Margarita Alegria1,2,3, Ora Nakash1,4, Kirsten Johnson5, Andrea Ault-Brutus6, Nicholas Carson3,7, Mirko Fillbrunn1,2, Ye Wang1, Alice Cheng8, Treniece Harris3,9, Antonio Polo10, Alisa Lincoln11, Elmer Freeman12,13, Benjamin Bostdorf14, Marcos Rosenbaum15, Claudia Epelbaum16, Martin LaRoche3,17, Ebele Okpokwasili-Johnson18, MaJose Carrasco19, Patrick E Shrout20. 1. Disparities Research Unit, Department of Medicine, Massachusetts General Hospital, Boston. 2. Department of Medicine, Harvard Medical School, Boston, Massachusetts. 3. Department of Psychiatry, Harvard Medical School, Boston, Massachusetts. 4. Baruch Ivcher School of Psychology Interdisciplinary Center, Herzliya, Israel. 5. Department of Psychology, Northeastern University, Boston, Massachusetts. 6. Mental Health Innovation Laboratory, New York City Department of Health and Mental Hygiene, New York City, New York. 7. Center for Multicultural Mental Health Research, Cambridge Health Alliance, Cambridge, Massachusetts. 8. Department of Psychology, University of Hartford, Hartford, Connecticut. 9. Department of Psychiatry, Cambridge Health Alliance, Cambridge, Massachusetts. 10. Department of Psychology, DePaul University, Chicago, Illinois. 11. Department of Sociology and Heath Sciences, Institute on Urban Health Research, Northeastern University, Boston, Massachusetts. 12. Office of Urban Health Programs, Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts. 13. Center for Community Health Education Research and Service, Inc, Northeastern University, Boston, Massachusetts. 14. Psyche Skype, Greater Boston Area, Massachusetts. 15. private practice, Brookline, Massachusetts. 16. Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts. 17. Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts. 18. Behavioral Health Services, South End Community Health Center, Boston, Massachusetts. 19. National Alliance on Mental Illness, Arlington, Virginia. 20. Department of Psychology, New York University, New York City, New York.
Abstract
Importance: Few randomized clinical trials have been conducted with ethnic/racial minorities to improve shared decision making (SDM) and quality of care. Objective: To test the effectiveness of patient and clinician interventions to improve SDM and quality of care among an ethnically/racially diverse sample. Design, Setting, and Participants: This cross-level 2 × 2 randomized clinical trial included clinicians at level 2 and patients (nested within clinicians) at level 1 from 13 Massachusetts behavioral health clinics. Clinicians and patients were randomly selected at each site in a 1:1 ratio for each 2-person block. Clinicians were recruited starting September 1, 2013; patients, starting November 3, 2013. Final data were collected on September 30, 2016. Data were analyzed based on intention to treat. Interventions: The clinician intervention consisted of a workshop and as many as 6 coaching telephone calls to promote communication and therapeutic alliance to improve SDM. The 3-session patient intervention sought to improve SDM and quality of care. Main Outcomes and Measures: The SDM was assessed by a blinded coder based on clinical recordings, patient perception of SDM and quality of care, and clinician perception of SDM. Results: Of 312 randomized patients, 212 (67.9%) were female and 100 (32.1%) were male; mean (SD) age was 44.0 (15.0) years. Of 74 randomized clinicians, 56 (75.7%) were female and 18 (4.3%) were male; mean (SD) age was 39.8 (12.5) years. Patient-clinician pairs were assigned to 1 of the following 4 design arms: patient and clinician in the control condition (n = 72), patient in intervention and clinician in the control condition (n = 68), patient in the control condition and clinician in intervention (n = 83), or patient and clinician in intervention (n = 89). All pairs underwent analysis. The clinician intervention significantly increased SDM as rated by blinded coders using the 12-item Observing Patient Involvement in Shared Decision Making instrument (b = 4.52; SE = 2.17; P = .04; Cohen d = 0.29) but not as assessed by clinician or patient. More clinician coaching sessions (dosage) were significantly associated with increased SDM as rated by blinded coders (b = 12.01; SE = 3.72; P = .001; Cohen d = 0.78). The patient intervention significantly increased patient-perceived quality of care (b = 2.27; SE = 1.16; P = .05; Cohen d = 0.19). There was a significant interaction between patient and clinician dosage (b = 7.40; SE = 3.56; P = .04; Cohen d = 0.62), with the greatest benefit when both obtained the recommended dosage. Conclusions and Relevance: The clinician intervention could improve SDM with minority populations, and the patient intervention could augment patient-reported quality of care. Trial Registration: clinicaltrials.gov Identifier: NCT01947283.
RCT Entities:
Importance: Few randomized clinical trials have been conducted with ethnic/racial minorities to improve shared decision making (SDM) and quality of care. Objective: To test the effectiveness of patient and clinician interventions to improve SDM and quality of care among an ethnically/racially diverse sample. Design, Setting, and Participants: This cross-level 2 × 2 randomized clinical trial included clinicians at level 2 and patients (nested within clinicians) at level 1 from 13 Massachusetts behavioral health clinics. Clinicians and patients were randomly selected at each site in a 1:1 ratio for each 2-person block. Clinicians were recruited starting September 1, 2013; patients, starting November 3, 2013. Final data were collected on September 30, 2016. Data were analyzed based on intention to treat. Interventions: The clinician intervention consisted of a workshop and as many as 6 coaching telephone calls to promote communication and therapeutic alliance to improve SDM. The 3-session patient intervention sought to improve SDM and quality of care. Main Outcomes and Measures: The SDM was assessed by a blinded coder based on clinical recordings, patient perception of SDM and quality of care, and clinician perception of SDM. Results: Of 312 randomized patients, 212 (67.9%) were female and 100 (32.1%) were male; mean (SD) age was 44.0 (15.0) years. Of 74 randomized clinicians, 56 (75.7%) were female and 18 (4.3%) were male; mean (SD) age was 39.8 (12.5) years. Patient-clinician pairs were assigned to 1 of the following 4 design arms: patient and clinician in the control condition (n = 72), patient in intervention and clinician in the control condition (n = 68), patient in the control condition and clinician in intervention (n = 83), or patient and clinician in intervention (n = 89). All pairs underwent analysis. The clinician intervention significantly increased SDM as rated by blinded coders using the 12-item Observing Patient Involvement in Shared Decision Making instrument (b = 4.52; SE = 2.17; P = .04; Cohen d = 0.29) but not as assessed by clinician or patient. More clinician coaching sessions (dosage) were significantly associated with increased SDM as rated by blinded coders (b = 12.01; SE = 3.72; P = .001; Cohen d = 0.78). The patient intervention significantly increased patient-perceived quality of care (b = 2.27; SE = 1.16; P = .05; Cohen d = 0.19). There was a significant interaction between patient and clinician dosage (b = 7.40; SE = 3.56; P = .04; Cohen d = 0.62), with the greatest benefit when both obtained the recommended dosage. Conclusions and Relevance: The clinician intervention could improve SDM with minority populations, and the patient intervention could augment patient-reported quality of care. Trial Registration: clinicaltrials.gov Identifier: NCT01947283.
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