"Many miles to go...": a systematic review of the implementation of patient decision support interventions into routine clinical practice

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  • Elwyn, Glyn
    • Other Affiliation: Cochrane Institute of Primary Care and Public Health, Cardiff University School of Medicine, Heath Park, CF14 4YS, UK
  • Scholl, Isabelle
    • Other Affiliation: Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D - 20246 Hamburg, Germany
  • Tietbohl, Caroline
    • Other Affiliation: Department of Health Services Research, Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, California, 94301, USA
  • Mann, Mala
    • Other Affiliation: Cochrane Institute of Primary Care and Public Health, Cardiff University School of Medicine, Heath Park, CF14 4YS, UK
  • Edwards, Adrian G.K.
    • Other Affiliation: Cochrane Institute of Primary Care and Public Health, Cardiff University School of Medicine, Heath Park, CF14 4YS, UK
  • Clay, Catharine
    • Other Affiliation: Office of Professional Education and Outreach, The Dartmouth Institute of Health Policy and Clinical Practice, 46 Centerra Parkway, Suite 203, Lebanon, New Hampshire, 03766, USA
  • Légaré, France
    • Other Affiliation: Knowledge Transfer and Health Technology Assessment Research Group, Research Centre of Centre Hospitalier Universitaire de Québec, Hôpital Saint-François D'Assise, 10, rue de l’Espinay, Québec, QC, G1L 3L5, Canada
  • Weijden, Trudy van der
    • Other Affiliation: Department of General Practice, School CAPHRI, Peter Debyeplein 1, 6229 HA, Maastricht, The Netherlands
  • Lewis, Carmen L.
    • Affiliation: School of Medicine
  • Wexler, Richard M.
    • Other Affiliation: Informed Medical Decisions Foundation, 40 Court Street, Suite 300, Boston, Massachusetts, 02108, USA
  • Frosch, Dominick L.
    • Other Affiliation: Department of Health Services Research, Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Palo Alto, California, 94301, USA
Abstract
  • Abstract: Background: Two decades of research has established the positive effect of using patient-targeted decision support interventions: patients gain knowledge, greater understanding of probabilities and increased confidence in decisions. Yet, despite their efficacy, the effectiveness of these decision support interventions in routine practice has yet to be established; widespread adoption has not occurred. The aim of this review was to search for and analyze the findings of published peer-reviewed studies that investigated the success levels of strategies or methods where attempts were made to implement patient-targeted decision support interventions into routine clinical settings. Methods: An electronic search strategy was devised and adapted for the following databases: ASSIA, CINAHL, Embase, HMIC, Medline, Medline-in-process, OpenSIGLE, PsycINFO, Scopus, Social Services Abstracts, and the Web of Science. In addition, we used snowballing techniques. Studies were included after dual independent assessment. Results: After assessment, 5322 abstracts yielded 51 articles for consideration. After examining full-texts, 17 studies were included and subjected to data extraction. The approach used in all studies was one where clinicians and their staff used a referral model, asking eligible patients to use decision support. The results point to significant challenges to the implementation of patient decision support using this model, including indifference on the part of health care professionals. This indifference stemmed from a reported lack of confidence in the content of decision support interventions and concern about disruption to established workflows, ultimately contributing to organizational inertia regarding their adoption. Conclusions: It seems too early to make firm recommendations about how best to implement patient decision support into routine practice because approaches that use a ‘referral model’ consistently report difficulties. We sense that the underlying issues that militate against the use of patient decision support and, more generally, limit the adoption of shared decision making, are under-investigated and under-specified. Future reports from implementation studies could be improved by following guidelines, for example the SQUIRE proposals, and by adopting methods that would be able to go beyond the ‘barriers’ and ‘facilitators’ approach to understand more about the nature of professional and organizational resistance to these tools. The lack of incentives that reward the use of these interventions needs to be considered as a significant impediment.
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Resource type
  • Article
Rights statement
  • In Copyright
Rights holder
  • Glyn Elwyn et al.; licensee BioMed Central Ltd.
License
Journal title
  • BMC Medical Informatics and Decision Making
Journal volume
  • 13
Journal issue
  • Suppl 2
Page start
  • S14
Language
  • English
Is the article or chapter peer-reviewed?
  • Yes
ISSN
  • 1472-6947
Bibliographic citation
  • BMC Medical Informatics and Decision Making. 2013 Nov 29;13(Suppl 2):S14
Publisher
  • BioMed Central Ltd
Access right
  • Open Access
Date uploaded
  • August 26, 2015

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file details 1472-6947-13-s2-s14.pdf 2019-05-07 Public Download
file details Table S1: Summaries of patient decision support implementation studies: Aims, implementation strategies, outcomes 2019-05-07 Public Download
file details Appendix 1: Search strategy 2019-05-07 Public Download
file details Table S2: Reported barriers, facilitators, and levels of implementation 2019-05-07 Public Download