Medical Decision Making

Helfand, Mark

doi: 10.1177/0272989X070270050101pmid: 17921449

Kremer, Heidemarie; Ironson, Gail; Schneiderman, Neil; Hautzinger, Martin

doi: 10.1177/0272989X07306782pmid: 17873261

Objective. This study explores how much people with HIV/AIDS wanted and how much they actually perceived being involved in the decision to take or not to take antiretroviral treatment (ART). The congruence between desired and perceived decisional involvement was also related to decisional conflict. Method. Cross-sectional (N = 79), the Control Preferences Scale assessed patients' preferred versus perceived role in treatment decision making. The Decisional Conflict Scale measured patients' perceived difficulties in decision making. Results. Although a minority of patients (32%) perceived their role as shared decision making, the majority (59%) preferred shared decision making. Some did not desire shared decision making, with 28% preferring to decide on their own versus 13% wanting their physicians to decide for them. Overall, 58% did not feel they had achieved their desired role in decision making (half of whom perceived more control and the other half less control than preferred). Participants declining ART felt more pressure to decide alone compared with those taking ART (P < 0.01). Decisional conflict was expressed by 53% and was highest when physicians unilaterally made decisions about ART for patients who preferred shared decision making (P < 0.001). Conclusions. In this study, most physicians do not meet their patients' desired roles in decision making. One-third of people taking ART feel less involved than they desire. More critically, half of those declining ART feel pressured to decide alone, suggesting that physicians should remain involved in the decision to reject treatment, as this requires careful monitoring and periodical revisiting. Because lack of shared decision making is related to decisional conflict, physicians may reduce decisional conflict by meeting patients' desires for shared decision making.

Fraenkel, Liana; McGraw, Sarah

doi: 10.1177/0272989X07306784pmid: 17873253

Purpose. Variability in reports of patients' preferences to participate in decision making may be due in part to a lack of understanding about how patients conceptualize their participation. The authors sought to learn more about how patients view their involvement in decisions related to their health care. Methods. The authors conducted individual interviews to allow patients to frame the decision-making process from their own perspective. The constant comparative-method approach to analysis was employed to ensure that the analysts defined the codes in a consistent manner. Results. Twenty-six persons were interviewed. The main themes discussed by the participants reflecting how they viewed their involvement in medical decision making are the following: 1) decision making is often an ongoing process in which patient participation may change over time, 2) decision making is performed within an extended social context, 3) the decisions patients report being involved in are often distinct from those traditionally studied (choice of treatment or screening strategies), 4) patient involvement in decision making occurs in response to physicians' recommendations, and 5) patients make choices in the context of their specific illness perceptions. Conclusions. Participants in this study view their participation in decision making as including ideas distinct from those traditionally discussed by researchers. These findings suggest that the variability in patient participation noted in previous studies may be due in part to limitations in study design.

Moumjid, Nora; Gafni, Amiram; Brémond, Alain; Carrère, Marie-Odile

doi: 10.1177/0272989X07306779pmid: 17873252

Objective. This article aims to explore 1) whether after all the research done on shared decision making (SDM) in the medical encounter, a clear definition (or definitions) of SDM exists; 2) whether authors provide a definition of SDM when they use the term; 3) and whether authors are consistent, throughout a given paper, with respect to the research described and the definition they propose or cite. Methods. The authors searched different databases (Medline, HealthStar, Cinahl, Cancerlit, Sociological Abstracts, and Econlit) from 1997 to December 2004. The keywords used were informed decision making and shared decision making as these are the keywords more often encountered in the literature. The languages selected were English and French. Results. The 76 reported papers show that 1) several authors clearly define what they mean by SDM or by another closely related phrase, such as informed shared decision making. 2) About a third of the papers reviewed (25/76) cite these authors although 8 of them do not use the term in a manner consistent with the definition cited. 3) Certain authors use the term SDM inconsistently with the definition they propose, and some use the terms informed decision making and SDM as if they were synonymous. 4) Twenty-one papers do not provide or cite any definition, or their use of the term (i.e., SDM) is not consistent with the definition they provide. Conclusion. Although several clear definitions of shared decision making have been proposed, they are cited by only about a third of the papers reviewed. In the other papers, authors refer to the term without specifying or citing a definition or use the term inconsistently with their definition. This is a problem because having a clear definition of the concept and following this definition are essential to guide and focus research. Authors should use the term consistently with the identified definition.

Pignone, Michael

doi: 10.1177/0272989X07307520pmid: 17921450

Street, Richard L.

doi: 10.1177/0272989X07307581pmid: 17921451

O'Connor, Annette M.; Stacey, Dawn; Barry, Michael J.; Col, Nananda F.; Eden, Karen B.; Entwistle, Vikki; Fiset, Valerie; Holmes-Rovner, Margaret; Khangura, Sara; Llewellyn-Thomas, Hilary; Rovner, David R.

doi: 10.1177/0272989X07307319

Protheroe, Joanne; Bower, Peter; Chew-Graham, Carolyn; Peters, Tim J.; Fahey, Tom

doi: 10.1177/0272989X07306785pmid: 17898242

Background. Computerized decision aids have the potential to increase patient involvement in the decision-making process. However, most published evidence concerning the effectiveness of decision aids is from secondary care. Aim. To evaluate whether the addition of a computerized decision aid to written information improves decision making in women consulting their general practitioner with menorrhagia comparedwithwritten informationalone. Design of study. Randomized controlled trial. Setting. Nineteen general practices in the North of England. Method. One hundred forty-nine women presenting with menorrhagia were randomized to receive written information and access to a computerized decision aid or written information alone. Outcomes were assessed using postal questionnaires. These were scores on the Decisional Conflict Scale and State-Trait Anxiety Inventory anxiety scale at 2 weeks and the Menorrhagia Specific Utility quality-of-life scale, knowledge about menorrhagia, and anxiety and process measures at 6 months. Results. Two weeks after the intervention, there was significantly less decisional conflict in the intervention group (adjusted difference = −16.6; 95% confidence interval [CI] = −21.5 to −11.7; P < 0.001). At 6 months, the intervention group showed better knowledge about menorrhagia (adjusted difference = 9.3 ; 95% CI = 1.9 to 16.6; P = 0.014) and menorrhagia quality of life (adjusted difference = 10.9; 95% CI = 0.9 to 21.0; P = 0.033). There was no difference in anxiety scores at either 2 weeks or 6 months. Conclusions. A computerized decision aid, used outside of the primary care consultation, is effective in increasing patient involvement in decision making in primary care.

Col, Nananda F.; Ngo, Long; Fortin, Jennifer M.; Goldberg, Robert J.; O'Connor, Annette M.

doi: 10.1177/0272989X07306781pmid: 17873260

Purpose. To compare the effectiveness of an individualized decision aid (DA) with standard educational materials on decisions about menopausal treatments and to assess the feasibility of integrating this DA into clinical practice, with and without coaching. Methods. We conducted a 3-armed randomized controlled trial in 3 clinics, enrolling menopausal women between the ages of 45 and 65 years with primary care appointments. Of the 145 women included, 99 completed a 2-week follow-up. The control group received generic educational materials, 1 intervention group received an individualized computer-generated DA mailed to patients and their clinicians before clinic appointment, and the 2nd intervention group received the same DA along with coached care before clinic appointment (DA + CC). Decisional conflict, satisfaction, and knowledge were measured 2 weeks after clinic appointment. Results. Participants' mean age was 52 years, and 97% were white. Most women (98%) read all or most of the documents. Decisional conflict was significantly lower in both intervention groups but not in the control group. DA reduced decisional conflict from preintervention to postintervention (pre—post change) by 0.70 (SD = 0.56) points (on a 1—5 scale), compared to reductions of 0.51 (SD = 0.51) and 0.09 (SD = 0.44) for the DA + CC group and the control group, respectively. Satisfaction with the decision made was significantly higher at 2 weeks in the DA v. control group. Self-reported knowledge significantly improved in DA + CC compared to controls. Conclusion. Our decision aid lowered decisional conflict and improved patient satisfaction; adding coaching provided little additional benefit.

Holmes-Rovner, Margaret; Nelson, Wendy L.; Pignone, Michael; Elwyn, Glyn; Rovner, David R.; O'Connor, Annette M.; Coulter, Angela; Correa-de-Araujo, Rosaly

doi: 10.1177/0272989X07307272pmid: 17873257

This article reports on the International Patient Decision Aid Standards Symposium held in 2006 at the annual meeting of the Society for Medical Decision Making in Cambridge, Massachusetts. The symposium featured a debate regarding the proposition that ``decision aids are the best way to improve clinical decision making.'' The formal debate addressed the theoretical problem of the appropriate gold standard for an improved decision, efficacy of decision aids, and prospects for implementation. Audience comments and questions focused on both theory and practice: the often unacknowledged roots of decision aids in expected utility theory and the practical problems of limited patient decision aid implementation in health care. The participants' vote on the proposition was approximately half for and half against.