Informed Decision Making in Outpatient Practice

Braddock, Clarence H.; Edwards, Kelly; Hasenberg, Nicole M.; Laidley, Tracy L.; Levinson, Wendy

doi:10.1001/jama.282.24.2313

Cited by 1,048 publications

(853 citation statements)

References 27 publications

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“…21,54,55 However, in studies that have examined actual provider-patient interactions, researchers found that healthcare professionals almost always fail to adequately educate patients and enlist them in a process that meets the criteria for fully informed decisionmaking. 56,57 In a study of fully insured individuals, after adjusting for potential confounders including health literacy and education, patients' perceived lack of SDM was significantly associated with primary medication non-adherence (i.e., not filling a new prescription; RR = 2.42, p < 0.05), early nonpersistence (RR = 1.34, p < 0.01), and new prescription medication gap (5 % greater gap in medication supply, p < 0.01). 58 The benefits of SDM include incorporating evidence and patient preferences into a consultation; improving patient knowledge, risk perception accuracy, and patient-clinician communication; and reducing decisional conflict, feeling uninformed, and inappropriate use of tests and treatments.…”

Section: Shared Decision-making To Optimize Medica-tion Usementioning

confidence: 99%

Recommendations for Providers on Person-Centered Approaches to Assess and Improve Medication Adherence

et al. 2016

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Medication non-adherence is a significant clinical challenge that adversely affects psychosocial factors, costs, and outcomes that are shared by patients, family members, providers, healthcare systems, payers, and society. Patient-centered care (i.e., involving patients and their families in planning their health care) is increasingly emphasized as a promising approach for improving medication adherence, but clinician education around what this might look like in a busy primary care environment is lacking. We use a case study to demonstrate key skills such as motivational interviewing, counseling, and shared decisionmaking for clinicians interested in providing patientcentered care in efforts to improve medication adherence. Such patient-centered approaches hold considerable promise for addressing the high rates of nonadherence to medications for chronic conditions. A dherence to medications is often suboptimal-up to 50 % of patients do not take their prescribed medication as recommended. 1-4 Medication non-adherence is associated with adverse health outcomes as well as negative social and economic consequences. [5][6][7] The problem of medication nonadherence is often multifaceted and multifactorial; in general, most conceptual models of medication non-adherence take an ecological perspective, and include patient factors (e.g., literacy, cognitive function), provider factors (e.g., complex regimens), social/community factors (e.g., access to providers and pharmacy), health care factors (e.g., interaction with healthcare system, trust, prior authorization, fragmentation), and policy implications (e.g., coverage of medication). 8-10 Thus, to be effective, interventions designed to improve appropriate medication use must adopt a comprehensive approach, often combining numerous proven strategies. Several evidence reviews have identified interventions with modest effects in promoting both overall and condition-specific medication adherence. [11][12][13][14][15][16] Given the complex, multifactorial cause of medication non-adherence, interventions can be similarly multifactorial and multi-level. In this paper we focus on the physician-patient level to furnish providers with a guide to applying adherence research in the clinical encounter.Evidence increasingly demonstrates that adopting a personcentered approach for medication use that incorporates patient beliefs, preferences, goals, and barriers to medication-taking (e.g., cost, technological ability, concerns about medication prescribing and use) leads to better clinical outcomes. 17,18 Clinicians are in a key position to elicit this information from patients and to incorporate it into medication-related decisions, thereby improving medication adherence rates. Person-centered care focuses on providing patients with greater choice, recognizing their roles as consumers of health care who know best their own beliefs and preferences. This care is meant to encourage value concordance-in this case, the match between the treatment that is selected and the treatment that i...

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Section: Shared Decision-making To Optimize Medica-tion Usementioning

confidence: 99%

Recommendations for Providers on Person-Centered Approaches to Assess and Improve Medication Adherence

et al. 2016

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“…In clinical epileptology, information provision about treatment options is part of the evidence-based guidance for high quality care [7]; and patient engagement is critical for the negotiation of anti-epileptic drug (AED) adherence [8] or the referral of patients with nonepileptic seizures (NES) for psychotherapy [9]. However, observational studies have found low levels of patient participation in decision-making [10][11][12][13][14][15], and patients often report a lack of negotiation about treatment options [15][16]. A study of AED treatment decisions found that the process was perceived to be clinician-dominated [17].…”

Section: Introductionmentioning

confidence: 99%

Offering patients choices: A pilot study of interactions in the seizure clinic

Toerien

Shaw

Duncan

et al. 2011

Epilepsy & Behavior

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Using Conversation Analysis (CA), we studied conversations between one UK-based epilepsy specialist and thirteen seizure patients in whom there was uncertainty about the diagnosis, and for whom different treatment and investigational options were being considered. In line with recent communication guidance, the specialist offered some form of choice to all patients: in eight cases, a course of action was proposed, to be accepted or rejected, and in the remaining five a "menu" of options was offered. Even when presenting a menu, the specialist sometimes conveyed his own preferences in how he described the options, and in some cases the menu was used for reasons other than offering choice (e.g. to address patient resistance). Close linguistic and interactional analysis of clinical encounters can show why doctors may feel they are offering choices when patients report that the decision was clinician-dominated.

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“…He places these examinations in categories from zero to low in a simple color-coded graph. Informed choice places the emphasis on the "decision-making process as a meaningful path toward fostering patient involvement" rather than satisfying an administrative requirement or protecting oneself from liability [5].…”

Section: Informed Choice Is a Better Optionmentioning

confidence: 99%

“…Informed decision-making calls for "a meaningful dialogue between physician and patient instead of unidirectional, dutiful disclosure of alternatives, risks, and benefits by the physician" with informed consent [5]. The two concepts, informed consent and informed decision-making, can be quite different in their intent and outcome.…”

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confidence: 99%