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Simons M, Fisher G, Spanos S, Zurynski Y, Davidson A, Stoodley M, Rapport F, Ellis LA. Integrating training in evidence-based medicine and shared decision-making: a qualitative study of junior doctors and consultants. BMC Med Educ 2024; 24:418. [PMID: 38637798 PMCID: PMC11027546 DOI: 10.1186/s12909-024-05409-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 04/09/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND In the past, evidence-based medicine (EBM) and shared decision-making (SDM) have been taught separately in health sciences and medical education. However, recognition is increasing of the importance of EBM training that includes SDM, whereby practitioners incorporate all steps of EBM, including person-centered decision-making using SDM. However, there are few empirical investigations into the benefits of training that integrates EBM and SDM (EBM-SDM) for junior doctors, and their influencing factors. This study aimed to explore how integrated EBM-SDM training can influence junior doctors' attitudes to and practice of EBM and SDM; to identify the barriers and facilitators associated with junior doctors' EBM-SDM learning and practice; and to examine how supervising consultants' attitudes and authority impact on junior doctors' opportunities for EBM-SDM learning and practice. METHODS We developed and ran a series of EBM-SDM courses for junior doctors within a private healthcare setting with protected time for educational activities. Using an emergent qualitative design, we first conducted pre- and post-course semi-structured interviews with 12 junior doctors and thematically analysed the influence of an EBM-SDM course on their attitudes and practice of both EBM and SDM, and the barriers and facilitators to the integrated learning and practice of EBM and SDM. Based on the responses of junior doctors, we then conducted interviews with ten of their supervising consultants and used a second thematic analysis to understand the influence of consultants on junior doctors' EBM-SDM learning and practice. RESULTS Junior doctors appreciated EBM-SDM training that involved patient participation. After the training course, they intended to improve their skills in person-centered decision-making including SDM. However, junior doctors identified medical hierarchy, time factors, and lack of prior training as barriers to the learning and practice of EBM-SDM, whilst the private healthcare setting with protected learning time and supportive consultants were considered facilitators. Consultants had mixed attitudes towards EBM and SDM and varied perceptions of the role of junior doctors in either practice, both of which influenced the practice of junior doctors. CONCLUSIONS These findings suggested that future medical education and research should include training that integrates EBM and SDM that acknowledges the complex environment in which this training must be put into practice, and considers strategies to overcome barriers to the implementation of EBM-SDM learning in practice.
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Affiliation(s)
- Mary Simons
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia.
- Australian Institute of Health Innovation, 75 Talavera Rd, Macquarie Park, NSW, 2109, Australia.
| | - Georgia Fisher
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Samantha Spanos
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Yvonne Zurynski
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Andrew Davidson
- Department of Neurosurgery, The Royal Melbourne Hospital, Parkville, VIC, 3050, Australia
| | - Marcus Stoodley
- Department of Clinical Medicine, Macquarie University, Sydney, NSW, 2109, Australia
| | - Frances Rapport
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Louise A Ellis
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
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Waddell A, Goodwin D, Spassova G, Sampson L, Candy A, Bragge P. "We will be the ones bearing the consequences": A qualitative study of barriers and facilitators to shared decision-making in hospital-based maternity care. Birth 2024. [PMID: 38270268 DOI: 10.1111/birt.12812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 12/15/2023] [Accepted: 12/21/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Pregnant women involved in decisions about their care report better health outcomes for themselves and their children. Shared decision-making (SDM) is a priority for health services; however, there is limited research on factors that help and hinder SDM in hospital-based maternity settings. The purpose of this study was to explore barriers and facilitators to SDM in a large tertiary maternity care service from the perspectives of multiple stakeholders. METHODS Qualitative semi-structured interviews were undertaken with 39 participants including women, clinicians, health service administrators and decision-makers, and government policymakers. The interview guide and thematic analysis were based on the Theoretical Domains Framework to identify barriers and facilitators to SDM. RESULTS Women expect to be included in decisions about their care. Health service administrators and decision-makers, government policymakers, and most clinicians want to include them in decisions. Key barriers to SDM included lack of care continuity, knowledge, and clinician skills, as well as professional role and decision-making factors. Key facilitators pertained to policy and guideline changes, increased knowledge, professional role factors, and social influences. CONCLUSION This study revealed common barriers and facilitators to SDM and highlighted the need to consider perspectives outside the patient-clinician dyad. It adds to the limited literature on barriers and facilitators to SDM in hospital care settings. Organizational- and system-wide changes to service delivery are necessary to facilitate SDM. These changes may be enabled by education and training, changes to policies and guidelines to include and support SDM, and adequately timed information provision to enable SDM conversations.
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Affiliation(s)
- Alex Waddell
- Safer Care Victoria, Victorian Department of Health, Melbourne, Victoria, Australia
- Monash Sustainable Development Institute, Monash University, Clayton, Victoria, Australia
| | - Denise Goodwin
- BehaviourWorks Australia, Monash University, Clayton, Victoria, Australia
| | - Gerri Spassova
- Department of Marketing, Monash Business School, Caulfield East, Victoria, Australia
| | | | - Alix Candy
- Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Peter Bragge
- Monash Sustainable Development Institute Evidence Review Service, Monash University, Clayton, Victoria, Australia
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Shankar KN, Li A. Older Adult Falls in Emergency Medicine, 2023 Update. Clin Geriatr Med 2023; 39:503-518. [PMID: 37798062 DOI: 10.1016/j.cger.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Of 4 older adults, 1 will fall each year in the United States. Based on 2020 data from the Centers of Disease Control, about 36 million older adults fall each year, resulting in 32,000 deaths. Emergency departments see about 3 million older adults for fall-related injuries with falls having the ability to cause serious injury such as catastrophic head injuries and hip fractures. One-third of older fall patients discharged from the ED experience one of these outcomes at 3 months.
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Affiliation(s)
- Kalpana N Shankar
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Neville House, Boston, MA 02115, USA.
| | - Angel Li
- Department of Emergency Medicine, The Ohio State University, 376 West 10th Avenue, Columbus, OH 43210, USA
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Warner BE, Lound A, Grailey K, Vindrola-Padros C, Wells M, Brett SJ. Perspectives of healthcare professionals and older patients on shared decision-making for treatment escalation planning in the acute hospital setting: a systematic review and qualitative thematic synthesis. EClinicalMedicine 2023; 62:102144. [PMID: 37588625 PMCID: PMC10425683 DOI: 10.1016/j.eclinm.2023.102144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/18/2023] [Accepted: 07/24/2023] [Indexed: 08/18/2023] Open
Abstract
Background Shared Decision-Making (SDM) between patients and clinicians is increasingly considered important. Treament Escalation Plans (TEP) are individualised documents outlining life-saving interventions to be considered in the event of clinical deterioration. SDM can inform subjective goals of care in TEP but it remains unclear how much it is considered beneficial by patients and clinicians. We aimed to synthesise the existing knowledge of clinician and older patient (generally aged ≥65 years) perspectives on patient involvement in TEP in the acute setting. Methods Systematic database search was performed in MEDLINE, EMBASE, PsycInfo and CINAHL databases as well as grey literature from database inception to June 8, 2023, using the Sample (older patients, clinicians, acute setting; studies relating to patients whose main diagnosis was cancer or single organ failure were excluded as these conditions may have specific TEP considerations), Phenomenon of Interest (Treatment Escalation Planning), Design (any including interview, observational, survey), Evaluation (Shared Decision-Making), Research type (qualitative, quantitative, mixed methods) tool. Primary data (published participant quotations, field notes, survey results) and descriptive author comments were extracted and qualitative thematic synthesis was performed to generate analytic themes. Quality assessment was made using the Critical Appraisal Skills Programme and Mixed Methods Appraisal Tools. The GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research) approach was used to assess overall confidence in each thematic finding according to methodology, coherence, adequacy and relevance of the contributing studies. The study protocol was registered on PROSPERO, CRD42022361593. Findings Following duplicate exclusion there were 1916 studies screened and ultimately 13 studies were included, all from European and North American settings. Clinician-orientated themes were: treatment escalation is a medical decision (high confidence); clinicians want the best for their patients amidst uncertainty (high confidence); involving patients and families in decisions is not always meaningful and can involve conflict (high confidence); treatment escalation planning exists within the clinical environment, organisation and society (moderate confidence). Patient-orientated themes were: patients' relationships with Treatment Escalation Planning are complex (low confidence); interactions with doctors are important but communication is not always easy (moderate confidence); patients are highly aware of their families when considering TEP (moderate confidence). Interpretation Based on current evidence, TEP decisions appear dominated by clinicians' perspectives, motivated by achieving the best for patients and challenged by complex decisions, communication and environmental factors; older patients' perspectives have seldom been explored, but their input on decisions may be modest. Presenting the context and challenge of SDM during professional education may allow reflection and a more nuanced approach. Future research should seek to understand what approach to TEP decision-making patients and clinicians consider to be optimum in the acute setting so that a mutually acceptable standard can be defined in policy. Funding HCA International and the NIHR Imperial Biomedical Research Centre.
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Affiliation(s)
- Bronwen E. Warner
- Division of Anaesthetics, Pain Management and Intensive Care, Department of Surgery and Cancer, Imperial College London, UK
| | - Adam Lound
- Patient Experience Research Centre, School of Public Health, Imperial College London, London, UK
| | - Kate Grailey
- Centre for Health Policy, Institute for Global Health Innovation, Department of Surgery and Cancer, Imperial College London, UK
| | | | - Mary Wells
- Department of Surgery and Cancer, Imperial College London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Stephen J. Brett
- Division of Anaesthetics, Pain Management and Intensive Care, Department of Surgery and Cancer, Imperial College London, UK
- Department of Intensive Care Medicine, Imperial College Healthcare NHS Trust London, London, UK
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Rasmussen MLT, Lomborg K, Konradsen H. Patient involvement in decisions about discharge from the emergency department: A qualitative interview study of the healthcare professionals' experiences. Int Emerg Nurs 2023; 69:101307. [PMID: 37267846 DOI: 10.1016/j.ienj.2023.101307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/21/2023] [Accepted: 05/03/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Patients in the emergency department are less involved in making decisions than they would like to be. Involving patients improves health-related outcomes, but success depends on the healthcare professional's ability to act in a patient-involving manner, and therefore more knowledge is needed about the healthcare professional's perspective of involving patients in the decisions. AIM To explore what challenges healthcare professionals experience in their daily practice regarding patient involvement in decisions when planning discharge from the emergency department. METHOD Five focus group interviews were conducted with nurses and physicians. The data were analyzed using content analysis. FINDINGS The healthcare professionals described how they experienced that there is no choice to offer the patients in the clinical practice. First, they had to manage the department's routines, which directed them to focus on acute needs and avoid overcrowding. Second, it was too difficult to navigate the diversity of patients with different characteristics. Third, they wanted to guard the patient from a lack of genuine options. CONCLUSION The healthcare professionals experienced patient involvement as incompatible with professionalism. If patient involvement is to be practiced, then new initiatives are needed to improve the conversation with the individual patient about decisions regarding their discharge.
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Affiliation(s)
| | - Kirsten Lomborg
- Department of Clinical Research, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, 2730 Herlev, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen N, Denmark.
| | - Hanne Konradsen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen N, Denmark; Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, 171 77 Stockholm, Sweden; Department of Gastroenterology, Copenhagen University Hospital - Herlev and Gentofte, 2750 Herlev, Denmark.
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van der Horst DEM, Garvelink MM, Bos WJW, Stiggelbout AM, Pieterse AH. For which decisions is Shared Decision Making considered appropriate? - A systematic review. Patient Educ Couns 2023; 106:3-16. [PMID: 36220675 DOI: 10.1016/j.pec.2022.09.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/26/2022] [Accepted: 09/26/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To identify decision characteristics for which SDM authors deem SDM appropriate or not, and what arguments are used. METHODS We applied two search strategies: we included SDM models from an earlier review (strategy 1) and conducted a new search in eight databases to include papers other than describing an SDM model, such as original research, opinion papers and reviews (strategy 2). RESULTS From the 92 included papers, we identified 18 decision characteristics for which authors deemed SDM appropriate, including preference-sensitive, equipoise and decisions where patient commitment is needed in implementing the decision. SDM authors indicated limits to SDM, especially when there are immediate life-saving measures needed. We identified four decision characteristics on which authors of different papers disagreed on whether or not SDM is appropriate. CONCLUSION The findings of this review show the broad range of decision characteristics for which authors deem SDM appropriate, the ambiguity of some, and potential limits of SDM. PRACTICE IMPLICATIONS The findings can stimulate clinicians to (re)consider pursuing SDM in situations in which they did not before. Additionally, it can inform SDM campaigns and educational programs as it shows for which decision situations SDM might be more or less challenging to practice.
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Affiliation(s)
- Dorinde E M van der Horst
- St. Antonius Hospital, Department of Internal Medicine, Nieuwegein, the Netherlands; Santeon, Utrecht, the Netherlands; Leiden University Medical Centre, Department of Internal Medicine, Leiden, the Netherlands.
| | - Mirjam M Garvelink
- St. Antonius Hospital, Department of Value Based Healthcare, Nieuwegein, the Netherlands
| | - Willem Jan W Bos
- St. Antonius Hospital, Department of Internal Medicine, Nieuwegein, the Netherlands; Leiden University Medical Centre, Department of Internal Medicine, Leiden, the Netherlands
| | - Anne M Stiggelbout
- Leiden University Medical Centre, Department of Biomedical Data Sciences, Leiden, the Netherlands; Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Arwen H Pieterse
- Leiden University Medical Centre, Department of Biomedical Data Sciences, Leiden, the Netherlands
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Burstein DS, Chretien KC, Puchalski C, Teufel K, Aivaz M, Kaboff A, Tuck MG. Internal Medicine Residents' Experience Performing Routine Assessment of What Matters Most to Patients Upon Hospital Admission. Teach Learn Med 2023; 35:83-94. [PMID: 35067146 DOI: 10.1080/10401334.2021.2018696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 11/24/2021] [Indexed: 06/14/2023]
Abstract
PROBLEM Failure to elicit patients' values, goals, and priorities can result in missed opportunities to provide patient-centered care. Little is known about resident physicians' direct experience of eliciting patients' values, goals, and priorities and integrating them into routine hospital care. INTERVENTION In 2017, we asked resident physicians on general internal medicine wards rotations to elicit and document a "Personal History" from patients upon hospital admission, in addition to a traditional social history. We defined a Personal History as documenting "what matters most to the patient and why." The purpose of the Personal History was to understand and consider patients' values, goals, and priorities. We then conducted qualitative interviews of the resident physicians to understand their experiences eliciting and integrating patients' values, goals, and priorities in routine hospital care. CONTEXT We performed this exploratory intervention at a large high-volume urban hospital. Two teams from general medicine wards participated in the Personal History intervention. We conducted voluntary interviews of eligible residents (n = 14/15; 93%) about their experience after they completed their general wards rotations. Using the coproduction model, our aim was to explore how patients' self-expertise can be combined with physicians' medical expertise to achieve patient-centered care. IMPACT Four major themes were identified: 1) Taking a Personal History had value, and eliciting patients' self-expertise had the potential to change medical decision making, 2) Situational and relational factors created barriers to obtaining a Personal History, 3) Variability in buy-in with the proposed intervention affected effort, and 4) Meaningful Personal History taking could be an adaptive and longitudinal process. Perceived benefits included improved rapport with patients, helpful for patients with complex medical history, and improved physician-patient communication. Barriers included patient distress, lack of rapport, and responses from patients which did not add new insights. Accountability from attending physicians affected resident effort. Suggested future applications were for patients with serious illness, integration into electronic health records, and skills taught in medical education. LESSONS LEARNED Resident physicians had generally positive views of eliciting a Personal History from patients upon admission to the hospital. Overall, many residents conveyed the perceived ability to elicit and consider patient's values, goals, and priorities in certain situations (e.g., patient not in distress, adequate rapport, lack of competing priorities such as medical emergencies or overwhelming workloads). External factors, such as electronic health record design and accountability from attending physicians, may further promote residents' efforts to routinely incorporate patients' values, goals, and priorities in clinical care. Increasing familiarity among both resident physicians and patients in routinely discussing patients' values, goals, and priorities may facilitate patient-centered practice.
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Affiliation(s)
- David S Burstein
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Katherine C Chretien
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christina Puchalski
- Department of Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Karolyn Teufel
- Department of Internal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Marudeen Aivaz
- General Surgery, Northwell Health, New York, New York, USA
| | - Austin Kaboff
- Internal Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Matthew G Tuck
- Department of Medicine, The George Washington University School of Medicine and Health Sciences, Veterans Affairs Medical Center, Washington, DC, USA
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Galletta M, Piazza MF, Meloni SL, Chessa E, Piras I, Arnetz JE, D’Aloja E. Patient Involvement in Shared Decision-Making: Do Patients Rate Physicians and Nurses Differently? Int J Environ Res Public Health 2022; 19:14229. [PMID: 36361109 PMCID: PMC9656720 DOI: 10.3390/ijerph192114229] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/23/2022] [Accepted: 10/27/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Shared decision-making implies that patients and healthcare professionals make decisions together about clinical exams, available treatments, choice of options, and the benefit or downside of every choice. Patients involved in the shared decision-making process are more compliant with treatments and have a reduced risk of complications related to the pathology. In Italy, patient involvement in caring processes is still barely investigated. AIM To investigate patients' perceptions about shared decision-making with physicians and nurses, respectively, and to examine the relationship between shared decision-making and patient satisfaction and perceived quality of care/treatment. METHODS The study was performed between March and June 2019 in two wards of one Italian hospital. A questionnaire was administered to inpatients at the time of admission and again at discharge, including demographic information and measurement scales regarding patient involvement in shared decision-making, patient satisfaction, and perceived quality of treatment/care. RESULTS A total of 151 out of 301 patients completed questionnaires at both admission and discharge. Patients' scores for shared decision-making (information, patient needs, treatment planning) were significantly different for physicians and nurses. At both admission and discharge, patients rated shared decision-making significantly higher for physicians compared to nurses, while there were no differences in their satisfaction ratings. Patient ratings of physicians did not change from admission (information: mean (M) = 3.50, standard deviation (SD) = 0.81; patient need: M = 3.05, SD = 1.05; treatment planning: M = 2.75, SD = 1.23) to discharge (information: M = 3.50, SD = 0.79; patient need: M = 3.17, SD = 1.02; treatment planning: M = 2.66, SD = 1.23) (p = 0.924, p = 0.098, p = 0.293, respectively), but patients' ratings of nurses' behavior increased significantly from admission (information: M = 2.44, SD = 1.23; patient need: M = 2.27, SD = 1.17; treatment planning: M = 2.12, SD = 1.19) to discharge (information: M = 2.62, SD = 1.22; patient need: M = 2.53, SD = 1.24; treatment planning: M = 2.35, SD = 1.21) (p = 0.019, p = 0.001, p = 0.003, respectively). Attention to patients' needs was the key determinant of both satisfaction with nurses (OR = 3.65, 95% CI = 1.31-10.14, p = 0.013) and perceived quality of care (OR = 3.97, 95% CI = 1.49-10.55, p = 0.006). Providing appropriate information about disease progress and treatments was a key determinant of both satisfaction with physicians (OR = 19.75, 95% CI = 7.29-53.55, p < 0.001) and perceived quality of treatment (OR = 8.03, 95% CI = 3.25-19.81, p < 0.001). DISCUSSION Nurses should be sensitized to involving patients in the decision-making process, especially upon hospital admission. Specific training about effective communication techniques can be implemented to manage relationships with patients in different caring situations. Practical implications and future directions are discussed.
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Affiliation(s)
- Maura Galletta
- Department of Medical Sciences and Public Health, University of Cagliari, 09100 Cagliari, Italy
| | | | - Stefania Luisa Meloni
- Department of Medical Sciences and Public Health, University of Cagliari, 09100 Cagliari, Italy
| | - Elsa Chessa
- Intensive Care Unit, Binaghi Hospital, ASL Cagliari, 09100 Cagliari, Italy
| | - Ilenia Piras
- Emergency Department, SS. Trinità Hospital, ASL Cagliari, 09100 Cagliari, Italy
| | - Judith E. Arnetz
- Department of Family Medicine, Michigan State University, Grand Rapids, MI 48824, USA
| | - Ernesto D’Aloja
- Department of Medical Sciences and Public Health, University of Cagliari, 09100 Cagliari, Italy
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Koyama T, Nawa N, Itsui Y, Okada E, Fujiwara T. Facilitators and barriers to implementing shared decision making: A cross-sectional study of physicians in Japan. Patient Educ Couns 2022; 105:2546-2556. [PMID: 35184910 DOI: 10.1016/j.pec.2022.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 12/13/2021] [Accepted: 01/25/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Shared decision making (SDM) is a collaborative process in which patients and healthcare providers jointly make a medical decision. This cross-sectional study aimed to identify the facilitators and barriers to self-reported implementation of SDM in Japan, and to explore if there is effect modification by hospital types. METHODS A total of 129 physicians in Japan completed a questionnaire that asked about their perception of SDM based on SDM-Q-Doc and its facilitators and barriers, which corresponded to each construct of the integrated behavioral model (IBM). The association between facilitators and barriers and SDM-Q-doc score was assessed using linear regression analysis. Stratified analysis by hospital types was also performed. RESULTS Significant facilitators included physicians' attitude, injunctive norm, intention and habit. Significant barriers included physicians' unfavorable attitude, lack of self-efficacy, knowledge, salience and experience. Moreover, experiential attitude (concerning patient characteristics), injunctive norm (concerning patient preferences), and physician's habit were significant facilitators for physicians working in university hospitals when compared to those working in municipal hospitals. CONCLUSION The facilitators and barriers to implementing SDM in Japan were identified. PRACTICE IMPLICATIONS More opportunities for training on SDM are needed to provide knowledge and skills, which will enhance salience and contribute their habitual practice.
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Affiliation(s)
- Teruchika Koyama
- Professional Development Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nobutoshi Nawa
- Professional Development Center, Tokyo Medical and Dental University, Tokyo, Japan; Department of Medical Education Research and Development, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuhiro Itsui
- Professional Development Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Eriko Okada
- Professional Development Center, Tokyo Medical and Dental University, Tokyo, Japan; Department of Medical Education Research and Development, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takeo Fujiwara
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan.
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Tang C, Wang A, Yan J. Exploring motivations and resistances for implementing shared decision-making in clinical practice: A systematic review based on a structure-process-outcome model. Health Expect 2022; 25:1254-1268. [PMID: 35662361 PMCID: PMC9327808 DOI: 10.1111/hex.13541] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 04/22/2022] [Accepted: 05/17/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Shared decision-making (SDM) as a multicollaborative approach is vital for facilitating patient-centred care. Considering the limited clinical practice, we attempted to synthesize the motivations and resistances, and investigate their mutual relationships for advancing the implementation of SDM. METHODS A comprehensive systematic review using Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines was performed. 'Shared decision making' was searched as the mesh term through PubMed, Web of Science and EBSCO from 2000 to 2021, and the quality of literature was appraised using the QualSyst Tool. Motivations and resistances were categorized based on content analysis and the 'structure-process-outcome' model. RESULTS From 8319 potential citations, 105 were included, comprising 53 qualitative studies (the average quality score is 0.92) and 52 quantitative studies (the average quality score is 0.95). A total of 42 categories of factors were identified into 11 themes and further grouped into three dimensions: structure, process and outcome. The structure dimension comprised six themes (71.43%), the process dimension contained four themes (11.01%) and the outcome dimension covered only one theme. Across all categories, decision-making time and patients' decision preparedness in the process dimension were the most reported, followed by physicians' communication skills and health care environment in the structure dimension. Analysis of implementation of SDM among various types of diseases showed that more influencing factors were extracted from chronic diseases and unspecified disease decisions. CONCLUSIONS The major determinants for the implementation of SDM are focused on the structural dimension, which challenges the health systems of both developed and low- and middle-income countries. Furthermore, we consider it important to understand more about the interactions among the factors to take integrated measures to address the problems and to ensure the effectiveness of implementing SDM. PATIENT OR PUBLIC CONTRIBUTION Patients, healthcare professionals and other stakeholders articulated their perspectives on the implementation of SDM actively, and these were adopted and analysed in this study. However, the above-mentioned individuals were not directly involved in the process of this study. Protocol was registered on PROSPERO (CRD42021259309).
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Affiliation(s)
- Changhai Tang
- School of Public Health, Weifang Medical University, Weifang, Shandong, China
| | - Anqi Wang
- School of Public Health, Weifang Medical University, Weifang, Shandong, China
| | - Jingjing Yan
- School of International and Public Affairs, Shanghai Jiao Tong University, Shanghai, China
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Souza ADZD, Hoffmeister LV, Moura GMSSD. FACILITATORS AND BARRIERS OF PATIENT INVOLVEMENT IN HOSPITAL SERVICES: INTEGRATIVE REVIEW. Texto contexto - enferm 2022. [DOI: 10.1590/1980-265x-tce-2020-0395en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective to identify the facilitating factors and barriers that influence patient involvement in hospital services. Method integrative review; search of articles published between January 2011 and December 2020, in the electronic databases PubMed, Web of Science, Cinahl, Lilacs and Scopus, using descriptors related to "patient involvement", Barriers, Facilitators, in English, Spanish and Portuguese. Data collection was performed from May to June 2021, identifying 32 publications that met the inclusion criteria. Results the analysis resulted in three categories of facilitating factors and barriers: communication, actors of involvement and organizational culture, allowing the elaboration of a theoretical model of patient involvement. This model shows that in the centrality of the process are the actors involved, that is, patients and professionals, inserted in an organizational context, being influenced by leadership, culture, environment, available resources and processes, where communication permeates as a basis for involvement. Conclusion the facilitating factors and barriers identified in this review, synthesized in a theoretical model, allow transcending theoretical knowledge for practice. The complexity to operationalize this model requires patients, professionals, health services and society join forces to make this theoretical proposition a practice incorporated by the services.
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Affiliation(s)
| | - Louíse Viecili Hoffmeister
- Universidade NOVA de Lisboa, Portugal; Comprehensive Health Research Center, Portugal; Escola Superior de Enfermagem de Lisboa, Portugal
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Souza ADZD, Hoffmeister LV, Moura GMSSD. FACILITADORES E BARREIRAS DO ENVOLVIMENTO DO PACIENTE NOS SERVIÇOS HOSPITALARES: REVISÃO INTEGRATIVA. Texto contexto - enferm 2022. [DOI: 10.1590/1980-265x-tce-2020-0395pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
RESUMO Objetivo identificar os fatores facilitadores e as barreiras que influenciam no envolvimento do paciente nos serviços hospitalares. Método revisão integrativa; realizada busca de artigos publicados entre janeiro de 2011 e dezembro de 2020, nas bases eletrônicas PubMed, Web of Science, Cinahl, Lilacs e Scopus, utilizando descritores relacionados a “patient involvement”, Barriers, Facilitators, nos idiomas inglês, espanhol e português. Coleta de dados realizada de maio a junho de 2021, identificando-se 32 publicações que atenderam aos critérios de inclusão. Resultados a análise resultou em três categorias de fatores facilitadores e barreiras: comunicação, atores do envolvimento e cultura organizacional, permitindo a elaboração de um modelo teórico de envolvimento do paciente. Esse modelo mostra que na centralidade do processo estão os atores envolvidos, ou seja, pacientes e profissionais, inseridos em um contexto organizacional, sendo influenciados pela liderança, cultura, ambiente, recursos disponíveis e processos, onde a comunicação perpassa como base para o envolvimento. Conclusão os fatores facilitadores e as barreiras identificadas nesta revisão, sintetizados num modelo teórico, permitem transcender o conhecimento teórico para a prática. A complexidade para operacionalizar esse modelo requer que pacientes, profissionais, serviços de saúde e sociedade unam os esforços para tornar esta proposição teórica em uma prática incorporada pelos serviços.
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Affiliation(s)
| | - Louíse Viecili Hoffmeister
- Universidade NOVA de Lisboa, Portugal; Comprehensive Health Research Center, Portugal; Escola Superior de Enfermagem de Lisboa, Portugal
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Bean G, Krishnan U, Stone JR, Khan M, Silva A. Utilization of Chest Pain Decision Aids in a Community Hospital Emergency Department: A Mixed-methods Implementation Study. Crit Pathw Cardiol 2021; 20:192-207. [PMID: 34570011 DOI: 10.1097/hpc.0000000000000269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Chest pain is a common reason for emergency department (ED) visits. Evidence-based decision aids assessing risk for an adverse cardiac event are underused in community hospital emergency care. This study explored the acceptability, barriers, facilitators, and potential strategies for implementation of the HEART Score risk stratification tool, accelerated diagnostic pathway, and shared decision-making visual aid with physicians and chest pain patients ages >45 in a community hospital ED. METHODS Single center, mixed-methods study. (1) Physician semistructured interviews using The Consolidated Framework for Implementation Research for systematic analysis. (2) Patient and physician surveys. (3) 16-week intervention of physician training and pilot testing of decision aids with ED patients. RESULTS Physician interviews (n = 19); key facilitators: electronic medical record decision support, ease of use, risk stratification and disposition support, and shared decision-making training. Key barriers: time constraints, patient ability, and/or willingness to participate in shared decision-making, lack of integration with medical record and change in practice workflow. Patient study participants (n = 184) with a survey response rate of 92% (n = 170). Most patients (85%) were satisfied with the shared decision-making visual aid. Physicians surveyed (n = 84) with a response rate of 50% (n = 42). Most physicians, 95% (n = 40), support use of the HEART Score, with limited acceptance of the shared decision-making visual aid of 57% (n = 24). CONCLUSIONS Using evidence-based chest pain decision aids in a community hospital ED is feasible and acceptable. Key barriers and facilitators for implementation were identified. Further research in community hospitals is needed to verify findings, examine generalizability, and test implementation strategies.
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Affiliation(s)
- Glenn Bean
- From the Department of Preventive Cardiology, Pulse Heart Institute, Tacoma General Hospital, Tacoma, WA
| | - Uma Krishnan
- Department of Cardiology, Pulse Heart Institute, Tacoma, WA
| | - Jason R Stone
- Emergency Department, Good Samaritan Hospital, Puyallup, WA
| | - Madiha Khan
- Department of Hospital Medicine, Good Samaritan Hospital, Puyallup, WA
| | - Angela Silva
- Institute for Research and Innovation, MultiCare Health System, Tacoma, WA
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Abstract
BACKGROUND Diagnostic uncertainty (DU) in primary care is ubiquitous, yet no review has specifically examined its communication, or the associated ethical issues. OBJECTIVES To identify what is known about the communication of DU in primary care and the associated ethical issues. METHODS Systematic review, critical interpretive synthesis and ethical analysis of primary research published worldwide. Medline, Embase, Web of Science and SCOPUS were searched for papers from 1988 to 2020 relating to primary care AND diagnostic uncertainty AND [ethics OR behaviours OR communication]. Critical interpretive synthesis and ethical analysis were applied to data extracted. RESULTS Sixteen papers met inclusion criteria. Although DU is inherent in primary care, its communication is often limited. Evidence on the effects of communicating DU to patients is mixed; research on patient perspectives of DU is lacking. The empirical literature is significantly limited by inconsistencies in how DU is defined and measured. No primary ethical analysis was identified; secondary analysis of the included papers identified ethical issues relating to maintaining patient autonomy in the face of clinical uncertainty, a gap in considering the direct effects of (not) communicating DU on patients, and considerations regarding over-investigation and justice. CONCLUSIONS This review highlights significant gaps in the literature: there is a need for explicit ethical and patient-centred empirical analyses on the effects of communicating DU, and research directly examining patient preferences for this communication. Consensus on how DU should be defined, and greater research into tools for its measurement, would help to strengthen the empirical evidence base.
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Affiliation(s)
- Caitríona L Cox
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Isla Kuhn
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Zoë Fritz
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Abstract
BACKGROUND AND OBJECTIVE The objective with this study was to describe pediatric emergency department (ED) physicians' perspective on the evaluation and management of brief resolved unexplained events (BRUEs) to help support the development of quality improvement interventions for this population. METHODS We conducted qualitative semistructured interviews with pediatric ED providers who practice in a single state. Interviews were audio-recorded and transcribed and demographic information was also obtained. The 6-phase approach to reflexive thematic analysis was used to conduct the qualitative analysis. RESULTS Nineteen pediatric ED physicians practicing in 4 institutions across our state participated in the study. The majority of participants (95%) practice in a university-affiliated setting. The primary themes related to providing care for patients with a BRUE identified in our analysis were (1) reassurance, (2) caregiver or provider concern, and (3) clinical practice guideline availability and interpretation. Closely intertwined underlying topics informing BRUE patient management were also noted: (1) ambiguity in the BRUE diagnosis and its management; (2) a need for shared decision-making between the caregiver and the provider; and (3) concern over the increased time spent with caregivers during an ED visit for a diagnosis of BRUE. These complex relationships were found to influence patient evaluation and disposition. CONCLUSION Multifaceted quality improvement interventions should address caregiver and provider concerns regarding the diagnosis of BRUE while providing decision aids to support shared decision-making with caregivers.
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Affiliation(s)
- Karolina Maksimowski
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Rita Haddad
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Amy M DeLaroche
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
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Waddell A, Lennox A, Spassova G, Bragge P. Barriers and facilitators to shared decision-making in hospitals from policy to practice: a systematic review. Implement Sci 2021; 16:74. [PMID: 34332601 PMCID: PMC8325317 DOI: 10.1186/s13012-021-01142-y] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 07/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background Involving patients in their healthcare using shared decision-making (SDM) is promoted through policy and research, yet its implementation in routine practice remains slow. Research into SDM has stemmed from primary and secondary care contexts, and research into the implementation of SDM in tertiary care settings has not been systematically reviewed. Furthermore, perspectives on SDM beyond those of patients and their treating clinicians may add insights into the implementation of SDM. This systematic review aimed to review literature exploring barriers and facilitators to implementing SDM in hospital settings from multiple stakeholder perspectives. Methods The search strategy focused on peer-reviewed qualitative studies with the primary aim of identifying barriers and facilitators to implementing SDM in hospital (tertiary care) settings. Studies from the perspective of patients, clinicians, health service administrators, and decision makers, government policy makers, and other stakeholders (for example researchers) were eligible for inclusion. Reported qualitative results were mapped to the Theoretical Domains Framework (TDF) to identify behavioural barriers and facilitators to SDM. Results Titles and abstracts of 8724 articles were screened and 520 were reviewed in full text. Fourteen articles met inclusion criteria. Most studies (n = 12) were conducted in the last four years; only four reported perspectives in addition to the patient-clinician dyad. In mapping results to the TDF, the dominant themes were Environmental Context and Resources, Social/Professional Role and Identity, Knowledge and Skills, and Beliefs about Capabilities. A wide range of barriers and facilitators across individual, organisational, and system levels were reported. Barriers specific to the hospital setting included noisy and busy ward environments and a lack of private spaces in which to conduct SDM conversations. Conclusions SDM implementation research in hospital settings appears to be a young field. Future research should build on studies examining perspectives beyond the clinician-patient dyad and further consider the role of organisational- and system-level factors. Organisations wishing to implement SDM in hospital settings should also consider factors specific to tertiary care settings in addition to addressing their organisational and individual SDM needs. Trial Registration The protocol for the review is registered on the Open Science Framework and can be found at https://osf.io/da645/, DOI 10.17605/OSF.IO/DA645. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-021-01142-y.
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Affiliation(s)
- Alex Waddell
- Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton Campus, Melbourne, VIC, 3800, Australia. .,Safer Care Victoria, 50 Lonsdale St, Melbourne, VIC, 3000, Australia.
| | - Alyse Lennox
- Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton Campus, Melbourne, VIC, 3800, Australia
| | - Gerri Spassova
- Department of Marketing, Monash Business School, Level 6, Building S, Caulfield Campus 26 Sir John Monash Drive, Caulfield East, VIC, 3145, Australia
| | - Peter Bragge
- Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard, Clayton Campus, Melbourne, VIC, 3800, Australia
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Plaster AL, Faulks ER, Gillen JN, Tegge AN, Matos MA, Lollar DI, Bower KL, Nussbaum MS, Collier BR, Hamill ME. Different Perceptions Exist Between Health Care Providers and the General Population Regarding the Importance of Findings on Additional Imaging for Trauma Consults. Am Surg 2020; 86:830-836. [PMID: 32731746 DOI: 10.1177/0003134820940249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Approximately one-third of additional imaging for trauma consults results in the discovery of new injuries. No studies have addressed the perception of these findings in non-health care providers. Our hypothesis was that significant differences in perception of the importance of injuries would exist between health care providers (HCPs) and the general population. METHODS Six standardized scenarios were developed detailing common new injury findings on additional imaging in trauma consults. Demographics as well as information regarding the significance of findings, potential for change in care, and the importance of patient notification were collected. Surveys were electronically distributed to HCPs in our system and the public. Data analysis was performed with generalized linear modeling. RESULTS A total of 339 public and 129 HCP surveys were returned. HCPs included attending staff, residents, and advanced care providers from a variety of specialties. Significant differences in perception were found in traumatic brain injury, spine fractures, and rib fractures, with HCPs rating most findings as less clinically important than the general population, while rating patient notification as more important. Perceived importance decreased with increased age in the general population. Increasing HCP age or length in practice did not significantly affect perception of clinical importance, except for rib fractures. DISCUSSION Differences in perception exist regarding the significance of additional injuries between HCPs and the general population. Perceptions of the general population also change with age. Decisions to pursue additional imaging in trauma patients should include consideration of these differences in perception to help support quality patient-centered care.
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Affiliation(s)
- Andrew L Plaster
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,San Antonio Uniformed Services Health Education Consortium, JBSA Fort Sam Houston, TX, USA
| | - Emily R Faulks
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Jacob N Gillen
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Allison N Tegge
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Department of Statistics, Virginia Tech, Blacksburg, VA, USA
| | - Miguel A Matos
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Daniel I Lollar
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Katie L Bower
- 22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Michael S Nussbaum
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Bryan R Collier
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Mark E Hamill
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
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Schoenfeld EM, Houghton C, Patel PM, Merwin LW, Poronsky KP, Caroll AL, Sánchez Santana C, Breslin M, Scales CD, Lindenauer PK, Mazor KM, Hess EP. Shared Decision Making in Patients With Suspected Uncomplicated Ureterolithiasis: A Decision Aid Development Study. Acad Emerg Med 2020; 27:554-565. [PMID: 32064724 DOI: 10.1111/acem.13917] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/04/2020] [Accepted: 01/08/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective was to develop a decision aid (DA) to facilitate shared decision making (SDM) around whether to obtain computed tomography (CT) imaging in patients presenting to the emergency department (ED) with suspected uncomplicated ureterolithiasis. METHODS We used evidence-based DA development methods, including qualitative methods and iterative stakeholder engagement, to develop and refine a DA. Guided by the Ottawa Decision Support Framework, International Patient Decision Aid Standards (IPDAS), and a steering committee made up of stakeholders, we conducted interviews and focus groups with a purposive sample of patients, community members, emergency clinicians, and other stakeholders. We used an iterative process to code the transcripts and identify themes. We beta-tested the DA with patient-clinician dyads facing the decision in real time. RESULTS From August 2018 to August 2019, we engaged 102 participants in the design and iterative refinement of a DA focused on diagnostic options for patients with suspected ureterolithiasis. Forty-six were ED patients, community members, or patients with ureterolithiasis, and the remaining were emergency clinicians (doctors, residents, advanced practitioners), researchers, urologists, nurses, or other physicians. Patients and clinicians identified several key decisional needs including an understanding of accuracy, uncertainty, radiation exposure/cancer risk, and clear return precautions. Patients and community members identified facilitators to SDM, such as a checklist of signs and symptoms. Many stakeholders, including both patients and ED clinicians, expressed a strong pro-CT bias. A six-page DA was developed, iteratively refined, and beta-tested. CONCLUSIONS Using stakeholder engagement and qualitative inquiry, we developed an evidence-based DA to facilitate SDM around the question of CT scan utilization in patients with suspected uncomplicated ureterolithiasis. Future research will test the efficacy of the DA in facilitating SDM.
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Affiliation(s)
- Elizabeth M. Schoenfeld
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
- Institute for Healthcare Delivery and Population Science University of Massachusetts Medical School–Baystate Springfield MA
| | - Connor Houghton
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | - Pooja M. Patel
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | - Leanora W. Merwin
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | - Kye P. Poronsky
- Department of Emergency Medicine University of Massachusetts Medical School–Baystate Springfield MA
| | | | | | - Maggie Breslin
- Design for Social Innovation Program School of Visual Arts (SVA) New York NY
| | - Charles D. Scales
- Duke Clinical Research Institute and Division of Urologic Surgery Duke University School of Medicine Durham NC
| | - Peter K. Lindenauer
- Institute for Healthcare Delivery and Population Science University of Massachusetts Medical School–Baystate Springfield MA
| | - Kathleen M. Mazor
- Department of Medicine University of Massachusetts Medical Schooland the Meyers Primary Care Institute Worcester MA
| | - Erik P. Hess
- Department of Emergency Medicine University of Alabama at Birmingham Birmingham AL
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