Use Of Patient Decision Aids Research Articles

Implementing shared decision making in Denmark: First steps and future focus areas

What about the political climate?Although there is no explicit description of patient involvement in Danish legislation, patient-centred care is on the political agenda in Denmark. It is integrated as one of eight new national indicators of quality in health care, as well as in the most recent national plan for cancer treatment.What about tools for patient decision support?Development of evidence-based patient decision aids (PDAs) are still at an early stage in Denmark, but recent national and private funding has helped push the field forward. Furthermore, a few stakeholders have started working more systematically with developing and testing PDAs in clinical settings.What about implementation?There is growing interest among Danish health care professionals, but SDM is still far from standard practice in Denmark. Although some courses in SDM and use of PDAs now exist, few health care professionals have received systematic training, and there is little knowledge about implementation and sustainability of SDM in daily clinical practice.What does the future look like for SDM in Denmark?Future progress will depend on the extent to which SDM is systematically integrated in the daily routines of health care professionals and in patient trajectories across treatment courses. The Danish health care system needs to invest further in training and to start addressing the challenges on the organisational and system level, which affect implementation.

Capsule Commentary on Ivlev et al., Use of Patient Decision Aids Increased Younger Women's Reluctance to Begin Screening Mammography: A Systematic Review and Meta-Analysis.

Capsule Commentary on Ivlev et al., Use of Patient Decision Aids Increased Younger Women's Reluctance to Begin Screening Mammography: A Systematic Review and Meta-Analysis.

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.

Use of patient decision aids increased younger women's reluctance to begin screening mammography: a systematic review and meta-analysis.

As breast cancer screening guidelines have changed recently, additional investigation is needed to understand changes in women's behavior after using breast cancer screening patient decision aids (BCS-PtDAs) and the potential effect on mammography utilization. This systematic review and meta-analysis sought to evaluate the effect of BCS-PtDAs on changes in women's intentions to undergo screening mammography and whether women deciding to begin or discontinue screening mammography displayed similar changes in screening intentions after using a BCS-PtDA. We searched Medline, Scopus, PsycINFO, CENTRAL, Health and Psychosocial Instruments, Health Technology Assessment Database, PsycARTICLES, and cited references in eligible papers for randomized controlled trials (RCTs) and observational studies, published through August 24, 2016. The proportions of women who did and not intend to undergo screening and who were uncertain about undergoing screening mammography were pooled, using risk ratios (RR) and random effects. According to the protocol, RCTs or observational studies and any language were considered eligible for systematic review if they included data about women for which shared decision making is recommended. We ultimately included six studies with screening intention data for 2040 women. Compared to usual care, the use of BCS-PtDAs in three RCTs resulted in significantly more women deciding not to undergo screening mammography (RR 1.48 [95% CI 1.04-2.13]; P = 0.03), particularly for younger (38-50 years) women (1.77 [1.34-2.34]; P < 0.001). The use of BCS-PtDAs had a non-significant effect on the intentions of older women (69-89 years) to discontinue screening. The use of BCS-PtDAs increased younger women's reluctance to undergo screening for breast cancer. The implementation of such BCS-PtDAs in clinical practice would be expected to result in a 77% increase in the number of younger women (aged 38-50) who do not intend to be screened, and as a consequence, may reduce utilization of screening mammography. The protocol of this review is registered in the PROSPERO database, #CRD42016036695.

The Preoperative ‘6 Pack’ for Patients With Ankle Arthritis

Category: Ankle Arthritis Introduction/Purpose: There is paucity of literature relating to information needs of patients in Orthopaedic Surgery, despite the fact that Orthopaedic Surgeons in the UK welcome the use of patient decision aids for joint replacement surgery. This multi- centre study aimed to study the information needs of patients for surgical treatment of ankle arthritis from 6 different hospitals across the North East region of England. Methods: Ethical permissions were obtained for this multi-centre qualitative research study. The study recruited 18 patients from 6 hospitals across the North East of England. They were invited to take part in patient focus group meetings. 3 focus groups were conducted with 4-8 patients/ group. These groups were facilitated by independent researchers using a semi-structured discussion approach. Patients were asked for their views on information needs for surgical treatment of ankle arthritis. The focus group meetings were digitally recorded and transcribed verbatim. Data was analysed using the nVIVO software with framework analysis. Results: The analysis highlighted 4 main themes: A) Factors influencing surgical decision making B) Information needs of patients C) Information provision and D) Patient expectations. Theme B is discussed in detail for this abstract. Primary information needs requested by over 70% of patients were: 1. Desire to meet with patients who had undergone similar surgical procedure 2. Information on post-operative rehabilitation 3. Information on return to work and driving 4. Experience of consultant team 5. Written information regarding procedures (advantages, disadvantages, survivorship and outcomes) and 6. Personalized decision support based on individual patient’s lifestyle and preferences. These components form the Preoperative/information ‘6 pack’. Conclusion: When developing information materials and decision tools for patients, providing them with the Ankle Arthritis ‘6 pack’ will enable them to make a more informed choice of the surgical options offered by the consultant.

Ten Years, Forty Decision Aids, And Thousands Of Patient Uses: Shared Decision Making At Massachusetts General Hospital.

Shared decision making is a core component of population health strategies aimed at improving patient engagement. Massachusetts General Hospital's integration of shared decision making into practice has focused on the following three elements: developing a culture receptive to, and health care providers skilled in, shared decision making conversations; using patient decision aids to help inform and engage patients; and providing infrastructure and resources to support the implementation of shared decision making in practice. In the period 2005-15, more than 900 clinicians and other staff members were trained in shared decision making, and more than 28,000 orders for one of about forty patient decision aids were placed to support informed patient-centered decisions. We profile two different implementation initiatives that increased the use of patient decision aids at the hospital's eighteen adult primary care practices, and we summarize key elements of the shared decision making program.

Shared decision‐making and the use of patient decision aids

As part of our series on the NICE Medicines Optimisation guideline,1 this article discusses the section of the guidance concerning shared decisionmaking and the use of patient decision aids.

Decision Aids in the United States: the Patient Response

Background: In the United States and elsewhere, a growing chorus of voices is calling for the routine use of patient decision aids (DAs) and shared decision making (SDM) in day-to-day care. A frequently cited barrier to this approach is the belief that many patients will not be able to understand key clinical information and/or prefer to delegate decision making to providers. These beliefs, often held by providers, are thought to be particularly applicable to elderly and less educated patients.Objectives: To test the perception that older and less educated patients will not value or benefit from DAs.Research design: Self-administered questionnaires completed by patients after viewing DAs.Subjects: 3001 patients in six primary care practice sites facing one of sixteen common medical decisions.Measures: Amount of DA viewed, knowledge about medical tests or treatments, DA rating, and importance of receiving DAs from providers.Results: Across age and education level, higher self-reported exposure to the DAs was associated with higher knowledge scores. Those over 65 and those who had not attended college had knowledge gains at least has high as those in other groups. There were no statistically significant differences by age or education in patient assessment of the importance of using DAs.Conclusions: Patients in primary care settings in the U.S. learn from DAs, rate them highly, and believe that providers should make them available in ways that are mainly independent of patient age or formal education.

Decision aid on radioactive iodine treatment for early stage papillary thyroid cancer: update to study protocol with follow-up extension.

BackgroundPatient decision aids (P-DAs) are used to inform patients about healthcare choices, but there is limited knowledge about their longer term effects, beyond the time period of decision-making.Methods/DesignWe developed a computerized P-DA that explains the choice of radioactive iodine (RAI) adjuvant treatment or no RAI, for patients with low risk papillary thyroid cancer after total thyroidectomy. The original protocol for a randomized controlled trial, comparing the use of the P-DA (with usual care) to usual care alone, has been published in Trialshttp://www.trialsjournal.com/content/11/1/81. We found that P-DA (with usual care) significantly improved patients’ medical knowledge at the time of decision-making (primary outcome) compared to usual care alone (control). In this update, we present the protocol for an extended follow-up study (15 to 23 months post-randomization), including qualitative and quantitative methods. The patient outcomes evaluated using quantitative questionnaires include: the degree to which patients feel well-informed about their RAI treatment choice, decision satisfaction, decision regret, cancer-related worry, mood, and trust in the treating physician. The qualitative component explores the experiences of RAI treatment decision-making, treatment satisfaction, and trial participation in a representative subgroup of patients. Extended follow-up study results will be described for the entire study population, and data will be compared between the P-DA and control groups.Result and ConclusionThis mixed methods extended follow-up study will provide data on long term outcomes, relating to the use of a computerized P-DA in decision-making about adjuvant RAI treatment in early stage papillary thyroid cancer.DiscussionOur results are intended to inform future research in this area, particularly relating to long term effects of the use of P-DAs in making healthcare choices.Trial registrationClinicaltrials.gov identifier NCT01083550, registered 24 February 2010 and last updated 5 January 2015

Do GPs think patient decision aids are a useful tool?

A small survey among a group of GPs has identified certain barriers to the use of patient decision aids. But without such aids can we really claim to practice shared decision making?

The Attitude of Physicians toward the Use of Patient Decision Aids in Iran as a Developing Country.

Background:The patient decision aids (PDAs), which can facilitate the decision-making process when choosing the optimal method of treatment, are a challenge to patients. This study tried to determine the attitude of physicians on the barriers of using PDAs in the way of prioritizing and proposing solutions to them.Methods:This study was a cross-sectional research carried out on 150 clinical faculty members of research centers and scientific associations affiliated with Tehran University of Medical Sciences. The participants were chosen using the convenience sampling method. The attitude of physicians toward the application of PDAs was interviewed using a self-made questionnaire composed of 23 questions. The association between physicians’ attitude to the use of PDAs and their characteristics was examined using the t-test, analysis of variance, and correlation test.Results:The mean score of physicians’ attitude was 76.2 (standard deviation =11.9) and the range was 33–107. There was a significant and direct association between the attitude toward the use of PDA and the respondents’ age (r = 0.237, P = 0.007), years of experience (r = 0.205, P = 0.02), being male (P = 0.04), and working in the private sector (P = 0.009). The attitude score of instructors was significantly lower than that of professors (P = 0.02).Conclusions:The general attitude of physicians toward the use of PDAs was positive. However, apparently as a result of problems mentioned in this study for the developing countries such as Iran, it is much easier to employ these tools in centers run by the private sector. Usage of such tools in public centers necessitates systemic infrastructure as well as credits and budgets required for the training of patients and physicians.

Enablers and barriers to using patient decision aids in early stage breast cancer consultations: a qualitative study of surgeons' views.

BackgroundFor early stage breast cancer, randomized controlled trials (RCTs) have shown that patient decision aids (PtDAs), when used by surgeons, result in increased patient knowledge about options and different patient treatment choices as compared to standard care. Yet, recent data suggests that PtDAs are used by less than 25% of Canadian cancer physicians. We conducted a study to explore breast cancer surgeons’ views on enablers and barriers to the use of PtDAs in their practice.MethodsPurposeful sampling was used to select breast cancer surgeons in three Ontario health regions to participate in semi-structured interviews. Inductive coding and the constant comparative method were used to identify the main themes.ResultsTwenty-two surgeons (79%) agreed to participate (median age, 50 years; 9 (40%) female). Surgeons practiced in academic (n = 7, 32%) or community (n = 15, 68%) hospitals. Fourteen surgeons were aware of PtDAs, nine had used a PtDA with patients as part of an RCT, and six had developed their own informal PtDA for use in their practice. Enablers of informal PtDA use included surgeon exposure during training and surgeon perceived need for a systematic approach when communicating risks and benefits of surgical treatments with patients. Barriers to formal PtDA use included high surgeon confidence in their verbal communication skills, surgeon belief that patients understood conveyed information, and difficulties embedding such tools in practice routines.ConclusionsSurgeons in this study valued systematic communication with patients. Several surgeons changed their practice to include formal or informal PtDAs provided they perceived there was a clear benefit to themselves or to patients. However, high surgeon confidence in their personal communications skills coupled with beliefs that patients understand conveyed information may be key barriers to PtDA uptake once surgeons have established communication routines.

Incentivizing shared decision making in the USA – where are we now?

BackgroundThe Affordable Care Act raised significant interest in the process of shared decision making, the role of patient decision aids, and incentivizing their utilization. However, it has not been clear how best to put incentives into practice, and how the implementation of shared decision making and the use of patient decision aids would be measured. Our goal was to review developments and proposals put forward. MethodsWe performed a qualitative document analysis following a pragmatic search of Medline, Google, Google Scholar, Business Source Complete (Ebscohost), and LexisNexis from 2009–2013 using the following key words: “Patient Protection and Affordable Care Act”, “Decision Making”, “Affordable Care Act”, “Shared Decision Making”, “measurement”, “incentives”, and “payment.” ResultsWe observed a lack of clarity about how to measure shared decision making, about how best to reward the use of patient decisions aids, and therefore how best to incentivize the process. Many documents clearly imply that providing and disseminating patient decision aids might be equivalent to shared decision making. However, there is little evidence that these tools, when used by patients in advance of clinical encounters, lead to significant change in patient-provider communication. The assessment of shared decision making for performance management remains challenging. ConclusionEfforts to incentivize shared decision making are at risk of being limited to the promotion of patient decision aids, passing over the opportunity to influence the communication processes between patients and providers.

An introduction to patient decision aids

Patient decision aids are a means of helping people make informed choices about healthcare that take into account their personal values and preferences. Decision aids are a part of a...

Osteoarthritis patients' perceptions of “appropriateness” for total joint replacement surgery

To understand patients' perspectives on 'appropriateness' for hip and knee total joint arthroplasty (TJA). Focus groups were conducted, stratified by history of a previous TJA, in English-speaking men and women aged 40+ years with moderate to severe hip and knee osteoarthritis. Participants discussed: their appropriateness for TJA; the ideal candidate; patients' role in TJA decision making; and the relationship between appropriateness and willingness to consider TJA. Participants self-completed a questionnaire assessing demographics, arthritis severity (Western Ontario McMaster University Osteoarthritis index - WOMAC), perceived TJA candidacy and willingness to consider TJA. Focus groups were audio-taped and transcribed verbatim. Content analysis was performed. Eleven focus groups were conducted with 58 participants in total: mean age 72 years; 79% female; 25 (43%) with prior TJA; mean WOMAC summary score 43.1. Half reported willingness to consider TJA and 43% felt they were appropriate for TJA. Appropriateness was equated with candidacy for the procedure. Pain intensity and the ability to cope with pain were identified as the most important factors determining surgical candidacy, but felt to be inadequately evaluated by physicians. TJA appropriateness and willingness were felt to be distinct, yet related, concepts; those unwilling had stricter criteria about candidacy than those who were willing. Participants equated appropriateness for TJA with surgical candidacy. Patients' pain experience (intensity, impact on quality of life, ability to cope) was seen as most important in determining appropriateness, but felt to be inadequately evaluated currently. Enhanced patient-physician communication, possibly through use of patient decision aids, has potential to improve patient selection for TJA.

Making high quality decisions in pregnancy: how should interventions which aim to improve decision quality be evaluated?

BackgroundIncreasing importance is placed on offering women choices about their obstetric care. Shared decision making (SDM) is an approach where patients and clinicians make decisions collaboratively combining the clinical expertise...

Clinical effectiveness of a patient decision aid to improve decision quality and glycaemic control in people with diabetes making treatment choices: a cluster randomised controlled trial (PANDAs) in general practice

ObjectiveTo determine the effectiveness of a patient decision aid (PDA) to improve decision quality and glycaemic control in people with diabetes making treatment choices using a cluster randomised controlled trial...

Using Quality Improvement Techniques to Increase Colon Cancer Screening

Screening has been shown to be effective and cost-effective in reducing the incidence of, and mortality from, colorectal cancer. Despite its demonstrated efficacy, colon cancer screening remains underused, with fewer than 60% of age-eligible adults reporting being up to date with recommended screening tests. Several factors account for the low rates of utilization, including patient, provider and system-related issues. Several interventions have been shown to be effective in overcoming these barriers, including the use of patient decision aids. Patient decision aids are tools designed to provide information to patients about screening options, help them consider the pros and cons of the alternatives, and assist them to reach a decision consistent with their values. The use of decision aids in clinical practice can increase screening rates by up to 14 percentage points. Mailing the decision aids to patients in advance of office visits appears to be a cost-effective means of implementation.

Patient decision aids in joint replacement surgery: a literature review and an opinion survey of consultant orthopaedic surgeons.

Patient decision aids could facilitate shared decision-making in joint replacement surgery. However, patient decision aids are not routinely used in this setting. With a view to developing a patient decision aid for UK hip/knee joint replacement practice, we undertook a systematic search of the literature for evidence on the use of shared decision-making and patient decision aids in orthopaedics, and a national survey of consultant orthopaedic surgeons on the potential acceptability and feasibility of patient decision aids. We found little published evidence regarding shared decision-making or patient decision aids in orthopaedics. In the survey, 362 of 639 (57%) randomly selected consultant orthopaedic surgeons responded. Respondents appear representative of consultant orthopaedic surgeons in the UK. Of 272 valid responses, 79% (95% CI, 73-85%) thought patient decision aids a good or excellent idea. There was consensus on the potential helpfulness of patient decision aids and core content. A booklet to take home was the preferred medium/practice model. Despite the increased emphasis on patient involvement in decision-making, there is little evidence in the medical literature relating to shared decision-making or the use of patient decision aids in orthopaedic surgery. Further research in this area of clinical practice is required. Our survey shows that consultant orthopaedic surgeons in the UK are generally positive about the use of patient decision aids for joint replacement surgery. Survey results could inform future development of patient decision aids for joint replacement practice in the UK.

Shared decision-making in Canada: update, challenges and where next!

There is considerable interest for shared decision-making (SDM) within the Canadian healthcare system. The current state of SDM in Canada and challenges with implementation are addressed in the paper at three levels of patient involvement: (1) healthcare system (macro-level); (2) institutions (meso-level) and (3) clinical/medical encounter (micro-level). The legal obligation for doctors to fully disclose information enabling patients’ participation in decisions has spawned professional codes and guidelines with a vision of patient's empowerment through the use of patient decision aid and SDM. Nevertheless, a survey of general practitioners in 2002 indicated that they perceived their role as relieving anxiety induced in patients rather than engaging them in informed decision-making. The virtue of SDM has gained recognition through increased research funding, medical training and some initiatives embedding patient decision aids within the process of care. Future perspectives of SDM in Canada are highlighted such as evaluation of the long-term impact of and costs associated with patient participation in decisions as well as interprofessional approaches to SDM.