Medical Decision MakingUsing a ‘talk’ model of shared decision making to propose an observation-based measure: Observer OPTION5 Item
Introduction
Measuring shared decision making is a challenge, despite reasonable consensus about its core characteristics [1]. To achieve shared decision making, providers should ensure that patients are informed about options, and supported to deliberate about those options. Both patients and providers should consider the role of evidence as well as each other's preferences as they deliberate. Ideally, end-users, that is, patients, would be asked to assess whether or not they experienced shared decision making. However, despite many efforts over the last decade to develop valid, reliable patient-reported measures of shared decision making, it has proved difficult to be confident that these measures are accurate assessments of the target phenomenon [2], [3].
The difficulty probably lies in the novelty of the construct. When asked whether they have been ‘involved in decisions’ patients tend to interpret the question as one about satisfaction, either with their provider or with their experience of care [3], [4]. The data from patient-reported measures of shared decision making typically provide scores at the upper end of scales, with relatively little variation [5], [6]. However, data from ratings of audio and videotapes, i.e. observational process assessments such as the Observer OPTION12 Item measure [7], show that practitioners seldom achieve high levels of performance in tasks characteristic of shared decision making, a finding confirmed by Couët's recent review of 29 studies [8], and by studies using other observational measures [9], [10], [11], [12]. Over the last decade, further consensus has been achieved about the characteristics of shared decision making [1], [13]. We therefore considered it opportune to revisit the issue of observational measurement to evaluate whether improvements could be made to the existing Observer OPTION12 Item [7].
There are a number of observational measures of shared decision making or efforts to provide ‘decision support’ to patients. These include Braddock's Informed Decision Making Scale [9], the Rochester Participatory Decision Making Scale [11] and Stacey's Decision Support Analysis Tool [12]. The Observer OPTION12 Item measure is used to assess audio- or video-recordings of clinical encounters. Twelve items are scored and re-scaled to provide a score between 0 and 100, indicating “the extent to which providers involve patients in [shared] decision making” [7]. However, application of the measure over the last decade has revealed areas where improvement could be made. Observers, using Observer OPTION12 Item to assess provider performance have noted the relative lack of attention to the elicitation of patient preferences, an important weakness of the measure [7].
Studies show significant variation in inter-rater agreement, particularly at item rather than global-score levels [8]. There are items that are not specific to the construct of involving patients in decision making, and some items specify behaviors that seem to be idealized constructions rarely observed in routine practice. For example, item 3 in the original instrument, see Table 1, specifies whether providers ask patients about their preferred information format, e.g. risk portrayal in graphs or number formats. Although plausible, this level of checking is unlikely in routine care. The inclusion of items that are never observed contributes to floor effects in the measure.
We appreciate that a shorter tool risks not being able to cover the specified construct of shared decision making fully, and might therefore be less valid and reliable, and this risk will need to be empirically tested in future studies. Our hypothesis is that a more focused, briefer measure would offer the following potential benefits:
- (1)
Improved construct validity, given a focus on a set of behaviors specific to shared decision making;
- (2)
Improved reliability because raters would be required to assess fewer, more relevant, and defined, observable behaviors;
- (3)
Increased efficiency because of shorter completion time.
The aim of this study therefore is to propose a shorter version of Observer OPTION12 Item based on our analysis of published shared decision making models.
Section snippets
Methods
We addressed this aim by analyzing published shared decision making models to confirm a recently proposed conceptual framework [14]. We then revised the existing measure based on empirical data from a large observational study of clinical practice in Canada where Observer OPTION measure was used, as well as a review of all existing studies using the OPTION instrument [8], and our own experience in providing training for over 20 researchers to use the Observer OPTION12 Item measure since 2001.
Analysis of shared decision making models
We examined all the models in Makoul and Clayman's [1] table of prominently cited models [17], [18], [19], [20], [21], [22], [23], [24], [25], [26]. In addition, from the search, after removing duplicates, our search identified 247 candidate articles. We excluded 228 by screening titles and abstracts, and assessed 19 full text articles. Of these 19, we excluded 11 citations [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], and included 8 for analysis, alongside those identified
Discussion
By combining data from three sources, experiential, qualitative, and quantitative, we have proposed a new observational measure of shared decision making, which is briefer than the previous Observer OPTION12 Item scale. This new measure is based on a more robust conceptual model, and offers the ability to give credit to providers who make efforts to engage patients in decision making processes over multiple encounters.
Although we were able to use quantitative data from a large observational
Competing interests
All authors declare they have no competing interests.
Funding
This work was supported by the Dartmouth Center for Health Care Delivery Science.
Acknowledgements
We acknowledge the significant contribution of Albert Mulley and Chris Trimble in refining the Talk Model of Shared Decision Making, and to all collaborators in the MAGIC Program in the UK for the early work on this model. Thanks also to Thomas Mead, information scientist for search support, to Stuart Grande, Thomas Walsh, Rachel Thompson and Paul Barr for contributions and comments.
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