Reflecting on shared decision making: A reflection‐quantification study

Abstract

Background Reflecting (“stop‐and‐think”) before rating may help patients consider the quality of shared decision making (SDM) and mitigate ceiling/halo effects that limit the performance of self‐reported SDM measures. Methods We asked a diverse patient sample from the United States to reflect on their care before completing the 3‐item CollaboRATE SDM measure. Study 1 focused on rephrasing CollaboRATE items to promote reflection before each item. Study 2 used 5 open‐ended questions (about what went well and what could be improved upon, signs that the clinician understood the patient's situation, how the situation will be addressed, and why this treatment plan makes sense) to invite reflection before using the whole scale. A linear analogue scale assessed the extent to which the plan of care made sense to the patient. Results In Study 1, 107 participants completed surveys (84% response rate), 43 (40%) rated a clinical decision of which 27 (63%) after responding to reflection questions. Adding reflection lowered CollaboRATE scores (“less” SDM) and reduced the proportion of patients giving maximum (ceiling) scores (not statistically significant). In Study 2, 103 of 212 responders (49%) fully completed the version containing reflection questions. Reflection did not significantly change the distribution of CollaboRATE scores or of top scores. Participants indicated high scores on the sense of their care plan (mean 9.7 out of 10, SD 0.79). This rating was weakly correlated with total CollaboRATE scores (rho = .4, P = .0001). Conclusion Reflection‐before‐quantification interventions may not improve the performance of patient‐reported measures of SDM with substantial ceiling/halo effects.

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

“…Patient perspectives of a medical decision process often also integrate patient satisfaction with care 13,34 and other important aspects of patient experience that may not be part of the specific decision-making process evaluated by a given observer. 35 Observer ratings of shared decision making, often done by a trained assessor, are supposed to reflect the objective assessment of shared decision making happening in a specific and often single clinical consultation. 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.…”

“…On a scale of 0 to 100, the minimum OPTION-5 score was 0, the maximum was 55, and the median score (interquartile range [IQR]) was 25 (20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35) (Figure 1). The estimated proportion of observer-rating risk communication and values clarification (RCVC-observer) was 63% across all consultations (95% confidence interval [CI], 54%-70%).…”

Do Shared Decision-Making Measures Reflect Key Elements of Shared Decision Making? A Content Review of Coding Schemes

“…These self-report instruments tend to show ceiling effects (i.e., scores are generally high without much variance), 7,8 possibly due to halo effects (i.e., SDM is difficult to disentangle from other qualities attributed to the care received or from overall satisfaction). 9 Other SDM instruments are observer-based coding schemes, requiring a trained assessor to observe and code the patient-clinician conversation. This is time and resource consuming, but raters are trained in the evaluation of SDM and thus can be expected to apply stricter criteria and avoid ceiling effects.…”

Envisioning Shared Decision Making: A Reflection for the Next Decade

“…44,45 We recently showed that patient evaluations of the process of SDM and of the quality or sense of the final decision, that is, the outcome of SDM, are only weakly correlated. 46 This would suggest a gap in the validity of SDM process measures to the extent that they fail to award the best score to the best care. 47 Recognizing that the purpose of SDM is to contribute to care by working through how best to respond the patient's human problem, and that different modes of SDM are needed to respond to different kinds of problems, then the way to measure SDM should reflect which purpose SDM pursues in the situation under evaluation.…”