Shared Decision-making Outcomes Research Articles

Shared Decision Making in Acute Pain Management in Patients with Opioid Use Disorder: A Scoping Review.

The treatment of acute pain over the years has changed with increasing alternative therapies and increased scrutiny of opioid prescriptions. Shared Decision Making (SDM) has become a vital tool in increasing patient engagement and satisfaction in treatment decisions. SDM has been successfully implemented in the management of pain in a variety of settings; however, information regarding the use of SDM for treating acute pain in patients with a history of opioid use disorder (OUD) remains scarce. Following the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR), we conducted a review to understand how SDM is used in acute pain management in patients with OUD. We searched Medline, Embase, CINAHL, and PsychInfo databases for relevant articles. Articles were screened and SDM outcomes of eligible articles were charted. The results were grouped by sub-theme based on a 1997 SDM model. There were three original research studies and one quality improvement study. The remaining articles were split evenly between reviews and reviews of clinical guidelines. Four themes emerged from the review: prior judgment and stigma related to OUD, trust and sharing of information, clinical tools, and interprofessional teams. This scoping review consolidated and expounded the current literature on SDM in the management of acute pain in patients with OUD. More work is needed to address prior judgments by both providers and patients and to build greater dialogue. Clinical tools may aid this process as well as the involvement of a multidisciplinary team.

Predicting decisional conflict: Anxiety and depression in shared decision making

ObjectivesEmotional distress can be a potential barrier to shared decision making (SDM), yet affect is typically not systematically assessed in medical consultation. We examined whether urological patients report anxiety or depression prior to a consultation and if emotional distress predicts decisional conflict thereafter. MethodsWe recruited a large sample of urological outpatients (N = 397) with a range of different diagnoses (42 % oncological). Prior to a medical consultation, patients filled in questionnaires, including the Hospital Anxiety and Depression Scale. After the consultation, patients completed the Decisional Conflict Scale. We scored the rate of anxiety and depression in our sample and conducted multiple regression analysis to examine if emotional distress before the consultation predicts decisional conflict thereafter. ResultsAbout a quarter of patients reported values at or above cut-off for clinically relevant emotional distress. Emotional distress significantly predicted a higher degree of decisional conflict. There were no differences in emotional distress between patients with and without uro-oncological diagnosis. ConclusionsEmotional distress is common in urology patients – oncological as well as non-oncological. It predicts decisional conflict after physician consultation. Practice ImplicationsEmotional distress should be systematically assessed in clinical consultations. This may improve the process and outcome of SDM.

Effect of a Prostate Cancer Screening Decision Aid for African-American Men in Primary Care Settings.

African-American men have an elevated risk of developing and dying from prostate cancer. Shared decision-making (SDM) about prostate cancer screening is recommended but does not always occur. We pilot-tested an online decision aid (DA) in primary care settings using a pre/postevaluation design among African-American men ages 45 to 70 years. Men completed surveys before and after using the DA, which had interactive segments (e.g., values clarification) and provided individualized assessment of prostate cancer risk. Primary outcomes included prostate cancer knowledge, confidence in ability to make informed decisions, decisional conflict, and satisfaction with the decision. Immediately after the clinical visit, patients reported the degree to which they were engaged by their provider in SDM. Among this sample of men (n = 49), use of the DA was associated with increased knowledge about prostate cancer [mean = 55.3% vs. 71.2%; 95% confidence interval (CI), 9.8-22.1; P < 0.001], reduced decisional conflict (mean = 33.4 vs. 23.6; 95% CI, -18.1 to -1.6; P = 0.002) on a scale from 0 to 100, and a decreased preference to be screened (88% vs. 69%; 95% CI, 0.09-0.64; P = 0.01). Most (89%) reported that the DA prepared them well/very well for SDM with their provider. Following the clinical visit with providers, scores on perceived involvement in SDM were 68.1 (SD 29.1) on a 0 to 100 scale. The DA improved men's knowledge, reduced decisional conflict, and promoted the perception of being prepared for SDM. Findings suggest that use of an online DA to improve SDM outcomes warrants further testing in a future trial.

The current extent of and need for shared decision making in atopic dermatitis and psoriasis in the Netherlands: an online survey study amongst patients and physicians.

BackgroundIn shared decision making (SDM), patients and physicians work together to choose the best treatment option for an individual patient. Atopic dermatitis (AD) and psoriasis are particularly suitable for SDM, considering that the best treatment option depends on a patient’s preferences and values (preference‐sensitive decisions). Currently, it is unknown to what extent SDM is applied in treatment decisions for these diseases in the Netherlands.ObjectivesPrimary, to assess the current extent of SDM in AD and psoriasis in the Netherlands amongst patients and dermatologists. Secondary, to assess the degree to which patients and physicians endorse SDM, to explore which characteristics are related to their preference to be involved in SDM and to identify which barriers and facilitators for SDM they perceive.MethodsTwo similar online surveys, one for patients with AD or psoriasis and one for (resident) dermatologists, were carried out. The surveys comprised validated questionnaires (shared decision making questionnaire (SDM‐Q; range 0–100), Control Preference Scale) and study‐specific statements mainly regarding barriers and facilitators for SDM.ResultsThe responses of 219 patients and 147 physicians were analysed. Dermatologists experienced significantly more SDM than patients (SDM‐Q 82 vs 55; P < 0.01).Most patients and dermatologists prefer to share treatment decisions. Mainly facilitators for SDM were perceived, including the positive perception of patients and dermatologists regarding SDM. The perceived barriers included lack of continuity of care by the same physician and lack of time.ConclusionDespite the dermatologists’ optimistic perspective, patients experience a limited extent of SDM and physicians should be aware of this gap. Improvement of SDM in AD and psoriasis is needed. The positive attitude of patients and dermatologists towards the process and outcome of SDM is important facilitators, while barriers were mainly perceived on an organizational level.

Abstract 202: A Pilot Study to Evaluate the Impact of Decision Aid Timing on Mandatory Shared Decision Making for Defibrillator Implantation

Background: In 2018, CMS required shared decision-making (SDM) with a decision (DA) prior to implantation of a primary prevention cardioverter defibrillator (ICD). Little is known about how DAs should be incorporated, but the implementation strategy may affect the process. Providing DAs prior to the SDM visit may facilitate informed discussion. However, this requires identifying ICD candidates ahead of time which may be logistically challenging. Providing the DA during the office visit requires less administrative effort but may reduce the impact of the DA. Objective: To evaluate the impact of DA timing on SDM outcomes. Methods: Patients referred for ICD implantation were block randomized across 3 clinics to receive the DA 30 minutes prior to, or at the end of the SDM visit. Patients were surveyed on implant day in several SDM domains including knowledge about ICDs, decisional conflict, values-choice concordance and the extent to which patients felt engaged in the decision-making process. Patients who chose not to have an ICD implanted after the SDM visit were surveyed by mail. Implanting physicians were also surveyed to assess perceptions about the impact of the DA. Results: Of 42 randomized patients, 24 completed the survey with 9 who received the DA before and 15 after the SDM visit. Three chose not to have an ICD implanted: 1 received the DA before and 2 after the visit. Though overall knowledge about ICDs was similar between groups (Table), every patient who received the DA before the encounter understood the primary purpose of the ICD, compared with 10/15 who received the DA after the visit. Receiving the DA earlier showed a numerically higher rate of understanding the risk of inappropriate ICD shocks. No significant differences were observed in decisional conflict, values-choice concordance, or reported patient engagement in decision-making. Conclusion: Patients who received a DA prior to the visit had numerically, but not significantly, higher rates of understanding the purpose of the ICD and risk of inappropriate shocks. These pilot data suggest that efforts to provide DAs ahead of time may strengthen SDM interaction and that an implementation strategy is critical to study. Important knowledge gaps remain in both groups, suggesting opportunities to improve SDM for ICDs.

Occupational Therapy Shared Decision Making in Adolescent Mental Health

Shared decision making (SDM) shares values of client-centered practice; however, a few studies exist that explore experiences of occupational therapists (OTs) working in adolescent mental health. This study aims to better understand SDM in adolescent mental health using the Canadian Model of Client-Centered Enablement. A qualitative study included interviews (n = 6) and analysis using an inductive approach. The role of the OT, client factors, therapeutic relationship, and nature of the decision were identified as influencing the process and outcome of SDM. The study helps better understand SDM in practice, the need for specialized education for OTs and has identified future research areas.

Trends and perspectives of shared decision-making in schizophrenia and related disorders

Shared decision-making (SDM) is a model of how doctors and patients make medical decisions, which is seen as very applicable to mental health. This review addresses the following issues: Do patients and professionals see the need for SDM? Does SDM actually take place for patients with schizophrenia? What are facilitators and barriers of SDM in schizophrenia treatment? What are the outcomes of SDM? Publications in the last 18 months showed the following: Both patients and providers acknowledge the desirability of SDM. SDM occurs less often in mental health than desired by patients and less frequently compared with general practice. SDM in mental health is complex, takes time and involves more than just two participants; patients' lack of decisional capacity is seen as the major barrier. There are only a few interventional studies measuring the outcome of SDM; existing research constantly shows positive, but small effects. SDM is highly accepted and wanted in the treatment of schizophrenia and related disorders, but more research is needed regarding how SDM can be implemented in regular care. Healthcare professionals need more training in how to deal with difficult decisional situations.

Shared Decision Making

A primary challenge to the American healthcare system is to improve quality by being more evidence based, cost-effective, and patient centered.1,2 The first 2 markers of quality are familiar to physicians and policy makers, wherein disease-specific performance measures and cost data are commonly used to gauge outcomes. The third quality parameter, patient-centered care, has gained increased awareness among the healthcare community but remains elusive to many. Patient-centered outcomes focus on patients’ experiences (eg, symptoms, quality of life) and preferences for these and other outcomes. Thus, the best outcome may be different for different individuals, depending on their priorities, values, and goals. For example, in assessing the outcome of implanting a defibrillator in an 80-year-old patient, we may need to look beyond 1-year mortality and ask whether the decision is consistent with the patient’s values concerning dying and acceptance of potential inappropriate shocks.3 In a patient-centered model, the focus is on high-quality decision making, stemming from the exchange of (1) balanced, evidence-based, disease-specific information; (2) presentation of treatment options and their inherent benefits and tradeoffs; (3) assessment of patient values, priorities, and goals; and (4) alignment of patient values with treatment decisions.4 This process of shared decision making (SDM) has the potential to advance patients’ desired wishes and to achieve better patient-centered outcomes while lowering the costs of care should patients choose less expensive treatment options.5,6 Decision aids are commonly used to facilitate SDM, conveying information about a particular disease and the risks and benefits associated with different treatment strategies, including no treatment at all.7 Decision aids may take the form of a Web-based tool, video, or pamphlet and may be administered in the hospital or office or even independently by patients before their visit. To date, >86 randomized trials have been …