Understanding and overcoming the barriers of implementing patient decision aids in clinical practice*

Abstract

Patient decision aids (ptDAs) have been developed to assist patients with difficult health-related decisions. Despite their proven effects on decision quality in numerous efficacy trials, we lack an evidence-based approach for implementing them as part of the process of care. Pragmatic trials of ptDAs have uncovered a myriad of implementation challenges; therefore we need a better understanding of the barriers and strategies to overcome them to facilitate their widespread uptake. The following paper provides an overview of the barriers related to the uptake of ptDAs within the process of care and the strategies, opportunities and research priorities to overcome them. This report is based on our interpretation of the literature and our collective experience in implementing ptDAs within trials and other contexts.

Patient Decision Aids for Prostate Cancer Treatment: A Systematic Review of the Literature

“…53 The trials in our review presented limited data regarding the feasibility of implementing DAs into routine practice, and the data reported did not address important dimensions such as staff training and time, patient completion rates of DAs, usability for diverse patient populations, methods for incorporating the DAs into office workflows, DA timing (eg, should it be viewed or used before, during, or after a visit) and delivery, and cost-effectiveness and reimbursement issues. 54 Thus, there is a need for more research on identifying barriers to implementing DAs, methods of reducing those barriers, and best practices for implementation. For example, it may be feasible to incorporate DAs into shared medical appointments in which providers could refer patients considering prostate cancer treatment to a session in which the DA is viewed by multiple patients, followed by a question/answer session with a physician.…”

A randomized trial of a breast/ovarian cancer genetic testing decision aid used as a communication aid during genetic counseling

“…For example, O'Cathain and Thomas reported similar clinician reluctance when evaluating decision aids in the maternity care setting, despite reporting that they approved of the decision aids before the commencement of the trial [17]. Similarly, O'Donnell et al listed the following possible clinician-related barriers to decision aid implementation: lack of clinician awareness, lack of knowledge and skills in the use of decision aids and a perceived lack of suitability of decision aids to meet the needs of participants with diverse needs [41]. In addition, there are organizational barriers to decision aid implementation, including the organization's culture and priorities, structural issues that make it difficult to incorporate decision aids into the workflow, and the costs of purchasing and updating decision aids [41].…”

“…Similarly, O'Donnell et al listed the following possible clinician-related barriers to decision aid implementation: lack of clinician awareness, lack of knowledge and skills in the use of decision aids and a perceived lack of suitability of decision aids to meet the needs of participants with diverse needs [41]. In addition, there are organizational barriers to decision aid implementation, including the organization's culture and priorities, structural issues that make it difficult to incorporate decision aids into the workflow, and the costs of purchasing and updating decision aids [41]. Given the disparity between positive evaluations of decision aids by consumers [16] and published [17,42] and anecdotal reports that our experiences of clinician reluctance are not unusual, research into how to successfully implement decision aids in a real-world setting is urgently needed.…”

The Herzl Patient Health Information Service: An innovative solution to the problem of informing patients in primary care

“…When the explicit purpose of the consult was to assist the patient with a difficult decision, decision aids were provided. 3 A search for medical literature was conducted for patients with an advanced understanding of their condition and a demonstrated high level of health literacy. Consults lasted from 5 minutes to 1 hour depending on the nature of the question and the information needed and were documented in the patients' chart (Appendix 3).…”

“…The Herzl Patient Health Information Service was intended to address known difficulties of informing patients in primary care, namely time, tools, and training [1][2][3]. The addition of a health information professional (HIP) to the healthcare team reduced the burden of informing patients for health professionals (HP), facilitated access to resources, and provided instructional support.…”