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INTRODUCTION: Decision aids aimed at men with benign prostatic hyperplasia used in clinical trials have decreased the use of procedures and affected elements of decisional quality. We employed an online, interactive decision aid for men with benign prostatic hyperplasia as a routine part of care with a urologist and tracked subsequent treatment choice. We further evaluated the role of patient preferences on treatment selection. METHODS: Men scheduled for a new patient visit with a urologist for benign prostatic hyperplasia at a single tertiary care center were invited to use a decision aid prior to their visit. We compared treatment patterns in men who used the decision aid to a usual care group identified prior to the decision aid's introduction. Latent class analysis identified clusters of patients by their treatment preferences, which were then compared to their treatment choice. RESULTS: The rate of procedures in the decision aid group was significantly lower than in the usual care group (6% vs 15%; p=0.0250), matching the rates reporting a procedure as their preferred treatment choice in the post-consult questionnaire (5% vs 15%; p=0.0082). Of the patients in our project 36% had never tried an alpha blocker prior to their urology consult. Latent class analysis found 2 clusters of patient preferences but without a significant association with final treatment selection. CONCLUSIONS: Use of a decision aid was associated with a significant decrease in procedural management of benign prostatic hyperplasia. A high proportion of patients were evaluated by urologists without exhausting primary care management options.
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OBJECTIVE: To measure decisional quality, physician loyalty, and treatment preference in patients diagnosed with urolithiasis, a "preference-sensitive" condition, to identify areas of improvement to be addressed by a targeted shared decision-making intervention. METHODS: We identified patients who presented for an initial consultation for urolithiasis from March 2016 to May 2017. Patients completed a 24-item patient experience questionnaire after the consultation which assessed decisional quality domains, physician loyalty, and treatment preference. We summarized treatment preferences before and after the consultation and described the changes. RESULTS: Among the total of 113 patients who met inclusion criteria, 78 (69%) patients chose to participate. Thirty-six (46%) of those patients had evidence of decisional conflict and 42 (54%) did not. Only 1 in 5 patients experiencing decisional conflict reported knowing the benefits and risks of each treatment option. Patients with decisional conflict reported lower perceived shared decision-making, treatment satisfaction, and urolithiasis knowledge. Physician loyalty was lower among patients with decisional conflict as well. Thirty-nine percent of them were 'Promoters' of their urologist, compared to 71% of patients without decisional conflict. Sixty-four percent of patients without decisional conflict identified a treatment preference before consultation, while only 17% of patients who experienced decisional conflict were able to do so. CONCLUSION: Many patients with urolithiasis experience decisional conflict and are unsure of their preferences when making a treatment choice. Uncertainty can correlate with low physician loyalty after consultation. This population may benefit from a shared decision-making intervention that improves decisional quality while incorporating patient-specific preferences.
Assuntos
Tomada de Decisões , Participação do Paciente , Preferência do Paciente , Urolitíase/terapia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Autorrelato , Adulto JovemRESUMO
OBJECTIVE: To evaluate barriers to implementation of patient decision aids (PDAs) issued in an electronic medical record (EMR). We undertook an implementation outcomes analysis focused on what proportion of men eligible for the PDA received it (penetration), and of the men who received it, how many used it as intended (fidelity). We also evaluated various patient-centered outcomes related to decision-making. MATERIALS AND METHODS: Men with incident localized prostate cancer were recruited from at UCLA from 2013 to 2017. PDA eligibility was determined via weekly EMR review. We also performed a retrospective chart review of all patients seen in clinic for one sample week to identify patients that were missed by the initial eligibility algorithm, and investigated the cause for miscategorization. We analyzed differences in patient-centered outcomes between those who did and did not receive the PDA. RESULTS: About 314/374 men with incident prostate cancer completed the PDA conferring 84% fidelity. PDA penetration under initial identification prospective algorithm was assessed at 100% (nâ¯=â¯2/nâ¯=â¯2). However, penetration assessed by manual retrospective chart review was 20% (nâ¯=â¯2/nâ¯=â¯10). Improvements to the identification algorithm, including new EMR visit types, were identified. PDA completion was associated with less decisional conflict and higher perceived Shared decision-making (all P<.03). CONCLUSION: No previous studies have investigated the challenges of implementing a PDA facilitated by the EMR. We identified modifiable system and EMR-related factors that limited program penetration. Our PDA showed decisional quality benefits.