PURPOSE: Randomized Control Trials have shown that “decision aid (DAs) improve people's knowledge of the options, create realistic expectations of their benefits and harms, reduce difficulty with decision making, and increase participation in the process” (O'Connor et al., 2002). While DA use has been well studied in specialty practice, additional research is needed in the primary care setting. Following the Performance Improvement Model used by the Institute for Healthcare Improvement, the University of California, San Diego Shared Decision Making research project partnered with two of its practice-based research network (PBRN) sites to identify potential system barriers and challenges that preclude physician-directed distribution of DA and to address them systematically.

METHODS: Two diverse practices were selected to emphasize challenges faced in primary care practices. One clinic employs eight providers and utilizes an EMR to care for its 13,000 patients, mostly Caucasians and of higher socio-economic status. The other clinic employs four physicians and, using a paper-based medical record system, provides care for 12,000 patients, mostly of African American or Hispanic descent and lower SES. These differences in clinic and patient characteristics provide an excellent opportunity to identify barriers and challenges in distributing DAs that may be specific to each clinic.

RESULTS: Both clinics faced many challenges that resulted in low DA distribution during their first four-week Plan-Do-Study-Act (PDSA) cycle, distributing DAs to less than 8% of eligible patients. In focus group assessment, both clinics identified that physicians cannot solely be responsible for patient health education and using allied health personnel to discuss DAs with patients resulted in increased distribution. Both clinics found it very difficult to identify eligible patients (having an EMR did not ease the identification process) and both believed that more direct-to-consumer distribution would yield better outcomes. However, each clinic identified different solutions to solve their distribution challenges: one clinic chose to rely on patient-initiated activities while the other decided to use incentives for clinic staff. We will also report on these next PDSA cycles.

CONCLUSIONS: This project highlights the difficulty of translating research into practice. It also offers some practical solutions for research centers and community clinics interested in promoting DA distribution and Shared Decision Making.