Celia E. Wills

An Educational Intervention as Decision Support for Menopausal Women

The purpose of this study was to develop and test a decision support intervention (DSI) to assist women to make and act on informed decisions that are consistent with their values in the area of menopause and hormone replacement therapy (HRT). Mode and intensity of intervention were tested in midlife women (N = 248), randomly assigned to one of three intervention formats: written information only, guided discussion, or personalized decision exercise. Data were collected over 12 months. Knowledge, decisional conflict, satisfaction with health care provider, and self-efficacy improved following intervention and were maintained for 12 months for all groups. Womens adherence to their own plans over 12 months was 59% (exercise), 76% (calcium intake), and 89% (HRT). Carefully written information is effective in promoting knowledge, adherence, and satisfaction among well-educated, interested women. It was concluded that women can understand complex information, including tradeoffs regarding treatment options. Women will adhere to their own plans, suggesting that consumer rather than provider plans may be the more appropriate gold standard for measuring adherence.

Establishing the effectiveness of patient decision aids: key constructs and measurement instruments

BackgroundEstablishing the effectiveness of patient decision aids (PtDA) requires evidence that PtDAs improve the quality of the decision-making process and the quality of the choice made, or decision quality. The aim of this paper is to review the theoretical and empirical evidence for PtDA effectiveness and discuss emerging practical and research issues in the measurement of effectiveness.MethodsThis updated overview incorporates: a) an examination of the instruments used to measure five key decision-making process constructs (i.e., recognize decision, feel informed about options and outcomes, feel clear about goals and preferences, discuss goals and preferences with health care provider, and be involved in decisions) and decision quality constructs (i.e., knowledge, realistic expectations, values-choice agreement) within the 86 trials in the Cochrane review; and b) a summary of the 2011 Cochrane Collaboration’s review of PtDAs for these key constructs. Data on the constructs and instruments used were extracted independently by two authors from the 86 trials and any disagreements were resolved by discussion, with adjudication by a third party where required.ResultsThe 86 studies provide considerable evidence that PtDAs improve the decision-making process and decision quality. A majority of the studies (76/86; 88%) measured at least one of the key decision-making process or decision quality constructs. Seventeen different measurement instruments were used to measure decision-making process constructs, but no single instrument covered all five constructs. The Decisional Conflict Scale was most commonly used (n = 47), followed by the Control Preference Scale (n = 9). Many studies reported one or more constructs of decision quality, including knowledge (n = 59), realistic expectation of risks and benefits (n = 21), and values-choice agreement (n = 13). There was considerable variability in how values-choice agreement was defined and determined. No study reported on all key decision-making process and decision quality constructs.ConclusionsEvidence of PtDA effectiveness in improving the quality of the decision-making process and decision quality is strong and growing. There is not, however, consensus or standardization of measurement for either the decision-making process or decision quality. Additional work is needed to develop and evaluate measurement instruments and further explore theoretical issues to advance future research on PtDA effectiveness.

Clarifying Values: An updated review

BackgroundConsensus guidelines have recommended that decision aids include a process for helping patients clarify their values. We sought to examine the theoretical and empirical evidence related to the use of values clarification methods in patient decision aids.MethodsBuilding on the International Patient Decision Aid Standards (IPDAS) Collaboration’s 2005 review of values clarification methods in decision aids, we convened a multi-disciplinary expert group to examine key definitions, decision-making process theories, and empirical evidence about the effects of values clarification methods in decision aids. To summarize the current state of theory and evidence about the role of values clarification methods in decision aids, we undertook a process of evidence review and summary.ResultsValues clarification methods (VCMs) are best defined as methods to help patients think about the desirability of options or attributes of options within a specific decision context, in order to identify which option he/she prefers. Several decision making process theories were identified that can inform the design of values clarification methods, but no single “best” practice for how such methods should be constructed was determined. Our evidence review found that existing VCMs were used for a variety of different decisions, rarely referenced underlying theory for their design, but generally were well described in regard to their development process. Listing the pros and cons of a decision was the most common method used. The 13 trials that compared decision support with or without VCMs reached mixed results: some found that VCMs improved some decision-making processes, while others found no effect.ConclusionsValues clarification methods may improve decision-making processes and potentially more distal outcomes. However, the small number of evaluations of VCMs and, where evaluations exist, the heterogeneity in outcome measures makes it difficult to determine their overall effectiveness or the specific characteristics that increase effectiveness.

Complementary and Alternative Medicine Use, Spending, and Quality of Life in Early Stage Breast Cancer

Background: Up to 80% of women with breast cancer use complementary and alternative medicine (CAM) therapies to improve quality of life (QOL) during treatment. Objective: The objective of this study was to explore the association between CAM therapy use, spending on CAM therapies, demographic variables, surgical treatment, and QOL. Methods: A secondary analysis was conducted for women with early stage breast cancer (N = 222) who were enrolled in a nursing intervention study after breast surgery. The complementary therapy utilization instrument included specific CAM therapies used, number of treatments, and spending. The number of major categories of CAM and the specific CAM therapies used were analyzed in relation to study variables using proportional odds logistic regression models. The outcome of spending for major CAM categories was analyzed using linear mixed effects modeling. Results: A majority of women (56.8%) used at least one CAM therapy, and the biologically based therapies category was most frequently used (43.7%). Women with less than a college level of education were less likely to use CAM (odds ratio [OR] = 0.36, 95% confidence interval [CI] = 0.15-0.86, p < .01). Women who were employed were more likely to use therapies from multiple CAM categories (OR = 2.42, 95% CI = 1.00-5.88, p < .05), and those with lower QOL were more likely to use CAM (OR = 0.97, 95% CI = 0.95-0.99, p < .01). The results support that women with early stage breast cancer, especially those with lower QOL, are highly likely to use CAM therapies. Further research is needed on CAM interventions to enhance supportive care for breast cancer.

Depressed patients' perceptions of depression treatment decision-making.

Objective  Little is known about the feasibility and effects of patient‐clinician shared decision‐making (SDM) for depression treatment. Within a goal of informing the design of a SDM intervention, the objective of this study was to investigate depressed patients’ perceptions of the treatment decision‐making process with general practitioners (GPs).

Shared Decision Making and Other Variables as Correlates of Satisfaction with Health Care Decisions in a United States National Survey

OBJECTIVE The purpose of this study was to examine the relationship between shared decision-making (SDM) and satisfaction with decision (SWD) within a larger survey of patient decision-making in health care consultations. METHODS A randomly selected age-proportionate national sample of adults (aged 21-70 years) stratified on race, ethnicity, and gender (N=488) was recruited from a health research volunteer registry and completed an online survey with reference to a recent health consultation. Measures included the shared decision making-9 questionnaire (SDM-Q-9), Satisfaction With Decision (SWD) scale, sociodemographic, health, and other standardized decision-making measures. Forward selection weighted multiple regression analysis was used to model correlates of SWD. RESULTS After controlling for sociodemographic variables, SDM-Q-9 total score was associated with SWD, adjusted R(2)=.368, p<.001. Three of nine SDM-Q-9 items accounted for significant proportions of variance in SWD. CONCLUSION SDM was positively associated with SWD and was strongest for three areas of SDM: patients being helped in a health care consultation with understanding information, with treatment preference elicitation, and with weighing options thoroughly. PRACTICE IMPLICATIONS By identifying variables such as SDM that are associated with SWD, health care interventions can better target modifiable factors to enhance satisfaction and other outcomes.

Preliminary validation of the Satisfaction With Decision scale with depressed primary care patients.

Objective To conduct a preliminary validation of the Satisfaction With Decision (SWD) scale with depressed primary care patients.

Improving informed consent: insights from behavioral decision research.

Background. With publication of The Belmont Report concerning ethical principles, informed consent gained explicit guidelines for the protection of human subjects of research. However, there is still little evidence about how well informed consent works to assist patients to reach informed decisions about research participation. Objective. To review behavioral decision theory and research to identify implications for informed consent. Research Design. Traditional literature review and hand search of literature were used. Results. Psychological research on biases and heuristics identifies cognitive biases in information processing (selection and interpretation of risks and benefits) that have implications for improving the informing process. A growing literature on patient decision aids provides evidence for the feasibility of more fully informing patients, and includes examples of “debiasing” procedures (to improve information comprehension and consent). Conclusions. Informing and consenting involve conceptually different challenges concerning effectiveness versus values. Debiasing techniques need to be developed and empirically tested to determine their effectiveness in informing patients. Consenting involves both social and individual values. Appealing to altruism when summarizing the goals of research may increase research participation and does not necessarily violate voluntariness of informed consent. Additional research is needed to determine when information-processing biases occur problematically in health-related informed consent, and whether appealing to altruism increases research participation.

Using patient-centered interviewing skills to manage complex patient encounters in primary care

Purpose: To describe effective and efficient patient‐centered interviewing strategies to enhance the management of complex primary care patient encounters. Data sources: Research literature and applied case study analysis. Conclusions: Patient‐centered interviewing can enhance effectiveness of care in complex patient encounters. A relatively small investment of time and energy has positive yields in regard to improvements in longer term physiological status, treatment adherence, quality of life, patient–provider working relationship, and patient and nurse practitioner satisfaction. Implications for practice: Use of patient‐centered interviewing strategies can enhance effectiveness of patient care processes and outcomes while retaining efficiency of patient management.

Decision Aids for Benign Prostatic Hyperplasia: Applicability across Race and Education

Background/Method. Decision aids have not been widely tested in diverse audiences. The authors conducted interviews in a 2 2 race by education design with participants who were 50 years old (n = 188). The decision aid was a benign prostatic hyperplasia videotape. Results. There was an increase in knowledge equal in all groups, with baseline knowledge higher in whites. The decision stage increased in all groups and was equivalent in the marginal-illiterate subgroup (n = 0.15). Conclusion. Contrary to expectations, results show no difference by race or college education in knowledge gain or increase in reported readiness to decide. The video appeared to produce change across race and education. The end decision stage was high, especially in less educated men. Results suggest that decision aids may be effective without tailoring, as suggested previously to enhance health communication in diverse audiences. Research should test findings in representative samples and in clinical encounters and identify types of knowledge absorbed from decision aids and whether the shift to decision reflects data/ knowledge or shared decision-making message.