Primary health care professionals’ views on barriers and facilitators to the implementation of the Ottawa Decision Support Framework in practice
Introduction
Recent years have seen the emergence of new conceptual frameworks of shared decision making that address gaps in mutual understanding of facts and values between patients and health professionals [1], [2]. Shared decision making is defined as decisions that are shared by doctors and patients, informed by the best evidence available and weighted according to the specific characteristics and values of the patient [2]. It is said to occur in a partnership that rests on explicitly acknowledged rights and duties and on an expectation of benefit to both parties [2]. In a review of conceptual models of shared decision making, Makoul and Clayman summarized its key elements in one integrative model: (1) definition/explanation of problem, (2) presentation of options, (3) discussion of pros/cons, (4) exploration of patient values/preferences, (5) discussion of patient ability/self-efficacy, (6) presentation of doctor knowledge/recommendations, (7) clarification of understanding, (8) making or explicitly deferring decision, and (9) arranging follow-up [3].
The Ottawa Decision Support Framework (ODSF) was elaborated to guide the development of interventions aimed at preparing patients and health professionals for shared decision making [1], [4]. One of the important contributions of the ODSF is to identify decisional conflict as one of the key elements in decision making. The ODSF uses the fundamental theories, methodologies and data necessary to operationalise the relevant concepts in health care decision making and help with the development of interventions supporting health decision making in the context of uncertainty. These interventions aim at improving the quality of the decision making process by addressing the intermediary modifiable determinants of decision making that are suboptimal. This decisional process does not aim at the adoption of a decision determined a priori by the expert. It seeks to ensure that the decision made by the patient is informed by the best evidence and is in line with the patient's values. When compared to usual care or simpler information leaflets, decision support interventions based on the ODSF performed better with patients in terms of: (1) greater knowledge, (2) more realistic expectations, (3) lower decisional conflict, (4) increased proportion of people active in decision making, (5) reduced proportion of people who remained undecided, and (6) greater agreement between values and choice [5], [6], [7], [8], [9], [10]. It also appears that when compared to a simpler information leaflet, such interventions improved agreement between patients and their physician on the decisional conflict score [11].
Evidence suggests that, overall, shared decision making has not been adopted by health professionals [12], [13], [14], [15], [16], [17]. Only recently have barriers to its implementation been the object of a growing interest [18], [19], [20], [21]. However, at the time this study was conducted, no other study had targeted the identification of barriers and facilitators to the implementation of the ODSF itself. Therefore, this paper reports on data collected during a before/after implementation trial of the ODSF. Most specifically, it describes primary health care professionals’ views on barriers and facilitators to the implementation of the ODSF in their practice.
Section snippets
Study design
A before/after trial that aimed at implementing the ODSF in primary care practices was conducted using a multifaceted implementation strategy that was comprised of individual feedback, a reminder at the point of care and an interactive workshop. Fig. 1 shows the different stages of this trial. At entry into the study, participants signed a consent form and completed an entry questionnaire. Each recruited five patients from their clinics for whom they felt a decision had been made. Both the
Participants
A total of 67 clinical teachers and 53 residents in family medicine enrolled in the overall implementation trial (response rate = 75%). In one site, one nurse and one nutritionist also enrolled hence a total of 122 providers were included in the overall trial. Fig. 2 presents the flow of participants for the sample frame of clinical teachers and residents who completed the full implementation trial. However, because of the pragmatic nature of the trial, a total of 64 clinical teachers, 50
Discussion
Results from this study are important because they provide a structured approach to the views of 118 primary health care professionals on implementing the ODSF in their practice, a decision support framework that facilitates shared decision making. They have the potential to help translate shared decision making in clinical practice for the following reasons.
In this study, a taxonomy of barriers to the implementation of clinical practice guidelines was adapted to content-analyse the material
Acknowledgements
At the time this study was conducted, Dr. Légaré was supported by a scholarship from the Canadian Institutes of Health Research (CIHR) and Institute of Health Services and Policy Research (IHSPR). Dr. Légaré currently holds a clinical scientist award from the Fonds de la Recherche en Santé du Québec (FRSQ). Dr. O’Connor is Tier 1 Canada Research Chair in Health Related Decision Support. This research was supported by the Canada Research Chair in Health Related Decision Support, KT-ICE ICEBERG,
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