Elements Of Shared Decision-making Research Articles

Is Everyone Beating Around the Bush?: A Qualitative Study Examining the Status of Shared Decision-Making Between Veterans Affairs Providers and Surgical Patients in the ICU

Objective: We sought to determine if and how providers use elements of shared decision-making (SDM) in the care of surgical patients in the intensive care unit (ICU). Background: SDM is the gold standard for decision-making in the ICU. However, it is unknown if this communication style is used in caring for critically ill surgical patients. Methods: Qualitative interviews were conducted with providers who provide ICU-level care to surgical patients in Veterans Affairs hospitals. Interviews were designed to examine end-of-life care among veterans who have undergone surgery and require ICU-level care. Results: Forty-eight providers across 14 Veterans Affairs hospitals were interviewed. These participants were diverse with respect to age, race, and sex. Participant dialogue was deductively mapped into 8 established SDM components: describing treatment options; determining roles in the decision-making process; fostering partnerships; health care professional preferences; learning about the patient; patient preferences; supporting the decision-making process; and tailoring the information. Within these components, participants shared preferred tools and tactics used to satisfy a given SDM component. Participants also noted numerous barriers to achieving SDM among surgical patients. Conclusions: Providers use elements of SDM when caring for critically ill surgical patients. Additionally, this work identifies facilitators that can be leveraged and barriers that can be addressed to facilitate better communication and decision-making through SDM. These findings are of value for future interventions that seek to enhance SDM among surgical patients both in the ICU and in other settings.

Adaptation of a Tailored Lung Cancer Screening Decision Aid for People With HIV

BackgroundPeople with HIV (PWH) are both at elevated risk of lung cancer and high risk of multimorbidity, which makes shared decision-making (SDM) for lung cancer screening (LCS) in PWH complex. There are currently no tools adapted for SDM in PWH. Research QuestionCan a SDM decision aid be adapted to include HIV-specific measures with input from both PWH and their providers? Study Design and MethodsThis study utilized qualitative methods including focus groups with PWH and interviews with HIV-care providers to adapt and iterate an SDM tool for PWH. Eligible participants were PWH enrolled in an HIV primary care clinic who met age and smoking eligibility criteria for LCS and HIV care providers at the clinic. Both the focus groups and interviews included semi-structured discussions of SDM and decision aid elements for PWH. We used a framework-guided thematic analysis, mapping themes onto the Health Equity Implementation framework. ResultsForty-three PWH participated in 8 focus groups; 10 providers were interviewed. Key themes from patients included broad interest in adapting LCS SDM specifically for PWH, a preference for clear LCS recommendations, and the need for positive framing emphasizing survival. Providers were enthusiastic about personalized LCS risk assessments and point-of-care tools. Both patients and providers had mixed views on the utility of HIV-specific risk measures in patient-facing tools. Themes were utilized to adapt a personalized and flexible SDM tool for LCS in PWH. InterpretationPWH and providers were enthusiastic about specific tools for SDM which are personalized and tailored for PWH, make recommendations, and that inform LCS decision-making. Divergent views on presenting patient-facing quantitative risk assessments suggests these elements could be optional but available for review. This tool may have utility in complex decision-making for LCS in this population and is currently being evaluated in a pilot prospective trial.

Shared decision making in integrated complex youth care

Introduction: Families with multiple and enduring problems receive care from various care providers. There is a focus on different areas of life, such as mental health, parenting, financial and social problems. However, due to insufficient coherence and coordination in the care process and fragmentation of services, the support provided often fails to match what a family really needs and wants (Nooteboom et al., 2021). An integrated approach in which the various family members and professionals collaboratively decide on the most adequate care on various life domains is essential to provide families with matching and coherent care. Shared decision making (SDM) can ensure a family-centered approach and family’s active involvement in decision making (Pii et al., 2020). However, the complexity of problems and multiple stakeholder involvement of youth, parents and professionals impact the SDM process, leading to specific needs and preferences in SDM. In this qualitative study we explored the perspectives of families and professionals on essential elements of SDM in integrated complex youth care.
 Method: In this participatory action research project, we worked with families and professionals from Specialist Integrated Teams (SIT). In these teams professionals from different youth and adult care services and with various areas of expertise collaboratively deliver care to families with multiple and enduring problems. Data were collected through (1) semi-structured interviews with youth, parents and professionals and (2) observations of SIT case meetings. Professionals and a parent with experiential knowledge worked as co-researchers. Through learning sessions with parents, youth, professionals and policymakers, the data collected were validated and further deepened. Makoul and Clayman's SDM model of essential elements forms the frame for data analysis (Makoul & Clayman, 2006). Using the qualitative method of abduction, we studied both the practical implementation of this model with families with multiple and enduring problems, and elements not included in the existing model that families and professionals consider essential.
 Preliminary results: Final results will be presented at the conference after further analyses. First rounds of coding shows that the essential elements of SDM are implemented adapted to families with multiple and enduring problems. Shared decisions are achieved through (1) a broad view on multiple family members and professionals, different life domains and both the short and long term of decisions, (2) matching the family’s pace and rhythm, (3) constantly balancing the professional and family roles in decision making, and (4) parallel processes of decision-making between professionals and with the family. Building trust through open and equal relationships appears to be a key element to fluent decision-making.
 Conclusion: In integrated complex youth care the known essential elements of SDM are realized at a different pace and in continuous coherence. Professionals must consider a broad view on multiple family members, life domains and care providers, a continuous and cyclical process of larger and smaller decisions, and take time to build collaborative relationships and trust with families and the care network. 
 In further analyses, we focus on facilitators and barriers in SDM with families with multiple and enduring problems.

Lessons Learned from Shared Decision Making with Oral Anticoagulants: A Literature Review and Evidence-Based Guide for Development of Oral Chemotherapy Decision Aids

Background: Oral systemic treatment is becoming an increasingly common modality of chemotherapy. By providing patients with Decision Aids (DAs), clinicians can facilitate shared decision making (SDM) and aid patients in making a treatment choice aligned with their goals and values. Though considerable research exists on DAs in oncology overall, and some products exist commercially, there is little evidence to inform the development and efficacy of DAs targeting the unique challenges of oral anticancer therapy, including difficulties with adherence and self-administration. Our objective was to examine the literature on DAs developed for oral anticoagulation, as well as patient preferences and DAs in oncology, to guide the development of DAs for oral anticancer therapy. Methods: We conducted an in-depth literature review using PubMed, MEDLINE, and Google Scholar with keywords “decision aids AND oral anticoagulation,” “shared decision-making AND oral anticoagulation,” “decision aids AND oral chemotherapy,” “shared decision-making AND oral chemotherapy,” “decision aids AND oncology,” and “shared decision-making AND oncology.” Selected articles addressed the development, efficacy, and/or patient experience of DAs for SDM in oral anticoagulation therapy and/or oncologic conditions. Results & Discussion: Our focused search identified 57 potential articles related to our research question; of them, 25 were most relevant that met our inclusion criteria.Effective DAs in oral anticoagulation improved patient knowledge, lowered decisional conflict, and increased medication adherence. They covered a broad range of six SDM elements: situation diagnosis, choice awareness, option clarification, harms and benefits, patient preferences, and decision making. A common shortcoming was a lack of information on the day-to-day patient experience. In oncology, DAs increased patient knowledge and lowered decisional conflict, aligning patients' ultimate decision with their personal values, especially when including a specific, value-eliciting survey. Ineffective oncology DAs included those that provided general, unclear, or overly optimistic information. Patients with cancer preferred their DAs to be highly specific, including a list of treatment pros and cons, key questions to ask, information regarding side effects, and clear discussion of expected quality of life resulting from treatment. The concern that providing too much information may be overwhelming or distressing was largely empirical and not evidence-based, as no studies showed harm with DAs providing more information. In addition to following these lessons, considerations in the development of oral chemotherapy DAs include involving patients in early-stage development and addressing barriers to implementation. The challenges presented by integrating a user-friendly interface with the sufficient detail required to make complex decisions can be addressed by including essential points on a single screen and incorporating links providing granular detail for those who seek it. Variable health literacy, computer experience, and language skills mandate consideration and can be addressed through user experience trials, audio-only pages, and placing open access, pre-downloaded healthcare content on mobile devices. Providing DAs ahead of appointments has also proven more effective than during appointments, improving SDM and facilitating discussion. Conclusion: There is a need for evidence-based, effective decision aids to facilitate SDM for patients considering systemic oral chemotherapy. Developers can use lessons learned from oral anticoagulation DAs studies, the use of DAs in cancer care, and patient preference surveys to develop DAs for oral chemotherapy that can help optimize shared decision making.

Potential Adverse Outcomes of Shared Decision Making about Palliative Cancer Treatment: A Secondary Analysis of a Randomized Trial

Background While shared decision making (SDM) is advocated for ethical reasons and beneficial outcomes, SDM might also negatively affect patients with incurable cancer. The current study explored whether SDM, and an oncologist training in SDM, are associated with adverse outcomes (i.e., patient anxiety, tension, helplessness/hopelessness, decisional uncertainty, and reduced fighting spirit). Design A secondary analysis of a randomized clinical trial investigating the effects of SDM interventions in the context of advanced cancer. The relations between observed SDM (OPTION12), specific SDM elements (4SDM), oncologist SDM training, and adverse outcomes were analyzed. We modeled adverse outcomes as a multivariate phenomenon, followed by univariate regressions if significant. Results In total, 194 patients consulted by 31 oncologists were included. In a multivariate analysis, observed SDM and adverse outcomes were significantly related. More specifically, more observed SDM in the consultation was related to patients reporting more tension ( P = 0.002) and more decisional uncertainty ( P = 0.004) at 1 wk after the consultation. The SDM element “informing about the options” was especially found to be related to adverse outcomes, specifically to more helplessness/hopelessness ( P = 0.002) and more tension ( P = 0.016) at 1 wk after the consultation. Whether the patient consulted an oncologist who had received SDM training or not was not significantly related to adverse outcomes. No relations with long-term adverse outcomes were found. Conclusions It is important for oncologists to realize that for some patients, SDM may temporarily be associated with negative emotions. Further research is needed to untangle which, when, and how adverse outcomes might occur and whether and how burden may be minimized for patients. Highlights Observed shared decision making was related to more tension and uncertainty postconsultation in advanced cancer patients However, training oncologists in SDM did not affect adverse outcomes. Further research is needed to untangle which, when, and how adverse outcomes might occur and how burden may be minimized

Abstract 17327: Heterogenous Shared Decision-Making Approaches to Sports Eligibility Decisions for Athletes With Cardiovascular Disease

Background: Historically, almost all pathologic cardiovascular (CV) diagnoses led to complete restriction from competitive sports. In 2015, the American College of Cardiology (ACC) and American Heart Association began to embrace a more nuanced, patient-centered approach to sports eligibility using shared decision-making (SDM). While SDM is a conceptually defensible approach to sports eligibility, operationalization is complex, and we know very little about how physicians understand and deploy it. Methods: To assess sports cardiologists’ understandings of SDM and approaches to eligibility decisions, in-depth interactive interviews were conducted with (N=20) self-identified sports cardiologists. Participants were sampled at random from the ACC Sports and Exercise Cardiology Section. Interviews were conducted using video conference or telephone, and transcripts were analyzed for qualitative description of key domains. Results: Analysis revealed heterogeneity regarding core elements of SDM. All 20 clinicians endorsed SDM, but conceptions of what SDM means varied. Some emphasized communication between physicians rather than with patients, and there was variation in describing the clinician’s role primarily as a provider of information or a more active driver of the decision. Furthermore, even though lifestyle considerations are a key component of SDM for sports eligibility, few clinicians (n=6) specifically referenced elicitation of a patient’s preferences as part of the SDM process. Clinicians also stated highly variable thresholds for prohibitive annual risk of sudden cardiac death during sports participation ranging from <1% to >10%, and they expressed heterogenous views of how athletes interpret risk. Some believed athletes can interpret risk in similar ways as other people; others felt they are largely blind to risk. Conclusions: These data collectively demonstrate heterogenous views of and approaches to SDM for sports eligibility decisions that likely result in very different encounters and decision outcomes. There is a need to develop a more robust understanding of how SDM is operationalized in this context and determine an evidence-based approach to SDM for sports and exercise eligibility in the context of CV disease.

Predictors of Better Shared Decision Making in Goals-Of-Care Clinician-Family Meetings for Critically Ill Neurologic Patients: A Multi-Center Mixed Methods Pilot Study (S4.003)

<h3>Objective:</h3> To characterize and quantify SDM in GOC meetings To identify factors associated with higher SDM score <h3>Background:</h3> Shared decision making (SDM) is recommended by experts to improve difficult decisions in ICUs; yet for the most difficult decision of all, the goals-of-care (GOC) decision, empirical research in medical-surgical ICUs demonstrated that only 2% of clinician-family meetings contained all SDM elements. Little is known about the extent and predictors of SDM in critically-ill neurological patients (CINPs). <h3>Design/Methods:</h3> Two qualitative coders applied a validated 10-element SDM instrument to 63 GOC clinician-family meetings for CINPs, audio-recorded at seven U.S. medical centers. Clinicians and families completed post-meeting questionnaires assessing their own prognostic estimates. We defined the Clinician-Family-Prognostic-Discordance-Score as the difference between both estimates and prognostic discordance as ≥20% difference. We applied univariate and multivariable longitudinal regression to identify predictors of more SDM. <h3>Results:</h3> The median SDM score (total number of unique SDM elements per meeting) was 7 (range 1–10; IQR 5–8). Only 6% of meetings contained all 10 SDM elements. The most common SDM elements were “<i>discussing uncertainty”</i>(89%) and <i>“assessing family understanding”</i>(86%); the least frequent elements were <i>“assessing the need for input from others”</i>(40%) and <i>“eliciting the context of the decision”</i>(32%). Prognostic discordance was 60% and 45% for hospital-survival and 6-month independent functioning, respectively. In univariate analyses, more SDM was associated with female clinicians, and Cohort 2. Meetings with less clinician-surrogate survival discordance approached significance. After adjustment, there was a trend towards clinician gender being an independent predictor of more SDM(p=0.11), but none of the variables were independent predictors. <h3>Conclusions:</h3> Few clinician-family GOC-meetings for CINPs contained all SDM elements. We uncovered modifiable gaps as opportunities for improvement. While our sample was too small to find independent predictors of SDM, our data supports the urgent need to continue our mixed-method of examination of clinician-family GOC-meetings in larger cohorts. <b>Disclosure:</b> Miss Fleming has nothing to disclose. Mr. Prasad has nothing to disclose. Ms. Ge has nothing to disclose. Mr. Meraj has nothing to disclose. Miss Franco has received personal compensation for serving as an employee of Umass Medical School. The institution of Catherine Hough has received research support from NIH. Bernard Lo has nothing to disclose. Shannon Carson has nothing to disclose. The institution of Jay Steingrub has received research support from NHLBI. Douglas White has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for uptodate. Douglas White has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Journal of Respiratory and Critical Care Medicine. The institution of Dr. Muehlschlegel has received research support from NIH. The institution of Dr. Muehlschlegel has received research support from NIH. The institution of an immediate family member of Dr. Muehlschlegel has received research support from NIH. Dr. Muehlschlegel has a non-compensated relationship as a Member of Board of Directors with Neurocritical Care Society that is relevant to AAN interests or activities.

Evaluating Shared Decision-Making in Postpartum Contraceptive Counseling Using Objective Structured Clinical Examinations.

Shared decision-making (SDM) may support widespread uptake of progestin-containing long-acting reversible contraceptives in the immediate postpartum period. We piloted an Objective Structured Clinical Examination (OSCE) to evaluate first-year obstetrics and gynecology resident physicians' use of SDM in postpartum contraception counseling. As part of their 2015 and 2016 OSCEs, first-year OB/GYN residents were instructed to provide contraceptive counseling to a Standardized Patient (SP) portraying a 29-year-old postpartum patient seen during rounds on the morning following her delivery. Three investigators independently scored each resident encounter using a 10-item rubric adapted from a 9-item SDM measure and assigned scores of 0 (absent), 1 (partial), or 2 (complete). Each encounter was video and audio recorded, then transcribed for qualitative analysis. Descriptive statistics was produced using SPSS version 24. Eighteen residents participated. The majority (78%) discussed contraceptive options and timing of initiation. Nearly 33% elicited factors most important to the SP in influencing her preference. Only 6% discussed the benefits of exclusive breastfeeding, and few addressed the uncertainty of progesterone on milk supply and production. Although residents conveyed ample clinical information, the vast majority did not discuss elements of SDM, such as her preferences, values, and goals for future fertility and breastfeeding. Our work revealed that critical elements of SDM are often not explored and deliberated by resident physicians. Trainings (e.g., OSCEs) are needed to equip residents with effective communication skills to facilitate more SDM in postpartum contraceptive care.

Shared Decision-Making in Preventive Activities

Shared Decision-Making in Preventive Activities Abstract. Shared Decision-Making (SDM) is particularly useful in conditions where decisions are preference-sensitive, i.e., where preferences and values of patients are crucial for the further proceeding. This typically applies to conditions where the potential benefit and the potential harm are similar. Preventive activities are characterized by the fact that there is no current burden of disease and the benefit to expect is far in the future. Therefore, it is preference-sensitive if the current effort really pays off. The procedure of SDM in (preventive) counselling can be classified into three steps: Team Talk, Option Talk and Decision Talk. For every step, we present examples of how to talk. After an overview of the current evidence, we present four examples of how to apply SDM in preventive conditions: quit-smoking counselling, lifestyle coaching, vaccination counselling and screening for cancer. Finally, we focus on the role of activated patients and point out the opportunity for SDM during check-up examinations. For all these implementation issues useful tools and links are presented. In summary, important elements of SDM, such as patient centeredness, clarifying needs/goals and shared responsibility, are crucial for the entire spectre of caring for patients, not only for prevention.

Patients' and physicians' gender and perspective on shared decision-making: A cross-sectional study from Dubai.

Delivering patient-centered care is a declared objective of many health delivery systems globally, especially in an era of value-based health care. It entails the active engagement of the patients in healthcare decisions related to their health, also known as shared decision making (SDM). Little is known about the role of gender in shaping the perspective of patients on their opportunity for engaging in SDM in the Arabian Gulf Region. The aim of this study is to investigate the role of gender in shaping patients' perspectives toward their opportunity for SDM in Dubai, UAE. This study utilized a cross-sectional survey consisting of sociodemographic questions and the 9-item Shared Decision-Making Questionnaire (SDM-Q-9). A total of 50 physicians (25 females and 25 males), practicing at a large private healthcare delivery network in Dubai, were recruited using convenience sampling. Ten patients of every recruited physician (5 male and 5 female) were surveyed (i.e., a total of 500 patients). Statistical analysis assessed the differences in patients' perceptions of physician SDM attitude scores by physicians' and patients' gender using independent t-test, ANOVA-test, and Chi-square analyses. A total of 50 physicians and 500 patients (250 male patients and 250 female patients) participated in this study. The odd of patients agreement was significantly lower for male physicians, compared to their female counterparts, on the following elements of SDM: the doctor precisely explaining the advantages and disadvantages of the treatment (OR = 0.55, 95%CI: 0.34-0.88, p = 0.012); the doctor helping them understand the information (OR = 0.47, 95%CI: 0.23-0.97, p = 0.038), the doctor asking about preferred treatment option (OR = 0.52, 95%CI: 0.35-0.77, p = 0.001), and the doctor thoroughly weighting the different treatment options (OR = 0.60, 95%CI: 0.41-0.90, p = 0.013). No significant associations were observed between patients' gender and their perception of their opportunity for SDM. Likewise, no significant associations were observed between the same or different physician-patient gender and patients' perception of physicians' SDM attitudes. Statistically significant associations were observed between physician-patient gender and preferred treatment option for patients (p = 0.012). Study findings suggest that while there were no differences in patients' perspective on SDM by the gender of patients, significant differences were observed by the gender of physicians. Female physicians, compared to their male counterparts, were more engaged in SDM, with both male and female patients. Male physician-female patient dyad received the lowest scores on SDM. This could be explained by the cultural, social, and religious sensitivities that infiltrate the physician-patient relationship in the Arab contexts. Despite the multi-cultural nature of the country, some female patients may still experience some discomfort in opening up and in discussion preferences with male physicians. For physicians, striking the right balance between assertiveness and SDM is necessary within the cultural context, especially among male providers. Offering targeted learning and development programs on the importance and practice of SDM is also necessary to ensure equitable opportunity for engagement in SDM for all patients irrespective of the gender of their provider.

Shared Decision-making in the U.S.: Evidence exists, but implementation science must now inform policy for real change to occur

Shared decision making (SDM) is defined as an approach in which clinicians and patients share the best available evidence when faced with the task of making decisions, and in which patients are supported to consider options to achieve informed preferences [1]. Over the past decade, SDM has been increasingly recognized as a component of value-based care in the US. There is greater acceptance overall that SDM is a key strategy for achieving patient-centered care, enhancing patient safety, and achieving the triple aim of better health, better care, and lower costs [2]. Essential elements of SDM include recognizing and acknowledging that a decision is required; knowing and understanding the best available evidence on risks and benefits; and incorporating the patient's values and preferences into the decision [3]. This paper provides an update of our previous review of SDM in the US published in 2017. We describe changes in healthcare policies to support SDM at the federal and state levels, the integration of SDM into clinical practice, and the role of implementation science to advance SDM. Finally, we discuss potential next steps to inform policies for SDM and facilitate uptake of SDM in clinical practice.

Feasibility of a Digital Patient-Provider Communication Intervention to Support Shared Decision-Making in Chronic Health Care, InvolveMe: Pilot Study.

BackgroundEnhanced communication with health care providers (HCPs) can improve symptom management and health-related quality of life (HRQoL) for patients with chronic health conditions. Access to appropriate communication venues is needed to improve communication, however. As such, digital communication interventions mediated by patient portals carry the potential to support patient-provider communication and interaction and through this, also facilitate shared decision-making (SDM). The InvolveMe intervention was designed to provide patients with the opportunity to communicate symptoms and informational needs prior to consultation via digital assessment, including prioritizing what is most important to discuss with their HCPs, as well as to interact with HCPs through secure messages between outpatient visits.ObjectiveThe aim of this study was to assess the feasibility of the InvolveMe intervention by investigating acceptability, demand (ie, system use), and limited efficacy.MethodsThe study was designed as a single-arm, pre-post feasibility study combining quantitative and qualitative methods for data collection. Patients from an endocrine outpatient clinic were invited to use the InvolveMe intervention for 3 months, and HCPs administering InvolveMe were invited to participate in a focus group. Guided by descriptions of how to design feasibility studies by Bowen et al, feasibility was tested by exploring (1) acceptability, using data collected during recruitment from patient participants and nonparticipants (ie, declined to participate or did not meet study requirements), HCP experiences with recruitment, and the System Usability Scale (SUS); (2) demand via exploration of system use through extraction of system log data and HCP experiences with system use; and (3) limited efficacy testing, via exploration of potential effects from the Short-Form Health Survey (RAND 36), Hospital Anxiety and Depression Scale, and Health Literacy Questionnaire.ResultsPatient participants (N=23) were a median 54 (range 26-78) years old and primarily male (14/23, 61%). Nonparticipants (N=16) were a median 73 (range 55-80) years old and primarily male (12/16, 75%). The average SUS score was 72.2, indicating good system usability. Assessments were completed by 8 participants from home prior to outpatient visits. The assessments entailed various bodily symptoms and needs for information. Participants sent 17 secure messages related to patient administrative matters, symptoms, and challenges. Focus group participants (N=4) were all female and registered nurses. Data were analyzed in 2 predefined themes: Acceptability and Demand. Acceptability included the subthemes intervention attractiveness and intervention suitability. Demand included the subthemes elements of SDM and intervention challenges and opportunities. All patient participants completed outcome measures at baseline, and 19 (19/23, 83%) completed outcome measures at 3 months. These preliminary efficacy findings were mixed and inconclusive.ConclusionsThe study design provided findings from both patient and HCP perspectives and supported feasibility of the InvolveMe intervention. The investigation of acceptability and demand supported the potential for remote SDM mediated by patient portals using assessments and secure messages.Trial RegistrationClinicalTrials.gov NCT NCT04218721; https://www.clinicaltrials.gov/ct2/show/NCT04218721

Shared decision-making conceptual models for physiotherapy: a theory analysis

ObjectiveTo conduct a theory analysis of shared decision-making (SDM) conceptual models relevant to physiotherapy (PT) to help understand theoretical foundations of SDM for the PT discipline. DesignA systematic review was used and updated to select models. The theory analysis was conducted following Walker and Avant’s approach and relevance to six PT competency domains. ResultsOf the 42 SDM models identified, three were eligible. One model (PT-SDM) is explicitly for PTs, one for multimorbidity with older patients (Dynamic Model-SDM), and one for multimorbidity and chronic care (Dual Layer-SDM). Models were published between 2016 and 2019, based on the literature and developed by a range of developers. All propose a schematic linear representation, but two models highlight SDM as an iterative process (PT-SDM, Dynamic Model-SDM). Two models (PT-SDM, Dynamic Model-SDM) are inductive, logical and clear, with the PT-SDM the most generalizable to different decision and setting. Strengths of models: a) all included key SDM elements; b) all involved a variety of stakeholders during development; c) all aimed to fill a gap in clinical practice; d) two are easier to use in clinical practice (PT-SDM, Dynamic Model-SDM); and e) all are generalizable to various healthcare professionals. Limitations of models: a) two poorly described the development process (PT-SDM, Dual Layer-SDM); b) none have been tested; c) none incorporated various actors despite acknowledging the importance of multidisciplinary teams; and d) one has an important logical fallacy (Dual Layer-SDM). ConclusionTwo models could support physiotherapists intending to use SDM in clinical practice. Contribution of the Paper•Out of 42 SDM conceptual models identified, only one was specifically developed for physiotherapists. The PT-SDM contributes explicitly on how SDM fits within physiotherapy practice.•The roles and contributions toward SDM for physiotherapists in the PT-SDM are similar to the other conceptual models. Yet, PTs are more likely to recognize their role in the conceptual model that explicitly targets them.•The PT-SD and DM-SDM could support physiotherapists intending to use SDM in clinical practice.

Holistic Nurse Practitioner Care Including Promotion of Shared Decision-Making.

The purpose of this quantitative, descriptive, exploratory study was to gauge the degree to which nurse practitioners (NPs) incorporate holistic nursing values in their care, with a special focus on shared decision-making (SDM), using the Nurse Practitioner Holistic Caring Instrument (NPHCI), an investigator-developed scale. A single open-ended question inviting free-text comment was also included, soliciting participants' views on the holistic attributes of their care. A convenience sample of NPs (n = 573) was recruited from a southeastern U.S. state Board of Nursing's (BON) publicly available list of licensed NPs. Results suggest that NPs do indeed perceive their care to be holistic, and that they routinely incorporate elements of SDM in their care. Highest scores were accorded to listening, taking time to talk to patients, knowledge of physical condition, soliciting patient input in care decisions, considering how other areas of a patient's life may affect their medical condition, and attention to "what matters most" to the patient. Age, gender, level of education, practice specialty, and location were also associated with inclusion of holistic care. Free-text responses revealed that NPs value holistic care and desire to practice holistically, but identify "lack of time" to incorporate or practice holistic care as a barrier.

Decision aids for shared decision-making and appropriate anticoagulation therapy in patients with atrial fibrillation: a systematic review and meta-analysis.

Underuse of oral anticoagulants (OACs) is commonly observed among patients with atrial fibrillation (AF), which hinders stroke prevention in AF. Shared decision-making (SDM) can help enhance adherence by minimizing patients' misunderstanding of treatment and aligning care with their preferences. Decision aids (DAs) have been developed to facilitate the SDM process. This study aimed to: (i) evaluate the effects of DAs on AF patients' knowledge, decisional conflict, OAC uptake, and adherence and on the incidence of stroke and bleeding; and (ii) explore characterizing factors associated with enhanced DA effectiveness. Five databases were searched. Meta-analysis was conducted using RevMan 5.3 when data were available. Comparative analysis between effective and ineffective DAs was conducted to determine the DA designs associated with better effects. Ten studies were included. Pooling results indicated that DAs reduce decisional conflict related to warfarin use [mean difference = -0.10; 95% confidence interval (CI): -0.18 to -0.02; P = 0.01] and enhance OAC uptake [risk ratio: 1.03; 95% CI: 1.01-1.05; P = 0.004]. The effects of DAs on adherence and incidence of stroke and bleeding were unclear. Comparative analysis revealed that DAs with key elements of SDM (situation diagnosis, choice awareness, option clarification, benefits and disadvantages, and patient's preference) and pre-consultation delivery are more likely to be effective in promoting SDM and OAC uptake. DAs are promising in promoting SDM and OAC uptake in patients with AF. The evidence on adherence and incidence of stroke and bleeding remains uncertain. More trials with rigorous study design and longer follow-up are necessary to obtain evidence.

Supporting Communication of Shared Decision-Making Principles in US Preventive Services Task Force Recommendations.

Aims. This methods project was conducted to support the US Preventive Services Task Force’s (USPSTF) consideration of how information pertinent to shared decision making (SDM) can be best communicated in its recommendations. Methods. The project included a literature scan to identify SDM frameworks, audit of six USPSTF recommendations to judge the completeness of SDM communication, input from eight SDM experts on the most helpful SDM guidance to provide in USPSTF recommendations, and review of USPSTF recommendations and evidence reports to establish criteria for identifying topics that would most benefit from additional communication resources. Results. We identified eight SDM frameworks and selected one to guide the audit of USPSTF recommendations. All six recommendations include SDM elements related to the patient’s role in decision making, preventive service being considered, pros and cons of options, uncertainties about benefits and harms, and importance of patient preferences. Two SDM elements are not routinely communicated in the recommendations—identification of not screening or initiating preventive medication as an alternative and the importance of patient understanding of options. Experts offered suggestions for essential SDM elements to address, such as assessing decisional conflict to measure patient uncertainty in choosing an option and highlighting uncertainty in estimates of benefit and harm, credibility of the evidence base, precision of estimates, and applicability to the individual patient. We developed six criteria for selection of USPSTF recommendations to supplement with a communication resource. Conclusions. The findings of this project can assist the USPSTF and other clinical guideline developers in incorporating SDM information in recommendations and determining which topics would most benefit from additional communication resources to support clinicians in engaging patients in SDM.

Using behavioral theory and shared decision-making to understand clinical trial recruitment: interviews with trial recruiters

BackgroundClinical trial recruitment is a continuing challenge for medical researchers. Previous efforts to improve study recruitment have rarely been informed by theories of human decision making and behavior change. We investigate the trial recruitment strategies reported by study recruiters, guided by two influential theoretical frameworks: shared decision-making (SDM) and the Theoretical Domains Framework (TDF) in order to explore the utility of these frameworks in trial recruitment.MethodsWe interviewed all nine active study recruiters from a multi-site, open-label pilot trial assessing the feasibility of a large-scale randomized trial. Recruiters were primarily nurses or master's-level research assistants with a range of 3 to 30 years of experience. The semi-structured interviews included questions about the typical recruitment encounter, questions concerning the main components of SDM (e.g. verifying understanding, directive vs. non-directive style), and questions investigating the barriers to and drivers of their recruitment activities, based on the TDF. We used directed content analysis to code quotations into TDF domains, followed by inductive thematic analysis to code quotations into sub-themes within domains and overarching themes across TDF domains. Responses to questions related to SDM were aggregated according to level of endorsement and informed the thematic analysis.ResultsThe analysis helped to identify 28 sub-themes across 11 domains. The sub-themes were organized into six overarching themes: coordinating between people, providing guidance to recruiters about challenges, providing resources to recruiters, optimizing study flow, guiding the recruitment decision, and emphasizing the benefits to participation. The SDM analysis revealed recruiters were able to view recruitment interactions as successful even when enrollment did not proceed, and most recruiters took a non-directive (i.e. providing patients with balanced information on available options) or mixed approach over a directive approach (i.e. focus on enrolling patient in study). Most of the core SDM constructs were frequently endorsed.ConclusionsIdentified sub-themes can be linked to TDF domains for which effective behavior change interventions are known, yielding interventions that can be evaluated as to whether they improve recruitment. Despite having no formal training in shared decision-making, study recruiters reported practices consistent with many elements of SDM. The development of SDM training materials specific to trial recruitment could improve the informed decision-making process for patients.

Shared decision-making and the implementation of treatment recommendations for depression

ObjectiveThis study aimed to examine the relationship between shared decision-making (SDM) and the implementation of treatment recommendations amongst outpatients at a specialist Depression Clinic. MethodsA total of 110 adult outpatients in a specialist Depression Clinic in Sydney, Australia, completed an online survey examining their experiences of shared decision-making (SDM) during their psychiatrist consultation and the extent to which they later implemented Depression Clinic treatment recommendations. ResultsThe odds of implementing treatment recommendations were over four times higher in patients who reported a high level of SDM in their consultation, compared to those who reported a low level of SDM. Further, three elements of patient-rated SDM were significantly associated with an increased likelihood of implementing depression treatment recommendations. These three elements were: i) being given the opportunity to ask questions or voice concerns; ii) being asked about any problems or side effects from previous treatments; and iii) being involved in deciding their treatment plan. ConclusionsSDM was significantly associated with an increased likelihood of implementing psychiatrists’ treatment recommendations at a specialist Depression Clinic. Practice implications: We recommend that clinicians be informed of the potential benefits of SDM and adopt SDM when developing treatment plans with patients living with depression.

Shared Decision-Making During Initial Diagnostic and Treatment Planning Visits for Children with Autism Spectrum Disorder.

Although shared decision-making (SDM) can improve patient engagement, adherence, and outcomes, evidence on the use of SDM within the context of autism spectrum disorder (ASD) initial diagnosis and treatment planning remains limited. The goal of this study was to objectively assess the occurrence of SDM in these visits and to compare this assessment with parent and provider perceptions of SDM in the same encounter. After audio-recording and transcribing initial clinical visits between parents (n = 22) and developmental behavioral pediatricians (n = 6) discussing the diagnosis of ASD and treatment options, we used the OPTION5 Item scale to assess the occurrence of SDM. Afterward, parents and providers completed the OPTION5 Item, and parents also participated in a semistructured qualitative interview. Analysis consisted of descriptive statistics for OPTION5 Item scores and a modified grounded theory framework for interviews. Low levels of SDM were observed, with 41% of visits having no elements of SDM. On average, visits scored 1.1 of a possible 20 points on the OPTION5 Item scale for SDM. By contrast, parents and providers indicated on the OPTION5 Item scale that providers made a "moderate" to "skilled" effort to engage parents in SDM. Qualitative interviews with parents were consistent with their OPTION5 Item ratings. The level of SDM determined by parent and provider reports was higher than the level of SDM determined by objective observation using a standard validated rating method. The findings reinforce the need for further research into barriers and facilitators of SDM methods and outcomes within ASD.

Current Status and Future Prospects for Shared Decision Making Before and After Total Knee Replacement Surgery-A Scoping Review.

Background. To gain insight into the current state-of-the-art of shared decision making (SDM) during decisions related to pre and postoperative care process regarding primary total knee replacement (TKR). Methods. A scoping review was performed to synthesize existing scientific research regarding (1) decisional needs and preferences of patients preparing for, undergoing and recovering from TKR surgery, (2) the relation between TKR decision-support interventions and SDM elements (i.e., team talk, option talk, and decision talk), (3) the extent to which TKR decision-support interventions address patients’ decisional needs and preferences. Results. 2526 articles were identified, of which 17 articles met the inclusion criteria. Of the 17 articles, ten had a qualitative study design and seven had a quantitative study design. All included articles focused on the decision whether to undergo TKR surgery or not. Ten articles (all qualitative) examined patients’ decisional needs and preferences. From these, we identified four domains that affected the patients’ decision to undergo TKR: (1) personal factors, (2) external factors, (3) information sources and (4) preferences towards outcome prediction. Seven studies (5) randomized controlled trials and 2 cohort studies) used quantitative analyses to probe the effect of decision aids on SDM and/or clinical outcomes. In general, existing decision aids did not appear to be tailored to patient needs and preferences, nor were the principles of SDM well-articulated in the design of decision aids. Conclusions. SDM in TKR care is understudied; existing research appears to be narrow in scope with limited relevance to established SDM principles and the decisional needs of patients undertaking TKR surgery.