Shared-decision-making interventions

Last time I posted I promised that I would talk more in depth about models that help health professionals implement shared-decision-making (SDM). The evidence suggests that such a model would be useful since health professionals find it difficult to implement SDM even when they feel it would positively impact patient outcomes.¹

I was hoping to find something like the PLISSIT model.* PLISSIT outlines the steps that a health professional can take to address the issue of sexuality with cancer patients, and one of the steps involves addressing their information needs:

P = permission (follow above link for explanation)

LI = limited information i.e. addressing the patient's information needs, conducting the reference interview, either providing information, discussing information that has already been found, or directing the patient to trustworthy information on the topic. Here's where a librarian or an information service might come in handy.

SS = Specific suggestion (follow above link for explanation)
IT = Intensive therapy (follow above link for explanation)

Unfortunately, besides LI, these steps are not particularly relevant to SDM, so the model is not transferable.

I have since had the chance to take a closer look at the literature and found exactly just such a model: The Ottawa Decision Support Framework (ODSF). Hurray! I love when I find exactly what I'm looking for. It also comes with a handy implementation toolkit, and evidence to support that it reduces decisional conflict between patients and physicians.²

Unfortunately the model does not provide a clear point at which information needs are addressed, making it more difficult to use it in conjunction with an information service. At the very least however, such a service could support the process by providing on-demand access to decision aids, which are known to

help patients participate in decision making, leading to informed choices that are consistent with their values.³

I also found a useful scale for measuring patient involvement,⁴ which seems like an important step to take before attempting to facilitate or improve implementation of SDM.



*
As mentioned in my last post, I came across this model recently while researching the question of how to help HPs bring up sexuality issues with gynecologic cancer patients.

1 Gravel K, Légaré F, Graham ID. Barriers and facilitators to implementing shared decision-making in clinical practice: a systematic review of health professionals' perceptions. Implementation Science 2006; 1:16

2 Légaré F, O’Connor AM, Graham ID, Wells GA, Tremblay S. Impact of the Ottawa Decision Support Framework on the Agreement and the Difference between Patients’ and Physicians’ Decisional Conflict. Med Decis Making 2006; 26:373–390

3 O’Connor AM, Wennberg JE, Legare F, Llewellyn-Thomas HA, Moulton BW, Sepucha KR, Sodano AG, King JS. Toward The ‘Tipping Point’: Decision Aids And Informed Patient Choice. Health Affairs 2007;26(3): 716–725

4 G Elwyn, A Edwards, M Wensing, K Hood, C Atwell, R Grol. Shared decision making: developing the OPTION scale for measuring patient involvement. Qual Saf Health Care 2003;12:93–99

Barriers to use and referral: challenge

As time has passed I have been able to identify some of the potential barriers to use and to referral. I thought I would share these as they may benefit those of you who are interested in implementing a similar health information service at point of care (I know of at least one other centre that is considering doing so). That said I feel I should emphasize that this is based on my own personal observations and on the casually reported observations of others, rather than on any systematic study of the issue. We do intend to do a formal evaluation of the service, at which point we will be able to see whether these hypothesis are correct.

Not in order of importance:

1. Distractions in the waiting room. We have two big, beautiful, flat screen TVs in the waiting room that are impossible to ignore if you're sitting there, no matter which way you're facing. I just went out there to see what's playing. On one you have a talk show and on the other a soap opera. Even on mute they seem to be serious competition for my service. Gone are the interminable boring waits during which patients had time to think about where they were (the doctor's office), why they were there (sickness, checkup etc.), and maybe formulate a few questions they'd like answered. You may want to think about what could potentially distract your users from dropping in with questions. It could be TVs. It could be something else.
   
   The good a) patient satisfaction no doubt increases (time flies when you're having fun), b) as far as the TVs are concerned, there is an opportunity for promotion, to develop programming that could include information about the clinic and the service. The bad people may be distracted from asking questions while they wait.
   
   
2. The InfoRx. On the part of the HP, there may be uncertainty about how to insert the referral into a transaction with the patient. It may be hard for HPs to know when would be a good time to mention it, or who might benefit. Time is certainly a factor and it is probably all too easy to forget to write up an InfoRx. Telling HPs that they should consider referring a patient whenever they make a new diagnosis, prescribe a new medication, or the patient is faced with a treatment decision may not be enough. The idea that a librarian is now acting as a member of the team at point of care and can have patients referred to them same as any other specialist may be new and it may take a long time before knowledge becomes practice, even when everyone buys in to the idea. My feeling is that this is a change management issue. It has to do with the gap between theory and practice, between intention and action.
   
   Hoping to find something along the lines of the PLISSIT model* that could be used to assist health professionals at that crucial moment during their visit with the patient and family, I've been doing some reading about barriers to improving practice, and barriers to implementing practice guidelines and shared-decision-making. I think the latter is particularly relevant, because helping a patient or family member become well informed is a crucial component of the shared-decision-making process.**
   
   The bad this is a very complex issue that may be difficult, if not impossible, to solve, The good this could be an opportunity to further develop a new model of health care, and there may be evidence to help us in the process.
   
   
3. The Internet. You will likely wish to have a web component to your service, as I have done. Our website is advertised in our H-PHIS brochures which are disappearing from the displays at a steady rate. Statistics show that the website is being visited regularly. From this I feel I can say that I am successfully helping people help themselves. I wonder if this makes them less likely to ask for help.
   
   The good people will probably use a website if you have one, The bad people may go to your website instead of using your service.
   
   
4. Availability. It is unlikely that you will be on site and available every day all day. I am only on site 7 hrs per week, and the librarian at the Monkfield Medical Practice was also there only part time. This means that you may not always be available when needed, and not always be around to remind people to use the service and to guide people through the process. The point of having a service on site is to avoid the whole "out of site out of mind" thing.
   
   The good the demand may be greater than the supply, which may justify an increase in staffed hours The bad not having enough hours to make the service work.
   

I would love to know your thoughts on these issues, so any comments or suggestions from my readers are very welcome. Since I began writing this post I have found a couple of models that may be useful in facilitating shared-decision-making. Stay tuned. I will discuss them in my next posts...


*
I came across this model recently while researching the question of how to help HPs bring up sexuality issues with gynecologic cancer patients.

**
Haines A, Kuruvilla S, Borchert M. Bridging the implementation gap between knowledge and action for health. Bulletin of the World Health Organization 2004;82:724-32.

Cabana MD, Rand CS, Powe N, et al. Why don't physicians follow clinical practice guidelines?: A framework for improvement. JAMA 1999;282(15):1458-1465 (doi:10.1001/jama.282.15.1458)

Freeman AC, Sweeney K. Why general practitioners do not implement evidence: A qualitative study. BMJ 2001;323:1100-2.

Gravel K, Legare F, Graham ID. Barriers and facilitators to implementing shared-decision-making in clinical practice: A systematic review of health professionals' perceptions. Implementation Science 2006;1:16. (doi:10.1186/1748-5908-1-16)

These are just a few of the articles I've found. I will try to include a more detailed list in a future post.

Privacy and professional autonomy: challenges

Dean Giustini recently brought me to the attention of his readers on the Google Scholar blog which prompted some very interesting questions in the comments. I promised to respond to those questions here.

Q: The first question raised by Anon had to do with patient privacy, a question that was not raised at the CHLA conference and has in fact not come up at all until now. The poster expressed legitimate concerns over whether placing my consults in the patient charts* is "a violation of the librarian's code of ethics to keep questions confidential."

A: I completely agree that when I am in the library and a person approaches me with a question it should be kept confidential, and this is our practise, except when I am seeing a Herzl patient at the library, in which case I make a copy of the consult and place in the their chart at the clinic, this being considered an extension of my service there. In the case of the Herzl service, it is being delivered at point of care, and the expectations of privacy and confidentiality are different. I am recognized as being a member of the team who participates in the provision of care. Most people come to me having been referred by their physician or nurse in the first place which means that the question is already known to them.

I make a point of explaining to anyone who comes to me without a referral or meets with me in the library exactly how the system works i.e. that the consult will end up in their chart and why this is so. I also let them know that if this bothers them I will keep it confidential. So far no one has expressed concern over this or refused to have their consult put into the chart. Perhaps I should try to make the process more transparent by explaining it every time. I haven’t always done this for the same reason I know it is difficult for health professionals to remember to send their patients to the library or to my service: time can be an issue, and also it doesn’t always occur to me when I am focused on conducting a thorough reference interview and answering the question. You have given me something to think about.

Q: The second question/comment had to do with professional autonomy. Anon wondered whether it would be difficult for a librarian to maintain professional autonomy given the hierarchical nature of the clinical setting.

A: If I understand correctly, Anon is expressing concern that a librarian in my situation could be pressured to provide information to patients in support of whatever treatment decision was being recommended by the referring health care professional. It is not always easy for librarians, even for those of us working in a clinical setting, to uphold another of our professional codes which is to provide access to balanced and unbiased information to all, regardless of what our own opinions are on the question or the asker. We are human after all. And often we are limited by what information is actually available to us. Regardless, I do my very best to uphold this code. I am also very careful to make it clear that I cannot interpret the information I am providing access to, nor can I offer any kind of opinion regarding treatment.

There have been a a few cases where the information I have provided has suggested a different course to the patient than the one originally proposed by their referring physician. There have also been cases where the patient only agreed to the proposed treatment after receiving information from me. I see both as examples of shared decision-making and am pleased to have played a part in that process. My impression is that the health care providers I work with are aware that it could go either way when they send someone to me, and this is a risk they take because they believe in the process.

*Important note: the charts I am referring to are kept at the Herzl and are not available hospital-wide or electronically.