Differences in Implementation Outcomes of a Shared Decision-Making Program for Men with Prostate Cancer between an Academic Medical Center and County Health Care System

Abstract

Background Shared decision making (SDM) has long been advocated as the preferred way for physicians and men with prostate cancer to make treatment decisions. However, the implementation of formal SDM programs in routine care remains limited, and implementation outcomes for disadvantaged populations are especially poorly described. We describe the implementation outcomes between academic and county health care settings. Methods We administered a decision aid (DA) for men with localized prostate cancer at an academic center and across a county health care system. Our implementation was guided by the Consolidated Framework for Implementation Research and the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. We assessed the effectiveness of the DA through a postappointment patient survey. Results Sites differed by patient demographic/clinical characteristics. Reach (DA invitation rate) was similar and insensitive to implementation strategies at the academic center and county (66% v. 60%, P = 0.37). Fidelity (DA completion rate) was also similar at the academic center and county (77% v. 80%, P = 0.74). DA effectiveness was similar between sites, except for higher academic center ratings for net promoter for the doctor (77% v. 37%, P = 0.01) and the health care system (77% v. 35%, P = 0.006) and greater satisfaction with manner of care (medians 100 v. 87.5, P = 0.04). Implementation strategies (e.g., faxing of patients’ records and meeting patients in the clinic to complete the DA) represented substantial practice changes at both sites. The completion rate increased following the onset of reminder calls at the academic center and the creation of a Spanish module at the county. Conclusions Successful DA implementation efforts should focus on patient engagement and access. SDM may broadly benefit patients and health care systems regardless of patient demographic/clinical characteristics.

Patient Perceptions of a Decision Support Tool for Men with Localized Prostate Cancer

“…In a prior study using this tool, men exhibited very low levels of decisional conflict after using the decision aid. 24…”

“…In a prior study using this tool, men exhibited very low levels of decisional conflict after using the decision aid. 24 There is also a possibility that the observed disconnect between patients' views of process and outcome does not accurately reflect patients' preferences but rather reflects cognitive biases. These might include choice-supportive bias, hindsight bias, and the ''IKEA effect.''…”

Health System Perspective on Cost for Delivering a Decision Aid for Prostate Cancer Using Time-driven Activity-based Costing

“…At the County hospital, the DA was delivered electronically on an iPad in the waiting room but switched to telemedicine delivery mode. Details of the DA and decisional quality outcomes have been reported 10 . We interviewed and observed a team of 3 urology faculty attending physicians and administrative staff including departmental chief financial officers, operations administrators, and clinic assistants to gain an understanding of current workflow practices, personnel, space, materials, and devices required for SDM module delivery.…”

“…Details of the DA and decisional quality outcomes have been reported. 10 We interviewed and observed a team of 3 urology faculty attending physicians and administrative staff including departmental chief financial officers, operations administrators, and clinic assistants to gain an understanding of current workflow practices, personnel, space, materials, and devices required for SDM module delivery. From this information, we created a process map of the step-by-step sequence of tasks, starting with screening patient eligibility for SDM module assignment and concluding with attending physician review of SDM individualized patient results.…”