Little is known about how physicians present diagnosis and treatment planning in routine practice in preference-sensitive treatment decisions. We evaluated completeness and quality of informed decision making in localized prostate cancer post biopsy encounters.
We analyzed audio-recorded office visits of 252 men with presumed localized prostate cancer (Gleason 6 and Gleason 7 scores) who were seeing 45 physicians at 4 Veterans Affairs Medical Centers. Data were collected between September 2008 and May 2012 in a trial of 2 decision aids (DAs) Braddock's previously validated Informed Decision Making (IDM) system was used to measure quality. Latent variable models for ordinal data examined the relationship of IDM score to treatment received.
Mean IDM score showed modest quality (7 61±2 45 out of 18) and high variability. Treatment choice and risks and benefits were discussed in approximately 95% of encounters. However, in more than one-third of encounters, physicians provided a partial set of treatment options and omitted surveillance as a choice. Informing quality was greater in patients treated with surveillance (β = 1 1, p = 04) Gleason score (7 vs 6) and lower age were often cited as reasons to exclude surveillance. Patient preferences were elicited in the majority of cases, but not used to guide treatment planning. Encounter time was modestly correlated with IDM score (r = 0 237, p = 01) DA type was not associated with IDM score.
Physicians informed patients of options and risks and benefits, but infrequently engaged patients in core shared decision-making processes. Despite patients having received DAs, physicians rarely provided an opportunity for preference-driven decision making. More attention to the underused patient decision-making and engagement elements could result in improved shared decision making.
Medical decision making : an international journal of the Society for Medical Decision Making 2015 Aug 24 [Epub ahead of print]
Margaret Holmes-Rovner, Jeffrey S Montgomery, David R Rovner, Laura Scherer, Jesse Whitfield, Valerie C Kahn, Edgar C Merkle, Peter A Ubel, Angela Fagerlin
Michigan State University Center for Ethics, College of Human Medicine, East Lansing, MI, USA (MHR, JW)Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA (MHR, DRR)Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA (JSM)Section of Urology, Department of Surgery, VA Ann Arbor, Ann Arbor, MI, USA (JSM)Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA (LS, VCK, AF)VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA (VCK, AF)Department of Psychological Sciences, University of Missouri, Columbia, MO, USA (LS, ECM)Department of Medicine, Duke University Medical Center, Durham, NC, USA (PAU)Fuqua School of Business, Duke University, Durham, NC, USA (PAU)Departments of Internal Medicine and Psychology, University of Michigan, Ann Arbor, MI, USA (AF) mholmes@msu edu , Michigan State University Center for Ethics, College of Human Medicine, East Lansing, MI, USA (MHR, JW)Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA (MHR, DRR)Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA (JSM)Section of Urology, Department of Surgery, VA Ann Arbor, Ann Arbor, MI, USA (JSM)Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA (LS, VCK, AF)VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA (VCK, AF)Department of Psychological Sciences, University of Missouri, Columbia, MO, USA (LS, ECM)Department of Medicine, Duke University Medical Center, Durham, NC, USA (PAU)Fuqua School of Business, Duke University, Durham, NC, USA (PAU)Departments of Internal Medicine and Psychology, University of Michigan, Ann Arbor, MI, USA (AF) , Michigan State University Center for Ethics, College of Human Medicine, East Lansing, MI, USA (MHR, JW)Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA (MHR, DRR)Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA (JSM)Section of Urology, Department of Surgery, VA Ann Arbor, Ann Arbor, MI, USA (JSM)Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA (LS, VCK, AF)VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA (VCK, AF)Department of Psychological Sciences, University of Missouri, Columbia, MO, USA (LS, ECM)Department of Medicine, Duke University Medical Center, Durham, NC, USA (PAU)Fuqua School of Business, Duke University, Durham, NC, USA (PAU)Departments of Internal Medicine and Psychology, University of Michigan, Ann Arbor, MI, USA (AF) , Michigan State University Center for Ethics, College of Human Medicine, East Lansing, MI, USA (MHR, JW)Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA (MHR, DRR)Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA (JSM)Section of Urology, Department of Surgery, VA Ann Arbor, Ann Arbor, MI, USA (JSM)Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA (LS, VCK, AF)VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA (VCK, AF)Department of Psychological Sciences, University of Missouri, Columbia, MO, USA (LS, ECM)Department of Medicine, Duke University Medical Center, Durham, NC, USA (PAU)Fuqua School of Business, Duke University, Durham, NC, USA (PAU)Departments of Internal Medicine and Psychology, University of Michigan, Ann Arbor, MI, USA (AF) , Michigan State University Center for Ethics, College of Human Medicine, East Lansing, MI, USA (MHR, JW)Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA (MHR, DRR)Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA (JSM)Section of Urology, Department of Surgery, VA Ann Arbor, Ann Arbor, MI, USA (JSM)Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA (LS, VCK, AF)VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA (VCK, AF)Department of Psychological Sciences, University of Missouri, Columbia, MO, USA (LS, ECM)Department of Medicine, Duke University Medical Center, Durham, NC, USA (PAU)Fuqua School of Business, Duke University, Durham, NC, USA (PAU)Departments of Internal Medicine and Psychology, University of Michigan, Ann Arbor, MI, USA (AF) , Michigan State University Center for Ethics, College of Human Medicine, East Lansing, MI, USA (MHR, JW)Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA (MHR, DRR)Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA (JSM)Section of Urology, Department of Surgery, VA Ann Arbor, Ann Arbor, MI, USA (JSM)Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA (LS, VCK, AF)VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA (VCK, AF)Department of Psychological Sciences, University of Missouri, Columbia, MO, USA (LS, ECM)Department of Medicine, Duke University Medical Center, Durham, NC, USA (PAU)Fuqua School of Business, Duke University, Durham, NC, USA (PAU)Departments of Internal Medicine and Psychology, University of Michigan, Ann Arbor, MI, USA (AF) , Michigan State University Center for Ethics, College of Human Medicine, East Lansing, MI, USA (MHR, JW)Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA (MHR, DRR)Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA (JSM)Section of Urology, Department of Surgery, VA Ann Arbor, Ann Arbor, MI, USA (JSM)Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA (LS, VCK, AF)VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA (VCK, AF)Department of Psychological Sciences, University of Missouri, Columbia, MO, USA (LS, ECM)Department of Medicine, Duke University Medical Center, Durham, NC, USA (PAU)Fuqua School of Business, Duke University, Durham, NC, USA (PAU)Departments of Internal Medicine and Psychology, University of Michigan, Ann Arbor, MI, USA (AF) , Michigan State University Center for Ethics, College of Human Medicine, East Lansing, MI, USA (MHR, JW)Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA (MHR, DRR)Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA (JSM)Section of Urology, Department of Surgery, VA Ann Arbor, Ann Arbor, MI, USA (JSM)Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA (LS, VCK, AF)VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA (VCK, AF)Department of Psychological Sciences, University of Missouri, Columbia, MO, USA (LS, ECM)Department of Medicine, Duke University Medical Center, Durham, NC, USA (PAU)Fuqua School of Business, Duke University, Durham, NC, USA (PAU)Departments of Internal Medicine and Psychology, University of Michigan, Ann Arbor, MI, USA (AF) , Michigan State University Center for Ethics, College of Human Medicine, East Lansing, MI, USA (MHR, JW)Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA (MHR, DRR)Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA (JSM)Section of Urology, Department of Surgery, VA Ann Arbor, Ann Arbor, MI, USA (JSM)Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA (LS, VCK, AF)VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA (VCK, AF)Department of Psychological Sciences, University of Missouri, Columbia, MO, USA (LS, ECM)Department of Medicine, Duke University Medical Center, Durham, NC, USA (PAU)Fuqua School of Business, Duke University, Durham, NC, USA (PAU)Departments of Internal Medicine and Psychology, University of Michigan, Ann Arbor, MI, USA (AF)