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Background: Optimal treatment for localized prostate cancer (LPC) is controversial. We assessed the effects of personality, specialists seen, and involvement of spouse, family, or friends on treatment decision/decision-making qualities., Methods: We surveyed a population-based sample of men ≤ 75 years with newly diagnosed LPC about treatment choice, reasons for the choice, decision-making difficulty, satisfaction, and regret., Results: Of 160 men (71 black, 89 white), with a mean age of 61 (±7.3) years, 59% chose surgery, 31% chose radiation, and 10% chose active surveillance (AS)/watchful waiting (WW). Adjusting for age, race, comorbidity, tumor risk level, and treatment status, men who consulted friends during decision-making were more likely to choose curative treatment (radiation or surgery) than WW/AS (OR = 11.1, p < 0.01; 8.7, p < 0.01). Men who saw a radiation oncologist in addition to a urologist were more likely to choose radiation than surgery (OR = 6.0, p = 0.04). Men who consulted family or friends (OR = 2.6, p < 0.01; 3.7, p < 0.01) experienced greater decision-making difficulty. No personality traits (pessimism, optimism, or faith) were associated with treatment choice/decision-making quality measures., Conclusions: In addition to specialist seen, consulting friends increased men's likelihood of choosing curative treatment. Consulting family or friends increased decision-making difficulty.

Objective: To assess the influence of patient preferences and urologist recommendations in treatment decisions for clinically localized prostate cancer., Methods: We enrolled 257 men with clinically localized prostate cancer (prostate-specific antigen <20; Gleason score 6 or 7) seen by urologists (primarily residents and fellows) in 4 Veterans Affairs medical centers. We measured patients' baseline preferences prior to their urology appointments, including initial treatment preference, cancer-related anxiety, and interest in sex. In longitudinal follow-up, we determined which treatment patients received. We used hierarchical logistic regression to determine the factors that predicted treatment received (active treatment v. active surveillance) and urologist recommendations. We also conducted a directed content analysis of recorded clinical encounters to determine if urologists discussed patients' interest in sex., Results: Patients' initial treatment preferences did not predict receipt of active treatment versus surveillance, Δχ 2 (4) = 3.67, P = 0.45. Instead, receipt of active treatment was predicted primarily by urologists' recommendations, Δχ 2 (2) = 32.81, P < 0.001. Urologists' recommendations, in turn, were influenced heavily by medical factors (age and Gleason score) but were unrelated to patient preferences, Δχ 2 (6) = 0, P = 1. Urologists rarely discussed patients' interest in sex (<15% of appointments)., Conclusions: Patients' treatment decisions were based largely on urologists' recommendations, which, in turn, were based on medical factors (age and Gleason score) and not on patients' personal views of the relative pros and cons of treatment alternatives., (© The Author(s) 2016.)

Background: Use of Shared Decision-Making (SDM) and Decision Aids (DAs) has been encouraged but is not regularly implemented in primary care. The Office-Guidelines Applied to Practice (Office-GAP) intervention is an application of a previous model revised to address guidelines based care for low-income populations with diabetes and coronary heart disease (CHD)., Objective: To evaluate Office-GAP Program feasibility and preliminary efficacy on medication use, patient satisfaction with physician communication and confidence in decision in low-income population with diabetes and coronary heart disease (CHD) in a Federally Qualified Healthcare Center (FQHC)., Method: Ninety-five patients participated in an Office-GAP program. A quasi-experimental design study, over 6 months with 12-month follow-up. Office-GAP program integrates health literacy, communication skills education for patients and physicians, patient/physician decision support tools and SDM into routine care., Main Measures: 1) Implementation rates of planned program elements 2) Patient satisfaction with communication and confidence in decision, and 3) Medication prescription rates. We used the GEE method for hierarchical logistic models, controlling for confounding., Results: Feasibility of the Office-GAP program in the FQHC setting was established. We found significant increase in use of Aspirin/Plavix, statin and beta-blocker during follow-up compared to baseline: Aspirin OR 1.5 (95 % CI: 1.1, 2.2) at 3-months, 1.9 (1.3, 2.9) at 6-months, and 1.8 (1.2, 2.8) at 12-months. Statin OR 1.1 (1.0, 1.3) at 3-months and 1.5 (1.1, 2.2) at 12-months; beta-blocker 1.8 (1.1, 2.9) at 6-months and 12-months. Program elements were consistently used (≥ 98 % clinic attendance at training and tool used). Patient satisfaction with communication and confidence in decision increased., Conclusions: The use of Office-GAP program to teach SDM and use of DAs in real time was demonstrated to be feasible in FQHCs. It has the potential to improve satisfaction with physician communication and confidence in decisions and to improve medication use. The Office-GAP program is a brief, efficient platform for delivering patient and provider education in SDM and could serve as a model for implementing guideline based care for all chronic diseases in outpatient clinical settings. Further evaluation is needed to establish feasibility outside clinical study, reach, effectiveness and cost-effectiveness of this approach.

Background: Hypertension (HTN) in people with diabetes doubles the risk of cardiovascular disease. Prior patient activation studies largely show improved communication but little impact on behavior or health outcomes. We sought to 1) assess the impact of Office-Based Guidelines Applied to Practice (Office-GAP) Program on blood pressure (BP) control; 2) determine the rate and predictors of BP control in patients with HTN and/or diabetes mellitus (DM) in federally qualified health centers. Methods: Sample: Patients with coronary heart disease (CHD) and/or DM with history of HTN; analyzed patients with DM and HTN compared to HTN without DM., Intervention: Office-GAP included physician training, patient activation, and an Office-GAP decision checklist. Two-site intervention/control design; data collection at baseline and after 3, 6, and 12 months. Logistic regression with propensity scoring assessed impact on BP control over time. Results: Of 243 patients, HTN was present in 75% at baseline; 32% had BP controlled. Consistent trend showed Office-GAP slightly improved the rate of BP control across time, while the control arm showed a nonsignificant decrease in the rate of BP control across time, compared to baseline. BP improved at 6 months at the intervention site compared to control site (odds ratio = 2.92; 95% confidence interval = 1.11-7.69). Conclusion: BP control was better at the intervention site compared to the control site at 6 months. Office-GAP shows promise to implement guidelines-based patient-centered care that improves BP., Competing Interests: The authors declare that they do not have any conflicts of interest.

Unlabelled: The burden of cardiovascular disease (CVD) among minority and low-income populations is well documented. This study aimed to assess the impact of patient activation and shared decision-making (SDM) on medication use through the Office-Guidelines Applied to Practice (Office-GAP) intervention in Federally Qualified Healthcare Centers (FQHCs). Patients (243) with diabetes and CHD participated in Office-GAP between October 2010 and March 2014. Two-site (FQHCs) intervention/control design. Office-GAP integrates health literacy, communication skills education for patients and physicians, decision support tools, and SDM into routine care., Main Measures: 1) implementation rates, 2) medication use at baseline, 3, 6, and 12 months, and 3) predictors of medication use. Logistic regression with propensity scoring assessed impact on medication use. Intervention arm had 120 and control arm had 123 patients. We found that program elements were consistently used. Compared to control, the Office-GAP program significantly improved medications use from baseline: ACEIs or ARBs at 3 months (OR 1.88, 95% CI = 1.07; 3.30, p < 0.03), 6 months (OR 2.68, 95% CI = 1.58;4.54; p < 0.01); statin at 3 months (OR 2.00, 95% CI = 0.1.22; 3.27; p < 0.05), 6 months (OR 3.05, 95% CI = 1.72; 5.43; p < 0.01), Aspirin and/or clopidogrel at 3 months OR 1.59, 95% CI = 1.02, 2.48; p < 0.05), 6 months (OR 3.67, 95% CI = 1.67; 8.08; p < 0.01). Global medication adherence was predicted only by Office-GAP intervention presence and hypertension. Office-GAP resulted in increased use of guideline-based medications for secondary CVD prevention in underserved populations. The Office-GAP program could serve as a model for implementing guideline-based care for other chronic diseases.

Background: There is evidence suggesting that active participation of patients in their health care can improve the quality of care and decrease health-care costs. Further, patient reports of their health-care experience are increasingly used to monitor health-care quality., Objective: This paper describes a systematic review of peer-reviewed studies to identify measures of patients' active participation in their encounters with health-care providers., Methods: A systematic literature review was conducted for publications indexed from 1975 to 2011. Of interest were self-reported measures of patient participation that were not limited to a specific health concern. All abstracts were reviewed independently by two authors, and the full paper was considered for those meeting inclusion criteria., Main Results: From a review of 4528 citations, ten measures were identified. The approaches to development of the measures varied considerably, as did their study samples and their psychometric quality., Discussion: These measures represented three conceptual frameworks: empowerment and self-efficacy, therapeutic alliance, and consumerism/satisfaction. They provide a more comprehensive perspective of patients' experiences of their provider encounters, and a better understanding patient behaviour enhanced the quality of health-care delivery or improved health outcomes. These measures underscore the continuing challenge of defining patient participation and the multiple theoretical approaches that underlie this form of patient behaviour., Conclusions: Current interest in quality-related physician report cards gives significant weight to patients' self-reported experiences as one dimension of physician performance. It is critical to identify the specific focus and quality of measures selected for this and research purposes., (© 2014 John Wiley & Sons Ltd.)

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 (β = 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., (© The Author(s) 2015.)

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., (© 2013 John Wiley & Sons Ltd.)

Objective: With increasing exposure, medical students may forget that technical jargon is unfamiliar to laypeople. To investigate this possibility, authors assessed student perceptions of patient understanding across different years in medical school., Methods: 533 students at 4 U.S. medical schools rated the proportion of patients likely to understand each of twenty-one different jargon terms. Students were either in the first month of their first year, the middle of their first year, or the middle of their fourth year of medical school., Results: Fourth-year students were slightly more pessimistic about patients' understanding compared to new first-year students (mean percent understanding of 55.1% vs. 58.6%, p=0.004). Students both over- and under-estimated patient understanding of specific words compared to published estimates. In a multivariate model, other factors did not explain these differences., Conclusion: Students do not generally presume that patients understand medical jargon. In many cases they actually underestimate patients' understanding, and these estimates may become more pessimistic longitudinally. Jargon use in communication with patients does not appear to stem from unrealistic presumptions about patients' understanding or from desensitization to jargon during medical school., Practice Implications: Training about patient knowledge of medical jargon may be a useful addition to communication skills curricula., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Context: Advances in screening and treatment of prostate cancer have dramatically increased the number of survivors in the US population. Yet the effect of screening is controversial, and in some instances may not be beneficial. Previous studies have typically only reported outcomes of treatment and symptoms within a short time frame following treatment. The persistence of such symptoms over time necessitates an improvement of survivor care so that the medical and support needs of these patients are met., Objective: This study aims to perform a patient-centered survey of prostate cancer survivors in the Michigan Cancer Registry to identify treatment side effect rates, evaluate survivors' access to preventive care services post-prostate cancer treatment, and assess the informational needs of these survivors regarding their prostate cancer., Design, Setting, and Patients: Linking case files of the Michigan Cancer Registry with records from the National Death Index, we identified prostate cancer patients diagnosed between 1985 and 2004 and alive on 31 December 2005. Participants were selected using a stratified cross-sectional sampling strategy to ensure adequate inclusion of survivors based upon race and ethnicity, urban versus rural location, and number of years since diagnosis of prostate cancer. A total of 2,499 surveys were completed and returned., Main Outcome Measures: (1) Physical symptoms--assessing bowel, sexual, urinary, and vitality symptoms by treatment modality. (2) Access to care--identifying whether diagnostic tests for prostate cancer (prostate-specific antigen (PSA) and digital rectal examination) were performed. Determining whether the survivors had knowledge of the "watchful waiting" paradigm for prostate cancer surveillance. (3) Informational needs--assessing whether the informational needs of patients were addressed by providers. Evaluating the significant predictors associated with seeking information about prostate cancer from any other source. Identifying what factors influenced a person to actively seek out information and what factors guide which primary information source a survivor would use., Results: Median duration between prostate cancer diagnosis and survey response was 9 years. Of the study population, 80 % was diagnosed at an early stage. Survivors had reported significant problems in the 4 weeks prior to survey. Of the survivors, 88.1 % reported having a PSA test since diagnosis of prostate cancer, with 93 % of them having it done at least once per year. Of the survivors, 82.6 % reported that a healthcare provider gave them information on prostate cancer. Of this 82.6 %, 86.4 % had this information provided by a urologist, 45.4 % by a primary care physician, and 29.2 % by an oncologist. The primary source of information for these survivors was "healthcare provider" (59.2 %)., Conclusion: Persistent symptoms subsequent to prostate cancer treatment suggest a gap in symptom management. Future research should support long-term studies of active surveillance versus active treatment outcomes to understand the feasibility of minimizing the burden of long-term physical symptoms arising from prostate cancer treatment. Clinicians must assess post-treatment distress long after treatment has ended to identify when supportive care is needed. More informational resources should be allocated to prostate cancer survivors to ensure that they are well-educated about their prognosis., Implications for Cancer Survivors: This study is needed to ensure that the post-treatment symptoms of prostate cancer survivors are properly addressed and managed by healthcare providers over the long term.

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.

Background: Decision aids are intended to help people participate in decisions that involve weighing the benefits and harms of treatment options often with scientific uncertainty., Objectives: To assess the effects of decision aids for people facing treatment or screening decisions., Search Methods: For this update, we searched from 2009 to June 2012 in MEDLINE; CENTRAL; EMBASE; PsycINFO; and grey literature. Cumulatively, we have searched each database since its start date including CINAHL (to September 2008)., Selection Criteria: We included published randomized controlled trials of decision aids, which are interventions designed to support patients' decision making by making explicit the decision, providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies of participants making hypothetical decisions., Data Collection and Analysis: Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were:A) 'choice made' attributes;B) 'decision-making process' attributes.Secondary outcomes were behavioral, health, and health-system effects. We pooled results using mean differences (MD) and relative risks (RR), applying a random-effects model., Main Results: This update includes 33 new studies for a total of 115 studies involving 34,444 participants. For risk of bias, selective outcome reporting and blinding of participants and personnel were mostly rated as unclear due to inadequate reporting. Based on 7 items, 8 of 115 studies had high risk of bias for 1 or 2 items each.Of 115 included studies, 88 (76.5%) used at least one of the IPDAS effectiveness criteria: A) 'choice made' attributes criteria: knowledge scores (76 studies); accurate risk perceptions (25 studies); and informed value-based choice (20 studies); and B) 'decision-making process' attributes criteria: feeling informed (34 studies) and feeling clear about values (29 studies).A) Criteria involving 'choice made' attributes:Compared to usual care, decision aids increased knowledge (MD 13.34 out of 100; 95% confidence interval (CI) 11.17 to 15.51; n = 42). When more detailed decision aids were compared to simple decision aids, the relative improvement in knowledge was significant (MD 5.52 out of 100; 95% CI 3.90 to 7.15; n = 19). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.82; 95% CI 1.52 to 2.16; n = 19). Exposure to a decision aid with explicit values clarification resulted in a higher proportion of patients choosing an option congruent with their values (RR 1.51; 95% CI 1.17 to 1.96; n = 13).B) Criteria involving 'decision-making process' attributes:Decision aids compared to usual care interventions resulted in:a) lower decisional conflict related to feeling uninformed (MD -7.26 of 100; 95% CI -9.73 to -4.78; n = 22) and feeling unclear about personal values (MD -6.09; 95% CI -8.50 to -3.67; n = 18);b) reduced proportions of people who were passive in decision making (RR 0.66; 95% CI 0.53 to 0.81; n = 14); andc) reduced proportions of people who remained undecided post-intervention (RR 0.59; 95% CI 0.47 to 0.72; n = 18).Decision aids appeared to have a positive effect on patient-practitioner communication in all nine studies that measured this outcome. For satisfaction with the decision (n = 20), decision-making process (n = 17), and/or preparation for decision making (n = 3), those exposed to a decision aid were either more satisfied, or there was no difference between the decision aid versus comparison interventions. No studies evaluated decision-making process attributes for helping patients to recognize that a decision needs to be made, or understanding that values affect the choice.C) Secondary outcomes Exposure to decision aids compared to usual care reduced the number of people of choosing major elective invasive surgery in favour of more conservative options (RR 0.79; 95% CI 0.68 to 0.93; n = 15). Exposure to decision aids compared to usual care reduced the number of people choosing to have prostate-specific antigen screening (RR 0.87; 95% CI 0.77 to 0.98; n = 9). When detailed compared to simple decision aids were used, fewer people chose menopausal hormone therapy (RR 0.73; 95% CI 0.55 to 0.98; n = 3). For other decisions, the effect on choices was variable.The effect of decision aids on length of consultation varied from 8 minutes shorter to 23 minutes longer (median 2.55 minutes longer) with 2 studies indicating statistically-significantly longer, 1 study shorter, and 6 studies reporting no difference in consultation length. Groups of patients receiving decision aids do not appear to differ from comparison groups in terms of anxiety (n = 30), general health outcomes (n = 11), and condition-specific health outcomes (n = 11). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive., Authors' Conclusions: There is high-quality evidence that decision aids compared to usual care improve people's knowledge regarding options, and reduce their decisional conflict related to feeling uninformed and unclear about their personal values. There is moderate-quality evidence that decision aids compared to usual care stimulate people to take a more active role in decision making, and improve accurate risk perceptions when probabilities are included in decision aids, compared to not being included. There is low-quality evidence that decision aids improve congruence between the chosen option and the patient's values.New for this updated review is further evidence indicating more informed, values-based choices, and improved patient-practitioner communication. There is a variable effect of decision aids on length of consultation. Consistent with findings from the previous review, decision aids have a variable effect on choices. They reduce the number of people choosing discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, cost-effectiveness, use with lower literacy populations, and level of detail needed in decision aids need further evaluation. Little is known about the degree of detail that decision aids need in order to have a positive effect on attributes of the choice made, or the decision-making process.

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., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Recent guidelines on cancer screening have provided not only more screening options but also conflicting recommendations. Thus, patients, with their clinicians' support, must decide whether to get screened, which modality to use, and how often to undergo screening. Decision aids could potentially lead to better shared decision-making regarding screening between the patient and the clinician. A total of 73 decision aids concerning screening for breast, cervical, colorectal, and prostate cancers were reviewed. The goal of this review was to assess the effectiveness of such decision aids, examine areas in need of more research, and determine how the decision aids can be currently applied in the real-world setting. Most studies used sound study designs. Significant variation existed in the setting, theoretical framework, and measured outcomes. Just over one-third of the decision aids included an explicit values clarification. Other than knowledge, little consistency was noted with regard to which patient attributes were measured as outcomes. Few studies actually measured shared decision-making. Little information was available regarding the feasibility and outcomes of integrating decision aids into practice. In this review, the implications for future research, as well as what clinicians can do now to incorporate decision aids into their practice, are discussed., (Copyright © 2013 American Cancer Society, Inc.)

Objective: The aim of this study was to develop and evaluate a nurse-led educational group visit (GV) as part of a multifaceted intervention, shared decision making (SDM) guidance reminders in practice, to prompt SDM in primary care about angiography in stable coronary artery disease., Methods: A process evaluation designed to test the feasibility of a nurse-led educational GV was conducted. The evaluation used retrospective pre-post surveys., Results: Nurse-led GV was well received and logistically feasible. Patients gained knowledge of options and confidence in doing SDM with providers. However, recruitment at the point of the educational GV was below the threshold of 12 patients per group that would support sustaining this approach in fee-for-service clinical practice., Conclusions: Nurse-led GV can produce gains in knowledge and confidence required for patients to participate in SDM. However, the constraints of time and personnel required to bring groups of patients together require new approaches. Future development will focus on adapting the content of the GV for SDM as an electronic teaching module associated with integrated personal health records.

Hypertension (HTN) is particularly burdensome in low-income groups. Federal-qualified health centers (FQHCs) provide care for low-income and medically underserved populations. To assess the rates and predictors of blood pressure (BP) control in an FQHC in Michigan, a retrospective analysis of all patients with HTN, coronary artery disease, and/or diabetes mellitus (DM) seen between January 2006 and December 2008 was conducted. Of 212 patients identified, 154 had a history of HTN and 122 had DM. BP control was achieved in 38.2% of the entire cohort and in 31.1% of patients with DM. The mean age was lower in patients with controlled BP in both the total population (P=.05) and the DM subgroup (P=.02). A logistic regression model found only female sex (odds ratio, 2.27; P=.02) to be associated with BP control and a trend towards an association of age with uncontrolled BP (odds ratio, 0.97; P=.06). BP control in nondiabetics was 47.8% vs 31.1% in diabetic patients (P=.02). We found that patients who attended the FQHC had a lower rate of BP control compared with the national average. Our study revealed a male sex disparity and significantly lower rate of BP control among DM patients., (© 2013 Wiley Periodicals, Inc.)

Background: Effective use of a patient decision aid (PtDA) can be affected by the user's health literacy and the PtDA's characteristics. Systematic reviews of the relevant literature can guide PtDA developers to attend to the health literacy needs of patients. The reviews reported here aimed to assess:, Methods: We reviewed literature for evidence relevant to these two aims. When high-quality systematic reviews existed, we summarized their evidence. When reviews were unavailable, we conducted our own systematic reviews., Results: Aim 1: In an existing systematic review of PtDA trials, lower health literacy was associated with lower patient health knowledge (14 of 16 eligible studies). Fourteen studies reported practical design strategies to improve knowledge for lower health literacy patients. In our own systematic review, no studies reported on values clarity per se, but in 2 lower health literacy was related to higher decisional uncertainty and regret. Lower health literacy was associated with less desire for involvement in 3 studies, less question-asking in 2, and less patient-centered communication in 4 studies; its effects on other measures of patient involvement were mixed. Only one study assessed the effects of a health literacy intervention on outcomes; it showed that using video to improve the salience of health states reduced decisional uncertainty. Aim 2: In our review of 97 trials, only 3 PtDAs overtly addressed the needs of lower health literacy users. In 90% of trials, user health literacy and readability of the PtDA were not reported. However, increases in knowledge and informed choice were reported in those studies in which health literacy needs were addressed., Conclusion: Lower health literacy affects key decision-making outcomes, but few existing PtDAs have addressed the needs of lower health literacy users. The specific effects of PtDAs designed to mitigate the influence of low health literacy are unknown. More attention to the needs of patients with lower health literacy is indicated, to ensure that PtDAs are appropriate for lower as well as higher health literacy patients.

Background: Communication problems in health care may arise as a result of healthcare providers focusing on diseases and their management, rather than people, their lives and their health problems. Patient-centred approaches to care delivery in the patient encounter are increasingly advocated by consumers and clinicians and incorporated into training for healthcare providers. However, the impact of these interventions directly on clinical encounters and indirectly on patient satisfaction, healthcare behaviour and health status has not been adequately evaluated., Objectives: To assess the effects of interventions for healthcare providers that aim to promote patient-centred care (PCC) approaches in clinical consultations., Search Methods: For this update, we searched: MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), and CINAHL (EbscoHOST) from January 2000 to June 2010. The earlier version of this review searched MEDLINE (1966 to December 1999), EMBASE (1985 to December 1999), PsycLIT (1987 to December 1999), CINAHL (1982 to December 1999) and HEALTH STAR (1975 to December 1999). We searched the bibliographies of studies assessed for inclusion and contacted study authors to identify other relevant studies. Any study authors who were contacted for further information on their studies were also asked if they were aware of any other published or ongoing studies that would meet our inclusion criteria., Selection Criteria: In the original review, study designs included randomized controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series studies of interventions for healthcare providers that promote patient-centred care in clinical consultations. In the present update, we were able to limit the studies to randomized controlled trials, thus limiting the likelihood of sampling error. This is especially important because the providers who volunteer for studies of PCC methods are likely to be different from the general population of providers. Patient-centred care was defined as a philosophy of care that encourages: (a) shared control of the consultation, decisions about interventions or management of the health problems with the patient, and/or (b) a focus in the consultation on the patient as a whole person who has individual preferences situated within social contexts (in contrast to a focus in the consultation on a body part or disease). Within our definition, shared treatment decision-making was a sufficient indicator of PCC. The participants were healthcare providers, including those in training., Data Collection and Analysis: We classified interventions by whether they focused only on training providers or on training providers and patients, with and without condition-specific educational materials. We grouped outcome data from the studies to evaluate both direct effects on patient encounters (consultation process variables) and effects on patient outcomes (satisfaction, healthcare behaviour change, health status). We pooled results of RCTs using standardized mean difference (SMD) and relative risks (RR) applying a fixed-effect model., Main Results: Forty-three randomized trials met the inclusion criteria, of which 29 are new in this update. In most of the studies, training interventions were directed at primary care physicians (general practitioners, internists, paediatricians or family doctors) or nurses practising in community or hospital outpatient settings. Some studies trained specialists. Patients were predominantly adults with general medical problems, though two studies included children with asthma. Descriptive and pooled analyses showed generally positive effects on consultation processes on a range of measures relating to clarifying patients' concerns and beliefs; communicating about treatment options; levels of empathy; and patients' perception of providers' attentiveness to them and their concerns as well as their diseases. A new finding for this update is that short-term training (less than 10 hours) is as successful as longer training.The analyses showed mixed results on satisfaction, behaviour and health status. Studies using complex interventions that focused on providers and patients with condition-specific materials generally showed benefit in health behaviour and satisfaction, as well as consultation processes, with mixed effects on health status. Pooled analysis of the fewer than half of included studies with adequate data suggests moderate beneficial effects from interventions on the consultation process; and mixed effects on behaviour and patient satisfaction, with small positive effects on health status. Risk of bias varied across studies. Studies that focused only on provider behaviour frequently did not collect data on patient outcomes, limiting the conclusions that can be drawn about the relative effect of intervention focus on providers compared with providers and patients., Authors' Conclusions: Interventions to promote patient-centred care within clinical consultations are effective across studies in transferring patient-centred skills to providers. However the effects on patient satisfaction, health behaviour and health status are mixed. There is some indication that complex interventions directed at providers and patients that include condition-specific educational materials have beneficial effects on health behaviour and health status, outcomes not assessed in studies reviewed previously. The latter conclusion is tentative at this time and requires more data. The heterogeneity of outcomes, and the use of single item consultation and health behaviour measures limit the strength of the conclusions.

Objective: To examine the feasibility of using automated interactive voice response calls to assess prostate cancer survivor quality of life (QOL). In light of an increasing focus on patient-centered outcomes, innovative and efficient approaches to monitor QOL among prostate cancer survivors are increasingly valuable., Methods: Forty prostate cancer survivors less than 1 year post-treatment were enrolled at a university-based cancer center clinic from July through August 2011. We adapted the Expanded Prostate Cancer Index Composite (EPIC) survey, a prostate cancer-specific QOL instrument, for use via personal telephone with interactive voice response. We compared written vs interactive voice response EPIC scores across urinary, sexual, bowel, and vitality domains., Results: The median age of respondents was 63 years (range, 41-76 years) and the majority had undergone surgery (97.5%). The entire interactive voice response call was completed by 35 participants (87.5%). Over half of all interactive voice response calls were answered after 2 attempts with a median length of 11.3 minutes. On average, interactive voice response EPIC scores were slightly lower than written scores (-2.1 bowel, P = .05; -4.6 urinary incontinence, P < .01). Test-retest reliability was very high for urinary incontinence (r = .97) and sexual function domains (r = .96). Although mean scores were similar for other domains, their distributions had significant ceiling effects limiting our reliability measure interpretation., Conclusion: Automated interactive voice response calls are a feasible strategy for assessing prostate cancer survivor QOL. Interactive voice response could provide a low cost, sustainable, and systematic approach to measuring patient-centered outcomes, conducting comparative effectiveness research, and monitoring the quality of prostate cancer care., (Published by Elsevier Inc.)

The purpose of these secondary analyses was to examine relationships between patient factors and patient-provider decision-making style (PDM) on heart-healthy behavior changes in 142 adults with diabetes after hospitalization for an acute coronary syndrome (ACS). A clinical trial randomized adults to either control or a telephone coaching intervention. Generalized estimating equations were used to analyze the relationship between patient factors and PDM style on longitudinal postdischarge changes in three heart-healthy behaviors, avoiding high fat foods, weight loss, and increased physical activity. Neither PDM style nor telephone coaching intervention affected heart-healthy behaviors in this population. Although adults with diabetes preferred collaborative patient-provider decision-making, present levels of provider engagement were not sufficient to support behavior change. Results suggest the need for sustained and tailored nursing interventions to facilitate heart-healthy behavior changes in adults with diabetes after ACS hospitalization.

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., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: Decision aids prepare people to participate in decisions that involve weighing benefits, harms, and scientific uncertainty., Objectives: To evaluate the effectiveness of decision aids for people facing treatment or screening decisions., Search Strategy: For this update, we searched from January 2006 to December 2009 in MEDLINE (Ovid); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, issue 4 2009); CINAHL (Ovid) (to September 2008 only); EMBASE (Ovid); PsycINFO (Ovid); and grey literature. Cumulatively, we have searched each database since its start date., Selection Criteria: We included published randomised controlled trials (RCTs) of decision aids, which are interventions designed to support patients' decision making by providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies in which participants were not making an active treatment or screening decision., Data Collection and Analysis: Two review authors independently screened abstracts for inclusion, extracted data, and assessed potential risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards, were:A) decision attributes;B) decision making process attributes.Secondary outcomes were behavioral, health, and health system effects. We pooled results of RCTs using mean differences (MD) and relative risks (RR), applying a random effects model., Main Results: Of 34,316 unique citations, 86 studies involving 20,209 participants met the eligibility criteria and were included. Thirty-one of these studies are new in this update. Twenty-nine trials are ongoing. There was variability in potential risk of bias across studies. The two criteria that were most problematic were lack of blinding and the potential for selective outcome reporting, given that most of the earlier trials were not registered.Of 86 included studies, 63 (73%) used at least one measure that mapped onto an IPDAS effectiveness criterion: A) criteria involving decision attributes: knowledge scores (51 studies); accurate risk perceptions (16 studies); and informed value-based choice (12 studies); and B) criteria involving decision process attributes: feeling informed (30 studies) and feeling clear about values (18 studies).A) Criteria involving decision attributes:Decision aids performed better than usual care interventions by increasing knowledge (MD 13.77 out of 100; 95% confidence interval (CI) 11.40 to 16.15; n = 26). When more detailed decision aids were compared to simpler decision aids, the relative improvement in knowledge was significant (MD 4.97 out of 100; 95% CI 3.22 to 6.72; n = 15). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.74; 95% CI 1.46 to 2.08; n = 14). The effect was stronger when probabilities were expressed in numbers (RR 1.93; 95% CI 1.58 to 2.37; n = 11) rather than words (RR 1.27; 95% CI 1.09 to 1.48; n = 3). Exposure to a decision aid with explicit values clarification compared to those without explicit values clarification resulted in a higher proportion of patients achieving decisions that were informed and consistent with their values (RR 1.25; 95% CI 1.03 to 1.52; n = 8).B) Criteria involving decision process attributes:Decision aids compared to usual care interventions resulted in: a) lower decisional conflict related to feeling uninformed (MD -6.43 of 100; 95% CI -9.16 to -3.70; n = 17); b) lower decisional conflict related to feeling unclear about personal values (MD -4.81; 95% CI -7.23 to -2.40; n = 14); c) reduced the proportions of people who were passive in decision making (RR 0.61; 95% CI 0.49 to 0.77; n = 11); and d) reduced proportions of people who remained undecided post-intervention (RR 0.57; 95% CI 0.44 to 0.74; n = 9). Decision aids appear to have a positive effect on patient-practitioner communication in the four studies that measured this outcome. For satisfaction with the decision (n = 12) and/or the decision making process (n = 12), those exposed to a decision aid were either more satisfied or there was no difference between the decision aid versus comparison interventions. There were no studies evaluating the decision process attributes relating to helping patients to recognize that a decision needs to be made or understand that values affect the choice.C) Secondary outcomesExposure to decision aids compared to usual care continued to demonstrate reduced choice of: major elective invasive surgery in favour of conservative options (RR 0.80; 95% CI 0.64 to 1.00; n = 11). Exposure to decision aids compared to usual care also resulted in reduced choice of PSA screening (RR 0.85; 95% CI 0.74 to 0.98; n = 7). When detailed compared to simple decision aids were used, there was reduced choice of menopausal hormones (RR 0.73; 95% CI 0.55 to 0.98; n = 3). For other decisions, the effect on choices was variable. The effect of decision aids on length of consultation varied from -8 minutes to +23 minutes (median 2.5 minutes). Decision aids do not appear to be different from comparisons in terms of anxiety (n = 20), and general health outcomes (n = 7), and condition specific health outcomes (n = 9). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive., Authors' Conclusions: New for this updated review is evidence that: decision aids with explicit values clarification exercises improve informed values-based choices; decision aids appear to have a positive effect on patient-practitioner communication; and decision aids have a variable effect on length of consultation.Consistent with findings from the previous review, which had included studies up to 2006: decision aids increase people's involvement, and improve knowledge and realistic perception of outcomes; however, the size of the effect varies across studies. Decision aids have a variable effect on choices. They reduce the choice of discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, patient-practitioner communication, cost-effectiveness, and use with developing and/or lower literacy populations need further evaluation. Little is known about the degree of detail that decision aids need in order to have positive effects on attributes of the decision or decision-making process.

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 in the United States has become an important element in health policy debates. The recently passed federal health care reform legislation includes several key provisions related to shared decision making (SDM) and patient decision support. Several states have passed or are considering legislation that incorporates SDM as a key component of improved health care provision. Research on SDM is funded by a range of public and private organizations. Non-profit, for-profit, academic and government organizations are developing decision support interventions for numerous conditions. Some interventions are publicly available; others are distributed to patients through health insurance and healthcare providers. A significant number of clinical implementation projects are underway to test and evaluate different ways of incorporating SDM and patient decision support into routine clinical care. Numerous professional organizations are advocating for SDM and social networking efforts are increasing their advocacy as well. Policy makers are intrigued by the potential of SDM to improve health care provision and potentially lower costs. The role of shared decision making in policy and practice will be part of the larger health care reform debate., (2011. Published by Elsevier GmbH.)

In its brief tenure evidence-based medicine (EBM) has proven to be a powerful magnet for criticism, while at the same time it has demonstrated impressive resilience. Located within the ongoing critical discourse surrounding the strengths and weaknesses of an EBM approach is the persistent question of the proper place of the social sciences relative to other disciplinary perspectives. This article considers one way the social sciences might usefully illuminate EBM-mediated human interactions to influence policy. We focus on the ethical nexus of the human impulse for unlimited consumption of health care resources in those situations where there exist competing clinical management options and suggest strategies for resource-preserving shared decision making. We conclude that a frugal default option is a fruitful avenue for future exploration in such situations.

Background: Decision aids prepare people to participate in 'close call' decisions that involve weighing benefits, harms, and scientific uncertainty., Objectives: To conduct a systematic review of randomised controlled trials (RCTs) evaluating the efficacy of decision aids for people facing difficult treatment or screening decisions., Search Strategy: We searched MEDLINE (Ovid) (1966 to July 2006); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library; 2006, Issue 2); CINAHL (Ovid) (1982 to July 2006); EMBASE (Ovid) (1980 to July 2006); and PsycINFO (Ovid) (1806 to July 2006). We contacted researchers active in the field up to December 2006. There were no language restrictions., Selection Criteria: We included published RCTs of interventions designed to aid patients' decision making by providing information about treatment or screening options and their associated outcomes, compared to no intervention, usual care, and alternate interventions. We excluded studies in which participants were not making an active treatment or screening decision, or if the study's intervention was not available to determine that it met the minimum criteria to qualify as a patient decision aid., Data Collection and Analysis: Two review authors independently screened abstracts for inclusion, and extracted data from included studies using standardized forms. The primary outcomes focused on the effectiveness criteria of the International Patient Decision Aid Standards (IPDAS) Collaboration: attributes of the decision and attributes of the decision process. We considered other behavioural, health, and health system effects as secondary outcomes. We pooled results of RCTs using mean differences (MD) and relative risks (RR) using a random effects model., Main Results: This update added 25 new RCTs, bringing the total to 55. Thirty-eight (69%) used at least one measure that mapped onto an IPDAS effectiveness criterion: decision attributes: knowledge scores (27 trials); accurate risk perceptions (11 trials); and value congruence with chosen option (4 trials); and decision process attributes: feeling informed (15 trials) and feeling clear about values (13 trials).This review confirmed the following findings from the previous (2003) review. Decision aids performed better than usual care interventions in terms of: a) greater knowledge (MD 15.2 out of 100; 95% CI 11.7 to 18.7); b) lower decisional conflict related to feeling uninformed (MD -8.3 of 100; 95% CI -11.9 to -4.8); c) lower decisional conflict related to feeling unclear about personal values (MD -6.4; 95% CI -10.0 to -2.7); d) reduced the proportion of people who were passive in decision making (RR 0.6; 95% CI 0.5 to 0.8); and e) reduced proportion of people who remained undecided post-intervention (RR 0.5; 95% CI 0.3 to 0.8). When simpler decision aids were compared to more detailed decision aids, the relative improvement was significant in knowledge (MD 4.6 out of 100; 95% CI 3.0 to 6.2) and there was some evidence of greater agreement between values and choice.In this review, we were able to explore the use of probabilities in decision aids. Exposure to a decision aid with probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.6; 95% CI 1.4 to 1.9). The effect was stronger when probabilities were measured quantitatively (RR 1.8; 95% CI 1.4 to 2.3) versus qualitatively (RR 1.3; 95% CI 1.1 to 1.5).As in the previous review, exposure to decision aids continued to demonstrate reduced rates of: elective invasive surgery in favour of conservative options, decision aid versus usual care (RR 0.8; 95% CI 0.6 to 0.9); and use of menopausal hormones, detailed versus simple aid (RR 0.7; 95% CI 0.6 to 1.0). There is now evidence that exposure to decision aids results in reduced PSA screening, decision aid versus usual care (RR 0.8; 95% CI 0.7 to 1.0) . For other decisions, the effect on decisions remains variable.As in the previous review, decision aids are no better than comparisons in affecting satisfaction with decision making, anxiety, and health outcomes. The effects of decision aids on other outcomes (patient-practitioner communication, consultation length, continuance, resource use) were inconclusive.There were no trials evaluating the IPDAS decision process criteria relating to helping patients to recognize a decision needs to be made, understand that values affect the decision, or discuss values with the practitioner., Authors' Conclusions: Patient decision aids increase people's involvement and are more likely to lead to informed values-based decisions; however, the size of the effect varies across studies. Decision aids have a variable effect on decisions. They reduce the use of discretionary surgery without apparent adverse effects on health outcomes or satisfaction. The degree of detail patient decision aids require for positive effects on decision quality should be explored. The effects on continuance with chosen option, patient-practitioner communication, consultation length, and cost-effectiveness need further evaluation.

Background: A hospital admission for a serious cardiac event offers a unique opportunity for smoking cessation. Understanding the factors that predict and enhance cessation among smoking cardiac inpatients is important for hospital physicians and clinical staff., Study Objective: To determine factors that predict smoking cessation, relapse, or continued smoking among posthospitalized cardiac patients who were smoking at the time of admission., Sample: Patients hospitalized with acute coronary syndrome (ACS) were recruited from 5 hospitals in Michigan to participate in a study assessing hospital quality improvement plus at-home health behavior change counseling., Measurements: Patient interview data were collected shortly after discharge and 3 and 8 months later to describe patient demographics, clinical characteristics, tobacco use, and other behaviors. Multinomial logit regression was used to predict smoking cessation, relapse, and continued smoking., Results: Of patients smoking at hospitalization who completed both follow-up interviews, 56.8% (n = 111) were not smoking at 8 months. A significant predictor of successful cessation was higher household income (odds ratio [OR] = 4.72; P = 0.003), while having other smokers in the household decreased the odds of cessation (OR = 0.20; P = 0.001). History of depression increased the odds of relapse (OR = 6.38; P = 0.002) and being a lighter smoker decreased the odds (OR = 0.16; P = 0.026)., Conclusions: Although approximately one-half of the smokers in this study reported successful cessation, interventions are still needed to assist all smokers to successfully quit smoking after an ACS hospitalization. Our data suggest targeting follow-up programs to include other family members and using specialized methods for heavy smokers., ((c) 2009 Society of Hospital Medicine.)

The most popular current models of medical decision making, identified by names such as shared decision making, informed decision making, and evidence-based patient choice, portray an empowered patient actively involved in his or her medical choices and generally assume that patient and physician reach agreement. These models are limited to a specific type of decision (in which there is more than one choice) and a specific process (in which agreement is reached). The authors extend the model of medical decision making beyond shared decisions in 2 dimensions. First, the authors incorporate a class of medical decisions in which there is only one medically reasonable treatment option, such as the removal of a primary melanoma. Patient preferences are irrelevant to whether or not the melanoma should be removed, so there is no treatment choice in which the patient can share. When there is only one realistic treatment option, the clinician's job is not to offer alternatives but to explain why there is only one viable choice and move the decision-making process forward. The physician does not thereby abridge the patient's autonomy; rather, the disease process itself constrains both patient and physician. Second, the authors include decisions in which patient and physician do not reach agreement. Sometimes the patient insists on a particular treatment and the physician reluctantly yields, sometimes it is the other way around, but disagreement is commonplace in clinical medicine and its presence deserves inclusion in the way we think about medical decisions. Conflict resolution requires acknowledging the potential for conflict.

Background: Telephone counseling in chronic disease self-management is increasing, but has not been tested in studies that control for quality of medical care., Objective: To test the effectiveness of a six-session outpatient telephone-based counseling intervention to improve secondary prevention (behaviors, medication) in patients with acute coronary syndrome (ACS) following discharge from hospital, and impact on physical functioning and quality of life at 8 months post-discharge., Design: Patient-level randomized trial of hospital quality improvement (QI-only) versus quality improvement plus brief telephone coaching in three months post-hospitalization (QI-plus)., Data: medical record, state vital records, patient surveys (baseline, three and eight months post-hospitalization)., Analysis: pooled-time series generalized estimating equations to analyze repeated measures; intention-to-treat analysis., Participants: Seven hundred and nineteen patients admitted to one of five hospitals in two contiguous mid-Michigan communities enrolled; 525 completed baseline surveys., Measurements: We measured secondary prevention behaviors, physical functioning, and quality of life., Results: QI-plus patients showed higher self-reported physical activity (OR = 1.53; p = .01) during the first three months, with decline after active intervention was withdrawn. Smoking cessation and medication use were not different at 3 or 8 months; functional status and quality of life were not different at 8 months., Conclusions: Telephone coaching post-hospitalization for ACS was modestly effective in accomplishing short-term, but not long-term life-style behavior change. Previous positive results shown in primary care did not transfer to free-standing telephone counseling as an adjunct to care following hospitalization.

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.

Purpose: The purpose of this study is to test the feasibility of a brief shared decision-making (SDM) goal-setting intervention among individuals with type 2 diabetes., Methods: A convenience sample of 58 patients from the University Internal Medicine Resident Clinic was recruited to participate in the study. Outcomes were tested through a pilot test of the intervention and ongoing conversations with clinic nursing staff and physicians. Patient outcomes included preintervention and postintervention hemoglobin A1C (HbA1c), weight and blood pressure levels, preintervention and postintervention patient survey questionnaires, and documented diabetes goals., Results: Most providers indicated that the SDM intervention did not impose major demands. Patient-centered interviewing and an SDM approach to goal setting led to 75.9% of patients having at least 1 diabetes management goal documented in their medical record after intervention. HbA1c level, weight, and diabetes empowerment score showed a trend toward improvement, as did patient ratings of "life disruption from having diabetes." Postintervention perceived knowledge of diabetes and treatments increased significantly (P = .001), as did the mean numbers of documented diabetes management goals (P < .001)., Conclusions: An SDM intervention for individuals with type 2 diabetes appears to be feasible and may improve major diabetes outcomes in primary care. SDM workbooks and activities can encourage patients to identify realistic diabetes goals with primary care providers. These results are encouraging. Future randomized trials with larger samples are warranted.

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.

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.

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.

Objective: To develop a set of quality criteria for patient decision support technologies (decision aids)., Design and Setting: Two stage web based Delphi process using online rating process to enable international collaboration., Participants: Individuals from four stakeholder groups (researchers, practitioners, patients, policy makers) representing 14 countries reviewed evidence summaries and rated the importance of 80 criteria in 12 quality domains on a 1 to 9 scale. Second round participants received feedback from the first round and repeated their assessment of the 80 criteria plus three new ones., Main Outcome Measure: Aggregate ratings for each criterion calculated using medians weighted to compensate for different numbers in stakeholder groups; criteria rated between 7 and 9 were retained., Results: 212 nominated people were invited to participate. Of those invited, 122 participated in the first round (77 researchers, 21 patients, 10 practitioners, 14 policy makers); 104/122 (85%) participated in the second round. 74 of 83 criteria were retained in the following domains: systematic development process (9/9 criteria); providing information about options (13/13); presenting probabilities (11/13); clarifying and expressing values (3/3); using patient stories (2/5); guiding/coaching (3/5); disclosing conflicts of interest (5/5); providing internet access (6/6); balanced presentation of options (3/3); using plain language (4/6); basing information on up to date evidence (7/7); and establishing effectiveness (8/8)., Conclusions: Criteria were given the highest ratings where evidence existed, and these were retained. Gaps in research were highlighted. Developers, users, and purchasers of patient decision aids now have a checklist for appraising quality. An instrument for measuring quality of decision aids is being developed.

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.

The importance of incorporating patient and provider decision-making processes is in the forefront of the National Institute of Mental Health (NIMH) agenda for improving mental health interventions and services. Key concepts in patient decision making are highlighted within a simplified model of patient decision making that links patient-level/"micro" variables to services-level/"macro" variables via the decision-making process that is a target for interventions. The prospective agenda for incorporating decision-making concepts in mental health research includes (a) improved measures for characterizing decision-making processes that are matched to study populations, complexity, and types of decision making; (b) testing decision aids in effectiveness research for diverse populations and clinical settings; and (c) improving the understanding and incorporation of preference concepts in enhanced intervention designs.

Background: To ensure that patients make informed medical decisions, patient education materials must communicate treatment risks and benefits., Objective: To survey publicly available patient education materials and assess their suitability to support informed decision making in early-stage prostate cancer., Design: Cross-sectional review of Internet, print, and multimedia sources., Setting: University data analysis laboratory., Measurements: The content of 44 materials that described all standard treatment options was reviewed. Top-rated documents underwent plain-language review. Total score on 54 content items and accuracy, balance, and plain-language evaluation was measured., Results: 502 of 546 patient education materials did not describe all standard treatments (watchful waiting, surgery, radiation, and hormone therapy). Eighty percent of the 44 materials that addressed standard treatments and underwent content review described anatomy, physiology, stage, and grade of cancer. Half of the materials fully described radical prostatectomy and radiation therapy. One third of the materials included risks and benefits of each treatment; none explicitly compared outcomes of all treatments in a single summary. Information was accurate and balanced but did not include key content for informed consent., Limitations: The search was restricted to publicly available materials and did not include books or materials written in languages other than English. The accuracy, balance, and plain-language reviews were evaluated by 1 reviewer. The criteria reflect the authors' focus on informed decision making. Other aspects of health education may require a different evaluation template., Conclusions: Currently available patient education materials on early-stage prostate cancer treatment do not contain comprehensive information about the risks and benefits of each treatment. To assist patients and physicians in choosing among prostate cancer treatment options, a new generation of materials is needed.

Statistical models have been used to assess the influence of clinical and demographic factors on hospital charge and length of stay (LOS). Hospital costs constitute a significant proportion of overall expenditure in health care. With escalating costs, knowing the correlates of LOS and in-hospital cost is important for decisions on allocating resources. However, hospital charge and LOS are correlated. We describe two regression models that permit estimation of mean charges as a function of patient hospital stay and adjust for the influence of patient characteristics and treatment procedures on LOS and charge. In the first model, the mean charge over a specified duration is a weighted average of the expected cumulative charge, with weighting determined by the distribution of LOS. The second model for LOS and charge explicitly accounts for their correlation and yields estimates of the average charge per average LOS. The methods are applied to assess mean charges and mean charge per day by cardiac procedure in a cohort of patients hospitalized for acute myocardial infarction, while adjusting for the impact of patient demographic and clinical factors on LOS and charge. For relatively short hospital stays, and when only total hospital charges are available, these models provide a flexible approach to estimating summary measures on resource use while controlling for the effects of covariates on LOS and charge., (Copyright 2002 John Wiley & Sons, Ltd.)

Objective: To conduct a preliminary validation of the Satisfaction With Decision (SWD) scale with depressed primary care patients., Design: Cross-sectional observational pilot study using a postal survey., Setting and Participants: Depressed primary care patients (n = 97) who recently had made a new decision about antidepressant medication use completed surveys regarding their treatment decisions., Main Variables: Measures included patient-reported satisfaction with decision, decisional conflict, knowledge about depression and treatment, decision involvement, pain and health status, antidepressant medication efficacy, and satisfaction with health services., Results: The SWD scale had good internal consistency reliability (alpha = 0.85). Evidence for construct validity was confirmed via a hypothesized pattern of relationships between the SWD scale and other measures. Decision satisfaction was associated with several issues of relevance for designing patient-centred decision support interventions: (1) knowledge about depression and treatment; (2) involvement in health-related decisions; and (3) aiding evaluation of trade-offs among pros and cons of treatment., Conclusions: The results of this pilot study show that the SWD scale appears to be a psychometrically sound and practical measure for research with this population. Additional research is needed on the theoretical nature of decision satisfaction and developing and testing patient-centred decision support interventions for depression treatment.

Background: Decision aids prepare people to participate in preference-sensitive decisions., Objectives: 1. Create a comprehensive inventory of patient decision aids focused on healthcare options. 2. Review randomized controlled trials (RCT) of decision aids, for people facing healthcare decisions., Search Strategy: Studies were identified through databases and contact with researchers active in the field., Selection Criteria: Two independent reviewers screened abstracts for interventions designed to aid patients' decision making by providing information about treatment or screening options and their associated outcomes. Information about the decision aids was compiled in an inventory; those that had been evaluated in a RCT were reviewed in detail., Data Collection and Analysis: Two reviewers independently extracted data using standardized forms. Results of RCTs were pooled using weighted mean differences (WMD) and relative risks (RR) using a random effects model., Main Results: Over 200 decision aids were identified. Of the 131 available decision aids, most are intended for use before counselling. Using the CREDIBLE criteria to evaluate the quality of the decision aids: a) most included potential harms and benefits, credentials of the developers, description of their development process, update policy, and were free of perceived conflict of interest; b) many included reference to relevant literature; c) few included a description of the level of uncertainty regarding the evidence; and d) few were evaluated. Thirty of these decision aids were evaluated in 34 RCTs and another trial evaluated a suite of eight decision aids. An additional 30 trials are yet to be published. Among the trials comparing decision aids to usual care, decision aids performed better in terms of: a) greater knowledge (WMD 19 out of 100, 95% CI: 13 to 24; b) more realistic expectations (RR 1.4, 95%CI: 1.1 to 1.9); c) lower decisional conflict related to feeling informed (WMD -9.1 of 100, 95%CI: -12 to -6); d) increased proportion of people active in decision making (RR 1.4, 95% CI: 1.0 to 2.3); and e) reduced proportion of people who remained undecided post intervention (RR 0.43, 95% CI: 0.3 to 0.7). When simpler were compared to more detailed decision aids, the relative improvement was significant in: a) knowledge (WMD 4 out of 100, 95% CI: 3 to 6); b) more realistic expectations (RR 1.5, 95% CI: 1.3 to 1.7); and c) greater agreement between values and choice. Decision aids appeared to do no better than comparisons in affecting satisfaction with decision making, anxiety, and health outcomes. Decision aids had a variable effect on which healthcare options were selected., Reviewer's Conclusions: The availability of decision aids is expanding with many on the Internet; however few have been evaluated. Trials indicate that decision aids improve knowledge and realistic expectations; enhance active participation in decision making; lower decisional conflict; decrease the proportion of people remaining undecided, and improve agreement between values and choice. The effects on persistence with chosen therapies and cost-effectiveness require further evaluation. Finally, optimal strategies for dissemination need to be explored.

Purpose: The purpose of this study was to provide insight into the modest success of a physician and patient education and reminder program that improved screening rates from 37% to 49% among rural Medicaid-eligible patients in western Michigan., Description of Study: The following four focus groups were conducted: African American men, African American women, White men, and White women, matched with moderators by gender and ethnicity. The sample was selected by contacting prior eligible screening refusers, completing groups with a convenience sample who had accepted screening. Twenty-one patients participated who were ages >50 years. The screening refusal rates were 19% for men and 9% for women. Open-ended questions guided the discussion of colorectal cancer (CRC) attitudes, beliefs, and practices., Results: All participants believed in the efficacy of cancer screening. White women were better informed about screening purposes and procedures. The major barriers to screening were quality of care (ie, the perceived lack of offering screening and the follow-up of test results) and the potential for pain from screening or treatment of CRC, should it be discovered., Clinical Implications: Successful efforts to improve awareness of the importance and efficacy of screening must further address deeply held skepticism and fears about CRC screening in this population. A fruitful direction for this difficult problem appears to be improved communication (both negative and positive test results). Without feedback, patients with negative results may assume lack of provider follow-through.

Background: With publication of The Belmont Report concerning ethical principles, informed consent gained explicit guidelines for the protection of human subjects of research. However, there is still little evidence about how well informed consent works to assist patients to reach informed decisions about research participation., Objective: To review behavioral decision theory and research to identify implications for informed consent., Research Design: Traditional literature review and hand search of literature were used., Results: Psychological research on biases and heuristics identifies cognitive biases in information processing (selection and interpretation of risks and benefits) that have implications for improving the informing process. A growing literature on patient decision aids provides evidence for the feasibility of more fully informing patients, and includes examples of "debiasing" procedures (to improve information comprehension and consent)., Conclusions: Informing and consenting involve conceptually different challenges concerning effectiveness versus values. Debiasing techniques need to be developed and empirically tested to determine their effectiveness in informing patients. Consenting involves both social and individual values. Appealing to altruism when summarizing the goals of research may increase research participation and does not necessarily violate voluntariness of informed consent. Additional research is needed to determine when information-processing biases occur problematically in health-related informed consent, and whether appealing to altruism increases research participation.

Objective: To assess the influence of race and gender influence on the use of invasive procedures in patients with acute myocardial infarction (AMI) in community hospitals., Design: Prospective, observational., Setting: Five mid-Michigan community hospitals., Patients: All patients (838) identified with AMI between January 1994 and April 1995 in 1 of these hospitals., Measurements and Main Results: After adjusting for age, hospital of admission, insurance type, severity of AMI, and comorbidity, using white men as the reference group, the rate of being offered cardiac catheterization (CC) was 0.88 (95% confidence interval [95% CI], 0.60 to 1.29) for white women; 0.79 (95% CI, 0.41 to 1.50) for black men; and 1.14 (95% CI, 0.53 to 2.45)for black women. Among patients who underwent CC, after also adjusting for coronary artery anatomy, the rate of being offered angioplasty, using white men as the reference group, was 1.22 (95% CI, 0.75 to 1.98) for white women; 0.61 (5% CI, 0.29 to 1.28, P =.192) for black men; and 0.40 (95% CI, 0.14 to 1.13) for black women The adjusted rate of being offered bypass surgery was 0.47 (95% CI, 0.24 to 0.89) for white women; 0.36 (95% CI, 0.12 to 1.06) for black men; and 0.37 (95% CI, 0.11 to 1.28)for black women., Conclusions: Our study shows that white women are less likely than white men to be offered bypass surgery after AMI. Although black men and women with AMI are less likely than white men to be offered percutaneous transluminal coronary angioplasty or coronary artery bypass grafting in both unadjusted and adjusted analyses, these findings did not reach statistical significance. Our study is limited in power due to the small number of blacks in the sample.

OBJECTIVE: Determine feasibility of shared decision-making programmes in fee-for-service hospital systems including physicians' offices and in-patient facilities. DESIGN: Survey and participant observation. Data obtained during Phase 1 of a patient outcome study. SETTINGS AND PARTICIPANTS: Three hospitals in Michigan: one 299-bed rural regional hospital, one 650-bed urban community hospital, one 459-bed urban and suburban teaching hospital. All nurses and physicians who agreed to use the programmes participated in the evaluation (n = 34). INTERVENTION: Two shared decision-making(R) (SDP) multimedia programmes: surgical treatment choice for breast cancer and ischaemic heart disease treatment choice. MAIN OUTCOME MEASURES: (1) clinicians' evaluations of programme quality; (2) challenges in hospital settings; and (3) patient referral rates. RESULTS: SDP programmes were judged to be clear, accurate and about the right length and amount of information. Programmes were judged to be informative and appropriate for patients to see before making a decision. Clinicians were neutral about patients' desire to participate in treatment decision-making. Referral volume to SDPs was lower than expected: 24 patients in 7 months across three hospitals. Implementation challenges centred on time pressures in patient care. CONCLUSIONS: Productivity and time pressure in US health care severely constrain shared decision-making programme implementation. Physician referral may not be a reliable mechanism for patient access. Possible innovations include: (1) incorporation into the informed consent process; (2) provider or payer negotiated requirement in the routine hospital procedure to use the SDP as a quality indicator; and (3) payer reimbursement to professional providers who make SDP programmes available to patients.

Patient decision support (PDS) tools or decision aids have been developed as adjuncts to the clinical encounter. Their aim is to support evidence-based patient choice. Clinical trials of PDS tools have used an array of outcome measures to determine efficacy, including knowledge, satisfaction, health status and consistency between patient choice and values. This paper proposes that the correlation between 'subjective expected utility' (SEU) and decision may be the best primary endpoint for trials. SEU is a measure usually used in behavioural decision theory. The paper first describes how decision support tools may use decision analysis to structure the presentation of evidence and guide patient decision-making. Uses of expected utility (EU) are suggested for evaluating PDS tools when improving population health status is the objective. SEU is the theoretically better measure when internal consistency of patient choices is the objective.

Background: Previous studies documenting underutilization of angiotensin-converting enzyme inhibitors (ACEIs) in acute myocardial infarction (AMI) have been limited to Medicare populations., Hypothesis: This study examines ACEI prescription rates and predictors in a community sample of hospitalized patients with AMI., Methods: The charts of 1163 community patients with AMI, prospectively identified at admission between January 1, 1994, and April 30, 1995, were reviewed., Results: Only 64 of 158 (40%) patients considered ideal candidates for ACEI prescription were discharged with a prescription for an ACEI. In a multivariate logistic regression model, prior ACEI utilization [adjusted odds ration (OR) = 3.26; 95% confidence interval (CI) = 2.05-5.20], presence of congestive heart failure (OR = 2.33; CI = 1.50-3.61) and black race (OR = 2.20; CI = 1.34-3.64) were identified as positive predictors of ACEI prescription. Conversely, lack of left ventricular ejection fraction (LVEF) measurement (OR = 0.46; CI = 0.28-0.75), LVEF > 40 ( OR = 0.27; CI = 0.18-0.40), and acute renal failure (OR = 0.08; CI = 0.01-0.44) were negative predictors. Women were also less likely to be discharged with an ACEI prescription (OR = 0.71; CI = 0.48-1.05). Furthermore, women were significantly less likely to have LVEF measured prior to discharge than were males (77 vs. 85%, p = 0.001)., Conclusion: This study underscores the need for improvement in the utilization of ACEI in eligible patients with AMI. It also identifies opportunities for improvement in prescription rates, especially in women.