Shared Decisionmaking About Screening and Chemoprevention: Background Article (continued)

How Might Clinicians Facilitate Patient Participation in Decisionmaking?

Although there are distinct barriers to shared decisionmaking about screening and chemoprevention, clinicians can facilitate this type of decisionmaking using the techniques described below.

Know What It Takes to Make Informed and Joint Decisions

The length of discussions about screening and chemoprevention may vary according to the scientific evidence for that service; the health, preferences, and concerns of each patient; the decisionmaking style of each clinician; and the practical constraints of any office visit. The measure of an informed and joint decision, however, should not vary (Figure 2). A decision should be considered to be adequately informed if the patient:

1. Understands the risk or seriousness of the disease or condition to be prevented.
2. Understands the preventive service, including the risks, benefits, alternatives, and uncertainties.
3. Has weighed his or her values regarding potential benefits and harms associated with the service.

The decision should be considered jointly made if the patient and clinician participate as partners, each clarifying their knowledge and preferences for the decision.

In practice, patient participation in decisionmaking is on a continuum, ranging from no participation to complete control of the decision, and, although joint decisionmaking may be ideal, participation should be considered satisfactory when the patient has participated at a level at which he or she desires and feels comfortable.

To facilitate patient understanding about screening and chemoprevention, the USPSTF suggests that all clinicians be prepared to respond to patients' needs for balanced, unbiased, and evidence-based information to patients. To facilitate accurate weighing of patient preferences, clinicians should contrast the rationales used by patients who decide for screening or chemoprevention and those who decide against it. Clinicians should also encourage patients to consider their own values for the potential harms and benefits associated with the decision. Ideally, clinicians would help patients to identify and overcome social, financial, or other barriers that, if absent, would alter their decision.

Figure 2. Characteristics of an Informed and Joint Decision

Set Reasonable Expectations

Patients are often eligible for more than 1 preventive service for which shared decisionmaking might be a useful adjunct. Performing shared decisionmaking for all such services in 1 office visit, however, is rarely feasible. Clinicians who have ongoing relationships with patients may stagger discussions across several office visits, focusing first on the issue that they and their patients mutually identify as the highest priority and deferring other discussions to a later date. The initial discussion can represent the first step in the shared decisionmaking process; patients can then be encouraged to review additional information at home and further consider their preferences before making a final decision at a future visit. Clinicians may also want to involve other staff in the shared decisionmaking process, allowing the clinician to focus on answering questions and negotiating an agreement. Other staff could spend more time with the patient on education and decision support.

Consider Decision Aids

The USPSTF suggests that clinicians consider decision aids as a way of providing information in an efficient and tailored manner. Good decision aids, including pamphlets, computer programs, audio-guided workbooks, videotapes, videodiscs, decision boards, and web-based tools, can offer balanced, unbiased, and evidence-based information, in addition to values clarification,²⁷ and can be employed both within and outside the patient-clinician encounter to promote shared decisionmaking. As previously noted, these aids have been shown to extend participation in medical decisionmaking and enhance knowledge about the decision.²⁹ Several are now available at www.healthdialog.com⁷³ or www.ohri.ca/programs/clinical_epidemiology/OHDEC/default.asp.⁷⁴

Use Effective Strategies for Communicating Information

Even when relying on decision aids, clinicians may need to answer questions, help patients clarify their thinking, and negotiate a decision. This participation requires the use of effective strategies for communicating information.

Although few studies have examined how differences in the medium of information presentation affect outcomes, some studies²⁷ have shown that the information content significantly affects the outcomes of decisions. For instance, decision aids with detail, probabilities, examples, and personal guidance are more acceptable to patients than decision aids without these characteristics. Tailored communications, which provide information specific to the individual, may also be better remembered, read, and perceived as relevant and/or credible than non-tailored communications.⁷⁵

Alternate presentations of the same information also yield different outcomes. For instance, the presentation of probabilities as relative risk reductions are more persuasive than presentations as absolute risk reductions; by contrast, presentations of probabilities as absolute risk reductions are more understandable.⁷⁶ Framing (e.g., the chance of survival vs the chance of death) also influences choices.⁷⁶ Because clinicians may influence patient choices, ideally clinicians would make a special effort to be aware of effective communication strategies and would choose their words, as well as their nonverbal cues, carefully to avoid unintended effects on the patient.⁷⁷

Consider a Systematic Approach

Because the evidence about shared decisionmaking is limited, and the patient-clinician partnership is complex, defining how any given interaction about screening and chemoprevention should transpire is impossible. A systematic approach, however, is likely to improve the quality of interactions and provide the foundation for systematic study of patient-clinician interactions concerning screening and chemoprevention.

Figure 3 outlines 1 possible approach for patient-clinician interactions. This approach approximates the 5 As framework (ask, advise, agree, assist, arrange),⁷⁸ which the USPSTF has supported for behavioral counseling interventions and which is consistent with its previous suggestions about how clinicians might interact with patients on screening and chemoprevention recommendations. The approach leads clinicians through a stepped process of assessing patients' needs for preventive services, determining their desire to be involved in decisionmaking, conveying information on the disease and preventive services, eliciting patient values, negotiating a course of action, and delivering the preventive service. Importantly, it acknowledges the characteristics of an informed and joint decision and can be adopted for the "A," "B," "C," "D," and "I" recommendations of the USPSTF.

Figure 3. An Approach to Interactions About Screening and Chemoprevention

Assess Assess patient's health needs: Acute issues. Eligibility for preventive services. Assess patient's desired role in decisionmaking.

Advise Inform the patient about recommended preventive services (USPSTF A or B). If time permits, inform the patient about other services (USPSTF C, D, or I) with: High visibility. Special individual importance. If needed, provide balanced, evidence-based information about the service: Benefits. Harms. Alternatives. Scientific Uncertainties. If appropriate (A, B, D), make a recommendation.

Agree Elicit patient's values and determine preferences. Negotiate a course of action.

Assist Deliver or prescribe service.

Arrange Arrange followup or plan to revisit in the future.

Figure 4 provides an example of how one might apply this approach for an individual patient in clinical practice.

Figure 4. Applying a Consistent Approach

Although not highlighted in Figure 4, an important part of this systematic approach is clear documentation of the agenda setting and decisionmaking. Such documentation mitigates against lapses in followup when discussions span more than 1 visit and safeguards against the potential medico-legal consequences of subsequent detection of a potentially preventable disease when discussions are delayed. What constitutes adequate documentation is something the medical and legal communities need to further explore.

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Conclusions

The USPSTF places a high value on informed and joint decisions about screening and chemoprevention; such decisions are essential for making recommendations to individual patients concerning interventions that have net benefit for some patients, but not for others. One approach to encouraging informed and joint decisions is shared decisionmaking. Although the effect of this approach on health outcomes is uncertain, shared decisionmaking is supported by ethical, interpersonal, and educational considerations. Clinicians might, therefore, consider incorporating elements of shared decisionmaking into appropriate interactions with patients about screening and chemoprevention.

Future research should address the objective impact of this approach on relevant health outcomes, consider ways to improve the feasibility of this approach in current medical practice, and identify best practices in performing and teaching the shared decisionmaking process. Researchers should devote particular attention to measuring the effects of shared decisionmaking for value-sensitive decisions under each of 4 distinct circumstances:

1. When the benefits of a preventive service clearly outweigh the harms for the majority of the population.
2. When the harms of the service clearly outweigh the benefits for the majority of the population.
3. When the balance of harms and benefits is too close to call.
4. When there is insufficient evidence to know the balance of harms and benefits.

In the latter 2 settings, measurement should focus on whether shared decisionmaking improves adherence to and satisfaction with a chosen course of action. Researchers should be vigilant in measuring patients' desired and actual levels of participation in decisionmaking and should distinguish this clearly from their desired and actual levels of information receipt. To assess the feasibility of shared decisionmaking in clinical practice, researchers should continue to develop and evaluate novel practice- and system-level interventions. These should be tested not only for effectiveness, but also for cost-effectiveness and practicality both within and outside the clinical arena. Details about practical, effective interventions should be made available to clinicians, health systems, educators, and researchers alike.

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Acknowledgments

This study was conducted by the Research Triangle Institute-University of North Carolina Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality, Rockville, MD (Contract No. 290-97-0011).

We are grateful to other members of the U.S. Preventive Services Task Force's Shared Decisionmaking Workgroup, including Cynthia D. Mulrow, M.D., M.Sc. (University of Texas Health Science Center, San Antonio, TX); C. Tracy Orleans, Ph.D. (The Robert Wood Johnson Foundation, Princeton, NJ); Jonathan D. Klein, M.D., M.P.H. (University of Rochester School of Medicine, Rochester, NY); Charles J. Homer, M.D., M.P.H. (National Initiative for Children's Healthcare Quality, Boston, MA); Steven M. Teutsch, M.D., M.P.H. (Merck & Company, Inc., West Point, PA); Peter A. Briss, M.D., M.P.H. (Centers for Disease Control and Prevention, Atlanta, GA); and Barbara Reilley, Ph.D., R.N., (Health Program Development, Houston, TX).

We also thank and acknowledge clinicians and researchers, including Harold Sox, M.D. (American College of Physicians-American Society of Internal Medicine, Philadelphia, Pennsylvania); Annette O'Connor, Ph.D., M.Sc.N., (University of Ottawa Health Research Institute, Ottawa, Ontario, Canada); Clarence H. Braddock III., M.D., M.P.H. (University of Washington, Seattle, WA); Nananda Col, M.D. (Brigham and Women's Hospital, Harvard Medical School, Boston, MA); and Michael Pignone, M.D., M.P.H. (University of North Carolina, Chapel Hill, NC), who contributed to our thinking through participation in a workshop at the National Society of General Internal Medicine Meeting in 2001, and Pamela Christy Parham-Vetter, M.D., M.A., M.P.H. (University of Pittsburgh, Pittsburgh, PA) for her contributions regarding ethical considerations. Finally, we thank the staff of the RTI International-University of North Carolina Evidence-based Practice Center: Carol Krasnov; Kathleen Lohr, Ph.D.; Sonya Sutton, B.S.P.H.; and Loraine Monroe.

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Author Affiliations

^a Division of General Medicine and Clinical Epidemiology, University of North Carolina, Chapel Hill, NC.
^b The Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC.
^c Departments of Family Practice, Preventive Medicine, and Community Health, Virginia Commonwealth University, Fairfax, VA.

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Copyright and Source Information

This document is in the public domain within the United States as stated in AHRQ's license agreement with the American Journal of Preventive Medicine. For information on reprinting, contact Randie Siegel, Director, Division of Printing and Electronic Publishing, Agency for Healthcare Research and Quality, 540 Gaither Road, Suite 2000, Rockville, MD 20850. Requests for linking or to incorporate content in electronic resources should be sent to: info@ahrq.gov.

Source: Sheridan SL, Harris RP, Woolf SH, for the Shared Decisionmaking Workgroup, Third U.S. Preventive Services Task Force. Current methods of the U.S. Preventive Services Task Force: a review of the process. Am J Prev Med 2004;26(1):56-66.

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Current as of December 2003

Internet Citation:

Shared Decisionmaking About Screening and Chemoprevention: A Suggested Approach from the U.S. Preventive Services Task Force. Article originally in Am J Prev Med 2004;26(1):56-66. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/shared/sharedba.htm

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