Quality Improvement Summit 2016: Shared Decision Making and Prostate Cancer Screening.

INTRODUCTION: The American Urological Association Quality Improvement Summit occurs regularly to provide education and promote dialogue around the issues of quality improvement and patient safety. Nearly all prostate cancer screening guidelines recommend shared decision making strategies when determining whether prostate specific antigen testing is right for a specific patient. This summit, held in partnership with the Society for Medical Decision Making, focused on techniques to identify and understand patient values in relation to prostate cancer screening and treatment, and to promote incorporation of shared decision making into prostate cancer screening discussions. METHODS: Information presented at the Quality Improvement Summit was provided by physicians and leading experts in the field of shared decision making. The open forum of this summit encouraged contributions from participants about their personal experiences with shared decision making and their thoughts on the tools presented during the day. RESULTS: Shared decision making supports collaboration between physician and patient in situations where there are multiple preference sensitive options. CONCLUSIONS: Practitioners should include formal shared decision making procedures surrounding prostate specific antigen testing in their practices to ensure that testing is in accordance with patient values and desired outcomes. Tools and strategies like those reviewed in this Quality Improvement Summit are invaluable for alleviating potential burden on providers, ensuring communication and improving quality of care.

Decision aid use during post-biopsy consultations for localized prostate cancer.

BACKGROUND: Decision Aids (DAs) effectively translate medical evidence for patients but are not routinely used in clinical practice. Little is known about how DAs are used during patient-clinician encounters. OBJECTIVE: To characterize the content and communicative function of high-quality DAs during diagnostic clinic visits for prostate cancer. PARTICIPANTS: 252 men newly diagnosed with localized prostate cancer who had received a DA, 45 treating physicians at 4 US Veterans Administration urology clinics. METHODS: Qualitative analysis of transcribed audio recordings was used to inductively develop categories capturing content and function of all direct references to DAs (booklet talk). The presence or absence of any booklet talk per transcript was also calculated. RESULTS: Booklet talk occurred in 55% of transcripts. Content focused on surgical procedures (36%); treatment choice (22%); and clarifying risk classification (17%). The most common function of booklet talk was patient corroboration of physicians' explanations (42%), followed by either physician or patient acknowledgement that the patient had the booklet. Codes reflected the absence of DA use for shared decision-making. In regression analysis, predictors of booklet talk were fewer years of patient education (P = .027) and more time in the encounter (P = .027). Patient race, DA type, time reading the DA, physician informing quality and physician age did not predict booklet talk. CONCLUSIONS: Results show that good decision aids, systematically provided to patients, appeared to function not to open up deliberations about how to balance benefits and harms of competing treatments, but rather to allow patients to ask narrow technical questions about recommended treatments.

Informed Decision Making: Assessment of the Quality of Physician Communication about Prostate Cancer Diagnosis and Treatment.

INTRODUCTION: Little is known about how physicians present diagnosis and treatment planning in routine practice in preference-sensitive treatment decisions. We evaluated completeness and quality of informed decision making in localized prostate cancer post biopsy encounters. METHODS: We analyzed audio-recorded office visits of 252 men with presumed localized prostate cancer (Gleason 6 and Gleason 7 scores) who were seeing 45 physicians at 4 Veterans Affairs Medical Centers. Data were collected between September 2008 and May 2012 in a trial of 2 decision aids (DAs). Braddock's previously validated Informed Decision Making (IDM) system was used to measure quality. Latent variable models for ordinal data examined the relationship of IDM score to treatment received. RESULTS: Mean IDM score showed modest quality (7.61±2.45 out of 18) and high variability. Treatment choice and risks and benefits were discussed in approximately 95% of encounters. However, in more than one-third of encounters, physicians provided a partial set of treatment options and omitted surveillance as a choice. Informing quality was greater in patients treated with surveillance (ß = 1.1, p = .04). Gleason score (7 vs 6) and lower age were often cited as reasons to exclude surveillance. Patient preferences were elicited in the majority of cases, but not used to guide treatment planning. Encounter time was modestly correlated with IDM score (r = 0.237, p = .01). DA type was not associated with IDM score. DISCUSSION: Physicians informed patients of options and risks and benefits, but infrequently engaged patients in core shared decision-making processes. Despite patients having received DAs, physicians rarely provided an opportunity for preference-driven decision making. More attention to the underused patient decision-making and engagement elements could result in improved shared decision making.

Patient-physician communication about early stage prostate cancer: analysis of overall visit structure.

BACKGROUND: We know little about patient-physician communication during visits to discuss diagnosis and treatment of prostate cancer. OBJECTIVE: To examine the overall visit structure and how patients and physicians transition between communication activities during visits in which patients received new prostate cancer diagnoses. PARTICIPANTS: Forty veterans and 18 urologists at one VA medical centre. METHODS: We coded 40 transcripts to identify major communication activities during visits and used empiric discourse analysis to analyse transitions between activities. RESULTS: We identified five communication activities that occurred in the following typical sequence: 'diagnosis delivery', 'risk classification', 'options talk', 'decision talk' and 'next steps'. The first two activities were typically brief and involved minimal patient participation. Options talk was typically the longest activity; physicians explicitly announced the beginning of options talk and framed it as their professional responsibility. Some patients were unsure of the purpose of visit and/or who should make treatment decisions. CONCLUSION: Visits to deliver the diagnosis of early stage prostate cancer follow a regular sequence of communication activities. Physicians focus on discussing treatment options and devote comparatively little time and attention to discussing the new cancer diagnosis. Towards the goal of promoting patient-centred communication, physicians should consider eliciting patient reactions after diagnosis delivery and explaining the decision-making process before describing treatment options.

Refining a brief decision aid in stable CAD: cognitive interviews.

BACKGROUND: We describe the results of cognitive interviews to refine the "Making Choices©" Decision Aid (DA) for shared decision-making (SDM) about stress testing in patients with stable coronary artery disease (CAD). METHODS: We conducted a systematic development process to design a DA consistent with International Patient Decision Aid Standards (IPDAS) focused on Alpha testing criteria. Cognitive interviews were conducted with ten stable CAD patients using the "think aloud" interview technique to assess the clarity, usefulness, and design of each page of the DA. RESULTS: Participants identified three main messages: 1) patients have multiple options based on stress tests and they should be discussed with a physician, 2) take care of yourself, 3) the stress test is the gold standard for determining the severity of your heart disease. Revisions corrected the inaccurate assumption of item number three. CONCLUSIONS: Cognitive interviews proved critical for engaging patients in the development process and highlighted the necessity of clear message development and use of design principles that make decision materials easy to read and easy to use. Cognitive interviews appear to contribute critical information from the patient perspective to the overall systematic development process for designing decision aids.

Primary care perspectives on prostate cancer survivorship: implications for improving quality of care.

OBJECTIVES: Primary care providers often care for men with prostate cancer due to its prolonged clinical course and an increasing number of survivors. However, their attitudes and care patterns are inadequately studied. In this context, we surveyed primary care providers regarding the scope of their prostate cancer survivorship care. METHODS: The 2006 Early Detection and Screening for Prostate Cancer Knowledge, Attitudes and Practice Survey conducted by the Michigan Public Health Institute investigated the beliefs and practice patterns of primary care providers in Michigan. We evaluated responses from 902 primary care providers regarding the timing and content of their prostate cancer survivorship care and relationships with specialty care. RESULTS: Two-thirds (67.6%) of providers cared for men during and after prostate cancer treatment. Providers routinely inquired about incontinence, impotence and bowel problems (83.3%), with a few (14.2%) using surveys to measure symptoms. However, only a minority felt 'very comfortable' managing the side effects of prostate cancer treatment. Clear plans (76.1%) and details regarding management of treatment complications (65.2%) from treating specialists were suboptimal. Nearly one-half (45.1%) of providers felt it was equally appropriate for them and treating specialists to provide prostate cancer survivorship care. CONCLUSIONS: Primary care providers reported that prostate cancer survivorship care is prevalent in their practice, yet few felt very comfortable managing side effects of prostate cancer treatment. To improve quality of care, implementing prostate cancer survivorship care plans across specialties, or transferring primary responsibility to primary care providers through survivorship guidelines, should be considered.

Primary care perspectives on prostate cancer screening.

Although the effectiveness of prostate cancer screening is controversial, screening rates have risen dramatically among primary care providers in the United States. The authors' findings suggest more collaboration among primary care and specialty organizations, especially with respect to decision aid endorsement, is needed to achieve more discriminatory and patient-centered prostate cancer screening.

Shared Decision Making Guidance Reminders in Practice (SDM-GRIP).

OBJECTIVE: Develop a system of practice tools and procedures to prompt shared decision making in primary care. SDM-GRIP (Shared Decision Making Guidance Reminders in Practice) was developed for suspected stable coronary artery disease (CAD), prior to the percutaneous coronary intervention (PCI) decision. METHODS: Program evaluation of SDM-GRIP components: Grand Rounds, provider training (communication skills and clinical evidence), decision aid (DA), patient group visit, encounter decision guide (EDG), SDM provider visit. RESULTS: Participation-Physician training=73% (21/29); patient group visits=25% of patients with diagnosis of CAD contacted (43/168). SDM visits=16% (27/168). Among SDM visit pairs, 82% of responding providers reported using the EDG in SDM encounters. Patients valued the SDM-GRIP program, and wanted to discuss comparative effectiveness information with a cardiologist. SDM visits were routinely reimbursed. CONCLUSION: Program elements were well received and logistically feasible. However, recruitment to an extra educational group visit was low. Future implementation will move SDM-GRIP to the point of routine ordering of non-emergent stress tests to retain pre-decision timing of PCI and to improve coordination of care, with SDM tools available across primary care and cardiology. PRACTICE IMPLICATIONS: Guidance prompts and provider training appear feasible. Implementation at stress testing requires further investigation.

Are patient decision aids the best way to improve clinical decision making? Report of the IPDAS Symposium.

This article reports on the International Patient Decision Aid Standards Symposium held in 2006 at the annual meeting of the Society for Medical Decision Making in Cambridge, Massachusetts. The symposium featured a debate regarding the proposition that "decision aids are the best way to improve clinical decision making.'' The formal debate addressed the theoretical problem of the appropriate gold standard for an improved decision, efficacy of decision aids, and prospects for implementation. Audience comments and questions focused on both theory and practice: the often unacknowledged roots of decision aids in expected utility theory and the practical problems of limited patient decision aid implementation in health care. The participants' vote on the proposition was approximately half for and half against.

Do patient decision aids meet effectiveness criteria of the international patient decision aid standards collaboration? A systematic review and meta-analysis.

OBJECTIVE: To describe the extent to which patient decision aids (PtDAs) meet effectiveness standards of the International Patient Decision Aids Collaboration (IPDAS). DATA SOURCES: Five electronic databases (to July 2006) and personal contacts (to December 2006). RESULTS: Among 55 randomized controlled trials, 38 (69%) used at least 1 measure that mapped onto an IPDAS effectiveness criterion. Measures of decision quality were knowledge scores (27 trials), accurate risk perceptions (12 trials), and value congruence with the chosen option (3 trials). PtDAs improved knowledge scores relative to usual care (weighted mean difference [WMD] = 15.2%, 95% confidence interval [CI] = 11.7 to 18.7); detailed PtDAs were somewhat more effective than simpler PtDAs (WMD = 4.6%, 95% CI = 3.0 to 6.2). PtDAs with probabilities improved accurate risk perceptions relative to those without probabilities (relative risk = 1.6, 95% CI = 1.4 to 1.9). Relative to simpler PtDAs, detailed PtDAs improved value congruence with the chosen option. Only 2 of 6 IPDAS decision process criteria were measured: feeling informed (15 trials) and feeling clear about values (13 trials). PtDAs improved these process measures relative to usual care (feeling uninformed WMD = -8.4, 95% CI = -11.9 to -4.8; unclear values WMD = -6.3, 95% CI = -10.0 to -2.7). There was no difference in process measures when detailed and simple PtDAs were compared. CONCLUSIONS: PtDAs improve decision quality and the decision process's measures of feeling informed and clear about values; however, the size of the effect varies across studies. Several IPDAS decision process measures have not been used. Future trials need to use a minimum data set of IPDAS evaluation measures. The degree of detail PtDAs require for positive effects on IPDAS criteria should be explored.

Shared decision-making in the US--research & development outpaces delivery.

Researchers interested in shared decision-making in the US have developed a set of tools including decision aids and instruction in counseling, to help patients and physicians fully discuss treatment decisions. Although fundamental research and development continues, these tools are disseminated largely through for-profit and not-for-profit companies to group practices and insurance providers. Data on the number of patients and physicians who have access to decision aids and who have ever used a decision aid are not available, but the number may be small. Policy organisations support the integration of shared decision-making into routine medical care. However, widespread adoption is hindered by lack of evidence for a direct impact on the quality or cost of health care, by limited provider use and lack of patient demand. Future growth requires that people learn about and come to expect that they will discuss treatment options and routinely share making decisions about their care with their care providers--and that their providers welcome and support their patients in doing so.

Men's interpretations of graphical information in a videotape decision aid.

OBJECTIVE: To examine men's interpretations of graphical information types viewed in a high-quality, previously tested videotape decision aid (DA). SETTING, PARTICIPANTS, DESIGN: A community-dwelling sample of men >50 years of age (N = 188) balanced by education (college/non-college) and race (Black/White) were interviewed just following their viewing of a videotape DA. A descriptive study design was used to examine men's interpretations of a representative sample of the types of graphs that were shown in the benign prostatic hyperplasia videotape DA. MAIN VARIABLES STUDIED: Men provided their interpretation of graphs information presented in three formats that varied in complexity: pictograph, line and horizontal bar graph. Audiotape transcripts of men's responses were coded for meaning and content-related interpretation statements. RESULTS: Men provided both meaning and content-focused interpretations of the graphs. Accuracy of interpretation was lower than hypothesized on the basis of literature review (85.4% for pictograph, 65.7% for line graph, 47.8% for horizontal bar graph). Accuracy for pictograph and line graphs was associated with education level, chi2(1) = 3.94, P = 0.047, and chi2(1) = 7.55, P = 0.006, respectively. Accuracy was uncorrelated with men's reported liking of the graphs, chi2(1) = 2.00, P = 0.441. CONCLUSION: While men generally liked the DA, accuracy of graphs interpretation was associated with format complexity and education level. Graphs are often recommended to improve comprehension of information in DAs. However, additional evaluation is needed in experimental and naturalistic observational settings to develop best practice standards for data representation.

Outpatient medication use and health outcomes in post-acute coronary syndrome patients.

OBJECTIVE: To investigate the pattern of postdischarge evidence-based outpatient medication use and its impact on subsequent hospital readmissions in post-acute coronary syndrome (ACS) patients. STUDY DESIGN: Prospective observational study. METHODS: A telephone survey was conducted to collect information from discharge to 8 months after discharge for 433 patients hospitalized with a primary diagnosis of ACS in 5 mid-Michigan hospitals. The survey data were then merged with chart review data from the initial hospitalization. We first conducted a longitudinal descriptive analysis of the utilization patterns of patient self-reported medication use from discharge to the 8-month survey. Then, multivariable logit analysis was used to estimate the effect of post-ACS medication use on self-reported hospital readmission at 3 months and 8 months after discharge. Propensity score matching was used to counter the possible bias induced by self-selection of outpatient medication use. RESULTS: The pattern of outpatient medication use was dynamic. Most changes to medication regimens occurred within 3 months after discharge, with fewer changes in the subsequent 5 months. Taking a beta-blocker, angiotensin-converting enzyme inhibitor, or angiotension receptor blocker significantly reduced the probability of hospital readmission 3 months after discharge. Propensity score matching produced similar statistically significant results. Re-hospitalization within 3 months after discharge was a strong predictor of later hospital readmission up to 8 months. CONCLUSION: Timely and appropriate medication adjustment in outpatient settings appears to be critically important to reduce hospital readmission among ACS patients.

Men's theories about benign prostatic hyperplasia and prostate cancer following a benign prostatic hyperplasia decision aid.

OBJECTIVE: To use qualitative methods to explore audiotape evidence of unanticipated confusion between benign prostatic hyperplasia (BPH) and prostate cancer in using a videotape BPH treatment decision aid (DA). DESIGN: Qualitative analysis of semi-structured interviews and surveys originally collected to study men's interpretation of a DA. SETTING AND PARTICIPANTS: Community sample of college and noncollege educated African American and white men (age> or =50; n=188). MEASURES: Transcript analysis identified themes in men's comments about BPH and cancer. Surveys measured BPH general and prostate cancer-specific knowledge, literacy (Short Test of Functional Health Literacy in Adults), BPH symptoms, and demographics. RESULTS: In transcript analysis, 18/188 men spontaneously talked about BPH and cancer as being related to each other, despite explicit statements to the contrary in the video. Survey data suggest that up to 126/188 men (67%) persisted in misconceptions even after viewing the DA video. Three themes were identified in the transcripts: (1) BPH and cancer are equated, (2) BPH surgery is for the purpose of removing cancer, and (3) BPH leads to cancer. CONCLUSIONS: Overall knowledge increases with DA use may mask incorrect theories of disease process. Further research should identify decision support designs and clinical counseling strategies to address persistence of beliefs contrary to new information presented in evidence-based DAs.

Evidence-based patient choice: a prostate cancer decision aid in plain language.

BACKGROUND: Decision aids (DA) to assist patients in evaluating treatment options and sharing in decision making have proliferated in recent years. Most require high literacy and do not use plain language principles. We describe one of the first attempts to design a decision aid using principles from reading research and document design. The plain language DA prototype addressed treatment decisions for localized prostate cancer. Evaluation assessed impact on knowledge, decisions, and discussions with doctors in men newly diagnosed with prostate cancer. METHODS: Document development steps included preparing an evidence-based DA in standard medical parlance, iteratively translating it to emphasize shared decision making and plain language in three formats (booklet, Internet, and audio-tape). Scientific review of medical content was integrated with expert health literacy review of document structure and design. Formative evaluation methods included focus groups (n = 4) and survey of a new sample of men newly diagnosed with prostate cancer (n = 60), compared with historical controls (n = 184). RESULTS: A transparent description of the development process and design elements is reported. Formative evaluation among newly diagnosed prostate cancer patients found the DA to be clear and useful in reaching a decision. Newly diagnosed patients reported more discussions with doctors about treatment options, and showed increases in knowledge of side effects of radiation therapy. CONCLUSION: The plain language DA presenting medical evidence in text and numerical formats appears acceptable and useful in decision-making about localized prostate cancer treatment. Further testing should evaluate the impact of all three media on decisions made and quality of life in the survivorship period, especially among very low literacy men.

Decision aids for benign prostatic hyperplasia: applicability across race and education.

BACKGROUND/METHOD: Decision aids have not been widely tested in diverse audiences. The authors conducted interviews in a 2 x 2 race by education design with participants who were 50 years old (n = 188). The decision aid was a benign prostatic hyperplasia videotape. RESULTS: There was an increase in knowledge equal in all groups, with baseline knowledge higher in whites. The decision stage increased in all groups and was equivalent in the marginal-illiterate subgroup (n = 0.15). CONCLUSION: Contrary to expectations, results show no difference by race or college education in knowledge gain or increase in reported readiness to decide. The video appeared to produce change across race and education. The end decision stage was high, especially in less educated men. Results suggest that decision aids may be effective without tailoring, as suggested previously to enhance health communication in diverse audiences. Research should test findings in representative samples and in clinical encounters and identify types of knowledge absorbed from decision aids and whether the shift to decision reflects data/knowledge or shared decision-making message.