Health Literacy and Disease Knowledge of Patients With Peripheral Arterial Disease or Abdominal Aortic Aneurysm: A Scoping Review

OBJECTIVE

This scoping review summarises health literacy and disease knowledge in patients with abdominal aortic aneurysm (AAA) or peripheral arterial disease (PAD) and the influencing factors.

DATA SOURCES

A systematic search was conducted in PubMed, Embase, PsychINFO, and CINAHL covering the period January 2012 to October 2022.

REVIEW METHODS

This scoping review was undertaken in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Inclusion criteria encompassed studies addressing health literacy, knowledge, perception, or awareness in patients with AAA or PAD. Two authors independently reviewed abstracts and full texts, resolving any discrepancies through discussion or by consulting a third author for consensus. All article types were included except letters, editorials, study protocols, reviews, and guidelines. No language restrictions were applied. Primary outcomes were health literacy and disease knowledge. Secondary outcomes were factors that could influence this. Quality assessment was done using the Mixed Methods Appraisal Tool (MMAT).

RESULTS

The review included 32 articles involving a total of 5 268 patients. Four articles reported health literacy and the rest disease knowledge. Ten studies (31%) met all quality criteria. Twenty studies were quantitative, eight were qualitative, and four were mixed methods studies. The review revealed inadequate health literacy in the majority of patients, and disease knowledge was relatively low among patients with AAA and PAD, with disparities in measures and assessment tools across studies. Factors influencing health literacy and disease knowledge included socioeconomic status, education, income, and employment.

CONCLUSION

This scoping review revealed low health literacy and low disease knowledge in patients with AAA and PAD. Standardised health literacy assessment may contribute to improve communication strategies and decision aids to enhance patients' understanding and engagement in healthcare decisions, however further research is needed to prove its merits.

Exploring the medical decision-making patterns and influencing factors among the general Chinese public: a binary logistic regression analysis

OBJECTIVE

With the ongoing evolution of the healthcare system and shifts in cultural paradigms, there is a pressing need to delve into the medical decision-making behaviors of general Chinese public and understand their underlying motivations. This research seeks to elucidate the prevailing tendencies in these decision-making processes and to empirically validate the pivotal factors that shape their choices, offering valuable insights for healthcare policymakers and institutions.

METHOD

A comprehensive survey was administered to 2,696 Chinese residents to examine their medical decision-making patterns. These patterns were classified into two primary categories: Unilateral Decision-making (Doctor-dominant, Family-centric, and Patient-driven subtypes) and Collaborative Decision-making (Doctor-led, Doctor-Patient, Patient-Family, and Doctor-Patient-Family subtypes). Binary logistic regression analysis was employed to empirically pinpoint the significant factors influencing these decision-making frameworks.

RESULTS

The study's analysis reveals distinct preferences in medical decision-making among Chinese residents. In the Collaborative Decision-making category, chosen by 70.81% of participants, the subtypes are as follows: Doctor-led (29.90%), Doctor-Patient (13.54%), Patient-Family (2.93%), and Doctor-Patient-Family (24.44%). The Unilateral Decision-making, preferred by 29.19%, includes Doctor-dominant (23.22%), Family-centric (1.74%), and Patient-driven (4.23%) models. The preference for Collaborative Decision-making is associated with higher educational levels, specific marital statuses (particularly married but childless), and choices of rural residents' basic medical insurance or occupational basic medical insurance. In contrast, Unilateral Decision-making correlates with males, individuals with religious beliefs, certain occupational roles (like civil servants), and holders of commercial or publicly funded medical insurance.

CONCLUSION

This study elucidates the complex interplay of socio-cultural and individual determinants shaping medical decision-making in China. The findings reveal a marked inclination towards collaborative models, closely linked to educational level, marital status, and specific insurance types, reflecting an evolving trend towards participatory healthcare. Simultaneously, the persistence of unilateral models, influenced by gender, religious beliefs, and occupational roles, highlights the heterogeneity within Chinese healthcare preferences. These insights are crucial for policymakers and healthcare practitioners, underscoring the need for adaptable, culturally attuned healthcare frameworks that cater to this diversity, thereby enhancing patient engagement and healthcare efficacy.

A joint venture: patients' experiences with goal setting in rheumatology rehabilitation - a qualitative study

PURPOSE

To explore how patients with rheumatic musculoskeletal diseases (RMDs) perceive participation in the goal setting process prior to interdisciplinary rehabilitation.

METHODS

We conducted semi-structured interviews with 22 participants admitted to an interdisciplinary rehabilitation stay for patients with RMDs at two Danish rehabilitation centres. Qualitative content analysis was applied.

RESULTS

The participants perceived goal setting as a joint venture between two parties: the health professionals and the participant. Three categories were formed, which described both facilitators and barriers in the process. Responsibility for goal setting described the importance of shared responsibility, or health professionals as experts, taking full responsibility for goal setting. Equipped for goal setting included perceptions of being well prepared for the process, or considerations that goal setting was difficult because of a lack of information. An equal member of the team entailed both the feeling of being recognised as one in the team, or feeling like an outsider.

CONCLUSION

Goal setting is perceived as a challenge by some patients. Participation in goal setting depends on both the capacity and the opportunity to participate which are factors linked to patients' level of health literacy.

Understanding perceptions of tumor genomic profile testing in Black/African American cancer patients in a qualitative study: the role of medical mistrust, provider communication, and family support

Tumor genomic profiling (TGP) examines genes and somatic mutations specific to a patient's tumor to identify targets for cancer treatments but can also uncover secondary hereditary (germline) mutations. Most patients are unprepared to make complex decisions related to this information. Black/African American (AA) cancer patients are especially at risk because of lower health literacy, higher levels of medical mistrust, and lower awareness and knowledge of genetic testing. But little is known about their TGP attitudes or preferences. Five in-person focus groups were conducted with Black/AA cancer patients (N = 33) from an NCI-designated cancer center and an affiliated oncology unit in an urban safety-net hospital located in Philadelphia. Focus groups explored participants' understanding of TGP, cultural beliefs about genetics, medical mistrust, and how these perceptions informed decision-making. Participants were mostly female (81.8%), and one-third had some college education; mean age was 57 with a SD of 11.35. Of patients, 33.3% reported never having heard of TGP, and 48.5% were not aware of having had TGP as part of their cancer treatment. Qualitative analysis was guided by the principles of applied thematic analysis and yielded five themes: (1) mistrust of medical institutions spurring independent health-information seeking; (2) genetic testing results as both empowering and overwhelming; (3) how provider-patient communication can obviate medical mistrust; (4) how unsupportive patient-family communication undermines interest in secondary-hereditary risk communication; and (5) importance of developing centralized patient support systems outside of treatment decisions. Results improve understanding of how Black/AA patients perceive of TGP and how interventions can be developed to assist with making informed decisions about secondary hereditary results.

Development and evaluation of a decision aid for women eligible for organized breast cancer screening according to international standards: A multi-method study

BACKGROUND

and purpose: In France, women lack information to make a shared decision to start breast cancer screening. Decision aids are useful to facilitate this discussion, yet few meet international standards. The objective of this project was to build, validate and measure the quality of a decision aid for organized breast screening in France, in line with international standards, intended for both women and healthcare professionals.

MATERIALS AND METHODS

This mixed-methods study was conducted between January 2017 and June 2022. The prototype was developed from a qualitative study, systematic review and targeted literature review and alpha tested during two Delphi rounds. Readability was evaluated with the Flesch score and content with International Patient Decision Aid Standards Instrument (IPSASi).

RESULTS

An online decision aid, accessible at www.Discutons-mammo.fr, written in French was developed. The content included eligibility, information about breast screening the advantages and disadvantages of screening, patient preferences and a patient-based discussion guide using text, infographics, and videos. The Flesch readability test score was 65.4 and the IPDASi construct quality score was 176 out of 188.

CONCLUSIONS

This decision aid complies with IPDASi standards and could help women eligible for breast screening in France make a shared decision with a specialized healthcare professional about whether or not to participate in organized breast screening.

Factors influencing the engagement of older adults with neurocognitive disorders in the design of decision aids: A qualitative descriptive study

OBJECTIVE

To identify factors influencing the engagement of older adults with neurocognitive disorders (NCDs) in the design of decision aids (DAs).

METHODS

We conducted a qualitative descriptive study using semi-structured interviews with 23 older adults with NCDs who were accompanied by 27 caregivers. This is a secondary analysis of a published study to identify the features of DAs designed for this population and their caregivers.

RESULTS

Several behaviours and attitudes of caregivers and researchers hindered the older adults' engagement in the DA design process. Specific communication strategies can be employed to support their engagement and overcome the communication challenges inherent to this population, such as memory, attention, hearing, or visual impairments. Adopting the appropriate attitude, taking the time, and providing guidance to the older person can help them focus on the topic, while developing trust between participants is a facilitator to obtain their feedback.

CONCLUSION

Findings from this project could serve to inform the communication and co-design of DAs with older people with NCDs and their caregivers.

PRACTICE IMPLICATIONS

Caregivers and researchers have key roles to play in facilitating communication with older persons with NCDs so they are empowered to help in co-designing DAs.

Development and usability of a decision aid to initiate anti-osteoporosis medication treatment in patients visiting the fracture liaison service with a recent fracture

This study describes the development of a decision aid (DA), aimed at supporting patients in their decision whether to start anti-osteoporosis medication. People with recent fractures or osteoporosis and health professionals were supportive of the DA initiative. An experimental study been started to assess (cost-)effectiveness of the DA.

PURPOSE

At fracture liaison services (FLS), patients with a recent fracture ánd osteoporosis or a prevalent vertebral fracture are advised to start anti-osteoporosis medication (AOM). This study describes the development of a decision aid (DA) to support patients and healthcare providers (HCPs) in their decision about whether to start AOM.

METHODS

The DA was developed according to International Patient Decision Aid Standards (IPDAS). A systematic procedure was chosen including scope, design, prototype development, and alpha testing. A previously developed DA for women with osteoporosis was used as a basis. Furthermore, input from literature searches, the Dutch guideline on management of osteoporosis, and from people with a fracture or osteoporosis was used. The updated DA was evaluated during alpha testing.

RESULTS

The DA facilitates the decision of patients whether to initiate AOM treatment and provides information on fractures and osteoporosis, general risk factors that increase the likelihood of a subsequent fracture, the role of lifestyle, personalized risk considerations of a subsequent fracture with and without AOM treatment, and AOM options and their characteristics in an option grid. Alpha testing with 15 patients revealed that patient preferences and needs were adequately presented, and several suggestions for improvement (e.g. adding more specific information, simplifying terminology, improving icon use) were accounted for. Participants from the alpha testing recommended use of the DA during outpatient visits.

CONCLUSION

Professionals and persons with osteoporosis were supportive of the proposed DA and its usability. The DA could help in a shared decision-making process between patients and HCPs.

Communication of benefits and harms in shared decision making with patients with limited health literacy: A systematic review of risk communication strategies

OBJECTIVES

Risk communication (RC), as part of shared decision making, is challenging with people with limited health literacy (LHL). We aim to provide an overview of strategies to communicate benefits and harms of diagnostic and treatment options to this group.

METHODS

We systematically searched PubMed, Embase, Cinahl and PsycInfo. We included 28 studies on RC in informed/shared decision making without restriction to a health setting or condition and using a broad conceptualization of health literacy. Two researchers independently selected studies and one researcher performed data extraction. We descriptively compared findings for people with LHL towards recommendations for RC.

RESULTS

Health literacy levels varied in the included studies. Most studies used experimental designs, primarily on visual RC. Findings show verbal RC alone should be avoided. Framing of risk information influences risk perception (less risky when positively framed, riskier when negatively framed). Most studies recommended the use of icon arrays. Graph literacy should be considered when using visual RC.

CONCLUSIONS

The limited available evidence suggests that recommended RC strategies seem mainly to be valid for people with LHL, but more research is required.

PRACTICE IMPLICATIONS

More qualitative research involving people with LHL is needed to gain further in-depth insights into optimal RC strategies.

PROTOCOL REGISTRATION

PROSPERO ID 275022.

Shared Decision-Making and Cardiovascular Health: A Scientific Statement From the American Heart Association

Shared decision-making is increasingly embraced in health care and recommended in cardiovascular guidelines. Patient involvement in health care decisions, patient-clinician communication, and models of patient-centered care are critical to improve health outcomes and to promote equity, but formal models and evaluation in cardiovascular care are nascent. Shared decision-making promotes equity by involving clinicians and patients, sharing the best available evidence, and recognizing the needs, values, and experiences of individuals and their families when faced with the task of making decisions. Broad endorsement of shared decision-making as a critical component of high-quality, value-based care has raised our awareness, although uptake in clinical practice remains suboptimal for a range of patient, clinician, and system issues. Strategies effective in promoting shared decision-making include educating clinicians on communication techniques, engaging multidisciplinary medical teams, incorporating trained decision coaches, and using tools (ie, patient decision aids) at appropriate literacy and numeracy levels to support patients in their cardiovascular decisions. This scientific statement shines a light on the limited but growing body of evidence of the impact of shared decision-making on cardiovascular outcomes and the potential of shared decision-making as a driver of health equity so that everyone has just opportunities. Multilevel solutions must align to address challenges in policies and reimbursement, system-level leadership and infrastructure, clinician training, access to decision aids, and patient engagement to fully support patients and clinicians to engage in the shared decision-making process and to drive equity and improvement in cardiovascular outcomes.

The role of low health literacy in shared treatment decision-making in patients with kidney failure

The classic paternalist medicine in nephrology has been modified to a shared decision-making model that clearly offers a benefit in patients with kidney disease. One of the cornerstones of shared treatment decision in patients with kidney failure is the understanding of kidney disease. As kidney disease is silent until advanced stages and is also an entity with a complex pathophysiology with little knowledge in the general population, its presence and understanding are difficult for most people. Health literacy (HL) plays a crucial role in the care of patients with kidney disease and the shared treatment decision. Limited HL has been associated with inefficient use of health services, non-compliance of medications, worse quality of life and increased mortality. In this review, we will address the importance of low HL in nephrology in terms of diagnosis, measurement, its effect on shared decision-making and how to increase it in people with kidney disease.

Artificial Intelligence in Lung Cancer Screening: The Future Is Now

Lung cancer has one of the worst morbidity and fatality rates of any malignant tumour. Most lung cancers are discovered in the middle and late stages of the disease, when treatment choices are limited, and patients' survival rate is low. The aim of lung cancer screening is the identification of lung malignancies in the early stage of the disease, when more options for effective treatments are available, to improve the patients' outcomes. The desire to improve the efficacy and efficiency of clinical care continues to drive multiple innovations into practice for better patient management, and in this context, artificial intelligence (AI) plays a key role. AI may have a role in each process of the lung cancer screening workflow. First, in the acquisition of low-dose computed tomography for screening programs, AI-based reconstruction allows a further dose reduction, while still maintaining an optimal image quality. AI can help the personalization of screening programs through risk stratification based on the collection and analysis of a huge amount of imaging and clinical data. A computer-aided detection (CAD) system provides automatic detection of potential lung nodules with high sensitivity, working as a concurrent or second reader and reducing the time needed for image interpretation. Once a nodule has been detected, it should be characterized as benign or malignant. Two AI-based approaches are available to perform this task: the first one is represented by automatic segmentation with a consequent assessment of the lesion size, volume, and densitometric features; the second consists of segmentation first, followed by radiomic features extraction to characterize the whole abnormalities providing the so-called "virtual biopsy". This narrative review aims to provide an overview of all possible AI applications in lung cancer screening.

Health literate-sensitive shared decision-making in maternity care: needs for support among maternity care professionals in the Netherlands

BACKGROUND

Shared decision-making (SDM) in maternity care is challenging when clients have insufficient health literacy (HL) skills. This study gained insight in how professionals apply HL-sensitive SDM in Dutch maternity care and their needs for support therein.

METHODS

Maternity care professionals (n = 30) completed a survey on SDM and the role of HL. Midwives (n = 13) were observed during simulated conversations discussing pain relief options and interviewed afterwards. The client-actors were instructed to portrait specific inadequate HL skills. Observation items focused on adapting communication to HL, and SDM (OPTION-5).

RESULTS

In the survey, professionals indicated experiencing most challenges when estimating clients' information comprehension. Observations showed that most midwives created choice awareness and informed clients about options, whereas exploring preferences and actual decision-making together with clients were observed less frequently. Their perceived HL-related obstacles and needs for support related to clients' information comprehension. In the interviews, midwives reported putting much effort into explaining available options in maternity care, but also that decisions about pain relief are often postponed until the moment of labour.

CONCLUSION

Professionals' self-reported needs focus on clients' information comprehension. However, observations indicate that it is not the stage of informing, but rather value clarification and actual decision-making that need improvement in HL-sensitive SDM.

Digital encounter decision aids linked to clinical practice guidelines: results from user testing SHARE-IT decision aids in primary care

BACKGROUND

Encounter decision aids (EDAs) are tools that can support shared decision making (SDM), up to the clinical encounter. However, adoption of these tools has been limited, as they are hard to produce, to keep up-to-date, and are not available for many decisions. The MAGIC Evidence Ecosystem Foundation has created a new generation of decision aids that are generically produced along digitally structured guidelines and evidence summaries, in an electronic authoring and publication platform (MAGICapp). We explored general practitioners' (GPs) and patients' experiences with five selected decision aids linked to BMJ Rapid Recommendations in primary care.

METHODS

We applied a qualitative user testing design to evaluate user experiences for both GPs and patients. We translated five EDAs relevant to primary care, and observed the clinical encounters of 11 GPs when they used the EDA with their patients. We conducted a semi-structured interview with each patient after the consultation and a think-aloud interview with each GPs after multiple consultations. We used the Qualitative Analysis Guide (QUAGOL) for data analysis.

RESULTS

Direct observations and user testing analysis of 31 clinical encounters showed an overall positive experience. The EDAs created better involvement in decision making and resulted in meaningful insights for patients and clinicians. The design and its interactive, multilayered structure made the tool enjoyable and well-organized. Difficult terminology, scales and numbers hindered understanding of certain information, which was sometimes perceived as too specialized or even intimidating. GPs thought the EDA was not suitable for every patient. They perceived a learning curve was required and the need for time investment was a concern. The EDAs were considered trustworthy as they were provided by a credible source.

CONCLUSIONS

This study showed that EDAs can be useful tools in primary care by supporting actual shared decision making and enhancing patient involvement. The graphical approach and clear representation help patients better understand their options. To overcome barriers such as health literacy and GPs attitudes, effort is still needed to make the EDAs as accessible, intuitive and inclusive as possible through use of plain language, uniform design, rapid access and training.

TRIAL REGISTRATION

The study protocol was approved by the The Research Ethics Committee UZ/KU Leuven (Belgium) on 31-10-2019 with reference number MP011977.

Patient-Reported Outcomes of Breast Reconstruction: Does the Quality of Decisions Matter?

BACKGROUND

Little is known about how the quality of decisions influences patient-reported outcomes (PROs). We hypothesized that higher decision quality for breast reconstruction would be independently associated with better PROs.

METHODS

We conducted a prospective cohort study of patients undergoing mastectomy with or without reconstruction. Patients were enrolled before surgery and followed for 18 months. We used BREAST-Q scales to measure PROs and linear regression models to explore the relationship between decision quality (based on knowledge and preference concordance) and PROs. Final models were adjusted for baseline BREAST-Q score, radiation, chemotherapy, and major complications.

RESULTS

The cohort included 101 patients who completed baseline and 18-month surveys. Breast reconstruction was independently associated with higher satisfaction with breasts (β = 20.2, p = 0.0002), psychosocial well-being (β = 14.4, p = 0.006), and sexual well-being (β = 15.7, p = 0.007), but not physical well-being. Patients who made a high-quality decision had similar PROs as patients who did not. Among patients undergoing mastectomy with reconstruction, higher decision quality was associated with lower psychosocial well-being (β = -14.2, p = 0.01).

CONCLUSIONS

Breast reconstruction was associated with better PROs in some but not all domains. Overall, making a high-quality decision was not associated with better PROs. However, patients who did not have reconstruction had a trend toward better well-being after making a high-quality decision, whereas patients who did have reconstruction had poorer well-being after making a high-quality decision. Additional research on the relationship between decision quality and PROs is needed.

Racial Disparities in Psychiatric Decisional Capacity Consultations

OBJECTIVE

In this study, the authors examined potential disparities and biases in the placement and outcomes of decisional capacity evaluations across races, controlling for patient characteristics.

METHODS

The authors reviewed 181 patient decisional capacity consultations requested for the consultation-liaison psychiatry service at a tertiary care medical center from 2018 to 2019. The racial distribution of patients in these consultations was compared with the racial distribution of hospital inpatient admissions from 2018 to 2019. The authors analyzed patient outcomes by using logistic regression that controlled for race, gender, age, education, primary insurance, type of capacity assessment, and psychiatric diagnosis.

RESULTS

Decisional capacity consultations were placed disproportionately for Black (43% of consultations vs. 18% of total admissions) and Hispanic patients (26% of consultations vs. 21% of admissions) compared with White and Asian patients. Among 130 patients with a capacity determination, 95 (53% of total sample) were determined not to have capacity, an outcome that did not differ by race but was more likely to occur among patients diagnosed as having delirium. Sixty-seven patients with no capacity (37% of total sample) experienced a change in treatment, an outcome that was less likely to occur among Hispanic patients in the univariable analysis.

CONCLUSIONS

Significant racial disparities were observed during the placement of a decisional capacity consultation. These findings reveal the potential biases introduced with both the initial challenge to a patient's capacity and the subsequent outcomes of the consultation. As such, the balance of risk versus benefit or utility of these consultations in certain populations must be carefully considered.

Women's decision-making autonomy in Dutch maternity care

BACKGROUND

A positive childbirth experience is an important outcome of maternity care. A significant component of a positive birth experience is the ability to exercise autonomy in decision-making. In this study, we explore women's reports of their autonomy during conversations about their care with maternity care practitioners during pregnancy and childbirth.

METHOD

Data were obtained from a cross-sectional survey of women living in The Netherlands that asked about their experiences during pregnancy and childbirth, including their role in conversations concerning decisions about their care.

RESULTS

A total of 3494 women were included in this study. Most women scored high on autonomy in decision-making conversations. During the latter stage of pregnancy (32+ weeks) and in childbirth, women reported significantly lower levels of autonomy in their care conversations with obstetricians as compared with midwives. Linear regression analyses showed that women's perception of personal treatment increased women's reported autonomy in their conversations with both midwives and obstetricians. Almost half (49.1%) of the women who had at least one intervention during birth reported pressure to accept or submit to that intervention. This was indicated by 48.3% of women with induced labor, 47.3% who had an instrumental vaginal birth, 45.2% whose labor was augmented, and 41.9% of women who had a cesarean birth.

CONCLUSIONS

In general, women's sense of autonomy in decision-making conversations during prenatal care and birth is high, but there is room for improvement, and this appeared most notably in conversations with obstetricians. Women's sense of autonomy can be enhanced with personal treatment, including shared decision-making and the avoidance of pressuring women to accept interventions.

Exploring community pharmacists' use of health literacy interventions in their everyday practice

BACKGROUND

Limited health literacy often results in people inadequately understanding medicines-related information and subsequently not taking medicines as prescribed. Using health literacy interventions is important for community pharmacists, as they are increasingly managing long-term conditions. However, there appear to be no previous studies of community pharmacists' everyday use of health literacy interventions in the UK.

OBJECTIVES

To explore UK community pharmacists' perspectives on the usability of health literacy interventions in their everyday practice.

METHODS

Semi-structured interviews were conducted with participants, following attendance at health literacy training that included practicing the use of four health literacy interventions (Teach-Back, Chunk and Check, Simple Language and visual aids) and two months experience of attempting to use them in their everyday practice. Participants were pharmacists from community pharmacies in Staffordshire, England who were invited to participate by an email sent to the pharmacy. Interviews were audio-recorded, transcribed verbatim and analysed using the Framework Analysis technique.

RESULTS

Four themes emerged from 11 interviews undertaken: intervention appeal, limitations, adaptations and continued use. Participants reported using all four health literacy interventions in their everyday practice but Teach-Back appeared to be favoured most. Most participants talked about practicing Teach-Back before using it with patients but described it as useable with patients of all ages, without being prohibitively time consuming. Chunk and Check seemed to be viewed as a type of Teach-Back, whilst visual aids were reported as being used in conjunction with Teach Back rather than as a standalone intervention. Participants reported that Simple Language was an easy concept but easily 'slipped back' into medical jargon and were challenged to use simple enough words. All participants said they would continue to use all four health literacy interventions.

CONCLUSIONS

The findings suggest that with training, community pharmacists can successfully incorporate these four health literacy interventions into their everyday practice.

Implementing shared decision-making in Australia

Person-centred care (PCC) and shared decision-making (SDM) are part of national clinical standards for an increasing number of areas of health care delivery. In addition to existing standards for accrediting hospitals, day surgery facilities, public dental services and medical education in Australia, new standards governing primary health care and digital mental health services have been added. Implementation and measurement of PCC and SDM to comply with standards, and training of health professionals, remain challenges for the Australian health sector. Consumer involvement in health research, policy and clinical service governance continues to increase and the National Health and Medical Research Council has begun to encourage consumer and community involvement in health and medical research. This increased consumer engagement and moves towards more PCC provision is reflected in a focus on encouraging patients to ask questions during their clinical care and supports improvements in consumer health literacy. SDM support tools are now being culturally adapted whilst a need for more systemic approaches to their development and implementation persists. With increasing resources and tools for all aspects of PCC and SDM challenges to find sustainable solutions to ensure tools are kept up to date with the best available evidence remain.

Shared decision-making in urology and female pelvic floor medicine and reconstructive surgery

Shared decision-making (SDM) is a hallmark of patient-centred care that uses informed consent to help guide patients with making complex health-care decisions. In SDM, patients and providers work together to determine the best course of action based on both the current available evidence and the patient's values and preferences. SDM not only provides a framework for the legal and ethical obligations providers need to fulfil for informed consent, but also leads to improved knowledge of treatment options and satisfaction of decision-making for patients. Tools such as decision aids have been developed to support SDM for complex decisions. Several decision aids are available for use in the field of urology and female pelvic medicine and reconstructive surgery, but these decision aids are also associated with barriers to SDM implementation including patient, provider and systematic challenges. However, solutions to such barriers to SDM include continued development of SDM tools to improve patient engagement, expand training of providers in SDM communication models and a process to encourage implementation of SDM.

Decision support needs for shared clinical decision-making regarding HPV vaccination among adults 27-45 years of age

OBJECTIVE

Identify HPV information needs and shared clinical decision-making preferences among adults 27-45 and describe differences in needs and preferences among underserved and vulnerable populations.

METHODS

Participants 27-45 years old with no history of HPV vaccination completed a cross-sectional web-based survey between April-May 2020 (N = 702). Preferred role in shared clinical decision making was described across demographic groups and sociodemographic correlates of HPV vaccine information needs.

RESULTS

Most (77.6%) reported a preference to make a medical decision on their own or after consulting with a healthcare provider, while the remaining respondents preferred to make a joint decision (17.0%) or for their doctor to make the decision (5.4%). Over 80% needed more information about safety, effectiveness, personal benefit, provider recommendation, side effects, and risks. Education was the strongest demographic factors associated with higher information needs (p<0.05).

CONCLUSION

The majority of individuals across demographic groups were individually focused with regard to their healthcare decisions and wanted more information about HPV vaccine safety, side effects, and risks, in addition to personalized information about benefits from HPV vaccination.

PRACTICAL IMPLICATIONS

Patient-centered interventions are needed to engage adults in shared decision-making regarding HPV vaccination.

Role of weight bias and patient-physician communication in the underutilization of bariatric surgery

A growing body of evidence supports the efficacy and safety of bariatric surgery for clinically severe obesity. Despite this empirical support, bariatric surgery remains profoundly underutilized. The reasons for underutilization are likely multifactorial, including health insurance coverage and benefits design, lack of awareness about bariatric surgery by patients, and anecdotal concerns about safety. We believe that there are two other factors-the occurrence of weight stigma and bias and suboptimal communication between patients and providers-that also serve as barriers to greater utilization. The article reviews the existing literature related to these two factors. The review also highlights the science of shared medical decision-making as a potential strategy to promote appropriate conversations between patients and providers, both surgical and nonsurgical, about the efficacy and safety of bariatric surgery. Shared medical decision-making is used in other areas where complex medical decisions are required. We believe that it has great potential to contribute to the increased utilization for the millions of individuals who could benefit from bariatric surgery.

Personalising lung cancer screening: An overview of risk-stratification opportunities and challenges

Randomised clinical trials have shown the efficacy of computed tomography lung cancer screening, initiating discussions on whether and how to implement population‐based screening programs. Due to smoking behaviour being the primary risk‐factor for lung cancer and part of the criteria for determining screening eligibility, lung cancer screening is inherently risk‐based. In fact, the selection of high‐risk individuals has been shown to be essential in implementing lung cancer screening in a cost‐effective manner. Furthermore, studies have shown that further risk‐stratification may improve screening efficiency, allow personalisation of the screening interval and reduce health disparities. However, implementing risk‐based lung cancer screening programs also requires overcoming a number of challenges. There are indications that risk‐based approaches can negatively influence the trade‐off between individual benefits and harms if not applied thoughtfully. Large‐scale implementation of targeted, risk‐based screening programs has been limited thus far. Consequently, questions remain on how to efficiently identify and invite high‐risk individuals from the general population. Finally, while risk‐based approaches may increase screening program efficiency, efficiency should be balanced with the overall impact of the screening program. In this review, we will address the opportunities and challenges in applying risk‐stratification in different aspects of lung cancer screening programs, as well as the balance between screening program efficiency and impact.

Health Literacy and Shared Decision-making: Exploring the Relationship to Enable Meaningful Patient Engagement in Healthcare

Research into health literacy and shared decision-making has largely developed along parallel, but distinct lines over the past two decades. There is little evidence that the concepts and related practice have intersected except in the most functional way, for example, to simplify shared decision-making tools by improving readability scores of decision aids. This paper presents an integrated model to strengthen and sustain patient engagement in health care by drawing on the strengths of both concepts. This includes addressing patients' skills and capacities, alongside modifications to written and verbal information. We propose an expanded model of shared decision-making which incorporates health literacy concepts and promotes two-tiered intervention methods to improve the targeting and personalization of communication and support the development of transferable health literacy skills among patients.

Women's Participation in Decision-Making in Maternity Care: A Qualitative Exploration of Clients' Health Literacy Skills and Needs for Support

Shared decision-making requires adequate functional health literacy (HL) skills from clients to understand information, as well as interactive and critical HL skills to obtain, appraise and apply information about available options. This study aimed to explore women's HL skills and needs for support regarding shared decision-making in maternity care. In-depth interviews were held among women in Dutch maternity care who scored low (n = 10) and high (n = 13) on basic health literacy screening test(s). HL skills and perceived needs for support were identified through thematic analysis. Women appeared to be highly engaged in the decision-making process. They mentioned searching and selecting general information about pregnancy and labor, constructing their preferences based on their own pre-existing knowledge and experiences and by discussions with partners and significant others. However, women with low basic skills and primigravida perceived difficulties in finding reliable information, understanding probabilistic information, constructing preferences based on benefit/harm information and preparing for consultations. Women also emphasized dealing with uncertainties, changing circumstances of pregnancy and labor, and emotions. Maternity care professionals could further support clients by guiding them towards reliable information. To facilitate participation in decision-making, preparing women for consultations (e.g., agenda setting) and supporting them in a timely manner to understand benefit/harm information seem important.

Definitions and use of the teach-back method in healthcare consultations with patients: A systematic review and thematic synthesis

OBJECTIVE

To review and synthesise definitions of the teach-back method in the literature. The second aim is to synthesise the barriers, facilitators and perceptions of teach-back use in healthcare consultations with patients.

METHODS

A systematic review and thematic synthesis following Braun and Clarke's method.

RESULTS

The primary search found 1429 citations and the secondary search added 221 citations. Screening identified 66 citations eligible for data extraction. We contrasted and synthesised operational definitions of the teach-back method. The synthesis generated seven themes related to healthcare provider (HCP) and patient perceptions of teach-back (effectiveness, stigma and time-related perceptions), the universal application of teach-back, patient health outcomes and healthcare provider training.

DISCUSSION

Operational definitions of the teach-back method varied in the literature and contained implied steps. HCPs and patient perceptions of teach-back operated as both enablers and barriers to its use. HCPs training programs for the teach-back method were identified as beneficial for altering HCPs perceptions about the method and increased its use with patients.

PRACTICE IMPLICATIONS

Standardising operational definitions of the teach-back method can support replicability of research and enhance HCPs communication skills training programs. HCPs training on teach-back use can support the increased use of the technique with broader patient populations.

What matters most: Randomized controlled trial of breast cancer surgery conversation aids across socioeconomic strata

Background

Women of lower socioeconomic status (SES) with early‐stage breast cancer are more likely to report poorer physician‐patient communication, lower satisfaction with surgery, lower involvement in decision making, and higher decision regret compared to women of higher SES. The objective of this study was to understand how to support women across socioeconomic strata in making breast cancer surgery choices.

Methods

We conducted a 3‐arm (Option Grid, Picture Option Grid, and usual care), multisite, randomized controlled superiority trial with surgeon‐level randomization. The Option Grid (text only) and Picture Option Grid (pictures plus text) conversation aids were evidence‐based summaries of available breast cancer surgery options on paper. Decision quality (primary outcome), treatment choice, treatment intention, shared decision making (SDM), anxiety, quality of life, decision regret, and coordination of care were measured from T0 (pre‐consultation) to T5 (1‐year after surgery.

Results

Sixteen surgeons saw 571 of 622 consented patients. Patients in the Picture Option Grid arm (n = 248) had higher knowledge (immediately after the visit [T2] and 1 week after surgery or within 2 weeks of the first postoperative visit [T3]), an improved decision process (T2 and T3), lower decision regret (T3), and more SDM (observed and self‐reported) compared to usual care (n = 257). Patients in the Option Grid arm (n = 66) had higher decision process scores (T2 and T3), better coordination of care (12 weeks after surgery or within 2 weeks of the second postoperative visit [T4]), and more observed SDM (during the surgical visit [T1]) compared to usual care arm. Subgroup analyses suggested that the Picture Option Grid had more impact among women of lower SES and health literacy. Neither intervention affected concordance, treatment choice, or anxiety.

Conclusions

Paper‐based conversation aids improved key outcomes over usual care. The Picture Option Grid had more impact among disadvantaged patients.

Lay Summary

The objective of this study was to understand how to help women with lower incomes or less formal education to make breast cancer surgery choices.

Compared with usual care, a conversation aid with pictures and text led to higher knowledge. It improved the decision process and shared decision making (SDM) and lowered decision regret. A text‐only conversation aid led to an improved decision process, more coordinated care, and higher SDM compared to usual care. The conversation aid with pictures was more helpful for women with lower income or less formal education.

Conversation aids with pictures and text helped women make better breast cancer surgery choices.

A paper‐based pictorial conversation aid (pictures plus text) is beneficial to all patients with early‐stage breast cancer and particularly to disadvantaged patients. Between‐surgeon variation suggests that the maximal impact of such interventions requires standardized physician training combined with these interventions.

Envisioning Shared Decision Making: A Reflection for the Next Decade

Despite the evolving evidence in favor of shared decision making (SDM) and of decades-long calls for its adoption, SDM remains uncommon in routine care. Reflecting on this lack of progress, we sought to reimagine the future of SDM and the path to take us there. In late 2017, a multidisciplinary and international group of six researchers were challenged by a senior SDM scholar to envision the future and, based on a provocatively critical view of the present, to write letters to themselves from the year 2028. Letters were exchanged and discussed electronically. The group then met in person to discuss the letters. Since the letters painted a dystopian picture, they triggered questions about the nature of SDM, who should benefit from SDM, how to measure its contribution to care, and what new ways can be invented to design and test interventions to implement SDM in routine care. Through contrasting the purposefully generated dystopias with an ideal future for SDM, we generated reflections on a research agenda for SDM. These reflections hinged on recognizing SDM's contributing to care, that is, as a way to advance the problematic human situation of patients. These focused on three distinct yet complimentary contributors to SDM: 1) the process of making decisions, 2) humanistic communication, and 3) fit-to-care of the resulting decision. The group then concluded that to move SDM from envisioned to routine practice, and to ensure it reaches all, particularly persons rendered vulnerable by current forms of health care, a substantial investment in implementation research is necessary. Perhaps the discussion of these reflections can contribute to a path forward that will improve the likelihood of the future we dream for SDM.

Considerations for Designing EHR-Embedded Clinical Decision Support Systems for Antimicrobial Stewardship in Pediatric Emergency Departments

OBJECTIVE

This study was aimed to explore the intersection between organizational environment, workflow, and technology in pediatric emergency departments (EDs) and how these factors impact antibiotic prescribing decisions.

METHODS

Semistructured interviews with 17 providers (1 fellow and 16 attending faculty), and observations of 21 providers (1 physician assistant, 5 residents, 3 fellows, and 12 attendings) were conducted at three EDs in the United States. We analyzed interview transcripts and observation notes using thematic analysis.

RESULTS

Seven themes relating to antibiotic prescribing decisions emerged as follows: (1) professional judgement, (2) cognition as a critical individual resource, (3) decision support as a critical organizational resource, (4) patient management with imperfect information, (5) information-seeking as a primary task, (6) time management, and (7) broad process boundaries of antibiotic prescribing.

DISCUSSION

The emerging interrelated themes identified in this study can be used as a blueprint to design, implement, and evaluate clinical decision support (CDS) systems that support antibiotic prescribing in EDs. The process boundaries of antibiotic prescribing are broader than the current boundaries covered by existing CDS systems. Incongruities between process boundaries and CDS can under-support clinicians and lead to suboptimal decisions. We identified two incongruities: (1) the lack of acknowledgment that the process boundaries go beyond the physical boundaries of the ED and (2) the lack of integration of information sources (e.g., accessibility to prior cultures on an individual patient outside of the organization).

CONCLUSION

Significant opportunities exist to improve appropriateness of antibiotic prescribing by considering process boundaries in the design, implementation, and evaluation of CDS systems.

Ethnographic investigation of patient-provider communication among African American men newly diagnosed with prostate cancer: a study protocol

INTRODUCTION

In the USA, African American men bear a disproportionate burden of prostate cancer (PCa) compared with all other groups, having a higher incidence and mortality, poorer quality of life and higher dissatisfaction with care. They are also less likely to receive guideline-concordant treatment (eg, undertreatment of aggressive disease). Inadequate patient-provider communication contributes to suboptimal care, which can be exacerbated by patients' limited health literacy, providers' lack of communication skills and time constraints in low-resource, safety net settings. This study is designed to examine the communication experiences of African American patients with PCa as they undertake treatment decision-making.

METHODS AND ANALYSIS

Using an ethnographic approach, we will follow 25 African American men newly diagnosed with PCa at two public hospitals, from diagnosis through treatment decision. Data sources include: (1) audio-recorded clinic observations during urology, radiation oncology, medical oncology and primary care visits, (2) field notes from clinic observations, (3) patient surveys after clinic visits, (4) two in-depth patient interviews, (5) a provider survey, and (6) in-depth interviews with providers. We will explore patients' understanding of their diagnoses and treatment options, sources of support in decision-making, patient-provider communication and treatment decision-making processes. Audio-recorded observations and interviews will be transcribed verbatim. An iterative process of coding and team discussions will be used to thematically analyse patients' experiences and providers' perspectives, and to refine codes and identify key themes. Descriptive statistics will summarise survey data.

ETHICS AND DISSEMINATION

To our knowledge, this is the first study to examine in-depth patient-provider communication among African American patients with PCa. For a population as marginalised as African American men, an ethnographic approach allows for explication of complex sociocultural and contextual influences on healthcare processes and outcomes. Study findings will inform the development of interventions and initiatives that promote patient-centred communication, shared decision-making and guideline-concordant care. This study was approved by the University of California San Francisco and the Alameda Health System Institutional Review Boards.

Engaging Caregivers in Health-Related Housing Decisions for Older Adults With Cognitive Impairment: A Cluster Randomized Trial

Background and Objectives

Informal caregivers are rarely as involved as they want to be in the housing decisions of cognitively impaired older adults. Lack of awareness of available options and their benefits and risks may lead to decisions that do not reflect older adults’ preferences, and to guilt and regret. We assessed the effect of training home care teams in interprofessional shared decision-making (SDM) on the proportion of caregivers who report being active in this decision.

Research Design and Methods

In a two-arm pragmatic cluster randomized trial with home care teams working in health centers in the Province of Quebec, we randomized health centers to receive training in interprofessional SDM (intervention) or not (control). Eligible caregivers had made a housing decision for a cognitively impaired adult aged 65 years or older who was receiving services from a home care team. The primary outcome was the proportion of caregivers reporting an active role in decision making. We performed intention-to-treat multilevel analysis.

Results

We consecutively enrolled a random group of 16 health centers and recruited 309 caregivers, among whom 296 were included in the analysis. In the intervention arm, the proportion of caregivers reporting an active role in decision making increased by 12% (95% CI −2% to 27%; p = .10). After removal of an influential cluster outlier, the proportion increased to 18% (95% CI: 7%–29%; p < .01).

Discussion and Implications

Training home care teams in interprofessional SDM increased caregiver involvement in health-related housing decisions for cognitively impaired older adults.

Defining Patient Engagement in Research: Results of a Systematic Review and Analysis: Report of the ISPOR Patient-Centered Special Interest Group

OBJECTIVES

Lack of clarity on the definition of "patient engagement" has been highlighted as a barrier to fully implementing patient engagement in research. This study identified themes within existing definitions related to patient engagement and proposes a consensus definition of "patient engagement in research."

METHODS

A systematic review was conducted to identify definitions of patient engagement and related terms in published literature (2006-2018). Definitions were extracted and qualitatively analyzed to identify themes and characteristics. A multistakeholder approach, including academia, industry, and patient representation, was taken at all stages. A proposed definition is offered based on a synthesis of the findings.

RESULTS

Of 1821 abstracts identified and screened for eligibility, 317 were selected for full-text review. Of these, 169 articles met inclusion criteria, from which 244 distinct definitions were extracted for analysis. The most frequently defined terms were: "patient-centered" (30.5%), "patient engagement" (15.5%), and "patient participation" (13.4%). The majority of definitions were specific to the healthcare delivery setting (70.5%); 11.9% were specific to research. Among the definitions of "patient engagement," the most common themes were "active process," "patient involvement," and "patient as participant." In the research setting, the top themes were "patient as partner," "patient involvement," and "active process"; these did not appear in the top 3 themes of nonresearch definitions.

CONCLUSION

Distinct themes are associated with the term "patient engagement" and with engagement in the "research" setting. Based on an analysis of existing literature and review by patient, industry, and academic stakeholders, we propose a scalable consensus definition of "patient engagement in research."

The use of PROMs and shared decision-making in medical encounters with patients: An opportunity to deliver value-based health care to patients

BACKGROUND

The recent emphasis on value-based health care (VBHC) is thought to provide new opportunities for shared decision-making (SDM) in the Netherlands, especially when using patient-reported outcome measures (PROMs) in routine medical encounters. It is still largely unclear about how PROMs could be linked to SDM and what we expect from clinicians in this respect.

AIM

To describe approaches and lessons learned in the fields of SDM and VBHC implementation that converge in using PROMs in medical encounters.

APPROACH

Based on input from three Dutch forerunner case examples and available evidence about SDM and VBHC, we describe barriers and facilitators regarding the use of PROMs and SDM in the medical encounter. Barriers and facilitators were structured according to a conversational model that included monitoring and managing, team talk, option talk, choice talk, and decision talk. Key lessons learned and recommendations were synthesized.

RESULTS

The use of individual, N = 1 PROMs scores in the medical encounter has been largely achieved in the forerunner projects. Conversation on monitoring and managing is relatively well implemented, and option talk to some extent, unlike team talk, and decision talk. Aggregated PROMs information describing outcomes of treatment options seemed to be scarcely used. Experienced barriers largely corresponded to what is known from the literature, eg, perceived lack of time and lack of tools summarizing the options. Some concerns were identified about increasing health care consumption as a result of using PROMs and SDM in the medical encounter.

CONCLUSION

Successful implementation of SDM within VBHC initiatives may not be self-evident, even though individual, N = 1 PROMs scores are being used in the medical encounter. Education and staff resources on meso and macro levels may facilitate the more time-consuming SDM aspects. It seems fruitful to especially target team talk and choice talk in redesigning clinical pathways.

Decisional needs assessment of patients with complex care needs in primary care

RATIONALE

Patients with complex care needs who frequently use health services often face challenges in managing their health and with integrated care, leading to frequent decision making. These complex care needs require a good understanding of health issues and their impact on daily life. As the decisional needs of this particular clientele have yet to be described in scientific literature, they warrant further study.

OBJECTIVES

To assess the decision-making needs of patients with complex care needs (PCCN) who frequently use health care services.

METHODS

We performed a multicenter cross-sectional qualitative descriptive study in four institutions of the health and social services network of Quebec (Canada). We enrolled a convenience sample of PCCNs who frequently use health care services, health care providers, case managers, and decision-makers. We conducted interviews and focus groups and investigated decisional needs according to the Ottawa decision support framework: roles played and desired in the decision-making process, facilitators, and barriers. We conducted qualitative data collection and qualitative deductive/inductive thematic analysis within and across participating groups.

RESULTS

In total, 16 patients, 38 clinicians, six case managers, and 14 decision-makers participated in the study. The decisional needs of this clientele are numerous, varied and different from those of the general population. We identified 26 decisional needs grouped under five themes. The most frequent decisions related to visiting the emergency department, moving to a nursing home, and adhering to a plan or treatment. In addition, we identified new themes such as patients' fear and mistrust of health professionals, differences of opinion between health professionals and health professionals' preconceived opinions of patients.

CONCLUSION

We observed a wide range of types of decisions that patients face and differences in decision-making needs across participating groups. Our results should inform future research on the development of a patient decision aid tool.

Values clarification and parental decision making about newborn genomic sequencing

OBJECTIVE

Using an online decision aid developed to support parental decision making about newborn genomic sequencing, we tested whether adding a values clarification exercise to educational content would improve decision making outcomes and influence intention to pursue genomic sequencing. We also examined whether the effect of values clarification varied depending on one's health literacy level.

METHOD

In an online experiment, women and men aged 18 to 44 who were either pregnant or had a pregnant partner, were currently trying to get pregnant, or were preparing for a pregnancy within the next 2 years were randomly assigned to complete either a decision aid with educational information about newborn genomic sequencing or a decision aid with the same educational information and a values clarification exercise.

RESULTS

Of the 1,000 participants who completed the decision aid, those who completed the values clarification exercise reported less decision regret, F(1, 995) = 6.19, p = .01, and were clearer about their personal values, F(1, 995) = 6.39, p = .01. Moderation analyses revealed that the benefit of values clarification on decisional conflict was particularly evident among participants with lower health literacy, B = -3.94, SE = 1.67, t = -2.36, p = .018. There was not a significant moderation effect of health literacy and decision aid condition on decision regret.

CONCLUSIONS

Adding a values clarification exercise to decision aids for parents making decisions about genomic sequencing may improve the decision-making experience and provide some benefit to individuals with lower health literacy. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Effect of a Skills Training for Oncologists and a Patient Communication Aid on Shared Decision Making About Palliative Systemic Treatment: A Randomized Clinical Trial

BACKGROUND

Palliative systematic treatment offers uncertain and often limited benefits, and the burden can be high. Hence, treatment decisions require shared decision making (SDM). This trial examined the independent and combined effect of an oncologist training and a patient communication aid on SDM.

METHODS

In this multicenter randomized controlled trial with four parallel arms (2016-2018), oncologists (n = 31) were randomized to receive SDM communication skills training or not. The training consisted of a reader, two group sessions, a booster session, and a consultation room tool (10 hours). Patients (n = 194) with advanced cancer were randomized to receive a patient communication aid or not. The aid consisted of education on SDM, a question prompt list, and a value clarification exercise. The primary outcome was observed SDM as rated by blinded observers from audio-recorded consultations. Secondary outcomes included patient-reported SDM, patient and oncologist satisfaction, patients' decisional conflict, patient quality of life 3 months after consultation, consultation duration, and the decision made.

RESULTS

The oncologist training had a large positive effect on observed SDM (Cohen's d = 1.12) and on patient-reported SDM (d = 0.73). The patient communication aid did not improve SDM. The combination of interventions did not add to the effect of training oncologists only. The interventions affected neither patient nor oncologist satisfaction with the consultation nor patients' decisional conflict, quality of life, consultation duration, or the decision made.

CONCLUSION

Training medical oncologists in SDM about palliative systemic treatment improves both observed and patient-reported SDM. A patient communication aid does not. The incorporation of skills training in (continuing) educational programs for medical oncologists is likely to stimulate the widely advocated uptake of shared decision making in clinical practice.

TRIAL REGISTRATION

Netherlands Trial Registry NTR 5489.

IMPLICATIONS FOR PRACTICE

Treatment for advanced cancer offers uncertain and often small benefits, and the burden can be high. Hence, treatment decisions require shared decision making (SDM). SDM is increasingly advocated for ethical reasons and for its beneficial effect on patient outcomes. Few initiatives to stimulate SDM are evaluated in robust designs. This randomized controlled trial shows that training medical oncologists improves both observed and patient-reported SDM in clinical encounters (n = 194). A preconsultation communication aid for patients did not add to the effect of training oncologists. SDM training effectively changes oncologists' practice and should be implemented in (continuing) educational programs.

Culture, Self, and Medical Decision Making in Australia and China: A Structural Model Analysis

Objective. To explore and compare the influences of individual-level cultural values and personal attitudinal values on the desire for medical information and self-involvement in decision making in Australia and China. Methods. A total of 288 and 291 middle-aged adults from Australia and China, respectively, completed an online survey examining cultural and personal values, and their desired level of self-influence on medical decision making. Structural equation modeling was used to test 15 hypotheses relating to the effects of cultural and personal antecedents on the individual desire for influence over medical decision making. Results. Similar factors in both Australia and China (total variance explained: Australia 29%; China 35%) predicted desire for medical information, with interdependence (unstandardized path coefficient β_Australia = 0.102, P = 0.014; β_China = 0.215, P = 0.001), independence (β_Australia = 0.244, P < 0.001; β_China = 0.123, P = 0.037), and health locus of control (β_Australia = −0.140, P = 0.018; β_China = −0.138, P = 0.007) being significant and positive predictors. A desire for involvement in decisions was only predicted by power distance, which had an opposite effect of being negative for Australia and positive for China (total variance explained: Australia 11%; China 5%; β_Australia = 0.294, P < 0.001; China: β_China = −0.190, P = 0.043). National culture moderated the effect of independence on desire for medical information, which was stronger in Australia than China (Z score = 1.687, P < 0.05). Conclusions. Study results demonstrate that in both countries, desire for medical information can be influenced by individual-level cultural and personal values, suggesting potential benefits of tailoring health communication to personal mindsets to foster informed decision making. The desired level of self-involvement in decision making was relatively independent of other cultural and personal values in both countries, suggesting caution against cultural stereotypes. Study findings also suggest that involvement preferences in decision making should be considered separately from information needs at the clinical encounter.

Reducing complexity of patient decision aids for community-based older adults with dementia and their caregivers: multiple case study of Decision Boxes

OBJECTIVES

To identify patient decision aids' features to limit their complexity for older adults with dementia and their family caregivers.

DESIGN

Mixed method, multiple case study within a user-centred design (UCD) approach.

SETTING

Community-based healthcare in the province of Quebec in Canada.

PARTICIPANTS

23 older persons (aged 65+ years) with dementia and their 27 family caregivers.

RESULTS

During three UCD evaluation-modification rounds, participants identified strengths and weaknesses of the patient decision aids' content and visual design that influenced their complexity. Weaknesses of content included a lack of understanding of the decision aids' purpose and target audience, missing information, irrelevant content and issues with terminology and sentence structure. Weaknesses of visual design included critics about the decision aids' general layout (density, length, navigation) and their lack of pictures. In response, the design team implemented a series of practical features and design strategies, comprising: a clear expression of the patient decision aids' purpose through simple text, picture and personal stories; systematic and frequent use of pictograms illustrating key points and helping structure patient decision aids' general layout; a glossary; removal of scientific references from the main document; personal stories to clarify more difficult concepts; a contact section to facilitate implementation of the selected option; GRADE ratings to convey the quality of the evidence; a values clarification exercise formatted as a checklist and presented at the beginning of the document to streamline navigation; involvement of a panel of patient/caregiver partners to guide expression of patient priorities; editing of the text to a sixth grade reading level; UCD process to optimise comprehensiveness and relevance of content and training of patients/caregivers in shared decision-making.

CONCLUSIONS

The revised template for patient decision aids is designed to meet the needs of adults living with dementia and their caregivers better, which may translate into fewer evaluation-modification rounds.

Promoting shared decision making in advanced cancer: Development and piloting of a patient communication aid

OBJECTIVE

To learn how to configure a patient communication aid (PCA) to facilitate shared decision-making (SDM) about treatment for advanced cancer.

METHODS

The PCA consists of education about SDM, a question prompt list, and values clarification methods. Study 1. A first version was presented to 13 patients, 8 relatives and 14 bereaved relatives in interviews. Study 2. A second version was used by 18 patients in a pilot study. Patients and oncologists were interviewed, patients were surveyed, and consultations were audio-recorded.

RESULTS

Respondents reported that the aid facilitated patient control over information, raised choice awareness and promoted elaboration. Risks were identified, most importantly that the aid might upset patients. Also, some respondents reported that the PCA did not, or would not support decision making because they felt sufficiently competent, did not perceive a role for themselves, or did not perceive that the decision required elaboration.

CONCLUSIONS

Opinions on the usefulness of the PCA varied. It was challenging to raise awareness about the presence of a choice, and to find a balance between comprehensive information and sensitivity.

PRACTICE IMPLICATIONS

A future study should demonstrate whether the PCA can improve SDM, and whether this effect is stronger when oncologists receive training.

Development of a Patient Decision Aid on the Choice of Diabetes Medication for Filipino Patients with Type 2 Diabetes Mellitus

OBJECTIVE

To develop a locally adapted patient decision aid (PtDA) on treatment intensification among Filipino patients with Type 2 Diabetes Mellitus and to test the feasibility of using PtDAs in a low middle-income country.

METHODOLOGY

A qualitative approach and an iterative process of development of a PtDA were employed for this study. We describe the process of developing a Filipino version of the Diabetes Medication Decision Aid. This PtDA was designed to help the patient choose the appropriate treatment intensification based on his own values and preferences, in consultation with his physician. The process involved decisional needs assessment through focus group discussions and key informant interviews, systematic literature review, iterative process of the development of a PtDA with clinical encounters (pilot testing), and preliminary field testing.

RESULTS

Decisional needs assessment revealed that Filipino patients are open to participate in shared decision-making if given the opportunity, including those with low socioeconomic status who likely have low health literacy. Physicians prefer to have visual aid tools to help them support their patient's decision-making. A PtDA prototype of a set of flash cards in Filipino was created and revised in an iterative method. We developed a more visually appealing tool after inputs from the expert panel and patient advisory group. Its use during clinical encounters provided additional insights from patients and clinicians on how to improve the PtDA. Preliminary field testing showed that its use is feasible in the target patient population.

CONCLUSION

Filipino patients, clinicians, and diabetes nurse educators have contributed to the creation of the first Filipino PtDA for diabetes treatment intensification.

Numeracy and Risk Literacy: What Have We Learned so Far?

Numerical skills are essential to make informed decisions in our daily life. Unfortunately, many people lack basic numeracy, which limits their ability to accurately interpret risks (i.e., risk literacy). In this paper, we provide an overview of research investigating the role of numeracy in two prominent domains, where most research was concentrated, health and finance. We summarize what has been learned so far in these domains and suggest promising venues for future research. We conclude that it is important to conduct interventions to improve numeracy in less numerate individuals and to help them make informed decisions and achieve better life outcomes.

Hormonal contraception, breastfeeding and bedside advocacy: the case for patient-centered care

Postpartum contraceptive decision making is complex, and recommendations may be influenced by breastfeeding intentions. While biologically plausible, concerns about the adverse impact of hormonal contraception on breast milk production have not been supported by the clinical evidence to date. However, the data have limitations, which can lead providers with different priorities around contraception and breastfeeding to interpret the data in a way that advances their personal priorities. Discrepancies in interpretations can lead to divergent recommendations for individual women and may cause conflict. Furthermore, providers must recognize that decision making about contraception and breastfeeding takes place in complex cultural, historical and socioeconomic contexts. Implicit bias may influence a provider's counseling. Unrecognized biases toward one patient or another, or one practice or another, may influence a provider's counseling. It is crucial for providers to strive to recognize their own biases. Providers need to respectfully recognize each patient's values and preferences regarding hormonal contraception and breastfeeding. Developing a patient-centered decision tool or implementing patient-centered interview techniques specifically around breastfeeding and contraception could help to minimize provider-driven variability in care.

Factors influencing women's perceptions of shared decision making during labor and delivery: Results from a large-scale cohort study of first childbirth

OBJECTIVE

To examine correlates of shared decision making during labor and delivery.

METHODS

Data were from a cohort of women who gave birth to their first baby in Pennsylvania, 2009-2011 (N = 3006). We used logistic regression models to examine the association between labor induction and mode of delivery in relation to women's perceptions of shared decision making, and to investigate race/ethnicity and SES as potential moderators.

RESULTS

Women who were Black and who did not have a college degree or private insurance were less likely to report high shared decision making, as well as women who underwent labor induction, instrumental vaginal or cesarean delivery. Models with interaction terms showed that the reduction in odds of shared decision making associated with cesarean delivery was greater for Black women than for White women.

CONCLUSIONS

Women in marginalized social groups were less likely to report shared decision making during birth and Black women who delivered by cesarean had particularly low odds of shared decision making.

PRACTICE IMPLICATIONS

Strategies designed to improve the quality of patient-provider communication, information sharing, and shared decision making must be attentive to the needs of vulnerable groups to ensure that such interventions reduce rather than widen disparities.

Heuristics and biases in cardiovascular disease prevention: How can we improve communication about risk, benefits and harms?

OBJECTIVE

Cardiovascular disease (CVD) prevention guidelines recommend medication based on the probability of a heart attack/stroke in the next 5-10 years. However, heuristics and biases make risk communication challenging for doctors. This study explored how patients interpret personalised CVD risk results presented in varying formats and timeframes.

METHODS

GPs recruited 25 patients with CVD risk factors and varying medication history. Participants were asked to 'think aloud' while using two CVD risk calculators that present probabilistic risk in different ways, within a semi-structured interview. Transcribed audio-recordings were coded using Framework Analysis.

RESULTS

Key themes were: 1) numbers lack meaning without a reference point; 2) risk results need to be both credible and novel; 3) selective attention to intervention effects. Risk categories (low/moderate/high) provided meaningful context, but short-term risk results were not credible if they didn't match expectations. Colour-coded icon arrays showing the effect of age and interventions were seen as novel and motivating. Those on medication focused on benefits, while others focused on harms.

CONCLUSION

CVD risk formats need to be tailored to patient expectations and experiences in order to counteract heuristics and biases.

PRACTICE IMPLICATIONS

Doctors need access to multiple CVD risk formats to communicate effectively about CVD prevention.

Language-concordant automated telephone queries to assess medication adherence in a diverse population: a cross-sectional analysis of convergent validity with pharmacy claims

Background

Clinicians have difficulty accurately assessing medication non-adherence within chronic disease care settings. Health information technology (HIT) could offer novel tools to assess medication adherence in diverse populations outside of usual health care settings. In a multilingual urban safety net population, we examined the validity of assessing adherence using automated telephone self-management (ATSM) queries, when compared with non-adherence using continuous medication gap (CMG) on pharmacy claims. We hypothesized that patients reporting greater days of missed pills to ATSM queries would have higher rates of non-adherence as measured by CMG, and that ATSM adherence assessments would perform as well as structured interview assessments.

Methods

As part of an ATSM-facilitated diabetes self-management program, low-income health plan members typed numeric responses to rotating weekly ATSM queries: “In the last 7 days, how many days did you MISS taking your …” diabetes, blood pressure, or cholesterol pill. Research assistants asked similar questions in computer-assisted structured telephone interviews. We measured continuous medication gap (CMG) by claims over 12 preceding months. To evaluate convergent validity, we compared rates of optimal adherence (CMG ≤ 20%) across respondents reporting 0, 1, and ≥ 2 missed pill days on ATSM and on structured interview.

Results

Among 210 participants, 46% had limited health literacy, 57% spoke Cantonese, and 19% Spanish. ATSM respondents reported ≥1 missed day for diabetes (33%), blood pressure (19%), and cholesterol (36%) pills. Interview respondents reported ≥1 missed day for diabetes (28%), blood pressure (21%), and cholesterol (26%) pills. Optimal adherence rates by CMG were lower among ATSM respondents reporting more missed days for blood pressure (p = 0.02) and cholesterol (p < 0.01); by interview, differences were significant for cholesterol (p = 0.01).

Conclusions

Language-concordant ATSM demonstrated modest potential for assessing adherence. Studies should evaluate HIT assessments of medication beliefs and concerns in diverse populations.

Trial registration

NCT00683020, registered May 21, 2008.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3071-4) contains supplementary material, which is available to authorized users.

Patients With Limited Health Literacy Have Similar Preferences but Different Perceptions in Surgical Decision-making for Carpal Tunnel Release

BACKGROUND

Health literacy is the ability to obtain, process, and understand health information needed to make appropriate health decisions. The proper comprehension by patients regarding a given disease, its treatment, and the physician's instructions plays an important role in shared decision-making. Studies have disagreed over the degree to which differences in health literacy affect patients' preferences for shared decision-making; we therefore sought to evaluate this in the context of shared decision-making about carpal tunnel release.

QUESTIONS/PURPOSES

(1) Do patients with limited health literacy have different preferences of shared decision-making for carpal tunnel release than those with greater levels of health literacy? (2) How do patients with limited health literacy retrospectively perceive their role in shared decision-making after carpal tunnel release?

METHODS

Over a 32-month period, one surgeon surgically treated 149 patients for carpal tunnel syndrome. Patients were eligible if they had cognitive and language function to provide informed consent and complete a self-reported questionnaire and were not eligible if they had nerve entrapment other than carpal tunnel release or had workers compensation issues; based on those, 140 (94%) were approached for study. Of those, seven (5%) were lost to followup before 6 months, leaving 133 for analysis here. Their mean age was 55 years (range, 31-76 years), and 83% (111 of 133) were women. Thirty-three percent (44 of 133) of patients had less than a high school education. Health literacy was measured according to the Newest Vital Sign during the initial visit, and a score of ≤ 3 was considered limited health literacy. Forty-four percent of patients had limited health literacy. The Control Preferences Scale was used for patients to indicate their preferred role in surgical decision-making preoperatively and to assess their perceived level of involvement postoperatively. Bivariate and multivariable analyses were performed to determine whether patients' clinical, demographic, and health literacy factors accounted for the preoperative preferences and postoperative assessments of their role in shared decision-making. A total of 133 patients would provide 94% power for a medium effect size for linear regression with five main predictors.

RESULTS

We found no differences between patients with lower levels of health literacy and those with greater health literacy in terms of preferences of shared decision-making for carpal tunnel release (3.0 ± 1.6 versus 2.7 ± 1.4; mean difference, 0.3; 95% confidence interval, -0.2 to 0.8; p = 0.25). A history of surgical procedures (coefficient = -0.32, p < 0.01) and a lower Disabilities of the Arm, Shoulder and Hand score (coefficient = 0.17, p = 0.02) were independently associated with a preference for an active role in shared decision-making. However, patients with limited health literacy (coefficient = -0.31, p = 0.01) and an absence of a caregiver (coefficient = -0.28, p = 0.03) perceived a more passive role in actual decision-making.

CONCLUSIONS

Physicians should be aware of the discrepancy between preferences and perceptions of shared decision-making among patients with limited health literacy, and physicians should consider providing a decision aid tailored to basic levels of health literacy to help patients achieve their preferred role in decision-making.

LEVEL OF EVIDENCE

Level II, prognostic study.