Supporting Shared Decision Making Research Articles

P080 Supporting shared decision-making about osteoporosis medicines: Combining multiple methods to develop the prototype iFraP intervention

Abstract Background/Aims Shared decision-making (SDM) is a joint process in which a person and healthcare professional work together to reach decisions about care. The iFraP (Improving uptake of Fracture Prevention drug treatments) intervention comprises computerised decision aid (DA), Fracture Liaison Service (FLS) clinician training package, and information resources to support SDM about osteoporosis medicines. This abstract details our multi-method approach to develop this intervention. Methods Intervention development was underpinned by the Medical Research Council guidelines for development of complex interventions. Four studies guided intervention prototype development, including (1) an evidence synthesis of existing osteoporosis DAs to examine quality and effectiveness; (2) a review of patient information about osteoporosis to evaluate quality and optimal language for talking about osteoporosis; (3) a Delphi consensus survey with patients, carers, and health professionals to gain consensus on intervention content, informed by an evidence review of relevant clinical guidelines and behavioural theories; (4) and focus groups and interviews with patients recently attending FLS, FLS clinicians and general practitioners (GPs) to explore current FLS practice, and barriers and facilitators to change. Expert stakeholders and public contributors informed each sub-study. Results Studies one and two informed design of the iFraP computerised DA. Evidence reviews of existing osteoporosis DAs and patient information found that they did not meet patient needs and identified poor readability, variable quality, and unbalanced and confusing content. Public contributors preferred DAs which were individualised, and together with expert stakeholders, supported the development of understandable explanations of osteoporosis and osteoporosis medicines to include in iFraP resources. Study three identified essential components of the FLS consultation which directly informed DA content. Study four identified the need for complementary iFraP information resources, training, and potential barriers to iFraP DA use. Patients expressed that they did not feel adequately prepared for their FLS consultation, leading to the development of an enhanced leaflet to accompany their FLS appointment letter. Patients, FLS clinicians, and GPs all expressed the need for a patient-friendly individualised summary of the FLS consultation, to facilitate consistent information across services and reinforce FLS messaging. This finding informed development of the iFraP Bone Health Record, an individualised, easy-read PDF print-out of the iFraP DA. FLS clinicians identified training needs relating to communicating risk, involving patients in decisions and clinical decision-making. Barriers to use included concerns that the DA would increase consultation duration, and that SDM may undermine their goal to facilitate medicine adherence. Identified barriers to use and training needs informed the content and delivery of the interactive eLearning and role play session, with consideration of theoretically-informed behaviour change techniques. Conclusion The iFraP complex intervention development work demonstrates the use of multiple methods to develop an evidence-based and theoretically-driven intervention in-preparation for testing. Disclosure L. Bullock: None. J. Fleming: None. E.M. Clark: None. S. Leyland: None. S. Thomas: Grants/research support; ST owns Prescribing Decision Support Ltd that developed the iFraP decision aid. C. Gidlow: None. T.W. O'Neill: Grants/research support; TON is supported by the NIHR Manchester Biomedical Research Centre. C.P. Iglesias-Urrutia: None. A. Hawarden: Grants/research support; AH is funded by a Versus Arthritis Clinical Research Fellowship (reference 22726). F. Manning: None. J. Protheroe: None. J. Lefroy: None. S. Ryan: None. R. Horne: None. C.D. Mallen: Grants/research support; CM is funded by the NIHR Applied Research Collaboration West Midlands and the NIHR School for Primary Care Research. C. Jinks: Grants/research support; CJ is part funded by NIHR Applied Research Collaboration (ARC) West Midlands. Z. Paskins: Consultancies; ZP has received consultancy fees from UCB Pharma. Grants/research support; ZP is funded by the National Institute for Health Research (NIHR) [Clinician Scientist Award (CS-2018-18-ST2-010)/NIHR Academy].

Supporting shared decision-making in medicines use with people living with dementia and their carers.

Polypharmacy and inappropriate prescribing of psychotropic medicines are common among people living with dementia and pose considerable health risks. One way of addressing these issues is by involving the person and their carer in shared decision-making. This article discusses some of the issues related to polypharmacy and inappropriate prescribing in people living with dementia and examines the concept of shared decision-making in this context. The author details some practical aids that nurses and other healthcare professionals can use to engage people living with dementia and their carers in shared decision-making about medicines use.

Methodologies for Evaluating the Usability of Rehabilitation Technologies Aimed at Supporting Shared Decision-Making: Scoping Review.

The field of rehabilitation has seen a recent rise in technologies to support shared decision-making (SDM). Usability testing during the design process of SDM technologies is needed to optimize adoption and realize potential benefits. There is variability in how usability is defined and measured. Given the complexity of usability, a thorough examination of the methodologies used to measure usability to develop the SDM technologies used in rehabilitation care is needed. This scoping review aims to answer the following research questions: which methods and measures have been used to produce knowledge about the usability of rehabilitation technologies aimed at supporting SDM at the different phases of development and implementation? Which parameters of usability have been measured and reported? This review followed the Arksey and O'Malley framework. An electronic search was performed in the Ovid MEDLINE, Embase, CINAHL, and PsycINFO databases from January 2005 up to November 2020. In total, 2 independent reviewers screened all retrieved titles, abstracts, and full texts according to the inclusion criteria and extracted the data. The International Organization for Standardization framework was used to define the scope of usability (effectiveness, efficiency, and satisfaction). The characteristics of the studies were outlined in a descriptive summary. Findings were categorized based on usability parameters, technology interventions, and measures of usability. A total of 38 articles were included. The most common SDM technologies were web-based aids (15/33, 46%). The usability of SDM technologies was assessed during development, preimplementation, or implementation, using 14 different methods. The most frequent methods were questionnaires (24/38, 63%) and semistructured interviews (16/38, 42%). Satisfaction (27/38, 71%) was the most common usability parameter mapped to types of SDM technologies and usability evaluation methods. User-centered design (9/15, 60%) was the most frequently used technology design framework. The results from this scoping review highlight the importance and the complexity of usability evaluation. Although various methods and measures were shown to be used to evaluate the usability of technologies to support SDM in rehabilitation, very few evaluations used in the included studies were found to adequately span the selected usability domains. This review identified gaps in usability evaluation, as most studies (24/38, 63%) relied solely on questionnaires rather than multiple methods, and most questionnaires simply focused on the usability parameter of satisfaction. The consideration of end users (such as patients and clinicians) is of particular importance for the development of technologies to support SDM, as the process of SDM itself aims to improve patient-centered care and integrate both patient and clinician voices into their rehabilitation care.

Perioperative shared decision making – How do we train clinicians?

ObjectiveDecision making about high-risk surgery can be complex, particularly when outcomes may be uncertain. Clinicians have a legal and ethical responsibility to support decision making which fits with patients' values and preferences. In the UK, preoperative assessment and optimisation is led by Anaesthetists in clinic several weeks prior to planned surgery. Training in supporting shared decision making (SDM) has been identified as an area of need among UK anaesthetists with leadership roles in perioperative care. MethodsWe describe adaptation of a generic SDM workshop to perioperative care, in particular to decisions on high-risk surgery, and its delivery to UK healthcare professionals over a two-year period. Feedback from workshops were thematically analysed. We explored further improvements to the workshop and ideas for development and dissemination. ResultsThe workshops were well received, with high satisfaction for techniques used, including video demonstrations, role-play and discussions. Thematic analysis identified a desire for multidisciplinary training and training in using patient aids. ConclusionQualitative findings suggest workshops were considered useful with perceived improvement in SDM awareness, skills and reflective practice. InnovationThis pilot introduces a new modality of training in the perioperative setting providing physicians, particularly Anaesthetists, with previously unavailable training needed to facilitate complex discussions.

Use of Disease-Modifying Antirheumatic Drugs in Rheumatoid Arthritis: Supporting Shared Decision-Making Between Patients With Cancer and Clinicians.

Use of Disease-Modifying Antirheumatic Drugs in Rheumatoid Arthritis: Supporting Shared Decision-Making Between Patients With Cancer and Clinicians.

A blended learning for general practitioners and nurses on skills to support shared decision-making with patients about palliative cancer treatment: A one-group pre-posttest study

ObjectiveTo evaluate a newly developed blended learning programme for general practitioners (GPs) and nurses in supporting shared decision making (SDM) about palliative cancer treatment in a simulated setting. MethodsIn a pre-posttest study, healthcare professionals (HCPs) participated in the blended learning (i.e. e-learning and (online) training session). HCPs filled out surveys (T0 (baseline), T1 (after e-learning) and T2 (after full blended learning)) and engaged in simulated consultations at T0 and T2. The primary outcome was observed SDM support (Triple-S; DSAT-10 for validation). Secondary outcomes included satisfaction, knowledge about and attitude towards SDM support. Repeated measures General Linear Models were conducted. Results33 HCPs (17 GPs and 16 nurses) participated. SDM support significantly improved after training (Triple-S; medium effect). Observers’ overall rating of SDM support (medium effect) as well as HCPs’ knowledge (large effect) and beliefs about their capabilities (medium effect) improved after training. There was no difference in decision support skills (DSAT-10), HCPs’ other clinical behavioural intentions and satisfaction. HCPs evaluated the training positively. ConclusionBlended learning for HCPs on supporting SDM in palliative cancer care improved their skills, knowledge and confidence in simulated consultations. Practice implicationsThese first findings are promising for evaluating interprofessional SDM in clinical practice.

Supporting Shared Decision-making About Surveillance After Breast Cancer With Personalized Recurrence Risk Calculations: Development of a Patient Decision Aid Using the International Patient Decision AIDS Standards Development Process in Combination With a Mixed Methods Design.

Although the treatment for breast cancer is highly personalized, posttreatment surveillance remains one-size-fits-all: annual imaging and physical examination for at least five years after treatment. The INFLUENCE nomogram is a prognostic model for estimating the 5-year risk for locoregional recurrences and second primary tumors after breast cancer. The use of personalized outcome data (such as risks for recurrences) can enrich the process of shared decision-making (SDM) for personalized surveillance after breast cancer. This study aimed to develop a patient decision aid (PtDA), integrating personalized risk calculations on risks for recurrences, to support SDM for personalized surveillance after curative treatment for invasive breast cancer. For the development of the PtDA, the International Patient Decision Aids Standards development process was combined with a mixed methods design inspired by the development process of previously developed PtDAs. In the development, 8 steps were distinguished: establishing a multidisciplinary steering group; definition of the end users, scope, and purpose of the PtDA; assessment of the decisional needs of end users; defining requirements for the PtDA; determining the format and implementation strategy for the PtDA; prototyping; alpha testing; and beta testing. The composed steering group convened during regular working-group sessions throughout the development process. The "Breast Cancer Surveillance Decision Aid" consists of 3 components that support the SDM process: a handout sheet on which personalized risks for recurrences, calculated using the INFLUENCE-nomogram, can be visualized and which contains an explanation about the decision for surveillance and a login code for a web-based deliberation tool; a web-based deliberation tool, including a patient-reported outcome measure on fear of cancer recurrence; and a summary sheet summarizing patient preferences and considerations. The PtDA was assessed as usable and acceptable during alpha testing. Beta testing is currently ongoing. We developed an acceptable and usable PtDA that integrates personalized risk calculations for the risk for recurrences to support SDM for surveillance after breast cancer. The implementation and effects of the use of the "Breast Cancer Surveillance Decision Aid" are being investigated in a clinical trial.

Supporting Shared Decision-Making and Home Dialysis in End-Stage Kidney Disease.

It has been widely demonstrated that patient education and empowerment, especially involving shared treatment decisions, improve patient outcomes in chronic medical conditions, including chronic kidney disease requiring kidney replacement therapies. Accordingly, regulatory agencies in the US and worldwide recommend shared decision-making for finalizing one’s choice of kidney replacement therapy. It is also recognized that the US needs to substantially increase home dialysis utilization to leverage its positive impacts on patient and healthcare cost-related outcomes. This perspective highlights how the routine clinical use of the recommended practice of shared decision-making can exist in synergy with the system’s goal for increased home dialysis use. It introduces a pragmatic provider checklist, The Nephrologist’s Shared Decision-Making Checklist, grounded in the relevant theories of shared decision-making, and, unlike some research assessments and extant tools, is easy to understand and implement in clinical practice. This qualitative Checklist can help providers ensure that they have co-constructed an SDM experience with the patient and involved caretakers, helping them benefit from the improved outcomes associated with SDM.

Change in individual physicians’ screening mammography completion rates following the updated USPSTF guideline supporting shared decision making: An observational cohort study

ObjectiveTo understand changes in physician screening practices in response to the 2009 U.S. Preventive Services Task Force recommendation supporting shared decision making (SDM) for mammography in women aged 40–49 years. MethodsWe assessed screening completion rates for physicians in the Cleveland Clinic Health System pre-2009 (2006–2008) and post-2009 (2010–2015), and rates for physicians new to the system post-2009. We used mixed effects logistic regression to estimate the odds of a woman receiving screening post-2009. If physicians practiced SDM, we hypothesized their screening rates would change after 2009. To test this, we included each physician’s pre-2009 screening rate as a predictor in the model. ResultsAmong 125 physicians, the screening rate increased from 40% to 45% from pre-2009 to post-2009. For physicians new to the health system post-2009 the rate was 32%. In the mixed effects model (N = 17,007), the strongest predictor of mammography receipt among patients post-2009 was their physician’s pre-2009 screening rate (aOR:3.57 per 10% increase in pre-2009 rate; 95%CI:1.69–7.50). ConclusionsWhether a woman received a mammogram post-2009 was highly associated with her physicians’ pre-2009 screening rate, suggesting physicians are not individualizing screening decisions via SDM. Practice implicationsPhysicians may need support to effectively practice SDM.

What hinders the patient's involvement in defining the process of care?

Despite the available evidence supporting Shared Decision Making (SDM), the hidden-in-plain-sight barriers to its application in clinical practice continue to hinder its achievement. Yet, SDM is one of the most powerful instruments that doctors should be equipped with in order to navigate through uncertainty in medicine. This article provides a potential list of obstacles and solutions - from doctors' university training to clinical practice guidelines - to patient involvement in health decisions, and indicates which actions could be put in place to allow physicians to better take care of the individual patient they face every day.

Guiding Glucose Management Discussions Among Adults With Type 2 Diabetes in General Practice: Development and Pretesting of a Clinical Decision Support Tool Prototype Embedded in an Electronic Medical Record.

BackgroundManaging type 2 diabetes (T2D) requires progressive lifestyle changes and, sometimes, pharmacological treatment intensification. General practitioners (GPs) are integral to this process but can find pharmacological treatment intensification challenging because of the complexity of continually emerging treatment options.ObjectiveThis study aimed to use a co-design method to develop and pretest a clinical decision support (CDS) tool prototype (GlycASSIST) embedded within an electronic medical record, which uses evidence-based guidelines to provide GPs and people with T2D with recommendations for setting glycated hemoglobin (HbA1c) targets and intensifying treatment together in real time in consultations.MethodsThe literature on T2D-related CDS tools informed the initial GlycASSIST design. A two-part co-design method was then used. Initial feedback was sought via interviews and focus groups with clinicians (4 GPs, 5 endocrinologists, and 3 diabetes educators) and 6 people with T2D. Following refinements, 8 GPs participated in mock consultations in which they had access to GlycASSIST. Six people with T2D viewed a similar mock consultation. Participants provided feedback on the functionality of GlycASSIST and its role in supporting shared decision making (SDM) and treatment intensification.ResultsClinicians and people with T2D believed that GlycASSIST could support SDM (although this was not always observed in the mock consultations) and individualized treatment intensification. They recommended that GlycASSIST includes less information while maintaining relevance and credibility and using graphs and colors to enhance visual appeal. Maintaining clinical autonomy was important to GPs, as they wanted the capacity to override GlycASSIST’s recommendations when appropriate. Clinicians requested easier screen navigation and greater prescribing guidance and capabilities.ConclusionsGlycASSIST was perceived to achieve its purpose of facilitating treatment intensification and was acceptable to people with T2D and GPs. The GlycASSIST prototype is being refined based on these findings to prepare for quantitative evaluation.

The relation between memory and decision-making in multiple sclerosis patients

Background. Impairments in long-term and working memory are widespread in Multiple Sclerosis (MS), setting on in early disease stages. These memory impairments may limit patients’ ability to take informed and competent medical decisions, too. In healthy populations, memory abilities predict decision quality across a wide range of tasks. These studies suggest that higher working memory capacity supports decisions in cognitively taxing tasks, whereas better semantic memory facilitates decisions in tasks requiring knowledge retrieval. In individuals with MS, previous studies have linked less accurate decisions to memory deficits and reduced executive functioning, too. However, these studies focussed on decisions under risk and did not broadly assess decision making skills. We aimed to fill this gap in a cross-sectional study. Methods. Hundred thirty-seven participants with MS were recruited during their stay in an MS specialized rehabilitation centre. In a first test session, participants completed a standardized test battery for working memory and semantic memory, the inventory for memory diagnostics. In a second test session, participants filled out the Adult Decision Making Competence battery (A-DMC). This version of the A-DMC measured decision making competence on five subscales: Resistance to Framing Effects, Under/Overconfidence, Applying Decision Rules, Consistency in Risk Perception, and Resistance to Sunk Cost Effects. In addition, participants were screened for depression and cognitive fatigue. Results. Working memory was impaired in most participants, whereas semantic memory was not impaired. To understand which memory abilities underlie distinct components of decision making in people with MS, we used structural equation modelling. Replicating previous findings in a healthy sample, working memory capacity was associated with the ability to recall semantic knowledge. Participants with lower working memory capacity were less resistant to framing effects and adhered to decision rules less. In contrast, participants with worse semantic memory assessed their own knowledge less accurately, perceived risks less consistently, and made more errors in applying decision rules. Cognitive fatigue and depression unlikely explain these relationships. Conclusions. Taken together, our study suggests that the memory problems, frequently reported in MS patients, may reach out to higher-order cognitive functions, such as decision making skills. Supporting shared decision-making and patient autonomy within MS thus requires to take memory impairments into account and to match the information provided to the patient’s memory abilities.

Supporting shared decision-making about cardiopulmonary resuscitation using a video-based decision-support intervention in a hospital setting: a multisite before-after pilot study.

Inpatients are often prescribed cardiopulmonary resuscitation (CPR) without a shared decision-making process. Since implementation of decision aids into practice is highly sensitive to the clinical milieu, we performed a pilot study to refine our study procedures and to evaluate the acceptability and potential effectiveness of a shared decision-making intervention when implemented in a Canadian hospital setting. In this before-after pilot study, we recruited patients and family members on the medical wards of 2 Canadian teaching hospitals between September 2015 and March 2017. The intervention consisted of viewing a CPR decision video and completing a values-clarification worksheet; follow-up discussion with the physician was encouraged. The primary feasibility outcome was acceptability of the video, and the primary effectiveness outcome was change in the Decisional Conflict Scale score (lower scores being more desirable) after the intervention. Participants rated the extent of shared decision-making using the CollaboRATE instrument. Of the 71 participants (43 patients with a mean age of 79.0 [standard deviation (SD) 11.4] yr and 28 family members with a mean age of 61.0 [SD 10.0] yr), 65 (92%) rated the CPR decision video as good to excellent. The intervention was associated with an improvement in knowledge about CPR (+2.7 points, 95% confidence interval [CI] 2.2 to 3.3, effect size 1.5) and a reduction in the Decisional Conflict Scale score (-18.1 points, 95% CI -21.8 to -14.3, effect size 1.4). The 36 participants who had a discussion with a physician about CPR after watching the video rated the extent of shared decision-making as 6.3 (SD 1.7) (possible maximum score 9). There was a nonsignificant decrease in the proportion of patients with a medical order for CPR after the intervention (71% before v. 63% after, p = 0.06). The CPR decision video was acceptable to patients and family members. Our decision-support intervention may improve knowledge, reduce decisional conflict and reduce the prevalence of medical orders for CPR in the Canadian hospital setting.

Supporting shared decision-making for older people with multiple health and social care needs: a realist synthesis

BackgroundHealth-care systems are increasingly moving towards more integrated approaches. Shared decision-making (SDM) is central to these models but may be complicated by the need to negotiate and communicate decisions between multiple providers, as well as patients and their family carers; this is particularly the case for older people with complex needs.ObjectivesTo provide a context-relevant understanding of how models to facilitate SDM might work for older people with multiple health and care needs and how they might be applied to integrated care models.DesignRealist synthesis following Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) publication standards.ParticipantsTwenty-four stakeholders took part in interviews.Data sourcesElectronic databases including MEDLINE (via PubMed), The Cochrane Library, Scopus, Google and Google Scholar (Google Inc., Mountain View, CA, USA). Lateral searches were also carried out. All types of evidence were included.Review methodsIterative stakeholder-driven, three-stage approach, involving (1) scoping of the literature and stakeholder interviews (n = 13) to develop initial programme theory/ies, (2) systematic searches for evidence to test and develop the theories and (3) validation of programme theory/ies with stakeholders (n = 11).ResultsWe included 88 papers, of which 29 focused on older people or people with complex needs. We identified four theories (context–mechanism–outcome configurations) that together provide an account of what needs to be in place for SDM to work for older people with complex needs: understanding and assessing patient and carer values and capacity to access and use care; organising systems to support and prioritise SDM; supporting and preparing patients and family carers to engage in SDM; and a person-centred culture of which SDM is a part. Programmes likely to be successful in promoting SDM are those that create trust between those involved, allow service users to feel that they are respected and understood, and engender confidence to engage in SDM.LimitationsThere is a lack of evidence on interventions to promote SDM in older people with complex needs or on interprofessional approaches to SDM.ConclusionsModels of SDM for older people with complex health and care needs should be conceptualised as a series of conversations that patients, and their family carers, may have with a variety of different health and care professionals. To embed SDM in practice requires a shift from a biomedical focus to a more person-centred ethos. Service providers are likely to need support, both in terms of the way services are organised and delivered and in terms of their own continuing professional development. Older people with complex needs may need support to engage in SDM. How this support is best provided needs further exploration, although face-to-face interactions and ongoing patient–professional relationships are key.Future workThere is a need for further work to establish how organisational structures can be better aligned to meet the requirements of older people with complex needs. This includes a need to define and evaluate the contribution that different members of health and care teams can make to SDM for older people with complex health and care needs.Study registrationThis study is registered as PROSPERO CRD42016039013.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Supporting shared decision-making and people's understanding of medicines: An exploration of the acceptability and comprehensibility of patient information.

Background:Patient information may assist in promoting shared decision-making, however it is imperative that the information presented is comprehensible and acceptable to the target audience.Objective:This study sought to explore the acceptability and comprehensibility of the ‘ Medicines in Scotland: What’s the right treatment for you?’ factsheet to the general public.Methods:Qualitative semi-structured telephone interviews were conducted with members of the public. An interview schedule was developed to explore the acceptability and comprehensibility of the factsheet. Participants were recruited by a researcher who distributed information packs to attendees (n=70) of four community pharmacies. Interviews, (12-24 minutes duration), were audio recorded, transcribed verbatim and analysed using a framework approach.Results:Nineteen participants returned a consent form (27.1%), twelve were interviewed. Six themes were identified: formatting of the factsheet and interpretation; prior health knowledge and the factsheet; information contained in the factsheet; impact of the factsheet on behaviour; uses for the factsheet; and revisions to the factsheet.Conclusions:The factsheet was generally perceived as helpful and comprehensive. It was highlighted that reading the leaflet may generate new knowledge and may have a positive impact on behaviour.

Supporting Shared Decision-making for Children's Complex Behavioral Problems: Development and User Testing of an Option Grid™ Decision Aid.

There is a lack of research to guide collaborative treatment decision-making for children who have complex behavioral problems, despite the extensive use of mental health services in this population. We developed and pilot-tested a one-page Option Grid™ patient decision aid to facilitate shared decision-making for these situations. An editorial team of parents, child psychiatrists, researchers, and other stakeholders developed the scope and structure of the decision aid. Researchers included information about a carefully chosen number of psychosocial and pharmacological treatment options, using descriptions based on the best available evidence. Using semi-structured qualitative interviews (n = 18), we conducted user testing with four parents and four clinical prescribers and field testing with four parents, four clinical prescribers, and two clinic administrators. The researchers coded and synthesized the interview responses using mixed inductive and deductive methods. Parents, clinicians, and administrators felt the Option Grid had significant value, although they reported that additional training and other support would be required in order to successfully implement the Option Grid and achieve shared decision-making in clinical practice.

Supporting shared decision-making for older people with multiple health and social care needs: a protocol for a realist synthesis to inform integrated care models

IntroductionIncluding the patient or user perspective is a central organising principle of integrated care. Moreover, there is increasing recognition of the importance of strengthening relationships among patients, carers and practitioners,...

Implementation of shared decision making in cardiovascular care: past, present, and future.

Despite recent health policy recommendations supporting shared decision making (SDM), a rapidly growing evidence base supporting the desirable effects of tools to facilitate SDM, availability of SDM tools specifically designed for cardiovascular care (Table 1),1 and recent advocacy for SDM in cardiovascular guidelines,2,3 SDM has not been widely incorporated into routine clinical practice. Although tools that summarize the best scientific evidence to support decision making, communicate risk, and prompt clarification of patients’ values and preferences may be necessary to support SDM, they are insufficient in and of themselves to routinize SDM. This lack of uptake of SDM may reflect many challenges associated with incorporating complex interventions into healthcare delivery. In this article, we describe the main approaches to SDM published in the literature to date, highlight barriers and facilitators relevant to each approach, and suggest future work that is needed to facilitate implementation of SDM in cardiovascular practice. View this table: Table 1. Decision Aids to Facilitate Decision Making for Cardiovascular Conditions: Publicly Available Through the Ottawa Health Research Institute1 Investigators have designed and tested patient decision aids that are delivered at different points along the continuum of medical care. Out-of-visit decision aids seek to activate and empower patients by informing them of their treatment options outside the context of the clinical encounter. One factor that influenced the development of out-of-visit approaches to SDM was data demonstrating regional variation in treatment driven, in part, by differences in physician preferences rather than the health status of patients.4 An example of one such decision aid is the Living with Coronary Heart Disease program developed by the Informed Medical Decisions Foundation.5 This decision aid helps patients with stable coronary heart disease distinguish between treatments that relieve symptoms (eg, angioplasty and stenting) and choices they can make to decrease their future …

Lack of shared decision making in cancer screening discussions: results from a national survey.

Clinicians are encouraged to support patients in achieving shared decision making (SDM) for cancer screening. To describe decision making processes and outcomes for cancer screening discussions. A 2011 national Internet survey of adults aged ≥50 years who made cancer screening decisions (breast, BrCa; colorectal, CRC; prostate, PCa) within the previous 2 years was conducted. Participants were asked about their perceived cancer risk; how informed they felt about cancer tests; whether their healthcare provider addressed pros/cons of testing, presented the option of no testing, and elicited their input; whether they were tested; and their confidence in the screening decision. Data were analyzed in 2013-2014 with descriptive statistics and logistic regression. Overall, 1,134 participants (477 men, 657 women) aged ≥50 years made cancer screening decisions, and 1,098 (354, BrCa; 598, CRC; 146, PCa) decisions were discussed with a healthcare provider. Most discussions (51%-67%) addressed pros of screening some or a lot, but few (7%-14%) similarly addressed cons. For all cancer screening decisions, providers usually (63%-71%) explained that testing was optional, but less often asked women (43%-57%) than men (70%-71%) whether they wanted testing. Only 27%-38% of participants reported SDM, 69%-93% underwent screening, and 55%-76% would definitely make the same decision again. Perceived high/average cancer risk and feeling highly informed were associated with confidence in the screening decision. Discussions often failed to provide balanced information and meet SDM criteria. Supporting SDM could potentially improve the quality of cancer screening decisions.