Shared decision making with schizophrenic patients: a randomized controlled clinical trial with booster sessions (DECIDE Study)

BackgroundAlthough shared decision making (SDM) is key to delivering patient-centred care, there are barriers to GPs implementing SDM in practice. SDM training is undergoing development by organisations, including the Royal College of General Practitioners. However, GPs’ perceptions of the delivery of SDM training in general practice remain largely unexplored.AimTo explore GPs’ perceptions of teaching methods in SDM training.Design and settingQualitative study of GPs with teaching roles at the University of Exeter Medical School.MethodPurposive sampling recruited 14 GPs. Semi-structured interviews explored their SDM educational experiences. Data were analysed using thematic framework analysis.ResultsThree themes were identified. The GPs described role-play, receiving feedback, and on-the-job learning as modes of delivering SDM training that mostly informed their SDM in clinical practice positively. Learning from knowledgeable individuals and using realistic patient cases were perceived as beneficial components of SDM learning, although most learning occurred implicitly through reflections on their clinical experiences. The GPs identified that their training on SDM should reflect the uncertainty that is present when sharing decisions with patients in real-life general practice consultations. GPs also identified the targeting of individual GPs’ SDM learning needs and explanation of the potential benefits of SDM on consultation outcomes as important methods to facilitate the implementation of SDM in practice.ConclusionTo the authors’ knowledge, this is the first UK study to explore GPs’ perceptions of SDM training and provide recommendations for practice. As SDM occurs in partnership with patients, further research should obtain and incorporate patients’ views alongside those of GPs in the evaluation of future programmes.

BackgroundHealthcare providers need training to implement shared decision making (SDM). In Norway, we developed “Ready for SDM”, a comprehensive SDM curriculum tailored to various healthcare providers, settings, and competence levels, including a course targeting interprofessional healthcare teams. The overall aim was to evaluate a train-the-trainer (TTT) program for healthcare providers wanting to offer this course within their hospital trust.MethodsOur observational descriptive design was informed by Kirkpatrick´s Model of Educational Outcomes. The South-Eastern Regional Health Authority invited healthcare providers from all health trusts in its jurisdiction to attend. The TTT consisted of a one-day basic course with lectures on SDM, exercises and group reflections followed by a two-day advanced course including an SDM observer training. Immediately after each of the two courses, reaction and learning (Kirkpatrick levels 1 and 2) were assessed using a self-administered questionnaire. After the advanced course, observer skills were operationalized as accuracy of the participants’ assessment of a consultation compared to an expert assessment. Within three months post-training, we measured number of trainings conducted and number of healthcare providers trained (Kirkpatrick level 3) using an online survey. Qualitative and quantitative descriptive analysis were performed.ResultsTwenty-one out of 24 (basic) and 19 out of 22 (advanced) healthcare providers in 9 health trusts consented to participate. The basic course was evaluated as highly acceptable, the advanced course as complex and challenging. Participants identified a need for more training in pedagogical skills and support for planning implementation of SDM-training. Participants achieved high knowledge scores and were positive about being an SDM trainer. Observer skills regarding patient involvement in decision-making were excellent (mean of weighted t = .80). After three months, 67% of TTT participants had conducted more than two trainings each and trained a total of 458 healthcare providers.ConclusionFindings suggest that the TTT is a feasible approach for supporting large-scale training in SDM. Our study informed us about how to improve the advanced course. Further research shall investigate the efficacy of the training in the context of a comprehensive multifaceted strategy for implementing SDM in clinical practice.Trial registration: Retrospectively registered at ISRCTN (99432465) March 25, 2020.

Background. Shared decision making (SDM) is an essential component of patient-centered care and especially important in high-risk populations, such as older adults. Although surgery has unique risks and the potential to cause permanent disability, which can affect the patient’s quality of life, SDM is underused before surgery to explore these tradeoffs. This study’s aim is to characterize the priorities, barriers, resources, and age-specific considerations for SDM in older adults undergoing surgery. Study Design. Five semi-structured focus groups were completed from February 2022 to April 2022 with 24 participants including older adult surgical patients and caregivers as well as providers involved in the care of older adult surgical patients (e.g., surgery, intensive care, geriatrics, and palliative care). Interviews were transcribed, and qualitative thematic analysis was conducted. Results. Six major themes were identified and explored: components of SDM, barriers to SDM, importance of SDM, preparation for SDM, age-specific considerations, and suggestions for improvement. Results showed differing opinions between patients and providers about important information in the SDM process, minimal preparation for SDM in both groups, and difficulties around defining outcomes for this population, particularly in the emergent setting. Conclusion. This study identifies critical components of SDM, perceived barriers, preparation and training for SDM, as well as unique considerations in older adults from the perspectives of both patients and providers. Opportunities to improve SDM include dissemination of resources, training of surgical providers, and utilization of other providers as well as patient-centered discussions about postoperative outcomes. This highlights important areas for future work and particularly the utility of SDM tools and training for surgeons.HighlightsCritical components of shared decision making (SDM) identified in this study include understanding patient values, building trust, understanding the patient’s baseline function, and defining possible treatment outcomes.Specific components of SDM in older adults include navigating companions to conversations and the challenges of navigating potential postoperative changes to cognitive or physical function.Possible areas to improve SDM include improved dissemination of SDM resources; the importance of communication skills and empathy and an emphasis on additional training for this, particularly for trainees; improved engagement of patients in the SDM process; and using other care team members such as palliative care and social work when appropriate.

Use and Perceptions of Shared Decision-Making by General Surgery Faculty and Trainees.

Patient-centered communication has been linked to patient satisfaction, treatment adherence and outcomes. Shared decision making (SDM) has been advocated as an important and ethically essential aspect of patient-centered care, but SDM has received relatively little attention in mental health care, despite studies indicating that consumers want to be involved in making decisions. This is particularly important in a recovery-oriented system, where consumers are active participants in their treatment and rehabilitation. Because medication management is a key component of recovery from severe mental illnesses, this study explores how consumers and providers make decisions in medication management consultations. Four providers (3 psychiatrists, 1 nurse practitioner) and 40 consumers with severe mental illness (10 consumers per provider) were recruited from a community mental health center with a recovery-oriented focus. We directly observed 40 medication management appointments. Observations were audio recorded and transcribed. We used emergent thematic analysis to characterize decision making processes. Providers initiated most decisions, although they often invited consumers to participate in decision making. Decisions initiated by consumers elicited a greater degree of discussion and disagreement, but also frequently resulted in consumers' preferences prevailing. Consultations generally exhibited more characteristics of person-centeredness than SDM. While we observed a high degree of person-centeredness, SDM was not prevalent. Interventions helping consumers to take greater initiative when working with service providers may be helpful. For example, programs using tools such as peer instruction, Internet-based software, and individual case-manager instruction all have shown promise for enhancing SDM in mental health treatment. Further research is needed to determine the degree of SDM in other settings (e.g., with case managers) and the impact of SDM on consumers' recovery.

<i>Background &amp; rationale: </i>Evidence-based medicine (EBM) requires doctors to use their clinical expertise, the best current research evidence, and patient preferences to make optimal healthcare decisions. Healthcare systems recognise the importance of patient involvement in their care and recommend the practices of person-centred care and shared decision-making (SDM), where the doctor and patient make care decisions together. However, training in EBM has not kept pace with these developments, which has impacted doctors’ ability to effectively apply EBM principles to patients in their care. It has been suggested that training courses in EBM that incorporate principles of SDM can improve the inclusion of patient preferences into the EBM process and improve patient experiences and outcomes, such as compliance with a healthcare plan. However, there has been little research into how to train junior doctors to include the patient in EBM decision-making. <i>Objectives: </i>The overall aim of the thesis was to understand how training that integrates EBM and SDM can change junior doctors’ attitudes and intended practice of both concepts, and the barriers and facilitators to these changes. <i>Research articles: </i>This thesis contains five articles. Article I is a systematic review of the EBM training programs available for junior doctors, and how their outcomes are measured. Articles II and III are a scoping review and its protocol that examined whether EBM courses for junior doctors include SDM. Articles IV and V are empirical studies that explored the attitudes and perspectives of junior doctors and consultants about EBM and SDM. <i>Methods: </i>The research centred around an intervention, an EBM training course that included a component on SDM. An explanatory sequential research design used a mixed methods survey, and two rounds of interviews. Participants were junior doctors and consultants from a private health care setting on a university campus in Sydney. <i>Research findings</i>: Findings demonstrated junior doctors’ attitudes towards EBM and SDM were more positive following the training course. The findings also highlighted the barriers to the combined EBM and SDM practice experienced by junior doctors, in particular time factors, lack of prior training, and the medical hierarchy. <i>Contributions of the thesis: </i>By providing insights into existing gaps in EBM and SDM training, this thesis has identified key barriers to EBM-SDM learning and practice, and indicated ways of overcoming them, such as using champions to promote EBM and SDM learning and practice in clinical settings.

BackgroundHypertension is one of the key factors causing cardiovascular diseases. A substantial proportion of treated hypertensive patients do not reach recommended target blood pressure values. Shared decision making (SDM) is to enhance the active role of patients. As until now there exists little information on the effects of SDM training in antihypertensive therapy, we tested the effect of an SDM training programme for general practitioners (GPs). Our hypotheses are that this SDM training (1) enhances the participation of patients and (2) leads to an enhanced decrease in blood pressure (BP) values, compared to patients receiving usual care without prior SDM training for GPs.MethodsThe study was conducted as a cluster randomised controlled trial (cRCT) with GP practices in Southwest Germany. Each GP practice included patients with treated but uncontrolled hypertension and/or with relevant comorbidity. After baseline assessment (T0) GP practices were randomly allocated into an intervention and a control arm. GPs of the intervention group took part in the SDM training. GPs of the control group treated their patients as usual. The intervention was blinded to the patients. Primary endpoints on patient level were (1) change of patients’ perceived participation (SDM-Q-9) and (2) change of systolic BP (24h-mean). Secondary endpoints were changes of (1) diastolic BP (24h-mean), (2) patients’ knowledge about hypertension, (3) adherence (MARS-D), and (4) cardiovascular risk score (CVR).ResultsIn total 1357 patients from 36 general practices were screened for blood pressure control by ambulatory blood pressure monitoring (ABPM). Thereof 1120 patients remained in the study because of uncontrolled (but treated) hypertension and/or a relevant comorbidity. At T0 the intervention group involved 17 GP practices with 552 patients and the control group 19 GP practices with 568 patients. The effectiveness analysis could not demonstrate a significant or relevant effect of the SDM training on any of the endpoints.ConclusionThe study hypothesis that the SDM training enhanced patients’ perceived participation and lowered their BP could not be confirmed. Further research is needed to examine the impact of patient participation on the treatment of hypertension in primary care.Trial registrationGerman Clinical Trials Register (DRKS): DRKS00000125

Navigating shared decision-making in lung cancer screening: Insights into barriers, training, and referral propensity among clinicians.

Shared decision making for high-risk surgery

BackgroundCardiovascular disease (CVD) is the leading cause of death globally and in Canada. Diabetes and hypertension are major risk factors for CVD events. Despite the increasing availability of effective treatments, the majority of diabetic and hypertensive patients do not have adequate blood pressure and glycemic control. One of the major contributors is poor treatment adherence.ObjectiveThis study aims to evaluate the impact of treatment adherence for patients with both diabetes and hypertension on acute severe CVD events and intermediate clinical outcomes in Canadian primary care settings.MethodsWe will conduct a population-based retrospective cohort study of patients living with both diabetes and hypertension in Ontario, Canada, between January 1, 2008, and March 31, 2018. The Social Cognitive Theory will be used as a conceptual framework by which to frame the reciprocal relationship between treatment adherence, personal factors, and environmental determinants and how this interplay impacts CVD events and clinical outcomes. Data will be derived from the Diabetes Action Canada National Data Repository. A time-varying Cox proportional hazards model will be used to estimate the impacts of treatment adherence on CVD morbidity and mortality. Multivariable linear regression models and hierarchical regression models will be used to estimate the associations between treatment adherence of different medication categories and intermediate clinical outcomes. Our primary outcome is the association between treatment adherence and the risk of acute severe CVD events, including CVD mortality. The secondary outcome is the association between treatment adherence and intermediate clinical outcomes including diastolic and systolic blood pressures, glycated hemoglobin, low-density lipoprotein cholesterol, and total cholesterol. Owing to data limitation, we use medication prescriptions as a proxy to estimate treatment adherence. We assume that a patient adhered to medications if she or he had any prescription record in the 4 preceding quarters and 1 quarter after each quarter of interest. Acute severe CVD events are defined based on the World Health Organization’s Monitoring Trends and Determinants in Cardiovascular Disease Project, including acute coronary heart disease, stroke, and heart failure. As causes of death are not available, the number of CVD deaths will be computed using the most recent systolic blood pressure distributions and the population attributable risks related to systolic blood pressure level.ResultsThe project was funded by Diabetes Action Canada (reference number: 503854) and approved by the University of Toronto Research Ethics Board (reference number: 36065). The project started in June 2018 and is expected to be finished by September 2019.ConclusionsThe findings will be helpful in identifying the challenges of treatment adherence for diabetic and hypertensive patients in primary care settings. This will also help to develop intervention strategies to promote treatment adherence for patients with multi-morbidities.International Registered Report Identifier (IRRID)DERR1-10.2196/13571

BackgroundFrail older adults and caregivers need support from their home care teams in making difficult housing decisions, such as whether to remain at home, with or without assistance, or move into residential care. However, home care teams are often understaffed and busy, and shared decision-making training is costly. Nevertheless, overall awareness of shared decision-making is increasing. We hypothesized that distributing a decision aid could be sufficient for providing decision support without the addition of shared decision-making training for home care teams.ObjectiveWe evaluated the effectiveness of adding web-based training and workshops for care teams in interprofessional shared decision-making to passive dissemination of a decision guide on the proportion of frail older adults or caregivers of cognitively-impaired frail older adults reporting active roles in housing decision-making.MethodsWe conducted a stepped-wedge cluster randomized trial with home care teams in 9 health centers in Quebec, Canada. Participants were frail older adults or caregivers of cognitively impaired frail older adults facing housing decisions and receiving care from the home care team at one of the participating health centers. The intervention consisted of a 1.5-hour web-based tutorial for the home care teams plus a 3.5-hour interactive workshop in interprofessional shared decision-making using a decision guide that was designed to support frail older adults and caregivers in making housing decisions. The control was passive dissemination of the decision guide. The primary outcome was an active role in decision-making among frail older adults and caregivers, measured using the Control Preferences Scale. Secondary outcomes included decisional conflict and perceptions of how much care teams involved frail older adults and caregivers in decision-making. We performed an intention-to-treat analysis.ResultsA total of 311 frail older adults were included in the analysis, including 208 (66.9%) women, with a mean age of 81.2 (SD 7.5) years. Among 339 caregivers of cognitively-impaired frail older adults, 239 (70.5%) were female and their mean age was 66.4 (SD 11.7) years. The intervention increased the proportion of frail older adults reporting an active role in decision-making by 3.3% (95% CI –5.8% to 12.4%, P=.47) and the proportion of caregivers of cognitively-impaired frail older adults by 6.1% (95% CI -11.2% to 23.4%, P=.49). There was no significant impact on the secondary outcomes. However, the mean score for the frail older adults’ perception of how much health professionals involved them in decision-making increased by 5.4 (95% CI −0.6 to 11.4, P=.07) and the proportion of caregivers who reported decisional conflict decreased by 7.5% (95% CI −16.5% to 1.6%, P=.10).ConclusionsAlthough it slightly reduced decisional conflict for caregivers, shared decision-making training did not equip home care teams significantly better than provision of a decision aid for involving frail older adults and their caregivers in decision-making.Trial RegistrationClinicalTrials.gov NCT02592525; https://clinicaltrials.gov/show/NCT02592525

The aim of the present study was to determine the effectiveness of mindfulness-based therapy on treatment adherence and health anxiety in patients with non-alcoholic fatty liver disease. This study was a quasi-experimental design with pretest-posttest and a control group. The statistical population included all patients with non-alcoholic fatty liver disease in Tehran in 2024. From this population, 30 individuals were selected using convenience sampling and randomly assigned to two groups (15 in the experimental group and 15 in the control group). The measurement instruments included the Morisky Medication Adherence Scale (MMAS, 2008) and the Health Anxiety Questionnaire (HAQ-18, 2002). The experimental group underwent mindfulness-based therapy in eight weekly sessions of 90 minutes each, while the control group received no intervention. Data were analyzed using multivariate analysis of covariance (MANCOVA). The results of the analysis indicated that, after controlling for pretest scores, there was a significant difference at the 0.05 level between the experimental and control groups in posttest scores of treatment adherence and health anxiety. It is concluded that mindfulness-based therapy is effective in improving treatment adherence and reducing health anxiety in patients with non-alcoholic fatty liver disease.

To investigate the effects of comprehensive nursing interventions on psychological well-being and rehabilitation treatment adherence in patients with dementia. A retrospective analysis was conducted on 90 dementia patients treated at the First Hospital of Fuyang Hangzhou. Patients were divided into an observation group (n=45) and a control group (n=45). The control group received standard nursing care, while the observation group received comprehensive nursing interventions. Key outcomes included negative emotions, treatment adherence, quality of life, sleep quality, caregiver emotional well-being, and caregiver satisfaction. The observation group had significantly lower Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) scores than the control group (both P<0.001). Treatment adherence, including disease awareness, medication compliance, and nutritional support, was significantly higher in the observation group (all P<0.05). The observation group showed better quality of lifeand lower Pittsburgh Sleep Quality Index (PSQI) scores (all P<0.001). Caregivers in the observation group reported higher satisfaction, with significantly lower SAS and SDS scores (all P<0.05). Mini-Mental State Examination (MMSE) scores were also higher in the observation group post-intervention (P<0.05). Additionally, the observation group had a better prognosis with fewer complications (P<0.05). Comprehensive nursing interventions significantly improve psychological well-being, treatment adherence, cognitive function, and overall quality of life for dementia patients. They also reduce anxiety, depression, and complications, and improve caregiver satisfaction. These findings support the benefits of comprehensive nursing interventions.

While shared decision-making (SDM) training programmes for health professionals have been developed in several countries, few have been evaluated. In Norway, a comprehensive curriculum, "klar for samvalg" (ready for SDM), for interprofessional health-care teams was created using generic didactic methods and guidance to tailor training to various contexts. The programmes adapted didactic methods from an evidence-based German training programmes (doktormitSDM). The overall aim was to evaluate two particular SDM modules on facilitating SDM implementation into clinical practice. A descriptive mixed methods study using questionnaires and a focus group guided by the Medical Research Council Complex Interventions Framework. The training was provided as two different applications (module AB [introduction and SDM-basics] and module ABC [introduction, SDM-basics and interactive training]) with differing learning objectives, extent of interactivity, and duration (1 vs 2 hours). Groups of participants were recruited consecutively based on requests for health professional SDM training in university/college- and hospital-settings. By a focus group and a self-administered questionnaire comprehensibility, relevance and acceptance were assessed and qualitative feedback collected after the training. Data passed descriptive and content analysis, respectively. Knowledge was assessed twice using five multiple-choice items and analysed using paired t-tests. In 11 (six AB and five ABC) training sessions, 357/429 (296 AB and 133 ABC) eligible nurses, physicians and health professional students with varying clinical backgrounds and previous levels of SDM-knowledge participated. SDM-knowledge increased from 25-78% (range pretest) to 85-95% (range post-test) (P ≤ .001). The training was rated easy to understand, acceptable and relevant for practice. Findings to improve the education suggest higher emphasis on interprofessional teaching methods. The two SDM training modules met the basic requirements for use in a broader SDM implementation strategy and can even improve knowledge.

Objectives: This study examined the effect of a health literacy training intervention on self-care behaviors and treatment adherence in patients with ischemic heart disease (IHD). Methods: A quasi-experimental study was conducted in 2020, on 50 patients with IHD referred to a medical center in Kashan, Iran. The patients were assigned to a control group (n=25) and an intervention (n=25) group via a block randomization method. The intervention group received a health literacy training intervention, while the control group did not. The "Adherence to Treatment Questionnaire" and the "Self-Care Behavior Questionnaire" were used to gather the data at the start and the end of the study. Results: The mean baseline self-care behaviors in the intervention and the control groups were 61.56±10.99 and 56.25±8.42 (p=0.061) out of 100, which then changed to 85.24±4.06 and 53.01±4.86 (p<0.001). Also, the mean baseline treatment adherence in the intervention and the control groups were 84.77±29.19 and 84.40±13.89 (p=0.315) out of 200, which then changed to 179.08±8.59 and 95.76±9.24 (p<0.001). Conclusion: The health literacy training intervention could improve self-care behaviors and treatment adherence in patients with IHD. Nurses and the medical team are recommended to implement similar packages to improve the health literacy of patients with IHD. Keywords: Health literacy, Patients education, Ischemic heart disease, Self-care behaviors, Treatment adherence