Publications (64)182.47 Total impact
-
Article: Feasibility of a randomised trial of a continuing medical education program in shared decision-making on the use of antibiotics for acute respiratory infections in primary care: the DECISION+ pilot trial.
[show abstract] [hide abstract]
ABSTRACT: The misuse and limited effectiveness of antibiotics for acute respiratory infections (ARIs) are well documented, and current approaches targeting physicians or patients to improve appropriate use have had limited effect. Shared decision-making could be a promising strategy to improve appropriate antibiotic use for ARIs, but very little is known about its implementation processes and outcomes in clinical settings. In this matter, pilot studies have played a key role in health science research over the past years in providing information for the planning, justification, and/or refinement of larger studies. The objective of our study was to assess the feasibility and acceptability of the study design, procedures, and intervention of the DECISION+ program, a continuing medical education program in shared decision-making among family physicians and their patients on the optimal use of antibiotics for treating ARIs in primary care. A pilot clustered randomised trial was conducted. Family medicine groups (FMGs) were randomly assigned, to either the DECISION+ program, which included three 3-hour workshops over a four- to six-month period, or a control group that had a delayed exposure to the program. Among 21 FMGs contacted, 5 (24%) agreed to participate in the pilot study. A total of 39 family physicians (18 in the two experimental and 21 in the three control FMGs) and their 544 patients consulting for an ARI were recruited. The proportion of recruited family physicians who participated in all three workshops was 46% (50% for the experimental group and 43% for the control group), and the overall mean level of satisfaction regarding the workshops was 94%. This trial, while aiming to demonstrate the feasibility and acceptability of conducting a larger study, has identified important opportunities for improving the design of a definitive trial. This pilot trial is informative for researchers and clinicians interested in designing and/or conducting studies with FMGs regarding training of physicians in shared decision-making. Clinicaltrials.Gov NCT00354315.Implementation Science 01/2011; 6:5. · 3.10 Impact Factor -
Article: Presenting evidence to patients online: what do web users think of consumer summaries of cochrane musculoskeletal reviews?
[show abstract] [hide abstract]
ABSTRACT: The Internet has the potential to be an effective medium for delivering health care knowledge to consumers. While computer usability research makes recommendations about how to present Web-based information generally, there remains no clear guidance on how to present specific forms of health care research evidence online in a way that facilitates understanding and good health care decision making. The two goals of this study were to describe the Cochrane Musculoskeletal Group's (CMSG's) process for developing online patient-focused summaries of systematic reviews and to evaluate the impressions of these summaries formed by users. A process for summarizing the results of systematic reviews via consumer summaries has evolved over 15 years. An evaluation of this approach took the form of Internet surveys on the Arthritis Society of Canada website and surveys of members of the Canadian Arthritis Patient Alliance (CAPA). Respondents provided information on background, relationship to the decision, their satisfaction with and preparation for decision making, and suggestions for improvements to the summaries. Survey data were collected between August 1, 2005, and February 28, 2006. A total of 261 respondents completed the survey. The majority (226/261 or 87%) of respondents reported having an arthritis-related condition. The consumer summary approach was generally reviewed favorably by respondents, with most agreeing that the summary provided appropriate information (177/261 or 68%), would be useful to others (160/261 or 61%), was well laid out (159/261 or 61%), was easy to learn from (157/261 or 60%), and was useful to the reader (153/261 or 59%). Areas of potential improvement were indicated by relatively fewer respondents agreeing that they could easily find all the information they wanted (118/261 or 45%), by a substantial proportion being unable to judge whether the providers of the information are reliable (80/261 or 31%), and by a similar proportion being unable to determine whether the information presented was the best available (68/261 or 26%). The CMSG has developed an approach to summarizing the results of often-technical systematic reviews into public-friendly consumer summaries. Our online survey showed that this approach was generally well liked but identified specific areas for improvement. Feedback from this survey will help to reshape and improve the current template for consumer summaries used by the CMSG.Journal of Medical Internet Research 01/2011; 13(1):e5. · 4.41 Impact Factor -
Article: Development of instruments to measure the quality of breast cancer treatment decisions.
[show abstract] [hide abstract]
ABSTRACT: Women with early-stage breast cancer face a multitude of decisions. The quality of a decision can be measured by the extent to which the treatment reflects what is most important to an informed patient. Reliable and valid measures of patients' knowledge and their goals and concerns related to breast cancer treatments are needed to assess the decision quality. To identify a set of key facts and goals relevant to each of three breast cancer treatment decisions (surgery, reconstruction and adjuvant chemotherapy and hormone therapy) and to evaluate the validity of the methods used to identify them. Candidate facts and goals were chosen based on evidence review and qualitative studies with breast cancer patients and providers. Cross-sectional surveys of patients and providers were conducted for each decision. The accuracy, importance and completeness of the items were examined. Thirty-eight facts (11-14 per decision) and 27 goals (8-10 per decision) were identified. An average of 17 patients and 21 providers responded to each survey. The sets of facts were accurate and complete for all three decisions. The sets of goals and concerns were important for surgery and reconstruction, but not chemotherapy/hormone therapy. Patients and providers disagreed about the relative importance of several key facts and goals. Overall, breast cancer patients and providers found the sets of facts and goals accurate, important and complete for three treatment decisions. Because patients' and providers' perspectives are different, it is vital that instrument development should include items reflecting both views.Health expectations: an international journal of public participation in health care and health policy 09/2010; 13(3):258-72. · 1.80 Impact Factor -
Article: Skills training to support patients considering place of end-of-life care: a randomized control trial.
[show abstract] [hide abstract]
ABSTRACT: The effect of a program to train clinicians to support patients making decisions about place of end-of-life care was evaluated. In all, 88 oncology and/or palliative care nursing and allied health providers from three Ontario health networks were randomly assigned to an education or control condition. Quality of decision support provided to standardized patients was measured before and after training, as were participants' perceptions about the acceptability of the training program and their intentions to engage in patient decision support. Compared to controls, intervention group members improved the quality of decision support provided and were more likely to address a wider range of decision-making needs. Intervention group members scored higher on a knowledge test of decision support than controls and rated the components as acceptable. Improvements in the quality of decision support can be made by providing training and practical tools such as a patient decision aid.Journal of palliative care 01/2010; 26(2):112-21. · 0.93 Impact Factor -
Article: Responsiveness of the Effective Consumer Scale (EC-17).
[show abstract] [hide abstract]
ABSTRACT: The Effective Consumer Scale (EC-17) comprises 17 items measuring the main skills and behaviors people need to effectively manage their healthcare. We tested the responsiveness of the EC-17. Participants, in 2 waves of a 6-week Arthritis Self-Management Program (ASMP) from Arthritis Ireland, received a questionnaire at the first and last week of the weekly ASMP. The questionnaire included the EC-17 and 10 other measures for arthritis. Deficits, mean change, and standard deviations were calculated at baseline and Week 6. The EC-17 scores were compared to the Arthritis Self-Efficacy (ASE) and Patient Activation Measure (PAM) scales. Results were presented at OMERACT 9. There is some overlap between the EC-17 and the ASE and PAM; however, most items of greatest deficit in the EC-17 are not covered by those scales. In 327 participants representing both intervention waves (2006 and 2007), the EC-17 was more efficient than the ASE but less efficient than the PAM for detecting improvements after the ASMP, and was moderately correlated with the PAM. The EC-17 appears to measure different skills and attributes than the ASE and PAM. Discussions with participants at OMERACT 9 agreed that it is worthwhile to measure the skills and attributes of an effective consumer, and supported the development of an intervention (such as proposed online decision aids) that would include education in the categories in the EC-17.The Journal of Rheumatology 10/2009; 36(9):2087-91. · 3.69 Impact Factor -
Article: Reply to M. Mohiuddin et al.
Journal of Clinical Oncology 09/2009; · 18.37 Impact Factor -
Article: Validation of a preparation for decision making scale.
[show abstract] [hide abstract]
ABSTRACT: The Preparation for Decision Making (PrepDM) scale was developed to evaluate decision processes relating to the preparation of patients for decision making and dialoguing with their practitioners. The objective of this study was to evaluate the scale's psychometric properties. From July 2005 to March 2006, after viewing a decision aid prescribed during routine clinical care, patients completed a questionnaire including: demographic information, treatment intention, decisional conflict, decision aid acceptability, and the PrepDM scale. Four hundred orthopaedic patients completed the questionnaire. The PrepDM scale showed significant correlation with the informed (r=-0.21, p<0.01) and support (r=-0.13, p=0.01) subscales (DCS); and discriminated significantly between patients who did and did not find the decision aid helpful (p<0.0001). Alpha coefficients for internal consistency ranged from 0.92 to 0.96. The scale is strongly unidimensional (principal components analysis) and Item Response Theory analyses demonstrated that all ten scale items function very well. The psychometric properties of the PrepDM scale are very good. The scale could allow more comprehensive evaluation of interventions designed to prepare patients for shared-decision making encounters regarding complex health care decisions.Patient Education and Counseling 06/2009; 78(1):130-3. · 2.31 Impact Factor -
Article: Assessing the quality of decision support technologies using the International Patient Decision Aid Standards instrument (IPDASi).
[show abstract] [hide abstract]
ABSTRACT: To describe the development, validation and inter-rater reliability of an instrument to measure the quality of patient decision support technologies (decision aids). Scale development study, involving construct, item and scale development, validation and reliability testing. There has been increasing use of decision support technologies--adjuncts to the discussions clinicians have with patients about difficult decisions. A global interest in developing these interventions exists among both for-profit and not-for-profit organisations. It is therefore essential to have internationally accepted standards to assess the quality of their development, process, content, potential bias and method of field testing and evaluation. Scale development study, involving construct, item and scale development, validation and reliability testing. Twenty-five researcher-members of the International Patient Decision Aid Standards Collaboration worked together to develop the instrument (IPDASi). In the fourth Stage (reliability study), eight raters assessed thirty randomly selected decision support technologies. IPDASi measures quality in 10 dimensions, using 47 items, and provides an overall quality score (scaled from 0 to 100) for each intervention. Overall IPDASi scores ranged from 33 to 82 across the decision support technologies sampled (n = 30), enabling discrimination. The inter-rater intraclass correlation for the overall quality score was 0.80. Correlations of dimension scores with the overall score were all positive (0.31 to 0.68). Cronbach's alpha values for the 8 raters ranged from 0.72 to 0.93. Cronbach's alphas based on the dimension means ranged from 0.50 to 0.81, indicating that the dimensions, although well correlated, measure different aspects of decision support technology quality. A short version (19 items) was also developed that had very similar mean scores to IPDASi and high correlation between short score and overall score 0.87 (CI 0.79 to 0.92). This work demonstrates that IPDASi has the ability to assess the quality of decision support technologies. The existing IPDASi provides an assessment of the quality of a DST's components and will be used as a tool to provide formative advice to DSTs developers and summative assessments for those who want to compare their tools against an existing benchmark.PLoS ONE 02/2009; 4(3):e4705. · 4.09 Impact Factor -
Article: Decision aids for people facing health treatment or screening decisions.
[show abstract] [hide abstract]
ABSTRACT: Decision aids prepare people to participate in 'close call' decisions that involve weighing benefits, harms, and scientific uncertainty. To conduct a systematic review of randomised controlled trials (RCTs) evaluating the efficacy of decision aids for people facing difficult treatment or screening decisions. We searched MEDLINE (Ovid) (1966 to July 2006); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library; 2006, Issue 2); CINAHL (Ovid) (1982 to July 2006); EMBASE (Ovid) (1980 to July 2006); and PsycINFO (Ovid) (1806 to July 2006). We contacted researchers active in the field up to December 2006. There were no language restrictions. We included published RCTs of interventions designed to aid patients' decision making by providing information about treatment or screening options and their associated outcomes, compared to no intervention, usual care, and alternate interventions. We excluded studies in which participants were not making an active treatment or screening decision, or if the study's intervention was not available to determine that it met the minimum criteria to qualify as a patient decision aid. Two review authors independently screened abstracts for inclusion, and extracted data from included studies using standardized forms. The primary outcomes focused on the effectiveness criteria of the International Patient Decision Aid Standards (IPDAS) Collaboration: attributes of the decision and attributes of the decision process. We considered other behavioural, health, and health system effects as secondary outcomes. We pooled results of RCTs using mean differences (MD) and relative risks (RR) using a random effects model. This update added 25 new RCTs, bringing the total to 55. Thirty-eight (69%) used at least one measure that mapped onto an IPDAS effectiveness criterion: decision attributes: knowledge scores (27 trials); accurate risk perceptions (11 trials); and value congruence with chosen option (4 trials); and decision process attributes: feeling informed (15 trials) and feeling clear about values (13 trials).This review confirmed the following findings from the previous (2003) review. Decision aids performed better than usual care interventions in terms of: a) greater knowledge (MD 15.2 out of 100; 95% CI 11.7 to 18.7); b) lower decisional conflict related to feeling uninformed (MD -8.3 of 100; 95% CI -11.9 to -4.8); c) lower decisional conflict related to feeling unclear about personal values (MD -6.4; 95% CI -10.0 to -2.7); d) reduced the proportion of people who were passive in decision making (RR 0.6; 95% CI 0.5 to 0.8); and e) reduced proportion of people who remained undecided post-intervention (RR 0.5; 95% CI 0.3 to 0.8). When simpler decision aids were compared to more detailed decision aids, the relative improvement was significant in knowledge (MD 4.6 out of 100; 95% CI 3.0 to 6.2) and there was some evidence of greater agreement between values and choice.In this review, we were able to explore the use of probabilities in decision aids. Exposure to a decision aid with probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.6; 95% CI 1.4 to 1.9). The effect was stronger when probabilities were measured quantitatively (RR 1.8; 95% CI 1.4 to 2.3) versus qualitatively (RR 1.3; 95% CI 1.1 to 1.5).As in the previous review, exposure to decision aids continued to demonstrate reduced rates of: elective invasive surgery in favour of conservative options, decision aid versus usual care (RR 0.8; 95% CI 0.6 to 0.9); and use of menopausal hormones, detailed versus simple aid (RR 0.7; 95% CI 0.6 to 1.0). There is now evidence that exposure to decision aids results in reduced PSA screening, decision aid versus usual care (RR 0.8; 95% CI 0.7 to 1.0) . For other decisions, the effect on decisions remains variable.As in the previous review, decision aids are no better than comparisons in affecting satisfaction with decision making, anxiety, and health outcomes. The effects of decision aids on other outcomes (patient-practitioner communication, consultation length, continuance, resource use) were inconclusive.There were no trials evaluating the IPDAS decision process criteria relating to helping patients to recognize a decision needs to be made, understand that values affect the decision, or discuss values with the practitioner. Patient decision aids increase people's involvement and are more likely to lead to informed values-based decisions; however, the size of the effect varies across studies. Decision aids have a variable effect on decisions. They reduce the use of discretionary surgery without apparent adverse effects on health outcomes or satisfaction. The degree of detail patient decision aids require for positive effects on decision quality should be explored. The effects on continuance with chosen option, patient-practitioner communication, consultation length, and cost-effectiveness need further evaluation.Cochrane database of systematic reviews (Online) 02/2009; · 5.72 Impact Factor -
Article: Decisional conflict in patients and their physicians: a dyadic approach to shared decision making.
[show abstract] [hide abstract]
ABSTRACT: Decisional conflict is defined as personal uncertainty about which course of action to take when choice among competing options involves risk, regret, or challenge to personal life values. It is influenced by inadequate knowledge, unclear values, inadequate support, and the perception that an ineffective decision has been made. Until recently, it has been studied at the individual level, which ignores the interpersonal system between patients and physicians. To explore the effect of feeling uninformed, unclear values, inadequate support, and the perception that an ineffective decision has been made on one own's outcome (actor effect) and on the other person's outcome (partner effect). After a clinical encounter, modifiable deficits and personal uncertainty were measured in physicians and patients using the Decisional Conflict Scale. Structural equation modeling was used to measure the parameters of the Actor-Partner Interdependence Model. A total of 112 dyads of physicians and patients were included in the analysis. For both patients and physicians, 2 actor effects, unclear values (P < 0:0001) and the perception that an ineffective decision has been made (P < 0:0001), were found to be positively correlated with personal uncertainty. One partner effect, feeling uninformed (P=0:03), was found to be negatively correlated with personal uncertainty. Personal uncertainty of patients and physicians is influenced not only by their respective deficits but also by the deficits of the other member of the dyad. Our results indicate that the more unclear the expression of their own values and the more they perceive that an ineffective choice had been made, the more both physicians and patients experience personal uncertainty. They also indicate that the less uninformed they feel, the more both physicians and patients experience personal uncertainty.Medical Decision Making 02/2009; 29(1):61-8. · 2.33 Impact Factor -
Article: Integrating patient decision support in an undergraduate nursing curriculum: an implementation project.
[show abstract] [hide abstract]
ABSTRACT: A 4-year curriculum project (2004-2008) to integrate patient decision support into an existing curriculum was guided by the Knowledge-to-Action process model. The purpose of this project was to integrate a patient decision support theoretical framework and associated evidence-based resources throughout a four-year baccalaureate nursing curriculum. Interventions designed to adapt knowledge to local context and overcome barriers to knowledge use included faculty workshop to increase awareness, instructional resources designed for courses and core content, curricular blueprint of key threads to be included within courses, shared resources on the school of nursing internal website, and development of decision support resources in French. Curricular change and sustained use of knowledge was evidenced by repeated use of guest lecturers, assignments, and problem-based scenarios in courses, and students' evaluations on the tutorial and assignments.International Journal of Nursing Education Scholarship 02/2009; 6:Article10. -
Article: Can women with early-stage breast cancer make an informed decision for mastectomy?
[show abstract] [hide abstract]
ABSTRACT: The purpose of this study was to measure the degree to which informed women chose mastectomy, and to reveal their reasons for this choice. This was a prospective cohort study of patients radiographically and pathologically eligible for either mastectomy or breast-conserving surgery (BCS; n = 125). Participants completed questionnaires at three time points: baseline, after viewing a decision aid, and after a surgical consultation. Questionnaires assessed clinical history, preference for participation in decision making, information comprehension, values, decisional conflict, and preferred treatment. Of 125 participants, 44 (35%) chose mastectomy. Most understood that BCS and mastectomy offer an equivalent survival benefit (98%) and that BCS has a slightly higher local recurrence risk (63%); most accurately identified the magnitude of ipsilateral local recurrence risk (91%). Values assigned to three treatment attributes/outcomes ("remove breast for peace of mind," "avoid radiation," and "keep breast") clearly discriminated between patients choosing mastectomy or BCS. High decisional conflict scores improved after both the decision aid and surgical consultation. Although conventional wisdom may view BCS as the preferred treatment, a notable proportion of well informed women choose mastectomy. Whereas prior studies have linked objective factors to treatment choice, this study reveals subjective preferences that underlie decision making. The systematic use of a decision aid before the surgical consultation may help women make informed, values-based decisions, while clearly reducing decisional conflict.Journal of Clinical Oncology 01/2009; 27(4):519-25. · 18.37 Impact Factor -
Article: Women's decision-making needs related to treatment for recurrent ovarian cancer: a pilot study.
[show abstract] [hide abstract]
ABSTRACT: The purpose of this pilot study was to describe the decision-making needs of women with ovarian cancer related to treatment of recurrent disease. A retrospective, cross-sectional needs assessment was conducted. Data were collected using face-to-face interviews and analyzed using content analysis. Thirteen women were recruited. Eleven women did not report difficulty in making the decision. Five women perceived that they had options. Seven had a passive role in the decision. When considering future decisions, nine women preferred a shared or autonomous role; seven wanted to be presented with options. The role of nurses in providing information was emphasized. The findings provide some beginning direction for an inter-professional decision support approach, as well as implications for future research.Canadian oncology nursing journal = Revue canadienne de nursing oncologique 01/2009; 19(3):117-21. -
Article: Personal stories in publicly available patient decision aids.
[show abstract] [hide abstract]
ABSTRACT: To characterize the use of personal stories in publicly available patient decision aids (PtDAs). Descriptive study guided by a structured coding taxonomy based on the International Patient Decision Aid Standards, Ottawa Decision Support Framework, Decisional Conflict Scale and qualitative content analysis. Personal story was defined as an illustrative, first-person narrative in any format. Sampling from the 2007 Cochrane A to Z Inventory was stratified by developer and one-third of PtDAs were randomly sampled. Of 200 publicly available PtDAs from 5 developers, 168 from 3 developers contained stories. A stratified sample of 56 PtDAs contained 260 stories. Thirty of 56 PtDAs presented an equal number of stories favouring or against the most intensive option. Thirty PtDAs described narrators' satisfaction with outcome(s): 21 contained only stories portraying satisfaction; 9 contained stories portraying satisfaction and dissatisfaction. Publicly available PtDAs vary in their use of stories. Most PtDAs balance the number of stories favouring and against the most intensive option presented; most PtDAs do not balance the number of stories portraying satisfaction or dissatisfaction with the outcome(s) of the decision. Research is needed to better understand the impact of stories on patient decision making and to inform the guidelines for their inclusion in PtDAs.Patient Education and Counseling 10/2008; 73(3):456-64. · 2.31 Impact Factor -
Article: Developing instruments to measure the quality of decisions: early results for a set of symptom-driven decisions.
[show abstract] [hide abstract]
ABSTRACT: To identify a set of critical facts and key goals and concerns for five common medical conditions, benign prostate disease, hip and knee osteoarthritis, herniated disc and spinal stenosis and examine the validity of the method for identifying these items. Investigators identified facts and goals through literature reviews and qualitative work with patients and providers. A cross-sectional survey of patients and providers was conducted to examine the accuracy, importance and completeness of the identified items. 42 facts (6-16 per condition) and 31 goals and concerns (4-13 per condition) were identified. 182 responses were obtained from patients (76.5% response rate) and 113 responses from providers (78% response rate). Overall, the facts were accurate, important and complete across all conditions. For one condition (hip osteoarthritis), the goals did not meet the criteria for completeness. There was more disagreement between patients and providers around the ranking of goals than of facts. Overall, respondents found the identified facts and goals accurate, important and complete. Significant differences between patients' and providers' rankings highlight the importance of including both perspectives. Instruments to measure whether or not patients are informed and the extent to which treatments reflect patients' goals must balance patients' and providers' perspectives when selecting items to include.Patient Education and Counseling 09/2008; 73(3):504-10. · 2.31 Impact Factor -
Article: Audit and feedback using the brief Decision Support Analysis Tool (DSAT-10) to evaluate nurse-standardized patient encounters.
[show abstract] [hide abstract]
ABSTRACT: To evaluate the brief Decision Support Analysis Tool (DSAT-10) for auditing the quality of nurse-standardized patient encounters, structuring feedback for nurses, and testing instrument reliability. A systematic process was used to develop standardized patient scenarios, pilot-test scenarios, calibrate DSAT-10 coders, analyze taped telephone encounters using DSAT-10, and provide feedback. Inter-rater reliability was calculated using coder agreement, kappa, and intra-class correlation coefficients. Six scenarios portrayed patients' decisional uncertainty from either: pressure from others (n=2), unclear values (n=2), or inadequate information (n=2). Scenarios were easy to use over the telephone, produced realistic role performance, and were practical for audio-recording interactions. DSAT-10 analysis of 76 nurse-standardized patient encounters revealed nurses' strengths (e.g., information provision) and their limitations (e.g., lack of discussion of values and/or support needs). Scores discriminated between trained and untrained nurses. The kappa coefficient over all items was 0.55 (95% CI: 0.49, 0.61) with higher agreement for encounters involving trained nurses (0.62; 95% CI: 0.43, 0.80). Auditing nurse-standardized patient encounters using DSAT-10 and providing feedback to nurses was feasible. Although DSAT-10 items had adequate inter-rater reliability and discriminated between trained/untrained nurses, some items were problematic. Providing feedback on nurse encounters with standardized patients experiencing uncertainty has the potential to enhance nurses' decision support skills.Patient Education and Counseling 09/2008; 73(3):519-25. · 2.31 Impact Factor -
Article: Management of Chronic Pain: Improving shared decision making in osteoarthritis.
[show abstract] [hide abstract]
ABSTRACT: The burden of chronic pain for those who have it and their families is substantial, says Henry McQuay (doi: 10.1136/bmj.39520.699190.94), and these patients deserve better. Dawn Stacey and colleagues describe an example of quality improvement in practice for one group of people with chronic pain, those with osteoarthritisCommon treatments for osteoarthritis include physiotherapy, bracing, pharmacotherapy, and joint replacement surgery. When treatments are proposed that increase the risk of harm (such as non-steroidal anti-inflammatory drugs, opioids, or surgery), patients’ values concerning potential benefits and harms need to be considered. However, clinicians find it difficult to judge patients’ values, which are also often based on unrealistic expectations. Therefore tools that improve the shared decision making process are important.Shared decision making is a process in which the patient and clinician together reach an informed decision about the plan of care on the basis of the patient’s clinical needs, priorities, and values. The clinician’s expertise lies in diagnosing and identifying treatment options according to clinical priorities; the patient’s role is to identify and communicate their informed values and personal priorities, as shaped by their social circumstances. Patient decision aids are tools that prepare patients for consultations by explaining options, quantifying risks and benefits, helping patients to clarify their values, and providing structured guidance in deliberation and communication.1 A review of 10 systematic reviews of patient decision aids found that they improved patients’ participation, increased their knowledge of treatment options, realigned their expectations, and improved the match between their values and subsequent treatment decisions.2 The aids also reduced the overuse of elective surgery (for herniated disc, for example) without apparent adverse effects on health outcomes. Another study showed the potential for patient decision aids to reduce inequalities among ethnic groups.3 The Cochrane inventory of patient decision aids (www.ohri.ca/decisionaid) uses international standards to rate their quality.4 Decision aids for osteoarthritis treatment are available online, in brochures, and on DVD.In 2006, patient decision aids were accessed more than eight million times, mostly through the internet.1 Ideally, these tools should be linked to clinical care processes, but practitioners report several barriers to implementation: inappropriate content for their patients; forgetting to offer them; inadequate time; content that was too complex or too simple; and cost.5 Practitioners are more likely to use patient decision aids if they have a positive effect on patients’ outcomes or on the clinical interaction. Orthopaedic surgeons rated the content of patient decision aids for osteoarthritis treatments as good to excellent and were motivated to use them to improve patients’ understanding but had concerns about interrupting the flow of clinic work.6Patient decision aids have been implemented successfully in specialist clinics in the United Kingdom7 and Canada and in specialist and primary care clinics in the United States.8 9 Patients with osteoarthritis, for example, use decision aids together with balanced, evidence based information on the treatment options and the likelihood of the benefits and harms of those treatments. The decision aids help patients clarify their values concerning benefits and harms by describing what it is like to experience them. Patients then complete a personal decision form, which elicits their knowledge, values, preferred option, and any unresolved “decisional needs” (for example, uncertainty about their preference, gaps in their knowledge of the options, lack of clarity of their values concerning benefits and harms, and support needs). This information is summarised on a “patient preference report,” which is sent to the clinician to “close the loop” on decision making with the patient. In Canada, patients on the waiting list for a surgical consultation are screened for eligibility by trained general practitioners or physiotherapists before they receive a decision aid and personal decision form. The Canadian patient preference report (figure 1⇓) lists clinical priorities as determined by self reported pain and functional limitations, the trained screener’s assessment of surgical priority, and the patient’s preferences and decisional needs. The report is paper based, but one author (NC) has developed a similar computerised report as part of the US Veterans Administration’s electronic patient health records.View larger version:In a new windowDownload as PowerPoint SlideAn example of a patient preference report used in CanadaUsing the patient preference report together with patient decision aids has the potential to improve the clinical encounter and to provide the incentive that practitioners need to overcome their resistance to using the aids. For example, when patients arrive at a surgeon’s consultation with their preference report, the surgeon can focus on issues of concern to the patient, such as fears of side effects of surgery. Thus the surgeon’s time will be used more efficiently, and the care provided is more patient centred, so patients and practitioners are both more likely to be satisfied with the process.Outcomes such as pain reduction and improved function cannot be the sole quality indicators in treatments that involve trade-offs between potential benefits and harms. In such treatment decisions, the quality of decision making should be defined by how well the chosen treatment option matches the features that matter most to the informed patient.4 Patient preference reports document decision quality as an indicator of the shared decision making process. In addition to monitoring postoperative complications such as infections and blood clots, these reports can be used by quality improvement teams to monitor the extent to which high quality decisions are achieved and decisional needs met.10Patient decision aids prepare patients for making shared decisions concerning treatment. Patient preference reports that summarise patients’ clinical and decisional needs improve communication. With standardised measures and documentation of decisions, healthcare organisations can monitor and include decision quality as another indicator of the quality of their programmes.FootnotesCompeting interests: All authors have received grants from the US Foundation for Informed Decision Making. The non-profit foundation has a licensing agreement with Health Dialog, a commercial company that markets patient decision aids and health coaching services.Provenance and peer review: Commissioned; not externally reviewed.References↵O’Connor AM, Wennberg J, Legare F, Llewellyn-Thomas H, Moulton B, Sepucha K, et al. Towards the ‘tipping point’: decision aids and informed patient choice. Health Affairs2007;26:716-25.OpenUrlFREE Full Text↵Coulter A, Ellins J. Effectiveness of strategies for informing, educating, and involving patients. BMJ2007;335:24-7.OpenUrlFREE Full Text↵Weng HH, Kaplan RM, Boscardin WJ, MacLean CH, Lee IY, Chen W, et al. Development of a decision aid to address racial disparities in utilization of knee replacement surgery. Arthritis Rheum2007;57:568-75.OpenUrlCrossRefMedlineWeb of Science↵Elwyn G, O’Connor A, Stacey D, Volk R, Edwards A, Coulter A, et al. Developing a quality criteria framework for patient decision aids: online international Delphi consensus process. BMJ2006;333:417-22.OpenUrlFREE Full Text↵Gravel K, Legare F, Graham ID. Barriers and facilitators to implementing shared decision-making in clinical practice: a systematic review of health professionals’ perceptions. BMC Implement Sci2006;1:1-15.OpenUrlCrossRef↵Llewellyn-Thomas HA, Weinstein J, Mimnaugh D. Patients’ decision aids for elective total joint replacement: a national survey to identify orthopaedic surgeons’ preferences. Med Decis Making2003;23:551.OpenUrl↵National Steering Group for Decision Support Aids in Urology. Implementing patient decision aids in urology—final report. 2005. www.pickereurope.org/Filestore/Research/Urology_steering_group_report.pdf.↵Silvia KA, Sepucha KR. Decision aids in routine practice: lessons from the breast cancer initiative. Health Expect2006;9:255-64.OpenUrlCrossRefMedlineWeb of Science↵Weinstein JN, Clay K, Morgan TS. Informed patient choice: patient-centered valuing of surgical risks and benefits. Health Affairs2007;26:726-30.OpenUrlFREE Full Text↵Dartmouth-Hitchcock Medical Center. Quality reports: knee replacement. 2008. www.dhmc.org/qualityreports/list.cfm?metrics=KR.BMJ (Clinical research ed.). 05/2008; 336(7650):954-5. -
Article: Coaching to support patients in making decisions.
BMJ (Clinical research ed.). 03/2008; 336(7638):228-9. -
Article: Knowledge translation for effective consumers.
[show abstract] [hide abstract]
ABSTRACT: With the emergence of patient-centered care, consumers are becoming more effective managers of their care--in other words, "effective consumers." To support patients to become effective consumers, a number of strategies to translate knowledge to action (KTA) have been used with varying success. The use of a KTA framework can be helpful to researchers and implementers when framing, planning, and evaluating knowledge translation activities and can potentially lead to more successful activities. This article briefly describes the KTA framework and its use by a team based out of the University of Ottawa to translate evidence-based knowledge to consumers. Using the framework, tailored consumer summaries, decision aids, and a scale to measure consumer effectiveness were created in collaboration with consumers. Strategies to translate the products into action then were selected and implemented. Evaluation of the knowledge tools and products indicates that the products are useful to consumers. Current research is in place to monitor the use of these products, and future research is planned to evaluate the effect of using the knowledge on health outcomes. The KTA framework provides a useful and valuable approach to knowledge translation.Physical Therapy 01/2008; 87(12):1728-38. · 3.11 Impact Factor -
Article: Development of the effective musculoskeletal consumer scale.
[show abstract] [hide abstract]
ABSTRACT: Programs and initiatives have been created to empower, educate, and provide information to consumers; these are sometimes generically known as self-management interventions. Evaluating and comparing such programs has been a challenge, as many skills that consumers believe are important to manage and participate in their individual healthcare are not currently captured by existing tools. The objective of the Effective Musculoskeletal Consumer Project is to develop a scale to measure an effective consumer. A review of the literature, interviews, workshops, and preliminary surveys at OMERACT 7 (May 2005) were conducted in the first phases of the Project. A questionnaire consisting of 64 items was developed to measure the skills and attributes of an effective musculoskeletal (MSK) consumer. Content experts on our team reduced this scale to 48 items, which was pilot-tested with consumers from Canada and Australia. Dimensionality assessment showed that the scale was unidimensional. Classical and item response theory analyses showed that the 48-item scale had quite high reliability, but that 2 items were very poor. Based on the item analysis, 35 items were retained. The revised scale was presented at OMERACT 8, where a panel reviewed the scale and provided input. This input and another expert review by our team was used to further refine the Effective Consumer Scale to 17 items. Plans are now under way to validate this 17-item scale in self-management interventions.The Journal of Rheumatology 07/2007; 34(6):1392-400. · 3.69 Impact Factor
Top co-authors
Top Journals
Institutions
-
1999–2010
-
University of Ottawa
- School of Nursing
Ottawa, Ontario, Canada
-
-
2008–2009
-
Ottawa Hospital Research Institute
Ottawa, Ontario, Canada
-
-
2005
-
Methodist Rehabilitation Center
Jackson, MS, USA -
Carleton University
- Department of Systems and Computer Engineering
Ottawa, Ontario, Canada
-
