Medical educationOption Grids: Shared decision making made easier
Introduction
Implementing shared decision making into routine care is difficult, even though the approach is receiving increasing health policy interest in the US and Europe [1], [2]. Clinicians report many practical barriers, including a lack of tools and a shortage of time [3], [4]. Attempts to promote shared decision making by distributing decision support tools (also known as decision aids) for use by patients have not led to sustained implementation in routine services, despite positive outcomes in many randomized trials [5]. However, almost all research so far has been based on decision tools that have been designed for patients to use independently, either before or after they visit clinicians.
Research demonstrates that innovations are more likely to be adopted when they confer advantage, when they fit into existing workflows and when there is, at minimum, no conflict with existing priorities, targets and incentives [6]. It is not a surprise therefore that interventions that have been designed to support the active involvement of patients in decision making, such as patient ‘decision aids’, have failed so far to become embedded into routine practice [3]. The work of integrating these tools into clinical pathways, asking clinicians to portray options, to support patients to weigh pros and cons, and engage their families in a decision making process is more demanding than making a positive recommendation for treatment [7]. How best to implement shared decision making remains an unresolved challenge [8], [9].
This is despite a decade of evidence from over 86 randomized trials showing that patient decision support tools lead to positive effects: these tools increase patients’ knowledge, improve patients’ perception of risks, lead to choices that are ‘more congruent’ with their preferences as well as leading to reduced rates of elective surgery in some settings [5]. As Marshall and Bibby noted, many health care interventions have been supported and implemented on the basis of less evidence [10]. Yet, although these effects can be demonstrated in research contexts where there has been dedicated funding, these interventions seldom become embedded into clinical pathways, beyond the duration of the research [11], [12], [13].
It is also clear that implementing shared decision making will require more than embedding decision support tools into clinical pathways. Health professionals will need to develop positive attitudes to involving patients in decisions. This will be a difficult challenge. Health professionals cite multiple barriers – that time is short, that many patients do not want them, that the tools are not designed for use in face to face encounters and that other priorities and targets demand their attention [3]. Shared decision making is seen as an important aspiration albeit with the caveat that “it is not feasible in busy clinics”. If we are to make progress, what is to be done?
Although most research so far has been done on the use of extensive patient decision support tools (booklets, video, websites, etc.), other types of tools also exist, though they have had less attention [14]. Whelan and colleagues designed a decision board for use in a consultation in the early 1990s [15]. Elwyn and Edwards created brief bar charts for family doctors to communicate risk to patients during primary care encounters [16]. Montori and colleagues have designed ‘issues cards’ [17], which allow patients to prioritize areas for discussion in clinical encounters.
These brief tools are designed to facilitate a dialog about options but do not attempt to be comprehensive. It is worth noting that these brief tools have all been developed by medical clinicians attempting to implement shared decision making during clinical encounters. The documented advantages of this approach have been the impact on the dialog, an improved realization that options exist, and on tangible changes in the communication process, i.e. in terms of turn-taking and body language [18]. These tools are, by necessity, too brief to provide comprehensive information and many, though not all, patients may want more. This could be achieved by using short tools to initiate shared decision making in clinical encounters and then referring patients to more extensive tools (e.g. booklet, DVD, and other digital methods) to read and share with other family members [14], as described by a recent model of shared decision making [19].
To make progress, we designed interventions specifically used in clinical encounters. The aim of this article is to describe our experience with tools that have been designed for this purpose: we called these tools Option Grids.
Section snippets
Background: what are option grids?
An Option Grid is a brief summary of options organized in tabular format, limited to one side of standard size paper (see Fig. 1 – Option Grid for breast cancer surgery). The questions that patients frequently ask (FAQs), derived from patients’ common concerns, form the table rows. These questions should be simple, e.g. “What are the common side effects?” and “When can I return to work?” The features of the selected options are presented across the table columns, in a way that allows horizontal
How to use Option Grids
Based on observations and the result of workshops with clinicians, we observed that Option Grids were used in different ways. However, we noted that clinicians emphasized the value of following these key steps:
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Describe: that the goal of the Grid is to initiate a conversation about options, that it is organized as a table to enable comparison, using questions that many other patients found useful.
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Check: ask if the patients wish to read it themselves or whether they prefer the comparisons to be
Discussion
We have described the experience of UK NHS teams in a quality improvement project as that used a new type of tool to facilitate shared decision making. It fits the requirement of a conceptual model illustrated in Fig. 2, and described in detail elsewhere [19]. The model calls for two different types of tools to support shared decision making: brief tools for use inside clinical encounters and more elaborate tools for independent use. Option Grids stimulate choice talk and support option talk –
Funding
Work on developing Option Grids has been supported by Cancer Research UK (Bresdex), The Health Foundation (MAGIC), Cardiff University, UK and Dartmouth College, USA.
Conflict of interest
None of the authors have a conflict of interest to declare. At completion, Option Grids are published online on an open access website.
Acknowledgments
Development work on the Option Grids was facilitated by the MAGIC program (Cardiff: Glyn Elwyn (Co-PI), Natalie Joseph-Williams, Andrew Rix, Amy Lloyd, Emma Cording, Mike Spencer, Helen McGarrigle, Annette Beasley, Val Willmott, Adrian Edwards, Jan Davies, Alun Tomkinson, Keith Cass, Laura Roach; Newcastle: Richard Thomson (Co-PI), Carole Dodd, Lynne Stobbart, Dave Tomson, Diane Palmer, Sheila Macphail, Steve Robson, Claire Leader, Chris Watson, Rob Pickard, Jill Ferguson, Chris Hall, Matt
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