Comparison of Three Measures of Shared Decision Making: SDM Process_4, CollaboRATE, and SURE Scales

OMERACT Core outcome measurement set for shared decision making in rheumatic and musculoskeletal conditions: a scoping review to identify candidate instruments

OBJECTIVES

Shared decision making (SDM) is a central tenet in rheumatic and musculoskeletal care. The lack of standardization regarding SDM instruments and outcomes in clinical trials threatens the comparative effectiveness of interventions. The Outcome Measures in Rheumatology (OMERACT) SDM Working Group is developing a Core Outcome Set for trials of SDM interventions in rheumatology and musculoskeletal health. The working group reached consensus on a Core Outcome Domain Set in 2020. The next step is to develop a Core Outcome Measurement Set through the OMERACT Filter 2.2.

METHODS

We conducted a scoping review (PRISMA-ScR) to identify candidate instruments for the OMERACT Filter 2.2 We systematically reviewed five databases (Ovid MEDLINE®, Embase, Cochrane Library, CINAHL and Web of Science). An information specialist designed search strategies to identify all measurement instruments used in SDM studies in adults or children living with rheumatic or musculoskeletal diseases or their important others. Paired reviewers independently screened titles, abstracts, and full text articles. We extracted characteristics of all candidate instruments (e.g., measured construct, measurement properties). We classified candidate instruments and summarized evidence gaps with an adapted version of the Summary of Measurement Properties (SOMP) table.

RESULTS

We found 14,464 citations, read 239 full text articles, and included 99 eligible studies. We identified 220 potential candidate instruments. The five most used measurement instruments were the Decisional Conflict Scale (traditional and low literacy versions) (n=38), the Hip/Knee-Decision Quality Instrument (n=20), the Decision Regret Scale (n=9), the Preparation for Decision Making Scale (n=8), and the CollaboRATE (n=8). Only 44 candidate instruments (20%) had any measurement properties reported by the included studies. Of these instruments, only 57% matched with at least one of the 7-criteria adapted SOMP table.

CONCLUSION

We identified 220 candidate instruments used in the SDM literature amongst people with rheumatic and musculoskeletal diseases. Our classification of instruments showed evidence gaps and inconsistent reporting of measurement properties. The next steps for the OMERACT SDM Working Group are to match candidate instruments with Core Domains, assess feasibility and review validation studies of measurement instruments in rheumatic diseases or other conditions. Development and validation of new instruments may be required for some Core Domains.

Behavioural 'nudging' interventions to reduce low-value care for low back pain in the emergency department (NUDG-ED): protocol for a 2×2 factorial, before-after, cluster randomised trial

INTRODUCTION

Opioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and two in three will receive an opioid. NUDG-ED aims to determine the effectiveness of two different behavioural 'nudge' interventions on low-value care for ED patients with low back pain.

METHODS AND ANALYSIS

NUDG-ED is a 2×2 factorial, open-label, before-after, cluster randomised controlled trial. The trial includes 8 ED sites in Sydney, Australia. Participants will be ED clinicians who manage back pain, and patients who are 18 years or over presenting to ED with musculoskeletal back pain. EDs will be randomly assigned to receive (i) patient nudges, (ii) clinician nudges, (iii) both interventions or (iv) no nudge control. The primary outcome will be the proportion of encounters in ED for musculoskeletal back pain where a person received a non-indicated lumbar imaging test, an opioid at discharge or both. We will require 2416 encounters over a 9-month study period (3-month before period and 6-month after period) to detect an absolute difference of 10% in use of low-value care due to either nudge, with 80% power, alpha set at 0.05 and assuming an intra-class correlation coefficient of 0.10, and an intraperiod correlation of 0.09. Patient-reported outcome measures will be collected in a subsample of patients (n≥456) 1 week after their initial ED visit. To estimate effects, we will use a multilevel regression model, with a random effect for cluster and patient, a fixed effect indicating the group assignment of each cluster and a fixed effect of time.

ETHICS AND DISSEMINATION

This study has ethical approval from Southwestern Sydney Local Health District Human Research Ethics Committee (2023/ETH00472). We will disseminate the results of this trial via media, presenting at conferences and scientific publications.

TRIAL REGISTRATION NUMBER

ACTRN12623001000695.

Real-time monitoring and feedback to improve shared decision-making for surgery (the ALPACA Study): protocol for a mixed-methods study to inform co-development of an inclusive intervention

INTRODUCTION

High-quality shared decision-making (SDM) is a priority of health services, but only achieved in a minority of surgical consultations. Improving SDM for surgical patients may lead to more effective care and moderate the impact of treatment consequences. There is a need to establish effective ways to achieve sustained and large-scale improvements in SDM for all patients whatever their background. The ALPACA Study aims to develop, pilot and evaluate a decision support intervention that uses real-time feedback of patients' experience of SDM to change patients' and healthcare professionals' decision-making processes before adult elective surgery and to improve patient and health service outcomes.

METHODS AND ANALYSIS

This protocol outlines a mixed-methods study, involving diverse stakeholders (adult patients, healthcare professionals, members of the community) and three National Health Service (NHS) trusts in England. Detailed methods for the assessment of the feasibility, usability and stakeholder views of implementing a novel system to monitor the SDM process for surgery automatically and in real time are described. The study will measure the SDM process using validated instruments (CollaboRATE, SDM-Q-9, SHARED-Q10) and will conduct semi-structured interviews and focus groups to examine (1) the feasibility of automated data collection, (2) the usability of the novel system and (3) the views of diverse stakeholders to inform the use of the system to improve SDM. Future phases of this work will complete the development and evaluation of the intervention.

ETHICS AND DISSEMINATION

Ethical approval was granted by the NHS Health Research Authority North West-Liverpool Central Research Ethics Committee (reference: 21/PR/0345). Approval was also granted by North Bristol NHS Trust to undertake quality improvement work (reference: Q80008) overseen by the Consent and SDM Programme Board and reporting to an Executive Assurance Committee.

TRIAL REGISTRATION NUMBER

ISRCTN17951423; Pre-results.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICE IMPLICATIONS

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

Impact of an in-consult patient decision aid on treatment choices and outcomes of management for patients with an endoscopically resected malignant colorectal polyp: a study protocol for a non-randomised clinical phase II study

INTRODUCTION

Management of an endoscopically resected malignant colorectal polyps can be challenging due to the risk of residual tumour and lymphatic spread. International studies have shown, that of those choosing surgical management instead of surveillance strategy, there are between 54% and 82% of bowel resections without evidence of residual tumour or lymphatic spread. As surgical management entails risks of complications and surveillance strategy entails risks of residual tumour or recurrence, a clinical dilemma arises when choosing a management strategy. Shared decision-making is a concept that can be used in preference-sensitive decision-making to facilitate patient involvement and empowerment to facilitate active patient participation in the decision-making process.

METHODS AND ANALYSIS

This study protocol describes our clinical multi-institutional, non-randomised, interventional phase II study at Danish surgical departments planned to commence in the second quarter of 2024. The aim of this study is to examine whether shared decision-making and using a patient decision aid in consultations affect patients' choice of management, comparing with retrospective data. The secondary aim is to investigate patients' experiences, perceived involvement, satisfaction, decision conflict and other outcomes using questionnaire feedback directly from the patients.

ETHICS AND DISSEMINATION

There are no conflicts of interest for principal or local investigators in any of the study sites. All results will be published at Danish and international meetings, and in English language scientific peer-reviewed journals. Our study underwent evaluation by the Regional Committees on Health Research Ethics for Southern Denmark (file number 20232000-47), concluding that formal approval was not required for this kind of research.

TRIAL REGISTRATION NUMBER

NCT05776381.

Assessment of a venous thromboembolism prophylaxis shared decision-making intervention (DASH-TOP) using the decisional conflict scale: a mixed-method study

BACKGROUND

Venous thromboembolism (VTE) in pregnancy is a major cause of maternal morbidity and death. The use of low-molecular-weight heparin (LMWH), despite being the standard of care to prevent VTE, comes with some challenges. Shared decision-making (SDM) interventions are recommended to support patients and clinicians in making preference-sensitive decisions. The quality of the SDM process has been widely assessed with the decisional conflict scale (DCS). Our aim is to report participants' perspectives of each of the components of an SDM intervention (DASH-TOP) in relation to the different subscales of the DCS.

METHODS

Design: A convergent, parallel, mixed-methods design.

PARTICIPANTS

The sample consisted of 22 health care professionals, students of an Applied Clinical Research in Health Sciences (ICACS) master program.

INTERVENTION

We randomly divided the participants in three groups: Group 1 received one component (evidence -based information), Group 2 received two components (first component and value elicitation exercises), and Group 3 received all three components (the first two and a decision analysis recommendation) of the SDM intervention.

ANALYSIS

For the quantitative strand, we used a non-parametric test to analyze the differences in the DCS subscales between the three groups. For the qualitative strand, we conducted a content analysis using the decisional conflict domains to deductively categorize the responses.

RESULTS

Groups that received more intervention components experienced less conflict and better decision-making quality, although the differences between groups were not statistically significant. The decision analysis recommendation improved the efficacy with the decision-making process, however there are some challenges when implementing it in clinical practice. The uncertainty subscale showed a high decisional conflict for all three groups; contributing factors included low certainty of the evidence-based information provided and a perceived small effect of the drug to reduce the risk of a VTE event.

CONCLUSIONS

The DASH-TOP intervention reduced decisional conflict in the decision -making process, with decision analysis being the most effective component to improve the quality of the decision. There is a need for more implementation research to improve the delivery of SDM interventions in the clinical encounter.

Validation of two brief instruments (the SURE and CollaboRATE) to measure shared decision-making in patients with restless legs syndrome

Restless legs syndrome (RLS) is a common neurological disorder characterised by an urge to move arms and legs, usually associated with discomfort, pain, motor restlessness, and sleep disturbance. An individually adapted treatment is needed but difficult to optimise, which makes shared decision-making (SDM) important. However, brief validated instruments on how patients with RLS perceive their involvement in treatment decisions are lacking. Therefore, the aim was to validate two instruments, SURE (Sure of myself, Understand information, Risk-benefit ratio, Encouragement, i.e., to assess decisional conflict) and CollaboRATE (brief patient survey focused on SDM, i.e., to assess SDM), in patients with RLS. A cross-sectional design, including 788 participants with RLS (65% females, mean [SD] age 70.8 [11.4] years) from a national patient organisation for RLS, was used. A postal survey was sent out to collect data regarding weight, height, comorbidities, demographics, and RLS-related treatment data. The following instruments were included: the SURE, CollaboRATE, Restless Legs Syndrome-6 Scale, and eHealth Literacy Scale. Confirmatory factor analysis and Rasch models were used to assess the validity and reliability of the SURE and CollaboRATE. Measurement invariance, unidimensionality, and differential item functioning (DIF) across age, gender, and medication groups were assessed. The SURE and CollaboRATE were both identified as unidimensional instruments with satisfactory internal consistency. No DIF across age and gender was identified, while significant DIF was observed for both the SURE and CollaboRATE regarding medication use categories. However, both the SURE and CollaboRATE are potential instruments to be used in research, but also as reflection tools by healthcare professionals, patients, and students to explore and assess SDM, and support its development in clinical care.

Performance of the shared decision-making process scale for use in evaluation of hereditary cancer genetic testing decisions

This study aimed to evaluate feasibility, acceptability, reliability, and validity of the existing four-item Shared Decision Making (SDM) Process Scale for use in evaluating genetic testing decisions. Patients from a large hereditary cancer genetics practice were invited to participate in a two-part survey after completing pre-test genetic counseling. The online survey included the SDM Process Scale and the SURE scale, a measure of decisional conflict. SDM Process scores were compared to SURE scores to test convergent validity, and respondents were sent a second survey 1 week later to assess retest reliability. The response rate was 65% (n = 259/398) and missing data was low (<1%). SDM scores ranged from zero to four with a mean of 2.3 (SD = 1.1). Retest reliability was good, with intraclass correlation of 0.84, 95% confidence interval (0.79, 0.88). No relationship was found between SDM Process scores and decisional conflict (p = 0.46), likely because 85% of participants reported no decisional conflict. The four-item SDM Process Scale demonstrated feasibility, acceptability, and retest reliability, but not convergent validity with decisional conflict. These findings provide initial evidence for use of this scale to measure patient perceptions of SDM in pre-test counseling for hereditary cancer genetic testing.

Toward an operational definition of shared decision making: A conceptual analysis

RATIONALE

Shared decision making has been widely advocated and evaluated in diverse ways for 4 decades.

AIMS AND OBJECTIVES

But there is scant evidence that it is commonly accepted by or has influence on practitioners' behaviour or that it positively affects patient health outcomes. This situation may be due in part to the absence of a commonly agreed operational definition of the construct. This is admitted in the literature and has led to multiple approaches to evaluation.

METHOD

An operational definition is proposed based on ethical parity among parties, sharing of mutually interacting expectations and analysis of decisions as commitment to action rather than information.

RESULTS

Shared decision making occurs when two autonomous and uncoerced agents both commit to actions that neither has reason to want to change based on their understanding of anticipated outcomes given the situation at hand and of the intended actions of the other party.

CONCLUSION

It is a broader concept than providing information regarding treatment alternatives in the office.

Shared Decision Making for Elective Surgical Procedures in Older Adults with and without Cognitive Insufficiencies

PURPOSE

Older adults are prone to cognitive impairment, which may affect their ability to engage in aspects of shared decision making (SDM) and their ability to complete surveys about the SDM process. This study examined the surgical decision-making processes of older adults with and without cognitive insufficiencies and evaluated the psychometric properties of the SDM Process scale.

METHODS

Eligible patients were 65 y or older and scheduled for a preoperative appointment before elective surgery (e.g., arthroplasty). One week before the visit, staff contacted patients via phone to administer the baseline survey, including the SDM Process scale (range 0-4), SURE scale (top scored), and the Montreal Cognitive Assessment Test version 8.1 BLIND English (MoCA-blind; score range 0-22; scores < 19 indicate cognitive insufficiency). Patients completed a follow-up survey 3 mo after their visit to assess decision regret (top scored) and retest reliability for the SDM Process scale.

RESULTS

Twenty-six percent (127/488) of eligible patients completed the survey; 121 were included in the analytic data set, and 85 provided sufficient follow-up data. Forty percent of patients (n = 49/121) had MoCA-blind scores indicating cognitive insufficiencies. Overall SDM Process scores did not differ by cognitive status (intact cognition x ¯  = 2.5, s = 1.0 v. cognitive insufficiencies x ¯  = 2.5, s = 1.0; P = 0.80). SURE top scores were similar across groups (83% intact cognition v. 90% cognitive insufficiencies; P = 0.43). While patients with intact cognition had less regret, the difference was not statistically significant (92% intact cognition v. 79% cognitive insufficiencies; P = 0.10). SDM Process scores had low missing data and good retest reliability (intraclass correlation coefficient = 0.7).

CONCLUSIONS

Reported SDM, decisional conflict, and decision regret did not differ significantly for patients with and without cognitive insufficiencies. The SDM Process scale was an acceptable, reliable, and valid measure of SDM in patients with and without cognitive insufficiencies.

HIGHLIGHTS

Forty percent of patients 65 y or older who were scheduled for elective surgery had scores indicative of cognitive insufficiencies.Patient-reported shared decision making, decisional conflict, and decision regret did not differ significantly for patients with and without cognitive insufficiencies.The Shared Decision Making Process scale was an acceptable, reliable, and valid measure of shared decision making in patients with and without cognitive insufficiencies.

A prospective study of shared decision-making in brain tumor surgery

PURPOSE

Shared decision-making (SDM) is a key tenet of personalized care and is becoming an essential component of informed consent in an increasing number of countries. The aim of this study is to analyze patient and healthcare staff satisfaction with the SDM process before and after SDM was officially introduced as the standard of care. Decision grids are important tools in the SDM process, and we developed them for three different types of intracranial tumors.

METHODS

This prospective study was conducted in a high-volume neuro-oncological center on all consecutive eligible patients undergoing consideration of treatment for intracranial glioma and metastases. Twenty-two patients participated before and 74 after the introduction of SDM. Six and 5 staff members respectively participated in the analysis before and after team training and the introduction of SDM. The main outcome was patient and healthcare staff satisfaction with the SDM process.

RESULTS

Patients reported high satisfaction with the SDM process before (mean CollaboRATE score 26 of 27 points) and after (mean CollaboRATE score 26.3 of 27 points, p = 0.23) the introduction of SDM. Interestingly, staff attitude toward SDM improved significantly from 61.68 before to 90.95% after the introduction of SDM (p-value < 0.001). Decision grids that were developed for three different types of intracranial tumors are presented.

CONCLUSIONS

Team training in SDM and the introduction of techniques into daily practice can increase staff satisfaction with the SDM process. High levels of patient satisfaction were observed before, with a non-significant increase after the introduction of SDM. Decision grids are an important tool to facilitate the conveyance and understanding of complex information and to achieve SDM in daily clinical practice.

Rethinking Decision Quality: Measures, Meaning, and Bioethics

Studies of patient decision-making use many different measures to evaluate the quality of decisions and the decision-making process, partly to determine whether the ethical goals of informed consent, patient autonomy, and shared decision-making have been achieved. We describe these measures, grouped under three main approaches, and review their limitations, leading to three conclusions. First, no measure or combination of measures can provide a complete assessment of decision quality. Second, the quality of a decision is best characterized vaguely, for instance as "good," "satisfactory," or "poor," and these categorizations depend on qualitative judgments that go beyond quantitative measures. Third, bioethicists should focus on identifying and addressing poor or problematic decisions, rather than trying to incrementally increase decision quality, quantified by a measure. Decision-quality measures can be useful in research and in advancing important goals of bioethics, as long as the challenges of defining and measuring decision quality are recognized.

Measuring shared decision-making in younger and older adults with depression

BACKGROUND

This study examined the performance of the shared decision-making (SDM) Process scale in patients with depression, compared alternative wording of two items in the scale and explored performance in younger adults.

METHODS

A web-based non-probability panel of respondents with depression aged 18-39 (younger) or 40-75 (older) who talked with a health-care provider about starting or stopping treatment for depression in the past year were surveyed. Respondents completed one of two versions of the SDM Process scale that differed in the wording of pros and cons items and completed measures of decisional conflict, decision regret and who made the decision (mainly the respondent, mainly the provider or together). A subset of respondents completed a retest survey by 1 week. We examined how version and age group impacted SDM Process scores and calculated construct validity and retest reliability. We hypothesized that patients with higher SDM Process scores would show less decisional conflict using the SURE scale (range = 0-4); top score = no conflict versus other and less regret (range 1-4; higher scores indicated more regret).

RESULTS

The sample (N = 494) was majority White, non-Hispanic (82%) and female (72%), 48% were younger and 23% had a high school education or less. SDM Process scores did not differ by version (P = 0.09). SDM Process scores were higher for younger respondents (M = 2.6, SD = 1.0) than older respondents (M = 2.3, SD = 1.1; P = 0.001). Higher SDM Process scores were also associated with no decisional conflict (M = 2.6, SD = 0.99 vs. M = 2.1, SD = 1.2; P < 0.001) and less decision regret (r = -0.18, P < 0.001). Retest reliability was intraclass correlation coefficient = 0.81.

CONCLUSIONS

The SDM Process scale demonstrated validity and retest reliability in younger adults, and changes to item wording did not impact scores. Although younger respondents reported more SDM, there is room for improvement in SDM for depression treatment decisions.

Implementation of advance care planning decision aids for patients undergoing high-risk surgery: a field-testing study

BACKGROUND

Patients undergoing high-risk surgery are at a risk of sudden deterioration of their health. This study aimed to examine the feasibility of the development of two patient decision aids (PtDAs) to assist patients undergoing high-risk surgeries in informed decision-making about their medical care in a crisis.

METHODS

This field testing implemented two PtDAs that met the international criteria developed by the researchers for patients before surgery. Study participants were patients scheduled to be admitted to the intensive care unit after surgery at one acute care hospital in Japan and their families. The study used a mixed-methods approach. The primary outcome was patients' decision satisfaction evaluated by the SURE test. Secondary outcomes were the perception of the need to discuss advance care planning (ACP) before surgery and mental health status. The families were also surveyed on their confidence in proxy decision-making (NRS: 0-10, quantitative data). In addition, interviews were conducted after discharge to assess the acceptability of PtDAs. Data were collected before (preoperative outpatients, baseline: T0) and after providing PtDAs (in the hospital: T1) and following discharge (T2, T3).

RESULTS

Nine patients were enrolled, of whom seven agreed to participate (including their families). The SURE test scores (mean ± SD) were 2.1 ± 1.2 (T0), 3.4 ± 0.8 (T2), and 3.9 ± 0.4 (T3). The need to discuss ACP before surgery was 8.7 ± 1.3 (T1) and 9.1 ± 0.9 (T2). The degree of confidence in family surrogate decision-making was 6.1 ± 2.5 (T0), 7.7 ± 1.4 (T1), and 8.1 ± 1.5 (T2). The patients reported that using PtDAs provided an opportunity to share their thoughts with their families and inspired them to start mapping their life plans. Additionally, patients wanted to share and discuss their decision-making process with medical professionals after the surgery.

CONCLUSIONS

PtDAs supporting ACP in patients undergoing high-risk surgery were developed, evaluated, and accepted. However, they did not involve any discussion of patients' ACP treatment wishes with their families. Medical providers should be coached to provide adequate support to patients. In the future, larger studies evaluating the effectiveness of PtDAs are necessary.

Randomized control trial evaluating the use of a shared decision-making aid for older ventral hernia patients in the Geriatric Assessment and Medical Preoperative Screening (GrAMPS) Program

PURPOSE

Shared decision making (SDM) is ideally suited to abdominal wall surgery in older adults given the breadth of decision making required by the hernia surgeon and the impact on quality of life (QOL) by various treatment options. Given the paucity of literature surrounding SDM in hernia patients, the feasibility of a novel, formalized SDM aid/tool was evaluated in a pilot randomized trial.

METHODS

Patients 60 years or older with a diagnosed ventral hernia were prospectively randomized at an academic hernia center. In the experimental arm, a novel SDM tool, based on the SHARE Approach, guided the consultation. Previously validated SDM assessments and patient's hernia knowledge retention was measured.

RESULTS

Eighteen (18) patients were randomized (9 control and 9 experimental). Cohorts were well matched in age (p = 0.51), comorbidities (Charlson Comorbidity Score: p = 0.43) and frailty (mFI-11: p = 0.19; Risk Analysis Index: p = 0.33). Consultation time was 11 min longer in the experimental cohort (p < 0.01). There was a trend towards better Decisional Conflict Scores in the experimental group (p = 0.25) and the experimental cohort had improved post-visit retained hernia knowledge (p < 0.01). All patients in the experimental arm (100%) enjoyed working through the SDM aid/tool and felt it was a worthwhile exercise.

CONCLUSION

Incorporating a formalized SDM tool into a busy hernia surgical practice is feasible and well received by patients. In addition, early results suggest it improves retention of basic hernia knowledge and may reduce patient's decisional conflict. Next steps include condensing the SDM tool to enhance efficiency within the clinic and beginning a large, randomized control trial.

Validation of the Trust in the Surgical Decision Scale

OBJECTIVE

To develop and validate a short measure of trust in the surgical decision making process.

SUMMARY OF BACKGROUND DATA

Having a reliable and valid measure of trust is important to assess the quality of the patient-surgeon relationship when decisions about surgical procedures are made.

METHODS

A previously published 10-item trust scale was qualitatively tested with patients, and a revised set of 14 items was tested using a web-based survey of 300 people who had hip, knee or back surgery in the past 2 years. The 14 items were evaluated using patterns of correlations and relevance to medical decision making to create a 5-item version. A 5-item subset was compared to the 14-item version to assess reliability and validity of patient's trust in the surgical decision making process.

RESULTS

Of the 300 participants, 32% had hip surgery, 33% had knee surgery, and 34% back surgery. Mean age was 53 years, 45% female, 80% White, and 36% had a high school degree or less. The item intercorrelations for the 14 items were 0.43-0.72 and 0.58-0.71 for the 5 items. Correlation between the versions was 0.96 (P < 0.01). The 14- and 5-item versions were positively correlated with participants' shared decision making process scores (0.42 and 0.41, both P = 0.01), internal consistency reliability scores were 0.95 and 0.89, respectively, and were negatively correlated with their Decision Regret scores (-0.51 and -0.48, both P = 0.01).

CONCLUSION

The 5-item Trust in the Surgical Decision Scale has strong evidence of validity and reliability for patients who underwent common orthopedic procedures.

Dimensional Analysis of Shared Decision Making in Contraceptive Counseling

OBJECTIVE

To conduct a dimensional analysis to identify conceptual gaps around shared decision making (SDM) in reproductive health care and to refine the conceptual definition of SDM as related to contraceptive counseling.

DATA SOURCES

We identified source data through systematic searches of the CINAHL and PubMed databases.

STUDY SELECTION

We included peer-reviewed research and nonresearch articles that addressed contraceptive counseling for pregnancy prevention in the United States. We did not consider date of publication as an inclusion criterion. We included 35 articles in the final review.

DATA EXTRACTION

Using dimensional analysis, we extracted data to clarify the definition of SDM as a socially constructed concept that varies by perspective and context.

DATA SYNTHESIS

Data synthesis enabled us to compare SDM from patient and provider perspectives and to identify four primary dimensions of SDM that varied by context: Patient Preferences, Relationship, Provider Bias, and Clinical Suitability.

CONCLUSION

The four dimensions we identified illustrate the complexity and depth of SDM in contraceptive counseling encounters and broaden the definition of SDM to more than an encounter in which decision making incorporates clinician expertise and patient participation. We identified several assumptions that indicate the need for improved understanding that SDM is not a universal concept across perspectives and contexts. Most researchers in the included articles addressed the Patient Preferences dimension. Fewer considered the patient-provider relationship, the effect of provider bias, and the effect of specific clinical circumstances on SDM. We propose a conceptual map and model that can be used to refine the concepts that inform SDM and guide providers and researchers. Future research is needed to address the remaining gaps.

Patients Who Reviewed a Decision Aid Prior to Major Orthopaedic Surgery Reported Higher Trust in Their Surgeon

Background:

Decision aids (DAs) are utilized to ensure that patients are informed and involved in the decision-making process. Although DAs improve decision quality, other aspects of the decision-making process, such as trust and regret, are seldom measured. The objective of the present study was to determine whether patients given a DA prior to orthopaedic surgery had greater trust and lower regret at 6 months postoperatively.

Methods:

Consecutive patients were identified who underwent a hip or knee replacement or spine surgery from October 2018 to January 2020 and were subsequently surveyed at 6 months postoperatively. Outcomes included the Trust in the Surgical Decision and Decision Regret Scales. The primary analysis compared scores of patients who reviewed at least some of the DA to those who had not received or reviewed it. A sensitivity analysis compared patients with a DA order who reported reviewing it to those who did not. Multivariable models analyzed whether DA exposure predicted trust or regret. An exploratory mediation analysis examined the direct and indirect effects of DA exposure, including through the Shared Decision Making Process score.

Results:

The response rate was 56% (700 of 1,253). In the primary analysis, the proportion of patients who reported complete trust was 50.9% among those with no DA review and 63.8% among those with DA review (adjusted odds ratio, 1.62; 95% confidence interval, 1.11 to 2.36). A nonsignificant effect was observed comparing a DA order (59.9%) versus no DA order (51.4%; adjusted odds ratio, 1.30; 95% confidence interval, 0.80 to 2.11). Regret was unrelated to DA exposure. In the mediation analysis, 19.3% (95% confidence interval, 3.1% to 35.4%) of the effect of DA review on trust could be attributed to increased shared decision making.

Conclusions:

Patients who reviewed a DA prior to orthopaedic surgery reported higher trust in their surgeons.

Clinical Relevance:

Providing patients with a DA prior to orthopaedic surgery can improve trust in the surgeon. Improving trust between patients and surgeons may improve communication and help patients make better health decisions.

Validation of the SDM Process Scale to Evaluate Shared Decision-Making at Clinical Sites

The Shared Decision-Making (SDM) Process scale (scored 0-4) uses 4 questions about decision-making behaviors: discussion of options, pros, cons, and preferences. We use data from mail surveys of patients who made surgical decisions at 9 clinical sites and a national web survey to assess the reliability and validity of the measure to assess shared decision-making at clinical sites. Patients at sites using decision aids to promote shared decision-making for hip, knee, back, or breast cancer surgery had significantly higher scores than national cross-section samples of surgical patients for 3 of 4 comparisons and significantly higher scores for both comparisons with “usual care sites.” Reliability was supported by an intra-class correlation at the clinical site level of 0.93 and an average correlation of SDM scores for knee and hip surgery patients treated at the same sites of 0.56. The results document the reliability and validity of the measure to assess the degree of shared decision-making for surgical decisions at clinical sites.

Assessing the quality of shared decision making for elective orthopedic surgery across a large healthcare system: cross-sectional survey study

Background

Clinical guidelines recommend engaging patients in shared decision making for common orthopedic procedures; however, limited work has assessed what is occurring in practice. This study assessed the quality of shared decision making for elective hip and knee replacement and spine surgery at four network-affiliated hospitals.

Methods

A cross-sectional sample of 875 adult patients undergoing total hip or knee joint replacement (TJR) for osteoarthritis or spine surgery for lumbar herniated disc or lumbar spinal stenosis was selected. Patients were mailed a survey including measures of Shared Decision Making (SDMP scale) and Informed, Patient-Centered (IPC) decisions. We examined decision-making across sites, surgeons, and conditions, and whether the decision-making measures were associated with better health outcomes. Analyses were adjusted for clustering of patients within surgeons.

Results

Six hundred forty-six surveys (74% response rate) were returned with sufficient responses for analysis. Patients who had TJR reported lower SDMP scores than patients who had spine surgery (2.2 vs. 2.8; p < 0.001). Patients who had TJR were more likely to make IPC decisions (OA = 70%, Spine = 41%; p < 0.001). SDMP and IPC scores varied widely across surgeons, but the site was not predictive of SDMP scores or IPC decisions (all p > 0.09). Higher SDMP scores and IPC decisions were associated with larger improvements in global health outcomes for patients who had TJR, but not patients who had spine surgery.

Conclusions

Measures of shared decision making and decision quality varied among patients undergoing common elective orthopedic procedures. Routine measurement of shared decision making provides insight into areas of strength across these different orthopedic conditions as well as areas in need of improvement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04853-x.

Using Standardized Videos to Examine the Validity of the Shared Decision Making Process Scale: Results of a Randomized Online Experiment

BACKGROUND

The Shared Decision Making (SDM) Process scale is a brief, patient-reported measure of SDM with demonstrated validity in surgical decision making studies. Herein we examine the validity of the scores in assessing SDM for cancer screening and medication decisions through standardized videos of good-quality and poor-quality SDM consultations.

METHOD

An online sample was randomized to a clinical decision-colon cancer screening or high cholesterol-and a viewing order-good-quality video first or poor-quality video first. Participants watched both videos, completing a survey after each video. Surveys included the SDM Process scale and the 9-item SDM Questionnaire (SDM-Q-9); higher scores indicated greater SDM. Multilevel linear regressions identified if video, order, or their interaction predicted SDM Process scores. To identify how the SDM Process score classified videos, area under the curve (AUC) was calculated. The correlation between SDM Process score and SDM-Q-9 assessed construct validity. Heterogeneity analyses were conducted.

RESULTS

In the sample of 388 participants (68% white, 70% female, average age 45 years) good-quality videos received higher SDM Process scores than poor-quality videos (Ps < 0.001), and those who viewed the good-quality high cholesterol video first tended to rate the videos higher. SDM Process scores were related to SDM-Q-9 scores (rs > 0.58; Ps < 0.001). AUC was poor (0.69) for the high cholesterol model and fair (0.79) for the colorectal cancer model. Heterogeneity analyses suggested individual differences were predictive of SDM Process scores.

CONCLUSION

SDM Process scores showed good evidence of validity in a hypothetical scenario but were lacking in ability to classify good-quality or poor-quality videos accurately. Considerable heterogeneity of scoring existed, suggesting that individual differences played a role in evaluating good- or poor-quality SDM conversations.

Shared Decision-Making for Lung Cancer Screening: How Well Are We "Sharing"?

BACKGROUND

Lung cancer screening (LCS) reduces lung cancer mortality, but it also carries a range of risks. Shared decision-making (SDM) is a process of engaging patients in their health care decisions and is a vital component of LCS.

RESEARCH QUESTION

What is the quality of SDM among patients recently assessed for LCS?

STUDY DESIGN AND METHODS

Cross-sectional study of screened patients recruited from two academic tertiary care centers in the South Central Region of the United States. Self-reported surveys assessed patient demographics, values related to outcomes of LCS, knowledge, SDM components including receipt of educational materials, and decisional conflict.

RESULTS

Recently screened patients (n = 266) possessed varied LCS knowledge, answering an average of 41.4% of questions correctly. Patients valued finding cancer early over concerns about harms. Patients indicated that LCS benefits were presented to them by a health care provider far more often than harms (68.3% vs 20.8%, respectively), and 30.7% reported they received educational materials about LCS during the screening process. One-third of patients had some decisional conflict (33.6%) related to their screening decisions, whereas most patients (86.6%) noted that they were involved in the screening decision as much as they wanted. In multivariate models, non-White race and having less education were related to lower knowledge scores. Non-White patients and former smokers were more likely to be conflicted about the screening decision. Most patients (n = 227 [85.3%]) indicated that a health care provider had discussed smoking cessation or abstinence with them.

INTERPRETATION

Among recently screened patients, the quality of decision-making about LCS is highly variable. The low use of educational materials including decision aids and imbalance of conveying benefit vs risk information to patients is concerning. A structured approach using decision aids may assist with providing a balanced presentation of information and may improve the quality of SDM.

Development and Evaluation of the Shared Decision Making Process Scale: A Short Patient-Reported Measure

BACKGROUND

The Shared Decision Making (SDM) Process scale is a short patient-reported measure of the amount of SDM that occurs around a medical decision. SDM Process items have been used previously in studies of surgical decision making and exhibited discriminant and construct validity.

METHOD

Secondary data analysis was conducted across 8 studies of 11 surgical conditions with 3965 responses. Each study contained SDM Process items that assessed the discussion of options, pros and cons, and preferences. Item wording, content, and number of items varied, as did inclusion of measures assessing decision quality, decisional conflict (SURE scale), and regret. Several approaches for scoring, weighting, and the number of items were compared to identify an optimal approach. Optimal SDM Process scores were compared with measures of decision quality, conflict, and regret to examine construct validity; meta-analysis generated summary results.

RESULTS

Although all versions of the scale were highly correlated, a short, partial credit, equally weighted version of the scale showed favorable properties. Overall, higher SDM Process scores were related to higher decision quality (d = 0.18, P = 0.029), higher SURE scale scores (d = 0.57, P < 0.001), and lower decision regret (d = -0.34, P < 0.001). Significant heterogeneity was present in all validity analyses.

LIMITATIONS

Included studies all focused on surgical decisions, several had small sample sizes, and many were retrospective.

CONCLUSION

SDM Process scores showed resilience to coding changes, and a scheme using the short, partial credit, with equal weights was adopted. The SDM Process scores demonstrated a small, positive relationship with decision quality and were consistently related to lower decision conflict and less regret, providing evidence of validity across several surgical decisions.

Validation of the 3-item What Engagement Looks Like (WELL) scale in patients with diabetes

BACKGROUND

Patients' behaviors play a key role in chronic disease management, but how effective they are may depend on how engaged they feel. The objective was to develop a short measure of how much patients felt engaged in self-managing a chronic condition. Online test of a three-question series followed by a survey of physicians and their eligible diabetic patients. Physicians answered: 1) how well the physician thought the patient was managing his/her diabetes, and 2) how much effort the physician thought the patient was putting in. Each patient was mailed a survey that included three questions on self-management. Six hundred six patients from a national online consumer panel with diabetes or obesity, and 35 physicians from 3 primary care practices and a sample of 243 of their diabetic patients. Respondents were asked three questions about how much they thought their behavior could affect their health condition, how confident they were that they could do what was needed, and how involved they were in decisions about managing their condition. These items were summed to create a WELL score. Descriptive statistics and correlation coefficients were used to describe item relationships. Generalized Estimating Equations were used to predict how well the physician thought the patient was managing their diabetes and patient effort.

RESULTS

Correlations among the three patient-reported items ranged from - 0.01 to 0.45. The WELL score was correlated with an existing measure of patient activation commitment (r = .43, p < 0.001) and found to be a significant predictor of physicians' ratings of how much effort patients devoted to condition management (b = 0.02, p = 0.001, OR = 1.02) after adjusting for confounders. The WELL score didn't predict physicians' ratings of how effective patients were (b = 0.003, p = .526, OR = 1.004) after their A1c score had been taken into account.

CONCLUSION

Patients' WELL scores predicted physicians' ratings of patient effort in diabetes self-management.

New galaxies in the universe of shared decision-making and rheumatoid arthritis

PURPOSE OF REVIEW

Implementing shared decision-making (SDM) is a top international priority to improve care for persons living with rheumatoid arthritis. Using SDM tools, such as decision aids improve patients' knowledge and support communication with their clinicians on treatment benefits and risks. Despite calls for SDM in treat-to-target, studies demonstrating effective SDM strategies in rheumatology clinical practice are scarce. Our objective was to identify recent and relevant literature on SDM in rheumatoid arthritis.

RECENT FINDINGS

We found a burgeoning literature on SDM in rheumatoid arthritis that tackles issues of implementation. Studies have evaluated the SDM process within clinical consultations and found that uptake is suboptimal. Trials of newly developed patient decision aids follow high methodological standards, but large-scale implementation is lacking. Innovative SDM strategies, such as shared goals and preference phenotypes may improve implementation of treat-to-target approach. Research and patient engagement are standardizing measures of SDM for clinical uses.

SUMMARY

Uptake of SDM in rheumatoid arthritis holds promise in wider clinicians' and patients' awareness, availability of decision aids, and broader treat-to-target implementation strategies, such as the learning collaborative. Focused attention is needed on facilitating SDM among diverse populations and those at risk of poorer outcomes and barriers to communication.