LONG-FORM ORAL ABSTRACTS-2: IMPROVING PATIENT-PROVIDER DECISION MAKING
Despite extensive study of patient-provider decision making(MDM) in Western countries, research on patient involvement preferences in non-Western cultures is limited. Researchers from 5 Asia-Pacific countries collaborated through multiple online meetings over two years to investigate antecedents to preferred MDM involvement in 7 cultures. Development of cross-culturally valid scales measuring desired level of individual and family involvement in MDM as well as perceived prevalence of physician SDM-related practices constitutes a crucial first step.
The multinational team generated 6 disease-related treatment consultation scenarios that varied in severity. Following outside expert evaluation in each culture, scenarios were revised to maximize validity across countries. In each country, an online panel sample of approximately 300 middle class, urban adults(30-44; 50% female) completed a double-back translated survey(China, Thailand, Malaysia, Korea) and or an English language survey(US, Australia, and India). Multi-group confirmatory factor analysis(CFA) tested validity, common method bias and measurement invariance. Structural equation modeling (SEM) examined relationships between factors.
CFA revealed that the 2 less severe scenario conditions did not load consistently well on their factors in all 7 countries. Three inconsistent SDM prevalence items were also deleted. CFAs were conducted on remaining items measuring desired individual/family level of involvement and perceived SDM practices prevalence. CFAs surpassed fit criteria and established convergent/discriminant validity in all countries. Metric invariance with the US as baseline was also found. Common method bias(CMB) varied from 8.5% to 22%. SEM analysis was undertaken and structural coefficients were adjusted post-hoc for CMB. Perceived level of physician SDM-related practices had limited effects in only 2 countries. In contrast, respondents' desired level of individual involvement in MDM positively predicted desired level of family MDM involvement in all 7 countries.
Before expanding MDM research to non-Western cultures, cross-cultural validation of measures is critical to establishing scientific validity. Involving researchers from several countries, this project illustrates the value of multinational collaboration to MDM research. The team's findings also point to the importance of cross-cultural study of desired involvement in MDM. Researchers and providers should be aware that patients in diverse cultures who want to be involved in MDM also tend to want their families involved. Despite contrary theoretical predictions, this positive relationship was found in both collectivist and individualist cultures.
Despite the importance of shared decision making, doctors’ advice is rated as the most important factor influencing final treatment decision. Since it has been shown that patients and doctors differ in their preferences and trade-offs it is important to clarify the role of the doctor in the decision-making process. Therefore, our purpose was to investigate the influence of doctors` treatment preferences on patients’ treatment preferences in localized prostate cancer (PC) and to investigate the influence of a decision aid on their choice.
Between August 2014 and July 2015 we included 181 newly diagnosed patients with low- or intermediate-risk PC. All were offered a web-based Decision Aid (DA) to support treatment decision making. Initial treatment preference was asked prior to DA use by asking ‘Before using this DA, what is your initial treatment preference?’. Doctors treatment preference was obtained by a paper informed consent form for clinicians by asking ‘What is the most suitable treatment option for this patient according to you?’. This prospective study took place within an ongoing two-armed pragmatic Cluster Randomized Controlled Trial investigating the effects of a web based DA (Cuypers et. al, Trials 2015).
For 155 of 181 patients information about both doctors’ and patients’ preferences were available. Doctors indicated a specific preferred treatment option in 63% (98/155), patients in 74% (115/155). The most frequently indicated preferred treatment options by doctors were active surveillance (38%, 37/98) and surgery (37%, 36/98). In 62 % (61/98) patients’ initial treatment preference was in correspondence with their doctors treatment preference. When patients did not indicate a treatment preference after DA use, they eventually chose the treatment their doctor preferred.
In 63%, doctors indicate a specific treatment preference for PC patients and in 62 % of these cases the patients’ treatment preference is in correspondence with the doctor’s preference. The preferred doctors’ opinion may have the highest influence on patients without a treatment preference after DA use. It is therefore highly recommended to involve patients in decision making and to stimulate their own decision making to avoid biased decision making by only following the doctors preference.
Patient engagement plays an important role in while identifying and choosing treatment options based on the technology, efficacy, integrating patient values and preferences. The research context for the current study involves study of dental implants for replacement of missing tooth. Implant technology options are available in the market necessitate evaluation and selection of suitable implants by dentists based on the patient’s specific requirements/expectations. As per research literature, patient orientation to adopt dental implants hinges on dentist-patient engagement and the concept of shared decision-making has been attracting great attention in academic research. Current study proposes to examine the phases of patient engagement that enables the adoption of right choice of dental implants from both perspectives of dentists and patients.
Interactive Qualitative Analysis (IQA) is employed to map the phases of patient engagement model. It captures the dentist’s knowledge through inductive, deductive and axial coding. The phases were further explored to identify the importance Vs. performance from the perspective of both dentists and patients. Importance Performance Analysis (IPA) is deployed to identify the potential focus areas by employing survey instrument.
Patient engagement model has been developed with 11 key phases through group and individual interview coding. These phases further segregated into drivers and outcomes based on the level of influence. Dentist’s characteristics and patient orientation and information exchange are considered as drivers for the patient engagement. Constructive engagement, trust and deliberation are identified as secondary outcomes. Shared responsibility, implant choice and perceived (patient) value is considered as key outcomes of the patient engagement model.
These phases were further studied to understand its performance based on the perceived importance from the perspective of dentists and patients. Quality of information exchange, dentist’s self-efficacy, trust and hospital environment need focus.
Patient engagement model identified the key phases while facilitating the patients and dentists. Patient’s unmet expectations are resulted through the IPA study. Dentists should provide treatment explanation in laymen terms that enables the patients to appreciate the need for the treat choice.
Improve patient acceptance rate and reduce the communication time and improves the scale of operation.
Method(s): A questionnaire was administered at the 9th Asian Forum of Chronic Kidney Disease Initiative in May 2015 to 203 HCPs who treat or counsel ESRD patients in Indonesia. The questionnaire investigated HCPs’ preferred recommendations via a series of vignettes describing hypothetical patients with varying age (65, 75 and 85 years), comorbidities (diabetes, diabetes with congestive heart failure and advanced cancer), gender and socio-economic status (poor, middle-class, wealthy). HCPs were also asked to choose a preferred treatment for themselves in a series of hypothetical scenarios describing the age and comorbidities present when diagnosed with ESRD.
Result(s): As predicted, the likelihood of HCPs recommending CM over dialysis was greater for older patients, for poorer patients, and when the hypothetical patient was diagnosed with advanced cancer (compared to diabetes or heart failure). Gender did not have a significant influence on treatment recommendations. Treatment recommendations varied widely for any given patient profile except when the hypothetical patient was 85 years old or had advanced cancer, in which case the preference was to recommend CM in the vast majority of cases. Treatment choices for self were more homogenous and dialysis was chosen more than CM. HCPs also tended to choose CM less for themselves than for patients. CM was recommended 57% of the time for patients vs. 38% for themselves.
Conclusion(s): Results show that HCPs treatment recommendations were affected not only by patient comorbidities and age, but also patient socio-economic status. Efforts should be made to better understand the variation between HCPs in treatment recommendations for similar patient profiles; and also the difference between HCPs recommendations for patients and their own preferences.
Method(s): Focus group interviews were conducted in December 2014 with health professionals currently working in LTC setting. The participants were divided into groups by ranks and disciplines. The homogeneity in the group and the group dynamic encouraged them to share experiences and views more freely. This strategy allows researchers to elicit diverse perspectives, needs and concerns. All interviews were audiotaped and transcribed verbatim to facilitate analysis, but confidentiality and anonymity was assured. Qualitative content analysis was performed. The study was approved by the Cluster Clinical Research Ethics Committee.
Result(s): A total of 20 participants from different disciplines were divided into six groups. They included two medical doctors, ten registered nurses, five enrolled nurses, a social worker, a physiotherapist and an occupational therapist. All of them had rich clinical experience, with an average of 21 years (range: 10-30 years), but their working experience in their current unit varied from 1 to 24 years. Around one third of them had attended training workshops or seminars about palliative or EoL care. From their accounts of care experiences, the major challenges in EoL decision making in LTC setting are related to right timing, preparedness of health professionals, mental capacity of patients, and readiness of family.
Conclusion(s): There was consensus across participants of different disciplines that advance care planning (ACP) for patients in LTC setting is imperative because they generally have progressive debilitating conditions. However, a range of concerns were also identified that may hinder the planning process. For example, when is the appropriate time to plan for EoL care given that many patients have stayed in the care facility with stable condition for a period of time, who can take the lead in the EoL decision making, what would the patients want for their EoL care, how to prepare the family members for the EoL decision making, and how to align the care with the care goal. The findings of the study suggest that a number of strategies, including staff education, family-centred ACP programme, interdisciplinary communication, and tailored model of care delivery, are needed to be complementary to support health professionals to improve EoL decision making for patients in LTC setting.