Wynne Callon1, Somnath Saha2, Ira B Wilson3, Michael Barton Laws3, Michele Massa4, P Todd Korthuis5, Victoria Sharp6, Jonathan Cohn7, Richard D Moore4, Mary Catherine Beach4. 1. Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address: wcallon1@jhmi.edu. 2. Portland VA Medical Center, Portland, OR, USA; Department of Medicine, Oregon Health Sciences University, Portland, OR, USA. 3. Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA. 4. Johns Hopkins University School of Medicine, Baltimore, MD, USA. 5. Department of Medicine, Oregon Health Sciences University, Portland, OR, USA. 6. Saint-Lukes Roosevelt, New York, NY, USA. 7. Department of Medicine, Wayne State University, Detroit, MI, USA.
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 seven complex 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.
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 patientCD4 counts and evaluated SDM criteria fulfillment at each level of decision complexity. RESULTS: There were five basic, twelve intermediate, and seven complex 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.
Authors: Amy McQueen; L Kay Bartholomew; Anthony J Greisinger; Gilda G Medina; Sarah T Hawley; Paul Haidet; Judith L Bettencourt; Navkiran K Shokar; Bruce S Ling; Sally W Vernon Journal: J Gen Intern Med Date: 2009-09-18 Impact factor: 5.128