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For patients considering a left ventricular assist device (LVAD), we developed a decision aid (DA) and demonstrated its effectiveness. The I-DECIDE-LVAD project subsequently disseminated the DA to LVAD programs across the country and assessed its use, finding 70% of total programs adopted it into routine practice. Qualitative data were collected to further understand how and why the DA was implemented. Semi-structured interviews about the DA's use were conducted with a sub-set of LVAD programs. The interview guide and analysis were guided by RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance). Interviews were transcribed, coded, and analyzed using content analysis. We interviewed 37 participants from 20 different LVAD programs; 19 were LVAD coordinators, 18 heart failure cardiologists, 20 female, mean age of 44 years. Interviews showed the DA was used differently across programs. For Reach, sites distributed the DA 1) to all patients evaluated for LVAD as standard of care, 2) ad hoc, or 3) by specific clinicians but not as an organized programmatic effort. Distribution to caregivers was encouraged either by directly providing to caregivers or by asking patients to share it. Adoption of the DA occurred through both top-down (medical director to LVAD coordinator) and bottom-up (coordinator or social worker to leadership team) approaches, and successful adoption often required both committee/team approval and coordinator buy in. For Implementation, the DA was used in both inpatient and outpatient settings. Outpatient use was often earlier in disease progression and allowed patients to view the DA over time, at home with family. Inpatient use had both advantages and challenges; patients were captive audiences in their hospital rooms with time to review, but might be too sick or overwhelmed. The DA was typically provided by the LVAD coordinator around a formal teaching session, including 1) during, where it was used as a guide for teaching, 2) before, to prep the patients, or 3) after, as a resource. The DA was adopted across programs with various levels of Reach and Implementation, in part due to its versatility in how, when, and by whom it could be provided. Having one tool that can be used in multiple settings and in various capacities has likely increased its adoption into routine practice. [ABSTRACT FROM AUTHOR]

A pamphlet and video decision aid (DA) developed for patients and families considering a left ventricular assist device (LVAD) was previously shown to be effective in improving decision quality. Subsequently, the DA was disseminated to LVAD programs across the country as part of the I-DECIDE-LVAD project. A patient survey was performed to understand patients' experiences in shared decision making and in using the DA. Twenty programs that reported using the I-DECIDE-LVAD DA were selected to broadly represent various institutional types, program sizes, and geographic regions across the United States. Each site was asked to distribute a survey to up to 30 patients who had recently been evaluated for LVAD. The survey contained questions related to patients' decision experiences including a validated 4-item decision process measure (scored 0-4) and the 3-item CollaboRATE measure (scored 0-9); higher scores indicate higher-quality shared decision making for both measures. Additionally, the survey asked if and how the patient used the DA, and the validated Acceptability Questionnaire about the DA. Sixteen programs distributed 439 surveys and received 205 responses (response rate 46.7%). On the decision process measure, patients scored a mean of 2.8 out of 4 (range 0-4). On the CollaboRATE measure, patients scored a mean of 8.5 out of 9 (range 3.7 - 9.0). A total of 63.5% of respondents reported receiving the I-DECIDE DA pamphlet and 39.5% received the video. The majority (58.5%) of patients received the DA from an LVAD coordinator and most commonly (39.5%) over two weeks before their implant. Of those that received it, 47.5% spent more than 15 minutes with the pamphlet and 84.9% watched the entire video. Additionally, 94% reviewed the DA with someone, most commonly a wife (29%) or daughter (14%). The content of the DA was rated as highly acceptable, including that it was the right amount of information (66.4%), easy to understand (52.8%), and helpful in the decision-making process (83.6%); respondents also reported that the DA was either completely balanced (56.4%) or slanted towards getting an LVAD (23.5%). Patients who were evaluate for LVAD reported high-quality shared decision making. The majority of patients remember receiving the LVAD DA. How they used the DA in terms of when they received it and with whom they watched it varied. [ABSTRACT FROM AUTHOR]

Background and Objectives: Studies note a high prevalence of pediatric coronavirus disease 2019 (COVID-19)-specific vaccine hesitancy in the United States. Our objective was to assess whether clinicians perceive a spillover effect of COVID-19 vaccine hesitancy onto other vaccines, and the impact of this spillover on their general recommendation behavior., Methods: We conducted semistructured interviews with pediatricians in California and Colorado pediatric practices (January-March 2023). We transcribed, coded, and analyzed interviews using content analysis., Results: We interviewed 21 pediatricians (10 in California, 11 in Colorado). Clinicians observed some spillover effect of vaccine-favorable changes among some parents and greater hesitancy among others regarding the risks and benefits of childhood vaccination in general. This spillover was informed by 2 divergent patterns of parental trust in health systems and individual clinicians caused by the COVID-19 pandemic. Factors driving perceived changes included media coverage, greater knowledge about vaccination, and misinformation. Some clinicians felt that their approach to vaccine recommendations became more patient-centered, whereas others reported declining engagement in persuading hesitant parents about vaccination., Conclusions: Clinicians described a hardening of parental views toward vaccines in both directions, which impacted their recommendation behavior. There is a need for vaccine hesitancy monitoring and better training and support for clinicians facing vaccine hesitant parents., (Copyright © 2024 by the American Academy of Pediatrics.)

Objective: Higher uncertainty is associated with poorer quality of life and may be impacted by clinician communication about the future. We determined how patients undergoing lung transplant evaluation experience uncertainty and communication about the future from clinicians., Methods: We performed a convergent parallel mixed-methods study using a cross-sectional survey and semistructured interviews. Patients undergoing lung transplant evaluation at the University of Colorado and the University of Washington answered questions about future communication and completed the Mishel Uncertainty in Illness Scale-Adult (MUIS-A; range 33-165, higher scores indicate more uncertainty). Interviews were analyzed using content analysis. Integration of survey and interview results occurred during data interpretation., Results: A total of 101 patients completed the survey (response rate: 47%). Twelve survey participants completed interviews. In the survey, most patients identified changing family roles as important (76%), which was infrequently discussed with clinicians (31%). Most patients (86%) worried about the quality of their life in the future, and 74% said that not knowing what to expect in the future prevented them from making plans. The mean MUIS-A score was 85.5 (standard deviation 15.3). Interviews revealed three themes: (1) uncertainty of the future distresses participants; (2) participants want practical information from clinicians; and (3) communication preferences vary among participants., Conclusion: Participants experienced distressing uncertainty and wanted information about the future. Communication topics that were important to participants were not always addressed by physicians. Clinicians should address how chronic lung disease and lung transplant can directly impact patients' lives and support patients to cope with uncertainty., (© 2024 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: In the United States, there are no federal restrictions on the use of methadone to manage opioid withdrawal symptoms when patients are hospitalized with a medical or surgical condition other than addiction. In contrast, in an outpatient setting, methadone for opioid use disorder (OUD) is highly regulated by federal and state governments and can only be dispensed from an opioid treatment program (OTP). Discrepancies in regulatory requirements across these settings may lead to barriers in care for patients with OUD., Objective: Identify how methadone regulation impacts the care of patients with OUD during hospitalization, care transitions, and in the OTP setting., Methods: We completed 26 interviews with clinicians and social workers working on hospital-based addiction consultation services across the United States. Study findings are the result of a secondary content analysis of interviews to identifying the word "methadone" and construct themes resulting from the data., Results: We identified three major themes related to "methadone" for OUD treatment, all of which impacted patient care: (1) limited OTP hours leads to tenuous or delayed hospital discharges; (2) inadequate information-sharing between hospitals and OTPs leads to delays in care; and (3) methadone regulations create treatment barriers for the most vulnerable patients., Conclusion: Strict methadone regulations have resulted in unintended consequences for patients with OUD in the hospital setting, during care transitions, and in the OTP setting. Recent and ongoing federal efforts to reform methadone provision may improve some of the reported challenges, but significant hurdles remain in providing safe, equitable care to hospitalized patients with OUD., (© 2024 Society of Hospital Medicine.)

Background: The contribution of clinical inertia to suboptimal guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF) remains unclear., Objectives: This study examined reasons for GDMT nonintensification and characterized clinical inertia., Methods: In this secondary analysis of EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction), a randomized clinical trial evaluating a patient-activation tool on GDMT utilization, we performed a sequential, explanatory mixed-methods study. Reasons for nonintensification among 4 medication classes were assigned according to an expanded published taxonomy using structured chart reviews. Audio transcripts of clinic encounters were analyzed to further characterize nonintensification reasons. Integration occurred during the interpretation phase., Results: Among 292 HFrEF patients who completed a cardiology visit, 185 (63.4%) experienced no treatment intensification, of whom 90 (48.6%) had at least 1 opportunity for intensification of a medication class with no documented contraindication or barriers (ie, clinical inertia). Nonintensification reasons varied by medication class, and included heightened risk of adverse effects (range 18.2%-31.6%), patient nonadherence (range 0.8%-1.1%), patient preferences and beliefs (range 0.6%-0.9%), comanagement with other providers (range 4.6%-5.6%), prioritization of other issues (range 15.6%-31.8%), multiple categories (range 16.5%-22.7%), and clinical inertia (range 22.7%-31.6%). A qualitative analysis of 32 clinic audio recordings demonstrated common characteristics of clinical inertia: 1) clinician review of medication regimens without education or intensification discussions; 2) patient stability as justification for nonintensification; and 3) shorter encounters for nonintensification vs intensification., Conclusions: In this comprehensive study exploring HFrEF prescribing, clinical inertia is a main contributor to nonintensification within an updated taxonomy classification for suboptimal GDMT prescribing. This approach should help target strategies overcoming GDMT underuse., Competing Interests: Funding Support and Author Disclosures This project/publication is supported in part by National Institutes of Health/NCATS Colorado CTSA Grant Number UL1 TR002535. Contents are the authors’ sole responsibility and do not necessarily represent official National Institutes of Health views. Dr Swat has received funding from the National Institutes of Health T32 Training Grant 5T32-HL-007822-22. Dr Allen has received grant funding from the American Heart Association, National Institutes of Health, and Patient-Centered Outcomes Research Institute; and has received consulting fees from Abbott, ACI Clinical, Amgen, Boston Scientific, Cytokinetics, Novartis, Quidel, and UpToDate. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: The study aimed to investigate otolaryngologists' knowledge, trust, acceptance, and concerns with clinical applications of artificial intelligence (AI)., Methods: This study used mixed methods with survey and semistructured interviews. Survey was e-mailed to American Rhinologic Society members, of which a volunteer sample of 86 members responded. Nineteen otolaryngologists were purposefully recruited and interviewed until thematic saturation was achieved., Results: Seventy-six respondents (10% response rate) completed the majority of the survey: 49% worked in academic settings and 43% completed residency 10 or fewer years ago. Of 19 interviewees, 58% worked in academic settings, and 47% completed residency 10 or fewer years ago. Familiarity : Only 8% of survey respondents reported having AI training in residency, although 72% had familiarity with general AI concepts; 0 interviewees had personal experience with AI in clinical settings. Expected uses : Of the surveyed otolaryngologists, 82% would use an AI-based clinical decision aid and 74% were comfortable with AI proposing treatment recommendations. However, only 44% of participants would trust AI to identify malignancy and 53% to interpret radiographic images. Interviewees trusted AI for simple tasks, such as labeling septal deviation, more than complex ones, such as identifying tumors. Factors influencing AI adoption: 89% of survey participants would use AI if it improved patient satisfaction, 78% would be willing to use AI if experts and studies validated the technologies, and 73% would only use AI if it increased efficiency. Sixty-one percent of survey respondents expected AI incorporation into clinical practice within 5 years. Interviewees emphasized that AI adoption depends on its similarity to their clinical judgment and to expert opinion. Concerns included nuanced or complex cases, poor design or accuracy, and the personal nature of physician-patient relationships., Conclusion: Few physicians have experience with AI technologies but expect rapid adoption in the clinic, highlighting the urgent need for clinical education and research. Otolaryngologists are most receptive to AI "augmenting" physician expertise and administrative capacity, with respect for physician autonomy and maintaining relationships with patients., Level of Evidence: Level VI, descriptive or qualitative study., Competing Interests: The authors declare no conflicts of interest., (© 2023 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

In routine healthcare consultations, patients often use prefaces containing the word "thing", including "the thing is", "there's this thing" or "one more thing". Although "thing" is an all-encompassing term that is used in myriad ways, in this article we show that thing-prefaces perform a specific job. This study uses Conversation Analysis to analyze 90 video-recorded primary care consultations with 14 primary care physicians in the United States. Patients' thing-prefaces mark the upcoming talk as a disclosure of sensitive information that may reflect negatively on the patient, physician or service (e.g., medication nonadherence, refill was not sent to pharmacy). Patients pursue explicit resolution of these problems (e.g., personalized recommendation, lab work, referral) despite these problems being downplayed and treated as delicate. Because patients may "talk around" these sensitive issues, thing-prefaces can be an important cue for physicians that patients are seeking resolution for a sensitive healthcare problem.

Background: Overcoming non-standardization, vagueness, and subjectivity in sinus CT radiology reports is an ongoing need, particularly in keeping with data-driven healthcare initiatives. Our aim was to explore otolaryngologists' perceptions of quantitative objective disease measures as enabled by AI-based analysis, and determine preferences for sinus CT interpretation., Methods: A multi-methods design was used. We administered a survey to American Rhinologic Society members and conducted semi-structured interviews with a purposeful sample of otolaryngologists and rhinologists from varying backgrounds, practice settings and locations during 2020-2021. Interview topics included sinus CT reports, familiarity with AI-based analysis, and potential requisites for its future implementation. Interviews were then coded for content analysis. Differences in survey responses were calculated using Chi-squared test., Results: 120 of 955 surveys were returned, and 19 otolaryngologists (8 rhinologists) were interviewed. Survey data revealed more trust in conventional radiologist reports, but that AI-based reports would be more systematic and comprehensive. Interviews expanded on these results. Interviewees believed that conventional sinus CT reports had limited utility due to inconsistent content. However, they described relying on them for reporting incidental extra-sinus findings. Reporting could be improved with standardization and more detailed anatomical analysis. Interviewees expressed interest in AI-derived analysis given potential for standardization, although they desired evidence of accuracy and reproducibility to gain trust in AI-based reports., Conclusions: Sinus CT interpretation has shortcomings in its current state. Standardization and objectivity could be aided with deep learning-enabled quantitative analysis, although clinicians desire thorough validation to gain trust in the technology prior to its implementation., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Untreated opioid use disorder (OUD) is a significant public health problem. Buprenorphine is an evidence-based treatment for OUD that can be initiated in and prescribed from emergency departments (EDs) and office settings. Adoption of buprenorphine initiation among ED clinicians is low. The EMBED pragmatic clinical trial investigated the effectiveness of a clinical decision support (CDS) tool to promote ED clinicians' behavior related to buprenorphine initiation in the ED. While the CDS intervention was not associated with increased rates of buprenorphine treatment for patients with OUD at intervention ED sites, attending physicians at intervention EDs were more likely to initiate buprenorphine at least once over the duration of the study compared to those in the usual care arms (44.4% vs 34.0%, P = 0.01). This suggests the CDS intervention may be associated with increased adoption of buprenorphine initiation. As a secondary aim, we sought to identify the determinants of CDS adoption, implementation, and maintenance in a variety of ED settings and geographic locations., Methods: We purposively sampled and conducted semi-structured, in-depth interviews with clinicians across EMBED trial sites randomized to the intervention arm from five healthcare systems. Interviews elicited clinician experiences regarding buprenorphine initiation and CDS use. Interviews were analyzed using directed content analysis informed by the Practical, Robust Implementation and Sustainability Model (PRISM). We used a hybrid approach (a priori codes informed by PRISM and emergent codes) for codebook development. ATLAS.ti (version 9.0) was used for data management. Coded data were analyzed within individual interview transcripts and across all interviews to identify major themes. This process involved (1) combining, comparing, and making connections between codes; (2) writing analytic memos about observed patterns; and (3) frequent team meetings to discuss emerging patterns., Results: Twenty-eight interviews were conducted. Major themes that influenced the successful adoption, implementation, and maintenance of the EMBED intervention and ED-initiated BUP were organizational culture and commitment, clinician training and support, the ability to connect patients to ongoing treatment, and the ability to tailor implementation to each ED. These findings informed the identification of implementation strategies (framed using PRISM domains) to enhance the ED initiation of buprenorphine., Conclusion: The findings from this qualitative analysis can provide guidance to build better systems to promote the adoption of ED-initiated buprenorphine., (© 2023. The Author(s).)

Objective: Patient-clinician relationship quality and patient activation can both improve patient health outcomes, but prior work has primarily examined these factors independently. We examine how these two factors shape patient behavior in the setting of ambulatory heart failure care, where serial intensification of multiple medications is central to chronic care delivery., Methods: We used content analysis to analyze 22 in-depth patient interviews and 32 audio-recorded clinic visits collected for the EPIC-HF Trial. This was a secondary analysis providing qualitative depth to the parent RCT., Results: We identified a typology of patient activation and patient-clinician relationship quality, with four types: Supported, Skeptical, Deferential, and Unempowered. Types were sensitive to time and context; a given patient might occupy multiple types throughout the course of a single clinic visit. The effects of patient-activation and the patient-clinician relationship appeared to be bidirectional, with each influencing the other., Conclusion: Patient-clinician relationship quality and patient activation are dominant in shaping clinical interactions and disease management. This interaction is dynamic, and patients may change types depending on time, place, or context., Practice Implications: These findings suggest that both patient activation and high relationship quality work together to create a supportive environment for chronic care, where intermittent skepticism, deference or empowerment may be useful at particular times or in certain situations., Competing Interests: Declaration of Competing Interest Dr. Allen reports grant funding from AHA, NIH, and PCORI; and consulting fees from Abbott, ACI Clinical, Amgen, Boston Scientific, Cytokinetics, and Novartis. Remaining authors report no significant conflicts., (Copyright © 2022. Published by Elsevier B.V.)

Introduction: Inpatient Addiction Consultation Services (ACS) fill an important need by connecting hospitalized patients with substance use disorders with resources for treatment; however, providers of these services may be at risk for burnout. In this qualitative study, we aimed to identify factors associated with burnout and, conversely, resilience among multidisciplinary providers working on ACS., Methods: We completed 26 semi-structured interviews with clinicians working on ACS, including physicians, social workers, and advanced practice providers. Twelve institutions across the country were represented. The study recruited participants via email solicitation to ACS directors and then via snowball sampling. We used an inductive, grounded theory approach to analyze data., Results: Providers described factors contributing to burnout and strategies for promoting resilience, and three main themes arose: (1) Systemic barriers contributed to provider burnout, (2) Engaging in meaningful work increased resilience, and (3) Team dynamics influenced perceptions of burnout and resilience., Conclusion: Our results suggest that hospital-based addiction medicine work is intrinsically rewarding for many providers and that engaging with other addiction providers to debrief challenging encounters or engage in advocacy work can be protective against burnout. However, administrative and systemic factors are frequent sources of frustration for providers of ACS. Structured debriefings may help to mitigate burnout. Furthermore, training to enhance providers' ability to engage effectively in advocacy work within and between hospital systems has the potential to promote resilience and protect against burnout among ACS providers., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

In this review article, we examine some of the conceptual contributions of sociology of health and illness over the past fifty years. Specifically, we focus on research dealing with medicalization, the management of stigma, research on adherence and compliance, and patient-doctor interaction. We show how these themes that originated within sociology, diffused in other disciplines. Sociology in Social Science and Medicine started as an applied research tradition but morphed into a robust, stand-alone social science tradition., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: A growing body of literature documents the value of decision support interventions (DESIs) in facilitating patient participation in preference sensitive decision making, but little is known about their implementation in routine care., Objective: This study explored barriers and facilitators to prescribing DESIs in primary care., Setting and Participants: Four community-based primary care practices across Los Angeles County serving diverse low and middle income populations participated., Design: The first phase focused on implementing DESI prescribing into routine care. Weekly academic detailing visits served to identify barriers to DESI prescribing, generate ethnographic field notes and record DESI prescriptions. The second phase explored the impact of a financial incentive on DESI prescribing. At the project's conclusion, each physician completed an in-depth interview., Results: The four practices prescribed an average of 6.5 DESIs a month (range 3.6-9.2) during Phase I. The financial incentive increased DESI prescribing by 71% to 11.1 per month (range 3.5-21.4). The estimated percentages of patients who viewed the DESI were 37.9 and 43.9% during Phases I and II, respectively. Qualitative data suggest that physician buy-in with the project goal was crucial to DESI distribution success. Competing demands and time pressures were persistent barriers. The effects of the financial incentive were mixed., Conclusions: This study confirmed the importance of physician engagement when implementing DESIs and found mixed effects for providing financial incentives. The relatively low rate of DESI viewing suggests further research on increasing patient uptake of these interventions in routine practice is necessary., (© 2011 John Wiley & Sons Ltd.)

Despite the proven efficacy of decision aids as interventions for increasing patient engagement and facilitating shared decision making, they are not used routinely in clinical care. Findings from a project designed to achieve such integration, conducted at five primary care practices in 2010-12, document low rates of distribution of decision aids to eligible patients due for colorectal cancer screening (9.3 percent) and experiencing back pain (10.7 percent). There were also no lasting increases in distribution rates in response to training sessions and other promotional activities for physicians and clinic staff. The results of focus groups, ethnographic field notes, and surveys suggest that major structural and cultural changes in health care practice and policy are necessary to achieve the levels of use of decision aids and shared decision making in routine practice envisioned in current policy. Among these changes are ongoing incentives for use, physician training, and a team-based practice model in which all care team members bear formal responsibility for the use of decision aids in routine primary care.

Background: Two decades of research has established the positive effect of using patient-targeted decision support interventions: patients gain knowledge, greater understanding of probabilities and increased confidence in decisions. Yet, despite their efficacy, the effectiveness of these decision support interventions in routine practice has yet to be established; widespread adoption has not occurred. The aim of this review was to search for and analyze the findings of published peer-reviewed studies that investigated the success levels of strategies or methods where attempts were made to implement patient-targeted decision support interventions into routine clinical settings., Methods: An electronic search strategy was devised and adapted for the following databases: ASSIA, CINAHL, Embase, HMIC, Medline, Medline-in-process, OpenSIGLE, PsycINFO, Scopus, Social Services Abstracts, and the Web of Science. In addition, we used snowballing techniques. Studies were included after dual independent assessment., Results: After assessment, 5322 abstracts yielded 51 articles for consideration. After examining full-texts, 17 studies were included and subjected to data extraction. The approach used in all studies was one where clinicians and their staff used a referral model, asking eligible patients to use decision support. The results point to significant challenges to the implementation of patient decision support using this model, including indifference on the part of health care professionals. This indifference stemmed from a reported lack of confidence in the content of decision support interventions and concern about disruption to established workflows, ultimately contributing to organizational inertia regarding their adoption., Conclusions: It seems too early to make firm recommendations about how best to implement patient decision support into routine practice because approaches that use a 'referral model' consistently report difficulties. We sense that the underlying issues that militate against the use of patient decision support and, more generally, limit the adoption of shared decision making, are under-investigated and under-specified. Future reports from implementation studies could be improved by following guidelines, for example the SQUIRE proposals, and by adopting methods that would be able to go beyond the 'barriers' and 'facilitators' approach to understand more about the nature of professional and organizational resistance to these tools. The lack of incentives that reward the use of these interventions needs to be considered as a significant impediment.

Relatively little is known about why some patients are reluctant to engage in a collaborative discussion with physicians about their choices in health care. To explore this issue further, we conducted six focus-group sessions with forty-eight people in the San Francisco Bay Area. In the focus groups, we found that participants voiced a strong desire to engage in shared decision making about treatment options with their physicians. However, several obstacles inhibit those discussions. These include the fact that even relatively affluent and well-educated patients feel compelled to conform to socially sanctioned roles and defer to physicians during clinical consultations; that physicians can be authoritarian; and that the fear of being categorized as "difficult" prevents patients from participating more fully in their own health care. We argue that physicians may not be aware of a need to create a safe environment for open communication to facilitate shared decision making. Rigorous measures of patient engagement, and of the degree to which health care decisions truly reflect patient preferences, are needed to advance shared decision making in clinical practice.

Direct-to-consumer advertising (DTCA) of prescription drugs is the most common form of health communication Americans are exposed to. The effects of DTCA on prescription requests and utilization are well established, but little is known about the effects of advertisements on health behaviors. Many advertisements, especially those promoting drugs to prevent or treat cardiovascular disease, refer to lifestyle change as a way to improve health. However, no studies have examined how consumers interpret these frequently ambiguous messages. We used in-depth interviews with 45 participants, recruited in Los Angeles, USA between April 2007 and July 2008, to explore perceptions of 5 advertisements for drugs that prevent or treat cardiovascular disease (Lipitor(®), Vytorin(®), Zetia(®), Caduet(®), Plavix(®)). We found that participants interpreted advertising messages within their own life context and identified four trajectories for enacting behavior change versus taking prescription drugs: Negotiators, Avoiders, Embracers and Jumpstarters. Underlying these four typologies were beliefs about whether lifestyle change was something an individual could do or was willing to do. Our results also show how an advertisement narrative could potentially shift perceptions of causality by suggesting that high cholesterol is primarily hereditary, thereby obviating the need for lifestyle change. Some participants stated that they would prefer lifestyle change to a particular prescription drug, but felt that others would be more likely to embrace taking a prescription drug. This "Third Person Effect" may be masking participants' intentions by identifying a more socially desirable route to therapeutic change. These findings raise questions about how the typologies are distributed in the population and how advertising may shift consumers' beliefs over time, thereby contributing to new forms of medicalization. Effective regulation of DTCA may require expanding scrutiny beyond the accuracy of claims about benefits and risks, to also considering the broader narratives in which these claims are made., (Copyright © 2011 Elsevier Ltd. All rights reserved.)