Abstract
BackgroundMuch of the research on decision-making in health care has focused on consultation outcomes. Less is known about the process by which clinicians and patients come to a treatment decision. This study aimed to quantitatively describe the behaviour shown by doctors and patients during primary care consultations when three types of decision aids were used to promote treatment decision-making in a randomised controlled trial.MethodsA video-based study set in an efficacy trial which compared the use of paper-based guidelines (control) with two forms of computer-based decision aids (implicit and explicit versions of DARTS II). Treatment decision concerned warfarin anti-coagulation to reduce the risk of stroke in older patients with atrial fibrillation. Twenty nine consultations were video-recorded. A ten-minute 'slice' of the consultation was sampled for detailed content analysis using existing interaction analysis protocols for verbal behaviour and ethological techniques for non-verbal behaviour.ResultsMedian consultation times (quartiles) differed significantly depending on the technology used. Paper-based guidelines took 21 (19–26) minutes to work through compared to 31 (16–41) minutes for the implicit tool; and 44 (39–55) minutes for the explicit tool. In the ten minutes immediately preceding the decision point, GPs dominated the conversation, accounting for 64% (58–66%) of all utterances and this trend was similar across all three arms of the trial. Information-giving was the most frequent activity for both GPs and patients, although GPs did this at twice the rate compared to patients and at higher rates in consultations involving computerised decision aids. GPs' language was highly technically focused and just 7% of their conversation was socio-emotional in content; this was half the socio-emotional content shown by patients (15%). However, frequent head nodding and a close mirroring in the direction of eye-gaze suggested that both parties were active participants in the conversationConclusionIrrespective of the arm of the trial, both patients' and GPs' behaviour showed that they were reciprocally engaged in these consultations. However, even in consultations aimed at promoting shared decision-making, GPs' were verbally dominant, and they worked primarily as information providers for patients. In addition, computer-based decision aids significantly prolonged the consultations, particularly the later phases. These data suggest that decision aids may not lead to more 'sharing' in treatment decision-making and that, in their current form, they may take too long to negotiate for use in routine primary care.
Highlights
Much of the research on decision-making in health care has focused on consultation outcomes
In primary care, increased patient engagement in health care is reflected in a range of interventions aimed at developing patient-centred approaches during consultations which take into account patients' needs and anxieties concerning treatment [4,5]
The three armed trial sought to determine whether the two versions of the computerised decision aid, applied in the context of shared decision-making, were efficacious at reducing decisional conflict compared to a control condition of paper-based clinical guidelines derived from the same decision analysis and applied as a doctor-led source of advice
Summary
Much of the research on decision-making in health care has focused on consultation outcomes. In primary care, increased patient engagement in health care is reflected in a range of interventions aimed at developing patient-centred approaches during consultations which take into account patients' needs and anxieties concerning treatment [4,5]. Such approaches sit well with the acknowledgement that diagnostic uncertainty is common for primary care clinicians [6,7] and that patients are experts regarding the experience of their health condition with legitimate preferences for differing health states, treatments and outcomes [8]. Shared decision-making has been defined as a collaborative endeavour in which:
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