How does decision complexity affect shared decision making? An analysis of patient-provider antiretroviral initiation dialogue. Issue 5 (May 2017)

• Record Type: Journal Article
• Authors: Callon, Wynne; Saha, Somnath; Wilson, Ira B.; Laws, Michael Barton; Massa, Michele; Korthuis, P. Todd; Sharp, Victoria; Cohn, Jonathan; Moore, Richard D.; Beach, Mary Catherine
• Is Part Of: Patient education and counseling. Volume 100:Issue 5(2017)
• Page Start: 919
• Page End: 926
• Publication Date: 2017-05
• Subjects: Shared decision making -- Patient-provider communication -- Antiretroviral initiation -- HIV/AIDS; Patient education -- Periodicals; Health counseling -- Periodicals; Health education -- Periodicals; Counseling -- Periodicals; Patient Education -- Periodicals; Éducation des patients -- Périodiques; Counseling -- Périodiques; Éducation sanitaire -- Périodiques; 615.5071
• DOI: 10.1016/j.pec.2016.12.013
• Languages: English
• ISSNs: 0738-3991

Abstract

Highlights: Few dialogues met criteria for shared decision making (SDM). Frequency of each SDM criterion increased with increasing decision complexity. Discussion of pros/cons, alternatives, and uncertainties are frequently absent. Less SDM occurs when the provider or patient has a strong preference for a given option. Passively assessing patient preference/understanding is insufficient for SDM. Abstract: Objectives: This study analyzed patient-provider dialogue regarding anti-retroviral therapy (ART) initiation, assessing the degree to which shared decision making (SDM) occurred. Methods: We analyzed 24 audio-recorded dialogues between 14 HIV providers and their patients regarding ART initiation. We coded transcribed dialogues for seven SDM elements. We stratified dialogues into three levels of decision complexity (basic, intermediate, complex) based on patient CD4 counts and evaluated SDM criteria fulfillment at each level of decision complexity. Results: There were five basic, twelve intermediate, and sevenc omplex decisions in our sample. While only two met the defined criteria for SDM, the mean number of SDM elements present increased with each level of decision complexity. Discussion of the clinical issue requiring the decision occurred most frequently (88%), while discussion of pros/cons (13%), patient's understanding (21%), and decision alternatives (29%) occurred least frequently. Conclusion/Practice implications: While few dialogues met the defined SDM criteria, providers are having conversations that respond to decision complexity. Clinicians should be aware that discussion of pros/cons, alternatives, and uncertainties are frequently skipped, even when these elements are clearly relevant, as in complex decisions. In addition, rhetorical questions to assess patient preferences and understanding are insufficient to fully engage patients in SDM.