Development of a Conceptual Framework for Understanding Shared Decision making Among African-American LGBT Patients and their Clinicians

Peek, Monica E.; López, Fanny; Williams, H. Sharif; Xu, Lucy; McNulty, Moira; Acree, Mary Ellen; Schneider, John A.

doi:10.1007/s11606-016-3616-3

Cited by 89 publications

(115 citation statements)

References 66 publications

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“…However, we believe that almost all decisions can be viewed through the lens of SDM and can be a way to improve treatment adherence. 41 Another opportunity for promoting SDM for minority patients is to consider making changes in the clinical environment. 42 The reality is that DAs cannot be designed for every micro-decision that occurs in the life of a patient and it may be potentially more important to create a culture of SDM.…”

Section: Discussionmentioning

confidence: 99%

Use of Decision Aids with Minority Patients: a Systematic Review

et al. 2016

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BACKGROUND:One potential approach to reducing health disparities among minorities is through the promotion of shared decision making (SDM). The most commonly studied SDM intervention is the decision aid (DA). While DAs have been extensively studied, we know relatively little about their use in minority populations. We conducted a systematic review to characterize the application and effectiveness of DAs in racial, ethnic, sexual, and gender minorities. METHODS: We searched PubMed for randomized controlled trials (RCTs) evaluating DAs between 2004 and 2013. We included trials that enrolled adults (> 18 years of age) with > 50 % representation by minority patients. Four reviewers independently assessed 597 initially identified articles, and those with inconclusive results were discussed to consensus. We abstracted decision quality, patient-doctor communication, and clinical treatment decision outcomes. Results were considered significantly modified by the DA if the study reported p < 0.05. RESULTS: We reviewed 18 RCTs of DA interventions in minority populations. The majority of interventions (78 %) addressed cancer screening. The most common mode of delivery for the DAs was personal counseling (46 %), followed by multi-media (29 %), and print materials (25 %). Most of the trials studied racial (78 %) or ethnic (17 %) minorities with only one trial focused on sexual minorities and none on gender minorities. Ten studies tailored their interventions for their minority populations. Comparing intervention vs. control, decision quality outcomes improved in six out of eight studies and patient-doctor communication improved in six out of seven studies. Of the 15 studies that reported on clinical decisions, eight demonstrated significant changes in decisions with DAs. DISCUSSION: DAs have been effective in improving patient-doctor communication and decision quality outcomes in minority populations and could help address health disparities. However, the existing literature is almost non-existent for sexual and gender minorities and has not included the full breadth of clinical decisions that affect minority populations.KEY WORDS: shared decision making; disparities; race and ethnicity; minority health; systematic reviews; medical decision making.

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Section: Discussionmentioning

confidence: 99%

Use of Decision Aids with Minority Patients: a Systematic Review

et al. 2016

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“…[9][10][11][12] Racial and ethnic minority populations that are also LGBT are at especially high risk for poor SDM. 13,14 Clinicians often lack the training to encourage disclosure of sexual orientation, [15][16][17] resulting in inadequate communication and SDM. 18 Moreover, generic patient engagement approaches geared toward predominantly white LGBT populations may not be appropriate for patients with multiple minority identities.…”

Section: Introductionmentioning

confidence: 99%

A Model of Organizational Context and Shared Decision Making: Application to LGBT Racial and Ethnic Minority Patients

et al. 2016

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Shared decision making (SDM) occurs when patients and clinicians work together to reach care decisions that are both medically sound and responsive to patients' preferences and values. SDM is an important tenet of patient-centered care that can improve patient outcomes. Patients with multiple minority identities, such as sexual orientation and race/ethnicity, are at particular risk for poor SDM. Among these dualminority patients, added challenges to clear and open communication include cultural barriers, distrust, and a health care provider's lack of awareness of the patient's minority sexual orientation or gender identity. However, organizational factors like a culture of inclusion and private space throughout the visit can improve SDM with lesbian, gay, bisexual, and transgender (BLGBT^) racial/ethnic minority patients who have faced stigma and discrimination. Most models of shared decision making focus on the patient-provider interaction, but the health care organization's context is also critical. Context-an organization's structure and operations-can strongly influence the ability and willingness of patients and clinicians to engage in shared decision making. SDM is most likely to be optimal if organizations transform their contexts and patients and providers improve their communication. Thus, we propose a conceptual model that suggests ways in which organizations can shape their contextual structure and operations to support SDM. The model contains six drivers: workflows, health information technology, organizational structure and culture, resources and clinic environment, training and education, and incentives and disincentives. These drivers work through four mechanisms to impact care: continuity and coordination, the ease of SDM, knowledge and skills, and attitudes and beliefs. These mechanisms can activate clinicians and patients to engage in high-quality SDM. We provide examples of how specific contextual changes could make SDM more effective for LGBT racial/ethnic minority populations, focusing especially on transformations that would establish a safe environment, build trust, and decrease stigma.

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“…SDM, a fundamental component of patient-centered care, has been demonstrated to improve a variety of clinical outcomes, such as control of diabetes and hypertension. 6 Therefore, in 2014, our team at the University of Chicago, supported by funds from the Agency for Healthcare Research and Quality and the Patient-Centered Outcomes Research Trust Fund, began examining how to reduce disparities for LGBT racial/ethnic minority patients through improved SDM. We have three goals for improving SDM with LGBT racial/ethnic minority groups: 1) review what is known, 2) perform interviews and focus groups of patients and clinicians, and 3) develop tools and resources.…”

mentioning

confidence: 99%

“…[6][7][8] The three papers outline a conceptual model for SDM with LGBT racial/ethnic minority patients, and then present information that may guide interventions to assist individual clinicians and patients in improving their SDM, and may help health care organizations transform their structures to facilitate SDM.…”

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confidence: 99%

“…6 They elucidate the intersection of LGBT status and race by integrating and expanding Peek's adaptation of the Charles model of SDM for African Americans with the Model of Multiple Dimensions of Identity. 6 Key insights include the influence of each individual's perception of himself or herself, given his or her intersecting identity axes of sexual orientation, gender identity, race, and ethnicity; the clinician's perception of the patient, given these identities and vice versa; and the influence of social networks and society. Understanding these complex inter-and intra-personal dynamics is critical for engaging in effective, empathetic communication and SDM.…”

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confidence: 99%

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