The process of shared decision-making can be facilitated by the use of a decision aid. A decision aid helps patients to understand and evaluate the available treatment options in a clear manner and guides the patient through the decision-making process. Decision aids can be used as adjuncts to the consultation or as a way of preparation for a consultation with the physician (Holmes-Rovner, & Rovner, 2000). The goal of a decision aid as formulated by Charles et al. (1997, p. 684) is “to provide information and to promote ‘self help’ in the treatment decision-making process which enables the patient to more actively participate in this process, if this is her preference”. This makes decision aids well applicable within the shared decision-making model.
A decision aid can take on several forms, such as a brochure, an audiotape, a leaflet or a video. More tailored decision aids also occur. A tailored decision aid adapts the content of the material, or the way the content is presented, according to the needs of the individual (Bental, Cawsey, & Jones, 1999). Making the aid more applicable for a specific patient, the patient may perceive the information as more applying to him or her personally. Computer programmes and websites are making this form of tailoring more convenient. At a minimum, patient decision aids provide information about the available options and their associated relevant outcomes (Elwyn, O’Conner, Stacey, Volk, Edwards, & Coulter, 2006).
As with shared decision-making in general, there are pro’s en cons to the use of decision aids. A systematic review of published articles on this topic was performed by O’Connor, Rostom, et al. (2003). Benefits of the use of a decision aid summarized by these authors include improved quality of decision-making, more realistic expectations, improved agreement between values and choice and more active participation. Little information is available that addresses how and if decision aids are effectively incorporated by physicians and other medical staff into routine practice (Stevenson, 2003)
This study strived to survey how often physiatrists currently use decision aids and to what extent they hold a positive attitude towards them. It was expected that the use of a relatively simple aid such as a brochure will be common practice. The use of more elaborate decision aids like interactive websites might not be used often yet. The fourth and final research question was formulated as: To what extent do physiatrists consider decision aids to be useful for the decision-making process?
In the summer of 2007, research was done on shared decision-making in a Dutch rehabilitation centre by Pouw. A questionnaire, which was largely based on a questionnaire by Charles, Gafni, and Whelan (2004), and additional interviews were used to explore the implementation of the decision-making model in this rehabilitation centre. This previous study formed a starting point for the present study. Based on recommendations coming from this previous study, the goal was set out to have the questionnaire filled out by a larger group of physiatrists. With this data this study strives to gain more insight on the position of shared decision-making within the rehabilitation healthcare.
In short, the purpose of the present study was to explore the current decision-making process used by physiatrists and investigate their view on the applicability of the shared decision model in rehabilitation healthcare. Shared decision-making refers to a situation in which the patient has a great participation in the selection of therapeutic goals and treatment options. The results were also examined to see whether the attitudes towards shared decision-making show significant differences across physiatrists working in different medical settings. Also the use of a decision aid was explored from the physician’s perspective. The findings of this study might contribute to a better understanding of why agreement with shared decision-making in theory does not always translate into practice.
The study was guided by the following four research questions:
To what extend to physiatrists provide information to their patients and how do they make decisions for treatment?
How do physiatrists view the applicability of shared decision-making in the rehabilitation healthcare? Which barriers and facilitators do they encounter?
Which factors (gender, age, years of practice, patient group and work environment) influence the physiatrist’s attitude towards shared decision-making?
To what extent do physiatrists consider decision aids to be useful for the decision-making process?
A cross-sectional survey was undertaken in the summer of 2008. A self-report paper-and-pencil questionnaire was sent out to Dutch physiatrists.
2.2Participants and Data Collection
Physiatrists were identified through the Dutch association for physiatrists (VRA). Only practicing physiatrists were selected, leaving 408 eligible physiatrists. These physiatrists were sent the questionnaire along with a letter inviting them to participate in the study. An envelope to return the completed questionnaire was also enclosed to make participation in the study as convenient as possible. No incentive for participation was offered. The physiatrists were asked to return the completed questionnaire within two weeks. After this period, the nonresponsive physiatrists received a reminder letter.
A questionnaire was used to obtain information on background variables of the physiatrist and to assess the physiatrists’ attitudes towards both shared decision-making and the use of a decision aid during a clinical encounter. The questionnaire was primarily based on a pre-existing questionnaire by Charles, Gafni, and Whelan (2004) and question items by Holmes-Rovner et al. (2000).
Charles et al. (2004) used their questionnaire to assess the use of shared decision-making among breast cancer specialists and to explore the perceived barriers and facilitators for implementing this approach. The questions which were reported on in their article were all included, to make a future outcome comparison between different groups of respondents possible. Holmes-Rovner et al. (2000) used a questionnaire to measure the extent to which physicians consider decision aids useful in the clinical setting. The questions reported on in their article were also included in the present questionnaire.
Altogether the questionnaire consisted of 23 questions most of which had pre-structured answer formats. Some questions left room for physiatrists to place a comment or specify their answer. All questions were formulated in Dutch and made fit for physiatrists. The final version of the questionnaire can be found in the appendix.
The content of the questionnaire can generally be divided into four sections. The first three sections use items from Charles et al. (2004) to assess (a) characteristics of the respondents and their work setting, (b) their current degree of providing information, their use of the shared-decision making approach and level of comfort with several decision-making approaches, and (c) the barriers and facilitators for shared decision-making. The final questions of the questionnaire ask about the current use of and attitude towards decision aids, using items by Holmes-Rovner et al. (2000).
2.3.1 background variables
The background variables gender, clinical setting in which the respondent performs most clinical activities, average time spend on straight patient care, the patient groups they currently work with and the patient group encountered primarily were assed by directly asking the respondents and providing a pre-structured answer format. Variables as age, years in practice, average amount of patients seen per week and duration of an average consult were asked using an open answer format.
Physiatrists responses to which patient group they encountered primarily were collapsed. Working with patients who suffered a CVA or traumatic brain injury, was considered working with cognitive limited patients. All other patient groups were considered not to suffer cognitive impairments. Physiatrists were asked to keep the patient group they primarily work with in mind as they answered the following questions.
2.3.2current way of decision-making and providing information.
To asses the extent to which the physiatrists provide their patients information during a consultation, 10 information topics were posed. The physiatrist was asked to indicate to what extend they give information about each topic to their patients on a five-point Likert scale, ranging from 1 (no information) to 5 (a great deal of information). An average score over all ten items was calculated for each respondent to serve as a measure of information provision, with a score of 1 indication “no information sharing” and 5 “a great deal of information sharing”. This scale showed a reliability coefficient α of .760.
The physiatrists’ current approach to decision-making was assessed by asking which of four clinical decision-making examples shows the highest correspondence with their own usual way of decision-making. Each of the examples intends to reflect one of four approaches: (a) the paternalistic approach, (b) an approach where there is some degree of sharing, but the physiatrist is the sole decision-maker, (c) the shared decision-making approach and (d) the informed decision-making approach. Examples were constructed by Charles et al. (2004).
The same examples are used to gain insight in the levels of comfort physiatrists have with the various decision-making models. For each of the four examples, respondents were asked to indicate on a five-point Likert scale ranging from 1 (not comfortable) to 5 (extremely comfortable) how comfortable they are using that approach. A “high level of comfort” was operationalized as a score of 4 or 5.
2.3.3barriers and facilitators for shared decision-making.
To answer the research question how physiatrist view the applicability of shared decision-making with their specific patient group, respondents were asked to indicate for 19 factors to what extend they see the factor as a barrier for the decision-making process on a four-point Likert scale (with 1= never a barrier and 4= always a barrier). Another 11 factors were posed, asking the respondents to indicate for each factor if they considered it to be a facilitator for the decision making process, again on a four-point Likert scale (with 1=never a facilitator and 4=always a facilitator). The response categories were collapsed such that responses 1 and 2 were coded as ‘no, not a barrier’ and the categories 3 and 4 as ‘yes, a barrier’. The response categories for the question asking about facilitators were also collapsed. In accordance with Charles et al. (2004), responses 1 and 2 were coded as ‘no, not a facilitator’ and the categories 3 and 4 as ‘yes, a facilitator’.
2.3.4current use of and attitude towards decision aids
Respondents were asked to tick which of the seven decision aids they use during the decision-making process with their patients. The options ‘none of these’ and ‘other, namely’ are also included in the response format. The following question asked how often they use the decision aid(s) ticked at the previous question.
The final question of the questionnaire combines items from the questionnaire by Holmes-Rovner et al. (2000). The question poses 13 statements regarding decision aids. Each statement is followed by a five-point Likert scale on which the physiatrists can indicate to what extent they agree with the statement (1= strongly disagree, 5= strongly agree). An attitude score was obtained by averaging the scores on the 13 items. The scale showed a reliability of α= .758. This attitude score forms a measure of the physiatrist’s attitude towards the use of a decision-making aid. Scores are on a five-point scale running from 1 (negative attitude towards decision aids) till 5 (strongly positive attitude towards decision aids). Scores on item d (“a decision aid may cause some patients to make the wrong choice”), item i (“the majority of the patients does not wish to be involved in decision-making about their treatment”) and item j (“most patients prefer the doctor to take responsibility for their medical problems”) were reverse scored before computing the average score over all items.