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March 7, 2018

Fostering choice awareness for shared decision making

By Victor M. Montori

Marleen Kunneman, PhD; Megan Branda, MS; Ian Hargraves, PhD; Arwen Pieterse, PhD; Victor Montori, MD, MSc

Two roads diverged in a yellow wood,

And sorry I could not travel both

- Robert Frost “The Road Not Taken”

Although recommended, shared decision making (SDM) is still hard to implement in routine care. This is, we believe, in part because patients may not realize that there is more than one reasonable approach to address their situation, and that their involvement is critical in figuring out which care plan fits best. In other words, patients may lack ‘choice awareness’.

In a recently published paper, we aimed to assess the extent to which clinicians, using or not using conversation aids, foster choice awareness during clinical encounters. Also, we aimed to assess the extent to which fostering choice awareness, with or without conversation aids, is associated with greater patient involvement in SDM.

To this end, we randomly selected 100-video-recorded encounters from our database of 10 clinical trials of SDM interventions in 7 clinical contexts (low-risk acute chest pain, stable angina, diabetes, depression, osteoporosis, and Graves disease). Coders, unaware of our hypothesis, coded the recordings with the OPTION12-scale, which quantifies the extent to which clinicians involve patients in decision making (0-100 score, higher score is more involvement). Blind to these OPTION-12 scores, we used a self-developed coding scale to code whether and how choice awareness was fostered (see Table).

Fostering choice awareness behavior N (%)
Choice awareness not fostered 47
1. The clinician does not foster choice awareness; rather, the clinician informs on the next step in management without introducing other options for consideration 34 (72)
2. The clinician does not foster choice awareness; rather, the clinician makes a recommendation that implies the existence of alternatives, but without explicit mentioning these 13 (28)
Choice awareness fostered 53
3. The clinician fosters choice awareness by listing relevant options followed by recommending one of these to the patient 15 (28)
4. The clinician fosters choice awareness by listing relevant options without recommending one of these to the patient 38 (72)

We found that clinicians fostered choice awareness in about half of the encounters, mostly by listing relevant options without providing a recommendation (see Table). If clinicians did not foster choice awareness, they mostly presented the next step in management without explicit or implicit suggestion that there are other options for consideration. Fostering choice awareness was associated with a higher OPTION12 score (20 points difference on 0-100 scale), regardless of whether conversation aids were used. Removing OPTION items that focus specifically on fostering choice awareness did not change the results (20 points vs 19 points difference).

Our study suggests that fostering choice awareness is associated with a better execution of other SDM steps, such as informing patients or discussing preferences, even when SDM tools are not available or not used. In future research, we will examine the causality of this association.

The full paper was published (Open access) in Mayo Clinic Proceedings: Innovation, Quality and Outcomes. (https://doi.org/10.1016/j.mayocpiqo.2017.12.002)

This study is part of the Fostering Fit by Recognizing Opportunity STudy (FROST) program.

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