Shared Decision-making Performance Research Articles

Abstract P6-05-15: Standard of Care for HR+/HER2- Breast Cancer: Integrating The “Yale Model Shared Decision-Making Multidisciplinary Team Solution” into the Practice Setting

Abstract Background: Breast cancer patients are faced with treatment choices that can involve complex preference-sensitive decisions. The National Quality Forum initiated a “Call to Action” to integrate shared decision-making (SDM) processes into practice where clinicians and patients work together to make healthcare decisions that align with what matters most to patients. Projects In Knowledge, @Point of Care, Dartmouth and Yale collaborated to develop a pilot educational initiative to address and improve patient-centered care and SDM processes in the institutional cancer care setting. Methods: Training materials co-developed for the Yale Breast Cancer multidisciplinary team (N=11: oncologists, nurses/NPs, pharmacist) address SDM, CDK4/6 Inhibitor treatment of metastatic HR+ HER2- breast cancer, and clinician-patient role play methods implementing SDM in treatment discussions/decisions with patients. Reinforcement training, based on interim interview and case role play assessments, was customized to meet specific needs of the team. Qualitative semi-structured interviews and simulation case role play observational methods, using a two-rater system, were used to assess improved SDM performance. Baseline pre-intervention interviews and case role play assessments were compared to interim post-intervention and end of pilot (EOP) post-reinforcement training intervention interviews and case role play assessments (using a Likert scale 0-4 rating score: 0=0%; 1=25%, 2=50%; 3=75%; 4=100%). Following the training and assessments, a focus group of team members provided insights into the performance of the group, assessed the acceptability, feasibility, and repeatability of the program, and informed future education. Results: Semi-structured interview findings revealed that clinicians learned about nuances of CDK 4/6 inhibitors, crystallized their understanding of SDM through reinforcement training (customized in real time), and felt they were better able to implement SDM as a result of their case role play assessments. Training empowered the Yale Breast Cancer team to show pre- to post-education improvement in SDM case role play scenarios, ranging from 16% to 39%. Areas of greatest improvement: 1) determining decision style preference (+36%); 2) determining patients’ risk/burden tolerance (+32%); 3) determining patients’ activation, engagement, and self-efficacy (+34%), 4) determining trade-off decisions with patients (+39%), and 5) determining patients’ readiness to make a decision (+32%). Future research should explore how best to integrate SDM into the real world time restricted clinical practice. Conclusions: Educational training improved SDM skills for the multidisciplinary Yale Breast Cancer team, which can lead to improved clinician-patient decision-making and patient-centric care. The training process also facilitated team building and encouraged ongoing participation in SDM. Overall Yale Breast Cancer SDM Pilot Case Study Role-Play Assessments (Data reflect findings for 11 participants who completed their case role play) Citation Format: Elaine Rudell, Tarjani Agrawal, Patty Peterson, Michele Fallon Ingram, Brant Oliver, Kerin Adelson. Standard of Care for HR+/HER2- Breast Cancer: Integrating The “Yale Model Shared Decision-Making Multidisciplinary Team Solution” into the Practice Setting [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-05-15.

Primary Care Physician Perceptions of Shared Decision Making in Lung Cancer Screening.

The Centers for Medicare and Medicaid Services (CMS) supports lung cancer screening (LCS) with annual low-dose computed tomography (LDCT) for patients who undergo shared decision-making (SDM) about LCS. Unfortunately, SDM and LCS rates are low in primary care, and, as a result, the potential benefits of LCS are not being realized. The research team interviewed 16 primary care physicians in a large urban medical center (7 in Family and Community Medicine and 9 in Internal Medicine) on their views of SDM and LCS. Interview audio-recordings were transcribed. Coders analyzed the interview transcripts independently using direct content analysis to identify major themes and subthemes. Results of interview analyses show that physicians were aware of LCS but believed that they and their patients would benefit from receiving more information about screening guidelines. Physicians knew about SDM and felt that SDM performance could help to identify issues that are important to patients and may affect their receptivity to LCS. However, many physicians expressed concerns about the time required for SDM and completing SDM about LCS when other issues need to be addressed. They also acknowledged the challenge of engaging patients, especially those with low health literacy, in SDM. In practice, some physicians reported instead of engaging eligible patients in SDM, they simply encourage them to screen. Importantly, most physicians said that they would like to receive training in SDM. Findings from this study indicate that primary care physicians support the dissemination of information about LCS and understand the importance of SDM. Physicians also feel that performing SDM in routine care is challenging but are receptive to additional training in SDM. Health systems should take steps to support SDM and LCS performance in primary care.

NSCLC: Integrating the “Yale model shared decision-making solution” into the practice setting.

7054 Background: Lung cancer patients are faced with treatment choices that involve complex decisions that can be preference-sensitive. In 2017 the National Quality Forum initiated a “Call to Action” to integrate shared decision-making (SDM) processes into practice in which clinicians and patients work together to make healthcare decisions that align with what matters most to patients. Projects In Knowledge, @Point of Care, Dartmouth and Yale collaborated to develop a pilot educational initiative to address and improve patient-centered care and SDM processes in the institutional cancer-care setting. Methods: Training materials co-developed for the Yale NSCLC team members (oncologists, nurses/NPs, social worker) address SDM, Checkpoint Inhibitor Therapy in NSCLC, and clinician-patient role play methods for implementing SDM in treatment discussions/decisions. Qualitative interview and observational methods were used to assess improved SDM performance by the multidisciplinary Yale NSCLC team by comparing baseline pre-intervention to post-intervention interviews and rating observed performance on case study role-play scenarios. Following the training and assessments, a focus group that included all team members was conducted to assess the acceptability, feasibility, and repeatability of the program and to inform future education. Results: Training empowered all Yale NSCLC team members to show pre- to post-education improvement in SDM (34% to 88%). Areas of greatest improvement: 1) providing reasonable treatment options to patients (+58%); 2) determining decision style preference – to what extent a patient wants to participate in the treatment decision process with their clinician (+76%); 3) determining patients’ risk tolerance regarding treatments that may be more efficacious but may have more side effects (+77); and 4) determining patients’ goals/preferences (+88%). Conclusions: Educational training improved SDM skills by all Yale NSCLC team members, which can lead to improved clinician-patient decision-making and patient-centric care. The training process also facilitated team building and encouraged ongoing participation in SDM.

The Learning Curve for Shared Decision-making in Symptomatic Aortic Stenosis

Shared decision-making (SDM) is widely advocated for patients with valvular heart disease yet is not integrated into the heart team model for patients with symptomatic aortic stenosis. Decision aids (DAs) have been shown to improve patient-centered outcomes and may facilitate SDM. To determine whether the repeated use of a DA by heart teams is associated with greater SDM, along with improved patient-centered outcomes and clinician attitudes about DAs. This mixed-methods study included a nonrandomized pre-post intervention and clinician interviews. It was conducted between April 30, 2015, and December 7, 2017, with quantitative analysis performed between January 12, 2017, and May 26, 2017, within 2 academic medical centers in northern New England among 35 patients with symptomatic aortic stenosis who were at high to prohibitive risk for surgery. The qualitative analysis was performed between August 6, 2018, and May 7, 2019. The Severe Aortic Stenosis Decision Aid was delivered by 6 clinicians, with patients choosing between transcatheter aortic valve replacement and medical management. Clinician SDM performance was measured using the Observer OPTION5 scale with dual-independent coding of audiotaped clinic visits. Previsit and postvisit surveys measured the patient's knowledge, satisfaction, and decisional conflict. Audiotaped clinician interviews were coded, and qualitative thematic analysis was performed. Six male clinicians and 35 patients (19 of 34 women [55.9%; 1 survey was missing]; mean [SD] age, 85.8 [7.8] years) participated in the study. Shared decision-making increased stepwise with repeated use of the DA (mean [SD] Observer OPTION5 scores: usual care, 17.9 [7.6]; first use of a DA, 60.5 [30.9]; fifth use of a DA, 79.0 [8.4]; P < .001 for comparison between usual care and fifth use of DA). Multiple uses of the DA were associated with increased patient knowledge (mean difference, 18.0%; 95% CI, 1.2%-34.8%; P = .04) and satisfaction (mean difference, 6.7%; 95% CI, 2.5%-10.8%; P = .01) but not decisional conflict (mean [SD]: usual care, 96.0% [9.4%]; first use of DA, 93.8% [12.5%]; fifth use of DA, 95.0% [11.2%]; P = .60). Qualitative analysis of clinicians' interviews revealed that clinicians perceived that they used an SDM approach without DAs and that the DA was not well understood by elderly patients. There was infrequent values clarification or discussion of stroke risk. In a mixed-methods pilot study, use of a DA for severe aortic stenosis by heart team clinicians was associated with improved SDM and patient-centered outcomes. However, in qualitative interviews, heart team clinicians did not perceive a significant benefit of the DA, and therefore sustained implementation is unlikely. This pilot study of SDM clarifies new research directions for heart teams.

A multi-level assessment of shared decision making: An evaluation of clinician and patient attitudes and behaviors and the identification of predictive profiles

The objective of this study was to gain a greater understanding of shared decision making (SDM) by identifying the behaviors and attitudes of healthcare professionals (HCP) and patients that are associated with varying levels of SDM performance. The study centered on HCP and patient surveys that assessed a participant’s degree of endorsement of SDM favorable behaviors by asking them to predict how they might address a specific decision point in various healthcare interactions. Using quantitative (descriptive analytics, predictive and mixture modeling) and qualitative methods (grounded theory) to analyze the data, SDM skills were quantified in HCP and patient populations, and demographic and attitudinal factors that facilitate or hinder successful implementation of SDM were identified. Distinct HCP profiles (Motivated but Cautious, Insufficiently Engaged, and Pro-Autonomous) and patient profiles (Pro-Paternalistic, Pro-Autonomous, and Unconcerned but Open-Minded) were then defined. By characterizing these distinct profiles and the attitudes and preferences that are associated with one another, these results can be directly utilized by educational providers interested in teaching SDM skills to enable HCPs to individualize their SDM approach based on the recognition of these profiles while also providing the self-assessment needed to modify their own behaviors.

Shared Decision-Making Training in Internal Medicine: A Multisite Intervention Study.

Research shows that when patients and health care providers share responsibility for clinical decisions, both patient satisfaction and quality of care increase, and resource use decreases. Yet few studies have assessed how to train residents to use shared decision-making (SDM) in their practice. We developed and evaluated a SDM training program in internal medicine. Senior internal medicine residents from 3 hospitals in Switzerland were assessed shortly before and 2 months after completing a program that included a 2-hour workshop and pocket card use in clinical practice. Encounters with standardized patients (SPs) were recorded and SDM performance was assessed using a SDM completeness rating scale (scores ranging from 0 to 100), a self-reported questionnaire, and SPs rating the residents. Of 39 eligible residents, 27 (69%) participated. The mean (SD) score improved from 65 (SD 13) to 71 (SD 12; effect size [ES] 0.53; P = .011). After training, participants were more comfortable with their SDM-related knowledge (ES 1.42, P < .001) and skills (ES 0.91, P < .001), and with practicing SDM (ES 0.96, P < .001). Physicians applied SDM concepts more often in practice (ES 0.71, P = .001), and SPs felt more comfortable with how participants discussed their care (ES 0.44, P = .031). The SDM training program improved the competencies of internal medicine residents and promoted the use of SDM in clinical practice. The approach may be of interest for teaching SDM to residents in other disciplines and to medical students.

Medical Students' Knowledge and Attitudes Toward Shared Decision Making: Results From a Multinational, Cross-Sectional Survey.

Introduction. We aimed to conduct a multinational cross-sectional online survey of medical students’ attitudes toward, knowledge of, and experience with shared decision making (SDM). Methods. We conducted the survey from September 2016 until May 2017 using the following: 1) a convenience sample of students from four medical schools each in Canada, the United States, and the Netherlands (n = 12), and 2) all medical schools in the United Kingdom through the British Medical School Council (n = 32). We also distributed the survey through social media. Results. A total of 765 students read the information sheet and 619 completed the survey. Average age was 24, 69% were female. Mean SDM knowledge score was 83.6% (range = 18.8% to 100%; 95% confidence interval [CI] = 82.8% to 84.5%). US students had the highest knowledge scores (86.2%, 95% CI = 84.8% to 87.6%). The mean risk communication score was 57.4% (range = 0% to 100%; 95% CI = 57.4% to 60.1%). Knowledge did not vary with age, race, gender, school, or school year. Attitudes were positive, except 46% believed SDM could only be done with higher educated patients, and 80.9% disagreed that physician payment should be linked to SDM performance (increased with years in training, P < 0.05). Attitudes did not vary due to any tested variable. Students indicated they were more likely than experienced clinicians to practice SDM (72.1% v. 48.8%). A total of 74.7% reported prior SDM training and 82.8% were interested in learning more about SDM. Discussion. SDM knowledge is high among medical students in all four countries. Risk communication is less well understood. Attitudes indicate that further research is needed to understand how medical schools deliver and integrate SDM training into existing curricula.

Study protocol of a randomized controlled trial on two new dissemination strategies for a brief, shared-decision-making (SDM) training for oncologists: web-based interactive SDM online-training versus individualized context-based SDM face-to-face training

BackgroundOncological patients often feel left out of important treatment decisions. However, when physicians engage them in shared decision-making (SDM), patients benefit in many ways and the situation is improved. SDM can effectively be taught to physicians, but participation barriers for SDM physician group trainings are high, making it hard to convince physicians to participate.With this in mind, we aim to develop and evaluate two new dissemination strategies for a brief, SDM training program based upon a proven SDM group-training concept: an individualized context-based SDM face-to-face training (IG I) and a web-based interactive SDM online training (IG II).We aim to analyze which improvements can be achieved by IG I and II compared to a control group (CG) in physician SDM competence and performance as well as the impact on the physician-patient relationship. Furthermore, we analyze differences in satisfaction concerning the two dissemination strategies by means of a training evaluation.Methods/designWe examine – based on a three-armed randomized controlled trial (IG I, IG II, CG) – the effectiveness of two new dissemination strategies for a SDM training program compared to a CG receiving no SDM training (voluntary access to SDM training as an incentive for participation after completion of the study). We aim to include 162 physicians randomized to one of the three arms. There will be two assessment points in time (before intervention: T0 and post-training: T1). The main outcome is the SDM competence of physicians as measured by an established observational assessment rating system (OPTION-12) by means of consultations with Standardized Patients. Standardized Patients are individuals trained to act as “real” patients. Secondary outcome measures are the SDM performance (SDM-Q-9) and the Questionnaire on the Quality of Physician-Patient-Interaction (QQPPI) both rated by Standardized Patients as well as the physicians’ training evaluation.DiscussionThis trial will assess the effectiveness and acceptability of two new dissemination strategies for a brief, SDM training program for physicians. Opportunities and challenges regarding implementation in daily routines will be discussed.Trial registrationClinicalTrials.gov, Identifier: NCT02674360. Prospectively registered on 4 February 2016.