Normalization of a conversation tool to promote shared decision making about anticoagulation in patients with atrial fibrillation within a practical randomized trial of its effectiveness: a cross-sectional study

Gabriela Spencer-Bonilla, Anjali Thota, Paige Organick, Oscar J Ponce, Marleen Kunneman, Rachel Giblon, Megan E Branda, Angela L Sivly, Emma Behnken, Carl R May, Victor M Montori, Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators, Victor Montori, Megan E Branda, Juan Pablo Brito, Marleen Kunneman, Ian Hargraves, Angela L Sivly, Kirsten Fleming, Bruce Burnett, Mark Linzer, Haeshik Gorr, Elizabeth Jackson, Erik Hess, Takeki Suzuki, James Hamilton 4th, Peter A Noseworthy, Haeshik Gorr, Alexander Haffke, Mark Linzer, Jule Muegge, Sara Poplau, Benjamin Simpson, Miamoua Vang, Mike Wambua, Joel Anderson, Emma Behnken, Fernanda Bellolio, Renee Cabalka, Michael Ferrara, Rachel Giblon, Jonathan Inselman, Annie LeBlanc, Peter Noseworthy, Marc Olive, Paige Organick, Nilay Shah, Gabriela Spencer-Bonilla, Amy Stier, Anjali Thota, Henry Ting, Derek Vanmeter, Claudia Zeballos-Palacios, Park Nicollet-HealthPartners, Carol Abullarde, Lisa Harvey, Shelly Keune, Timothy Smith, Shannon Stephens, Bryan Barksdale, Theresa Hickey, Roma Peters, Memrie Price, Connie Watson, Douglas Wolfe, Gordon Guyatt, Brian Haynes, George Tomlinson, Paul Daniels, Bernard Gersh, Thomas Jaeger, Robert McBane, Gabriela Spencer-Bonilla, Anjali Thota, Paige Organick, Oscar J Ponce, Marleen Kunneman, Rachel Giblon, Megan E Branda, Angela L Sivly, Emma Behnken, Carl R May, Victor M Montori, Shared Decision Making for Atrial Fibrillation (SDM4AFib) Trial Investigators, Victor Montori, Megan E Branda, Juan Pablo Brito, Marleen Kunneman, Ian Hargraves, Angela L Sivly, Kirsten Fleming, Bruce Burnett, Mark Linzer, Haeshik Gorr, Elizabeth Jackson, Erik Hess, Takeki Suzuki, James Hamilton 4th, Peter A Noseworthy, Haeshik Gorr, Alexander Haffke, Mark Linzer, Jule Muegge, Sara Poplau, Benjamin Simpson, Miamoua Vang, Mike Wambua, Joel Anderson, Emma Behnken, Fernanda Bellolio, Renee Cabalka, Michael Ferrara, Rachel Giblon, Jonathan Inselman, Annie LeBlanc, Peter Noseworthy, Marc Olive, Paige Organick, Nilay Shah, Gabriela Spencer-Bonilla, Amy Stier, Anjali Thota, Henry Ting, Derek Vanmeter, Claudia Zeballos-Palacios, Park Nicollet-HealthPartners, Carol Abullarde, Lisa Harvey, Shelly Keune, Timothy Smith, Shannon Stephens, Bryan Barksdale, Theresa Hickey, Roma Peters, Memrie Price, Connie Watson, Douglas Wolfe, Gordon Guyatt, Brian Haynes, George Tomlinson, Paul Daniels, Bernard Gersh, Thomas Jaeger, Robert McBane

Abstract

Background: Shared decision making (SDM) implementation remains challenging. The factors that promote or hinder implementation of SDM tools for use during the consultation, including contextual factors such as clinician burnout and organizational support, remain unclear. We explored these factors in the context of a practical multicenter randomized trial evaluating the effectiveness of an SDM conversation tool for patients with atrial fibrillation considering anticoagulation therapy.

Methods: In this cross-sectional study, we recruited clinicians who were regularly involved in conversations with patients regarding anticoagulation for atrial fibrillation. Clinicians reported their characteristics and burnout symptoms using the two-item Maslach Burnout Inventory. Clinicians were trained in using the SDM tool, and they recorded their perceptions of the tool's normalization potential using the Normalization MeAsure Development (NoMAD) survey instrument and verbally reflected on their answers to these survey questions. When possible, the training sessions and clinicians' verbal responses to the conversation tool were recorded.

Results: Our study comprised 183 clinicians recruited into the trial (168 with survey responses and 112 with recordings). Overall, clinicians gave high scores to the normalization potential of the intervention; they endorsed all domains of normalization to the same extent, regardless of site, clinician characteristics, or burnout ratings. In interviews, clinicians paid significant attention to making sense of the tool. Tool buy-in seemed to depend heavily on their ability to see the tool as accurate and "evidence-based" and their perceptions of having time in the consultation to use it.

Conclusions: While time in the consultation remains a barrier, we did not find a significant association between burnout symptoms and normalization of an SDM conversation tool. Possible areas for improving the normalization of SDM conversation tools in clinical practice include enabling collaboration among clinicians to implement the tool and reporting how clinicians elsewhere use the tool. Direct measures of normalization (i.e., observing how often clinicians access the tool in practice outside of the clinical trial) may further elucidate the role that contextual factors, such as clinician burnout, play in the implementation of SDM.

Trial registration: ClinicalTrials.gov, NCT02905032. Registered on 9 September 2016.

Keywords: Anticoagulation; Atrial fibrillation; Burnout; Conversation aid; Normalization process theory; Shared decision making; Trial procedures; Trials.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Normalization of Anticoagulation Choice Decision Aid tool

References

    1. Lin GA, Halley M, Rendle KA, et al. An effort to spread decision aids in five California primary care practices yielded low distribution, highlighting hurdles. Health Aff (Millwood) 2013;32:311–320. doi: 10.1377/hlthaff.2012.1070.
    1. Oakley A, Strange V, Bonell C, Allen E, Stephenson J, Team RS. Process evaluation in randomised controlled trials of complex interventions. BMJ. 2006;332:413–416. doi: 10.1136/bmj.332.7538.413.
    1. May CR, Mair F, Finch T, et al. Development of a theory of implementation and integration: Normalization Process Theory. Implement Sci. 2009;4:29. doi: 10.1186/1748-5908-4-29.
    1. May CR, Mair FS, Dowrick CF, Finch TL. Process evaluation for complex interventions in primary care: understanding trials using the normalization process model. BMC Fam Pract. 2007;8:42. doi: 10.1186/1471-2296-8-42.
    1. Legare F, Witteman HO. Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health Aff (Millwood) 2013;32:276–284. doi: 10.1377/hlthaff.2012.1078.
    1. Zeballos-Palacios CL, Hargraves IG, Noseworthy PA, et al. Developing a conversation aid to support shared decision making: reflections on designing Anticoagulation Choice. Mayo Clin Proc. 2019;94:686–696. doi: 10.1016/j.mayocp.2018.08.030.
    1. Kunneman M, Branda ME, Noseworthy PA, et al. Shared decision making for stroke prevention in atrial fibrillation: study protocol for a randomized controlled trial. Trials. 2017;18:443. doi: 10.1186/s13063-017-2178-y.
    1. West CP, Dyrbye LN, Satele DV, Sloan JA, Shanafelt TD. Concurrent validity of single-item measures of emotional exhaustion and depersonalization in burnout assessment. J Gen Intern Med. 2012;27:1445–1452. doi: 10.1007/s11606-012-2015-7.
    1. Rafferty JP, Lemkau JP, Purdy RR, Rudisill JR. Validity of the Maslach Burnout Inventory for family practice physicians. J Clin Psychol. 1986;42:488–492. doi: 10.1002/1097-4679(198605)42:3<488::AID-JCLP2270420315>;2-S.
    1. Thomas NK. Resident burnout. JAMA. 2004;292:2880–2889. doi: 10.1001/jama.292.23.2880.
    1. Finch TL, Girling M, May CR, et al. Improving the normalization of complex interventions: part 2 - validation of the NoMAD instrument for assessing implementation work based on normalization process theory (NPT) BMC Med Res Methodol. 2018;18:135. doi: 10.1186/s12874-018-0591-x.
    1. Brannick MT, Erol-Korkmaz HT, Prewett M. A systematic review of the reliability of objective structured clinical examination scores. Med Educ. 2011;45:1181–1189. doi: 10.1111/j.1365-2923.2011.04075.x.
    1. Finch TL, Rapley T, Girling M, et al. Improving the normalization of complex interventions: measure development based on normalization process theory (NoMAD): study protocol. Implement Sci. 2013;8:43. doi: 10.1186/1748-5908-8-43.
    1. Borg Xuereb C, Shaw RL, Lane DA. Patients’ and health professionals’ views and experiences of atrial fibrillation and oral-anticoagulant therapy: a qualitative meta-synthesis. Patient Educ Couns. 2012;88:330–337. doi: 10.1016/j.pec.2012.05.011.
    1. Dobler CC, Sanchez M, Gionfriddo MR, et al. Impact of decision aids used during clinical encounters on clinician outcomes and consultation length: a systematic review. BMJ Qual Saf. 2019;28:499–510. doi: 10.1136/bmjqs-2018-008022.
    1. Huynh C, Bowles D, Yen MS, et al. Change implementation: the association of adaptive reserve and burnout among inpatient medicine physicians and nurses. J Interprof Care. 2018;32:549–555. doi: 10.1080/13561820.2018.1451307.
    1. Miller WL, Crabtree BF, Nutting PA, Stange KC, Jaen CR. Primary care practice development: a relationship-centered approach. Ann Fam Med. 2010;8 Suppl 1:S68–S79. doi: 10.1370/afm.1089.
    1. Lamothe M, Boujut E, Zenasni F, Sultan S. To be or not to be empathic: the combined role of empathic concern and perspective taking in understanding burnout in general practice. BMC Fam Pract. 2014;15:15. doi: 10.1186/1471-2296-15-15.
    1. Dobler CC, West CP, Montori VM. Can shared decision making improve physician well-being and reduce burnout? Cureus. 2017;9:e1615.
    1. Boissy A, Windover AK, Bokar D, et al. Communication skills training for physicians improves patient satisfaction. J Gen Intern Med. 2016;31:755–761. doi: 10.1007/s11606-016-3597-2.
    1. Stacey D, Legare F, Lewis K, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2017;4:CD001431.
    1. Lloyd A, Joseph-Williams N, Edwards A, Rix A, Elwyn G. Patchy ‘coherence’: using normalization process theory to evaluate a multi-faceted shared decision making implementation program (MAGIC) Implement Sci. 2013;8:102. doi: 10.1186/1748-5908-8-102.
    1. Elwyn G, Legare F, van der Weijden T, Edwards A, May C. Arduous implementation: does the Normalisation Process Model explain why it’s so difficult to embed decision support technologies for patients in routine clinical practice. Implement Sci. 2008;3:57. doi: 10.1186/1748-5908-3-57.

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa