Patient and provider perspectives on shared decision making: a systematic review of the peer-reviewed literature

People Living with Chronic Pain Experience a High Prevalence of Decision Regret in Canada: A Pan-Canadian Online Survey

Background(1) To estimate the prevalence of decision regret in chronic pain care, and (2) to identify factors associated with decision regret.DesignWe conducted a pan-Canadian cross-sectional online survey and reported the results following the Checklist for Reporting of Survey Studies guidelines. We recruited a sample of adults experiencing chronic noncancer pain. We used a stratified proportional random sampling based on the population and chronic pain prevalence of each province. We measured decision regret with the Decision Regret Scale (DRS) and decisional needs with the Ottawa Decision Support Framework. We performed descriptive analysis to estimate the prevalence and level of decision regret and multilevel multivariable regression analysis to identify factors associated with regret according to the STRengthening Analytical Thinking for Observational Studies recommendations.ResultsWe surveyed 1,649 people living with chronic pain, and 1,373 reported a most difficult decision from the 10 prespecified ones, enabling the collection of a DRS score. On a scale ranging from 0 to 100 where 1 reflects the presence of decision regret and 25 constitutes important decision regret, the mean DRS score in our sample was 28.8 (s = 19.6). Eighty-four percent of respondents experienced some decision regret and 50% at an important level. We identified 15 factors associated with decision regret, including 4 personal and 9 decision-making characteristics, and 2 consequences of the chosen option. Respondents with low education level and higher decisional conflict experienced more decision regret when the decision was deemed difficult.ConclusionsThis pan-Canadian survey highlighted a high prevalence and level of decision regret associated with difficult decisions for pain care. Decision making in pain care could be enhanced by addressing factors that contribute to decision regret.HighlightsWe conducted an online pan-Canadian survey and collected responses from a wide diversity of people living with chronic pain.More than 84% of respondents experienced decision regret and approximately 50% at an important level.We identified 15 factors associated with decision regret, including 4 personal and 9 decision-making characteristics, and 2 consequences of the chosen option.Our pan-Canadian survey reveals an urgent need of a shared decision-making approach in chronic pain care that can be potentiated by targeting multiple factors associated with decision regret.

Are Patient-Centered Care, Healthcare Consumerism, and Trust in Physicians Compatible?: Positioning Analysis of the Patient-Provider Relationship

Patient-centered care and healthcare consumerism are dominant models of the patient-provider relationship. Positioning theory was applied to examine consumers' and physicians' positions on patient-centered care and healthcare consumerism, along with their attitudes toward direct-to-consumer healthcare service advertising and trust in the medical profession. Surveys were conducted with a convenience sample of consumers and physicians respectively. Patient-centered care was the only theoretical construct that both consumers and physicians unequivocally embraced. Both groups were either ambivalent or skeptical of the other three concepts. Between the two groups, physicians exhibited a stronger endorsement of patient-centered care and more negative attitudes toward advertising than consumers. When the relationships among the theoretical constructs were examined, a negative correlation between patient-centered care and consumerism was found among consumers. Also, patient-centered care and trust were negatively correlated in both groups. Implications of these findings are discussed for strategic communication, consumer and physician education, and future research.

Ethics of Nudging in the COVID-19 Crisis and the Necessary Return to the Principles of Shared Decision Making: A Critical Review

Nudging, a controversial technique for modifying people's behavior in a predictable way, is claimed to preserve freedom of choice while simultaneously influencing it. Nudging had been largely confined to situations such as promoting healthy eating choices but has been employed in the coronavirus disease 2019 (COVID-19) crisis in a shift towards measures that involve significantly less choice, such as shoves and behavioral prods. Shared decision making (SDM), a method for direct involvement and autonomy, is an alternative approach to communicate risk. Predominantly peer-reviewed scientific publications from standard literature databases like PubMed, PsycInfo, and Psyndex were evaluated in a narrative review. The so-called fear nudges, as well as the dissemination of strongly emotionalizing or moralizing messages can lead to intense psycho-physical stress. The use of these nudges by specialized units during the COVID-19 pandemic generated a societal atmosphere of fear that precipitated a deterioration of the mental and physical health of the population. Major recommendations of the German COVID-19 Snapshot Monitoring (COSMO) study, which are based on elements of nudging and coercive measures, do not comply with ethical principles, basic psychological principles, or evidence-based data. SDM was misused in the COVID-19 crisis, which helped to achieve one-sided goals of governments. The emphasis on utilitarian thinking is criticized and the unethical behavior of decision makers is explained by both using the concept of moral disengagement and the maturity level of coping strategies. There should be a return to an open-ended, democratic, and pluralistic scientific debate without using nudges. It is therefore necessary to return to the origins of SDM.

Shared decision-making in scaling and root planing

INTRODUCTION

Estimate proportion of various approaches used by dental hygienists for engaging patients in decisions commonly arising during scaling and root planing. Distribution of approaches was compared across various task components in this procedure, practice experience of dental hygienists and patient compliance.

MATERIALS AND METHODS

Survey of graduates from and students in a baccalaureate dental hygiene program.

RESULTS

Paternalism (tell then do) and informed consent (give choices and reasons and ask for permission) were more common than shared decision-making (discuss alternatives, solicit patient input and arrive at a mutual decision) and disengagement (patient refusing offered service or avoiding further involvement) by a ratio of 4 to 1 for the first 2 compared with the latter 2. This relationship was held across selecting treatment, procedural adjuncts, homecare instructions and financial arrangements. Dental hygienists exhibited a range of personal preferences for engagement approaches. No-show rate, patient disengagement outside the office, was high (20%).

CONCLUSION

Dental hygienists reported using 'more controlled' approaches to engaging patients in decisions regarding treatment. Patients may prefer to engage in more shared decisions and choose this approach by staying away from the office. This may underestimate patients' decisions to stay away from treatment, for example by not showing for completion of the treatment or disregarding homecare routines.

Development of an adjective-selection measure evaluating clinicians' attitudes towards using patient decision aids: The ADOPT measure

BACKGROUND

The implementation of shared decision-making and patient decision aids (PDAs) is impeded by clinicians' attitudes.

OBJECTIVE

To develop a measure of clinician attitude towards PDAs.

METHODS

To develop the ADOPT measure, we used four stages, culminating in measure responses by medically qualified clinicians, 25 from each of the following specialties: emergency medicine, family medicine, oncology, obstetrics and gynaecology, orthopaedics, and psychiatry. To assess validity, we also posed three questions to assess the participants' attitudinal and behavioural endorsement of PDAs. Allocating a point per adjective, we calculated the sum as well as positive and negative scores. We used univariate logistic regression to determine associations between the scores and attitudinal or behavioural endorsements.

RESULTS

152 clinicians completed the measure. 'Time-saving' (39%) and 'easy' (34%) were the most frequently selected adjectives. 'Time-consuming' and 'unfamiliar' were the most frequently selected negative adjectives (both 19%). The sum scores were significantly associated with behavioural endorsement of PDAs.

DISCUSSION

Clinicians were able to respond to adjective-selection methods and the ADOPT measure could help assess clinician attitudes to PDAs. Validation will require further research.

PRACTICE IMPLICATIONS

The ADOPT measure could help identify the extent and source of attitudinal resistance.

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.

Italian Consensus Statement on Patient Engagement in Chronic Care: Process and Outcomes

Patient engagement has been recognized as a key priority in chronic care. However, scholars agree that guidelines are needed to ensure effective patient engagement strategies. To this end, a Consensus Conference process was promoted with the following methodological steps: (1) extensive literature review about patient engagement initiatives in chronic care; (2) a stakeholders survey to collect best practices and (3) workshops with experts. On the basis of the information collected, a consensus statement was drafted, revised, and finalized by a panel of select renowned experts. These experts agreed in defining engagement as an eco-systemic concept involving multiple actors all of which contribute to influence patients’ willingness and ability to engage in chronic care. Moreover, experts recommended, whenever possible, to adopt standardized instruments to assess engagement levels and related unmet needs. Then, experts strongly advised appropriate trainings for healthcare professionals about patient engagement strategies. Furthermore, the importance of promoting healthcare professionals’ wellbeing has been advocated. Family caregivers, as well as patients’ organizations - should be trained and engaged to increase the effectiveness of interventions dedicated to patients. Finally, experts agreed that digital technologies should be considered as a crucial enhancer for patient engagement in chronic care.

Factor Analysis and Psychometric Properties Adaption of Chinese Version of the Decisional Engagement Scale (DES-10)

OBJECTIVE

To translate and validate the DES-10 into Chinese and adapt the DES-10 among Chinese prostate cancer patients. To explore the impact of demographic data on the SDM of Chinese prostate cancer patients.

METHODS

Data were collected from December 2019 to January 2020 from four hospitals among prostatic cancer patients in Henan Province, by convenience sampling method. A demographic questionnaire, DES-10, and 9-item Shared Decision Making Questionnaire (SDM-Q-9) were administered. The exploratory and confirmatory factor analysis was carried out to test the content, construct, reliability, and concurrent validity of the translated DES-10. Then, Pearson's correlation, t-test, and analysis of variance were used to test the demographic difference of DES-10.

RESULTS

A total of 380 prostatic cancer patients completed the survey (96% response rate). The total score of DES-10 was 71.16±17.14. The Cronbach's ɑ coefficient was 0.87. Single factor structure was confirmed by exploratory factor analysis (explaining 50.14% of the variance). Model fitting indexes (RMSEA=0.07, CMIN/DF=2.92) were acceptable. The DES-10 scale showed good validity with the SDM-Q-9 as the criterion. Age, marital status, homeplace, and household monthly income could affect the shared decision-making of prostatic cancer patients.

CONCLUSION

The DES-10 was demonstrated to be a valid and reliable scale to assess the prostatic cancer patient's engagement in health care decision-making. And it is culturally appropriate for use in China. The influence of age, marital status, homeplace, and household monthly income should be considered in promoting patients' participation in shared decision-making.

Collaboration and Satisfaction About Care Decisions in Team questionnaire-Psychometric testing of the Norwegian version, and hospital healthcare personnel perceptions across hospital units

AIM

To translate "The Collaboration and Satisfaction About Care Decisions in Team" questionnaire (CSACD-T) into Norwegian and test it for psychometric properties. The further aim was to describe and compare healthcare personnel's collaboration and satisfaction about team decision-making (TDM) across hospital units.

DESIGN

A cross-sectional study.

METHODS

The questionnaire was translated into Norwegian. A total of 247 healthcare personnel at two hospitals responded to the questionnaire. An explorative factor analysis was performed to test the factor structure of the questionnaire, while a Cronbach's alpha analysis was used to test for internal consistency. A one-way ANOVA analysis and a Kruskal-Wallis test were applied to test for differences between hospital units.

RESULTS

The results demonstrate that the Norwegian version of the CSACD-T has promising psychometric properties regarding construct validity and internal consistency. The mean score of the CSACD-T was significantly higher in the maternity ward group than in the emergency room group.

The impact of DECISION+2 on patient intention to engage in shared decision making: secondary analysis of a multicentre clustered randomized trial

BACKGROUND

Training health professionals in shared decision making (SDM) may influence their patients' intention to engage in SDM.

OBJECTIVE

To assess the impact of DECISION+2, a SDM training programme for family physicians about the use of antibiotics to treat acute respiratory infections (ARIs), on their patients' intention to engage in SDM in future consultations.

DESIGN

Secondary analysis of a multicentre clustered randomized trial.

SETTING AND PARTICIPANTS

Three hundred and fifty-nine patients consulting family physicians about an ARI in nine family practice teaching units (FPTUs).

INTERVENTION

DECISION+2 (two-hour online tutorial, two-hour workshop, and decision support tools) was offered in the experimental group (five FPTUs, 162 physicians, 181 patients). Usual care was provided in the control group (four FPTUs, 108 physicians, 178 patients).

OUTCOME MEASURE

Change in patients' intention scores (range -3 to +3) between pre- and post-consultation.

RESULTS

The mean ± SD [median] scores of intention to engage in SDM were high in both study groups before consultation (DECISION+2 group: 1.4 ± 1.0 [1.7]; control group: 1.5 ± 1.1 [1.7]) and increased in both groups after consultation (DECISION+2 group: 2.1 ± 1.1 [2.7]; control group: 1.9 ± 1.2 [2.3]). Change of intention, classified as either increased, stable or decreased, was not statistically associated with the exposure to the DECISION+2 programme after adjusting for the cluster design (proportional odds ratio = 1.5; 95% confidence interval = 0.8-3.0).

CONCLUSION

DECISION+2 had no significant impact on patients' intention to engage in SDM for choosing to use antibiotics or not to treat an ARI in future consultations. Patient-targeted interventions may be necessary to achieve this purpose.

Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument

BACKGROUND

We have no clear overview of the extent to which health-care providers involve patients in the decision-making process during consultations. The Observing Patient Involvement in Decision Making instrument (OPTION) was designed to assess this.

OBJECTIVE

To systematically review studies that used the OPTION instrument to observe the extent to which health-care providers involve patients in decision making across a range of clinical contexts, including different health professions and lengths of consultation.

SEARCH STRATEGY

We conducted online literature searches in multiple databases (2001-12) and gathered further data through networking.

INCLUSION CRITERIA

(i) OPTION scores as reported outcomes and (ii) health-care providers and patients as study participants. For analysis, we only included studies using the revised scale.

DATA EXTRACTION

Extracted data included: (i) study and participant characteristics and (ii) OPTION outcomes (scores, statistical associations and reported psychometric results). We also assessed the quality of OPTION outcomes reporting.

MAIN RESULTS

We found 33 eligible studies, 29 of which used the revised scale. Overall, we found low levels of patient-involving behaviours: in cases where no intervention was used to implement shared decision making (SDM), the mean OPTION score was 23 ± 14 (0-100 scale). When assessed, the variables most consistently associated with higher OPTION scores were interventions to implement SDM (n = 8/9) and duration of consultations (n = 8/15).

CONCLUSIONS

Whatever the clinical context, few health-care providers consistently attempt to facilitate patient involvement, and even fewer adjust care to patient preferences. However, both SDM interventions and longer consultations could improve this.