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Abstract
The principles of shared decision making are well documented but there is a lack of
guidance about how to accomplish the approach in routine clinical practice. Our aim
here is to translate existing conceptual descriptions into a three-step model that
is practical, easy to remember, and can act as a guide to skill development. Achieving
shared decision making depends on building a good relationship in the clinical encounter
so that information is shared and patients are supported to deliberate and express
their preferences and views during the decision making process. To accomplish these
tasks, we propose a model of how to do shared decision making that is based on
choice, option and
decision talk. The model has three steps: a) introducing choice, b) describing options, often by
integrating the use of patient decision support, and c) helping patients explore preferences
and make decisions. This model rests on supporting a process of deliberation, and
on understanding that decisions should be influenced by exploring and respecting “what
matters most” to patients as individuals, and that this exploration in turn depends
on them developing informed preferences.
Given the fluidity with which the term shared decision making (SDM) is used in teaching, assessment and research, we conducted a focused and systematic review of articles that specifically address SDM to determine the range of conceptual definitions. In April 2005, we ran a Pubmed (Medline) search to identify articles published through 31 December 2003 with the words shared decision making in the title or abstract. The search yielded 681 citations, 342 of which were about SDM in the context of physician-patient encounters and published in English. We read and reviewed the full text of all 342 articles, and got any non-redundant references to SDM, which yielded an additional 76 articles. Of the 418 articles examined, 161 (38.5%) had a conceptual definition of SDM. We identified 31 separate concepts used to explicate SDM, but only "patient values/preferences" (67.1%) and "options" (50.9%) appeared in more than half the 161 definitions. Relatively few articles explicitly recognized and integrated previous work. Our review reveals that there is no shared definition of SDM. We propose a definition that integrates the extant literature base and outlines essential elements that must be present for patients and providers to engage in the process of SDM. The integrative definition of SDM is intended to provide a useful foundation for describing and operationalizing SDM in further research.
Decision aids prepare people to participate in decisions that involve weighing benefits, harms, and scientific uncertainty. To evaluate the effectiveness of decision aids for people facing treatment or screening decisions. For this update, we searched from January 2006 to December 2009 in MEDLINE (Ovid); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, issue 4 2009); CINAHL (Ovid) (to September 2008 only); EMBASE (Ovid); PsycINFO (Ovid); and grey literature. Cumulatively, we have searched each database since its start date. We included published randomised controlled trials (RCTs) of decision aids, which are interventions designed to support patients' decision making by providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies in which participants were not making an active treatment or screening decision. Two review authors independently screened abstracts for inclusion, extracted data, and assessed potential risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards, were:A) decision attributes;B) decision making process attributes.Secondary outcomes were behavioral, health, and health system effects. We pooled results of RCTs using mean differences (MD) and relative risks (RR), applying a random effects model. Of 34,316 unique citations, 86 studies involving 20,209 participants met the eligibility criteria and were included. Thirty-one of these studies are new in this update. Twenty-nine trials are ongoing. There was variability in potential risk of bias across studies. The two criteria that were most problematic were lack of blinding and the potential for selective outcome reporting, given that most of the earlier trials were not registered.Of 86 included studies, 63 (73%) used at least one measure that mapped onto an IPDAS effectiveness criterion: A) criteria involving decision attributes: knowledge scores (51 studies); accurate risk perceptions (16 studies); and informed value-based choice (12 studies); and B) criteria involving decision process attributes: feeling informed (30 studies) and feeling clear about values (18 studies).A) Criteria involving decision attributes:Decision aids performed better than usual care interventions by increasing knowledge (MD 13.77 out of 100; 95% confidence interval (CI) 11.40 to 16.15; n = 26). When more detailed decision aids were compared to simpler decision aids, the relative improvement in knowledge was significant (MD 4.97 out of 100; 95% CI 3.22 to 6.72; n = 15). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.74; 95% CI 1.46 to 2.08; n = 14). The effect was stronger when probabilities were expressed in numbers (RR 1.93; 95% CI 1.58 to 2.37; n = 11) rather than words (RR 1.27; 95% CI 1.09 to 1.48; n = 3). Exposure to a decision aid with explicit values clarification compared to those without explicit values clarification resulted in a higher proportion of patients achieving decisions that were informed and consistent with their values (RR 1.25; 95% CI 1.03 to 1.52; n = 8).B) Criteria involving decision process attributes:Decision aids compared to usual care interventions resulted in: a) lower decisional conflict related to feeling uninformed (MD -6.43 of 100; 95% CI -9.16 to -3.70; n = 17); b) lower decisional conflict related to feeling unclear about personal values (MD -4.81; 95% CI -7.23 to -2.40; n = 14); c) reduced the proportions of people who were passive in decision making (RR 0.61; 95% CI 0.49 to 0.77; n = 11); and d) reduced proportions of people who remained undecided post-intervention (RR 0.57; 95% CI 0.44 to 0.74; n = 9). Decision aids appear to have a positive effect on patient-practitioner communication in the four studies that measured this outcome. For satisfaction with the decision (n = 12) and/or the decision making process (n = 12), those exposed to a decision aid were either more satisfied or there was no difference between the decision aid versus comparison interventions. There were no studies evaluating the decision process attributes relating to helping patients to recognize that a decision needs to be made or understand that values affect the choice.C) Secondary outcomesExposure to decision aids compared to usual care continued to demonstrate reduced choice of: major elective invasive surgery in favour of conservative options (RR 0.80; 95% CI 0.64 to 1.00; n = 11). Exposure to decision aids compared to usual care also resulted in reduced choice of PSA screening (RR 0.85; 95% CI 0.74 to 0.98; n = 7). When detailed compared to simple decision aids were used, there was reduced choice of menopausal hormones (RR 0.73; 95% CI 0.55 to 0.98; n = 3). For other decisions, the effect on choices was variable. The effect of decision aids on length of consultation varied from -8 minutes to +23 minutes (median 2.5 minutes). Decision aids do not appear to be different from comparisons in terms of anxiety (n = 20), and general health outcomes (n = 7), and condition specific health outcomes (n = 9). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive. New for this updated review is evidence that: decision aids with explicit values clarification exercises improve informed values-based choices; decision aids appear to have a positive effect on patient-practitioner communication; and decision aids have a variable effect on length of consultation.Consistent with findings from the previous review, which had included studies up to 2006: decision aids increase people's involvement, and improve knowledge and realistic perception of outcomes; however, the size of the effect varies across studies. Decision aids have a variable effect on choices. They reduce the choice of discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, patient-practitioner communication, cost-effectiveness, and use with developing and/or lower literacy populations need further evaluation. Little is known about the degree of detail that decision aids need in order to have positive effects on attributes of the decision or decision-making process.
To examine the psychometric properties of a revised scale, named 'observing patient involvement in decision making' (OPTION), by analysing its reapplication to a sample of routine primary care consultations. The OPTION instrument assesses to what degree clinicians involve patients in decision making. Cross-sectional assessment of medical interaction by two calibrated raters. Primary care. Twenty-one general practitioners provided 186 consultations for assessment. Observational score using the OPTION instrument. Compared with the first version of the OPTION scale, the revised scale that uses a magnitude instead of an attitude scale, when applied to the same data set, resulted in improvement in the scale's reliability and to lower scores for the levels of involvement achieved by the practitioners. Factor analysis confirms that it is acceptable to regard the scale as a single construct. Although there is moderate variability when raters are assessed on an item by item basis, the agreements between raters at the level of the overall OPTION score is high (the intraclass correlation coefficient scores for total OPTION score was 0.77), a level that is acceptable for the evaluation of a set of consultations per practitioner (e.g. between 5 and 10 consultations), where aggregate scores would be used for determining overall performance. We conclude that OPTION is sufficiently reliable to be used for formal assessment at the level of the whole instrument (all 12 items).
[1
]Cochrane Institute of Primary Care and Public Health, Neuadd Meirionydd, Cardiff University,
Heath Park, Cardiff, UK CF14 4XN
[2
]The Dartmouth Center for Health Care Delivery Science, Dartmouth College, 37 Dewey
Field Road, New Hampshire, NH 03755 USA
[3
]Department of Health Services Research, Palo Alto Medical Foundation Research Institute,
795 El Camino Real, Palo Alto, CA 94301 USA
[4
]Department of Medicine, University of California, Los Angeles, 911 Broxton Avenue,
Los Angeles, CA 90024 USA
[5
]Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson
Road, Newcastle upon Tyne, NE2 4AX UK
[6
]Collingwood Health Group, New York Surgery, Brookland Terrace, New York, North Shields,
NE29 8EA UK
[7
]Clinical Governance & Risk department, Newcastle upon Tyne Hospitals NHS Foundation
Trust, Peacock Hall, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon
Tyne, NE1 4LP UK
[8
]General Medicine Division, Massachusetts General Hospital, 50 Staniford Street—9th
Floor, Boston, MA 0211440 USA
[9
]Informed Medical Decisions Foundation, 40 Court Street, Suite 300, Boston, MA 02108
USA
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