Disconnects between allergists, patients impact shared decision-making
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Key takeaways:
- 79% of allergists said they frequently used shared decision-making.
- 25% of patients said their provider used shared decision-making frequently or occasionally.
- Tools can guide these discussions.
There was a disconnect between allergists and patients in their perceptions of shared decision-making, according to a survey published in World Allergy Organization Journal.
The barriers to shared decision-making (SDM) in allergy care also were consistent with those across health care, De De Gardner, DrPH, RRT, RRT-NPS, FAARC, FCCP, chief research officer of Allergy & Asthma Network, and colleagues wrote.
“Shared decision-making tools exist for patients and health care professionals to work together to make the best health care decision for the patient,” Gardner told Healio.
The researchers launched the study after hearing from patients who were not involved in SDM about treatment for their conditions, yet who were having a conversation with health care providers (HCPs) who agreed they were using SDM tools to engage patients in their care.
“Here, we saw a disconnect,” Gardner said.
SDM is important for patient treatment choice, Gardner continued.
“It improves adherence to asthma and allergy treatment plans. It brings the patient’s voice into the decisions about how they want to best manage their disease,” she said.
Each patient is unique and has different lived experiences with their disease and/or treatments, Gardner added.
“Shared decision-making encourages patients to take a more active and central role in their care. It’s evidence-based and balances risks and results with a patient’s preferences and values,” she said.
Also, SDM encourages involvement from patients living in under-resourced communities who may feel marginalized.
“It brings their voice to the forefront of their own care and establishes trust between patients and HCPs,” she said.
Allergist perspectives
The survey polled 101 allergists aged 25 years and older who had been practicing for at least 3 years; who treat 26 or more patients with asthma, allergy and/or eczema each month; and who were members of the American College of Asthma, Allergy & Immunology and research partners with Dynasta, a marketing research firm.
Also, these allergists included 60% who were aged 35 to 54 years, 71% who were men, 44% who were in practice for more than 20 years and 81% who were in community-based or private practice.
Based on their own definition, 98% of the allergists said they were familiar with the concept of SDM, and 79% said they used it frequently, including with an average of 44% of their patients with asthma, allergy and eczema in the previous 12 months.
Although SDM tools are available from ACAAI, the researchers continued, only 23% said they were very familiar with them, and 4% said they were not familiar with them. Also, 43% said they had not used any SDM tools with their patients at all.
Next, the survey provided a definition of SDM.
“Shared decision-making occurs when a health care provider and a patient work together to make a health care decision that is best for the patient,” the definition read.
“The optimal decision takes into account evidence-based information about available options, the provider’s knowledge and experience, and the patient’s values and preferences,” it continued.
The definition further said that HCPs and patients both benefit from SDM, including improved quality of delivered care, increased patient satisfaction, improved patient care experiences and patient adherence, and trusting and lasting relationships between HCPs and patients.
Using this definition, 42% of the allergists who said they did not use SDM or who used it infrequently called it too time consuming, 37% believed their patients had low health literacy, 32% needed more information about SDM, and 32% believed their patients preferred their allergist to make recommendations.
Further, 59% said they were very likely or likely to recommend the ACAAI SDM tools to their colleagues, and 99% of those who used SDM believe their patients have positive experiences with it.
But despite open responses indicating that allergists believe SDM is a great tool, they also said it is not appropriate for all patients.
Yet SDM does improve results, Gardner said.
“More than 58% of allergists saw improved adherence to the treatment plan when shared decision-making was used, and 48% saw better patient-clinician communication when shared decision-making was used,” she said.
Patient perspectives
The 110 patients (63% women; 64% white) who participated all were aged 18 years and older, with 61% aged 25 to 55 years. Treatment in the previous 12 months included allergy (96%), asthma (34%) and eczema (16%), with all participants reporting that they usually see an allergist for these issues.
After the survey defined SDM for patients, 60% said they at least had some familiarity with the concept, and 25% said it was used frequently or occasionally when they were treated for allergies, asthma or eczema.
However, only 22% reported using SDM tools with their provider.
Of the 44 patients who said they were unfamiliar with SDM, 68% said they would be interested in learning more about it, including 89% of Black patients and 85% of those patients with at least a bachelor’s degree. These patients also included 55% who said they would be likely to ask their allergist about SDM.
The 56 patients who said their allergists infrequently or never used SDM included 70% who said they would be likely to ask their allergist to use it more often.
The patients who were unlikely to ask their allergist to use SDM or use it more frequently said that was because they did not know enough about SDM and needed more information, they preferred the allergist to make recommendations, they did not want or need to have input, or that their condition was simple to treat and SDM was not needed.
When the survey asked patients to rank the benefits of SDM, 15% said the most important benefit was better end results for them, and 14% said it was becoming more knowledgeable about their condition.
Also, 12% each cited incorporating their preferences into their discussions with their providers, better communications with their providers, and being more likely to follow treatment plans if they understand better.
Overall, 82% said that SDM helps them understand what treatment options are available along with their potential benefits and harms, and 77% agreed it made them more comfortable about their treatment.
Open-ended responses were overwhelmingly positive, the researchers continued, indicating that patients felt more in control of their treatment.
However, other responses suggested that patients were hesitant about SDM because they did not want to make stressful medical decisions or because they believed there was only one treatment option.
Barriers, disconnects
These responses indicate room for improvement with barriers on both sides of care, the researchers said, even though providers and patients alike both recognize the benefits of SDM.
Perceived barriers common to both providers and patients included the belief that patients prefer allergists to make decisions without their input. The researchers also cited allergist perceptions of low health literacy and inability to understand complex diseases among their patients, making SDM unnecessary.
“The fact that HCPs are concerned about patient health literacy brings to the forefront the importance of appropriate patient education for asthma and allergies,” Gardner said.
But this perception is driven by misunderstandings about SDM. According to the researchers, SDM is about obtaining the patient’s point of view and should draw out the patient perceptions and preferences that will affect disease management. Even if patients do not want to participate in SDM, the researchers said, finding that out is part of the process too.
SDM tools may help patients overcome patient passivity, the researchers wrote, because they are specifically designed to engage patient participation.
Finally, the researchers suggested, the perception that SDM was too time consuming was the top barrier described by allergists. The researchers suggested that staff involvement and allowing patients to use SDM tools before or after clinic visits may alleviate these concerns.
To improve these disconnects, the researchers called for more extensive training for allergists and staff in what SDM is and in how to engage patients across different socioeconomic and educational backgrounds, as well as greater use of available SDM resources.
“Patients and HCPs need education about SDM and how to use the tools available,” Gardner said. “HCPs need more guidance about how to incorporate SDM tools into their practice.”
Gardner recommended online resources about SDM available from the Allergy & Asthma Network and ACAAI.
Meanwhile, research continues.
“The next step is to repeat the survey in the next year or so with a larger sample size, and to add more questions specific to health equity,” Gardner said.
Perspective
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This is an interesting and important topic, not only for allergy and asthma providers, but for all providers who manage the health care of patients. There are many potential benefits of SDM.
When the provider includes patients in the health care plan, it empowers them. They become active participants in their health care. SDM also fosters a relationship of trust and mutual respect. This promotes patient confidence and ultimately more effective care and better outcomes.
When patients are educated, even on a basic level, and they have a better understanding of treatment options, their overall satisfaction improves, which can lead to increased compliance. Confident and empowered patients have less anxiety and uncertainty about the management of their condition, and this results in fewer office or ED visits and lower health care costs.
The findings of this study were not surprising to me but quite significant. I was not surprised that most providers practice SDM to some degree.
From my experience, I think almost all patients desire to have a part in the decision-making process. Even those with low health literacy can be educated on a basic level. Instead of overwhelming them, you can provide a bit of instruction at each visit.
I have had patients who would rather that I make treatment decisions for them and not have a part in the process, but I find this to be much more the exception than the rule. I have found through many years of experience that treatment success and patient satisfaction is more easily achieved when I include patients in decisions regarding their care.
According to the study, one of the barriers to using SDM stems from a misunderstanding of what it is. In simple terms, it is about obtaining the patient’s point of view. My recommendation to other providers would be to elicit the patient’s preferences and perceptions to gain a better understanding of where the patient is coming from.
The study found that the SDM process took less than 3 minutes during a typical consultation visit. So, I would recommend spending the extra time needed to include the patient and ultimately strengthen the relationship.
As long as there is a disconnect between allergists and their patients regarding SDM as well as barriers to the use of SDM that is consistent across the health care industry in general, more work needs to be done.
I believe the next step in research should be to improve training of providers with studies conducted to evaluate the effectiveness of the training. Research could also be conducted to better understand patient preferences and perceptions and how they influence decision-making.
Perspective
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Michael S. Blaiss, MD, FACAAI, FAAAAI
There are many benefits for both the patient and physician in performing SDM in the office practice. Patients can express their values and perceptions so the physician can consider them in their care and receive information on treatments including benefits, risks, outcomes and costs without medical jargon. Thus, we have a better educated patient.
When patients participate in SDM, studies show that they are more adherent to treatment and therefore get better outcomes, which is the goal for all physicians in caring for a patient. SDM also is shown to improve patient/physician communication and lead to higher patient satisfaction with their physician.
The findings in this study are not surprising. There have been many studies in numerous specialties showing the disconnect between physicians believing that they are doing SDM and the patients’ experience with the use of SDM by their physicians. It is not unique in the allergy community.
I commonly speak to physicians about SDM. I ask if they are doing it, and most say yes. But when I ask about specifics related to good SDM with SDM tools, most do not.
Physicians need formal education on how to do SDM. Most have never been taught the basics or how to use SDM tools. We need courses at all major medical meetings so physicians can develop skills in SDM. SDM education should be mandatory in all medical schools.
We need more data on showing the benefits of SDM for the patient and physician especially related to adherence and patient outcomes. There also is a need for more studies that clearly show the minimal increased time commitment needed for SDM, which is one of the major reasons why physicians say they do not do it. We need better SDM tools that are validated in caring for all the major chronic diseases.
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