Mittal
- Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | - Nirav Shastri
- Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Kansas
| | | | - Kathryn Westphal
- Division of Hospital Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Victoria Wilkins
- Division of Pediatric Hospital Medicine, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | - Joel Tieder
- Division of Pediatric Hospital Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| |
Collapse
|
5
|
Billah T, Gordon L, Schoenfeld EM, Chang BP, Hess EP, Probst MA. Clinicians' perspectives on the implementation of patient decision aids in the emergency department: A qualitative interview study. J Am Coll Emerg Physicians Open 2022; 3:e12629. [PMID: 35079731 PMCID: PMC8769071 DOI: 10.1002/emp2.12629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/22/2021] [Accepted: 11/09/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Decision aids (DAs) are tools to facilitate and standardize shared decision making (SDM). Although most emergency clinicians (ECs) perceive SDM appropriate for emergency care, there is limited uptake of DAs in clinical practice. The objective of this study was to explore barriers and facilitators identified by ECs regarding the implementation of DAs in the emergency department (ED). METHODS We conducted a qualitative interview study guided by implementation science frameworks. ECs participated in interviews focused on the implementation of DAs for the disposition of patients with low-risk chest pain and unexplained syncope in the ED. Interviews were recorded and transcribed verbatim. We then iteratively developed a codebook with directed qualitative content analysis. RESULTS We approached 25 ECs working in urban New York, of whom 20 agreed to be interviewed (mean age, 41 years; 25% women). The following 6 main barriers were identified: (1) poor DA accessibility, (2) concern for increased medicolegal risk, (3) lack of perceived need for a DA, (4) patient factors including lack of capacity and limited health literacy, (5) skepticism about validity of DAs, and (6) lack of time to use DAs. The 6 main facilitators identified were (1) positive attitudes toward SDM, (2) patient access to follow-up care, (3) potential for improved patient satisfaction, (4) potential for improved risk communication, (5) strategic integration of DAs into the clinical workflow, and (6) institutional support of DAs. CONCLUSIONS ECs identified multiple barriers and facilitators to the implementation of DAs into clinical practice. These findings could guide implementation efforts targeting the uptake of DA use in the ED.
Collapse
Affiliation(s)
- Tausif Billah
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiMount Sinai HospitalNew YorkNew YorkUSA
| | - Lauren Gordon
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiMount Sinai HospitalNew YorkNew YorkUSA
| | - Elizabeth M. Schoenfeld
- Department of Emergency MedicineUniversity of Massachusetts Medical School–BaystateSpringfieldMassachusettsUSA
| | - Bernard P. Chang
- Department of Emergency MedicineColumbia University Medical CenterNew YorkNew YorkUSA
| | - Erik P. Hess
- Department of Emergency MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Marc A. Probst
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiMount Sinai HospitalNew YorkNew YorkUSA
- Department of Emergency MedicineColumbia University Medical CenterNew YorkNew YorkUSA
| |
Collapse
|
6
|
Cox CL, Miller BM, Kuhn I, Fritz Z. Diagnostic uncertainty in primary care: what is known about its communication, and what are the associated ethical issues? Fam Pract 2021; 38:654-668. [PMID: 33907806 PMCID: PMC8463813 DOI: 10.1093/fampra/cmab023] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Diagnostic uncertainty (DU) in primary care is ubiquitous, yet no review has specifically examined its communication, or the associated ethical issues. OBJECTIVES To identify what is known about the communication of DU in primary care and the associated ethical issues. METHODS Systematic review, critical interpretive synthesis and ethical analysis of primary research published worldwide. Medline, Embase, Web of Science and SCOPUS were searched for papers from 1988 to 2020 relating to primary care AND diagnostic uncertainty AND [ethics OR behaviours OR communication]. Critical interpretive synthesis and ethical analysis were applied to data extracted. RESULTS Sixteen papers met inclusion criteria. Although DU is inherent in primary care, its communication is often limited. Evidence on the effects of communicating DU to patients is mixed; research on patient perspectives of DU is lacking. The empirical literature is significantly limited by inconsistencies in how DU is defined and measured. No primary ethical analysis was identified; secondary analysis of the included papers identified ethical issues relating to maintaining patient autonomy in the face of clinical uncertainty, a gap in considering the direct effects of (not) communicating DU on patients, and considerations regarding over-investigation and justice. CONCLUSIONS This review highlights significant gaps in the literature: there is a need for explicit ethical and patient-centred empirical analyses on the effects of communicating DU, and research directly examining patient preferences for this communication. Consensus on how DU should be defined, and greater research into tools for its measurement, would help to strengthen the empirical evidence base.
Collapse
Affiliation(s)
- Caitríona L Cox
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Isla Kuhn
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Zoë Fritz
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| |
Collapse
|
7
|
Björk J, Stenfors T, Juth N, Gunnarsson AB. Personal responsibility for health? A phenomenographic analysis of general practitioners' conceptions. Scand J Prim Health Care 2021; 39:322-331. [PMID: 34128751 PMCID: PMC8475098 DOI: 10.1080/02813432.2021.1935048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To analyse and describe general practitioners' perceptions of the notion of a 'personal responsibility for health'. DESIGN Interview study, phenomenographic analysis. SETTING Swedish primary health care. SUBJECTS General Practitioners (GPs). MAIN OUTCOME MEASURES Using the phenomenographic method, the different views of the phenomenon (here: personal responsibility for health) were presented in an outcome space to illustrate the range of perceptions. RESULTS The participants found the notion of personal responsibility for health relevant to their practice. There was a wide range of perceptions regarding the origins of this responsibility, which was seen as coming from within yourself; from your relationships to specific others; and/or from your relationship with the generalized other. Furthermore, the expressions of this responsibility were perceived as including owning your health problem; not offloading all responsibility onto the GP; taking active measures to keep and improve health; and/or accepting help in health. The GP was described as playing a key role in shaping and defining the patient's responsibility for his/her health. Some aspects of personal responsibility for health roused strong emotions in the participants, especially situations where the patient was seen as offloading all responsibility onto the GP. CONCLUSION The notion of personal responsibility for health is relevant to GPs. However, it is open to a broad range of interpretations and modulated by the patient-physician interaction. This may make it unsuitable for usage in health care priority settings. More research is mandated to further investigate how physicians work with patient responsibility, and how this affects the patient-physician relationship and the physician's own well-being.Key PointsThe notion of personal responsibility for health has relevance for discussions about priority setting and person-centred care.This study, using a phenomenographic approach, investigated the views of Swedish GPs about the notion of personal responsibility for health.The participants found the notion relevant to their practice. They expressed a broad range of views of what a personal responsibility for health entails and how it arises. The GP was described as playing a key role in shaping and defining the patient's responsibilities for his/her health.The notion was emotionally charged to the participants, and when patients were seen as offloading all responsibility onto the GP this gave rise to frustration.
Collapse
Affiliation(s)
- Joar Björk
- Stockholm Centre for Healthcare Ethics (CHE), LIME, Karolinska Institutet, Stockholm, Sweden
- Department of Research and Development, Region Kronoberg, Växjö, Sweden
- CONTACT Joar Björk Stockholm Centre for Healthcare Ethics (CHE), LIME, Karolinska Institutet, Tomtebodavägen 18 A, Stockholm, 171 77, Sweden
| | - Terese Stenfors
- Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | - Niklas Juth
- Stockholm Centre for Healthcare Ethics (CHE), LIME, Karolinska Institutet, Stockholm, Sweden
| | - A. Birgitta Gunnarsson
- Department of Research and Development, Region Kronoberg, Växjö, Sweden
- Institute of Neuroscience and Physiology, Section for Health and Rehabilitation, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
8
|
Maksimowski K, Haddad R, DeLaroche AM. Pediatrician Perspectives on Brief Resolved Unexplained Events. Hosp Pediatr 2021; 11:996-1003. [PMID: 34429345 DOI: 10.1542/hpeds.2021-005805] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE The objective with this study was to describe pediatric emergency department (ED) physicians' perspective on the evaluation and management of brief resolved unexplained events (BRUEs) to help support the development of quality improvement interventions for this population. METHODS We conducted qualitative semistructured interviews with pediatric ED providers who practice in a single state. Interviews were audio-recorded and transcribed and demographic information was also obtained. The 6-phase approach to reflexive thematic analysis was used to conduct the qualitative analysis. RESULTS Nineteen pediatric ED physicians practicing in 4 institutions across our state participated in the study. The majority of participants (95%) practice in a university-affiliated setting. The primary themes related to providing care for patients with a BRUE identified in our analysis were (1) reassurance, (2) caregiver or provider concern, and (3) clinical practice guideline availability and interpretation. Closely intertwined underlying topics informing BRUE patient management were also noted: (1) ambiguity in the BRUE diagnosis and its management; (2) a need for shared decision-making between the caregiver and the provider; and (3) concern over the increased time spent with caregivers during an ED visit for a diagnosis of BRUE. These complex relationships were found to influence patient evaluation and disposition. CONCLUSION Multifaceted quality improvement interventions should address caregiver and provider concerns regarding the diagnosis of BRUE while providing decision aids to support shared decision-making with caregivers.
Collapse
Affiliation(s)
- Karolina Maksimowski
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Rita Haddad
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Amy M DeLaroche
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| |
Collapse
|
9
|
Waddell A, Lennox A, Spassova G, Bragge P. Barriers and facilitators to shared decision-making in hospitals from policy to practice: a systematic review. Implement Sci 2021; 16:74. [PMID: 34332601 PMCID: PMC8325317 DOI: 10.1186/s13012-021-01142-y] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 07/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background Involving patients in their healthcare using shared decision-making (SDM) is promoted through policy and research, yet its implementation in routine practice remains slow. Research into SDM has stemmed from primary and secondary care contexts, and research into the implementation of SDM in tertiary care settings has not been systematically reviewed. Furthermore, perspectives on SDM beyond those of patients and their treating clinicians may add insights into the implementation of SDM. This systematic review aimed to review literature exploring barriers and facilitators to implementing SDM in hospital settings from multiple stakeholder perspectives. Methods The search strategy focused on peer-reviewed qualitative studies with the primary aim of identifying barriers and facilitators to implementing SDM in hospital (tertiary care) settings. Studies from the perspective of patients, clinicians, health service administrators, and decision makers, government policy makers, and other stakeholders (for example researchers) were eligible for inclusion. Reported qualitative results were mapped to the Theoretical Domains Framework (TDF) to identify behavioural barriers and facilitators to SDM. Results Titles and abstracts of 8724 articles were screened and 520 were reviewed in full text. Fourteen articles met inclusion criteria. Most studies (n = 12) were conducted in the last four years; only four reported perspectives in addition to the patient-clinician dyad. In mapping results to the TDF, the dominant themes were Environmental Context and Resources, Social/Professional Role and Identity, Knowledge and Skills, and Beliefs about Capabilities. A wide range of barriers and facilitators across individual, organisational, and system levels were reported. Barriers specific to the hospital setting included noisy and busy ward environments and a lack of private spaces in which to conduct SDM conversations. Conclusions SDM implementation research in hospital settings appears to be a young field. Future research should build on studies examining perspectives beyond the clinician-patient dyad and further consider the role of organisational- and system-level factors. Organisations wishing to implement SDM in hospital settings should also consider factors specific to tertiary care settings in addition to addressing their organisational and individual SDM needs. Trial Registration The protocol for the review is registered on the Open Science Framework and can be found at https://osf.io/da645/, DOI 10.17605/OSF.IO/DA645. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-021-01142-y.
Collapse
Affiliation(s)
- Alex Waddell
- Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton Campus, Melbourne, VIC, 3800, Australia. .,Safer Care Victoria, 50 Lonsdale St, Melbourne, VIC, 3000, Australia.
| | - Alyse Lennox
- Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton Campus, Melbourne, VIC, 3800, Australia
| | - Gerri Spassova
- Department of Marketing, Monash Business School, Level 6, Building S, Caulfield Campus 26 Sir John Monash Drive, Caulfield East, VIC, 3145, Australia
| | - Peter Bragge
- Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton Campus, Melbourne, VIC, 3800, Australia
| |
Collapse
|
10
|
Schoenfeld EM, Poronsky KE, Westafer LM, DiFronzo BM, Visintainer P, Scales CD, Hess EP, Lindenauer PK. Feasibility and efficacy of a decision aid for emergency department patients with suspected ureterolithiasis: protocol for an adaptive randomized controlled trial. Trials 2021; 22:201. [PMID: 33691760 PMCID: PMC7944622 DOI: 10.1186/s13063-021-05140-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 02/19/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Approximately 2 million patients present to emergency departments in the USA annually with signs and symptoms of ureterolithiasis (or renal colic, the pain from an obstructing kidney stone). Both ultrasound and CT scan can be used for diagnosis, but the vast majority of patients receive a CT scan. Diagnostic pathways utilizing ultrasound have been shown to decrease radiation exposure to patients but are potentially less accurate. Because of these and other trade-offs, this decision has been proposed as appropriate for Shared Decision-Making (SDM), where clinicians and patients discuss clinical options and their consequences and arrive at a decision together. We developed a decision aid to facilitate SDM in this scenario. The objective of this study is to determine the effects of this decision aid, as compared to usual care, on patient knowledge, radiation exposure, engagement, safety, and healthcare utilization. METHODS This is the protocol for an adaptive randomized controlled trial to determine the effects of the intervention-a decision aid ("Kidney Stone Choice")-on patient-centered outcomes, compared with usual care. Patients age 18-55 presenting to the emergency department with signs and symptoms consistent with acute uncomplicated ureterolithiasis will be consecutively enrolled and randomized. Participants will be blinded to group allocation. We will collect outcomes related to patient knowledge, radiation exposure, trust in physician, safety, and downstream healthcare utilization. DISCUSSION We hypothesize that this study will demonstrate that "Kidney Stone Choice," the decision aid created for this scenario, improves patient knowledge and decreases exposure to ionizing radiation. The adaptive design of this study will allow us to identify issues with fidelity and feasibility and subsequently evaluate the intervention for efficacy. TRIAL REGISTRATION ClinicalTrials.gov NCT04234035 . Registered on 21 January 2020 - Retrospectively Registered.
Collapse
Affiliation(s)
- Elizabeth M. Schoenfeld
- Department of Emergency Medicine and Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School – Baystate, Springfield, MA USA
| | - Kye E. Poronsky
- Department of Emergency Medicine and Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School – Baystate, Springfield, MA USA
| | - Lauren M. Westafer
- Department of Emergency Medicine and Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School – Baystate, Springfield, MA USA
| | - Brianna M. DiFronzo
- Department of Emergency Medicine and Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School – Baystate, Springfield, MA USA
| | - Paul Visintainer
- Department of Medicine, and Institute for Healthcare Delivery and Population Science Epidemiology and Biostatistics Research Core, University of Massachusetts Medical School – Baystate, Springfield, MA USA
| | - Charles D. Scales
- Duke Clinical Research Institute and Division of Urologic Surgery, Duke University School of Medicine, Durham, NC USA
| | - Erik P. Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, TN Memphis, USA
| | - Peter K. Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School – Baystate, Springfield, MA USA
- Department of Medicine, University of Massachusetts Medical School – Baystate, Springfield, MA USA
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA USA
| |
Collapse
|
11
|
Ishimine P. Sharing Is Caring: Can an App Help? Acad Emerg Med 2021; 28:138-140. [PMID: 32949065 DOI: 10.1111/acem.14133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Paul Ishimine
- Department of Emergency Medicine UC San Diego Health San DiegoCAUSA
- Division of Pediatric Emergency Medicine Rady Children's Hospital San Diego San DiegoCAUSA
- Departments of Emergency Medicine and Pediatrics University of CaliforniaSan Diego School of Medicine La Jolla CA USA
| |
Collapse
|
12
|
Kanzaria HK, Chen EH. Shared Decision Making for the Emergency Provider: Engaging Patients When Seconds Count. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2020; 16:10936. [PMID: 32875088 PMCID: PMC7449574 DOI: 10.15766/mep_2374-8265.10936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 01/24/2020] [Indexed: 06/11/2023]
Abstract
Introduction Physicians need to be able to communicate the myriad of management options clearly to patients and engage them in their health care decisions, even in the fast-paced environment of the emergency department. Shared decision making (SDM) is an effective communication strategy for physicians to share diagnostic uncertainty, avoid potentially harmful tests, and solicit patients' preferences for their care. Role-playing with just-in-time feedback is an effective method to learn and practice SDM before having these conversations with patients. Methods This flipped classroom workshop featured precourse materials and an in-class session incorporating a short lecture outlining a framework for SDM, followed by role-playing through patient scenarios. Learners took turns playing the physician or patient role and received feedback on their communication skills while in the physician role. A faculty examiner subsequently assessed skill attainment using a simulated patient encounter and checklist of critical actions. Results The workshop was an interactive and effective way to teach SDM to 28 PGY 1 and PGY 2 emergency medicine residents. Two months after attending the workshop, over 75% of the first-year residents were able to complete all the elements of the SDM process in a simulated patient encounter; four residents required no prompting by the examiner. Discussion A communications workshop that incorporates role-playing with different patient encounters is an interactive way to teach SDM for the emergency setting. Residents early in their clinical training can benefit from learning and practicing SDM in a simulated setting.
Collapse
Affiliation(s)
- Hemal K. Kanzaria
- Associate Professor of Clinical Emergency Medicine, Department of Emergency Medicine, University of California, San Francisco, School of Medicine
| | - Esther H. Chen
- Professor of Clinical Emergency Medicine, Department of Emergency Medicine, University of California, San Francisco, School of Medicine
| |
Collapse
|
13
|
Abstract
Despite the emphasis on engaging in shared decision-making for decisions involving life-prolonging interventions, there remains uncertainty about which communication strategies are best to achieve shared decision-making. In this paper, we present the communication strategies used in a code status discussion in a single case audio recorded as part of a research study of how patients and physicians make decisions about the plan of care during daily rounds. When presenting this case at various forums to demonstrate our findings, we found that some clinicians viewed the communication strategies used in the case as an exemplar of shared decision-making, whereas other clinicians viewed them as perpetuating paternalism. Given this polarized reaction, the purpose of this perspective paper is to examine the communication strategies used in the code status discussion and compare those strategies with our current conceptualization of shared decision-making and communication best practices.
Collapse
|
14
|
Dorsett M, Cooper RJ, Taira BR, Wilkes E, Hoffman JR. Bringing value, balance and humanity to the emergency department: The Right Care Top 10 for emergency medicine. Emerg Med J 2019; 37:240-245. [PMID: 31874920 DOI: 10.1136/emermed-2019-209031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/25/2019] [Accepted: 12/09/2019] [Indexed: 01/29/2023]
Affiliation(s)
- Maia Dorsett
- Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Richelle J Cooper
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Breena R Taira
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Erin Wilkes
- Kaiser Permanente LAMC, Los Angeles, California, USA
| | - Jerome R Hoffman
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
| |
Collapse
|
15
|
Schoenfeld EM, Probst MA, Quigley DD, St Marie P, Nayyar N, Sabbagh SH, Beckford T, Kanzaria HK. Does Shared Decision Making Actually Occur in the Emergency Department? Looking at It from the Patients' Perspective. Acad Emerg Med 2019; 26:1369-1378. [PMID: 31465130 PMCID: PMC8099042 DOI: 10.1111/acem.13850] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/15/2019] [Accepted: 08/23/2019] [Indexed: 01/08/2023]
Abstract
OBJECTIVE We sought to assess the frequency, content, and quality of shared decision making (SDM) in the emergency department (ED), from patients' perspectives. METHODS Utilizing a cross-sectional, multisite approach, we administered an instrument, consisting of two validated SDM assessment tools-the CollaboRATE and the SDM-Q-9-and one newly developed tool to a sample of ED patients. Our primary outcome was the occurrence of SDM in the clinical encounter, as defined by participants giving "top-box" scores on the CollaboRATE measure, and the ability of patients to identify the topic of their SDM conversation. Secondary outcomes included the content of the SDM conversations, as judged by patients, and whether patients were able to complete each of the two validated scales included in the instrument. RESULTS After exclusions, 285 participants from two sites completed the composite instrument. Just under half identified as female (47%) or as white (47%). Roughly half gave top-box scores (i.e., indicating optimal SDM) on the CollaboRATE scale (49%). Less than half of the participants were able to indicate a decision they were involved in (44%), although those who did gave high scores for such conversations (73/100 via the SDM-Q-9 tool). The most frequently identified decisions discussed were admission versus discharge (19%), medication options (17%), and options for follow-up care (15%). CONCLUSIONS Fewer than half of ED patients surveyed reported they were involved in SDM. The most common decision for which SDM was used was around ED disposition (admission vs. discharge). When SDM was employed, patients generally rated the discussion highly.
Collapse
Affiliation(s)
- Elizabeth M Schoenfeld
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Marc A Probst
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Peter St Marie
- Office of Research and the Epidemiology/Biostatistics Research Core, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Nikita Nayyar
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY
| | - Sarah H Sabbagh
- Department of Emergency Medicine, University of California at San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | | | - Hemal K Kanzaria
- Department of Emergency Medicine, University of California at San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| |
Collapse
|
16
|
Müller E, Diesing A, Rosahl A, Scholl I, Härter M, Buchholz A. Evaluation of a shared decision-making communication skills training for physicians treating patients with asthma: a mixed methods study using simulated patients. BMC Health Serv Res 2019; 19:612. [PMID: 31470856 PMCID: PMC6716840 DOI: 10.1186/s12913-019-4445-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 08/20/2019] [Indexed: 12/13/2022] Open
Abstract
Background Shared decision-making (SDM) is a key principle in asthma management, but continues to be poorly implemented in routine care. This study aimed to evaluate the impact of a SDM communication skills training for physicians treating patients with asthma on the SDM behaviors of physicians, and to analyze physician views on the training. Methods A mixed methods study with a partially mixed sequential equal status design was conducted to evaluate a 12 h SDM communication skills training for physicians treating patients with asthma. It included a short introductory talk, videotaped consultations with simulated asthma patients, video analysis in small group sessions, individual feedback, short presentations, group discussions, and practical exercises. The quantitative evaluation phase consisted of a before (t0) after (t1) comparison of SDM performance using the observer-rated OPTION5, the physician questionnaire SDM-Q-Doc, and the patient questionnaire SDM-Q-9, using dependent t-tests. The qualitative evaluation phase (t2) consisted of a content analysis of audiotaped and transcribed interviews. Results Initially, 29 physicians participated in the study, 27 physicians provided quantitative data, and 22 physicians provided qualitative data for analysis. Quantitative results showed significantly improved performance in SDM following the training (t1) when compared with performance in SDM before the training (t0) (OPTION5: t (26) = − 5.16; p < 0.001) (SDM-Q-Doc: t (26) = − 4.39; p < 0.001) (SDM-Q-9: t (26) = − 5.86; p < 0.001). The qualitative evaluation showed that most physicians experienced a change in attitude and behavior after the training, and positively appraised the training program. Physicians considered simulated patient consultations, including feedback and video analysis, beneficial and suggested the future use of real patient consultations. Conclusion The SDM communication skills training for physicians treating patients with asthma has potential to improve SDM performance, but would benefit from using real patient consultations.
Collapse
Affiliation(s)
- Evamaria Müller
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistr. 52 (W26), D-20246, Hamburg, Germany.
| | - Alice Diesing
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistr. 52 (W26), D-20246, Hamburg, Germany
| | - Anke Rosahl
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistr. 52 (W26), D-20246, Hamburg, Germany
| | - Isabelle Scholl
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistr. 52 (W26), D-20246, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistr. 52 (W26), D-20246, Hamburg, Germany
| | - Angela Buchholz
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistr. 52 (W26), D-20246, Hamburg, Germany
| |
Collapse
|
17
|
Schoenfeld EM, Mader S, Houghton C, Wenger R, Probst MA, Schoenfeld DA, Lindenauer PK, Mazor KM. The Effect of Shared Decisionmaking on Patients' Likelihood of Filing a Complaint or Lawsuit: A Simulation Study. Ann Emerg Med 2019; 74:126-136. [PMID: 30611638 PMCID: PMC6599569 DOI: 10.1016/j.annemergmed.2018.11.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 11/06/2018] [Accepted: 11/12/2018] [Indexed: 11/24/2022]
Abstract
STUDY OBJECTIVE Shared decisionmaking has been promoted as a method to increase the patient-centeredness of medical decisionmaking and decrease low-yield testing, but little is known about its medicolegal ramifications in the setting of an adverse outcome. We seek to determine whether the use of shared decisionmaking changes perceptions of fault and liability in the case of an adverse outcome. METHODS This was a randomized controlled simulation experiment conducted by survey, using clinical vignettes featuring no shared decisionmaking, brief shared decisionmaking, or thorough shared decisionmaking. Participants were adult US citizens recruited through an online crowd-sourcing platform. Participants were randomized to vignettes portraying 1 of 3 levels of shared decisionmaking. All other information given was identical, including the final clinical decision and the adverse outcome. The primary outcome was reported likelihood of pursuing legal action. Secondary outcomes included perceptions of fault, quality of care, and trust in physician. RESULTS We recruited 804 participants. Participants exposed to shared decisionmaking (brief and thorough) were 80% less likely to report a plan to contact a lawyer than those not exposed to shared decisionmaking (12% and 11% versus 41%; odds ratio 0.2; 95% confidence interval 0.12 to 0.31). Participants exposed to either level of shared decisionmaking reported higher trust, rated their physicians more highly, and were less likely to fault their physicians for the adverse outcome compared with those exposed to the no shared decisionmaking vignette. CONCLUSION In the setting of an adverse outcome from a missed diagnosis, use of shared decisionmaking may affect patients' perceptions of fault and liability.
Collapse
Affiliation(s)
- Elizabeth M Schoenfeld
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA; Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA.
| | - Shelby Mader
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Connor Houghton
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Robert Wenger
- Department of Emergency Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Marc A Probst
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David A Schoenfeld
- Department of Biostatistics, Harvard School of Public Health, and Harvard Medical School, Boston, MA
| | - Peter K Lindenauer
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Kathleen M Mazor
- Department of Medicine, University of Massachusetts Medical School, and Meyers Primary Care Institute, Worcester, MA
| |
Collapse
|
18
|
Forcino RC, Yen RW, Aboumrad M, Barr PJ, Schubbe D, Elwyn G, Durand MA. US-based cross-sectional survey of clinicians' knowledge and attitudes about shared decision-making across healthcare professions and specialties. BMJ Open 2018; 8:e022730. [PMID: 30341128 PMCID: PMC6196864 DOI: 10.1136/bmjopen-2018-022730] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE In this study, we aim to compare shared decision-making (SDM) knowledge and attitudes between US-based physician assistants (PAs), nurse practitioners (NPs) and physicians across surgical and family medicine specialties. SETTING We administered a cross-sectional, web-based survey between 20 September 2017 and 1 November 2017. PARTICIPANTS 272 US-based NPs, PA and physicians completed the survey. 250 physicians were sent a generic email invitation to participate, of whom 100 completed the survey. 3300 NPs and PAs were invited, among whom 172 completed the survey. Individuals who met the following exclusion criteria were excluded from participation: (1) lack of English proficiency; (2) area of practice other than family medicine or surgery; (3) licensure other than physician, PA or NP; (4) practicing in a country other than the US. RESULTS We found few substantial differences in SDM knowledge and attitudes across clinician types, revealing positive attitudes across the sample paired with low to moderate knowledge. Family medicine professionals (PAs) were most knowledgeable on several items. Very few respondents (3%; 95% CI 1.5% to 6.2%) favoured a paternalistic approach to decision-making. CONCLUSIONS Recent policy-level promotion of SDM may have influenced positive clinician attitudes towards SDM. Positive attitudes despite limited knowledge warrant SDM training across occupations and specialties, while encouraging all clinicians to promote SDM. Given positive attitudes and similar knowledge across clinician types, we recommend that SDM is not confined to the patient-physician dyad but instead advocated among other health professionals.
Collapse
Affiliation(s)
- Rachel C Forcino
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA
| | - Renata West Yen
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA
| | - Maya Aboumrad
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA
- White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Paul J Barr
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA
| | - Danielle Schubbe
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA
| | - Marie-Anne Durand
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA
| |
Collapse
|
19
|
Schoenfeld EM, Kanzaria HK, Quigley DD, Marie PS, Nayyar N, Sabbagh SH, Gress KL, Probst MA. Patient Preferences Regarding Shared Decision Making in the Emergency Department: Findings From a Multisite Survey. Acad Emerg Med 2018; 25:1118-1128. [PMID: 29897639 PMCID: PMC6185792 DOI: 10.1111/acem.13499] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 06/01/2018] [Accepted: 06/07/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES As shared decision making (SDM) has received increased attention as a method to improve the patient-centeredness of emergency department (ED) care, we sought to determine patients' desired level of involvement in medical decisions and their perceptions of potential barriers and facilitators to SDM in the ED. METHODS We surveyed a cross-sectional sample of adult ED patients at three academic medical centers across the United States. The survey included 32 items regarding patient involvement in medical decisions including a modified Control Preference Scale and questions about barriers and facilitators to SDM in the ED. Items were developed and refined based on prior literature and qualitative interviews with ED patients. Research assistants administered the survey in person. RESULTS Of 797 patients approached, 661 (83%) agreed to participate. Participants were 52% female, 45% white, and 30% Hispanic. The majority of respondents (85%-92%, depending on decision type) expressed a desire for some degree of involvement in decision making in the ED, while 8% to 15% preferred to leave decision making to their physician alone. Ninety-eight percent wanted to be involved with decisions when "something serious is going on." The majority of patients (94%) indicated that self-efficacy was not a barrier to SDM in the ED. However, most patients (55%) reported a tendency to defer to the physician's decision making during an ED visit, with about half reporting they would wait for a physician to ask them to be involved. CONCLUSION We found that the majority of ED patients in our large, diverse sample wanted to be involved in medical decisions, especially in the case of a "serious" medical problem, and felt that they had the ability to do so. Nevertheless, many patients were unlikely to actively seek involvement and defaulted to allowing the physician to make decisions during the ED visit. After fully explaining the consequences of a decision, clinicians should make an effort to explicitly ascertain patients' desired level of involvement in decision making.
Collapse
Affiliation(s)
- Elizabeth M Schoenfeld
- Department of Emergency Medicine, Springfield, MA
- Institute for Healthcare Delivery and Population Science, Springfield, MA
| | - Hemal K Kanzaria
- University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | | | - Peter St Marie
- Office of Research and the Epidemiology/Biostatistics Research Core, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Nikita Nayyar
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY
| | - Sarah H Sabbagh
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA
| | - Kyle L Gress
- Georgetown University School of Medicine, Washington, DC
| | - Marc A Probst
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
20
|
Schoenfeld EM, Goff SL, Downs G, Wenger RJ, Lindenauer PK, Mazor KM. A Qualitative Analysis of Patients' Perceptions of Shared Decision Making in the Emergency Department: "Let Me Know I Have a Choice". Acad Emerg Med 2018; 25:716-727. [PMID: 29577490 DOI: 10.1111/acem.13416] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 03/01/2018] [Accepted: 03/11/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite increasing attention to the use of shared decision making (SDM) in the emergency department (ED), little is known about ED patients' perspectives regarding this practice. We sought to explore the use of SDM from the perspectives of ED patients, focusing on what affects patients' desired level of involvement and what barriers and facilitators patients find most relevant to their experience. METHODS We conducted semistructured interviews with a purposive sample of ED patients or their proxies at two sites. An interview guide was developed from existing literature and expert consensus and based on a framework underscoring the importance of both knowledge and power. Interviews were recorded, transcribed, and analyzed in an iterative process by a three-person coding team. Emergent themes were identified, discussed, and organized. RESULTS Twenty-nine patients and proxies participated. The mean age of participants was 56 years (range, 20 to 89 years), and 13 were female. Participants were diverse in regard to race/ethnicity, education, number of previous ED visits, and presence of chronic conditions. All participants wanted some degree of involvement in decision making. Participants who made statements suggesting high self-efficacy and those who expressed mistrust of the health care system or previous negative experiences wanted a greater degree of involvement. Facilitators to involvement included familiarity with the decision at hand, physicians' good communication skills, and clearly delineated options. Some participants felt that their own relative lack of knowledge, compared to that of the physicians, made their involvement inappropriate or unwanted. Many participants had no expectation for SDM and although they did want involvement when asked explicitly, they were otherwise likely to defer to physicians without discussion. Many did not recognize opportunities for SDM in their clinical care. CONCLUSIONS This exploration of ED patients' perceptions of SDM suggests that most patients want some degree of involvement in medical decision making but more proactive engagement of patients by clinicians is often needed. Further research should examine these issues in a larger and more representative population.
Collapse
Affiliation(s)
- Elizabeth M. Schoenfeld
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
- Institute for Healthcare Delivery and Population Science Baystate Medical Center Springfield MA
| | - Sarah L. Goff
- Division of General Medicine University of Massachusetts Medical School–Baystate Springfield MA
- Institute for Healthcare Delivery and Population Science Baystate Medical Center Springfield MA
| | - Gwendolyn Downs
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | - Robert J. Wenger
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | - Peter K. Lindenauer
- Institute for Healthcare Delivery and Population Science Baystate Medical Center Springfield MA
| | - Kathleen M. Mazor
- Department of Medicine University of Massachusetts Medical School, and Meyers Primary Care Institute WorcesterMA
| |
Collapse
|
21
|
Probst MA, Hess EP, Breslin M, Frosch DL, Sun BC, Langan MN, Richardson LD. Development of a Patient Decision Aid for Syncope in the Emergency Department: the SynDA Tool. Acad Emerg Med 2018; 25:425-433. [PMID: 29288554 DOI: 10.1111/acem.13373] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 12/11/2017] [Accepted: 12/27/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objective was to develop a patient decision aid (DA) to promote shared decision making (SDM) for stable, alert patients who present to the emergency department (ED) with syncope. METHODS Using input from patients, clinicians, and experts in the field of syncope, health care design, and SDM, we created a prototype of a paper-based DA to engage patients in the disposition decision (admission vs. discharge) after an unremarkable ED evaluation for syncope. In phase 1, we conducted one-on-one semistructured exploratory interviews with 10 emergency physicians and 10 ED syncope patients. In phase 2, we conducted one-on-one directed interviews with 15 emergency care clinicians, five cardiologists, and 12 ED syncope patients to get detailed feedback on DA content and design. We iteratively modified the aid using feedback from each interviewee until clarity and usability had been optimized. RESULTS The 11 × 17-inch, paper-based DA, titled SynDA, includes four sections: 1) explanation of syncope, 2) explanation of future risks, 3) personalized 30-day risk estimate, and 4) disposition options. The personalized risk estimate is calculated using a recently published syncope risk-stratification tool. This risk estimate is stated in natural frequency and graphically displayed using a 100-person color-coded pictogram. Patient-oriented questions are included to stimulate dialogue between patient and clinician. At the end of the development process, patient and physician participants expressed satisfaction with the clarity and usability of the DA. CONCLUSIONS We iteratively developed an evidence-based DA to facilitate SDM for alert syncope patients after an unremarkable ED evaluation. Further testing is required to determine its effects on patient care. This DA has the potential to improve care for syncope patients and promote patient-centered care in emergency medicine.
Collapse
Affiliation(s)
- Marc A. Probst
- Department of Emergency Medicine; Mount Sinai Medical Center; New York NY
| | - Erik P. Hess
- Department of Emergency Medicine; Mayo Clinic; Rochester MN
| | | | | | - Benjamin C. Sun
- Center for Policy and Research in Emergency Medicine; Department of Emergency Medicine; Oregon Heath & Science University; Portland OR
| | - Marie-Noelle Langan
- Department of Medicine; Division of Cardiology; Mount Sinai Medical Center; New York NY
| | | |
Collapse
|
22
|
Schaffer JT, Hess EP, Hollander JE, Kline JA, Torres CA, Diercks DB, Jones R, Owen KP, Meisel ZF, Demers M, Leblanc A, Inselman J, Herrin J, Montori VM, Shah ND. Impact of a Shared Decision Making Intervention on Health Care Utilization: A Secondary Analysis of the Chest Pain Choice Multicenter Randomized Trial. Acad Emerg Med 2018; 25:293-300. [PMID: 29218817 DOI: 10.1111/acem.13355] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 11/09/2017] [Accepted: 12/01/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Patients at low risk for acute coronary syndrome are frequently admitted for observation and cardiac testing, resulting in substantial burden and cost to the patient and the health care system. OBJECTIVES The purpose of this investigation was to measure the effect of the Chest Pain Choice (CPC) decision aid on overall health care utilization as well as utilization of specific services both during the index emergency department (ED) visit and in the subsequent 45 days. METHODS This was a planned secondary analysis of data from a pragmatic multicenter randomized trial of shared decision making in adults presenting to the ED with chest pain who were being considered for observation unit admission for cardiac stress testing or coronary computed tomography angiography. The trial compared an intervention group engaged in shared decision making facilitated by the CPC decision aid to a control group receiving usual care. Hospital-level billing data were used to measure utilization for the index ED visit and during the following 45 days. Patients in both groups also were asked to keep a diary recording health care utilization over the same 45-day period. Outcomes assessed included length of time in the ED and observation, ED visits, office visits, hospitalizations, testing, imaging, and procedures. RESULTS Of the 898 patients included in the original trial, we were able to contact 834 (92.9%) patients for 45-day health care diary review. There was no difference in patient-reported health care utilization between the study arms. Hospital-level billing data were obtained for all 898 (100%) patients. During the initial ED visit the length of stay (LOS) was similar, and there was no difference in the frequency of observation unit admission between study arms. However, the mean observation unit LOS was 95 minutes (95% confidence interval [CI] = 40.8-149.8) shorter in the CPC arm and the mean number of tests was lower in the CPC arm (decrease in 19.4 imaging studies per 100 patients, 95% CI = 15.5-23.3). When evaluating the entire encounter and follow-up period, the intervention arm underwent fewer tests (decrease in 125.6 tests per 100 patients, 95% CI = 29.3-221.6). More specifically, there were fewer advanced cardiac imaging tests completed (25.8 fewer per 100 patients, 95% CI = 3.74-47.9) in the intervention arm. CONCLUSIONS Shared decision making in low-risk chest pain can lead to decreased diagnostic testing without worsening outcomes measured over 45 days.
Collapse
Affiliation(s)
| | - Erik P. Hess
- Department of Emergency Medicine Division of Emergency Medicine Research Mayo Clinic Rochester MN
- Division of Health Care Policy and Research Department of Health Sciences Research Mayo Clinic Rochester MN
- Knowledge and Evaluation Research Unit Rochester MN
| | - Judd E. Hollander
- Department of Emergency Medicine Thomas Jefferson University Philadelphia PA
| | - Jeffrey A. Kline
- Department of Emergency Medicine Indiana University Indianapolis IN
| | | | - Deborah B. Diercks
- Department of Emergency Medicine University of Texas Southwestern Dallas TX
| | - Russell Jones
- Department of Emergency Medicine University of California Davis Sacramento CA
| | - Kelly P. Owen
- Department of Emergency Medicine University of California Davis Sacramento CA
| | - Zachary F. Meisel
- Department of Emergency Medicine Perelman School of Medicine Philadelphia PA
| | | | - Annie Leblanc
- Knowledge and Evaluation Research Unit Rochester MN
- Caregiver Representative Rochester MN
| | - Jonathan Inselman
- Division of Health Care Policy and Research Department of Health Sciences Research Mayo Clinic Rochester MN
- Knowledge and Evaluation Research Unit Rochester MN
| | - Jeph Herrin
- Yale University School of Medicine New Haven CT
- Health Research & Educational Trust Chicago IL
| | - Victor M. Montori
- Division of Endocrinology Diabetes, Metabolism, and Nutrition Department of Internal Medicine Mayo Clinic Rochester MN
- Knowledge and Evaluation Research Unit Rochester MN
| | - Nilay D. Shah
- Division of Health Care Policy and Research Department of Health Sciences Research Mayo Clinic Rochester MN
- Knowledge and Evaluation Research Unit Rochester MN
| |
Collapse
|
23
|
Schoenfeld EM, Goff SL, Elia TR, Khordipour ER, Poronsky KE, Nault KA, Lindenauer PK, Mazor KM. A Qualitative Analysis of Attending Physicians' Use of Shared Decision-Making: Implications for Resident Education. J Grad Med Educ 2018; 10:43-50. [PMID: 29467972 PMCID: PMC5821016 DOI: 10.4300/jgme-d-17-00318.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 08/10/2017] [Accepted: 09/24/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Physicians need to rapidly and effectively facilitate patient-centered, shared decision-making (SDM) conversations, but little is known about how residents or attending physicians acquire this skill. OBJECTIVE We explored emergency medicine (EM) attending physicians' use of SDM in the context of their experience as former residents and current educators and assessed the implications of these findings on learning opportunities for residents. METHODS We used semistructured interviews with a purposeful sample of EM physicians. Interviews were transcribed verbatim, and 3 research team members performed iterative, open coding of transcripts, building a provisional codebook as work progressed. We analyzed the data with a focus on participants' acquisition and use of skills required for SDM and their use of SDM in the context of resident education. RESULTS Fifteen EM physicians from academic and community practices were interviewed. All reported using SDM techniques to some degree. Multiple themes noted had negative implications for resident acquisition of this skill: (1) the complex relationships among patients, residents, and attending physicians; (2) residents' skill levels; (3) the setting of busy emergency departments; and (4) individual attending factors. One theme was noted to facilitate resident education: the changing culture-with a cultural shift toward patient-centered care. CONCLUSIONS A constellation of factors may diminish opportunities for residents to acquire and practice SDM skills. Further research should explore residents' perspectives, address the modifiable obstacles identified, and examine whether these issues generalize to other specialties.
Collapse
|
24
|
Konstantinidou MK, Karaglani M, Panagopoulou M, Fiska A, Chatzaki E. Are the Origins of Precision Medicine Found in the Corpus Hippocraticum? Mol Diagn Ther 2017; 21:601-606. [DOI: 10.1007/s40291-017-0291-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|