Direct-Observation Cohort Study of Shared Decision Making in a Primary Care Clinic

Abstract

<jats:p> Background. Observational studies suggest that shared medical decision making (SMDM) is suboptimal. Our objective was to assess patient preferences, ratings, and objective measurements of decision making and their impact on patient outcomes. Methods. Hypertensive adults presenting for routine care with their primary care physician completed previsit surveys assessing SMDM preferences. Postvisit surveys assessed the degree of SMDM during the encounter, patient satisfaction, and trust. Encounters were audiotaped and transcripts were coded for type of decisions made as well as SMDM quality using OPTION-5. Adherence and blood pressure were measured at baseline and at 4 weeks. Results. Among 105 encounters, there were 7.4 decisions per visit; most were basic, such as refills and routine testing. Objective measures of decision making indicated that the degree of SMDM was lower than reported by patients or physicians, although physician ratings were more accurate. Previsit, 54% of patients expressed a desire for equally shared medical decision making, 24% preferred physician dominated decision making, and 18% preferred that they make the decisions. Postvisit, patients reported experiencing SMDM in 57% of encounters, with high concordance between desired and perceived decision making. Discordance between the patient’s desired and experienced SMDM reduced trust and satisfaction. The quality of shared decisions had no impact on adherence or blood pressure at 4 weeks. Limitations. Single site, small sample. Conclusions. Decisions are common during internal medicine primary care visits, and most are basic. Most patients preferred SMDM, and their perceptions of the visit decision-making style were concordant with their preferences although higher than objective measures suggested. Physician ratings of the quality of SMDM were more accurate than patient ratings. Discordance between patients’ expected and experienced SMDM lowered satisfaction and trust. </jats:p>

Observer Ratings of Shared Decision Making Do Not Match Patient Reports: An Observational Study in 5 Family Medicine Practices

“…It has been reported that, compared to OPTION-5, patients may unconsciously overestimate the occurrence of shared decision making by integrating in their evaluation prior visits or the relation with the clinician. 12,29 This is also plausible for RCVC-patient.…”

“…This implies that, when it comes to medical decisions requiring some amount of time and several patient-clinician encounters, using a single consultation to rate shared decision making may lead to an underestimation of the occurrence and the quality of the decision making process by observers compared to the patient's point of view. This may partly explain why patients' ratings of shared decision making tend to be higher than those of health professionals 12,32,36 and observers. 33,37,38 In addition, our measurements of SDM encompass different aspects of the SDM process.…”

“…2,10 Patients' perspectives of a decision making process are important indices of patients' experience and can help improve health services and patient outcomes. 11,12 Observers' perspectives of decision making are helpful to improve the quality of care as they reflect more objective assessment and report the occurrence of core competencies of shared decision making in clinical consultations. 13 The correlation of patient and observer ratings of shared decision making after a clinical consultation has been investigated in some studies.…”

Do consultants do what they say they do? Observational study of the extent to which clinicians involve their patients in the decision-making process

“…The previous literature comparing clinicians’ self-reported and actual decision-making style in medical consultations also showed that clinicians tend to overestimate the extent to which they apply SDM. 20 25 These studies analysed simple decisions in primary care such as refills and routine testing 20 or were performed in specific breast cancer or renal failure clinics in which the staff had been extensively trained in the application of SDM. 25 …”

“…Finally, like in earlier studies using the OPTION 5 instrument, our study focused on clinician behaviour and not on not on patients’ experiences. Given the scant literature on the topic, 20 28 29 more studies are needed to assess how patients experience the decision-making process in medical consultations…”