WHAT MAKES A DECISION SHARED? PATIENT AND OBSERVER PERCEPTIONS

Purpose: The U.S. Preventive Services Task Force advocates for the use of shared decision making when making preventive service recommendations to patients.  Yet, previous studies find discrepancies between observer- and patient-rated shared decision making (SDM) and the factors that lead patients to report decisions as shared are unknown.  We evaluate the association of observer- and patient-reported SDM use for colorectal cancer (CRC) screening with each other and with patient reports of relational communication.

Method: Study eligible physicians (N=61) are internists or family medicine physicians practicing in a salaried medical group in southeast Michigan.  Eligible patients are insured, aged 50-80 and due for CRC screening.  Patients scheduling a preventive visit with a participating physician are approached for study enrollment.  Enrollment includes completion of pre-visit interview, office visit audio-recording, and post-visit survey.  The latter includes patient report of SDM as well as items from the Relational Communication Scale (RCS) (Burgoon and Hale, 1987).  153 visits that include discussion of CRC screening were observer-rated for elements of SDM (i.e., involvement, sharing, preferences and agreement) (Charles et al, 1999). Association of patient- and observer-rated SDM with each other and with patient-reported relational communication are evaluated using generalized estimating equation approaches. 

Result: From the pre-visit survey, 72% of patients indicated that they would prefer to share decisions about preventive services with their doctor.  While 43% of patients reported SDM, only 22% of CRC screening discussions included all four elements of SDM per observer ratings.  Patient-reported SDM was not associated with observer-rated SDM (p=0.58) overall, but was significantly associated with the observer-rated involvement element (p<0.01).  Patient reports of SDM were significantly associated with affirmative responses to all 6 items of the “receptivity/trust” subscale of the RCS (all p<0.01).  Significant associations were found for 2 of the same RCS items with observer ratings (p<0.05) and an additional 2 items (formality and equality) were marginally associated (all p<0.10).

Conclusion: Shared decision making processes are recommended and patients report a preference for them.  Patients who report positive interpersonal relationships with their physician are more likely to report that decisions are shared.  Observer-ratings of SDM capture both discussion content and to some extent rapport.  Future studies are needed to understand whether patient-reported, observer-reported or both-reported SDM are associated with improved patient outcomes.