NEW YORK (Reuters Health) – Implementing both clinician and patient versions of the DECIDE intervention could improve shared decision making (SDM) and patient-reported quality of care, researchers suggest.
“Premature termination in treatment, poor satisfaction in care and problems in communication are persistent for racial and ethnic minority clients in behavioral healthcare,” Dr. Margarita Alegria of Massachusetts General Hospital in Boston said in an email.
“This study really opened our eyes to how providers do not recognize how their interactions in the clinical visit lead to disparities,” she told Reuters Health.
“We tested two interventions . . . to attempt to remediate these challenges by helping patients advocate for what they want in care and providers to be more inclusive of their patient’s perspective,” she said. “You would think this normally happens, but it does not.”
In a study involving patients and clinicians from 13 behavioral health clinics, Dr. Alegria and colleagues assessed the effectiveness of two versions of an SDM intervention known as DECIDE: decide the problem; explore the questions; closed or open-ended questions; identify the who, why, or how of the problem; direct questions to your healthcare professional; enjoy a shared solution.
One version is for clinicians (DECIDE-PC); the other is for patients (DECIDE-PA).
A total of 74 clinicians (mean age, 40; 76% women) were randomized to either usual care or DECIDE-PC, which was delivered in a 12-hour workshop and up to six coaching calls, aimed at promoting communication and a therapeutic alliance with the patient.
A total of 312 patients (mean age, 44; 68% women) were randomized to either usual care or DECIDE-PA, which involved three 60-minute sessions focused on improving perceived quality of care. Patients with serious mental health conditions were excluded.
The clinicians were about 58% non-Latino white, 20% Latino, 5% non-Latino black, and 16% Asian; corresponding percentages among the patients were 36%, 42%, 11%, and 11%.
There were four patient-clinician dyads: patient and clinician in the control condition (72 pairs); patient in the intervention and clinician in the control condition (68); patient in the control condition and clinician in the intervention (83); or patient and clinician in the intervention (89).
Trained, blinded coders rated SDM by listening to audio recordings and completing the Observing Patient Involvement in Shared Decision Making instrument. The patient Perceptions of Care Survey-Global Evaluation of Care Scale was administered, among other assessments, to evaluate the patient’s subjective rating of care.
Clinician and patient outcomes were assessed at baseline, at two months, and at four to six months.
As reported online February 21 in JAMA Psychiatry, the clinician intervention significantly increased SDM as rated by the coders, but not as assessed by clinician or patient. The more coaching sessions in which clinicians participated, the higher were the coder ratings of SDM.
However, the authors state, “the clinician intervention seemed to affect patient global evaluations of care more strongly when patients and clinicians did not have the same primary language.”
“The intervention may have a stronger effect on patient global evaluation of care in linguistically discordant patient-clinician relationships requiring greater clinician effort and a subjectively different, more apparent SDM experience for the patient,” they speculate.
The patient intervention significantly increased patient-perceived quality of care. The more sessions the patients attended, the greater the perceived quality, particularly when their clinicians also received more coaching sessions.
Dr. Alegria said, “From our collaboration with community stakeholders, we believe that dissemination of the DECIDE interventions is an extremely important next step.”
“Our team . . . is working to successfully disseminate the interventions to new clinical sites and community contexts,” she noted. “For instance, we want to examine how to streamline trainings and session times to best accommodate busy patients and clinicians.”
Dr. Benjamin Brody, a psychiatrist at Weill Cornell Medicine and NewYork-Presbyterian in New York City told Reuters Health, “The goal of enhancing communication between minority populations and mental healthcare providers is important, and this study demonstrates that patients perceive that their communication was improved by a simple intervention.”
“I think the biggest implications of this work,” he said by email, “are for physician and mental healthcare provider education, and possibly for patient education in specific regions that have large minority populations.”
However, he added, “there’s a big limitation that the authors do not discuss: they excluded patients with mania, psychosis, and suicidal ideation – and these are the very patients with whom psychiatrists have the most difficulty communicating and sharing common treatment goals. The limitation was based on feedback from the IRBs (institutional review boards) at the institutions, but led to a real weakening of the study.”
SOURCE: http://bit.ly/2op5wzl
JAMA Psychiatry 2018.
Tidak ada komentar:
Posting Komentar