Evidence summaries (decision boxes) to prepare clinicians for shared decision-making with patients: a mixed methods implementation study

Implementation Science

Pierre-Hugues Carmichael⁶  Matthew Greenway⁵  Michel Cauchon¹  France Légaré³  Pierre Pluye⁷  Roland Grad²  R Brian Haynes⁴  Michel Labrecque³  Anik MC Giguere⁶ 

[1] Office of Education and Continuing Professional Development, Department of Family and Emergency Medicine, Pavillon Ferdinand-Vandry, Laval University, Local 2881-C, 1050 avenue de la Medecine, Quebec City G1V 0A6, QC, Canada;Herzl Family Practice Centre, 3755 Cote Sainte Catherine, Montreal H3T 1E2, QC, Canada;Research Centre of the CHU de Quebec, Saint-Francois d¿Assise Hospital, 10 rue de l¿Espinay, D6-730, Quebec City G1L 3 L5, QC, Canada;Department of Medicine, DeGroote School of Medicine, McMaster University, 1280 Main Street West, CRL-125, Hamilton L8S 4 K1, Ontario, Canada;Department of Family Medicine, McMaster University, 118 Lake Street, St. Catharines L8S 4 L8, Ontario, Canada;Quebec Research Centre for Excellence in Aging, Research Centre of the CHU de Quebec, St. Sacrement Hospital, 1050 Chemin Sainte-Foy, Quebec City G1S 4 L8, QC, Canada;Department of Family Medicine, McGill University, 5858 Côte-des-neiges, 3rd Floor, Suite 300, Montreal H3S 1Z1, QC, Canada

关键词: Communication competency;    Continuing professional development;    User experience;    Patient-centred care;    Barriers;    Evidence-based practice;    Decision support;    Knowledge translation;    Clinical practice guidelines;   

Others  :  1146279
DOI  :  10.1186/s13012-014-0144-6

 received in 2014-05-14, accepted in 2014-09-19,  发布年份 2014

【 摘 要 】

Background

Decision boxes (Dboxes) provide clinicians with research evidence about management options for medical questions that have no single best answer. Dboxes fulfil a need for rapid clinical training tools to prepare clinicians for clinician-patient communication and shared decision-making. We studied the barriers and facilitators to using the Dbox information in clinical practice.

Methods

We used a mixed methods study with sequential explanatory design. We recruited family physicians, residents, and nurses from six primary health-care clinics. Participants received eight Dboxes covering various questions by email (one per week). For each Dbox, they completed a web questionnaire to rate clinical relevance and cognitive impact and to assess the determinants of their intention to use what they learned from the Dbox to explain to their patients the advantagesand disadvantages of the options, based on the theory of planned behaviour (TPB). Following the 8-week delivery period, we conducted focus groups with clinicians and interviews with clinic administrators to explore contextual factors influencing the use of the Dbox information.

Results

One hundred clinicians completed the web surveys. In 54% of the 496 questionnaires completed, they reported that their practice would be improved after having read the Dboxes, and in 40%, they stated that they would use this information for their patients. Of those who would use the information for their patients, 89% expected it would benefit their patients, especially in that it would allow the patient to make a decision more in keeping with his/her personal circumstances, values, and preferences. They intended to use the Dboxes in practice (mean 5.6?±?1.2, scale 1¿7, with 7 being ¿high¿), and their intention was significantly related to social norm, perceived behavioural control, and attitude according to the TPB (P?

Conclusions

Dboxes are valued by clinicians. Tailoring of Dboxes to their needs would facilitate their implementation in practice.

【 授权许可】

   
2014 Giguere et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]Stewart M: Reflections on the doctor-patient relationship: from evidence and experience. Br J Gen Pract 2005, 55:793-801.
• [2]Morrow CE, Reed VA, Eliassen MS, Imset I: Shared decision making: skill acquisition for year III medical students. Fam Med 2011, 43:721-725.
• [3]Charles C, Gafni A, Whelan T: Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med 1999, 49:651-661.
• [4]Legare F, Ratte S, Stacey D, Kryworuchko J, Gravel K, Graham ID, Turcotte S: Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database Syst Rev 2010, 5:CD006732.
• [5]Legare F, Turcotte S, Stacey D, Ratte S, Kryworuchko J, Graham ID: Patients¿ perceptions of sharing in decisions: a systematic review of interventions to enhance shared decision making in routine clinical practice. Patient 2012, 5:1-19.
• [6]Stacey D, Legare F, Col NF, Bennett CL, Barry MJ, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Thomson R: Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014, 1:CD001431.
• [7]Stacey D, Hill S: Patient-direct and patient-mediated KT interventions. In Knowledge Translation in Health Care: Moving from Evidence to Practice. Edited by Straus SE, Tetroe J, Graham ID. Wiley, Chichester; 2013.
• [8]Lin GA, Halley M, Rendle KAS, Tietbohl C, May SG, Trujillo L, Frosch DL: An effort to spread decision aids in five California primary care practices yielded low distribution, highlighting hurdles. Health Aff 2013, 32:311-320.
• [9]Legare F, Ratte S, Gravel K, Graham ID: Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals¿ perceptions. Patient Educ Couns 2008, 73:526-535.
• [10]Elwyn G, Scholl I, Tietbohl C, Mann M, Edwards A, Clay C, Legare F, Weijden Tvd, Lewis C, Wexler R, Frosch D: "Many miles to go ...": a systematic review of the implementation of patient decision support interventions into routine clinical practice. BMC Medical Informatics and Decision Making 2013, 13:S14. BioMed Central Full Text
• [11]Brackett C, Kearing S, Cochran N, Tosteson AN, Blair Brooks W: Strategies for distributing cancer screening decision aids in primary care. Patient Educ Couns 2010, 78:166-168.
• [12]Silvia KA, Ozanne EM, Sepucha KR: Implementing breast cancer decision aids in community sites: barriers and resources. Health Expect 2008, 11:46-53.
• [13]Silvia KA, Sepucha KR: Decision aids in routine practice: lessons from the breast cancer initiative. Health Expect 2006, 9:255-264.
• [14]Feibelmann S, Yang TS, Uzogara EE, Sepucha K: What does it take to have sustained use of decision aids? A programme evaluation for the Breast Cancer Initiative. Health Expect 2011, 14(Suppl 1):85-95.
• [15]Frosch DL, Singer KJ, Timmermans S: Conducting implementation research in community-based primary care: a qualitative study on integrating patient decision support interventions for cancer screening into routine practice. Health Expect 2011, 14(Suppl 1):73-84.
• [16]Elwyn G, Rix A, Holt T, Jones D: Why do clinicians not refer patients to online decision support tools? Interviews with front line clinics in the NHS. BMJ Open 2012, 2:e001530.
• [17]Uy V, May SG, Tietbohl C, Frosch DL: Barriers and facilitators to routine distribution of patient decision support interventions: a preliminary study in community-based primary care settings. Health Expect 2012, 17:353-364.
• [18]Holmes-Rovner M, Valade D, Orlowski C, Draus C, Nabozny-Valerio B, Keiser S: Implementing shared decision-making in routine practice: barriers and opportunities. Health Expect 2000, 3:182-191.
• [19]O¿Cathain A, Walters SJ, Nicholl JP, Thomas KJ, Kirkham M: Use of evidence based leaflets to promote informed choice in maternity care: randomised controlled trial in everyday practice. BMJ 2002, 324:643.
• [20]Krones T, Keller H, Sonnichsen A, Sadowski EM, Baum E, Wegscheider K, Rochon J, Donner-Banzhoff N: Absolute cardiovascular disease risk and shared decision making in primary care: a randomized controlled trial. Ann Fam Med 2008, 6:218-227.
• [21]Stacey D, Graham ID, O¿Connor AM, Pomey MP: Barriers and facilitators influencing call center nurses¿ decision support for callers facing values-sensitive decisions: a mixed methods study. Worldviews Evid Based Nurs 2005, 2:184-195.
• [22]Legare F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J: Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial. CMAJ 2012, 184:E726-E734.
• [23]Bieber C, Muller KG, Blumenstiel K, Schneider A, Richter A, Wilke S, Hartmann M, Eich W: Long-term effects of a shared decision-making intervention on physician-patient interaction and outcome in fibromyalgia. A qualitative and quantitative 1 year follow-up of a randomized controlled trial. Patient Educ Couns 2006, 63:357-366.
• [24]Allaire AS, Labrecque M, Giguere A, Gagnon MP, Legare F: What motivates family physicians to participate in training programs in shared decision making? J Contin Educ Health Prof 2012, 32:98-107.
• [25]Giguere A, Légaré F, Grad R, Pluye P, Haynes R, Cauchon M, Rousseau F, Argote J, Labrecque M: Decision boxes for clinicians to support evidence-based practice and shared decision making: the user experience. Implem Sci 2012, 7:72. BioMed Central Full Text
• [26]Giguere A, Legare F, Grad R, Pluye P, Rousseau F, Haynes RB, Cauchon M, Labrecque M: Developing and user-testing Decision boxes to facilitate shared decision making in primary care - a study protocol. BMC Med Inform Decis Mak 2011, 11:17-26. BioMed Central Full Text
• [27]van der Weijden T, Boivin A, Burgers J, Schunemann HJ, Elwyn G: Clinical practice guidelines and patient decision aids. An inevitable relationship. J Clin Epidemiol 2012, 65:584-589.
• [28]Fischhoff B, Brewer NT, Downs JS: Communicating Risks and Benefits: An Evidence-Based User¿s Guide. Food and Drug Administration (FDA), US Department of Health and Human Services, Silver Spring; 2011.
• [29]Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, Norris S, Falck-Ytter Y, Glasziou P, DeBeer H, Jaeschke R, Rind D, Meerpohl J, Dahm P, Schünemann HJ: GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol 2011, 64:383-394.
• [30]Légaré F, Witteman HO: Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health Aff 2013, 32:276-284.
• [31]Kerfoot BP, Brotschi E: Online spaced education to teach urology to medical students: a multi-institutional randomized trial. Am J Surg 2009, 197:89-95.
• [32]Kerfoot BP, DeWolf WC, Masser BA, Church PA, Federman DD: Spaced education improves the retention of clinical knowledge by medical students: a randomised controlled trial. Med Educ 2007, 41:23-31.
• [33]Kerfoot BP, Baker HE, Koch MO, Connelly D, Joseph DB, Ritchey ML: Randomized, controlled trial of spaced education to urology residents in the United States and Canada. J Urology 2007, 177:1481-1487.
• [34]Moore DE Jr, Green JS, Gallis HA: Achieving desired results and improved outcomes: integrating planning and assessment throughout learning activities. J Contin Educ Health Prof 2009, 29:1-15.
• [35]Giguere A, Labrecque M, Grad R, Cauchon M, Greenway M, Legare F, Pluye P, Turcotte S, Dolovich L, Haynes RB: Barriers and facilitators to implementing Decision Boxes in primary healthcare teams to facilitate shared decision making: a study protocol. BMC Med Inform Decis Mak 2012, 12:85. BioMed Central Full Text
• [36]Graham ID, Logan J: Innovations in knowledge transfer and continuity of care. Can J Nurs Res 2004, 36:89.
• [37]Graham K, Logan J: Using the Ottawa model of research use to implement a skin care program. J Nurs Care Qual 2004, 19:18-26.
• [38]Pluye P, Nha Hong Q: Combining the power of stories and the power of numbers: mixed methods research and mixed studies reviews. Annu Rev Public Health 2014, 35:29-45.
• [39]Pluye P, Grad RM, Johnson-Lafleur J, Bambrick T, Burnand B, Mercer J, Marlow B, Campbell C: Evaluation of email alerts in practice: part 2 - validation of the information assessment method. J Eval Clin Pract 2010, 16:1236-1243.
• [40]Ajzen I: The theory of planned behavior. Organ Behav Hum Decis Process 1991, 50:179-211.
• [41]Fereday J, Muir-Cochrane E: Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qual Meth 2006, 5:80-92.
• [42]Legare F, Stacey D, Gagnon S, Dunn S, Pluye P, Frosch D, Kryworuchko J, Elwyn G, Gagnon MP, Graham ID: Validating a conceptual model for an inter-professional approach to shared decision making: a mixed methods study. J Eval Clin Pract 2011, 17:554-564.
• [43]Marriott S, Palmer C, Lelliott P: Disseminating healthcare information: getting the message across. Qual Health Care 2000, 9:58-62.
• [44]Portnoy DB, Han PK, Ferrer RA, Klein WM, Clauser SB: Physicians¿ attitudes about communicating and managing scientific uncertainty differ by perceived ambiguity aversion of their patients. Health Expect 2011, 16:362-372.
• [45]Weick KE, Quinn RE: Organizational change and development. Annu Rev Psychol 1999, 50:361-386.
• [46]Lewiecki EM: Risk communication and shared decision making in the care of patients with osteoporosis. J Clin Densitom 2010, 13:335-345.
• [47]Legare F, St-Jacques S, Gagnon S, Njoya M, Brisson M, Fremont P, Rousseau F: Prenatal screening for Down syndrome: a survey of willingness in women and family physicians to engage in shared decision-making. Prenat Diagn 2011, 31:319-326.
• [48]Bieber C, Muller KG, Blumenstiel K, Hochlehnert A, Wilke S, Hartmann M, Eich W: A shared decision-making communication training program for physicians treating fibromyalgia patients: effects of a randomized controlled trial. J Psychosom Res 2008, 64:13-20.
• [49]Loh A, Simon D, Wills CE, Kriston L, Niebling W, Harter M: The effects of a shared decision-making intervention in primary care of depression: a cluster-randomized controlled trial. Patient Educ Couns 2007, 67:324-332.
• [50]Roshanov PS, Fernandes N, Wilczynski JM, Hemens BJ, You JJ, Handler SM, Nieuwlaat R, Souza NM, Beyene J, Spall HG, Garg AX, Haynes RB: Features of effective computerised clinical decision support systems: meta-regression of 162 randomised trials. BMJ 2013, 346:f657.
• [51]Elwyn G, Lloyd A, Joseph-Williams N, Cording E, Thomson R, Durand MA, Edwards A: Option grids: shared decision making made easier. Patient Educ Couns 2013, 90:207-212.
• [52]Mullan RJ, Montori VM, Shah ND, Christianson TJ, Bryant SC, Guyatt GH, Perestelo-Perez LI, Stroebel RJ, Yawn BP, Yapuncich V, Breslin MA, Pencille L, Smith SA: The diabetes mellitus medication choice decision aid: a randomized trial. Arch Intern Med 2009, 169:1560-1568.
• [53][http:/ / www.cmaj.ca/ content/ suppl/ 2012/ 08/ 03/ cmaj.120568v1.DC1/ train-legare-1-at.pdf] webcite Canadian Medical Association: DECISION 2+: diagnostic decision support tools. ? 2010, ? ? []
• [54]Kastner M, Lottridge D, Marquez C, Newton D, Straus SE: Usability evaluation of a clinical decision support tool for osteoporosis disease management. Implement Sci 2010, 5:96. BioMed Central Full Text
• [55]Kushniruk A: Evaluation in the design of health information systems: application of approaches emerging from usability engineering. Comput Biol Med 2002, 32:141-149.
• [56]Weyand SA, Frize M, Bariciak E, Dunn S: Development and usability testing of a parent decision support tool for the neonatal intensive care unit. Conference proceedings: Annual International Conference of the IEEE Engineering in Medicine and Biology Society IEEE Engineering in Medicine and Biology Society Conference 2011, 2011:6430-6433.
• [57]Neuhauser L, Paul K: Readablity, comprehension, and usability. In Communicating Risks and Benefits: An Evidence-Based User¿s Guide. Edited by Fischhoff B, Brewer NT, Downs JS. Food and Drug Administration (FDA), US Department of Health and Human Services, Silver Spring; 2011:129-148.
• [58]Pluye P, Grad RM, Repchinsky C, Jovaisas B, Lewis D, Tang DL, Granikov V, Bonar JG, Marlow B: Better than best¿ evidence? The Information Assessment Method can help information providers to use family physicians¿ feedback for 2-way knowledge translation. Can Fam Physician 2014, 60:415-417.
• [59]Tang DL: Towards Optimal Management of Health Information Users¿ Feedback: The Case of the Canadian Pharmacists Association. McGill, Montreal; 2012.