Shared decision-making in Canada: update, challenges and where next!

BackgroundA patient decision aid (PDA) is a tool for shared decision making (SDM), which emphasises patient empowerment. It is useful in chronic diseases and when there are multiple, no best...

<p>目的：探討使用決策輔助工具(patient decision aids, PDA)選擇戒菸藥物，是否能提升戒菸成效。</p> <p>方法：本研究是一篇歷史對照研究(historical control trial)，研發一份紙本決策輔助工具，輔助戒菸者在varenicline與合併尼古丁替代療法(combination nicotine replacement therapy)兩類藥物中做出選擇。2020年1月至2021年3月期間，於家庭醫學科戒菸門診進行收案，針對有意願接受藥物戒菸的民眾，由醫師擔任醫病共享決策的引導員(coach)，使用決策輔助工具協助其決定藥物的種類。對照組為2019年全年度在家庭醫學科戒菸門診接受藥物戒菸服務者，無使用決策輔助工具。以電話訪問調查第三個月以及第六個月的戒菸狀況，再以logistic regression等統計方法探討使用PDA是否影響戒菸成功率。</p> <p>結果：排除療程中更換處方和失聯者，總共199人被納入研究（PDA組62人：男性佔80.6%，平均年齡為46.0歲；對照組137人，男性佔74.5%，平均年齡為49.4歲）。PDA組傾向選擇varenicline作為戒菸藥物(aOR=1.94, 95% CI 1.02-3.71)；兩組六個月點戒菸率無顯著差異(aOR=1.43, 95% CI 0.74-2.79)。</p> <p>結論：以決策輔助工具選擇戒菸藥物，民眾偏好varenicline甚於合併尼古丁替代療法，但是並未對戒菸成功率造成顯著影響。醫病共享決策能否提升戒菸藥物的順從性，並增進戒菸治療的效益，需要進一步的研究。</p> <p> </p><p>Purpose: The study explored whether the use of patient decision aid (PDA) to select smoking cessation drugs can improve the effectiveness of smoking cessation.</p> <p>Methods: This historical control trail developed a paper-based PDA to help smokers choose between varenicline and a combination of nicotine replacement therapy. From January 2020 to March 2021, people visiting the smoking cessation clinic of a family medicine department and willing to take drugs to quit smoking were enrolled into the PDA group of the study with doctors serving as coaches for shared decision-making and applying the PDA to help them decide on the types of drugs to use. Members in the control group were enrolled from people receiving the drug smoking cessation services in the same smoking cessation clinic in 2019 without using PDA. The smoking status after 3 and 6 months were collected by telephone interview. The effects of using PDA on smoking cessation were analyzed by logistic regression.</p> <p>Results: A total of 199 people participating in the study, excluding those who changed prescriptions and lost contact during the course of treatment. Of the 62 participants in the PDA group, 80.6% were male, and the average age was 46.0. Of the 137 participants in the control group, 74.5% were male, and the average age was 49.4. The PDA group preferred varenicline as the smoking cessation drug (aOR=1.94, 95% CI 1.02-3.71). There was no significant difference in the smoking cessation rate between the two groups at six months (aOR=1.43, 95% CI 0.74-2.79).</p> <p>Conclusion: When using PDA to select smoking cessation drugs, people appear to prefer varenicline over a combination of nicotine replacement therapy; however, this preference produces no significant influence on the success rate of smoking cessation. Whether shared decision-making help improve the compliance with the instructions of smoking cessation products and enhance the effectiveness of smoking cessation treatment requires further research.</p> <p> </p>

Patient decision aids in knee replacement surgery

<h3>Background</h3> A patient decision aid (PDA) is a tool for shared decision making (SDM), which emphasises patient empowerment. It is useful in chronic diseases and when there are multiple, no...

Shared decision making for high-risk surgery

Patient participation in medical decision-making is widely advocated, but outcomes are inconsistent. We examined the associations between medical decision-making roles, and patients' perceptions of their care and knowledge while undergoing pulmonary nodule surveillance. The study setting was an academically affiliated Veterans Affairs hospital network in which 121 participants had 319 decision-making encounters. The Control Preferences Scale was used to assess patients' decision-making roles. Associations between decision-making, including role concordance (i.e., agreement between patients' preferred and actual roles), shared decision-making (SDM), and perceptions of care and knowledge, were assessed using logistic regression and generalized estimating equations. Participants had a preferred role in 98% of encounters, and most desired an active role (shared or patient controlled). For some encounters (36%), patients did not report their actual decision-making role, because they did not know what their role was. Role concordance and SDM occurred in 56% and 26% of encounters, respectively. Role concordance was associated with greater satisfaction with medical care (adjusted odds ratio [Adj-OR], 5.39; 95% confidence interval [CI], 1.68-17.26), higher quality of patient-reported care (Adj-OR, 2.86; 95% CI, 1.31-6.27), and more disagreement that care could be better (Adj-OR, 2.16; 95% CI, 1.12-4.16). Role concordance was not associated with improved pulmonary nodule knowledge with respect to lung cancer risk (Adj-OR, 1.12; 95% CI, 0.63-2.00) or nodule information received (Adj-OR, 1.13; 95% CI, 0.31-4.13). SDM was not associated with perceptions of care or knowledge. Among patients undergoing longitudinal nodule surveillance, a majority had a preference for having active roles in decision-making. Interestingly, during some encounters, patients did not know what their role was or that a decision was being made. Role concordance was associated with greater patient-reported satisfaction and quality of medical care, but not with improved knowledge. Patient participation in decision-making may influence perceptions of care; however, clinicians may need to focus on other communication strategies or domains to improve patient knowledge and health outcomes.

BackgroundMen with localized prostate cancer often have unrealistic expectations. Practitioners are poor judges of men’s preferences, contributing to preference misdiagnosis and unwarranted practice variation. Patient decision aids (PtDAs) can support men with decisions about localized prostate cancer. This is a comparative case study of two strategies for implementing PtDAs in clinical pathways for men with localized prostate cancer, evaluating (a) PtDA use; (b) impact on men, practitioners, and health system outcomes; and (c) factors influencing sustained use.Methods/designGuided by the Knowledge to Action Framework, this comparative case study will be conducted using administrative data, interviews, and surveys. Cases will be bound by geographic location (one hospital in Ontario; province of Saskatchewan) and time. Eligible participants will be all men newly diagnosed with localized prostate cancer, with outcomes assessed using administrative data and interviews. Nurses, urologists, radiation oncologists, and managers will be surveyed and a smaller sample interviewed. Cases will be established for each setting with findings compared across cases. Changes in the proportions of men given the PtDA over 2 years will be determined from administrative data. Factors associated with receiving the PtDA will be explored using multivariable logistic regression analysis. To assess the impact of the PtDA, outcomes will be described using mean and standard deviation (men’s decisional conflict) and frequency and proportions (practitioners consulted, uptake of treatment). To estimate the effect of the PtDA on these outcomes, adjusted mean differences and odds ratios will be calculated using exploratory multivariable general linear regression and binary or multinomial logistic regression. Factors influencing sustained PtDA use will be assessed using descriptive analysis of survey findings and thematic analysis of interview transcripts.DiscussionDetermining how to embed PtDAs effectively within clinical pathways for men with localized prostate cancer is essential. PtDAs have the potential to strengthen men’s active role in making prostate cancer decisions, enhance uptake of shared decision-making by practitioners, and reduce practice variation. Our team of researchers and knowledge users will use findings to improve current PtDA use and consider scaling-up implementation.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0451-1) contains supplementary material, which is available to authorized users.

ObjectiveTo integrate patient decision aid (DA) delivery to promote shared decision-making and provide more patient-centred care within an orthopaedic surgery department for treatment of hip and knee osteoarthritis, lumbar herniated...

Patient decision aids (PDAs) are evidence-based tools that facilitate shared decision-making (SDM) between patients and healthcare professionals. These tools are used when multiple treatment options exist, no clear choice prevails regarding risks versus benefits, and the best option may vary depending on patient values. A 2024 Cochrane review of 209 randomized controlled trials involving over 107,000 participants identified the substantial benefits of PDAs,1 including improved patient knowledge, increased SDM and enhanced accuracy of risk perceptions and alignment of decisions with patient values. Given these benefits, SDM tools are more widely used. However, their quality remains inconsistent, potentially limiting their benefit.2-4 Dermatology is particularly suited to SDM, given the wide-ranging and ever-evolving treatment options for conditions that often convey a significant psychological burden. A literature review was conducted to assess dermatologic PDAs for adherence with reporting the development process according to the International Patient Decision Aids Standards (IPDAS) Collaboration.5-8 A comprehensive search using MEDLINE (via PubMed) and EMBASE identified articles on dermatological PDA development from 2014 to 2024. After screening 509 publications, 11 studies describing 14 PDAs across eight conditions, psoriasis (2), acne (1), superficial, low and high-risk basal cell carcinoma (4), vitiligo (1), actinic keratoses (3), metastatic malignant melanoma (1), lentigo maligna (1) and hidradenitis suppurativa (1), were included. Data extraction followed Coulter et al.'s9 template for documenting PDA development, focusing on adherence to IPDAS reporting standards. Most studies (10/11) were published in the last 5 years (2020–2024). All PDAs aimed to support patients with a treatment decision (Table 1). Clinical guidelines (5/14) and literature reviews (4/14) were the most common information sources. Five studies did not report this step. Digital PDAs were most common (6/14), although 4 studies only provided images of the PDA, without stating the format. While most PDAs (10/14) reported adhering to the IPDAS framework with an iterative process, only three included all the required development steps (Figure 1). Clinician needs assessments were infrequently conducted (4/14), with just three specifying numbers involved. In contrast, patient needs assessments were more consistently reported (9/14), although only six provided details on patient numbers. Alpha testing with patients was reported in nearly all studies (12/14), reflecting strong patient engagement, but 4 of these did not provide participant numbers, limiting insight into testing scope. Across the PDAs, patient involvement was nearly double that of clinicians, with a median of 20 (IQR = 33) versus 13 (IQR = 38). Patient participation ranged widely from 7 to 322 individuals, while clinician numbers ranged from 8 to 51. Notably, no patient or clinician numbers were reported for any step in the development of PDAs that did not use the IPDAS development framework. This review of dermatologic PDAs reveals that many lack key elements of the IPDAS development process, such as expert panel involvement, needs assessments and usability testing. While most PDAs were reported to align with the IPDAS framework, a substantial number lacked transparency in their development process which may explain the previously reported variations in dermatologic PDA quality.4 For PDAs to effectively support patient-centred SDM, they must undergo a thorough development process with broad user engagement as demonstrated by our research group's development of a PDA for multiple AKs.10 We suggest developers follow the streamlined IPDAS development framework outlined by Witteman et al.7 and Coulter et al.9 which emphasizes iterative development, evidence-based content and stakeholder engagement through minimal, medium and maximal approaches. These approaches ensure both patients and clinicians are included in all development phases and define a minimum required number for user involvement. Future research should prioritize adherence to these standardized development frameworks. The study was completed in partial fulfillment of a doctorate of medicine funded by a research grant from The City of Dublin Skin and Cancer Hospital Charity. The funders were not involved in the study design, data collection, data analysis or manuscript preparation. The authors declare no conflicts of interest. Not applicable. Not applicable. The data that support the findings of this study are available from the corresponding author upon reasonable request.

Patient participation in decision-making has produced many debates among health care professionals. The research evidence concerning patient participation in decision-making is not clear, and shows conflicting results. To identify to what extent cancer patients participate in decision-making and to what extent background characteristics, information obtained and relationships with staff explain cancer patients' participation in decision-making. A structured questionnaire based on earlier research and qualitative interviews was designed. The questionnaire was completed by 273 cancer patients who were inpatients or outpatients in haematology, oncology clinics and other clinics at two university hospitals in Finland. The questionnaire consisted of five areas: (1) demographic data; (2) mood; (3) information obtained; (4) relationships with staff; and (5) decision-making. The scale used was ordinal. The data were analysed using descriptive statistics and nonparametric tests such as Mann-Whitney U-test, Kruskall-Wallis, and Wilcoxon matched-pairs signed-rank tests. The majority of the respondents perceived that they had participated in making treatment decisions at least to some extent, together with the physician. In decision-making about nursing care, respondents felt that they had participated most in decisions about personal hygiene, rest and sleep. Respondents' physical condition, marital status, age and time since diagnosis, as well as information obtained and relationships with staff, were associated with participation in decision-making. This study provided evidence that some cancer patients participated in decision-making and felt participation to be important. Staff played a crucial role in patient participation in decision-making. In future, staff should work to improve cancer patients' opportunities to participate in decision-making in order that those who wish to be involved can do so.

Patient decision aids (PDAs) are increasingly used to support treatment decision making in type 2 diabetes. However, research on PDAs generally involves quantitative analysis or focuses on physicians’ communicative practices, with limited data on how PDAs are used collaboratively in doctor-patient consultations. We apply discourse analytic methods to 11 recorded consultations during which a PDA on starting insulin was used. Purposive sampling was used to select participants from different healthcare settings and demographic profiles. Our analysis first addresses general questions on PDA use in the consultations, such as when it was used or mentioned in the consultation and by whom, before categorising the turns in which the PDA is mentioned or used by doctors and patients, according to the actions being performed. Next, we focus on consultations in which the patients have already read the PDA, and analyse the sequences of talk that occur after the doctor brings the PDA into the conversation. Our analysis shows that doctor talk on the PDA not only facilitated information provision, but also allowed doctors to elicit and explore the patient’s knowledge and perspectives. However, the kinds of questions that doctors asked tend to limit patient participation, and their focus on the PDA at times overshadowed patient contributions. More attention to doctors’ discursive choices can facilitate more patient-centred practices in using PDAs.

Coronary heart disease (CHD) is the leading cause of death in the world. There are some decision-making conflicts in the management of chest pain, treatment methods, stent selection, and other aspects due to the unstable condition of CHD in the treatment stage. Although using decision aids to facilitate shared decision-making (SDM) contributes to high-quality decision-making, it has not been evaluated in the field of CHD. This review systematically assessed the effects of SDM in patients with CHD. We conducted a systematic review and meta-analysis of randomized controlled trials of SDM interventions in patients with CHD from database inception to 1 June 2022 (PROSPERO [Unique identifier: CRD42022338938]). We searched for relevant studies in the PubMed, Embase, Cochrane Library, Web of Science, CNKI, and Wan Fang databases. The primary outcomes were knowledge and decision conflict. The secondary outcomes were satisfaction, patient participation, trust, acceptance, quality of life, and psychological condition. A total of 8244 studies were retrieved. After screening, ten studies were included in the analysis. Compared with the control group, SDM intervention with patient decision aids obviously improved patients' knowledge, decision satisfaction, participation, and medical outcomes and reduced decision-making conflict. There was no significant effect of SDM on trust. This study showed that SDM intervention in the form of decision aids was beneficial to decision-making quality and treatment outcomes among patients with CHD. The results of SDM interventions need to be evaluated in different environments.

According to a cross-country research in 2018, there are approximately 936 million people worldwide who suffer from obstructive sleep apnea (OSA), which is almost ten times the World Health Organization estimate before ten years. People with untreated sleep apnea stop breathing repeatedly during their sleep. This means the brain and their body may not get enough oxygen which may cause the development and progression of cardiovascular conditions. Actually, different people may have different traits and value preferences, so each patient may have different opinions and choices about various clinical decisions facing this disease. In order to help medical staffs and patients with OSA to discuss more closely, the process of share decision making (SDM) based on the evidence is the most important information for the patient. Patient decision aid (PDA) can ensure that patients have the knowledge and tools necessary to make the best health decisions with as much assistance as they want and need from their clinicians. Therefore, this study regards SDM for OSA examination, diagnosis and treatment as a service system. First, explores the interaction between physicians and patients through observations and interviews. Then, we draw stakeholder map and customer’s journey map according to the result of the interviews to define the shared decision making gap for clinical diagnosis or disposition to reveal design opportunities. Finally, we used scenario to build the script and propose the visualized prototype of PDA, which could be the useful tool for SDM for OSA. This tool makes it easier for clinicians and patients to combine their own preferences and values before making medical decisions related to sleep apnea. Through the participation of clinical staffs and patients, it is hoped that this innovative service model can achieve the purpose of SDM and support patients to make medical decisions that more closely meet user needs.

Patient decision aids are a means of helping people make informed choices about healthcare that take into account their personal values and preferences. Decision aids are a part of a...

As breast cancer screening guidelines have changed recently, additional investigation is needed to understand changes in women's behavior after using breast cancer screening patient decision aids (BCS-PtDAs) and the potential effect on mammography utilization. This systematic review and meta-analysis sought to evaluate the effect of BCS-PtDAs on changes in women's intentions to undergo screening mammography and whether women deciding to begin or discontinue screening mammography displayed similar changes in screening intentions after using a BCS-PtDA. We searched Medline, Scopus, PsycINFO, CENTRAL, Health and Psychosocial Instruments, Health Technology Assessment Database, PsycARTICLES, and cited references in eligible papers for randomized controlled trials (RCTs) and observational studies, published through August 24, 2016. The proportions of women who did and not intend to undergo screening and who were uncertain about undergoing screening mammography were pooled, using risk ratios (RR) and random effects. According to the protocol, RCTs or observational studies and any language were considered eligible for systematic review if they included data about women for which shared decision making is recommended. We ultimately included six studies with screening intention data for 2040 women. Compared to usual care, the use of BCS-PtDAs in three RCTs resulted in significantly more women deciding not to undergo screening mammography (RR 1.48 [95% CI 1.04-2.13]; P = 0.03), particularly for younger (38-50 years) women (1.77 [1.34-2.34]; P < 0.001). The use of BCS-PtDAs had a non-significant effect on the intentions of older women (69-89 years) to discontinue screening. The use of BCS-PtDAs increased younger women's reluctance to undergo screening for breast cancer. The implementation of such BCS-PtDAs in clinical practice would be expected to result in a 77% increase in the number of younger women (aged 38-50) who do not intend to be screened, and as a consequence, may reduce utilization of screening mammography. The protocol of this review is registered in the PROSPERO database, #CRD42016036695.