How does decision complexity affect shared decision making? An analysis of patient-provider antiretroviral initiation dialogue

Wynne Callon; Somnath Saha; Ira B Wilson; Michael Barton Laws; Michele Massa; P Todd Korthuis; Victoria Sharp; Jonathan Cohn; Richard D Moore; Mary Catherine Beach

doi:10.1016/j.pec.2016.12.013

How does decision complexity affect shared decision making? An analysis of patient-provider antiretroviral initiation dialogue

Patient Educ Couns. 2017 May;100(5):919-926. doi: 10.1016/j.pec.2016.12.013. Epub 2016 Dec 16.

Authors

Affiliations

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.

Keywords: Antiretroviral initiation; HIV/AIDS; Patient-provider communication; Shared decision making.

Publication types

Research Support, U.S. Gov't, Non-P.H.S.
Research Support, U.S. Gov't, P.H.S.
Research Support, N.I.H., Extramural

MeSH terms

Adult
Anti-Retroviral Agents / therapeutic use*
Communication*
Decision Making*
Decision Support Techniques*
HIV Infections / drug therapy*
Humans
Middle Aged
Patient Participation*
Patient Preference
Physician-Patient Relations*

Substances

Anti-Retroviral Agents

Abstract

Publication types

MeSH terms

Substances

Grants and funding