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Biomedical subjects

G Elwyn

Publications and source records attributed to G Elwyn.

At least 19 recordsLinked to original sources
PubMed2003

Personalised risk communication for informed decision making about entering screening programs.

BACKGROUND: There is a trend towards greater patient involvement in health care decisions. Adequate discussion of the risks and benefits associated with different choices is often required if involvement is to be genuine and effective. Achieving adequate involvement of consumers and informed decision making are now seen as important goals for any screening programme. Individualised risk estimates have been shown to be effective methods of risk communication in general, but the effectiveness of different strategies has not previously been examined. OBJECTIVES: To assess the effects of different types of individualised risk communication for consumers making decisions about participating in screening. SEARCH STRATEGY: We searched the Cochrane Consumers and Communication Review Group specialised register (searched March 2001), MEDLINE (1985 to 2001), EMBASE (1985 to 2001), CancerLit (1985 to 2001), CINAHL (1985 to 2001), ClinPSYC (1989 to 2001), and the Science Citation Index Expanded (searched March 2002). Follow-up searches involved hand searching Preventive Medicine, citation searches on seven authors, and searching reference lists of articles. SELECTION CRITERIA: Randomised controlled trials addressing the decision by consumers of whether or not to undergo screening, incorporating an intervention with a 'personalised risk communication element' and reporting cognitive, affective, or behavioural outcomes. A 'personalised risk communication element' is based on the individual's own risk factors for a condition (such as age or family history). It may be calculated from an individual's risk factors using formulae derived from epidemiological data, and presented as an absolute risk or as a risk score, or it may be categorised into, for example, high, medium or low risk groups. It may be less detailed still, involving a listing, for example, of a consumer's risk factors as a focus for discussion and intervention. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Data about the nature and setting of the intervention, and the relevant outcome data were extracted, along with items relating to methodological quality. MAIN RESULTS: Thirteen studies were included. Personalised risk communication (whether written, spoken or visually presented) was associated with increased uptake of screening tests (odds ratio (OR) 1.5 (95% confidence interval (CI) 1.11 to 2.03). There was no evidence from these studies that this increase in uptake of tests was related to informed decision making by consumers. More detailed personalised risk communication was associated with a smaller increase in uptake of tests. That is, for personalised risk communication which used and presented numerical calculations of risk, the OR for test uptake was 1.22 (95% CI 0.56 to 2.68). For risk estimates or calculations which were categorised into high, medium or low strata of risk, the OR was 1.42 (95% CI 1.07 to 1.88). For risk communication that simply listed risk personal risk factors the OR was 1.7 (95% CI 1.17 to 2.48). Most of the included studies addressed mammography programmes. These studies showed slightly smaller effects than the overall dataset, again with numerical calculated risk estimates being associated with lower ORs for uptake of tests (OR 1.13; 95% CI 0.98 to 1.29) than the other categories of (less detailed) personalised risk communication. The four studies examining risk communication in high risk individuals showed larger odds ratios for uptake of tests than the other studies. The OR for numerical calculated risk estimates was 1.48 (95% CI 1.06 to 2.07), compared to 4.66 (95% CI 2.24 to 9.69) for categorised risk estimates and 2.64 (95% CI 1.42 to 4.9) for listed personal risk factors. There were insufficient data from the included studies to report odds ratios on other key outcomes such as: intention to take tests, anxiety, satisfaction with decisions, decisional conflict, knowledge and risk perception. REVIEWER'S CONCLUSIONS: Personalised risk communication (as currently implemented in the included studies) is associated with increased uptake of screening programmes, but this may not be interpretable as evidence of informed decision making by consumers.

Communication↗
PubMed2003

Shared decision making: developing the OPTION scale for measuring patient involvement.

BACKGROUND: A systematic review has shown that no measures of the extent to which healthcare professionals involve patients in decisions within clinical consultations exist, despite the increasing interest in the benefits or otherwise of patient participation in these decisions. AIMS: To describe the development of a new instrument designed to assess the extent to which practitioners involve patients in decision making processes. DESIGN: The OPTION (observing patient involvement) scale was developed and used by two independent raters to assess primary care consultations in order to evaluate its psychometric qualities, validity, and reliability. STUDY SAMPLE: 186 audiotaped consultations collected from the routine clinics of 21 general practitioners in the UK. METHOD: Item response rates, Cronbach's alpha, and summed and scaled OPTION scores were calculated. Inter-item and item-total correlations were calculated and inter-rater agreements were calculated using Cohen's kappa. Classical inter-rater intraclass correlation coefficients and generalisability theory statistics were used to calculate inter-rater reliability coefficients. Basing the tool development on literature reviews, qualitative studies and consultations with practitioner and patients ensured content validity. Construct validity hypothesis testing was conducted by assessing score variation with respect to patient age, clinical topic "equipoise", sex of practitioner, and success of practitioners at a professional examination. RESULTS: The OPTION scale provided reliable scores for detecting differences between groups of consultations in the extent to which patients are involved in decision making processes in consultations. The results justify the use of the scale in further empirical studies. The inter-rater intraclass correlation coefficient (0.62), kappa scores for inter-rater agreement (0.71), and Cronbach's alpha (0.79) were all above acceptable thresholds. Based on a balanced design of five consultations per clinician, the inter-rater reliability generalisability coefficient was 0.68 (two raters) and the intra-rater reliability generalisability coefficient was 0.66. On average, mean practitioner scores were very similar (and low on the overall scale of possible involvement); some practitioner scores had more variation around the mean, indicating that they varied their communication styles to a greater extent than others. CONCLUSIONS: Involvement in decision making is a key facet of patient participation in health care and the OPTION scale provides a validated outcome measure for future empirical studies.

Decision Making↗
PubMed2002

Research on patients' views in the evaluation and improvement of quality of care.

The identification of methods for assessing the views of patients on health care has only developed over the last decade or so. The use of patients' views to improve healthcare delivery requires valid and reliable measurement methods. Four approaches are recognised: inclusion of patients' views in the information to those seeking health care, identification of patient preferences in episodes of care, patient feedback on delivery of health care, and patients' views in decision making on healthcare systems. Outcome measures for the evaluation of the use of patients' views should reflect the aims in terms of processes or outcomes of care, including possible negative consequences. Rigorous methodologies for the evaluation of methods have yet to be implemented.

Attitude to Health↗
PubMed2001

Decision analysis in patient care.

To help patients to fully participate in shared decision making is becoming an important goal in clinical practice and one which is receiving increasing attention in terms of the requisite skills and technological development. We discuss the potential application of decision analysis-a specific technology that has been introduced into clinical practice but to date only within research contexts-and examine the usefulness and feasibility of the technique for patients, particularly in settings where clinical presentations are diverse and characterised by uncertainty.

Decision Support Techniques↗
PubMed2001

Practice and professional development plans (PPDPs): results of a feasibility study.

BACKGROUND: Dissatisfaction with uniprofessional education structures as a means of improving the quality of healthcare has led to proposals to develop ways of integrating professional learning and organisational development. AIMS: Test the feasibility of introducing practice and professional development plans using a centrally sponsored project in Wales. DESIGN: Qualitative observational study. STUDY SAMPLE: All 541 practices in Wales were alerted to the project and invited to apply. A selection process was suggested to Health Authorities but not always efficiently conducted: 23 practices were selected and 18 participated in the process. METHOD: Central funding was made available to health authorities. The project framework was designed by an educational department and conceptualised as the development of personal portfolios linked to one key organisation change in each practice, facilitated by external consultants who would typically hold workshops or other events. An independent researcher using non-participant observation techniques at workshops and practices undertook documentary analysis and fieldwork in four health authorities. RESULTS: Difficulties were encountered with the process of implementing the project: marketing and practice selection inconsistencies delayed the work and it was difficult to recruit practices into the project. The lack of experienced individuals to do the work and practitioner suspicion about perceived 'management' agendas were significant problems. After initial hesitancies most practices appreciated the value of developing wider ownership and commitment to proposed practice changes. Organisations found it difficult to support individual completion of the personal portfolio component of the plans. The ability to develop systems for clinical services was dependent on having already established a culture of effective teamwork in the organisation. CONCLUSIONS: This work supports the view that organisational development has considerable potential for bringing about effective change, and individual contributions could form a valuable component of personal portfolios. We believe that the existing structures in education and management in the health service are not yet able to support these processes. Evidence from the fields of risk management and quality improvement all point to the need to develop effective organisational systems and the results of this feasibility study indicate that alternative models of sustaining organisational development need careful evaluation.

Education, Medical, Continuing↗
PubMed2001

Measuring the involvement of patients in shared decision-making: a systematic review of instruments.

We wanted to determine whether research instruments exist which focus on measuring to what extent health professionals involve patients in treatment and management decisions. A systematic search and appraisal of the relevant literature was conducted by electronic searching techniques, snowball sampling and correspondence with field specialists. The instruments had to concentrate on assessing patient involvement in decision-making by observation techniques (either direct or using audio or videotaped data) and contain assessments of the core aspects of 'involvement', namely evidence of patients being involved (explicitly or implicitly) in decision-making processes, a portrayal of options and a decision-making or deferring stage. Eight instruments met the inclusion criteria. But we did not find any instruments that had been specifically designed to measure the concept of 'involving patients' in decisions. The results reveal that little attention has been given to a detailed assessment of the processes of patient involvement in decision-making. The existing instrumentation only includes these concepts as sub-units within broader assessments, and does not allow the construct of patient involvement to be measured accurately. Instruments developed to measure 'patient-centeredness' are unable to provide enough focus on 'involvement' because of their attempt to cover so many dimensions. The concept of patient involvement (shared decision-making; informed collaborative choice) is emerging in the literature and requires an accurate method of assessment.

Decision Making↗
PubMed2001

Shared decision making observed in clinical practice: visual displays of communication sequence and patterns.

UNLABELLED: The aim of the study was to examine the communication strategies of general practitioners attempting to involve patients in treatment or management decisions. This empirical data was then compared with theoretical 'competences' derived for 'shared decision making'. The subjects were four general practitioners, who taped conducted consultations with the specific intent of involving patients in the decision-making process. The consultations were transcribed, coded into skill categorizations and presented as visual display using a specifically devised sequential banding METHOD: The empirical data from these purposively selected consultation from clinicians who are experienced in shared decision making did not match suggested theoretical frameworks. The views of patients about treatment possibilities and their preferred role in decision making were not explored. The interactions were initiated by a problem-defining phase, statements of 'equipoise' consistently appeared and the portrayal of option information was often intermingled with opportunities to allow patients to question and reflect. A decision-making stage occurred consistently after approximately 80% of the total consultation duration and arrangements were consistently made for follow-up and review. Eight of the 10 consultations took more than 11 min - these specific consultations were characterized by significant proportions of time provided for information exchange and patient interaction. The results demonstrate that some theoretical competences are not distinguishable in practice and other stages, not previously described, such as the 'portrayal of equipoise', are observed. The suggested ideal of a shared decision-making interaction will either require more time than currently allocated, or alternative strategies to enable information exchange outside the consultation.

Adult↗
PubMed2001

Consumers' views of quality in the consultation and their relevance to 'shared decision-making' approaches.

BACKGROUND: There is a recognized need to assess the effects of shared decision-making and other communication interventions. However, the outcomes usually assessed for evidence of 'effectiveness' are determined by researchers and have not been based on consumers' views. AIM: This study aimed to identify the important outcomes of consultations for consumers, and to compare with those reported in the current literature. SETTING AND PARTICIPANTS: Forty-seven participants attending six focus group interviews. Most interviews took place in and all were orientated towards the UK primary care setting. METHODS: Focus group study. RESULTS: Many affective outcomes were identified, consistent with the current literature trends. However, many cognitive and behavioural outcomes that are assessed in the current literature were not noted by participants as important. Furthermore, a broader range of outcomes than is evident in the current literature was viewed as important to these participants. CONCLUSIONS: There is a need to revisit the outcomes which are assessed in decision-making and communication research. The outcomes of greatest importance to consumers must be identified and confirmed by new research which is based directly on the views of consumers themselves.

Consumer Behavior↗
PubMed2001

Joining them up: the challenges of organisational change in the professional politic of general practice.

Primary health care in the UK is currently centred around independent contractor organisations (general practices). Although the development of these organisations is considered necessary to improve the quality of health care, no structures exist to support the systematic development necessary to attain this goal. Part of the failure to change clinical processes has been the requirement that general practitioners attend passive educational events for continuing professional development, without reference to organisational or local health priorities. A feasibility study to integrate professional and practice development planning sought to overcome this mismatch. NHS Staff College Wales, as a facilitating organisation in this study, developed a model to assist practices to identify, prioritise and implement developments, interlinked with individuals' professional development. The paper summarises the experiences of facilitators supporting this integrated approach, using Senge's model of the challenges to the successful implementation of change. The role of facilitation in negotiating these challenges is also explored. The paper concludes that the approach is effective in the integration of professional and practice development and offers a useful framework to progress the quality improvement agenda.

Cooperative Behavior↗
PubMed2001

Antibiotics and shared decision-making in primary care.

Antibiotics are often prescribed to patients with respiratory tract infections who are unlikely to benefit. Models of physician-patient interaction may help understanding of this problem and inform the design of communication skills interventions to enhance appropriate prescribing. The 'paternalistic model' of the consultation remains common in the setting of acute respiratory tract infections. However, the four assumptions that could support this model are not valid for most of these patients, because: best treatment is controversial; management is inconsistent; physicians are not in the best position to evaluate trade-offs between management options without understanding patients' perspectives; and many pressures (apart from patients' agendas) intrude into the consultation. One alternative is the 'informed model' of consulting, but this does not take society's interests into account. The 'shared decision-making model', however, provides a framework for addressing both clinicians' and patients' agendas, and could guide the development and evaluation of specific consultation strategies to promote more appropriate use of antibiotics in primary care.

Anti-Bacterial Agents↗
PubMed2001

Understanding risk and lessons for clinical risk communication about treatment preferences.

This paper defines risk and its component elements and describes where clinical practice may be starting from in terms of what is reported in the literature about understanding risks and the information requirements of consumers. It notes briefly how theoretical models in the literature contribute to our understanding by providing a basis from which to summarise current evidence about the effects of healthcare interventions which address risks and risk behaviour. The situations or types of interventions in which risk related interventions are most effective are described, but a significant caveat is noted about the types of outcomes which have been reported in the literature and which are most appropriate to evaluate. The effects of "framing" variations in the information given to consumers and the ethical dilemmas these raise for a debate about "informed choice" in healthcare programmes are discussed. In response to both the practical and ethical dilemmas that arise from the current evidence, some of the areas where attention should be focused in the future are outlined so that both health gain and informed choice might be achieved. These include the use of decision aids, although their implementation is not widespread at present. Lessons from the current literature on how further progress can be made towards improved communication, discussion between professionals and consumers, and enhancing informed choice are discussed.

Communication↗
PubMed2000

Organisational development in general practice: lessons from practice and professional development plans (PPDPs).

BACKGROUND: Improving the quality and effectiveness of clinical practice is becoming a key task within all health services. Primary medical care, as organised in the UK is composed of clinicians who work in independent partnerships (general practices) that collaborate with other health care professionals. Although many practices have successfully introduced innovations, there are no organisational development structures in place that support the evolution of primary medical care towards integrated care processes. Providing incentives for attendance at passive educational events and promoting 'teamwork' without first identifying organisational priorities are interventions that have proved to be ineffective at changing clinical processes. A practice and professional development plan feasibility study was evaluated in Wales and provided the experiential basis for a summary of the lessons learnt on how best to guide organisational development systems for primary medical care. RESULTS: Practice and professional development plans are hybrids produced by the combination of ideas from management (the applied behavioural science of organisational development) and education (self-directed adult learning theories) and, in conceptual terms, address the lack of effectiveness of passive educational strategies by making interventions relevant to identified system wide needs. In the intervention, each practice participated in a series of multidisciplinary workshops (minimum 4) where the process outcome was the production of a practice development plan and a set of personal portfolios, and the final outcome was a realised organisational change. It was apparent during the project that organisational admission to a process of developmental planning needed to be a stepwise process, where initial interest can lead to a fuller understanding, which subsequently develops into motivation and ownership, sufficient to complete the exercise. The advantages of introducing expert external facilitation were clear: evaluations of internal group processes were possible, strategic issues could be raised and explored and financial probity ensured. These areas are much more difficult to examine when only internal stakeholders are engaged in a planning process. CONCLUSIONS: It is not possible to introduce practice and professional development plans (organisational development and organisational learning projects) in a publicly funded health care system without first addressing existing educational and management structures. Existing systems are based on educational credits for attendance and emerging accountability frameworks (criteria checklists) for clinical governance. Moving to systems that are less summative and more formative, and based on the philosophies of continual quality improvement, require changes to be made in the relevant support systems in order achieve policy proposals.

Evidence-Based Medicine↗