Implementation Of Patient Decision Aids Research Articles

Value of patient decision aids for shared decision-making in kidney failure.

It is unknown how often Dutch patient decision aids are used during kidney failure treatment modality education and what their impact is on shared decision-making. We determined the use of Three Good Questions, 'Overviews of options', and Dutch Kidney Guide by kidney healthcare professionals. Also, we determined patient-experienced shared decision-making. Finally, we determined whether the experience of shared decision-making among patients changed after a training workshop for healthcare professionals. Quality improvement study. Healthcare professionals answered questionnaires regarding education/patient decision aids. Patients with estimated glomerular filtration rate <20 mL/min/1.73 m2 completed shared decision-making questionnaires. Data were analysed with one-way analysis of variance and linear regression. Of 117 healthcare professionals, 56% applied shared decision-making by discussing Three Good Questions (28%), 'Overviews of options' (31%-33%) and Kidney Guide (51%). Of 182 patients, 61%-85% was satisfied with their education. Of worst scoring hospitals regarding shared decision-making, only 50% used 'Overviews of options'/Kidney Guide. Of best scoring hospitals 100% used them, needed less conversations (p = 0.05), provided information about all treatment options and more often provided information at home. After the workshop, patients' shared decision-making scores remained unchanged. The use of specifically developed patient decision aids during kidney failure treatment modality education is limited. Hospitals that did use them had higher shared decision-making scores. However, the degree of shared decision-making experienced by patients remained unchanged after healthcare professionals were trained on shared decision-making and the implementation of patient decision aids.

Shared decision making in recurrent ovarian cancer: Implementation of patient decision aids across three departments of oncology in Denmark.

Patients with relapsed ovarian cancer are offered multiple treatment options. To match treatment with the individual patient's life situation and preferences, healthcare professionals can apply shared decision making (SDM) including patient decision aids (PtDAs).This study aimed to evaluate the implementation of two different PtDAs in consultations with patients suffering from relapsed ovarian cancer. We analyzed the following data before and after implementation of the PtDAs: 1) observed SDM using the OPTION instrument, 2) physician treatment recommendations, and 3) patients' and physicians' evaluations of SDM in consultations using the CollaboRATE, SDM-Q-9, and SDM-Q-Doc. Significant improvement in observed SDM was found after the implementation (p = 0.002). Improvement of SDM was detected in consultations conducted by physicians reporting more than two hours of SDM-training (p < 0.001), but not when physicians reported less than two hours of SDM-training.No before/after differences in treatment recommendations and in patients' and physicians' evaluations were found. Implementation of PtDAs improved the level of observed SDM. Training of physicians in SDM is necessary for improved SDM practice. Discussing oncological treatment options with the use of PtDAs is not standard practice in Denmark. The present study is one of the first Danish studies focusing on how to implement SDM and PtDAs in oncological consultations.

Implementation of patient-centred care in Denmark: The way forward with shared decision-making

Legal and political landscape in shared decision makingCurrent Danish legislation empowers patients in securing their rights, but there are no present legislative developments in Denmark to support patient involvement. Policy initiatives within health care, however, show positive trends by, for example, including recommendations for shared decision making (SDM) in national clinical guidelines and the allocation of resources to fund projects in SDM. Within the last five years, three out of five regions have launched centers in patient involvement and SDM to focus on training, implementation of patient decision aids (PtDAs) and to foster the cultural change in SDM. A national dissemination of a template for easy building of PtDAs accessible via an online platform is one of the latest initiatives. The way forwardAlthough the political discourse on SDM is gathering speed, an unclear definition and purpose of SDM is a barrier to real-life implementation. Politicians, leaders and clinicians seem to be moving at different paces and in different directions and are lacking consensus on SDM as a paradigm requiring training, leadership and a patient-centered mindset. ConclusionMany relevant initiatives are underway. However, SDM is also challenged by the lack of legislation and a central push for real SDM implementation in Denmark.

Clinicians' perspectives on the implementation of patient decision aids in the emergency department: A qualitative interview study.

ObjectiveDecision aids (DAs) are tools to facilitate and standardize shared decision making (SDM). Although most emergency clinicians (ECs) perceive SDM appropriate for emergency care, there is limited uptake of DAs in clinical practice. The objective of this study was to explore barriers and facilitators identified by ECs regarding the implementation of DAs in the emergency department (ED).MethodsWe conducted a qualitative interview study guided by implementation science frameworks. ECs participated in interviews focused on the implementation of DAs for the disposition of patients with low‐risk chest pain and unexplained syncope in the ED. Interviews were recorded and transcribed verbatim. We then iteratively developed a codebook with directed qualitative content analysis.ResultsWe approached 25 ECs working in urban New York, of whom 20 agreed to be interviewed (mean age, 41 years; 25% women). The following 6 main barriers were identified: (1) poor DA accessibility, (2) concern for increased medicolegal risk, (3) lack of perceived need for a DA, (4) patient factors including lack of capacity and limited health literacy, (5) skepticism about validity of DAs, and (6) lack of time to use DAs. The 6 main facilitators identified were (1) positive attitudes toward SDM, (2) patient access to follow‐up care, (3) potential for improved patient satisfaction, (4) potential for improved risk communication, (5) strategic integration of DAs into the clinical workflow, and (6) institutional support of DAs.ConclusionsECs identified multiple barriers and facilitators to the implementation of DAs into clinical practice. These findings could guide implementation efforts targeting the uptake of DA use in the ED.

Experts' views on the implementation of the prenatal screening decision aid in Iran: A qualitative study

Background &amp; Aim: Patient decision aids are detailed and personalized health education materials that assist patients in decision making. According to expert viewpoints, this study aimed to determine important factors in implementing the prenatal screening decision aid in Iran.&#x0D; Methods &amp; Materials: In this qualitative study, 24 experts, including seven obstetricians, four information scientists, five managers or policymakers, and eight midwives, were selected using purposive and snowball sampling approaches. Semi-structured interviews were conducted to collect the data between January 2020 and June 2020 in Tehran, Iran. A prenatal screening decision aid was presented to the participants, and we asked them to raise their concerns and thoughts regarding the factors influencing the implementation of patient decision aids. We used MAXQDA 10 and applied conventional content analysis for data analysis.&#x0D; Results: Two organizational and personal factors themes were identified to implement Iran's prenatal screening decision aids.&#x0D; Conclusion: We identified the viewpoints of experts regarding major factors in patient decision aids implementation for prenatal screening. Before implementing prenatal screening decision aids in Iran, it would be helpful to consider these organizational and personal factors. Prenatal screening decision aids can provide better information for pregnant women and strengthen their decision-making ability.

Maternal perceptions of cesarean birth care: A qualitative study to inform ERAS guideline development.

Cesarean birth (CB) is the most common inpatient surgical procedure, and until recently, there were no internationally accepted, standardized clinical guidelines available. The Enhanced Recovery After Surgery (ERAS® ) program aims to improve outcomes through the development of international guidelines (IGs). As an ERAS IG for CB was being developed, this qualitative study was conducted to explore and consolidate women's experiences with CB. Qualitative methods were used to assess the patient experience with current evidence-based CB protocols across operative phases. Twelve women who experienced CB at a single center in Canada were interviewed using an open-ended, semi-structured interview guide at six weeks postpartum. Two researchers coded the emerging themes separately and compared findings. Women described feeling informed, but felt they did not have a choice. Presurgery, women wanted more information about the risks of CB. Preoperatively, women expressed confusion with the procedures, but felt informed about local anesthesia and thermoregulation. Post-CB, women felt informed about pain and nausea control; however, urinary catheter removal was delayed when compared to the ERAS recommendations. Information about postpartum infant care was not well communicated, as many women were uninformed about delayed cord clamping and infant thermoregulation. This qualitative study provides opportunities to improve communication, the patient-practitioner relationship, and the overall satisfaction throughout the CB process. The findings support the implementation of patient decision aids and training with the shared decision model. The improved procedures recommended in the ERAS IG for CB have the potential to deliver significant improvements to patient care and patient satisfaction.

Clinician perspectives on a culturally adapted patient decision aid concerning maintenance therapy for asthma

Background and Objective Patients with persistent asthma often show poor adherence to inhaled corticosteroids (ICS). Shared decision-making can improve adherence rates in this population. Patient decision aids (PDAs) are tools to facilitate shared decision-making. To date, only one PDA, developed in a Canadian French-speaking population, exists for patients considering ICS maintenance therapy. This PDA has been culturally adapted in this study to contextualize to the needs of multi-ethnic Asian patients in Singapore. This study explored the views of local clinicians on the content, design and implementation of this newly-adapted PDA. Methods 24 clinicians, who were purposively sampled from polyclinics and a tertiary institution, were interviewed on the content, design and implementation of the PDA. The interviews were audio-recorded, transcribed and analyzed via thematic analysis. Results Clinicians generally accepted the design of the PDA. They suggested for the target users to be patients on Step 2 of GINA guidelines and the number of options to be reduced from four to two (do nothing or start inhaled corticosteroids). Moreover, they supported including a list of values for patients to select from given that Asian patients often do not articulate their values readily. The addition of more visual aids, the production of multilingual Asian editions and the involvement of nurses to administer the PDA was also suggested. Conclusion The PDA was culturally-adapted with local clinicians’ perspectives to target multi-ethnic Asian patients with persistent asthma (Step 2 GINA guidelines). The main changes include a list of values and addition of visual aids.

Integrating Option Grid Patient Decision Aids in the Epic Electronic Health Record: Case Study at 5 Health Systems.

BackgroundSome researchers argue that the successful implementation of patient decision aids (PDAs) into clinical workflows depends on their integration into electronic health records (EHRs). Anecdotally, we know that EHR integration is a complex and time-consuming task; yet, the process has not been examined in detail. As part of an implementation project, we examined the work involved in integrating an encounter PDA for symptomatic uterine fibroids into Epic EHR systems.ObjectiveThis study aims to identify the steps and time required to integrate a PDA into the Epic EHR system and examine facilitators and barriers to the integration effort. MethodsWe conducted a case study at 5 academic medical centers in the United States. A clinical champion at each institution liaised with their Epic EHR team to initiate the integration of the uterine fibroid Option Grid PDAs into clinician-facing menus. We scheduled regular meetings with the Epic software analysts and an expert Epic technologist to discuss how best to integrate the tools into Epic for use by clinicians with patients. The meetings were then recorded and transcribed. Two researchers independently coded the transcripts and field notes before categorizing the codes and conducting a thematic analysis to identify the facilitators and barriers to EHR integration. The steps were reviewed and edited by an Epic technologist to ensure their accuracy. ResultsIntegrating the uterine fibroid Option Grid PDA into clinician-facing menus required an 18-month timeline and a 6-step process, as follows: task priority negotiation with Epic software teams, security risk assessment, technical review, Epic configuration; troubleshooting, and launch. The key facilitators of the process were the clinical champions who advocated for integration at the institutional level and the presence of an experienced technologist who guided Epic software analysts during the build. Another facilitator was the use of an emerging industry standard app platform (Health Level 7 Substitutable Medical Applications and Reusable Technologies on Fast Healthcare Interoperability Resources) as a means of integrating the Option Grid into existing systems. This standard platform enabled clinicians to access the tools by using single sign-on credentials and prevented protected health information from leaving the EHR. Key barriers were the lack of control over the Option Grid product developed by EBSCO (Elton B Stephens Company) Health; the periodic Epic upgrades that can result in a pause on new software configurations; and the unforeseen software problems with Option Grid (ie, inability to print the PDA), which delayed the launch of the PDA. ConclusionsThe integration of PDAs into the Epic EHR system requires a 6-step process and an 18-month timeline. The process required support and prioritization from a clinical champion, guidance from an experienced technologist, and a willing EHR software developer team.

Factors influencing implementation of an insulin patient decision aid at public health clinics in Malaysia: A qualitative study.

Many patient decision aids (PDAs) are developed in academic settings by academic researchers. Academic settings are different from public health clinics where the focus is on clinical work. Thus, research on implementation in public health settings will provide insights to effective implementation of PDA in real-world settings. This study explores perceived factors influencing implementation of an insulin PDA in five public health clinics. This study adopted a comparative case study design with a qualitative focus to identify similarities and differences of the potential barriers and facilitators to implementing the insulin PDA across different sites. Focus groups and individual interviews were conducted with 28 healthcare providers and 15 patients from five public health clinics under the Ministry of Health in Malaysia. The interviews were transcribed verbatim and analysed using the thematic approach. Five themes emerged which were: 1) time constraint; 2) PDA costs; 3) tailoring PDA use to patient profile; 4) patient decisional role; and 5) leadership and staff motivation. Based on the interviews and drawing on observations and interview reflection notes, time constraint emerged as the common prominent factor that cut across all the clinics, however, tailoring PDA use to patient profile; patient decisional role; leadership and staff motivation varied due to the distinct challenges faced by specific clinics. Among clinics from semi-urban areas with more patients from limited education and lower socio-economic status, patients' ability to comprehend the insulin PDA and their tendency to rely on their doctors and family to make health decisions were felt to be a prominent barrier to the insulin PDA implementation. Staff motivation appeared to be stronger in most of the clinics where specific time was allocated to diabetes team to attend to diabetes patients and this was felt could be a potential facilitator, however, a lack of leadership might affect the insulin PDA implementation even though a diabetes team is present. This study found time constraint as a major potential barrier for PDA implementation and effective implementation of the insulin PDA across different public health clinics would depend on leadership and staff motivation and, the need to tailor PDA use to patient profile. To ensure successful implementation, implementers should avoid a 'one size fits all' approach when implementing health innovations.

Abstract P6-12-04: Does the addition of a patient decision aid video reduce decisional conflict in patients considering a de-escalation of radiotherapy trial? Results from the PRIMETIME study

Abstract Background: PRIMETIME is a UK-led prospective biomarker-directed cohort study aiming to identify a group of breast cancer patients who can safely avoid radiotherapy following breast conserving surgery. This group is deemed to be at such a low risk of local relapse that the potential benefits of radiotherapy are unlikely to outweigh the risks. The uncertainty patients face regarding healthcare decisions is known as decisional conflict. Patient decision aids (PDA) are interventions which help patients to weigh up the risks and benefits of treatments. Evidence suggests PDA reduce decisional conflict. A study within a trial (SWAT) concept which enables trialists to conduct research embedded within a larger trial was used to investigate if the introduction of a PDA video reduces decisional conflict within PRIMETIME. Methods: The PDA video was designed to be used in addition to the standard written information and developed in close collaboration with PRIMETIME patient advocates. The PRIMETIME SWAT was implemented using a cluster stepped-wedge trial design. Each cluster was defined as the radiotherapy centre and peripheral centres referring into that centre. All clusters began in the standard information group (receiving written information) and then crossed over to the enhanced information group (receiving written information and PDA video) at either 2, 4 or 6 months. The primary endpoint was a reduction in decisional conflict following PDA implementation. Decisional conflict was assessed using the validated decisional conflict scale questionnaire (0-100 scale with greater scores indicating more decisional conflict) in the standard and enhanced information groups. The target sample size was 288 patients from 24 clusters, to provide 84% power (alpha 0.05) with an effect size of 0.55 (assuming standard deviation, SD=18) across the 0-1 range of possible intra-class correlation values. For the primary endpoint an estimate of the difference in mean decisional conflict pre- and post-implementation of the PDA video was obtained from a multilevel mixed effects linear regression model. Results: In an interim analysis conducted on 2nd May 2019, 318 evaluable questionnaires were returned from 463 eligible patients (69%) recruited across 24 clusters; 158 questionnaires from the standard and 160 questionnaires from the enhanced group. 60/130 (53%) patients in the enhanced information group (with available data) reportedly did not watch the PDA video. The mean decisional conflict score in the standard group [158 patients] was 10.73 (SD=11.63) and 8.43 (10.83) in the enhanced group [160 patients]. There was a reduction in decisional conflict in the enhanced compared with the standard group, however the effect size was small and unlikely to be clinically significant [estimated difference in means = -2.50 (-4.73- -0.28), p=0.03, effect size=0.11]. The final analysis will be conducted after the last cluster has crossed over to the enhanced group in October 2019. Conclusions: A SWAT using a cluster stepped-wedge trial design testing the implementation of a PDA video on patient’s decisional conflict was conducted across multiple UK centres participating in PRIMETIME. The average decisional conflict scores were low therefore there is less scope for obtaining further reductions, and the difference we observed was not clinically significant. The low baseline scores may reflect the PRIMETIME study population who are at low risk of local recurrence. Almost half of patients reportedly did not watch the video; this may be due to the standard written information being sufficient to fulfil the needs of this patient population. Citation Format: Indrani Subarna Bhattacharya, Joanne Haviland, Ada Balasopoulou, Liba Stones, Hilary Stobart, Lesley Turner, Penelope Hopwood, Charlotte E Coles, Judith M Bliss. Does the addition of a patient decision aid video reduce decisional conflict in patients considering a de-escalation of radiotherapy trial? Results from the PRIMETIME study [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-12-04.

Implementation of the uterine fibroids Option Grid patient decision aids across five organizational settings: a randomized stepped-wedge study protocol

BackgroundUterine fibroids are non-cancerous overgrowths of the smooth muscle in the uterus. As they grow, some cause problems such as heavy menstrual bleeding, pelvic pain, discomfort during sexual intercourse, and rarely pregnancy complications or difficulty becoming pregnant. Multiple treatment options are available. The lack of comparative evidence demonstrating superiority of any one treatment means that choosing the best option is sensitive to individual preferences. Women with fibroids wish to consider treatment trade-offs. Tools known as patient decision aids (PDAs) are effective in increasing patient engagement in the decision-making process. However, the implementation of PDAs in routine care remains challenging. Our aim is to use a multi-component implementation strategy to implement the uterine fibroids Option Grid™ PDAs at five organizational settings in the USA.MethodsWe will conduct a randomized stepped-wedge implementation study where five sites will be randomized to implement the uterine fibroid Option Grid PDA in practice at different time points. Implementation will be guided by the Consolidated Framework for Implementation Research (CFIR) and Normalization Process Theory (NPT). There will be a 6-month pre-implementation phase, a 2-month initiation phase where participating clinicians will receive training and be introduced to the Option Grid PDAs (available in text, picture, or online formats), and a 6-month active implementation phase where clinicians will be expected to use the PDAs with patients who are assigned female sex at birth, are at least 18 years of age, speak fluent English or Spanish, and have new or recurrent symptoms of uterine fibroids. We will exclude postmenopausal patients. Our primary outcome measure is the number of eligible patients who receive the Option Grid PDAs. We will use logistic and linear regression analyses to compare binary and continuous quantitative outcome measures (including survey scores and Option Grid use) between the pre- and active implementation phases while adjusting for patient and clinician characteristics.DiscussionThis study may help identify the factors that impact the implementation and sustained use of a PDA in clinic workflow from various stakeholder perspectives while helping patients with uterine fibroids make treatment decisions that align with their preferences.Trial registrationClinicaltrials.gov, NCT03985449. Registered 13 July 2019, https://clinicaltrials.gov/ct2/show/NCT03985449

Evaluation of Implementation Outcomes After Initiation of a Shared Decision-making Program for Men With Prostate Cancer

ObjectiveTo evaluate barriers to implementation of patient decision aids (PDAs) issued in an electronic medical record (EMR). We undertook an implementation outcomes analysis focused on what proportion of men eligible for the PDA received it (penetration), and of the men who received it, how many used it as intended (fidelity). We also evaluated various patient-centered outcomes related to decision-making. Materials and MethodsMen with incident localized prostate cancer were recruited from at UCLA from 2013 to 2017. PDA eligibility was determined via weekly EMR review. We also performed a retrospective chart review of all patients seen in clinic for one sample week to identify patients that were missed by the initial eligibility algorithm, and investigated the cause for miscategorization. We analyzed differences in patient-centered outcomes between those who did and did not receive the PDA. ResultsAbout 314/374 men with incident prostate cancer completed the PDA conferring 84% fidelity. PDA penetration under initial identification prospective algorithm was assessed at 100% (n = 2/n = 2). However, penetration assessed by manual retrospective chart review was 20% (n = 2/n = 10). Improvements to the identification algorithm, including new EMR visit types, were identified. PDA completion was associated with less decisional conflict and higher perceived Shared decision-making (all P<.03). ConclusionNo previous studies have investigated the challenges of implementing a PDA facilitated by the EMR. We identified modifiable system and EMR-related factors that limited program penetration. Our PDA showed decisional quality benefits.

What will make patients use a patient decision aid? A qualitative study on patients' perspectives on implementation barriers and facilitators

Few studies focus on patients' views on factors influencing implementation of patient decision aids (PDAs). This study aims to explore patients' views on the factors influencing implementation of an "insulin choice" PDA in a primary care setting. This study used a descriptive qualitative study design. Interviews were conducted using a semistructured interview guide developed based on the theoretical domains framework. Nine in-depth interviews and three focus group discussions were conducted with patients with type 2 diabetes who have been advised to start insulin or were currently using insulin and those who had been seeking diabetes treatment in the clinic for more than 1year. Interviews were conducted after the participants were familiarized with the PDA. Data were analysed using a thematic approach. Five themes emerged from the data analysis: (a) trust in the physician (patients preferred physicians to other health care providers in delivering the insulin PDA to them as they trusted physicians more when it comes to making decisions such as starting insulin), (b) physician's attitude (patients were more likely to trust a physician who is friendly and sympathetic hence would be more willing to use the insulin PDA), (c) physician's communication style (patients were more willing to use the insulin PDA if the physicians would take time and guide them in the PDA use), (d) conducive environment (patients preferred to read the PDA at home), and (e) cost (patients would not be willing to pay to use the insulin PDA unless they needed it). Patients want physicians to play a major role in the implementation of the insulin PDA; physicians' communication style and commitment may influence implementation outcomes. Health care authorities need to create a conducive environment and provide patients with free access to PDA to promote effective implementation.

Patient and Provider Perspectives on a Decision Aid for Familial Hypercholesterolemia.

Familial Hypercholesterolemia (FH) is an inherited disorder associated with increased cardiovascular risk that requires patients to make multiple impactful decisions regarding the management of their condition. Patient decision aids (PDAs) can facilitate shared decision-making (SDM) and enable patients to make choices that are concordant with their goals and values. To inform the development of a PDA for patients with FH, we employed a qualitative inductive approach and focus group discussions with patients, physicians, and genetic counselors. We explored and analyzed the perceptions and understanding of these stakeholders related to a PDA for FH and identified important concepts to include in the PDA. Categories emerging from focus group discussions included: (a) perceptions of a PDA related to FH; (b) discussion about the content of a PDA related to FH; and (c) SDM. In general, stakeholders were in favor of developing tools which can inform and individualize discussion about genetic testing and treatment options for FH. Physicians valued a tool that facilitates knowledge transfer to FH patients. Patients desired a tool to help them understand the genetic aspects of and treatment options related to FH. Genetic counselors emphasized the inclusion of visual aids to support discussion with patients. Potential barriers to and facilitators of PDA implementation were identified. The input of various stakeholders will inform the development of a prototype tool that will be iteratively tested before implementation in the clinical setting.

Exploring the use of Option Grid™ patient decision aids in a sample of clinics in Poland

BackgroundResearch on the implementation of patient decision aids to facilitate shared decision making in clinical settings has steadily increased across Western countries. A study which implements decision aids and measures their impact on shared decision making has yet to be conducted in the Eastern part of Europe. ObjectiveTo study the use of Option GridTM patient decision aids in a sample of Grupa LUX MED clinics in Warsaw, Poland, and measure their impact on shared decision making. MethodWe conducted a pre-post interventional study. Following a three-month period of usual care, clinicians from three Grupa LUX MED clinics received a one-hour training session on how to use three Option GridTM decision aids and were provided with copies for use for four months. Throughout the study, all eligible patients were asked to complete the three-item CollaboRATE patient-reported measure of shared decision making after their clinical encounter. CollaboRATE enables patients to assess the efforts clinicians make to: (i) inform them about their health issues; (ii) listen to ‘what matters most’; (iii) integrate their treatment preference in future plans. A hierarchical logistic regression model was performed to understand which variables had an effect on CollaboRATE. Results2,048 patients participated in the baseline phase; 1,889 patients participated in the intervention phase. Five of the thirteen study clinicians had a statistically significant increase in their CollaboRATE scores (p<.05) when comparing baseline phase to intervention phase. All five clinicians were located at the same clinic, the only clinic where an overall increase (non-significant) in the mean CollaboRATE top score percentage occurred from baseline phase (M=60 %, SD=0.49; 95 % CI [57-63 %]) to intervention phase (M=62 %, SD=0.49; 95% CI [59-65%]). Only three of those five clinicians who had a statistically significant increase had a clinically significant difference. ConclusionThe implementation of Option GridTM helped some clinicians practice shared decision making as reflected in CollaboRATE scores, but most clinicians did not have a significant increase in their scores. Our study indicates that the effect of these interventions may be dependent on clinic contexts and clinician engagement.

Organic Dissemination and Real-World Implementation of Patient Decision Aids for Left Ventricular Assist Device.

Background. Although patient decision aids (PtDAs) have been shown to improve patient knowledge and satisfaction, they are infrequently used in the real world. We aimed to understand how our publicly available PtDAs developed for destination therapy left ventricular assist device (DT LVAD) were implemented in clinical practice and characterize factors influencing adoption. Methods. We contacted 39 people, 31 who had independently emailed inquiring about our DT LVAD PtDAs and 8 identified through snowball sampling. Thirty people from 23 programs participated in semistructured interviews, which were analyzed using normalization process theory. Results. Eleven programs currently use the PtDAs, 5 plan to use them but have not yet, and 7 do not currently use them nor have active plans to use them. Due to major tradeoffs and preference sensitivity of the DT LVAD decision, participants recognized a role for shared decision making and a need for significant information transfer. Due to a relative lack of resources, participants saw the PtDAs as a way to help facilitate a higher quality decision-making process. Limited time, lack of personnel, and perceived burden to implementing system-level change were cited as barriers to use. Initial implementation was accomplished by a champion of the PtDAs. Actual use of the PtDAs most commonly occurred through LVAD coordinators at the start of formal patient teaching sessions, where the PtDAs could be integrated into the existing LVAD consent and education structure. Conclusion. Interest in and implementation of PtDAs occurred independently at several LVAD programs due to a favorable decisional context, including a perceived role for shared decision making in the high-stakes decision around DT LVAD, unmet informational needs, preexisting education sessions, and invested clinical champions.

Shared decision making in Spain: Supportive policies and research initiatives, trends and directions for future

Patients’ rights to autonomy, information and participation in their own health care are recognized in the Spanish legal system from the early 2000's. Public institutions have progressively launched several initiatives to promote and improve patients’ empowerment and self-care. However, the concept of shared decision making (SDM), although embedded in the more general concept of “active/empowered patient”, usually has not been specifically advocated as an essential requisite for improving the quality of health services, either in the legal normative or the existing educational proposals. Research on SDM and the development of Patient Decision Aids (PtDAs) has increasingly grown and currently there are several of these materials available for patients with different diseases. Along with this research activity, the growing interest of patients and professionals in patient participation and SDM makes us optimistic about a gradual development of this care model in the medium term. However, there are several limitations and challenges that must be overcome in the near future. The implementation of PtDAs in clinical practice is imperative and issues such as their inclusion in clinical guidelines and electronic medical records should be encouraged. Concurrently, it is necessary to train professionals in SDM skills and the use of encounter PtDAs.

What factors hinder the decision-making process for women with cancer and contemplating fertility preservation treatment?

Although fertility preservation (FP) treatment options have increased, the existing evidence suggests that many women with cancer do not feel well supported in making these decisions, but find them stressful and complex and fail to take up fertility care at this crucial time. Whilst existing reviews have all made important contributions to our understanding of the FP decision-making process, none of them examine solely and specifically these processes for women of reproductive age with a diagnosis of any cancer, leaving a gap in the knowledge base. Given the expectation that care is patient-centred, our review aims to address this gap which may be of help to those managing patients struggling to make difficult decisions in the often brief period before potentially sterilizing cancer treatment is started. Underpinning this narrative review was the question 'What factors hinder the decision-making process for women with any cancer and contemplating FP treatment?' Our objectives were to (i) assess and summarize this existing literature, (ii) identify the factors that hinder this decision-making process, (iii) explore to what extent these factors may differ for women choosing different methods of FP and (iv) make recommendations for service delivery and future research. A systematic search of the medical and social science literature from the 1 January 2005 up to the end of January 2016 was carried out using three electronic databases (Web of Science (PubMed), Ovid SP Medline and CINAHL via Ebsco). Included in the review were quantitative, qualitative and mixed-method studies. Reference lists of relevant papers were also hand searched. From the 983 papers identified, 46 papers were included. Quality assessment was undertaken using the Mixed Methods Appraisal Tool and thematic analysis was used to analyse the data. From the analysis, 6 key themes with 15 sub-themes emerged: (i) fertility information provision (lack of information, timing of the information, patient-provider communication); (ii) fear concerning the perceived risks associated with pursuing FP (delaying cancer treatment, aggravating a hormone positive cancer and consequences of a future pregnancy); (iii) non-referral from oncology (personal situation, having a hormone positive cancer, FP not a priority and transition between service issues); (iv) the dilemma (in survival mode, whether to prioritize one treatment over another); (v) personal situation (parity, relationship status) and (iv) costs (financial concerns). This review has found that a wide range of internal and external factors impact the FP decision-making process. Key external issues related to current service delivery such as the provision and timing of FP information, and lack of referral from oncology to the fertility clinic. However, internal issues such as women's fears concerning the perceived risks associated with pursuing FP also hindered decision-making but these 'risks' were typically overestimated and non-evidence based. These findings suggest that the implementation of a range of decision support interventions may be of benefit within the clinical care pathway of FP and cancer. Women would benefit from the provision of more evidence-based FP information, ideally received at cancer diagnosis, in advance of seeing a fertility specialist, for example through the implementation of patient decision aids. Healthcare professionals in both oncology and fertility services may also benefit from the implementation of training programmes and educational tools targeted at improving the communication skills needed to improve collaborative decision-making and deliver care that is patient-centred. Exploration of the current barriers, both intellectual and practical, that prevent some patients from accepting FP will help care providers to do better for their patients in the future. Finally, the extent to which a poorer prognosis and moral, ethical and religious beliefs influence the FP decision-making process also warrant further research.

Factors influencing implementation of a patient decision aid in a developing country: an exploratory study

BackgroundMost studies on barriers and facilitators to implementation of patient decision aids (PDAs) are conducted in the west; hence, the findings may not be transferable to developing countries. This study aims to use a locally developed insulin PDA as an exemplar to explore the barriers and facilitators to implementing PDAs in Malaysia, an upper middle-income country in Asia.MethodsQualitative methodology was adopted. Nine in-depth interviews (IDIs) and three focus group discussions (FGDs) were conducted with policymakers (n = 6), medical officers (n = 13), diabetes educators (n = 5) and a nurse, who were involved in insulin initiation management at an academic primary care clinic. The interviews were conducted with the aid of a semi-structured interview guide based on the Theoretical Domains Framework. The interviews were audio-recorded, transcribed verbatim and analyzed using a thematic approach.ResultsFive themes emerged, and they were lack of shared decision-making (SDM) culture, role boundary, lack of continuity of care, impact on consultation time and reminder network. Healthcare providers’ (HCPs) paternalistic attitude, patients’ passivity and patient trust in physicians rendered SDM challenging which affected the implementation of the PDA. Clear role boundaries between the doctors and nurses made collaborative implementation of the PDA challenging, as nurses may not view the use of insulin PDA to be part of their job scope. The lack of continuity of care might cause difficulties for doctors to follow up on insulin PDA use with their patient. While time was the most commonly cited barrier for PDA implementation, use of the PDA might reduce consultation time. A reminder network was suggested to address the issue of forgetfulness as well as to trigger interest in using the PDA. The suggested reminders were peer reminders (i.e. HCPs reminding one another to use the PDA) and system reminders (e.g. incorporating electronic medical record prompts, displaying posters/notices, making the insulin PDA available and visible in the consultation rooms).ConclusionsWhen implementing PDAs, it is crucial to consider the healthcare culture and system, particularly in developing countries such as Malaysia where concepts of SDM and PDAs are still novel.

What Is Shared Decision Making? (and What It Is Not).

Both the practice of medicine and the expectations of patients regarding their care are changing. A point of confluence is in the need for medicine to be more patient centered, and in the need for patients to be more involved in their care.1,2 This confluence is particularly pertinent when more than one reasonable approach is available to manage the patient's situation, and when those approaches differ in ways that matter to patients.3 In shared decision-making (SDM), clinicians and patients work together to understand the patient's situation and to determine how best to address it. Emergency medicine is not exempt from these trends. In this paper we seek to define SDM and its role in contemporary healthcare. Our goal is to set the stage for the active exploration of SDM in the care of patients in the emergency department. This article is protected by copyright. All rights reserved.