Can consumers learn to ask three questions to improve shared decision making? A feasibility study of the ASK (AskShareKnow) Patient–Clinician Communication Model® intervention in a primary health-care setting

Funded by Informed Medical Decisions Foundation. Grant Number: #0175-1 National Health and Medical Research Council Public Health Training Fellowship. Grant Number: 568962Peer reviewedPublisher PD

Presenting quantitative information about decision outcomes: a risk communication primer for patient decision aid developers

Abstract Background Making evidence-based decisions often requires comparison of two or more options. Research-based evidence may exist which quantifies how likely the outcomes are for each option. Understanding these numeric estimates improves patients’ risk perception and leads to better informed decision making. This paper summarises current “best practices” in communication of evidence-based numeric outcomes for developers of patient decision aids (PtDAs) and other health communication tools. Method An expert consensus group of fourteen researchers from North America, Europe, and Australasia identified eleven main issues in risk communication. Two experts for each issue wrote a “state of the art” summary of best evidence, drawing on the PtDA, health, psychological, and broader scientific literature. In addition, commonly used terms were defined and a set of guiding principles and key messages derived from the results. Results The eleven key components of risk communication were: 1) Presenting the chance an event will occur; 2) Presenting changes in numeric outcomes; 3) Outcome estimates for test and screening decisions; 4) Numeric estimates in context and with evaluative labels; 5) Conveying uncertainty; 6) Visual formats; 7) Tailoring estimates; 8) Formats for understanding outcomes over time; 9) Narrative methods for conveying the chance of an event; 10) Important skills for understanding numerical estimates; and 11) Interactive web-based formats. Guiding principles from the evidence summaries advise that risk communication formats should reflect the task required of the user, should always define a relevant reference class (i.e., denominator) over time, should aim to use a consistent format throughout documents, should avoid “1 in x” formats and variable denominators, consider the magnitude of numbers used and the possibility of format bias, and should take into account the numeracy and graph literacy of the audience. Conclusion A substantial and rapidly expanding evidence base exists for risk communication. Developers of tools to facilitate evidence-based decision making should apply these principles to improve the quality of risk communication in practice.http://deepblue.lib.umich.edu/bitstream/2027.42/116070/1/12911_2013_Article_751.pd

A three-talk model for shared decision making: multistage consultation process

© 2017 The Authors. Published by BMJ. This is an open access article available under a Creative Commons licence. The published version can be accessed at the following link on the publisher’s website: https://doi.org/10.1136/bmj.j4891Objectives To revise an existing three-talk model for learning how to achieve shared decision making, and to consult with relevant stakeholders to update and obtain wider engagement. Design Multistage consultation process. Setting Key informant group, communities of interest, and survey of clinical specialties. Participants 19 key informants, 153 member responses from multiple communities of interest, and 316 responses to an online survey from medically qualified clinicians from six specialties. Results After extended consultation over three iterations, we revised the three-talk model by making changes to one talk category, adding the need to elicit patient goals, providing a clear set of tasks for each talk category, and adding suggested scripts to illustrate each step. A new three-talk model of shared decision making is proposed, based on “team talk,” “option talk,” and “decision talk,” to depict a process of collaboration and deliberation. Team talk places emphasis on the need to provide support to patients when they are made aware of choices, and to elicit their goals as a means of guiding decision making processes. Option talk refers to the task of comparing alternatives, using risk communication principles. Decision talk refers to the task of arriving at decisions that reflect the informed preferences of patients, guided by the experience and expertise of health professionals. Conclusions The revised three-talk model of shared decision making depicts conversational steps, initiated by providing support when introducing options, followed by strategies to compare and discuss trade-offs, before deliberation based on informed preferences

Protocol for a randomised controlled trial of a decision aid for the management of pain in labour and childbirth [ISRCTN52287533]

BACKGROUND: Women report fear of pain in childbirth and often lack complete information on analgesic options prior to labour. Preferences for pain relief should be discussed before labour begins. A woman's antepartum decision to use pain relief is likely influenced by her cultural background, friends, family, the media, literature and her antenatal caregivers. Pregnant women report that information about analgesia was most commonly derived from hearsay and least commonly from health professionals. Decision aids are emerging as a promising tool to assist practitioners and their patients in evidence-based decision making. Decision aids are designed to assist patients and their doctors in making informed decisions using information that is unbiased and based on high quality research evidence. Decision aids are non-directive in the sense that they do not aim to steer the user towards any one option, but rather to support decision making which is informed and consistent with personal values. METHODS/DESIGN: We aim to evaluate the effectiveness of a Pain Relief for Labour decision aid, with and without an audio-component, compared to a pamphlet in a three-arm randomised controlled trial. Approximately 600 women expecting their first baby and planning a vaginal birth will be recruited for the trial. The primary outcomes of the study are decisional conflict (uncertainty about a course of action), knowledge, anxiety and satisfaction with decision-making and will be assessed using self-administered questionnaires. The decision aid is not intended to influence the type of analgesia used during labour, however we will monitor health service utilisation rates and maternal and perinatal outcomes. This study is funded by a competitive peer-reviewed grant from the Australian National Health and Medical Research Council (No. 253635). DISCUSSION: The Pain Relief for Labour decision aid was developed using the Ottawa Decision Support Framework and systematic reviews of the evidence about the benefits and risks of the non-pharmacological and pharmacological methods of pain relief for labour. It comprises a workbook and worksheet and has been developed in two forms – with and without an audio-component (compact disc). The format allows women to take the decision aid home and discuss it with their partner

Effects of a web based decision aid on parental attitudes to MMR vaccination: a before and after study

Objective To determine whether an evidence based decision aid on the measles, mumps, and rubella (MMR) vaccine changed parents' attitudes towards vaccination. Design Before and after study. Setting Website promoted through search engines and online parenting and health websites. Participants 158 people completing online questions out of 1277 who accessed the website. Intervention Evidence based decision aid with text and graphical representation of the possible outcomes of measles, mumps, and rubella diseases compared with MMR vaccination. Main outcome measures Attitudes towards MMR vaccination. Results Significantly more participants indicated they were “leaning towards” vaccination after using the decision aid (39% before v 55% after, P < 0.001). Compared with those who were undecided or “leaning away from” vaccination after using the decision aid, participants “leaning towards” it were more likely to strongly value its potential to protect their children from the serious side effects of disease (98% v 84%) and other children who could not be vaccinated for medical reasons (68% v 25%). Participants with an unfavourable attitude to vaccination were more likely to be very concerned about the rare side effects of vaccination (78% v 57%), have residual concerns about autism and bowel disease (78% v 27%), and anticipate guilt should their child have an adverse reaction (77% v 50%). Those with a positive attitude to vaccination after using the decision aid were also more likely to feel well informed (83% v 48%). Conclusions A web based decision aid significantly improved parental attitudes to MMR vaccination. Residual concerns about autism and bowel disease and the rare chance of serious complications remained as attitudinal barriers to some parents

A systematic review of quality assessment methods for smartphone health apps

Introduction: There are large numbers of health-related applications (apps) available in various app stores for many smartphone devices. Consequently, increasing numbers of articles are attempting to evaluate the content and the quality of health-related smartphone apps for specific health conditions. The aim of this article is to describe and summarize the methodologies used to determine the quality of health-related apps targeting health consumers and to propose a set of criteria for evaluating the quality of smartphone health-related apps. Materials and Methods: In 2013, literature searches were performed using Medline and CINAHL, and we included all articles that had the aim of assessing the quality of health-related smartphone apps. The assessment method used in these studies was summarized and scored using a set of quality criteria developed for this study. Results: From 606 articles generated by the search, only 10 met the inclusion criteria. Based on our quality criteria, the mean score was 5.05 out of 8 (range, 2–7). Eighty percent of the studies did not identify the app store country in which the apps were found. Forty percent of the studies did not clearly mention whether they only had assessed the app description or had downloaded the app content for evaluation. Sixty percent of the studies did not provide a list of the apps they had evaluated. Overall, we identified six evaluation methodologies used to assess the quality of health-related apps described in Results. Conclusions: This article provides a summary of currently used methods for assessing the quality of smartphone health-related apps and proposes a set of criteria to enable future studies to consistently review health-related app quality in a standardized manner

Exploring patient involvement in healthcare decision making across different education and functional health literacy groups

Education and health literacy potentially limit a person's ability to be involved in decisions about their health. Few studies, however, have explored understandings and experiences of involvement in decision making among patients varying in education and health literacy. This paper reports on a qualitative interview study of 73 men and women living in Sydney, Australia, with varying education and functional health literacy levels. Participants were recruited from a community sample with lower educational attainment, plus an educated sample of University of Sydney alumni. The transcripts were analysed using the 'Framework' approach, a matrix-based method of thematic analysis. We found that participants with different education conceptualised their involvement in decision making in diverse ways. Participants with higher education appeared to conceive their involvement as sharing the responsibility with the doctor throughout the decision-making process. This entailed verifying the credibility of the information and exploring options beyond those presented in the consultation. They also viewed themselves as helping others in their health decisions and acting as information resources. In contrast, participants with lower education appeared to conceive their involvement in terms of consenting to an option recommended by the doctor, and having responsibility for the ultimate decision, to agree or disagree with the recommendation. They also described how relatives and friends sought information on their behalf and played a key role in their decisions. Both education groups described how aspects of the patient-practitioner relationship (e.g. continuity, negotiation, trust) and the practitioner's interpersonal communication skills influenced their involvement. Health information served a variety of needs for all groups (e.g. supporting psychosocial, practical and decision support needs). These findings have practical implications for how to involve patients with different education and literacy levels in decision making, and highlight the important role of the patient-practitioner relationship in the process of decision making

A comparative case study of bowel cancer screening in the UK and Australia: Evidence lost in translation?

Objectives (i) To document the current state of the English, Scottish, Welsh, Northern Irish and Australian bowel cancer screening programmes, according to seven key characteristics, and (ii) to explore the policy trade-offs resulting from inadequate funding. Setting United Kingdom and Australia. Methods A comparative case study design using document and key informant interview analysis. Data were collated for each national jurisdiction on seven key programme characteristics: screening frequency, population coverage, quality of test, programme model, quality of follow-up, quality of colonoscopy and quality of data collection. A list of optimal features for each of the seven characteristics was compiled, based on the FOBT screening literature and our detailed examination of each programme. Results Each country made different implementation choices or trade-offs intended to conserve costs and/or manage limited and expensive resources. The overall outcome of these trade-offs was probable lower programme effectiveness as a result of compromises such as reduced screening frequency, restricted target age range, the use of less accurate tests, the deliberate setting of low programme positivity rates or increased inconvenience to participants from re-testing. Conclusions Insufficient funding has forced programme administrators to make trade-offs that may undermine the potential net population benefits achieved in randomized controlled trials. Such policy compromise contravenes the principle of evidence-based practice which is dependent on adequate funding being made available

Pharmacists and patients sharing decisions about medicines: Development and feasibility of a conversation guide

Background: In Australia, the Home Medicines Review (HMR) is a nationally-funded program, led by pharmacists to optimize medication use for older people. A Medicines Conversation Guide was developed for pharmacists to use in the context of a HMR. The Guide aims to increase patient involvement and support discussions about: general health understanding, decision-making and information preferences, health priorities related to medicines, patient goals and fears, views on important activities and trade-offs. Objective: This study describes the development and feasibility testing of a Medicines Conversation Guide in HMRs with pharmacists and older patients. Methods: The Guide was developed using a systematic and iterative process, followed by testing in clinical practice with 11 pharmacists, 17 patients (aged 65+) and their companions. A researcher observed HMRs, surveyed and qualitatively interviewed patients and pharmacists to discuss feasibility. Transcribed recordings of the interviews were thematically coded and a Framework Analysis method used. Results: Pharmacists found the Guide to be an acceptable and useful component to the HMR, especially among patients with limited knowledge of their medicines. The Guide seemed most effective when integrated with the HMR and tailored to suit the individual patient. Some questions were difficult for patients to grasp (e.g. trade-offs) or sounded formal. Most patients found the Guide focused the HMR on their perspective and encouraged a more holistic approach to the HMR. From the quantitative survey, pharmacists found the Guide easy to implement, balanced and understandable. Conclusions: Pharmacists and patients reported the Guide fits with the HMR encounter relatively easily and promoted communication about goals and preferences in relation to medications. This study highlighted some key challenges for communication about medicines and how the Guide may help support the process of involving patients more in the HMR