Effectiveness of the DECIDE Interventions on Shared Decision Making and Perceived Quality of Care in Behavioral Health With Multicultural Patients : A Randomized Clinical Trial

Abstract

<p class="first" id="d1555920e619">This randomized clinical trial tests the effectiveness of patient and clinician interventions to improve shared decision making and quality of care among an ethnically/racially diverse sample from behavioral health clinics. </p><div class="section"> <a class="named-anchor" id="ab-yoi170110-1"> <!-- named anchor --> </a> <h5 class="section-title" id="d1555920e625">Question</h5> <p id="d1555920e627">How effective are the DECIDE (decide the problem; explore the questions; closed or open-ended questions; identify the who, why, or how of the problem; direct questions to your health care professional; enjoy a shared solution) patient and clinician interventions for improving shared decision making and quality of care for ethnic/racial minorities? </p> </div><div class="section"> <a class="named-anchor" id="ab-yoi170110-2"> <!-- named anchor --> </a> <h5 class="section-title" id="d1555920e630">Findings</h5> <p id="d1555920e632">In a randomized clinical trial of 312 dyads that included 74 behavioral health clinicians and 312 patients, the clinician intervention significantly improved shared decision making. Patients perceived higher quality of care when patients and clinicians received the recommended dosage of each intervention. </p> </div><div class="section"> <a class="named-anchor" id="ab-yoi170110-3"> <!-- named anchor --> </a> <h5 class="section-title" id="d1555920e635">Meaning</h5> <p id="d1555920e637">The clinician intervention could improve shared decision making with minority populations, and the patient intervention could improve patient-reported quality of care by incorporating patient preferences in health care. </p> </div><div class="section"> <a class="named-anchor" id="ab-yoi170110-4"> <!-- named anchor --> </a> <h5 class="section-title" id="d1555920e641">Importance</h5> <p id="d1555920e643">Few randomized clinical trials have been conducted with ethnic/racial minorities to improve shared decision making (SDM) and quality of care. </p> </div><div class="section"> <a class="named-anchor" id="ab-yoi170110-5"> <!-- named anchor --> </a> <h5 class="section-title" id="d1555920e646">Objective</h5> <p id="d1555920e648">To test the effectiveness of patient and clinician interventions to improve SDM and quality of care among an ethnically/racially diverse sample. </p> </div><div class="section"> <a class="named-anchor" id="ab-yoi170110-6"> <!-- named anchor --> </a> <h5 class="section-title" id="d1555920e651">Design, Setting, and Participants</h5> <p id="d1555920e653">This cross-level 2 × 2 randomized clinical trial included clinicians at level 2 and patients (nested within clinicians) at level 1 from 13 Massachusetts behavioral health clinics. Clinicians and patients were randomly selected at each site in a 1:1 ratio for each 2-person block. Clinicians were recruited starting September 1, 2013; patients, starting November 3, 2013. Final data were collected on September 30, 2016. Data were analyzed based on intention to treat. </p> </div><div class="section"> <a class="named-anchor" id="ab-yoi170110-7"> <!-- named anchor --> </a> <h5 class="section-title" id="d1555920e656">Interventions</h5> <p id="d1555920e658">The clinician intervention consisted of a workshop and as many as 6 coaching telephone calls to promote communication and therapeutic alliance to improve SDM. The 3-session patient intervention sought to improve SDM and quality of care. </p> </div><div class="section"> <a class="named-anchor" id="ab-yoi170110-8"> <!-- named anchor --> </a> <h5 class="section-title" id="d1555920e661">Main Outcomes and Measures</h5> <p id="d1555920e663">The SDM was assessed by a blinded coder based on clinical recordings, patient perception of SDM and quality of care, and clinician perception of SDM. </p> </div><div class="section"> <a class="named-anchor" id="ab-yoi170110-9"> <!-- named anchor --> </a> <h5 class="section-title" id="d1555920e666">Results</h5> <p id="d1555920e668">Of 312 randomized patients, 212 (67.9%) were female and 100 (32.1%) were male; mean (SD) age was 44.0 (15.0) years. Of 74 randomized clinicians, 56 (75.7%) were female and 18 (4.3%) were male; mean (SD) age was 39.8 (12.5) years. Patient-clinician pairs were assigned to 1 of the following 4 design arms: patient and clinician in the control condition (n = 72), patient in intervention and clinician in the control condition (n = 68), patient in the control condition and clinician in intervention (n = 83), or patient and clinician in intervention (n = 89). All pairs underwent analysis. The clinician intervention significantly increased SDM as rated by blinded coders using the 12-item Observing Patient Involvement in Shared Decision Making instrument ( <i>b</i> = 4.52; SE = 2.17; <i>P</i> = .04; Cohen <i>d</i> = 0.29) but not as assessed by clinician or patient. More clinician coaching sessions (dosage) were significantly associated with increased SDM as rated by blinded coders ( <i>b</i> = 12.01; SE = 3.72; <i>P</i> = .001; Cohen <i>d</i> = 0.78). The patient intervention significantly increased patient-perceived quality of care ( <i>b</i> = 2.27; SE = 1.16; <i>P</i> = .05; Cohen <i>d</i> = 0.19). There was a significant interaction between patient and clinician dosage ( <i>b</i> = 7.40; SE = 3.56; <i>P</i> = .04; Cohen <i>d</i> = 0.62), with the greatest benefit when both obtained the recommended dosage. </p> </div><div class="section"> <a class="named-anchor" id="ab-yoi170110-10"> <!-- named anchor --> </a> <h5 class="section-title" id="d1555920e709">Conclusions and Relevance</h5> <p id="d1555920e711">The clinician intervention could improve SDM with minority populations, and the patient intervention could augment patient-reported quality of care. </p> </div><div class="section"> <a class="named-anchor" id="ab-yoi170110-11"> <!-- named anchor --> </a> <h5 class="section-title" id="d1555920e714">Trial Registration</h5> <p id="d1555920e716">clinicaltrials.gov Identifier: <a data-untrusted="" href="https://clinicaltrials.gov/show/NCT01947283" id="d1555920e718" target="xrefwindow">NCT01947283</a> </p> </div>