Perceptions of shared decision making and decision aids among rural primary care clinicians

SEE-diabetes, a patient-centered diabetes self-management education and support for older adults: Findings and information needs from providers' perspectives

BACKGROUND AND AIMS

Diabetes self-management education and support (DSMES) can improve clinical and health outcomes of people with diabetes. However, DSMES has been underutilized because of many barriers. We aimed to develop a patient-centered educational aid, SEE-Diabetes (Support-Engage-Empower-Diabetes), that facilitates shared decision-making about DSMES between patient and provider during the follow-up visit. We investigated the information needs to inform the design of the SEE-Diabetes from the providers' perspective.

METHODS

We conducted an online survey (N = 42) and three focus groups (N = 13) involving providers who have experience managing diabetes in older patients. Survey collected demographics and assessed knowledge of DSMES. During the subsequent focus groups, participants evaluated the Assessment and Plan section of three clinic notes of older people with diabetes. We also demonstrated the potential workflow of DSMES documentation using SEE-Diabetes during clinical practice.

RESULTS

The survey showed 60% of providers were familiar with DSMES. Focus group findings showed clinic notes should convey concise information at an appropriate reading level, numbered problems, and less medical jargon to improve the readability of clinic notes. Application of SMART (Specific, Measurable, Attainable, Relevant, Time-bound) goals was suggested to deliver effective diabetes self-care information.

CONCLUSIONS

Providers should consider adopting validated DSMES guidelines along with goal-setting strategies to provide patient-centered care. The research team will integrate the provider recommendations when we develop SEE-Diabetes.

Medical treatment decision-making in rural cancer patients: A qualitative systematic review and meta-synthesis

OBJECTIVE

Rural cancer patients have unique care needs which may impact upon treatment decision-making. Our aim was to conduct a qualitative systematic review and meta-synthesis to understand their perspectives and experiences of making treatment decisions.

METHODS

A systematic search of MEDLINE, PsycINFO, CINAHL and RURAL was conducted for qualitative studies in rural cancer patients regarding treatment decision-making. Articles were screened for relevance, and data from the included articles were extracted and analysed using meta-thematic synthesis.

RESULTS

Twelve studies were included, with 4 themes and 9 subthemes identified. Many studies reported patients were not given a choice regarding their treatment. Choice, if given, was influenced by personal factors such as finances, proximity to social supports, convenience, and their personal values. Patients were also influenced by the opinions of others and cultural norms. Finally, it was reported that patients made choices in the context of seeking the best possible medical care and the patient-clinician relationship.

CONCLUSIONS

In the rural context, there are universal and unique factors that influence the treatment decisions of cancer patients.

PRACTICAL IMPLICATIONS

Our findings are an important consideration for clinicians when engaging in shared decision-making, as well as for policymakers, to understand and accommodate the unique rural perspective.

The submissive silence of others: Examining definitions of shared decision making

OBJECTIVE

Our aim was to use critical discourse analysis (CDA) to examine the most widely cited definitions of shared decision making so that we can evaluate how language is used to position participants. Based on our conceptual understanding, we presumed that shared decision making involves acts of communication where processes are collaborative.

METHODS

We used a CDA lens to closely examine the phrases, semantics, syntax, implied functions, and the social actions proposed in SDM definition texts. We conducted a systematic search guided by the PRISMA guidelines, to identify the most widely cited definitions of SDM.

RESULTS

A total of 72 studies met our inclusion criteria. While SDM is not consistently defined, it was striking to find that clinicians are constructed as active whereas patients were viewed to be passive participants. The definitions construct SDM to be a gift that the clinician has the power to offer, and the relationship in the definitions appears asymmetric, in which only one party seems to speak.

CONCLUSIONS

The SDM definitions examined convey a process characterized by a clinician who speaks, while a patient mostly listens, and is invited to contribute. An alternative definition might be constructed through references to joint activity via sentences in active voice.

PRACTICE IMPLICATIONS

Clinicians may be influenced by definitions of SDM that reinforce the positionality of active speaker versus passive recipient. Clearer definitions that address the constructs of power and roles may help support the implementation of SDM.

Shared decision-making in Argentina in 2022

Argentina is an upper-middle income country located in South America with an estimated population of 46.2 million inhabitants. There is no unified research agenda or government initiatives encouraging the implementation and research of Shared Decision-Making (SDM). Our working group at the Family and Community Medicine Division of the Hospital Italiano de Buenos Aires is the leading centre for research and implementation of SDM in the country. The implementation strategy is articulated in undergraduate, postgraduate and continuous medical education. However, it is challenged by the professionals' perception that they are already doing it or lack time during consultations. We have advanced research to understand how to adapt tools to measure and implement SDM in our settings. Still, we face additional challenges related to funding, accessing diverse populations beyond the reach of our institution and incorporating patients in the co-production of research. While most of our efforts arise from the voluntary work of our healthcare professionals, we believe this is a strength since SDM research and implementation are then directly linked to patient care.

The impact of patient narratives on medical students' perceptions of shared decision making: A randomized controlled trial

Successful shared decision making (SDM) in clinical practice requires that future clinicians learn to appreciate the value of patient participation as early as they can in their medical training. Narratives, such as patient testimonials, have been successfully used to support patients' decision-making process. Previous research suggests that narratives may also be used for increasing clinicians' empathy and responsiveness in medical consultations. However, so far, no studies have investigated the benefits of narratives for conveying the relevance of SDM to medical students. In this randomized controlled experiment, N = 167 medical students were put into a scenario where they prepared for medical consultation with a patient having Parkinson disease. After receiving general information, participants read either a narrative testimonial of a Parkinson patient or a fact-based information text. We measured their perceptions of SDM, their control preferences (i.e., their priorities as to who should make the decision), and the time they intended to spend for the consultation. Participants in the narrative patient testimonial condition referred more strongly to the patient as the one who should make decisions than participants who read the information text. Participants who read the patient narrative also considered SDM in situations with several equivalent treatment options to be more important than participants in the information text condition. There were no group differences regarding their control preferences. Participants who read the patient testimonial indicated that they would schedule more time for the consultation. These findings show that narratives can potentially be useful for imparting the relevance of SDM and patient-centered values to medical students. We discuss possible causes of this effect and implications for training and future research. Trial registration: The study was pre-registered on the pre-registration platform AsPredicted (aspredicted.org) before data collection began (registration number: #29,342). Date of registration: 17 October 2019.

The development of incorpoRATE: A measure of physicians' willingness to incorporate shared decision making into practice

OBJECTIVES

To develop 'incorpoRATE', a brief and broadly applicable measure of physicians' willingness to incorporate shared decision making (SDM) into practice.

METHODS

incorpoRATE was developed across three phases: 1) A review of relevant literature to inform candidate domain and item development, 2) Cognitive interviews with US physicians to iteratively refine the measure, and 3) Pilot testing of the measure across a larger sample of US physicians to explore item and measure performance.

RESULTS

The final measure consists of seven items that assess physician perspectives on various components of SDM use that may present as barriers in practice. During pilot testing, the majority of physicians expressed positive opinions about the overall concept of SDM, yet were less comfortable acting on informed patient choices when there was known incongruence with their own recommendations.

CONCLUSIONS

incorpoRATE is a novel physician-reported measure that assesses physicians' willingness to incorporate SDM in practice.

PRACTICE IMPLICATIONS

incorpoRATE has the potential to help us further understand the limited adoption of SDM and areas of focus for improving the use of SDM in the future. We recommend that incorpoRATE be subject to further psychometric, real-world testing, in order to explore its performance across different samples of physicians and organizations.

Group medical consultation for osteoporosis: a prospective pilot study of patient experience in Canadian tertiary care

BACKGROUND

Delivery of patient-centred care is limited by physician time. Group medical consultations may save physician time without compromising patient experience.

AIM

To assess patient experience and specialist physician time commitment in a group consultation for osteoporosis.

DESIGN AND SETTING

Prospective pilot study at a tertiary osteoporosis centre in Canada between May 2016 and June 2019.

METHOD

The authors evaluated women referred for osteoporosis who chose a 2-hour group consultation instead of a one-to-one consultation. Group consultations were led by an osteoporosis nurse and specialist physician, and consisted of individualised fracture risk assessment and education regarding osteoporosis therapies, followed by a decision-making exercise to choose a treatment plan. Patients then followed up with their GPs to implement this plan. Patient experience was assessed via a questionnaire immediately and 3 months post-consultation, at which time GP satisfaction and patient treatment status were also surveyed.

RESULTS

Of 560 referrals received, 18 patients declined osteoporosis specialist assessment, 54 could not be contacted, 303 attended a one-to- one consultation, and 185 attended a group consultation. Mean participant age was 62.8 years (standard deviation [SD] 5.8) and the Fracture Risk Assessment Tool (FRAX) 10-year osteoporotic fracture risk was 13.0 (SD 7.0)%. Immediately post-consultation, 104 (97.2%) patients were satisfied and 102 (95.3%) felt included in decision making. Satisfaction was reported by 95/99 (96.0%) patients and 27/36 (75.0%) GPs. Treatment plans had been enacted by 90 (90.1%) patients. For a matched number of individual consultations, each group session conferred a specialist physician time savings of 5.5 hours.

CONCLUSION

Group consultations represent a satisfactory and time-efficient alternative to one-to-one consultations for select patients with osteoporosis.

Qualitative exploration of factors associated with shared decision-making in diabetes management: a health care provider's perspective

OBJECTIVE

Internationally, patient-doctor interaction has shifted from the paternalist model to the shared decision-making (SDM) model, which is an essential part of effective management of chronic illnesses, especially diabetes. It is a relatively new concept in Pakistan, and data about healthcare providers' perspectives are lacking. The aim was to explore significant facilitators and barriers to effective SDM as perceived by endocrinologists.

DESIGN

A qualitative research using in-depth interviews based on grounded theory was done. It was written in line with the Consolidated Criteria for Reporting Qualitative Research checklist.

SETTING

The interviews were conducted at the workplace of the endocrinologist between April and July 2019.

PARTICIPANTS

Prominent endocrinologists of Pakistan residing in Lahore were approached for in-depth interviews. The transcripts were analyzed simultaneously, and theme saturation was achieved in 11 interviews.

MAIN OUTCOME MEASURES

Thematic analysis of data done using grounded theory.

RESULTS

Four major and two minor themes were identified. The most cited barriers to effective SDM from the doctors' side were the shortage of time during consultations and the absence of formal training of clinicians in communication skills. However, the patients' hesitation in questioning the doctor, perceiving him as a paternalist 'messiah' in society and lack of education limits their ability to understand and comprehend treatment options.

CONCLUSION

There are many barriers perceived by providers as well as clients/patients by effectively using SDM. Local cultural context is influencing a lot.

Patient and provider perspectives on uptake of a shared decision making intervention for asthma in primary care practices

OBJECTIVE

Poor outcomes and health disparities related to asthma result in part from difficulty disseminating new evidence such as shared decision making (SDM) into clinical practice. As part of a three-arm cluster randomized dissemination study, evaluation of the impact of different dissemination methods was studied. Here we evaluate themes from patient and provider focus groups to assess the impact of a facilitated, traditional dissemination approach, or no intervention, on patient and provider perspectives of asthma care.

METHODS

Using semi-structured questions, twenty-four pre- and post-intervention focus groups with patients and providers took place across primary care practices. Discussions were held in all three arms both before and after the time of intervention rollout. Audio recordings were transcribed and analyzed for themes.

RESULTS

Across all sites patients and providers discussed themes of communication, asthma self-management, barriers, education, and patient awareness. After the intervention, compared to traditional sites, facilitated practices were more likely to discuss themes related to SDM, such as patient-centered communication, patient-provider negotiation on treatment plan, planning, goal-setting, and solutions to barriers.

CONCLUSIONS

Emergent themes allowed for further understanding of how the SDM implementation was perceived at the patient and provider level. The facilitated implementation was associated with higher adoption of the SDM intervention. These themes and supporting quotes add to knowledge of best practices associated with implementing an evidence-based SDM intervention for asthma into primary care and will inform researchers, practices, and providers as they work to improve adoption of evidence-based interventions into practice.

Personalization and Patient Involvement in Decision Support Systems: Current Trends

OBJECTIVES

This survey aims at highlighting the latest trends (2012-2014) on the development, use, and evaluation of Information and Communication Technologies (ICT) based decision support systems (DSSs) in medicine, with a particular focus on patient-centered and personalized care.

METHODS

We considered papers published on scientific journals, by querying PubMed and Web of ScienceTM. Included studies focused on the implementation or evaluation of ICT-based tools used in clinical practice. A separate search was performed on computerized physician order entry systems (CPOEs), since they are increasingly embedding patient-tailored decision support.

RESULTS

We found 73 papers on DSSs (53 on specific ICT tools) and 72 papers on CPOEs. Although decision support through the delivery of recommendations is frequent (28/53 papers), our review highlighted also DSSs only based on efficient information presentation (25/53). Patient participation in making decisions is still limited (9/53), and mostly focused on risk communication. The most represented medical area is cancer (12%). Policy makers are beginning to be included among stakeholders (6/73), but integration with hospital information systems is still low. Concerning knowledge representation/management issues, we identified a trend towards building inference engines on top of standard data models. Most of the tools (57%) underwent a formal assessment study, even if half of them aimed at evaluating usability and not effectiveness.

CONCLUSIONS

Overall, we have noticed interesting evolutions of medical DSSs to improve communication with the patient, consider the economic and organizational impact, and use standard models for knowledge representation. However, systems focusing on patient-centered care still do not seem to be available at large.

Is Shared Decision Making a Utopian Dream or an Achievable Goal?

The idea of shared decision making (SDM) between patient and physician grew out of a generalized challenge to traditional social hierarchies that occurred in the middle of the last century. Governments have espoused SDM, thousands of articles about it have been published, and evidence has shown that it improves some of the healthcare processes as well as patient outcomes. Yet it has not been widely adopted. From their cross-disciplinary perspective (practical theology and clinical medicine), the authors locate this reluctance in the unfolding of scientific paradigm shifts, summarize the perceived risks and benefits of SDM and the evidence for each, and suggest practical, achievable approaches for clinicians. Finally, they explore some important emerging territories for SDM.

The Burden of Cognitive Impairment in Patients With End-Stage Renal Disease and Impact on Dialysis Modality Choice

Introduction

Kidney disease is associated with significant cognitive dysfunction. Subjective reports of cognitive ability have not been studied extensively in chronic kidney disease. We investigated the association between objective and subjective cognitive functions in predialysis patients and their association with self-care dialysis modality choice.

Methods

Cross-sectional data from the Barriers to Successful Implementation of Care in Home Haemodialysis study were used for the study of cognition in 220 predialysis patients. The data were used to ascertain the demographics, clinical, laboratory, and neuropsychometric variables. The latter includes Trail Making Tests (TMT) parts A and B, Modified Mini Mental State Examination, and metacognition questionnaire for subjective assessment of one's cognitive ability. The outcome variable was fully assisted and self-care dialysis modality choice.

Results

Within the study cohort, 90 patients chose fully assisted hemodialysis and 114 patients chose self-care dialysis. The median Modified Mini Mental State Examination, TMT part A, and TMT part B scores were greater for the assisted versus the self-care group. Metamemory was not significantly different between groups, but the metaconcentration score was significantly worse in the group choosing assisted dialysis. Higher (i.e., better) metaconcentration scores were significantly associated with the self-care modality choice in the univariate and hierarchical regression analyses. Adjusted and unadjusted analyses showed a significant association between perceived concentration and TMT part B scores (P < 0.01). With every 1.6-minute increase in TMT part B score, there was a 1-unit reduction in metaconcentration score, and the latter was associated with 20% lower odds of choosing self-care dialysis over a fully assisted dialysis modality.

Discussion

Patients' self-perception of cognitive ability is a significant predictor of self-care dialysis modality choice. Subjective report of "metaconcentration" is also strongly associated with poorer outcome on the TMT part B.

Patient engagement and shared decision-making: What do they look like in neurology practice?

Neurology is inherently patient-centered given that clinical uncertainty is common, forcing physicians, patients, and families to partner on treatment approach. An increasing emphasis on patient-centered care, patient engagement, and shared decision-making (SDM) in health care provides neurologists with an opportunity to reassess current clinical approaches to decision-making. Such assessment is not simply theoretical but has clear practice implications, with patients indicating a desire for SDM and calls for reimbursement to be tied to demonstration of SDM in practice. We present a framework for how neurologists enhance patient-centered practice by (1) eliciting patients' values and goals, (2) targeting discussion of clinical options to those values and goals, and (3) partnering with patients to make individualized decisions. We also highlight resources that facilitate SDM and examples of SDM in neurology clinical practice.

Healthcare decision-making in end stage renal disease-patient preferences and clinical correlates

Background

Medical decision-making is critical to patient survival and well-being. Patients with end stage renal disease (ESRD) are faced with incrementally complex decision-making throughout their treatment journey. The extent to which patients seek involvement in the decision-making process and factors which influence these in ESRD need to be understood.

Methods

535 ESRD patients were enrolled into the cross-sectional study arm and 30 patients who started dialysis were prospectively evaluated. Patients were enrolled into 3 groups- ‘predialysis’ (group A), ‘in-centre’ haemodialysis (HD) (group B) and self-care HD (93 % at home-group C) from across five tertiary UK renal centres. The Autonomy Preference Index (API) has been employed to study patient preferences for information-seeking (IS) and decision-making (DM). Demographic, psychosocial and neuropsychometric assessments are considered for analyses.

Results

458 complete responses were available. API items have high internal consistency in the study population (Cronbach’s alpha > 0.70). Overall and across individual study groups, the scores for information-seeking and decision-making are significantly different indicating that although patients had a strong preference to be well informed, they were more neutral in their preference to participate in DM (p < 0.05). In the age, education and study group adjusted multiple linear regression analysis, lower age, female gender, marital status; higher API IS scores and white ethnicity background were significant predictors of preference for decision-making. DM scores were subdivided into tertiles to identify variables associated with high (DM > 70: and low DM (≤30) scores. This shows association of higher DM scores with lower age, lower comorbidity index score, higher executive brain function, belonging in the self-caring cohort and being unemployed. In the prospectively studied cohort of predialysis patients, there was no change in decision-making preference scores after commencement of dialysis.

Conclusion

ESRD patients prefer to receive information, but this does not always imply active involvement in decision-making. By understanding modifiable and non-modifiable factors which affect patient preferences for involvement in healthcare decision-making, health professionals may acknowledge the need to accommodate individual patient preferences to the extent determined by the individual patient factors.

Electronic supplementary material

The online version of this article (doi:10.1186/s12882-015-0180-8) contains supplementary material, which is available to authorized users.

Physician attitudes toward shared decision making: A systematic review

OBJECTIVE

Although evidence suggests that shared decision-making (SDM) can improve patient outcomes, uptake to date has been sparse. The purpose of this review was to determine the reported opinions of physicians regarding the use of SDM in clinical practice and to identify strategies to promote uptake.

METHODS

We conducted a systematic review, including papers published between 2007 and 2014.

RESULTS

The electronic search yielded 11,761 results. Following abstract review, 123 papers were selected for full text review, and 43 papers were included for analysis. Fourteen of the included studies considered SDM within the context of primary care, 25 in secondary care, and 4 in both.

CONCLUSIONS

Physicians express positive attitudes toward SDM in clinical practice, although the level of support varies by clinical scenario, treatment decision and patient characteristics.

PRACTICE IMPLICATIONS

Physician support for SDM is a necessary, if not sufficient, condition to facilitate meaningful SDM. In order to garner support for SDM, additional empirical evidence regarding the clinical and patient important outcomes must be established. Based on the results of this review, the authors suggest assessing the impact of SDM within the context of chronic disease management where multiple therapeutic options exist, and outcomes may be measured long-term.

The opportunities and challenges for shared decision-making in the rural United States

The ethical standard for informed consent is fostered within a shared decision-making (SDM) process. SDM has become a recognized and needed approach in health care decision-making. Based on an ethical foundation, the approach fosters the active engagement of patients, where the clinician presents evidence-based treatment information and options and openly elicits the patient's values and preferences. The SDM process is affected by the context in which the information exchange occurs. Rural settings are one context that impacts the delivery of health care and SDM. Rural health care is significantly influenced by economic, geographical and social characteristics. Several specific distinctive features influence rural health care decision-making-poverty, access to health care, isolation, over-lapping relationships, and a shared culture. The rural context creates challenges as well as fosters opportunities for the application of SDM as a natural dynamic within the rural provider-patient relationship. To fulfill the ethical requirements of informed consent through SDM, it is necessary to understand its inherent challenges and opportunities. Therefore, rural clinicians and ethicists need to be cognizant of the impact of the rural setting on SDM and use the insights as an opportunity to achieve SDM.

Implementing and evaluating shared decision making in oncology practice

Engaging individuals with cancer in decision making about their treatments has received increased attention; shared decision making (SDM) has become a hallmark of patient-centered care. Although physicians indicate substantial interest in SDM, implementing SDM in cancer care is often complex; high levels of uncertainty may exist, and health care providers must help patients understand the potential risks versus benefits of different treatment options. However, patients who are more engaged in their health care decision making are more likely to experience confidence in and satisfaction with treatment decisions and increased trust in their providers. To implement SDM in oncology practice, physicians and other health care providers need to understand the components of SDM and the approaches to supporting and facilitating this process as part of cancer care. This review summarizes recent information regarding patient and physician factors that influence SDM for cancer care, outcomes resulting from successful SDM, and strategies for implementing SDM in oncology practice. We present a conceptual model illustrating the components of SDM in cancer care and provide recommendations for facilitating SDM in oncology practice.

Evaluation of a Mammography Screening Decision Aid for Women Aged 75 and Older: Protocol for a Cluster-randomized Controlled Trial

PURPOSE

There is insufficient evidence to recommend mammography for women >75 years. Guidelines recommend that older women be informed of the uncertainty of benefit and potential for harm, especially for women with short life expectancy. However, few older women are informed of harms of screening and many with short life expectancy are screened. Therefore, we aim to test whether a mammography screening decision aid (DA) for women >75 years affects their use of mammography, particularly for women with <10 year life expectancy.

METHODS/DESIGN

The DA is a self-administered pamphlet that includes information on screening outcomes, tailored information on breast cancer risk, health, life expectancy, and competing mortality risks, and includes a values clarification exercise. We are conducting a large cluster randomized controlled trial (RCT) of the DA with the primary care provider (PCP) as the unit of randomization to evaluate its efficacy. We plan to recruit 550 women 75-89 years from 100 PCPs to receive either the mammography DA or a pamphlet on home safety for older adults (control arm) before a visit with their PCP, depending on their PCP's randomization assignment. The primary outcome is receipt of mammography screening assessed through chart abstraction. Secondary outcomes include effect of the DA on older women's screening intentions, knowledge, and decisional conflict, and on documented discussions about mammography by their PCPs. We will recruit women from 5 Boston-based primary care practices (3 community-based internal medicine practices and 2 academic practices), and 2 North Carolina-based academic primary care practices.

DISCUSSION

It is essential that we test the DA in a large RCT to determine if it is efficacious and to substantiate the need for broad translation into clinical practice. Our DA has the potential to improve health care utilization and care in a manner dictated by patient preferences.

Shared decision making: examining key elements and barriers to adoption into routine clinical practice

For many patients, the time spent meeting with their physician-the clinical encounter-is the most opportune moment for them to become engaged in their own health through the process of shared decision making. In the United States shared decision making is being promoted for its potential to improve the health of populations and individual patients, while also helping control care costs. In this overview we describe the three essential elements of shared decision making: recognizing and acknowledging that a decision is required; knowing and understanding the best available evidence; and incorporating the patient's values and preferences into the decision. To achieve the promise of shared decision making, more physicians need training in the approach, and more practices need to be reorganized around the principles of patient engagement. Additional research is also needed to identify the interventions that are most effective.

Shared decision making and patient decision aids: knowledge, attitudes, and practices among Hawai'i physicians

As the health care field moves toward patient-centered care (PCC), increasing emphasis has been placed on the benefits of patient decision aids for promoting shared decision making (SDM). This study provides a baseline measure of knowledge, attitudes, and practices (KAP) among Hawai'i's physicians with respect to patient decision aids (DAs). Physicians throughout the State of Hawai'i were invited to complete a survey assessing their knowledge, attitudes, and practices with respect to the clinical use of DAs. One hundred and seventy four valid surveys were analyzed. Reported awareness and use of DAs were low, but recognition of the benefits of SDM and openness to the use of DAs were very high. The leading perceived barriers to the implementation of DAs were lack of awareness, lack of resources, and limited physician time to learn about DA technology. However, a significant majority of the respondents reported that DAs could empower patients by improving knowledge (88%), increasing satisfaction with the consultation process (81%), and increasing compliance (74%). Among physicians currently employing DAs, use of brochures or options matrix sheets was the most common aid tool. However, leading recommended DA formats were paper-based brochures for clinic use (75%) and interactive online website programs for outside clinic use (73.5%). Given growing emphasis on the PCC model and the recognized desire of many patients to participate in the medical decision making process, positive responses toward SDM and the use of DAs by Hawai'i physicians are promising.

Lessons learned from the conduct of a multisite cluster randomized practical trial of decision aids in rural and suburban primary care practices

Background

The decision aids for diabetes (DAD) trial explored the feasibility of testing the effectiveness of decision aids (DAs) about coronary prevention and diabetes medications in community-based primary care practices, including rural clinics that care for patients with type 2 diabetes.

Methods

As originally designed, we invited clinicians in eight practices to participate in the trial, reviewed the patient panel of clinicians who accepted our invitation for potentially eligible patients, and contacted these patients by phone, enrolling those who accepted our invitation. As enrollment failed to meet targets, we recruited four new practices. After discussing the study with the clinicians and receiving their support, we reviewed all clinic panels for potentially eligible patients. Clinicians were approached to confirm participation and patient eligibility, and patients were approached before their visit to provide written informed consent. This in-clinic approach required study coordinators to travel and stay longer at the clinics as well as to screen more patient records for eligibility. The in-clinic approach was associated with better recruitment rates, lower patient retention and outcome completion rates, and a better intervention effect.

Results

We drew four lessons: 1) difficulties identifying potentially eligible patients threaten the viability of practical trials of DAs; 2) to improve the recruitment yield, recruit clinicians and patients for the study at the clinic, just before their visit; 3) approaches that improve recruitment may be associated with reduced retention and survey response; and 4) procedures that involve working closely with the practice may improve recruitment and may also affect the quality of the implementation of the interventions.

Conclusion

Success in practice-based trials in usual primary care including rural clinics may require the smallest possible research footprint on the practice while implementing a streamlined protocol favoring in-clinic, in-person interactions with clinicians and patients.

Trial registration

ClinicalTrials.gov NCT01029288

Shared decision-making about colorectal cancer screening: a conceptual framework to guide research

OBJECTIVE

To develop a conceptual framework to guide research on shared decision-making about colorectal cancer (CRC) screening among persons at average risk and their providers.

METHODS

Based upon a comprehensive review of empirical literature and relevant theories, a conceptual framework was developed that incorporated patient characteristics, cultural beliefs, provider/health care system variables, health belief/knowledge/stage of adoption variables, and shared decision-making between patients and providers that may predict behavior. Relationships among concepts in the framework, shared decision-making process and outcomes, and CRC screening behavior were proposed. Directions for future research were presented.

RESULTS

Many of the concepts in the proposed framework have been examined in prior research. However, these elements have not been combined previously to explain shared decision-making about CRC screening.

CONCLUSION

Research is needed to test the proposed relationships and hypotheses and to refine the framework.

PRACTICE IMPLICATIONS

Findings from future research guided by the proposed framework may inform clinical practice to facilitate shared decision-making about CRC screening.

Opportunities for shared decision making in kidney transplantation

Health researchers and policy-makers increasingly urge both patient and clinician engagement in shared decision making (SDM) to promote patient-centered care. Although SDM has been examined in numerous clinical settings, it has received little attention in solid organ transplantation. This paper describes the application of SDM to the kidney transplantation context. Several distinctive features of kidney transplantation present challenges to SDM including fragmented patient-provider relationships, the time-sensitive and unpredictable nature of deceased organ offers, decision-making processes by transplant providers serving as both organ guardians (given the organ scarcity) versus advocates for specific patients seeking transplantation, variable clinical practices and policies among transplant centers, and patients' potentially compromised cognitive status and literacy levels. We describe potential barriers to and opportunities for SDM, and posit that SDM is feasible, warranting encouragement in kidney transplantation. We propose strategies to promote and overcome obstacles to SDM in kidney transplantation. We contend that engagement in SDM can be facilitated by re-organization of clinical care, communication and education of providers and patients.

Looking at Patients’ Choices through the Lens of Expected Utility

The expected utility framework underlies much research in medical decision making. Because the framework requires decisions to be decomposed into probabilities of states and the values of those states, researchers have investigated the two components separately from each other and from patients’ actual decisions. The authors propose that it would be productive to focus more research on the relationships among risk perceptions, outcome valuations, and choices in the same decision makers. They outline exploratory analyses based on two existing national surveys, the Medical Expenditure Panel Survey and the Joint Canada/United States Survey of Health.