BackgroundTwo decades of research has established the positive effect of using patient-targeted decision support interventions: patients gain knowledge, greater understanding of probabilities and increased confidence in decisions. Yet, despite their efficacy, the effectiveness of these decision support interventions in routine practice has yet to be established; widespread adoption has not occurred. The aim of this review was to search for and analyze the findings of published peer-reviewed studies that investigated the success levels of strategies or methods where attempts were made to implement patient-targeted decision support interventions into routine clinical settings.MethodsAn electronic search strategy was devised and adapted for the following databases: ASSIA, CINAHL, Embase, HMIC, Medline, Medline-in-process, OpenSIGLE, PsycINFO, Scopus, Social Services Abstracts, and the Web of Science. In addition, we used snowballing techniques. Studies were included after dual independent assessment.ResultsAfter assessment, 5322 abstracts yielded 51 articles for consideration. After examining full-texts, 17 studies were included and subjected to data extraction. The approach used in all studies was one where clinicians and their staff used a referral model, asking eligible patients to use decision support. The results point to significant challenges to the implementation of patient decision support using this model, including indifference on the part of health care professionals. This indifference stemmed from a reported lack of confidence in the content of decision support interventions and concern about disruption to established workflows, ultimately contributing to organizational inertia regarding their adoption.ConclusionsIt seems too early to make firm recommendations about how best to implement patient decision support into routine practice because approaches that use a ‘referral model’ consistently report difficulties. We sense that the underlying issues that militate against the use of patient decision support and, more generally, limit the adoption of shared decision making, are under-investigated and under-specified. Future reports from implementation studies could be improved by following guidelines, for example the SQUIRE proposals, and by adopting methods that would be able to go beyond the ‘barriers’ and ‘facilitators’ approach to understand more about the nature of professional and organizational resistance to these tools. The lack of incentives that reward the use of these interventions needs to be considered as a significant impediment.

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Recent developments in health reform related to the passage of the Affordable Care Act and ensuing regulations encourage delivery systems to engage in shared decision making, in which patients and providers together make health care decisions that are informed by medical evidence and tailored to the specific characteristics and values of the patient. To better understand how delivery systems can implement shared decision making, we interviewed representatives of eight primary care sites participating in a demonstration funded and coordinated by the Informed Medical Decisions Foundation. Barriers to shared decision making included overworked physicians, insufficient provider training, and clinical information systems incapable of prompting or tracking patients through the decision-making process. Methods to improve shared decision making included using automatic triggers for the distribution of decision aids and engaging team members other than physicians in the process. We conclude that substantial investments in provider training, information systems, and process reengineering may be necessary to implement shared decision making successfully.

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While ICU health care workers consistently identify a number of patient factors as important in decisions to withdraw care, there is extreme variability, which may be explained in part by the values of individual health care providers.

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BackgroundAlthough research suggests that patients prefer a shared decision making (SDM) experience when making healthcare decisions, clinicians do not routinely implement SDM into their practice and training programs are needed. Using a novel case-based strategy, we developed and pilot tested an online educational program to promote shared decision making (SDM) by primary care clinicians.MethodsA three-phased approach was used: 1) development of a conceptual model of the SDM process; 2) development of an online teaching case utilizing the Design A Case (DAC) authoring template, a well-tested process used to create peer-reviewed web-based clinical cases across all levels of healthcare training; and 3) pilot testing of the case. Participants were clinician members affiliated with several primary care research networks across the United States who answered an invitation email. The case used prostate cancer screening as the clinical context and was delivered online. Post-intervention ratings of clinicians’ general knowledge of SDM, knowledge of specific SDM steps, confidence in and intention to perform SDM steps were also collected online.ResultsSeventy-nine clinicians initially volunteered to participate in the study, of which 49 completed the case and provided evaluations. Forty-three clinicians (87.8%) reported the case met all the learning objectives, and 47 (95.9%) indicated the case was relevant for other equipoise decisions. Thirty-one clinicians (63.3%) accessed supplementary information via links provided in the case. After viewing the case, knowledge of SDM was high (over 90% correctly identified the steps in a SDM process). Determining a patient’s preferred role in making the decision (62.5% very confident) and exploring a patient’s values (65.3% very confident) about the decisions were areas where clinician confidence was lowest. More than 70% of the clinicians intended to perform SDM in the future.ConclusionsA comprehensive model of the SDM process was used to design a case-based approach to teaching SDM skills to primary care clinicians. The case was favorably rated in this pilot study. Clinician skills training for helping patients clarify their values and for assessing patients’ desire for involvement in decision making remain significant challenges and should be a focus of future comparative studies.Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6947-14-95) contains supplementary material, which is available to authorized users.

T HE LOCAL DIURNAL WINDS induced by temperature difference between land and sea are defined as land and sea breezes; the wind that blows from land to sea by night is the land breeze; the wind that blows from sea to land by day is the sea breeze.With the possible exception of some Arctic and sub-Arctic regions, land and sea breezes occur in coastal regions of continents, islands, or inland lakes. Their frequency on coasts depends essentially upon the latitude, season, cloudiness, and gradient wind. With hilly or mountainous terrain adjacent to the shore, the local winds are a combination of land and sea breezes with valley or slope winds and are thereby stronger and more frequent.In temperate latitudes land and sea breezes occur chiefly during the spring, fall, and summer with a maximum frequency in summer. On unseasonably warm days in February, sea breezes have been observed in Massachusetts. In the tropics, land and sea breezes are almost a daily phenomenon during the dry season and are also frequent though weaker during the wet season. Fishermen and sportsmen use the winds to sail out to sea in the morning and to return in the afternoon.With clear skies the frequency of the phenomenon is greatest. At Burgas, Bulgaria, with scattered clouds (0 to 5 tenths), a frequency of 90 per cent was found, while for broken (6 to 8 tenths) and overcast (9 to 10 tenths) skies, frequencies were 39 per cent and 27 per cent respectively. Temperature difference between land and sea, and therefore the sea breeze tendency, are evident even during rainy weather.Sea breezes occur more frequently during light gradient-wind conditions. An off-land gradient wind is more favorable for their development than gradient winds parallel to the coast.Frequencies of sea breezes will vary considerably for different locations, depending on the climatic factors. Frequencies of days with sea breezes during the summer on the coast of Massachusetts are 30 to 40 per cent, on the Baltic coast of Germany about 20 per cent, on the Catalonian coast of Spain, 80 to 90 per cent. Frequencies will also vary considerably from year to year. At Lake Constance the number of lake-breeze days varied from 6 to 22 during May for seven years of record.Further inland from the coast the occurrence of sea breeze decreases markedly. Coasts with nearby smaller islands have a decreased frequency of the sea breeze. A coastal station under such conditions would have temperature ranges more similar to an inland station. THEORYTwo distinct types of sea breezes exist: a sea breeze of gradual growth on calm or light-gradient-wind days and the frontal sea breeze on days with off-land gradient wind. The properties of each are quite different. The frontal sea breeze appears to be more frequent in temperate latitudes; of 50 cases of sea breezes at Danzig 43 were frontal.