Patient decision aids (PDAs) have been developed to enable people to be more involved in decisions and plans about their care. We briefly explore some of the key drivers and barriers to their adoption.
Patient decision aids (PDAs) are tools that are designed to help people participate in decision making about different care options. They provide information about the options and outcomes and help patients make informed decisions based on their values and preferences. They are designed to complement, rather than replace, counselling from a clinician. Self-management interventions are complex interventions that can be made up of many different components. Within the COMPAR-EU project we aim to provide PDAs to facilitate the self-management decision-making process for both patients and health care professionals. However, we are aware that we will be faced with a number of factors that will influence their real implementation.
While many clinicians feel they involve patients in their own care and they do not understand why their self-management recommendations are not being followed, patients do not feel involved or listened to and think things are being done “to” them rather that “with” them. Besides, clinicians are unaware of the values and preferences of patients whereas patients are unaware of the options and evidence that might influence their health outcomes. The result of this is that decisions and plans are less successful than they could be, and the level of satisfaction is low, resulting in wasted time, resources and opportunities (Lewis-Barnet, 2016).
Shared decision-making is part of patient-centred care whereby patients and clinicians decide on an intervention together. This is particularly relevant when the decision is preference-sensitive and when there is not too much evidence about the intervention. One way to promote this collaborative approach is by using a PDA, which provides information about the available options, benefits and risk of each option and ways to incorporate patients’ values and preferences.
Barriers to adoption
Although PDAs have been proven to be effective in involving patients in shared decision-making and improving their decision quality (Stacey, 2017), the adoption and implementation of PDAs remains poor (Lin, 2013). There are many factors that influence the implementation of PDAs in real practice.
A systematic review of health professionals’ perceptions highlighted that the most often reported barriers for implementing PDAs were time constraints, lack of applicability due to patient characteristics and the clinical situation (Légaré, 2008). In terms of attitudes and roles, some clinicians find the idea of partnership working disconcerting. Others feel that they already do it despite the evidence to the contrary. Furthermore, clinicians perceive poor interpersonal skills as a barrier to shared decision-making. Other issues relate to organizational and system level characteristics (Scholl, 2018). Organizational level factors include organizational leadership, culture, resources, and priorities, as well as teams and workflows (Scholl, 2018). System level characteristics that have been described as influencing factors are policies, clinical guidelines, incentives, culture, education, and licensing (Scholl, 2018).
The main barriers for PDA implementation as experienced by older patients are related to poor health and/or cognitive or physical impairments (Pel-Little, 2021). Socio-cultural barriers such as language barriers and clinician paternalism, and lack of resources in terms of infrastructure or technology development are potential influencing factors to be considered that may vary across countries.
Dr. Ana I. González
Ana is a senior researcher at FAD with several years of experience leading, managing and coordinating projects in Health Services Implementation Research. Since 2013, she belongs to the Research network on Health Services and Chronic Diseases (REDISSEC). She has been principal investigator of two projects within Spain with the aim to enhance patient empowerment.
Faciliators to adoption
Among the facilitators to implement PDAs in routine care, we should consider clinicians’ motivation, introduction of a system to identify eligible patients to use the PDAs ahead of clinical consultations, positive impact on the clinical process and patients’ outcomes (Légaré, 2008). Clinicians need a supporting organizational context and good communication skills to provide the individualized approach for patient care that using a PDA requires (Pel-Little, 2021).
Working in partnership with patients requires a change in attitudes skills and system to become part of normal practice. With COMPAR-EU we pretend to provide a clear understanding of what self-management interventions work and do not work. Incorporating PDAs as part of our goals considering all influential factors, we pretend to enhance their implementation in real practice.