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MAPPIN'SDM – The Multifocal Approach to Sharing in Shared Decision Making  [PDF]
Jürgen Kasper, Frauke Hoffmann, Christoph Heesen, Sascha K?pke, Friedemann Geiger
PLOS ONE , 2012, DOI: 10.1371/journal.pone.0034849
Abstract: Background The wide scale permeation of health care by the shared decision making concept (SDM) reflects its relevance and advanced stage of development. An increasing number of studies evaluating the efficacy of SDM use instruments based on various sub-constructs administered from different viewpoints. However, as the concept has never been captured in operable core definition it is quite difficult to link these parts of evidence. This study aims at investigating interrelations of SDM indicators administered from different perspectives. Method A comprehensive inventory was developed mapping judgements from different perspectives (observer, doctor, patient) and constructs (behavior, perception) referring to three units (doctor, patient, doctor-patient-dyad) and an identical set of SDM-indicators. The inventory adopted the existing approaches, but added additional observer foci (patient and doctor-patient-dyad) and relevant indicators hitherto neglected by existing instruments. The complete inventory comprising a doctor-patient-questionnaire and an observer-instrument was applied to 40 decision consultations from 10 physicians from different medical fields. Convergent validities were calculated on the basis of Pearson correlation coefficients. Results Reliabilities for all scales were high to excellent. No correlations were found between observer and patients or physicians neither for means nor for single items. Judgements of doctors and patients were moderately related. Correlations between the observer scales and within the subjective perspectives were high. Inter-perspective agreement was not related to SDM performance or patient activity. Conclusion The study demonstrates the contribution to involvement made by each of the relevant perspectives and emphasizes the need for an inter-subjective approach regarding SDM measurement.
Patients' and Observers' Perceptions of Involvement Differ. Validation Study on Inter-Relating Measures for Shared Decision Making  [PDF]
Jürgen Kasper, Christoph Heesen, Sascha K?pke, Gary Fulcher, Friedemann Geiger
PLOS ONE , 2011, DOI: 10.1371/journal.pone.0026255
Abstract: Objective Patient involvement into medical decisions as conceived in the shared decision making method (SDM) is essential in evidence based medicine. However, it is not conclusively evident how best to define, realize and evaluate involvement to enable patients making informed choices. We aimed at investigating the ability of four measures to indicate patient involvement. While use and reporting of these instruments might imply wide overlap regarding the addressed constructs this assumption seems questionable with respect to the diversity of the perspectives from which the assessments are administered. Methods The study investigated a nested cohort (N = 79) of a randomized trial evaluating a patient decision aid on immunotherapy for multiple sclerosis. Convergent validities were calculated between observer ratings of videotaped physician-patient consultations (OPTION) and patients' perceptions of the communication (Shared Decision Making Questionnaire, Control Preference Scale & Decisional Conflict Scale). Results OPTION reliability was high to excellent. Communication performance was low according to OPTION and high according to the three patient administered measures. No correlations were found between observer and patient judges, neither for means nor for single items. Patient report measures showed some moderate correlations. Conclusion Existing SDM measures do not refer to a single construct. A gold standard is missing to decide whether any of these measures has the potential to indicate patient involvement. Practice Implications Pronounced heterogeneity of the underpinning constructs implies difficulties regarding the interpretation of existing evidence on the efficacy of SDM. Consideration of communication theory and basic definitions of SDM would recommend an inter-subjective focus of measurement. Trial Registration Controlled-Trials.com ISRCTN25267500.
Shared Decision Making Does Not Influence Physicians against Clinical Practice Guidelines  [PDF]
Mireille Guerrier, France Légaré, Stéphane Turcotte, Michel Labrecque, Louis-Paul Rivest
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0062537
Abstract: Background While shared decision making (SDM) and adherence to clinical practice guidelines (CPGs) are important, some believe they are incompatible. This study explored the mutual influence between physicians’ intention to engage in SDM and their intention to follow CPGs. Methods Embedded within a clustered randomized trial to assess the impact of training physicians in SDM about using antibiotics to treat acute respiratory tract infections, this study evaluated physicians’ intentions to both engage in SDM and follow CPGs. A self-administered questionnaire based on the theory of planned behavior evaluated both behavioral intentions and their respective determinants (attitude, subjective norm and perceived behavioral control) at study entry and exit. We used path analysis to explore the relationships between the intentions. We conducted statistical analyses using the maximum likelihood method and the variance-covariance matrix. Goodness of fit indices encompassed the chi-square statistic, the comparative fit index and the root mean square error of approximation. Results We analyzed 244 responses at entry and 236 at exit. In the control group, at entry we observed that physicians’ intention to engage in SDM (r = 0, t = 0.03) did not affect their intention to follow CPGs; however, their intention to follow CPGs (r = ?0.31 t = ?2.82) did negatively influence their intention to engage in SDM. At exit, neither behavioral intention influenced the other. In the experimental group, at entry neither behavioral intention influenced the other; at exit, the intention to engage in SDM still did not influence the intention to use CPGs, although the intention to follow CPGs (r = ?0.15 t = ?2.02) slightly negatively influenced the intention to engage in SDM, but this was not clinically significant. Conclusion Physicians’ intention to engage in SDM does not affect their intention to adopt CPGs even after SDM training. Physicians’ intention to adopt CPGs had no clinically significant influence on intention to engage in SDM. Trial Registration ClinicalTrials.gov NCT01116076
Shared Decision Making in Residential Aged Care: A Framework Synthesis  [PDF]
Kaye Ervin, Irene Blackberry, Helen Haines
Open Journal of Nursing (OJN) , 2017, DOI: 10.4236/ojn.2017.77062
Abstract: Very little is known about shared decision making (SDM) in residential aged care, despite world-wide policy and imperatives that encourage resident choice and autonomy. This paper provides a framework synthesis of SDM in residential aged care (RAC) and potential barriers and enablers to implement SDM utilising a theoretical framework of implementation. A review of the literature on SDM in RAC from 2005 to 2016 was undertaken, using MEDLINE (Ovid), CINAHL, PsychINFO and Scopus. The articles were synthesised by utilising an implementation theory framework to better understand what may facilitate or hinder the introduction of SDM. Eighteen studies were identified and analysed to determine barriers and enablers to SDM in RAC from the perspectives of staff, residents and relatives. A workplace culture of person-centred care and judicious use of research evidence are enablers of SDM. There is a potential need for additional resources, such as education for staff and families to enable implementation of SDM. Implementation of any health care intervention, including SDM, relies on many complex factors but these are predominantly related to capacity. Determining current uptake and readiness of RAC organisations, residents and their families to adopt SDM is an essential starting point.
Shared decision making for prostate cancer screening: the results of a combined analysis of two practice-based randomized controlled trials
Sheridan Stacey L,Golin Carol,Bunton Audrina,Lykes John B
BMC Medical Informatics and Decision Making , 2012, DOI: 10.1186/1472-6947-12-130
Abstract: Background Professional societies recommend shared decision making (SDM) for prostate cancer screening, however, most efforts have promoted informed rather than shared decision making. The objective of this study is to 1) examine the effects of a prostate cancer screening intervention to promote SDM and 2) determine whether framing prostate information in the context of other clearly beneficial men’s health services affects decisions. Methods We conducted two separate randomized controlled trials of the same prostate cancer intervention (with or without additional information on more clearly beneficial men’s health services). For each trial, we enrolled a convenience sample of 2 internal medicine practices, and their interested physicians and male patients with no prior history of prostate cancer (for a total of 4 practices, 28 physicians, and 128 men across trials). Within each practice site, we randomized men to either 1) a video-based decision aid and researcher-led coaching session or 2) a highway safety video. Physicians at each site received a 1-hour educational session on prostate cancer and SDM. To assess intervention effects, we measured key components of SDM, intent to be screened, and actual screening. After finding that results did not vary by trial, we combined data across sites, adjusting for the random effects of both practice and physician. Results Compared to an attention control, our prostate cancer screening intervention increased men’s perceptions that screening is a decision (absolute difference +41%; 95% CI 25 to 57%) and men’s knowledge about prostate cancer screening (absolute difference +34%; 95% CI 19% to 50%), but had no effect on men’s self-reported participation in shared decisions or their participation at their preferred level. Overall, the intervention decreased screening intent (absolute difference 34%; 95% CI 50% to 18%) and actual screening rates (absolute difference 22%; 95% CI 38 to 7%) with no difference in effect by frame. Conclusions SDM interventions can increase men’s knowledge, alter their perceptions of prostate cancer screening, and reduce actual screening. However, they may not guarantee an increase in shared decisions. Trial registration #NCT00630188
Exploring dietitians' salient beliefs about shared decision-making behaviors
Sophie Desroches, Annie Lapointe, Sarah-Maude Deschênes, Marie-Pierre Gagnon, France Légaré
Implementation Science , 2011, DOI: 10.1186/1748-5908-6-57
Abstract: Twenty-one dietitians were allocated to four focus groups. Facilitators conducted the focus groups using a semistructured interview guide based on the Theory of Planned Behavior. Discussions were audiotaped, transcribed verbatim, coded, and analyzed with NVivo8 (QSR International, Cambridge, MA) software.Most participants stated that better patient adherence to treatment was an advantage of adopting the two SDM behaviors. Dietitians identified patients, physicians, and the multidisciplinary team as normative referents who would approve or disapprove of their adoption of the SDM behaviors. The most often reported barriers and facilitators for the behaviors concerned patients' characteristics, patients' clinical situation, and time.The implementation of SDM in nutrition clinical practice can be guided by addressing dietitians' salient beliefs. Identifying these beliefs also provides the theoretical framework needed for developing a quantitative survey questionnaire to further study the determinants of dietitians' adoption of SDM behaviors.The past two decades have witnessed growing interest in the decision-making processes that occur during clinical encounters. One of these processes is shared decision making (SDM), in which a healthcare choice is made jointly by the health professional and the patient [1]. SDM is primarily employed in cases where several treatment alternatives are available, but there is no single best option. Examples include treatments for type 2 diabetes [2] and hypertension [3]. SDM is positioned as the middle ground between the paternalistic model, where the health professional assumes the leading role in treatment decisions, and the informed patient choice model, where the health professional's role is limited to giving information and the patient is responsible for deciding on treatment [4,5].SDM is increasingly advocated in healthcare because of its potential to improve the decision-making process for patients and increase patients' adherence
Feasibility of a randomised trial of a continuing medical education program in shared decision-making on the use of antibiotics for acute respiratory infections in primary care: the DECISION+ pilot trial
Annie LeBlanc, France Légaré, Michel Labrecque, Gaston Godin, Robert Thivierge, Claudine Laurier, Luc C?té, Annette M O'Connor, Michel Rousseau
Implementation Science , 2011, DOI: 10.1186/1748-5908-6-5
Abstract: A pilot clustered randomised trial was conducted. Family medicine groups (FMGs) were randomly assigned, to either the DECISION+ program, which included three 3-hour workshops over a four- to six-month period, or a control group that had a delayed exposure to the program.Among 21 FMGs contacted, 5 (24%) agreed to participate in the pilot study. A total of 39 family physicians (18 in the two experimental and 21 in the three control FMGs) and their 544 patients consulting for an ARI were recruited. The proportion of recruited family physicians who participated in all three workshops was 46% (50% for the experimental group and 43% for the control group), and the overall mean level of satisfaction regarding the workshops was 94%.This trial, while aiming to demonstrate the feasibility and acceptability of conducting a larger study, has identified important opportunities for improving the design of a definitive trial. This pilot trial is informative for researchers and clinicians interested in designing and/or conducting studies with FMGs regarding training of physicians in shared decision-making.Clinicaltrials.Gov NCT00354315The misuse and limited effectiveness of antibiotics for acute respiratory infections (ARIs) are well documented, and current approaches targeting physicians or patients to improve appropriate use have had limited effect [1-4]. Only a few interventions combining physician, patient, and public education have been successful in reducing antibiotic prescribing for inappropriate indications [2]. In this regard, shared decision-making (SDM) could be a promising strategy to improve appropriate antibiotic use for ARIs [5].SDM is a process by which a healthcare choice is made by physician together with the patient and is characterised by a two-way exchange of information, values, and preferences, both parties taking steps to build a consensus and reach an agreement on the decision to be made [6,7]. From a patient's perspective, SDM interventions or programs (i
Shared decision making and behavioral impairment: a national study among children with special health care needs
Alexander G Fiks, Stephanie Mayne, A Localio, Chris Feudtner, Evaline A Alessandrini, James P Guevara
BMC Pediatrics , 2012, DOI: 10.1186/1471-2431-12-153
Abstract: CSHCN aged 5-17?years in the 2002-2006 Medical Expenditure Panel Survey were followed for 2?years. The validated Columbia Impairment Scale measured impairment. SDM was measured with 7 items addressing the 4 components of SDM. The main exposures were (1) the mean level of SDM across the 2 study years and (2) the change in SDM over the 2?years. Using linear regression, we measured the association of SDM and behavioral impairment.Among 2,454 subjects representing 10.2 million CSHCN, SDM increased among 37% of the population, decreased among 36% and remained unchanged among 27%. For CSHCN impaired at baseline, the change in SDM was significant with each 1-point increase in SDM over time associated with a 2-point decrease in impairment (95% CI: 0.5, 3.4), whereas the mean level of SDM was not associated with impairment. In contrast, among those below the impairment threshold, the mean level of SDM was significant with each one point increase in the mean level of SDM associated with a 1.1-point decrease in impairment (0.4, 1.7), but the change was not associated with impairment.Although the change in SDM may be more important for children with behavioral impairment and the mean level over time for those below the impairment threshold, results suggest that both the change in SDM and the mean level may impact behavioral health for CSHCN.Shared decision making (SDM) is defined as the active participation of both clinicians and families in treatment decisions, the exchange of information, discussion of preferences, and a joint determination of the treatment plan [1]. Given benefits of SDM in increasing families’ knowledge, decreasing uncertainty, and pairing families with treatments they find most acceptable [2], the Institute of Medicine (IOM) recently stressed the importance of research assessing the comparative effectiveness of SDM in pediatrics [3] and the 2010 Patient Protection and Affordable Care Act supported the implementation of SDM in clinical settings [4]. Despite
Deconstructing patient centred communication and uncovering shared decision making: an observational study
Michel Wensing, Glyn Elwyn, Adrian Edwards, Eric Vingerhoets, Richard Grol
BMC Medical Informatics and Decision Making , 2002, DOI: 10.1186/1472-6947-2-2
Abstract: This study aimed to examine PCC and SDM empirically with respect to their mutual association, the variation in practitioners' working styles, and the associations with patient characteristics.Sixty general practitioners recruited 596 adult patients who gave written consent to have their consultations videotaped. The tapes were assessed by two researchers, using a standardised instrument for global communication. For the purpose of this exploratory study, scales for PCC and SDM were based on subsamples of items in the MAAS.The scales for PCC and SDM were weakly associated (Pearson correlation: 0.25). Physicians varied more on SDM than on PCC. The intracluster correlation of the PCC and SDM scales were, respectively, 0.34 and 0.19. However, hypotheses regarding associations with patient characteristics were not confirmed. Neither PCC nor SDM scores were related to patient gender, education, age, functional health status or existence of chronic conditions.The study provides evidence that PCC and SDM can be differentiated and comprise approaches to communication between clinicians and patients which may be more clearly distinguished by further focused research and training developments.The patient-centred communication method suggests that a care provider should 'understand the meaning of illness for the patient as well as interpret it in terms of the medical frame of reference' [1]. Although an extensive body of literature on the method has emerged, recent evaluations have led to concerns about possible multi-dimensionality and consensus as to its meaning has been difficult to achieve [2]. An alternative focus for an analysis of the doctor-patient interaction concerns the locus of decisional responsibility. Shared decision making has been introduced as a proposed middle ground between paternalistic decision-making and what has been termed 'informed' or 'consumer' choice where decisional responsibility is placed with patients [3]. This study examines the concepts of sha
Shared decision-making in Israel: status, barriers, and recommendations
Talya Miron-Shatz, Ofra Golan, Mayer Brezis, Gil Siegal, Glen M Doniger
Israel Journal of Health Policy Research , 2012, DOI: 10.1186/2045-4015-1-5
Abstract: Shared decision making (SDM), "the attempt to involve patients in decision-making tasks, especially where decisions, in the face of uncertain or equivocal evidence of benefit, are sensitive to personal preferences" [1], has grown in prevalence worldwide over the last two decades [2]. SDM relates to involving patients in various issues, including screening, treatment options, administration of medication, nutrition, and lifestyle interventions. SDM has influenced the way medicine is practiced and has sparked interest in exploring ways to involve patients in their healthcare decisions and measure the effects of this involvement [3].Indeed most patients wish to take an active part in choosing among alternative courses of action regarding their health, with the physician either participating in the decision or providing relevant information and then allowing the patient to decide autonomously [4]. Beyond the higher ethical standards associated with greater patient involvement as compared with physician paternalism, SDM has practical merits. An impressive corpus of research has shown that patient involvement leads to better knowledge about treatment options, more realistic expectations concerning disease course and treatment, improved adherence, enhanced patient satisfaction, and sometimes a better clinical outcome [5].Though ultimately manifest at the level of the patient-physician encounter, SDM must first be legally mandated and medical professionals must be trained to incorporate its principles into their practice. Further, research studies are necessary to monitor its status and drive improvement. Moreover, these activities must be supported and promoted by national health, legal, and other organizations. Some countries have allocated resources for the promotion and evaluation of SDM. In Germany, the ministry of health funded the research consortium ''Patient as partner in medical decision-making'' [6]. In Canada, the importance of SDM is reflected in increased fund
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