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Background: Decision aids educate patients about treatment options and outcomes. Communication aids include question lists, consultation summaries, and audio-recordings. In efficacy studies, decision aids increased patient knowledge, while communication aids increased patient question-asking and information recall. Starting in 2004, we trained successive cohorts of post-baccalaureate, pre-medical interns to coach patients in the use of decision and communication aids at our university-based breast cancer clinic., Methods: From July 2005 through June 2012, we used the RE-AIM framework to measure Reach, Effectiveness, Adoption, Implementation and Maintenance of our interventions., Results: 1. Reach: Over the study period, our program sent a total of 5,153 decision aids and directly administered 2,004 communication aids. In the most recent program year (2012), out of 1,524 eligible patient appointments, we successfully contacted 1,212 (80%); coached 1,110 (73%) in the self-administered use of decision and communication aids; sent 958 (63%) decision aids; and directly administered communication aids for 419 (27%) patients. In a 2010 survey, coached patients reported self-administering one or more communication aids in 81% of visits 2. Effectiveness: In our pre-post comparisons, decision aids were associated with increased patient knowledge and decreased decisional conflict. Communication aids were associated with increased self-efficacy and number of questions; and with high ratings of patient preparedness and satisfaction 3. Adoption: Among visitors sent decision aids, 82% of survey respondents reviewed some or all; among those administered communication aids, 86% reviewed one or more after the visit 4., Implementation: Through continuous quality adaptations, we increased the proportion of available staff time used for patient support (i.e. exploitation of workforce capacity) from 29% in 2005 to 84% in 2012 5. Maintenance: The main barrier to sustainability was the cost of paid intern labor. We addressed this by testing a service learning model in which student interns work as program coaches in exchange for academic credit rather than salary. The feasibility test succeeded, and we are now expanding the use of unpaid interns., Conclusion: We have sustained a clinic-wide implementation of decision and communication aids through a novel staffing model that uses paid and unpaid student interns as coaches.

Objective: Explore the validity of using patient reports to measure shared decision making (SDM)., Methods: 178 patients diagnosed with breast cancer obtained SDM assistance in a university-based clinic. Trained observers rated physician SDM behaviors and surveyed patients. We calculated the frequency with which patients and observers reported maximum SDM behaviors for each survey item. We also calculated agreement frequency between patients and observers., Results: Over 90% of patients rated doctors as reflecting SDM competencies. Patients reported doctors making recommendations more than soliciting their preferred choice (90% vs. 69%, p<0.001). Patients heard benefits discussed "a lot" more often than they heard risks and side effects discussed "a lot" (81% vs. 58%, p<0.001). Agreement between patients and observers was 75%. In cases of disagreement, patients more frequently perceived SDM behaviors than did observers (15% vs. 9%, p=0.002), suggesting a possible agreement bias., Conclusions: High agreement supports further investigation into using patients as efficient and effective raters of SDM. Patient ratings may be inflated by agreement bias., Practice Implications: Doctors presentations may be biased toward discussing benefits more than risks. Policy makers can solicit patient ratings of SDM as long as they are aware of possibly inflated ratings due to agreement bias., (Copyright © 2012. Published by Elsevier Ireland Ltd.)