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Abstract
Introduction In shared decision making (SDM), patients and clinicians collaborate to make decisions based on best available evidence and what matters to patients. This study characterizes patient- centeredness of explicitly stated rationales in clinicians’ recommendations and final decisions.
Methods Patients with atrial fibrillation were randomized to usual care with or without using a within- encounter SDM tool to decide about anticoagulation. Video-recorded patient-clinician encounters were coded for explicitly stated rationales for clinician recommendations and decisions on whether and how to anticoagulate. Rationales were coded as patient-centered when they cited a patient’s unique situation, preferences, or expressions of will, and not when they cited the clinician’s experience, evidence, or guidelines. Reviewers, blinded to rationale classification, rated encounters on clinicians’ efforts to involve patients (OPTION12).
Results Of the 922 trial encounters, 830 had video recordings available for analysis. Clinicians made recommendations for whether (N=274, 33% of encounters) or how (N=158, 19%) to anticoagulate; these were largely not patient-centered (‘whether’ N=269, 98%; ‘how’ N=122, 77%). Final decisions were justified using patient-centered rationales in 465 instances, nonpatient-centered ones in 188, and a combination in 82. Encounters in which patient-centered rationales were provided showed higher OPTION12 scores (β, 11.70; 95%CI, 9.98–13.41; P<0.001), with also higher scores in the intervention arm compared to usual care (figure 1).
Discussion Although most clinicians made recommendations based on factors not particular to each patient, most final treatment decisions had patient-centered rationales. Irrespective of the patient- centeredness of provided rationales, using an effective SDM encounter tool led to higher patient involvement scores.
Distribution of OPTION12 scores by final decision rationale and study arm