Physicians' intentions and use of three patient decision aids

<p>Abstract</p> <p>Background</p> <p>Decision aids are evidence based tools that assist patients in making informed values-based choices and supplement the patient-clinician interaction. While there is evidence to show that decision aids improve key indicators of patients' decision quality, relatively little is known about physicians' acceptance of decision aids or factors that influence their decision to use them. The purpose of this study was to describe physicians' perceptions of three decision aids, their expressed intent to use them, and their subsequent use of them.</p> <p>Methods</p> <p>We conducted a cross-sectional survey of random samples of Canadian respirologists, family physicians, and geriatricians. Three decision aids representing a range of health decisions were evaluated. The survey elicited physicians' opinions on the characteristics of the decision aid and their willingness to use it. Physicians who indicated a strong likelihood of using the decision aid were contacted three months later regarding their actual use of the decision aid.</p> <p>Results</p> <p>Of the 580 eligible physicians, 47% (n = 270) returned completed questionnaires. More than 85% of the respondents felt the decision aid was well developed and that it presented the essential information for decision making in an understandable, balanced, and unbiased manner. A majority of respondents (>80%) also felt that the decision aid would guide patients in a logical way, preparing them to participate in decision making and to reach a decision. Fewer physicians (<60%) felt the decision aid would improve the quality of patient visits or be easily implemented into practice and very few (27%) felt that the decision aid would save time. Physicians' intentions to use the decision aid were related to their comfort with offering it to patients, the decision aid topic, and the perceived ease of implementing it into practice. While 54% of the surveyed physicians indicated they would use the decision aid, less than a third followed through with this intention.</p> <p>Conclusion</p> <p>Despite strong support for the format, content, and quality of patient decision aids, and physicians' stated intentions to adopt them into clinical practice, most did not use them within three months of completing the survey. There is a wide gap between intention and behaviour. Further research is required to study the determinants of this intention-behaviour gap and to develop interventions aimed at barriers to physicians' use of decision aids.</p

Implementing cardiovascular disease prevention guidelines to translate evidence-based medicine and shared decision making into general practice: theory-based intervention development, qualitative piloting and quantitative feasibility

Background: The use of cardiovascular disease (CVD) prevention guidelines based on absolute risk assessment is poor around the world, including Australia. Behavioural barriers amongst GPs and patients include capability (e.g. difficulty communicating/understanding risk) and motivation (e.g. attitudes towards guidelines/medication). This paper outlines the theory-based development of a website for GP guidelines, and piloting of a new risk calculator/decision aid. Methods: Stage 1 involved identifying evidence-based solutions using the Behaviour Change Wheel (BCW) framework, informed by previous research involving 400 GPs and 600 patients/consumers. Stage 2 co-developed website content with GPs. Stage 3 piloted a prototype website at a national GP conference. Stage 4 iteratively improved the website based on "think aloud" interviews with GPs and patients. Stage 5 was a feasibility study to evaluate potential efficacy (guidelines-based recommendations for each risk category), acceptability (intended use) and demand (actual use over 1 month) amongst GPs (n = 98). Results: Stage 1 identified GPs as the target for behaviour change; the need for a new risk calculator/decision aid linked to existing audit and feedback training; and online guidelines as a delivery format. Stage 2-4 iteratively improved content and format based on qualitative feedback from GP and patient user testing over three rounds of website development. Stage 5 suggested potential efficacy with improved identification of hypothetical high risk patients (from 26 to 76%) and recommended medication (from 57 to 86%) after viewing the website (n = 42), but prescribing to low risk patients remained similar (from 19 to 22%; n = 37). Most GPs (89%) indicated they would use the website in the next month, and 72% reported using it again after one month (n = 98). Open feedback identified implementation barriers including a need for integration with medical software, low health literacy resources and pre-consultation assessment. Conclusions: Following a theory-based development process and user co-design, the resulting intervention was acceptable to GPs with high intentions for use, improved identification of patient risk categories and more guidelines-based prescribing intentions for high risk but not low risk patients. The effectiveness of linking the intervention to clinical practice more closely to address implementation barriers will be evaluated in future research

Development and preliminary evaluation of a clinical guidance programme for the decision about prophylactic oophorectomy in women undergoing a hysterectomy

Objectives: To develop a decision analysis based and computerised clinical guidance programme (CGP) that provides patient specific guidance on the decision whether or not to undergo a prophylactic oophorectomy to reduce the risk of subsequent ovarian cancer and to undertake a preliminary pilot and evaluation. Subjects: Women who had already agreed to have a hysterectomy who otherwise had no ovarian pathology. Setting: Oophorectomy decision consultation at the outpatient or pre-admission clinic. Methods: A CGP was developed with advice from gynaecologists and patient groups, incorporating a set of Markov models within a decision analytical framework to evaluate the benefits of undergoing a prophylactic oophorectomy or not on the basis of quality adjusted life expectancy, life expectancy, and for varying durations of hormone replacement therapy. Sensitivity analysis and preliminary testing of the CGP were undertaken to compare its overall performance with established guidelines and practice. A small convenience sample of women invited to use the CGP were interviewed, the interviews were taped and transcribed, and a thematic analysis was undertaken. Results: The run time of the programme was 20 minutes, depending on the use of opt outs to default values. The CGP functioned well in preliminary testing. Women were able to use the programme and expressed overall satisfaction with it. Some had reservations about the computerised format and some were surprised at the specificity of the guidance given. Conclusions: A CGP can be developed for a complex healthcare decision. It can give evidence-based health guidance which can be adjusted to account for individual risk factors and reflects a patient’s own values and preferences concerning health outcomes. Future decision aids and support systems need to be developed and evaluated in a way which takes account of the variation in patients’ preferences for inclusion in the decision making process

'Experts', 'partners' and 'fools': exploring agency in HIV treatment seeking among African migrants in London

In an attempt to promote patient agency and foster more egalitarian relationships between patients and doctors, discourse concerning health and wellbeing in the UK has increasingly centred around the notion of informed and 'expert' patients who are able to effectively input into the direction and management of their own health care and treatment. While the relationship between a patient and their doctor can play a vital role in influencing the treatment decisions and health-related outcomes of people living with long term illness, little is known about the ways in which people living with HIV actually perceive their relationship with their doctors, nor the implications this may have for the types of treatment they may seek to use and the related information that they share. Drawing on 11 focus group discussions and 20 repeat interviews undertaken in 2008-2009 with HIV-positive adult migrants from Zambia, Zimbabwe and South Africa living in the UK, this paper argues that patient-doctor relationships can be heavily influenced by the perceived legitimacy of different forms of medical knowledge and treatments and by culturally influenced ideas regarding health, wellbeing and agency. Despite a desire amongst some migrants to use 'traditional' medicines from southern Africa as well as other non-biomedical treatments and therapies, the research found that the perceived lack of legitimacy associated with these treatments in the UK rendered their use a largely clandestine activity. At the same time, many patients made clear distinctions concerning issues affecting their immediate health and factors influencing their more general wellbeing, which in turn, impacted upon the information that they chose to share with, or conceal from, their doctors. Such findings challenge assumptions underpinning policy promoting patient agency and have significant and, in cases, potentially adverse implications for the safety and effective administration and management of HIV treatments in African migrant populations and possibly more generally. (C) 2009 Elsevier Ltd. All rights reserved

Communication interventions in adult and pediatric oncology: A scoping review and analysis of behavioral targets

BackgroundImproving communication requires that clinicians and patients change their behaviors. Interventions might be more successful if they incorporate principles from behavioral change theories. We aimed to determine which behavioral domains are targeted by communication interventions in oncology.MethodsSystematic search of literature indexed in Ovid Medline, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov (2000-October 2018) for intervention studies targeting communication behaviors of clinicians and/or patients in oncology. Two authors extracted the following information: population, number of participants, country, number of sites, intervention target, type and context, study design. All included studies were coded based on which behavioral domains were targeted, as defined by Theoretical Domains Framework.FindingsEighty-eight studies met inclusion criteria. Interventions varied widely in which behavioral domains were engaged. Knowledge and skills were engaged most frequently (85%, 75/88 and 73%, 64/88, respectively). Fewer than 5% of studies engaged social influences (3%, 3/88) or environmental context/resources (5%, 4/88). No studies engaged reinforcement. Overall, 7/12 behavioral domains were engaged by fewer than 30% of included studies. We identified methodological concerns in many studies. These 88 studies reported 188 different outcome measures, of which 156 measures were reported by individual studies.ConclusionsMost communication interventions target few behavioral domains. Increased engagement of behavioral domains in future studies could support communication needs in feasible, specific, and sustainable ways. This study is limited by only including interventions that directly facilitated communication interactions, which excluded stand-alone educational interventions and decision-aids. Also, we applied stringent coding criteria to allow for reproducible, consistent coding, potentially leading to underrepresentation of behavioral domains

No. 65: Brain Drain and Regain: The Migration Behaviour of South African Medical Professionals

Since the end of apartheid, South Africa has experienced a significant outflow of health professionals. The out-migration of health professionals from the country is part of a broader global trend of health professional migration from the Global South to the Global North. In the health sector, this “brain drain” has led to a significant decline in the quality of care in affected countries. The costs of health professional migration for countries of origin are usually measured in terms of lost investment in training and the gaps in medical care left by their departure. One recent study, for example, estimated that the cost to South Africa in lost investment in training from the emigration of health physicians to Australia, Canada, the United States and the United Kingdom amounts to USD1.4 billion. Previous studies have predicted that medical migration from South Africa is unlikely to subside in the short and medium term as health professionals and trainees exhibit very high emigration potential. This report provides an updated (2013) picture of the state of mind of South African health professionals. It also allows an assessment of whether professional attitudes and perceptions have changed between 2007 and 2013 including (a) whether levels of satisfaction with work and life in South Africa have improved or worsened; (b) whether emigration potential has declined or intensified amongst health professionals and (c) whether the “brain drain” from South Africa is likely to continue. These questions are of particular relevance given various changes in the health sector since 2007. Return migration has been advocated internationally as an antidote to the brain drain and an important downstream benefit for countries of origin in the South. This report therefore provides important new information about the implications of health professional return migration to South Africa. Another strategy adopted by some countries is to use immigration policy as a means of dealing with health professional shortages. South Africa is a destination country for health professionals from some countries although, with the exception of official schemes to temporarily import Cuban and Tunisian doctors, this is not official policy. Significantly, the medical professions have only just appeared on the government scarceskills lists that have been published for nearly a decade. This survey provided an opportunity to profile a sub-group of non-South African doctors to assess whether they are more inclined to remain in the country than their South African counterparts. The current survey was developed in collaboration with the Institute of Population Health at the University of Ottawa as part of a CIHR-funded global project on health professional migration from India, Jamaica, the Philippines and South Africa. The questionnaire was hosted on the MEDpages website and potential respondents were invited by email to complete the survey. A total of 1,383 completed questionnaires were received from physicians, dentists and pharmacists – a response rate of 7%

Brain Drain and Regain: The Migration Behaviour of South African Medical Professionals (Migration Policy Series No. 65)

Since the end of apartheid, South Africa has experienced a significant outflow of health professionals. The out-migration of health professionals from the country is part of a broader global trend of health professional migration from the Global South to the Global North. In the health sector, this “brain drain” has led to a significant decline in the quality of care in affected countries. The costs of health professional migration for countries of origin are usually measured in terms of lost investment in training and the gaps in medical care left by their departure. One recent study, for example, estimated that the cost to South Africa in lost investment in training from the emigration of health physicians to Australia, Canada, the United States and the United Kingdom amounts to USD1.4 billion. Previous studies have predicted that medical migration from South Africa is unlikely to subside in the short and medium term as health professionals and trainees exhibit very high emigration potential. This report provides an updated (2013) picture of the state of mind of South African health professionals. It also allows an assessment of whether professional attitudes and perceptions have changed between 2007 and 2013 including (a) whether levels of satisfaction with work and life in South Africa have improved or worsened; (b) whether emigration potential has declined or intensified amongst health professionals and (c) whether the “brain drain” from South Africa is likely to continue. These questions are of particular relevance given various changes in the health sector since 2007. Return migration has been advocated internationally as an antidote to the brain drain and an important downstream benefit for countries of origin in the South. This report therefore provides important new information about the implications of health professional return migration to South Africa. Another strategy adopted by some countries is to use immigration policy as a means of dealing with health professional shortages. South Africa is a destination country for health professionals from some countries although, with the exception of official schemes to temporarily import Cuban and Tunisian doctors, this is not official policy. Significantly, the medical professions have only just appeared on the government scarceskills lists that have been published for nearly a decade. This survey provided an opportunity to profile a sub-group of non-South African doctors to assess whether they are more inclined to remain in the country than their South African counterparts. The current survey was developed in collaboration with the Institute of Population Health at the University of Ottawa as part of a CIHR-funded global project on health professional migration from India, Jamaica, the Philippines and South Africa. The questionnaire was hosted on the MEDpages website and potential respondents were invited by email to complete the survey. A total of 1,383 completed questionnaires were received from physicians, dentists and pharmacists – a response rate of 7%

The Patient-Physician Relationship: Overcoming Language and Cultural Barriers

The patient-physician relationship governs the field of medicine, forming the basis for all relationships, interactions, and procedures in medicine. The degree to which a patient trusts his physician and thus is willing to be receptive to medical advice and adhere to assigned treatment is dependent on the quality of his relationship with his physician. The method of relationship chosen will dictate how the patient feels he is perceived and thus to what extend he will participate in his healthcare. A patient-centered approach to medicine will increase this confidence and lead to improved clinical results. Additionally, the rise of physician burnout has also had an effect on this foundational relationship, creating division between the patient and his physician primarily due to complaints against the excessive use of EHRs (electronic health records) and time constraints. Furthermore, in a country of immigrants, the differences in not only language but also between separate cultures and levels of health literacy divides physicians and large populations of their limited English proficiency (LEP) patients. This is a huge detriment to the patient-physician relationship. Lawmakers have created federal and state laws in an effort to install legal action to remedy this, but significant work is still needed to fully bridge the gap. Several solutions have been proposed to do this with the hopeful effect of finally providing equal and better care to all

Usability and feasibility of consumer-facing technology to reduce unsafe medication use by older adults

Background Mobile health technology can improve medication safety for older adults, for instance, by educating patients about the risks associated with anticholinergic medication use. Objective This study's objective was to test the usability and feasibility of Brain Buddy, a consumer-facing mobile health technology designed to inform and empower older adults to consider the risks and benefits of anticholinergics. Methods Twenty-three primary care patients aged ≥60 years and using anticholinergic medications participated in summative, task-based usability testing of Brain Buddy. Self-report usability was assessed by the System Usability Scale and performance-based usability data were collected for each task through observation. A subset of 17 participants contributed data on feasibility, assessed by self-reported attitudes (feeling informed) and behaviors (speaking to a physician), with confirmation following a physician visit. Results Overall usability was acceptable or better, with 100% of participants completing each Brain Buddy task and a mean System Usability Scale score of 78.8, corresponding to “Good” to “Excellent” usability. Observed usability issues included higher rates of errors, hesitations, and need for assistance on three tasks, particularly those requiring data entry. Among participants contributing to feasibility data, 100% felt better informed after using Brain Buddy and 94% planned to speak to their physician about their anticholinergic related risk. On follow-up, 82% reported having spoken to their physician, a rate independently confirmed by physicians. Conclusion Consumer-facing technology can be a low-cost, scalable intervention to improve older adults’ medication safety, by informing and empowering patients. User-centered design and evaluation with demographically heterogeneous clinical samples uncovers correctable usability issues and confirms the value of interventions targeting consumers as agents in shared decision making and behavior change