Arthritis Care & Research Vol. 67, No. 10, October 2015, pp 1463–1470 DOI 10.1002/acr.22605 C 2015, American College of Rheumatology V

ORIGINAL ARTICLE

Rheumatologists’ Views and Perceived Barriers to Using Patient Decision Aids in Clinical Practice JEFF Y. ZONG,1 JENNY LEESE,1 ALEXANDRIA KLEMM,1 ERIC C. SAYRE,2 JASMINA MEMETOVIC,2 JOHN M. ESDAILE,1 AND LINDA C. LI1

Objective. To explore rheumatologists’ perceptions of patient decision aids (PtDAs) and identify barriers to using them in clinical practice. Methods. A cross-sectional online survey of all members of the Canadian Rheumatology Association (CRA; n 5 459) was conducted. We subsequently invited 10 respondents to participate in a 30-minute telephone interview to further explore their views on using PtDAs in clinical practice. Interview participants were purposefully sampled to achieve a balance in sex, years in clinical practice, and types of practice. Results. In August and September 2013, 153 CRA members responded to the survey (response rate 33.3%); of those, 113 completed the entire questionnaire. Sixty-three respondents (55.8%) were male, 54 (47.8%) were ‡50 years of age, and 55 (48.7%) practiced in a multidisciplinary setting. When asked about their intention to use PtDAs, participants rated mean 6 SD 5.7 6 2.9 (where 0 5 not likely and 10 5 very likely). Sixty-four (56.6%) believed that rheumatologists were unfamiliar with PtDAs, and 76 (67.3%) thought that PtDAs would disturb their workflow. In-depth interviews revealed the following: the perception that PtDAs were no different from any other patient education tools, the concern that PtDAs were of limited value in real life since they relied solely on data from randomized controlled trials, and the fear that PtDAs could impair doctor–patient communication. Conclusion. There was a sense of ambivalence among rheumatologists about PtDAs. Our interviews further revealed concerns regarding the utility and benefits of PtDAs in clinical practice. The results show a need to familiarize physicians with PtDAs and to develop strategies to support their integration in clinical practice.

INTRODUCTION Clinical practice is shifting from traditional paternalistic models to shared decision-making. This process involves an exchange of information in order to prepare patients to participate in making treatment decisions with their physicians (1,2). From a patient’s perspective, there are 2 Mr. Zong’s work was supported by a Canadian Rheumatology Association summer studentship. Dr. Li’s work was supported by the Canadian Research Chair Program, the Harold Robinson/Arthritis Society Chair in Arthritic Diseases, and the Michael Smith Foundation for Health Research Scholar Award. 1 Jeff Y. Zong, HBSc, Jenny Leese, BA, MA, Alexandria Klemm, BKin, John M. Esdaile, MD, MPH, FRCPC, Linda C. Li, PT, PhD: University of British Columbia and Arthritis Research Canada, Vancouver, British Columbia, Canada; 2 Eric C. Sayre, PhD, Jasmina Memetovic, MSc: Arthritis Research Canada, Vancouver, British Columbia, Canada. Address correspondence to Linda C. Li, PT, PhD, Arthritis Research Canada, 5591 No. 3 Road, Richmond, British Columbia, Canada V6X 2C7. E-mail: [email protected]. Submitted for publication December 29, 2014; accepted in revised form April 21, 2015.

types of treatment decisions. The first type is called effective decisions and typically involves treatments with proven effectiveness and minimal tradeoffs (e.g., those related to side effects and costs). In other words, compared to other plausible options, there are clear winners. Usually, physicians would prescribe these treatments and most patients would follow the recommendation with minimal uncertainty and concern (3). One example is starting symptomatic knee osteoarthritis patients on a progressive exercise program. This approach has been recommended in clinical practice guidelines (4), is supported by strong evidence (5), and has minimal side effects. The other type of decision involves patients choosing from a number of options that have varying degrees of benefit and harm. These, called preference-sensitive decisions, typically involve multiple treatment options, and none is a clear winner, based on the available evidence (6). Each option has its unique pros and cons, which may weigh differently for different patients. Thus, these types of decisions are usually made based on patients’ individual preferences. For instance, in the use of biologic therapy for treating rheumatoid arthritis, there is no single superior option that makes a clear difference in health outcomes 1463

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Significance & Innovations  Patient decision aids (PtDAs) complement counseling from physicians by involving patients in preference-sensitive health care decisions. Although there is evidence supporting the effectiveness of PtDAs in facilitating shared decision-making, and improving patient knowledge and satisfaction with their decision, uptake of PtDAs by health professionals in clinical practice is poor. This research will explore rheumatologists’ perceptions of PtDAs and their intention to use them in clinical practice.  Numerous PtDAs are being developed for patients with arthritis. This study will assist their application by identifying rheumatologists’ perceived barriers to implementing these tools in a clinical setting.  This study will be the first to use a mixed quantitative and qualitative approach to investigate rheumatologists’ views and perceptions of PtDAs and their implementation.

and side effects (7). In this case, other attributes, such as cost, the availability of cumulative evidence of new products versus older products, and the method and frequency of administration, become important factors in the individual’s decision. The ranking of one attribute over another is based on the patient’s preference, but during a clinic visit, patients may not have sufficient time or the pertinent information to be able to consider all of the options. As a result, they may arrive at a decision that is not congruent with their own preferences, which may consequently affect treatment adherence (8). To address this issue, patient decision aids (PtDAs) have been developed to provide a structure to guide patients when they are considering treatment options. PtDAs are evidence-based tools designed to help patients recognize the preference-sensitive nature of the different choices, as well as their personal values regarding the benefits, harms, and scientific uncertainties of each treatment option (9–12). Thus, they prepare patients to discuss their preferences, as well as questions and concerns about treatment options, with their physicians (11). PtDAs are tools designed to supplement, not replace, the process of physician counseling. A 2014 Cochrane systematic review found that patients who used decision aids had a lower level of decisional conflict (i.e., a sense of uncertainty), were more engaged in the process of treatment decision-making, and were more likely to reach a treatment decision (13). The use of PtDAs was also found to reduce the use of invasive surgical procedure by 24%, without adversely affecting health outcomes (13). The use of a PtDA provides a process that prepares individuals to engage in meaningful discussions with their physicians (14). This sets the stage for shared decision-making, whereby patients are better equipped to identify and communicate preferences and concerns, and then make the decision jointly with their physicians (15). Although a number of PtDAs have been developed for patients with arthritis (16–18), they have not been well

Zong et al integrated in clinical practice. Previous studies have found that various barriers, such as time constraints and a perceived lack of applicability of PtDAs to the patient or the clinical situation, may be significant barriers to PtDA use (19,20), but it is unclear whether these factors are specific to rheumatology. Also, given that many studies were published before online PtDAs were available, we can identify new factors by interviewing rheumatologists. Therefore, the objective of this study was to explore rheumatologists’ perceptions of PtDAs, as well as barriers and facilitators to using these types of tools in clinical practice.

MATERIALS AND METHODS Study design. We used a mixed quantitative and qualitative methods approach. Specifically, we conducted an online survey of rheumatologists across Canada and indepth interviews with a purposive sample of survey respondents to further explore this topic. Online survey. A cross-sectional online survey of members of the Canadian Rheumatology Association (CRA) was conducted between August and September 2013. All 459 members, including rheumatologists, emeriti, trainees, and honoraries, received an invitation from the CRA to participate. We employed a modified Dillman technique (21) to elicit the fullest possible participation in the survey. A reminder e-mail was sent 2 and 4 weeks after the initial invitation. The survey was administered using LimeSurvey, with the data stored at Arthritis Research Canada. The questionnaire was adapted from 2 sources: the survey instrument developed by Stacey et al (22) to assess factors influencing health professionals who provide support for individuals preparing to make health decisions and the survey by Graham et al (23) of physicians’ intentions and use of 3 PtDAs (see Supplementary Appendix A, available in the online version of this article at http://onlinelibrary. wiley.com/doi/10.1002/acr.22605/abstract). It consisted of 12 questions about rheumatologists’ intentions and views regarding the use of PtDAs, and the perceived barriers to implementing PtDAs in clinical practice settings. Participants were also asked to select and rank the top 3 essential attributes of a PtDA and the top 3 barriers to using PtDAs. Individual interviews. A sample of the respondents were invited to participate in a 30-minute telephone or face-to-face interview to further explore the reported barriers to using PtDAs in their clinical practices. Participants were purposefully selected using the following criteria to ensure a broad representation of individual characteristics, including sex, geographic location (by province), practice setting, and practice experience (#2 years versus .2 years in rheumatology practice). This technique ensured that diverse views could be obtained from the interviews (24,25). Interviews were conducted by 2 authors (JYZ and JL) using a semistructured interview guide to explore barriers/facilitators to implementing decision aids in rheumatology practice (see Supplementary Appendix B, available in the online version of this article at http://onlinelibrary.wiley.

Decision Aids Survey Among Rheumatologists

Table 1.

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Characteristics of survey respondents* Completed survey respondents (n 5 113)

Age, years ,39 40–49 50–59 $60 Male Practicing full time Years in rheumatology practice ,2 2–10 11–20 21–30 .30 Type of practice Solo practice Multidisciplinary clinic Community rheumatology clinic Geographic region Urban/suburban Rural/remote Province British Columbia Ontario Quebec Prairie provinces (Manitoba, Saskatchewan, Alberta) Maritime provinces (New Brunswick, Nova Scotia, Prince Edward Island)

Interview participants (n 5 10)

22 37 25 29 63 87

(19.5) (32.7) (22.1) (25.7) (55.8) (77.0)

2 2 3 3 6 10

(20) (20) (30) (30) (60) (100)

9 24 33 21 22

(8.0) (21.2) (29.2) (18.6) (19.5)

2 (20) 0 (0) 3 (30) 2 (20) 3 (30)

45 (40.0) 55 (48.7) 9 (8.0)

4 (40) 5 (50) 1 (10)

102 (90.3) 7 (6.2)

10 (100) 0 (0)

33 (29.2) 31 (27.4) 11 (9.7) 33 (29.2) 5 (4.4)

3 (30) 5 (50) 0 (0) 2 (20) 0 (0)

* Values are the number (percentage). Category percentages may add up to less than 100% due to missing data.

com/doi/10.1002/acr.22605/abstract). Informed consent was obtained from all who agreed to participate. All sessions were audio-recorded and later transcribed verbatim. All physicians who participated in the interview received a small cash honorarium for their time.

Table 2.

Statistical analysis. For the survey, descriptive statistics were used to summarize barriers to using PtDAs and respondents’ personal/practice characteristics. Rank scores were calculated for the “essential attributes of PtDAs” and “barriers to using PtDAs.” A score of 3 was assigned

Rheumatologists’ attitudes toward PtDAs (n 5 113)* Strongly agree/ Strongly disagree/ agree Neutral disagree

Most rheumatologists are confident in guiding patients in the steps for making a treatment decision. Rheumatologists have access to good resources to support patients making treatment decisions. PtDAs would enhance the care provided by rheumatologists. Most rheumatologists are familiar with PtDAs. Most patients facing treatment decisions should be referred to use a PtDA. It will require a lot of human resources to implement PtDAs in my practice. It will be difficult for my staff to learn how to use PtDAs. It will be inconvenient to administer PtDAs in my practice. The use of PtDAs will require reorganization of my practice/workflow. None of my colleagues will support the use of PtDAs. * Values are the number (percentage). PtDAs 5 patient decision aids.

93 (82.3)

14 (12.4)

6 (5.31)

55 (48.7)

28 (24.8)

30 (26.5)

77 (68.1) 22 (19.5) 40 (35.4)

23 (20.4) 27 (23.9) 48 (42.5)

13 (11.5) 64 (56.6) 25 (22.1)

45 (39.8)

31 (27.4)

37 (32.7)

25 55 76 13

39 33 24 50

49 25 13 50

(22.1) (48.7) (67.3) (11.5)

(34.5) (29.2) (21.2) (44.3)

(43.4) (22.1) (11.5) (44.3)

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Table 3.

Essential attributes of and barriers to using PtDAs* Rank, mean 6 SD score

Essential attributes of PtDAs 1. Description of risks/benefits of choices is supported by evidence. 2. The evidence of treatment options is presented in an unbiased manner. 3. The information presented in the PtDA is up to date. 4. The PtDA content is compatible with how I think patients should be informed about the options. 5. Development of the PtDA is not influenced by third-party financial interests. 6. Information presented reflects my understanding of the evidence of the treatment options. 7. The PtDA developers are credible. Barriers to using PtDAs 1. Time constraints in explaining to patients how to use a PtDA 2. Unfamiliar with the content of PtDAs 3. Do not know if a PtDA exists for a specific treatment decision 4. Do not believe there is a need for PtDAs 5. Believe that information covered by most PtDAs is too complex 6. Uncertain if PtDAs are evidence based 7. Do not believe PtDAs can change patient outcome 8. Believe that the use of PtDAs requires a drastic change to the rheumatologist’s clinical practice 9. Believe that the information covered by most PtDAs is too simplistic

1.75 6 1.23 1.05 6 0.99 1.01 6 1.18 0.81 6 1.12 0.62 6 1.02 0.42 6 0.90 0.24 6 0.64 1.39 6 1.15 1.09 6 1.19 1.05 6 1.31 0.43 6 0.96 0.41 6 0.81 0.38 6 0.76 0.38 6 0.88 0.37 6 0.78 0.15 6 0.49

* For each survey response, 3 points were assigned to the first-rank item, 2 points to the second-rank item, and 1 point to the third-rank item. Each section also contained an “other” category that could be ranked. PtDAs 5 patient decision aids.

to the first-rank item, 2 to the second-rank item, and 1 to the third-rank item. The mean rank score 6 SD was calculated for each of the 2 variables. For the individual interviews, we conducted content analysis using an iterative process, whereby codes were identified and then revised as more interviews were analyzed. Initial open coding, and assigning conceptual labels to the content was followed by clustering the labels into thematic categories using NVivo software. Quotes representative of the thematic categories were identified. The study protocol was approved by the University of British Columbia Behavioural Research Ethics Board (application number H13-01817).

Table 4. Respondent ID 001 002 004 006 007 008 010 011 012 014

RESULTS Survey. Of the 459 CRA members, 153 responded to the survey (response rate 33.3%) and 113 completed the entire questionnaire (Table 1). The 40 incomplete surveys were not included in the data analysis. Respondents rated mean 6 SD 5.7 6 2.9 on their intention to use a PtDA in clinical practice (where 0 5 not likely and 10 5 very likely). The majority of them (n 5 93, 82.3%) believed that rheumatologists were confident in guiding patients in making a treatment decision, but less than half (n 5 55, 48.7%) said that they had access to good resources for their patients (Table 2). Although 68% agreed that PtDAs

Interview participant characteristics (n 5 10)

Sex

Province

City type

Setting

Practice experience, years

Female Male Male Female Male Male Female Female Male Male

Alberta Ontario Alberta British Columbia Ontario British Columbia Ontario Ontario Ontario British Columbia

Urban/suburban Urban/suburban Urban/suburban Urban/suburban Urban/suburban Urban/suburban Urban/suburban Urban/suburban Urban/suburban Urban/suburban

Multidisciplinary clinic* Solo practice Solo practice Multidisciplinary clinic Multidisciplinary clinic Multidisciplinary clinic Solo practice Solo practice Multidisciplinary clinic Community rheumatology clinic

2 or less 21–30 11–20 11–20 30 or more 11–20 30 or more 2 or less 20–30 30 or more

* Multidisciplinary clinic category includes hospital-based and community-based clinics.

Decision Aids Survey Among Rheumatologists

Table 5.

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Supporting quotations from the qualitative interviews*

Theme 1: PtDAs offered patient education rather than decision support General comments “It is an aid; it is a tool no different than my speech, my talking, or my ability to listen is a tool. So it has to be in conjunction with a professional interface.” (Respondent 007) “. . .what I think a decision aid is trying to do is have a computer, you know, answer this question what’s of value to you and then this is a better product for you versus this.” (Respondent 006) “. . .anything that helps the patient come to a conclusion and decide. . .can be a handout . . . can be just their own independent research, it can be, unfortunately, talking to friends and family. . . PtDA versus pamphlets from Rheuminfo: I don’t see them being different, I’m just providing information. . .I just don’t see these particular aids as being more valuable than these handouts that I provide for patients.” (Respondent 004) “. . .what is a patient decision aid. . . off the cuff I would have said you know it’s a, my information to them, it’s web sites and/or literature.” (Respondent 014) If there were a PtDA available for you, how would you decide whether to use it or not? “I would look at. . . how much I thought it would answer the questions the way I would like the questions to be answered.” (Respondent 015) “I think it’s a structured tool that sort of guides the patient at a decision point in, you know, considering appropriately all their alternatives. . . It doesn’t have to follow my practice exactly but, again, if what it recommends or the things it takes into account aren’t things I’m comfortable with, I probably won’t use that decision aid.” (Respondent 002) “. . .decision aids have that little, almost like an algorithm, you know, do you have enough information? Right, and they’re trying to force people down a particular pathway on how to think about medications, right?” (Respondent 004) “A patient decision aid is. . .it’s a device that tries to, in narrative and textually, present information that presents things proportionally and absolutely, in a cascading fashion that goes through a normal narrative but allows the patient to do it, at times independently with access to a professional or at times using the aid, sorry, the professional using the aid, as an attempt to have a congruent, consistent message.” (Respondent 007) What do you think would be the outcome of using PtDAs? “Hopefully a more informed patient. . . if I just tell somebody to do something and they haven’t, you know, they’re not emotionally invested in it and don’t feel they’ve participated in it, they’re likely not to be very adherent.” (Respondent 002) “Patients will be more aware of why we’re using certain medications. If they feel like they’ve decided and they understand it well, they may be more compliant or adherent to taking the medication [. . .]. They will have less side effects because they will pick them up earlier if they understand the medication better, so they’ll notice if they’re getting an infection or, you know, they’ll, perhaps they’ll do their blood tests more frequently appropriately so we can pick up side effects earlier.” (Respondent 008) Theme 2: The treatment information in PtDAs was limited What would be some barriers to using PtDAs in clinical practice? “[. . .] When you have, you know, 8 biologic alternatives and the decision aid says you can take Enbrel or decline it, but really the decision is, Do I take Enbrel, do I take Humira, do I take Orencia, do I take one of the other 5, or I could decline everything, which might not be a wise choice. You know, it’s more complicated than looking at each drug in isolation. You know, like the Enbrel decision aid gives you the benefit versus placebo but it doesn’t compare on one page the benefit of Enbrel versus Humira versus Simponi, versus the other 5 versus placebo. . .so it’s a little on the simple side that way, I think.” (Respondent 002) “It’s difficult for a patient to know. . . this is what this data shows, this appears based on this study that this issue is more with this drug than this drug but the patient populations were different [. . .] I worry that [patients] don’t have the clinical context in which to put, extrapolate all that data into [. . .] if we just looked at clinical trial data, people might say no, I won’t take rituximab, but, you know, if they have the right combination of manifestations, it might be the right drug for them.” (Respondent 006) “The same thing is going to apply with these decision aids. . . people just don’t have the statistical background to figure these things out [. . .] people always focus on, oh, I’m going to get this side effect, I could get that side effect; it’s like, yeah, but look at the complications you’re going to get if you don’t [. . .] for the Enbrel [PtDA]. . .you know 50 improved and 79 don’t improve, wow, that’s a 1 in 2. Joint damage. . .what does joint damage mean?. . .It just means, you know, erosion or joint space narrowing.” (Respondent 004) Theme 3: PtDAs could impair rheumatologist–patient communication Those kinds of decisions that aren’t black and white, how do you deal with that. . .when the patient is facing more complicated. . .decisions? “Well, you have to sit and talk to them about it. . . It’s part of how you make rapport, it’s part of how they learn to trust you. . . And I don’t think a decision aid gives you that. . . Patients will often ask me, have you had a patient take this drug? Yes. Have you had any bad outcomes? No. . . They’ll ask me personally that because that is important to people when they’re making a decision. So I think having a computer and asking a patient would you rather have A, B, or C. . . I think that it’s very artificial.” (Respondent 006) And so if you were going to administer a PtDA in whatever format that you desire, how would you incorporate it into your practice? “. . .well, at the appropriate timing say we’re going to be having, unless you’re a lot better with this intervention by the next visit. . . we’re going to have a look at intervention X, so I’d like you to go to website Y and look at that and go to perhaps Rheuminfo and look at that so when you come back, you can have some thoughts on it and we can discuss any (continued)

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Table 5.

(Cont’d)

questions and we’ll go further from there [. . .] My suspicion is it won’t save any time, but it’ll make patients, patient discussion, one would hope, a little more informed.” (Respondent 014) “. . .my biggest concern about shared decision aids is if you go through them all, it always comes down to, you know, you still need more information to ask your doctor. . .it always seems to boil down to the doctor that ends up answering the questions [. . .] I gotta take the extra time to answer questions because people just don’t have the statistical background.” (Respondent 004) “People are set in their ways so they may not want to change their practice to incorporate the decision aid. . . I know [rheumatologist’s name], for example, sends the patient to a room where there’s a stand-alone computer and some videos that he has of him talking to the patient about methotrexate. So there are ways you have to change your patient flow that are hard to do for people who are set in their ways.” (Respondent 008) “I don’t have the time to chase down all the patients who’ve taken home a decision aid to think about you know did they call me back. . . So there’s a danger of sort of slipping through the cracks.” (Respondent 002) * PtDAs 5 patient decision aids.

would enhance patient care, most of them felt that rheumatologists were unfamiliar with these types of tools (n 5 64, 56.6%). Nearly 65% disagreed or were neutral about referring patients to use a PtDA. Opinions varied about the human resources required to implement PtDAs in practice, or whether it would be difficult to train staff to use them. However, 48.7% indicated that it would be inconvenient to use PtDAs and more than two-thirds believed that it would interrupt their workflow. Only 13 respondents (11.5%) felt that their colleagues would oppose the use of PtDAs, but 50 (44.3%) remained neutral on this topic. The 3 highest-ranked attributes of a good PtDA were the following: the PtDA information is supported by evidence, the evidence of treatment options is presented in an unbiased manner, and the information is up to date (Table 3). The 3 highest-ranked barriers for rheumatologists to implementing PtDAs were the following: time constraints in explaining to patients how to use a PtDA, unfamiliarity with the content of PtDAs, and uncertainty about whether a PtDA was available for a specific treatment decision. Interview. Fifteen survey respondents indicated an interest in the qualitative interview and 10 of them provided consent and participated (Tables 1 and 4). Analysis from the in-depth interviews further revealed rheumatologists’ beliefs about PtDAs. Three themes were identified: the perception that PtDAs offered patient education rather than decision support, that there was limited treatment information in PtDAs, and that PtDAs could impair rheumatologist–patient communication. Theme 1: PtDAs offered patient education rather than decision support. Interviewees described PtDAs as tools no different from other information tools available to patients (Table 5, Respondents 007, 006, 004, and 014). It was perceived that PtDAs should be structured to educate patients on a specific treatment decision that was appropriate and congruent with the rheumatologist’s own beliefs (Respondents 015, 002, 004, and 007). One interviewee described PtDAs as educational tools that could make patients feel more informed, more involved in their care, and more invested in treatment decisions (Respondent 002). It was felt that a more informed patient would

understand why certain medications were recommended and would therefore adhere to the recommendations (Respondent 008). Interestingly, no interviewee described PtDAs as tools that could assist patients in assessing the pros and cons of treatment options based on the available evidence and the patient’s own preference. Theme 2: The treatment information in PtDAs was limited. There was a common perception among interviewees that information presented in PtDAs was too simplistic (i.e., lacking context) for patients considering multiple treatment options (Table 5, Respondent 002). Rheumatologists understood each PtDA to present information about a single treatment in isolation from other available options and, in doing so, to offer patients a simple yes or no choice. In reality, however, patients might need to compare multiple options in relation to each other; hence the process was seen as more complicated than what a PtDA could address. Concerns were also raised that patients might experience difficulty in interpreting the information presented by PtDAs (Respondent 006). Without the medical background necessary to interpret randomized controlled trials data that forms the basis of PtDAs, patients could be left nonplussed with “a whole slew of questions” (Respondent 004) and a skewed view of which medication would be appropriate for their individual circumstance. There were also doubts about patients’ ability to conceptualize the risk of harms as presented in PtDAs, due to a lack of statistical background. This could lead to errors in judging the benefits versus harms of treatment options (Respondent 004). Theme 3: PtDAs could impair rheumatologist–patient communication. The rheumatologist’s role of providing context to more complicated treatment decisions based on individuals’ preferences was understood as important to building trust and rapport with patients (Table 5, Respondent 006). PtDAs were viewed as an inadequate replacement for the direct communication between rheumatologists and patients. Some interviewees expressed concerns that the “artificial” computerized format of online PtDAs was too rigid to “factor in lots of little things that might be unique to each individual person” (Respondent 006). While some rheumatologists felt that PtDAs could improve patients’ participation in the discussion by making it more informed, there were associated tensions that could impair rheumatologist–

Decision Aids Survey Among Rheumatologists patient communication (Respondents 014 and 004). More intensive and frequent discussion with patients could lead to rheumatologists needing more time to clarify information that patients had reviewed alone. The perceived added time and potential disruption that PtDAs might pose to the patient flow could prevent rheumatologists from communicating optimally with patients (Respondents 004, 008, and 002).

DISCUSSION More than two-thirds of Canadian rheumatologists who participated in this study agreed that PtDAs could further enhance patient care. However, nearly 65% disagreed or felt neutral about referring patients to use a PtDA. Although PtDAs were viewed positively by some as a way to engage patients in making treatment decisions, participants also identified time constraints and unfamiliarity with PtDAs in rheumatology as major barriers to using this type of tool. Results from the in-depth interviews further revealed a limited understanding about the content and utility of PtDAs, which might have contributed to a sense of ambivalence about using PtDAs in clinical practice. The reluctance of physicians in using PtDAs has been reported in other studies (23,26,27). For example, a survey of Canadian family physicians, respirologists, and geriatricians found that although more than 80% believed that PtDAs could prepare patients to make informed treatment decisions, only 54% indicated an intention to use a PtDA in their practice, and less than one-third followed through (23). Interestingly, a 2012 survey in the Oregon Rural Practice-Based Research Network (n 5 174) found that 91% of rural primary physicians had used a paper-based or online PtDA in their clinical practice (28). The authors, however, cautioned that the positive result might be in part attributable to some respondents considering informationbased patient education tools to be PtDAs. Our survey identified time constraints and a lack of knowledge about PtDAs as major barriers to introducing these tools in clinical practice. Similar barriers have been reported in previous studies on the implementation of PtDAs and shared decision-making (26–33). Despite the evidence supporting the use of PtDAs (13) and the growing number of these tools developed for people with arthritis (16–18), fewer than 20% of our participants believed that PtDAs were known to rheumatologists. In-depth interviews revealed the further misconception that PtDAs were merely a type of information-based patient education tool. The lack of understanding about the content and function of PtDAs has been identified in previous studies (27,30,33), suggesting the need to provide rheumatologists with clear information about these types of tools and support for their use in busy clinical practices. Perhaps there is a need to introduce PtDAs as a part of education for medical students or physicians-in-training in order to prepare future clinicians to implement this type of tool. One way to improve the use of PtDAs and minimize the burden on the rheumatologist’s time is to involve decision coaches. Research in PtDA implementation recommends the involvement of a decision coach, who may be a nurse, a pharmacist, or a rehabilitation professional, to counsel

1469 the patient while using a PtDA (34,35). Stacey et al (35) describe decision coaching as a 4-step process that involves: 1) assessing patients’ knowledge needs and clarity in treatment preferences; 2) facilitating patients’ use of decision aids, verifying their understanding about the content, clarifying their preferences, and building communication skills; 3) monitoring their progress in decisionmaking; and 4) screening for factors that influence the implementation of their decisions. The ultimate goal is to assist patients in reaching a decision that is right for them. A systematic review by Stacey et al (36) found that decision coaching plus PtDAs may be more cost-effective than usual care or a PtDA alone. Further research into the use of decision coaches could provide insight on improving the update of PtDAs in arthritis care. Our study has several limitations. First, the response rate of the survey is low (33.3%). Hence, the findings are subject to response bias, where those who responded may be systematically different from those who did not, thus affecting the generalizability of the study results. Second, most participants had limited exposure to PtDAs. Although we provided links to several online PtDAs in arthritis treatments, the views of individuals who had no experience with PtDAs might be more restricted than those who had used PtDAs previously. Third, although the qualitative interviews yielded a variety of opinions from rheumatologists, none of the participants were from rural communities or from Quebec or the Maritime provinces. Therefore, our findings might not be directly transferrable to other health professionals. In conclusion, this study provides insights into the perceived barriers to introducing PtDAs in rheumatology practice. We have identified what rheumatologists consider to be good PtDAs, as well as the key issues related to their use. By understanding rheumatologists’ views on PtDAs, this study will inform the future development of this type of tool and guide its implementation in clinical practice.

ACKNOWLEDGMENT The authors thank the Canadian Rheumatology Association for its collaboration in conducting the online survey. AUTHOR CONTRIBUTIONS All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be submitted for publication. Dr. Li had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study conception and design. Zong, Esdaile, Li. Acquisition of data. Zong, Leese, Li. Analysis and interpretation of data. Zong, Leese, Klemm, Sayre, Memetovic, Esdaile, Li.

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