ORAL ABSTRACTS: SHARED DECISION MAKING AND DECISION SUPPORT INTERVENTIONS
Methods: Pre-post test design. As part of a hospital-wide SDM implementation project, social workers in a pediatric type 1 diabetes clinic were trained as decision coaches through an online, self-directed tutorial (Ottawa Decision Support Tutorial) and a skill-building workshop that provided foundational SDM knowledge and practise using simulated clinical encounters, audit and feedback. Youth and their parents considering a change in the youth’s insulin delivery method were referred for decision coaching by their diabetes physician. Decision coaches followed a standardized coaching protocol using the dyadic Ottawa Family Decision Guide pre-populated for insulin delivery options. Data were collected from participating family members immediately pre-coaching (T1) and 10-14 days post (T2). Primary outcome was youth and parent decisional conflict measured with the low literary Decisional Conflict Scale (DCS), and compared at T1 and T2 using a paired t-test. Other outcomes included choice predisposition vs actual choice (T1&T2), Preparation for Decision Making Scale (PrepDM) (T2), and satisfaction with coaching questionnaire (T2).
Results: 42 families participated, each consisting of 1 youth and 1-2 parents. Youth (n=42), 52% male, median age 11.5 years (range 6.3-17.7). Parents (n=62), 40% male. Twenty sessions involved youth and both parents (17 youth and female parent; 5 youth and male parent). Coaching sessions averaged 55.2±8.9 minutes. Mean youth DCS decreased from 36.4±19.8(SD) (T1) to 4.6±10.0 (T2) (p<0.0001). Mean parent DCS decreased from 42.0±24.0 (T1) to 3.8±8.0 (T2) (p<0.0001). Between T1 and T2, choice predisposition changed for parents but not youth. 54.6% of youth preferred to share the decision with others; 45.5% preferred to decide themselves after hearing others’ views. Mean PrepDM scores (T2) were 79.0±14.7 for youth and 77.8.2±17.4 for parents. Ninety-one percent of parents and 58.6% of youth rated the coaching session length as appropriate. Youth (88.9-96.3%) and parents (87.8-100%) rated the coaching session as helpful, clear, balanced, and would definitely/probably recommend it.
Conclusion: Decision coaching with a decision aid reduced decisional conflict for youth and parents facing a preference-sensitive insulin delivery decision. Youth and parents were satisfied with the decision coaching intervention.
This systematic review of shared decision making interventions sought to 1) determine the level of evidence for the effectiveness of shared decision making interventions for individuals who experience mental health concerns and 2) identify directions for future research and intervention development for shared decision making in mental health treatment.
A systematic search of Psychinfo, Pubmed and CINAHL-Plus (2008-2014) yielded 502 abstracts. Included in this review were studies that a) reported results of a shared decision making intervention (defined as one that aimed to facilitate communication and patient engagement), b) used at least a pre/post test study design, and c) targeted a consumer group with mental health issues. Design, participant, and methodological characteristics of each study were analyzed. Quality ratings were assigned by 2 reviewers using the Quality Assessment Tool for Quantitative Studies (Thomas et al, 2004).
20 studies met criteria for this review, 14 of which were randomized controlled trials. Most interventions were delivered in outpatient settings. Intervention types included those targeted at increasing provider competencies (n=3), consumer competencies (n=3) or both (n=14). All but 3 of the studies included a written component in the intervention; 4 included video; 8 included web-based; and 19 were interactive.
Studies that measured patient attitudes/activation (n=9) generally found positive effects (n=7 with significant findings). Provider/consumer interactions were also effective in 5 of 6 studies. Functional outcomes including symptoms, hospital readmissions or follow up with treatment were measured in 11 studies and 6 found significant effects. Length of interventions ranged from 20 minutes to 12 months but there was no evidence that longer interventions were more effective. Interventions that focused solely on providers or solely on patients tended to narrowly define success in terms of patient activation or increased patient centeredness in the interactions compared to broader interventions that more often measured functional outcomes.
Rigorous research on Shared Decision Making interventions has proliferated over the last four years; the majority of which employed rigorous study designs. Interventions that measured patient activation or patient centeredness have generally reported success in these outcomes.
But, it is less clear whether this translates into improved functioning or treatment engagement. Just over half of studies in this review that measured functional outcomes found significant results, indicating promising directions for future research.
Test the comparative effectiveness of two interventions designed to improve patient centered communication and decision-making in primary care.
We conducted a cluster randomized pilot trial to compare “Open Communication” (OpenComm), “Ask 3 Questions” (Ask3), and usual care in a fully crossed 2x2 design. Four primary care clinics were randomized, one to each trial arm. The novel OpenComm intervention, co-developed with a group of clinician, patient stakeholders, and user-experience design consultants, consists of: (1) an animated-video to encourage open communication between patients and physicians; (2) a patient visit companion booklet to enable patients to delineate issues that matter the most to them and to review and record their next steps; and (3) the use of Standardized Patient Instructors to provide communication coaching for physicians. Ask3 is an evidence-based three-question prompt list, encouraging patients to ask about options, potential benefits and risks and their individual likelihood.
We collected 300 post-visit surveys from patients served by 26 primary care physicians (75 unique patient visits/clinic, average 11.5 visits/physician). Outcome measures included the percentage of patient participants who gave the highest possible score on CollaboRATE, a validated 3-item patient engagement measure that captures patient perceptions of patient centeredness of communication and decision-making in a consultation.
Descriptive analyses and logistic regression with cluster robust standard errors were used to analyze the data. Covariates included patient age, sex, race/ethnicity, and education.
The proportion of patients who gave the highest possible score on CollaboRATE was 74.3% in the OpenComm clinic, 72.0% in the Ask3 clinic, 74.3% in the OpenComm combined with Ask3 clinic, and 67.6% in the usual care clinic. Compared with visits in the OpenComm clinic, the odds ratios of giving the highest possible CollaboRATE score were 0.75 (s.e.=0.05, p<0.01), 0.58 (s.e.=0.12, p<0.01), and 0.52 (s.e.=.05, p<0.01) in the Ask3, OpenComm+Ask3, and usual care clinics, respectively.
CollaboRATE scores were highest in the OpenComm arm, and higher than Ask3 alone, the combination of both approaches, or usual care. The multidimensional OpenComm approach offers a promising approach to improve patient centered communication and decision-making in primary care office visits.
Method: 461 cancer survivors from 12 cancer centers across AL, MS, GA, FL, and TN completed telephone surveys. Participants were ≥65 years old, had completed treatment, and were ≥2 years post-diagnosis. We assessed whether they had received a written treatment summary and whether a health care professional explained their follow-up care plan. Respondents completed the Stanford Chronic Illness Management Self-Efficacy Scale and self-reported ER visits and hospitalizations in the past year. Multiple linear regression models estimated the association of 1) treatment summary and 2) follow-up care plan explanation with total self-efficacy score, controlling for race, age, sex, years since diagnosis, disease severity, and enrollment status in a navigation program. Multiple logistic regression models examined the association of self-efficacy scores with 1) ER visits and 2) hospitalizations (yes/no) while adjusting for covariates. We explored mediation and moderation analyses to examine the potential relationship between treatment summaries, self-efficacy, and ER/hospitalizations.
The majority of survivors were female (53%) and 21% were minorities. Survivors were on average 75 years old and 4.6 years from diagnosis. The most frequent diagnoses were breast (15%), prostate (17%), or lung (11%). Approximately 38% reported receiving a written treatment summary plan and 75% reported that a health care professional explained their follow-up care plan. In the adjusted models, receiving treatment summaries and follow-up care instructions were significantly associated with higher self-efficacy scores (B=0.47, SD=0.23, p=0.04 and B=0.75, SD=0.27, p=0.007, respectively). In the adjusted logistic regression models, higher self-efficacy scores were significantly associated with decreased odds of ER visits (OR:0.85; 95% CI:0.77, 0.93) and hospitalizations (OR:0.87 95% CI:0.79, 0.96) in the past year. Self-efficacy mediated the relationship between follow-up care instructions and ER use.
Conclusion: Verbal explanations of the follow-up care plan by a health care professional to older cancer survivors, beyond the written component of the care plan, may enhance survivor self-efficacy for managing cancer as a chronic condition. Self-efficacy may be associated with lower odds of health care utilization, but the mechanism through which self-efficacy is associated with ER/hospitalizations needs further examination.
Methods: Pre-post test design. The published PtDA was evaluated using International PtDA Standards (IPDAS) criteria. We surveyed a multi-stakeholder group to identify key elements for the Ottawa EPI PtDA and sought feedback from the local SDM program, neonatologists and parents. Four neonatologists were trained in DC and alpha-tested our PtDA. Our PtDA and DC were field (beta) tested with women and partners at risk of delivering at 23 - 24 weeks gestational age (GA). Primary outcome measure was change in Decisional Conflict Scale (DCS) from pre-DC (T1), to immediately post-DC (T2), and 12-48 hours post-DC (T3), using paired T-tests. Secondary measures included change in choice predisposition and parents’ satisfaction with the PtDA and DC.
Results: The Ottawa EPI PtDA addressed the deficits in the published PtDA (IPDAS score 13/35) providing more information about quality of life, maternal impact, local outcome data, and the option of palliative care. Post-modification IPDAS score increased to 31/35 (p<0.001). Eleven DC sessions involved 18 parents (mean GA 23.3 weeks; 10 female, 8 male) and lasted 30-65 minutes (mean 50). Total DCS (mean±SD) decreased from 50.3±25.7 (T1) to 7.7±15.0 (T2) (p<0.001). Three parents didn’t complete T3 DCS due to infants’ early delivery. There was no change in DCS between T2 and T3 (n=15; p=0.51). Parents’ preferences: T1: 4 intensive care, 2 palliative care, 2 uncertain, and 10 unaware of options vs. T2: 12 intensive care, 5 palliative care, 1 uncertain, and all knew options. 94% of parents said DC with the Ottawa EPI PtDA helped to identify what they needed to make a decision.
Conclusion: The quality of an existing yet untested PtDA was improved using multi-source feedback, alpha-testing, and incorporation of local data. Field testing demonstrates the promise of the Ottawa EPI PtDA combined with DC to help parents engage in SDM at the limit of viability.
To analyze the impact of a novel intervention for improving patient-physician communication by evaluating how physicians engage patients in shared decision-making.
A cluster randomized controlled trial tested two interventions at four primary care clinics of a multispecialty group practice: (1) usual care, (2) Ask 3 Questions, an existing tool encouraging patients to ask questions, (3) Open Communication, a novel intervention combining physician and patient coaching, and (4) Ask 3+Open Communication. The Open Communication intervention incorporated the “Visit Companion Booklet”, video coaching for patients, and Standardized Patient Instructor communication coaching for physicians. Of the 300 adult patients who participated, 40 visits were audio-recorded (10 per clinic). Observer OPTION5, a validated observer measure, was used to evaluate how physicians present options, establish a partnership with the patient, describe pros and cons of options, elicit patient preferences, and integrate patient preferences into the decision. Two qualitative researchers blinded to intervention arms jointly identified “topics” requiring decisions, scored each item, and then averaged across coders to create final scores.
We used descriptive statistics and linear regression with cluster robust standard errors to analyze the OPTION5 item and final scores (scaled 0-100) for 200 topics. The models included the main effects for both interventions, their interaction, and controlled for patient demographics.
The average number of “topics” per visit coded ranged from 4.8 to 5.2 [min=1, max=13, s.d. 2.15-3.36].
Overall, presenting options and describing pros and cons of options had the highest average scores (7.65 and 7.24). For presenting options, the coefficient on the main effect for Ask 3 was positive and statistically significant (coeff=0.90, p<0.05). The scores for Ask 3+Open Communication were significantly lower than usual care for presenting options (coeff=-.49, p<0.01) and establishing partnership (coeff=-1.3, p<0.01). There were no other statistically significant results for comparisons to usual care.
While the general level of shared decision-making was low, the use of the Ask 3 prompt led to a small but significant increase in physicians presenting options to patients. No other significant improvements in other aspects of shared decision-making were present. These findings illustrate how difficult it is to change physician communication with patients, and the overall low final scores (under 30%) suggest that it is imperative to find methods to better engage patients in sharing decision-making.