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Patient, clinician interventions benefit shared decision-making, quality of care

Among behavioral health clinic patients, a clinician intervention improved shared decision-making and a patient intervention improved quality of care, according to data published in JAMA Psychiatry.

“Implementing [shared decision-making] in behavioral health care poses challenges,” Margarita Alegria, PhD, of Massachusetts General Hospital and Harvard Medical School, and colleagues wrote. “Clinicians are trained as clinical experts; [shared decision-making] represents a paradigmatic shift in acknowledging patients as experts of their illness experience and asking them to voice visit agendas. Clinician stereotyping, bias and lack of skills to address power differentials are additional barriers.”

Alegria and colleagues examined the effectiveness of patient and clinician DECIDE interventions in improving shared decision-making and quality of care. The DECIDE intervention was previously developed as a tool to improve patient activation and self-management among patients receiving behavioral health care. They conducted a cross-level 2×2 randomized, clinical trial that included clinicians at level 2 and patients at level 1. The researchers randomly selected clinicians and patients (1:1) at each site for each 2-person block.

Behavioral health professionals who were trained by the researchers delivered the clinician intervention, which involved a 12-hour workshop based on recorded clinical sessions. Coaches coded behaviors from 1 to 6 extra patient-clinician recorded sessions and offered feedback via phone to encourage communication and therapeutic connection. In the patient intervention, patients received three 60-minute sessions that taught them about their role, choices and agency in clinical visits, trained them to understand treatment decisions and encouraged them to ask questions. Researchers assessed shared decision-making based on clinical recordings, patient perception of decision-making and quality of care and clinician perception of shared decision-making.

In total, 312 patients and 74 clinicians took part in the analysis. The researchers allocated patient-clinician pairs to one of the following design arms: patient and clinician in the control condition, patient in intervention and clinician in the control condition, patient in the control condition and clinician in intervention or patient and clinician in intervention.

Although the interventions were not considered significant for shared decision-making when assessed by the clinicians and patients, the clinician intervention increased shared decision-making (P=.04) as rated by blinded coders. According to the coders, more clinician coaching sessions were linked to an increase in shared decision-making (P=.001). Furthermore, the researchers observed a significant connection between patient and clinician dosage; the greatest benefit was seen when both took the recommended dosage.

For quality of care, analysis showed that the patient intervention significantly increased patient-perceived quality of care by 2.27 points on a 100-point scale. However, patient-perceived and clinician-perceived shared decision-making were not associated with significant intervention effects; in addition, there were no individually significant coefficients.

“Our findings reveal how professional knowledge and collaborative dialogue can coexist,” Alegria and colleagues wrote. “Results suggest that an adequate threshold of [shared decision-making] training promotes a gradual philosophical transformation for clinicians, whereby patient preferences, choices and agency come to the forefront, all of which are important components of achieving better health outcomes.” – by Savannah Demko

Disclosures: The authors report no relevant financial disclosures.