Background: Despite a growing body of evidence supporting the use of decision aids (DAs) to increase patient participation in clinical decision making, little is known about using these tools outside of academically affiliated practices. As interest in dissemination and diffusion of DAs grows, there is a critical need for research to help us understand the barriers and facilitators to integration in clinical practices in the community. The current project focused on solo practitioners, which currently account for 43% of primary care practices in the US.

Methods: 10 community-based primary care clinics in predominately low-income minority neighborhoods of Los Angeles were recruited into the study using the AMA Masterfile database. Each clinic recruited 20 patients into pamphlet (n=100) and video DA (n=100) groups. Practices received a fixed budget to purchase equipment to show video DAs and project staff worked with practices to find a tailored solution to integrating DAs into the clinical workflow. Patients reviewed DAs in the practice before the consultation with a physician. Questionnaires were completed before and after the consultation and included measures of patient role preferences, decision-specific knowledge, decisional conflict and ratings of the decision aid.

Results: Practices took different approaches to integrating DAs, including showing video DAs in the waiting room using portable DVD players and showing them in private exam rooms or practice staff lounges. Utilization of DAs varied significantly between practices. High utilizing practices were characterized by strong cohesion between physician and staff, used appointments to schedule patients and had a slower overall pace. Most of the patients were African American (41%) or Latino (41%) and had annual incomes below $25k. Patients who reviewed a pamphlet DA reported lower decisional conflict than those who watched a video DA (Informed subscale p<.05), however, decision-specific knowledge scores were significantly higher among those who saw a video (p<.005). The majority of patients (71%) reported that the DA helped them recognize that a decision needs to be made and most (82%) felt that the tools were helpful in making a decision with their physician.

Conclusions: Community-based primary care practices were able to integrate DAs with varying success. Underserved ethnic minority patients found the decision support tools useful, but felt more conflicted after reviewing detailed video DAs that performed better in increasing decision-specific knowledge.