Shared Decision-making Conversations Research Articles

Development of Worksheets for Immunomodulator Shared Decision-Making to Facilitate Patient-Clinician Communication: A Quality Improvement Project Employing Design Thinking Principles.

Shared decision-making (SDM) is a principle of humanistic, patient-centered health care within the field of rheumatology. However, clear communication between patients and their clinicians regarding the benefits and risks of immunomodulators may be challenging in a clinical setting. The design-thinking process is a human-centered approach to quality improvement that can help to identify insights to uphold high-quality communication. The development process adhered to the Stanford design thinking process framework, encompassing 5 stages: (1) empathize, (2) define, (3) ideate, (4) prototype, and (5) test. During the empathy stage, quality improvement members spent 4 hours immersed in the clinical setting observing how patients and clinicians engage in SDM conversations. These observations were augmented by unstructured debriefing sessions to better understand the needs and drivers of high-quality SDM. Following this, a rapid ideation workshop was convened to generate creative solutions. These led to rapid prototyping and testing, yielding a final product. The iterative design process identified 4 critical needs: (1) ensuring comprehensibility of materials, (2) upholding accuracy of information, (3) balancing standardization with individualization, and (4) promoting retention of knowledge. During the rapid ideation workshop, the concept of a Worksheet for Immunomodulator Shared Decision-Making (WISDM) was introduced and selected for further elaboration. This led to the creation of 5 prototypes for methotrexate, which were subsequently tested. These were reconciled and modified to make a final product. The WISDM template contains 7 elements that support SDM. Forty-five WISDMs were created for 23 immunomodulators. Further investigation will focus on how WISDMs exactly impact SDM.

Feasibility and acceptability of the ShareD dEciSIon making for patients with kidney failuRE to improve end-of-life care intervention: A pilot multicentre randomised controlled trial

BackgroundKidney failure is associated with a high disease burden and high mortality rates. National and international guidelines recommend health professionals involve patients with kidney failure in making decisions about end-of-life care, but implementation of these conversations within kidney services varies. We developed the DESIRE (ShareD dEciSIon-making for patients with kidney failuRE to improve end-of-life care) intervention from our studies investigating multiple decision maker needs and experiences of end-of-life care in kidney services. The DESIRE intervention's three components are a training programme for health professionals, a patient decision aid, and a kidney service consultation held to facilitate shared decision-making conversations about planning end-of-life care. ObjectivesTo assess the feasibility and acceptability of integrating the DESIRE intervention within kidney services. DesignA pilot study using a multicentre randomised controlled design. SettingFour Danish nephrology departments. ParticipantsPatients with kidney failure who were 75 years of age or above, their relatives, and health professionals. MethodsPatients were randomised to either the intervention or usual care. Feasibility data regarding delivering the intervention, the trial design, and outcome measures were collected through questionnaires and audio recordings at four points in time: before, during, post, and 3 months after the intervention. Acceptability data were collected through semi-structured interviews with patients and relatives, as well as a focus group with health professionals post the intervention. ResultsTwenty-seven patients out of the 32 planned were randomised either to the intervention (n= 14) or usual care (n= 13). In addition, four relatives and 12 health professionals participated. Follow-up was completed by 81 % (n= 22) of patient participants. We found that both feasibility and acceptability data suggested health professionals improved their decision support and shared decision-making skills via the training. Patient and relative participants experienced the intervention as supporting a shared decision-making process; from audio recordings, we showed health professionals were able to support proactively decision-making about end-of-life care within these consultations. All stakeholders perceived the intervention to be effective in promoting shared decision-making and relevant for supporting end-of-life care planning. ConclusionsParticipant feedback indicated that the DESIRE intervention can be integrated into practice to support patients, relatives, and health professionals in planning end-of-life care alongside the management of worsening kidney failure. Minimising exhaustion and enhancing engagement with the intervention should be a focus for subsequent refinement of the intervention. RegistrationThe study has been registered at ClinicalTrials.gov with the identifier: NCT05842772. Date of first recruitment: March 20, 2023.

Options for evaluating communication strategies in treatment and clinical trial discussions.

11083 Background: Nationally, participation in oncology clinical trials is low, with lack of representation of women and ethnic and racial minorities. Interventions to increase patient enrollment in clinical trials and to ensure equity are necessary to improve cancer care for all patients. Shared decision-making conversations are in physicians’ control and are amenable to intervention. However, we must understand the current communication strategies used by medical oncologists in their discussions with patients about high-stakes treatment decisions, including participation in clinical trials. Methods: This was an observational qualitative study conducted between Jan 2022 to Feb 2023. We recruited US medical oncologists who routinely treat colon cancer and have access to clinical trials. Oncologists participated in a simulated, recorded telehealth encounter with a standardized patient recently diagnosed with advanced colon cancer and referred for discussion of treatment options, including a possible clinical trial. Oncologists were provided with the same background information on the patient. Four actors, a Black female, Black male, White female, and White male, were trained to represent the same patient with the same values. Results: 107 physicians at 42 academic institutions across 27 states were contacted via email, 47 responded (44%). 26 consented, and 21 completed the study. Participants were a median age of 41 (range 31-71 years), 48% female, 29% Asian, 5% Black. Encounter length ranged from 28:25 to 76:12 minutes (average 44:05 min). One to four treatment options were discussed during the encounter, including standard of care (1 or 2 options), clinical trial, and best supportive care. Clinical trials were explicitly discussed in nearly all (20/21) conversations and were introduced as an option 1st (1/20), 2nd (5/20), 3rd (12/20), 4th (2/20). Clinical trial discussion length ranged from 3:34 to 19:40 min (average 8:30 min). Discussions were shorter with Black vs White patient, average time 7:00 vs 10:00 min, respectively (p = 0.05), female vs male patient was 9:53 vs 7:34 min, respectively (p = 0.12). Recommendations varied from strong recommendation for a clinical trial (9/21), decision deferred to patient (9/21), recommendation for standard of care (3/21). Conclusions: The way oncologists discuss treatment options with their patients powerfully influences the outcome of the conversation and potentially the decision to participate in a clinical trial. In our study, fewer than half of academic GI oncologists recommend a trial. There is significant variability in option talk including the order as well as the content, duration, detail, and recommendations. Clinical trial discussions were shorter for Black patients. A structured approach to this complex decision-making conversation may help oncologists communicate treatment options to patients in a more equitable and effective way.

Medical record prompts improve the frequency and documentation of dizziness and driving conversations in the ENT balance clinic.

Driving capacity is affected by vestibular disorders and the medications used to treat them. Driving is not considered during medical consultations, with 92 per cent of patients attending a centre for dizziness not discussing it with the doctor. To investigate if medical record prompts facilitate dizziness and driving conversations in ENT balance clinics. A questionnaire was designed to reflect the current standards of practice and advice given regarding driving and dizziness during balance clinic consultations. Medical record prompts facilitated the improved frequency and recording of shared decision-making conversations about driving and dizziness in 98 per cent of consultations. This study highlights the benefits of medical record prompts for documented and accurate shared decision-making conversations surrounding dizziness, vertigo, vestibular conditions and driving. This potentially improves safety for all road users, and protects the patient and clinician in the event of road traffic accidents and medico-legal investigations.

Prevalence and determinants of shared decision-making for PSA testing in the United States.

Shared decision-making (SDM) is recommended for prostate-specific antigen (PSA) testing but appears underutilized. This population-based study assessed the prevalence and determinants of SDM for PSA testing among US men. We assessed PSA testing rates and SDM engagement in men aged 40 and older without prostate cancer history using the 2019 National Health Interview Survey. SDM was defined as discussing the advantages and disadvantages of PSA testing with a physician. We used multivariable logistic regression with machine learning to identify factors associated with lack of SDM. Among 9723 eligible participants (mean age 58 years), lifetime PSA testing prevalence was 45.9% and the 1-year testing incidence was 29.1%. Only 24.1% reported engaging in SDM with a physician, while 62.9% never discussed PSA testing. Younger age and lower education levels were the primary determinants of decreased SDM engagement. Men with less education engaged in SDM less than half as often as those with higher education levels across all age groups. Societal guidelines recommend SDM for PSA testing. However, most men, regardless of age, have never engaged in SDM conversations with a healthcare provider about PSA testing, especially those with less education. More efforts are needed to improve patient-provider conversations about the potential benefits and harms of PSA testing.

Patient Characteristics and the Extent to Which Clinicians Involve Patients in Decision Making: Secondary Analyses of Pooled Data.

The occurrence of shared decision making (SDM) in daily practice remains limited. Various patient characteristics have been suggested to potentially influence the extent to which clinicians involve patients in SDM. To assess associations between patient characteristics and the extent to which clinicians involve patients in SDM. We conducted a secondary analysis of data pooled from 10 studies comparing the care of adult patients with (intervention) or without (control) a within-encounter SDM conversation tool. We included studies with audio(-visual) recordings of clinical encounters in which decisions about starting or reconsidering treatment were discussed. In the original studies, the Observing Patient Involvement in Decision Making 12-items (OPTION12 item) scale was used to code the extent to which clinicians involved patients in SDM in clinical encounters. We conducted multivariable analyses with patient characteristics (age, gender, race, education, marital status, number of daily medications, general health status, health literacy) as independent variables and OPTION12 as a dependent variable. We included data from 1,614 patients. The between-arm difference in OPTION12 scores was 7.7 of 100 points (P < 0.001). We found no association between any patient characteristics and the OPTION12 score except for education level (p = 0.030), an association that was very small (2.8 points between the least and most educated), contributed mostly by, and only significant in, control arms (6.5 points). Subanalyses of a stroke prevention trial showed a positive association between age and OPTION12 score (P = 0.033). Most characteristics showed no association with the extent to which clinicians involved patients in SDM. Without an SDM conversation tool, clinicians devoted more efforts to involve patients with higher education, a difference not observed when the tool was used. Most sociodemographic patient characteristics show no association with the extent to which clinicians involve patients in shared decision making.Clinicians devoted less effort to involve patients with lower education, a difference that was not observed when a shared decision-making conversation tool was used.SDM conversation tools can be useful for clinicians to better involve patients and ensure patients get involved equally regardless of educational background.

Challenges Addressing Lung Cancer Screening for Patients With Multimorbidity in Primary Care: A Qualitative Study.

Many individuals who are eligible for lung cancer screening have comorbid conditions complicating their shared decision-making conversations with physicians. The goal of our study was to better understand how primary care physicians (PCPs) factor comorbidities into their evaluation of the risks and benefits of lung cancer screening and into their shared decision-making conversations with patients. We conducted semistructured interviews by videoconference with 15 PCPs to assess the extent of shared decision-making practices and explore their understanding of the intersection of comorbidities and lung cancer screening, and how that understanding informed their clinical approach to this population. We identified 3 themes. The first theme was whether to discuss or not to discuss lung cancer screening. PCPs described taking additional steps for individuals with complex comorbidities to decide whether to initiate this discussion and used subjective clinical judgment to decide whether the conversation would be productive and beneficial. PCPs made mental assessments that factored in the patient's health, life expectancy, quality of life, and access to support systems. The second theme was that shared decision making is not a simple discussion. When PCPs did initiate discussions about lung cancer screening, although some believed they could provide objective information, others struggled with personal biases. The third theme was that ultimately, the decision to be screened was up to the patient. Patients had the final say, even if their decision was discordant with the PCP's advice. Shared decision-making conversations about lung cancer screening differed substantially from the standard for patients with complex comorbidities. Future research should include efforts to characterize the risks and benefits of LCS in patients with comorbidities to inform guidelines and clinical application.

"We will be the ones bearing the consequences": Aqualitative study of barriers and facilitators to shared decision-making in hospital-based maternity care.

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. 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. 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. 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.

Shared decision-making and social science: A patient perspective.

Shared decision making (SDM) between doctors and patients has been deemed important when providing care. Yet, it can be difficult to achieve. Specific examples from a patient perspective are integrated with the social science literature to provide an overview of components of SDM including the role of fit, trust, information asymmetry, cognitive decision frames and balancing medical and patient outcomes. Consideration of these issues should facilitate higher quality SDM conversations.

Abstract A059: The role of conversational chatbots in enhancing shared decision making for African American men with early stage prostate cancer

Abstract Introduction : Enhancing shared decision making (SDM) for African American (AA) men with early stage prostate cancer using conversational chatbots (CCs) aims to improve communication, provide information, and empower them in their treatment decision making process. SDM is a collaborative approach that involves patients and healthcare providers working together based on medical evidence and patient preferences. However, AA men face significant disparities in prostate cancer (PCa) outcomes, including higher incidence and mortality rates compared to other racial/ethnic groups in the United States. Limited access to recommended PCa information and inadequate information during SDM conversations contribute to the challenges AA men face when making treatment decisions. The purpose of this study was to develop a conversational chatbot (CC) to provide PCa information in real time thus, enhancing SDM for AA men with PCa. Methods: The Ottawa Decision Support Framework and the International Patient Decision Aids Standards provided guidance and framework for the development of the CC. Our participatory research approach involved a diverse Community-Based Participatory Research Advisory Board (CBPRAB) consisting of twelve members. The CBPRAB included AA PCa survivors, AA men, caregivers, advocates, community leaders, and cancer care providers. Through training in research methods and focus group facilitation, CBPRAB members actively contributed their valuable insights, ensuring a collaborative and inclusive research process. Results: Five stakeholder focus groups (n = 44) comprising AA men, PCa survivors, spouses, healthcare professionals, and advocates provided valuable input for the development of the CC. In total, 819 questions were generated through interviews conducted during the focus groups. These questions were either inferred from the discussions or explicitly provided by the participants. The answers to these questions were developed from evidence based sources, such as the American Cancer Society and National Comprehensive Cancer Network Guidelines. An Android-based smartphone application that allows users to submit questions via speech was created. The application matches the user's question within the data set of 819 questions and provides answers in both voice and text formats. Conclusion : The Android-based smartphone application was alpha tested on four stakeholder focus groups (n=35). The CC developed in the smartphone application demonstrated the capacity to provide real time responses to user questions sourced from an 819-question database derived from our stakeholder focus groups. By offering evidence based information and directing users to additional resources if the question is not in the database, the CC can improve accessibility to medical information, thus enhancing the SDM process regarding early stage prostate cancer. Citation Format: Angela D. Adams. The role of conversational chatbots in enhancing shared decision making for African American men with early stage prostate cancer [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A059.

External validation of GO-FAR 2 calculator for outcomes after in-hospital cardiac arrest with comparison to GO-FAR and trial of expanded applications

AimExternally validate the GO-FAR 2 tool for predicting survival with good neurologic function after in-hospital cardiac arrest with comparison to the original GO-FAR tool. Additionally, we collected qualitative descriptors and performed exploratory analyses with various levels of neurologic function and discharge destination. MethodsRetrospective chart review of all patients who underwent in-hospital resuscitation after cardiac arrest during the calendar years 2016–2019 in our institution (n = 397). GO-FAR and GO-FAR 2 scores were calculated based on information available in the medical record at the time of hospital admission. Cerebral performance category (CPC) scores at the time of admission and discharge were assessed by chart review. ResultsThe GO-FAR 2 score accurately predicted outcomes in our study population with a c-statistic of 0.625. The original GO-FAR score also had accurate calibration with a stronger c-statistic of 0.726. The GO-FAR score had decreased predictive value for lesser levels of neurologic function (c-statistic 0.56 for alive at discharge) and discharge destination (0.69). Descriptors of functional status by CPC score were collected. ConclusionOur findings support the validity of the GO-FAR and GO-FAR 2 tools as published, but the c-statistics suggest modest predictive discrimination. We include functional descriptors of CPC outcomes to aid clinicians in using these tools. We propose that information about expected outcomes could be valuable in shared decision-making conversations.

908-P: Incorporating Shared Decision Making (SDM) to Improve Adoption of Connected Insulin Pens (CIP)

Background: CIP can improve glycemic control and quality of life for people with diabetes on multiple daily injections (MDI). Despite its benefits, providers may sub optimally prescribe CIP. The purpose of this study is to use quality improvement methods to successfully implement a validated attitude assessment to foster SDM conversations around CIP. Method: The T1D Exchange recruited seven pediatric and adult diabetes centers to participate in this project from June - November 2022. The centers applied QI principles to implement the Diabetes Technology Attitude (DTA) questionnaire, a validated tool to facilitate SDM conversations. Positive responses prompted discussion about CIP. Each center contributed their data from a sample of people with Type 1 Diabetes (T1D) and Type 2 Diabetes on Insulin (T2D) who responded to the DTA. Result: Eighty-eight people with diabetes and CGM but not on CIP naive completed the SDM tool. Over 70% of both T1D and T2D patients agreed that diabetes technology made their lives easier, does ‘more good than bad,’ and that they feel lucky to live in a time with so much technology (Figure 1). Sixty-nine percent of the cohort were prescribed CIP as a result of intentional SDM conversations based on the DTA results. Conclusion: Validated SDM tools, such as DTA, can be a viable, low burden strategy to introduce conversations on the use of diabetes technology like CIP in clinical practice. Disclosure O.Odugbesan: None. A.K.Myers: Research Support; Neurocrine Biosciences, Inc. O.Ebekozien: Advisory Panel; Medtronic, Research Support; Eli Lilly and Company, Dexcom, Inc. D.T1d exchange quality improvement collaborative (t1: n/a. N.A.Xavier: Employee; Eli Lilly and Company, Speaker's Bureau; Boehringer Ingelheim and Eli Lilly Alliance. T.Wright: None. G.Nelson: None. J.Friedman: None. G.Aleppo: Advisory Panel; Medscape, Consultant; Bayer Inc., Insulet Corporation, Research Support; Dexcom, Inc., Eli Lilly and Company, Emmes, Insulet Corporation, Fractyl Health, Inc., WellDoc, Speaker's Bureau; Dexcom, Inc. G.O'malley: Research Support; Dexcom, Inc., Abbott Diabetes, Tandem Diabetes Care, Inc., Omnipod, Eli Lilly and Company. A.M.Mckee: Advisory Panel; Medtronic, Novo Nordisk. B.Miyazaki: None. Funding Eli Lilly and Company

Shared Decision Making in the Care of Patients With Cancer.

Shared decision making (SDM) is a method of care that is suitable for the care of patients with cancer. It involves a collaborative conversation seeking to respond sensibly to the problematic situation of the patient, cocreating a plan of care that makes sense intellectually, practically, and emotionally. Genetic testing to identify whether a patient has a hereditary cancer syndrome represents a prime example of the importance for SDM in oncology. SDM is important for genetic testing because not only results affect current cancer treatment, cancer surveillance, and care of relatives but also these tests generate both complex results and psychological concerns. SDM conversations should take place without interruptions, disruptions, or hurry and be supported, where available, by tools that assist in conveying the relevant evidence and in supporting plan development. Examples of these tools include treatment SDM encounter aids and the Genetics Adviser. Patients are expected to play a key role in making decisions and implementing plans of care, but several evolving challenges related to the unfettered access to information and expertise of varying trustworthiness and complexity in between interactions with clinicians can both support and complicate this role. SDM should result in a plan of care that is maximally responsive to the biology and biography of each patient, maximally supportive of each patient's goals and priorities, and minimally disruptive of their lives and loves.

Prevalence of Shared Decision-making in Prostate Cancer Screening in New York State.

Current guidelines recommend that physicians use a shared decision-making (SDM) approach to engage with patients on the potential benefits and harms of prostate cancer screening based on their individual risk. In a sample of 4,118 men aged 55-69 from the 2018 New York State Behavioral Risk Factor Surveillance Survey (BRFSS), we compared the frequency of screening recommendations and SDM conversations according to four race/ethnic groups. In logistic regression, we evaluated the likelihood of SDM conversations between race/ethnic groups. Our findings suggest that the odds of never having a SDM conversation with their healthcare provider were significantly higher among Hispanic men (OR 95% CI: 2.10, 1.11-3.99) and other/multiracial men (OR, 95% CI: 3.08, 1.46-6.52) compared to white men, while black men had comparable odds (1.52, 0.98-2.34). The lower frequency of SDM conversation among Hispanic and other/multiracial men suggest a missed opportunity for healthcare providers to guide informed screening decisions.

Implementing shared decision making according to the choosing wisely programme: Perioperative medicine for older people undergoing surgery.

Shared decision making (SDM) is the process whereby patients and healthcare professionals work together to achieve a consensus management decision, based on best clinical evidence and patient's preferences. No formal approach to documentation of SDM conversations exists in setting of peri-operative medicine. To assess and improve the quality and consistency of documentation regarding SDM conversations in an elective surgical outpatient population and appraise the satisfaction of patients and professionals in SDM. The study was conducted in a geriatrician led perioperative medicine for older people undergoing surgery service, at an inner-city teaching hospital serving a tertiary surgical referral population. The quality improvement programme intervention comprised a Choosing Wisely, UKSDM tool, consisting of Benefits, Risks, Alternatives and Doing Nothing(BRAN mnemonic), clinic posters, patient leaflets, and an introductory SDM workshop and education sessions, and observation and standardised feedback of SDM. Clinic letters were reviewed to identify SDM documentation compliance. Participants included clinicians of all grades and disciplines, and consecutive patients attending the clinic. Clinician interviews revealed inconsistent documentation of SDM. We reviewed 203 clinic letters following the initial implementation of SDM documentation tool, only 59% (n = 120) had fully completement BRAN tool. Additional interventions improved clinic SDM documentation compliance to 98%. A prospective observation study conducted revealed patients and clinician satisfaction at 93% and 79%, respectively. The BRAN tool is adaptable to many health decision settings, including discussions related to treatment, investigations, and procedures, which expands its potential to improve patient safety.

"I'm Clean and Sober, But Not Necessarily Free": Perceptions of Buprenorphine Among Patients in Long-Term Treatment.

Patients receiving buprenorphine for the treatment of opioid use disorder (OUD) experience a roughly 50% reduction in mortality risk relative to those not receiving medication. Longer periods of treatment are also associated with improved clinical outcomes. Despite this, patients often express desires to discontinue treatment and some view taper as treatment success. Little is known about the beliefs and medication perspectives of patients engaged in long-term buprenorphine treatment that may underlie motivations to discontinue. This study was conducted at the VA Portland Health Care System (2019-2020). Qualitative interviews were conducted with participants prescribed buprenorphine for ≥2 years. Coding and analysis were guided by directed qualitative content analysis. Fourteen patients engaged in office-based buprenorphine treatment completed interviews. While patients expressed strong enthusiasm for buprenorphine as a medication, the majority expressed the desire to discontinue, including patients actively tapering. Motivations to discontinue fell into 4 categories. First, patients were troubled by perceived side effects of the medication, including effects on sleep, emotion, and memory. Second, patients expressed unhappiness with being "dependent" on buprenorphine, framed in opposition to personal strength/independence. Third, patients expressed stigmatized beliefs about buprenorphine, describing it as "illicit," and associated with past drug use. Finally, patients expressed fears about buprenorphine unknowns, including potential long-term health effects and interactions with medications required for surgery. Despite recognizing benefits, many patients engaged in long-term buprenorphine treatment express a desire to discontinue. Findings from this study may help clinicians anticipate patient concerns and can be used to inform shared decision-making conversations regarding buprenorphine treatment duration.

Implementation of shared decision-making conversations in the preoperative evaluation clinic: Developing an educational curriculum and improving quality

BackgroundThe American College of Surgeons created the Geriatric Surgical Verification program to improve the quality of perioperative care for geriatric patients. The standards include the incorporation of shared decision-making with goals of care discussions as well as frailty and cognitive impairment assessments. As perioperative physicians, anesthesiologists can provide many of these discussions in the preoperative assessment clinic. Our project developed an educational curriculum for anesthesiology residents to train them to effectively conduct these conversations, eventually expanding these assessments to all providers in our perioperative clinic. We describe our team's implementation of shared decision-making conversations and frailty assessments into preoperative evaluation clinic workflow for patients greater than 65 years old MethodsUsing the six-step approach to curriculum development, we provided resources to improve anesthesiology residents’ communication skills and ability to use shared decision-making conversations to guide perioperative management.1 We also used Plan-Do-Study-Act cycles to streamline the assessments and expand its utilization for all providers seeing geriatric patients in the perioperative assessment clinic. We measured added time to clinic visit and volume of patients. We provided templates and literature with faculty support for residents. The documentation was further integrated with the preoperative assessment note. ResultsDuring the initial implementation period, 110 patients participated in shared decision-making conversation with residents, increasing visit time by an average of 7.29 minutes. This was a small enough increase that the template was expanded to all providers in the preoperative assessment clinic. Residents had only 1-5 prior goals of care discussions, and believed the curriculum provided greater opportunity and structure to improve their skills in this domain. ConclusionWe found this implementation to be successful with increased value in the preoperative evaluation clinic while also bolstering our shared decision-making educational curriculum for our anesthesiology residents. Since this study is a pilot, the impact and finalized intervention and curriculum are still being refined.

Abstract 9623: Shared Decision Making for Atrial Fibrillation: An Overview of Seven Studies Within an Encounter - Randomized Trial

Introduction: Shared decision-making (SDM) about anticoagulant treatment in patients with atrial fibrillation (AF) is widely recommended but its effectiveness is unclear. We assessed the extent to which using an SDM tool promotes high-quality SDM. Hypothesis: SDM will improve communication quality, knowledge, and decisional conflict and will translate to improved medication adherence and outcomes. Methods: In this multicentre encounter-randomized trial, we included patients with nonvalvular AF considering starting/reviewing anticoagulation, and their clinicians. We compared usual care with or without ANTICOAGULATION CHOICE, an SDM conversation tool for use during the clinical encounter that presents individualized risk estimates and compares anticoagulation options across patient important issues. Results: We enrolled and video-recorded 922 patient-clinician encounters. So far, our data have shown that participants in both arms reported near-optimal communication quality, knowledge, and decisional conflict (JAMA IM-2020). Patients in intervention-arm estimated their stroke risks more accurately and were more involved in decision-making (JAMA IM-2020), clinicians were more satisfied (JAMA IM-2020), and cost conversation were more common (JAMA NO-2021). Use of the intervention had no effect on treatment decisions, encounter duration (JAMA IM-2020), treatment adherence, clinical outcomes (JAHA-epub) or patient-perceived sense of the care plan (PEC-epub). New analyses have shown that compared to eligible white participants, black participants more frequently did not enrol to the study. Enrolment of Black, indigenous, and people of colour benefited most form including and prioritizing practices most likely to care for them. We found no evidence of contamination (tool use, functional, or learned) between study arms. Conclusions: Use of an SDM tool improved some measures of SDM quality, without affecting treatment decisions and their sensibility, encounter duration, patient adherence, or clinical outcomes. Our results should calibrate expectations as to what could be accomplished by implementing SDM tools about anticoagulation in the care of patients with AF

Shared decision-making for the treatment of proximal femoral fractures in frail institutionalised older patients: healthcare providers' perceived barriers and facilitators.

IntroductionProximal femoral fractures are common in frail institutionalised older patients. No convincing evidence exists regarding the optimal treatment strategy for those with a limited pre-fracture life expectancy, underpinning the importance of shared decision-making (SDM). This study investigated healthcare providers’ barriers to and facilitators of the implementation of SDM.MethodsDutch healthcare providers completed an adapted version of the Measurement Instrument for Determinants of Innovations questionnaire to identify barriers and facilitators. If ≥20% of participants responded with ‘totally disagree/disagree’, items were considered barriers and, if ≥80% responded with ‘agree/totally agree’, items were considered facilitators.ResultsA total of 271 healthcare providers participated. Five barriers and 23 facilitators were identified. Barriers included the time required to both prepare for and hold SDM conversations, in addition to the reflective period required to allow patients/relatives to make their final decision, and the number of parties required to ensure optimal SDM. Facilitators were related to patients’ values, wishes and satisfaction, the importance of SDM for patients/relatives and the fact that SDM is not considered complex by healthcare providers, is considered to be part of routine care and is believed to be associated with positive patient outcomes.ConclusionAwareness of identified facilitators and barriers is an important step in expanding the use of SDM. Implementation strategies should be aimed at managing time constraints. High-quality evidence on outcomes of non-operative and operative management can enhance implementation of SDM to address current concerns around the outcomes.

Shared Decision-Making Concerning Anal Cancer Screening in Persons With Human Immunodeficiency Virus.

Anal high-grade squamous intraepithelial lesion (aHSIL) is the immediate precursor of anal cancer. Anal cytology is a recommended screening test to identify aHSIL among people with human immunodeficiency virus (HIV; PWH). Heterogeneity of risk for invasive anal cancer among PWH suggests the value of a shared decision-making framework regarding screening. Using a longitudinal HIV cohort with a comprehensive anal cancer screening program, we estimated the adjusted probabilities of having aHSIL on the first anal cytology. We used logistic regression models with inverse probability weighting to account for differential screening in the cohort and to construct a predicted probability nomogram for aHSIL. Sensitivity analysis was performed to estimate aHSIL prevalence corrected for misclassification bias. Of 8139 PWH under care between 2007 and 2020, 4105 (49.8%) underwent at least 1 anal cytology test. First-time cytology aHSIL was present in 502 (12.2%) PWH. The adjusted probability of having aHSIL varied from 5% to 18% depending on patient characteristics. Prespecified factors in the aHSIL prediction model included nadir CD4 cell count, ethnicity, race, age, sex, gender identity, and HIV risk factors. The ability of the model to discriminate cytological aHSIL was modest, with an area under the curve of 0.63 (95% confidence interval, .60-.65). PWH are at increased risk for aHSIL and invasive anal cancer. Risk, however, varies by patient characteristics. Individual risk factor profiles predictive of aHSIL can be modeled and operationalized as nomograms to facilitate shared decision-making conversations concerning anal cancer screening.