We have often discussed supporting patients who have to make various preference-based decisions. First, we discussed the general philosophy of non-directive counselling,[1] then we discussed information overload and the information paradox.[2] Last month we reviewed literature on the design of decision aids.[3]
This article is concerned with integrating them decision aids in routine clinical pathways, a topic on which we major, because preference-based medicine is a key component of both our NIHR Applied Research Collaboration (ARC) West Midlands and our NIHR Midlands Patient Safety Research Collaboration (PSRC).
It is first worth making a distinction between patient leaflets and decision aids. An information leaflet is focussed on delivering straightforward information, while a decision aid is structured to help individuals actively make choices based on that information.
A very thorough, review from the International Patient Decision Aid Standards (IPDAS) collaboration, provides essential reading.[4] It is co-authored by Angela Coulter, who is a valued advisor to our PSRC. The authors consider barriers and facilitators in implementing decision aids in routine clinical settings. The review excludes all studies carried out in controlled settings or as part of clinical trials; the focus is very much on the real world.
They start by pointing out that decision aids are widely studied, but very seldom implemented in routine practice. This is despite almost uniform evidence that they are beneficial, as stated in previous articles in this series. The review summarises evidence from just 23 distinct studies, and the information is arranged, not surprisingly, according to the five CFIR domains (with which News Blog readers will be familiar!).
In our work on uptake of surgical trial results, we find that intervention characteristics and the strength of evidence dominate as barriers to uptake. However, in the case of decision aids, this is not a major factor, save that the simpler the decision aid, the more likely it is to be used. One of the emerging themes from the series is that it is necessary in the design of decision aids to compromise and not allow the ideal to be the enemy of the good.
The inner setting emerges as a very important facilitator, since the attitude of staff makes a big difference to implementation. In particular, implementation is fostered if there is pervasive support across the hierarchy. Dedicated clinical leadership was crucially important, as was developing and supporting skills in the use of decision support. This point reminded me of an article on education for cardiologists reported in an earlier News Blog.[5]
Another strong facilitator, is advising patients ahead of time that they will be introduced to decision support and making patients feel that they all supported in autonomous decision-making
A further article looks at the provision of decision coaching when decision aids are used.[6] Decision coaching relates to the advice and support that a clinician gives to a patient alongside the use of a decision aid. A scoping review of this topic did not find much evidence to support its use.[7] However, the evidence is not strong either way. It seems a sensible thing to do, and is supported by the International Patient Decision Aid Standards.
— Richard Lilford, NIHR ARC West Midlands Director; NIHR Midlands PSRC Co-Director
References:
- Lilford RJ. Informing and Facilitating Choice in Maternity Care: What Do We Know & Where Are the Research Gaps? NIHR ARC West Midlands News Blog. 30 June 2023; 5(6):3-6..
- Lilford RJ. The Information Paradox at the Heart of Non-Directive Counselling. NIHR ARC West Midlands News Blog. 20 September 2024; 6(4): 1-3.
- Lilford RJ. Decision Aids to Help People Make Difficult Decisions. NIHR ARC West Midlands News Blog. 15 November 2024; 6(5): 1-4.
- Joseph-Williams N, Abhyankar P, Boland L, et al. What Works in Implementing Patient Decision Aids in Routine Clinical Settings? A Rapid Realist Review and Update from the International Patient Decision Aid Standards Collaboration. Medical Decision Making. 2021;41(7):907-937.
- Lilford RJ. One-to-One Coaching Improves Cardiologists’ Communication Style. NIHR ARC West Midlands News Blog. 10 May 2023; 5(4): 6.
- Stacey D, Kryworuchko J, Bennett C, Murray MA, Mullan S, Légaré F. Decision Coaching to Prepare Patients for Making Health Decisions: A Systematic Review of Decision Coaching in Trials of Patient Decision Aids. Medical Decision Making. 2012;32(3):E22-E33.
- Rahn AC, Jull J, Boland L, et al. Guidance and/or Decision Coaching with Patient Decision Aids: Scoping Reviews to Inform the International Patient Decision Aid Standards (IPDAS). Medical Decision Making. 2021;41(7):938-953.