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Decisions, choice and shared decision making in antenatal clinics: An observational study
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PEC-5027; No. of Pages 6 Patient Education and Counseling xxx (2015) xxx–xxx
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Medical Decision Making
Decisions, choice and shared decision making in antenatal clinics: An observational study Francesca Garrard a,*, Matthew Ridd b, Harini Narayan c, Alan A. Montgomery d a
School of Acute Care Common Stem, Severn Deanery, Bristol, UK Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK c The Great Western Hospital, Swindon, UK d Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 May 2014 Received in revised form 3 April 2015 Accepted 4 April 2015
Objective: The UK Government has prioritised shared decision making (SDM) and choice in maternity services, but no studies have explored the breadth of antenatal decisions or the feasibility of this aspiration. This study aimed to describe the decisions made, investigate the factors associated with choice and explore SDM practice. Methods: Cross-sectional audio-recording of consultations in a UK district general hospital. Multi-level regression models were used to investigate associations between choice and doctor, patient, consultation and decision variables. Results: 585 decisions were documented with a mean of 3.0 (SD 1.5) per consultation. No choice was offered in 75% of decisions. Choice was associated with the decision topic, consultation length, Royal College membership status and presence on the specialist register. Conclusions: Without a choice, it will be challenging for a patient and their healthcare profession to truly share decisions. Practice Implications: If universal SDM is the aim, then further work is required to understand the factors impacting choice availability and SDM, while engaging and supporting healthcare professionals to offer options and share decisions with patients. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Shared decision making Choice Option Decisions Antenatal Obstetrics Maternity
1. Introduction Shared decision making has been described as a middle ground between paternalism and informed choice. It involves the health care professional and patient exchanging information, discussing different options and making a decision together [1–3]. In 2010, the UK government prioritised shared decision making and choice, particularly in maternity services [4]. This reflected the belief that sharing decisions with patients was not only an ethical obligation, but would improve patient satisfaction, understanding and adherence. Within a culture of promoting patient engagement and selfcare, it aimed to improve health outcomes and reduce health costs. A key model of shared decision making proposed by Elwyn et al includes a list of competencies, which are shown in Box 1 [2]. Elwyn’s model emphasises that shared decision making is
* Corresponding author at: School of Acute Care Common Stem, Severn Deanery, Deanery House, Vantage Business Park, Old Gloucestershire Road, Hambrook, Bristol, BS16 1GW, UK. E-mail address: [email protected] (F. Garrard).
dependent on having a choice between equally valid options, known as equipoise [2]. In these decisions professionals are unable to have a clear preference based on research evidence. These decisions have been described as ‘‘common’’ but their frequency has never been formally described [5]. A number of studies suggest that shared decision making is associated with improved patient satisfaction, but there is limited evidence of an impact on treatment adherence or clinical outcomes [6]. There has also been little research documenting the range of decisions made within medical consultations or the factors affecting patient choice. Braddock et al. have demonstrated that American community consultations contain a mean of 3.2 decisions (range 1–8). Most decisions in this study were of basic or intermediate complexity (94%), and were initiated by doctors (86%) [7,8]. When O’Cathain et al surveyed women in Wales, 54% felt they had made informed antenatal and postnatal choices, but informed choice varied between decisions (foetal monitoring 31%, foetal screening 73%) and was associated with patient characteristics [9]. In order to establish if shared decision making is feasible, it is important to understand whether the decisions being made commonly involve multiple options.
http://dx.doi.org/10.1016/j.pec.2015.04.004 0738-3991/ß 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Garrard F, et al. Decisions, choice and shared decision making in antenatal clinics: An observational study. Patient Educ Couns (2015), http://dx.doi.org/10.1016/j.pec.2015.04.004
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Box 1. Competencies for shared decision making
Implicit or explicit involvement of patients in decision making process. Explore ideas, fears and expectations of the problem and possible treatments. Portrayal of equipoise and options. Identify preferred format and provide tailor-made information. Checking process: understanding of information and reactions (e.g. ideas, fears and expectations of possible options). Checking process: acceptance of process and decision making role preference, involving the patient to the extent they desire to be involved. Make, discuss or defer decisions. Arrange follow-up. Based on competencies included in Elwyn G, Edwards A, Kinnersley P, Grol R. Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices. Br J Gen Pract 2000 Nov;50(460):892–9. [Research Support, Non-U.S. Gov’t].
Therefore, we aimed to describe the decisions made in a secondary care obstetric clinic; including the options offered to women and the factors associated with more than one option (choice) being offered. 2. Methods This was a cross-sectional study, which took place in the obstetric outpatient department of a southwest UK district general hospital. This service runs approximately 7500 antenatal appointments per year and is staffed by six consultants, five Obstetrics and Gynaecology trainees, six career grade doctors (non-consultant staff grade doctors) and two locums (temporary staff), each with a midwife. All women attending clinics during the study period were recruited, if they were able to provide written consent; not previously taken part; and at least 18 years old. However, they were excluded if they did not receive the posted information leaflet; or if the midwives, doctors or any friends or family attending with them did not provide written consent. As this was an exploratory study a formal sample size was not determined, but we aimed to recruit as many women as possible over a two-week period. This was extended to enrol more women from clinics with low recruitment rates and data were collected between January and March 2011. This descriptive study observed medical consultations via audio recording and coded the decisions made and options available, in each consultation. The participants were blinded to the exact outcomes of the study. They were informed that the study was investigating communication skills, in order to prevent any change in decision making behaviour. Midwives and doctors were given information leaflets prior to the start of the study and consented before each clinic. Where staff members notified the research team that they didn’t wish to take part, their patients were not approached. Prior to the start of each clinic, recording equipment was set up in the consulting room and the patient lists were labelled with study numbers. Patients were approached as they checked in for their appointment and patients who consented were given a card. If the patient had a card then the doctor would start recording, and read out the study number from their patient list before carrying on the consultation as normal. All recordings were checked prior to coding and a few were excluded
because they were incomplete. One researcher coded all the consultations (FG) and a second researcher (MR) rated a sample of thirteen recordings (one from each doctor), to assess inter-rater reliability of the classification system and choice variable. Anonymous data on gestation, age and deprivation (index of multiple deprivation score) were collected for all patients who were booked to attend the clinics, to allow a comparison between participants and non-participants [10–13]. The IMD is a geographically based deprivation score produced by the UK Government that includes data on areas such as income, employment, education, housing and child poverty. Across the UK, the IMD ranges from 0.53 to 87.8, with higher scores indicating more deprivation. Across the hospitals local authority, the mean IMD is 17.2 (SD 13.6). For participants, consultation duration and type (first or follow up appointment) were also collected. Doctors were asked to provide basic demographic data; including grade, membership status and general medical council (GMC) number. The GMC number was used to obtain publically available data in place of graduation and presence on the specialist register [14]. In joint obstetrician–physician clinics, the obstetricians’ demographic data were used for analysis. Decisions were defined as ‘‘a verbalised choice or deferment of choice that could alter the patient’s current or planned management.’’ This was based on Braddock’s original definition, but adapted to include deferment as a valid outcome [2,7,8]. Care was taken to distinguish between decision-making and information giving. Information giving occurred when women asked a question and the doctor responded with advice, but there was no commitment to a particular course of action and hence a decision was not made. In the absence of any known system for classifying obstetric decisions by topic, the authors developed a categorisation system de novo. While listening to the consultations, decisions were identified and sorted into sub-categories, until no new decisions were found. Each time a decision was identified, it was either matched with an existing decision (and coded similarly) or it was added as a new decision under a sub-category. For the purposes of analysis, the subcategories were grouped into five decision categories (DCs): Delivery; Care Structure (appointments, referrals and admissions); Investigations; Medication and other therapy; and Other. Each consultation was reported as a binary variable (category discussed or not discussed) for each of these five categories. The number of different options that were offered and available to be chosen were counted per decision. Where the option of doing nothing was offered, this was counted. However, options that were excluded by the healthcare professionals as impractical or unsafe did not count (see Fig. 1). Each decision was converted into a binary variable indicating that a choice between multiple options was or was not offered. The number of decisions with choice was divided by the total number of decisions in the consultation and reported as a percentage. This percentage was called the decisions with choice (DWC) variable and formed the study’s primary outcome. The secondary outcome measures included the number of decisions per consultation, who initiated the decision discussion and the range of decisions made. They also included the proportion of decisions where the option to do nothing or defer the decision was offered, and the proportion of decisions that were deferred. Basic descriptive statistics (percentages, means and standard deviation) were used to analyse and present the decisions made. Agreement between the two raters was assessed using a Bland– Altman plot. This scatter plot compares the pair mean with the pair difference for each observation [15]. In doing so, it uses the pair mean as an estimate for the unknown true value and the mean difference as an estimate of bias [16,17]. The Bland-Altman compares points in relation to a horizontal line at a mean difference of 0, which indicates perfect agreement. In normally distributed data, 95% of observations should lie within two
Please cite this article in press as: Garrard F, et al. Decisions, choice and shared decision making in antenatal clinics: An observational study. Patient Educ Couns (2015), http://dx.doi.org/10.1016/j.pec.2015.04.004
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Invalid opons (Not included) Only one opon was menoned or The opons were discussed and clearly discussed. Asking the paent for consent available to be chosen when decisions or approval on a single opon ie “is that were made. ok?” was not counted as a choice. Paent adds an opon, which is not Doctor dismissed an opon as invalid, excluded as invalid by the doctor and and explicitly said this to the paent. It was considered when the final decision was not considered when the decision was made. was finally made. Direcon of management was enrely dependent on clinical course, so that no The paent was offered a single opon alternaves were available to the but had a clear choice of whether to paent. For example, the mode of accept or reject it. The opon had to be delivery of twins in an otherwise normal phrased so that either choosing or pregnancy was enrely dependent on rejecng the intervenon would be valid. the posion of the leading twin. If the In this situaon the paent was offered a leading twin was breech then the doctor choice between doing nothing and the told the paent she would need a proposed course of acon. caesarean secon, but if the leading twin was head-down then a vaginal delivery could be considered. Discussion between different opons Where mulple opons are discussed and their exclusion involved the paent. between healthcare professionals, but This represents a process of choosing only one was offered to the paent. As such, only the offered opon would be between valid opons and therefore each opon was counted. defined as valid or available. Valid opons (Included)
Fig. 1. Examples of valid and invalid options.
standard deviations of the mean observed differences and lines of agreement can be plotted at these limits [18]. It also allows assessment of whether the degree of agreement between raters is constant across the range of mean scores. The Bland–Altman plot
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demonstrated a small mean difference (0.07) and 95% limits of agreement from 0.7 to 0.6, indicating good agreement between the two raters. The two raters also agreed on 63% of the decision category (DC) variables. The associations between patient, doctor, decision and consultation variables and the decisions with choice (DWC) variable were investigated using multilevel regression models. The total number of decisions per consultation was included as a covariate. Both intra-class correlation coefficients (ICC) and a likelihood ratio test revealed that the clinic level did not significantly alter the output (clinic ICC 0.01 and doctor ICC 0.11, clinic only model ICC 0.05). Therefore a two level model was used to allow for clustering at the doctor level only. A Wald test was used to give a global p value for the association between DWC and membership status. 3. Results Fifteen doctors (13 obstetricians and 2 physicians) were invited to take part and three obstetricians (or their midwife colleague) did not consent. Consultations in 9 of the 43 eligible clinics were not audio-recorded because the staff did not provide consent. Overall the number of recordings reflects clinic attendance, but the previous caesarean section and poor obstetric history clinics were over-represented; and the general clinic was under-represented. The median contribution of each doctor was 17 recordings (range 5 to 66). The recordings are generally representative of the number of women seen by each doctor, although one doctor contributed over a third of recordings. Of the 508 booked women, 38% (194 participants) were included in the study (see Fig. 2). On average the patients
Fig. 2. Flow diagram of patient recruitment.
Please cite this article in press as: Garrard F, et al. Decisions, choice and shared decision making in antenatal clinics: An observational study. Patient Educ Couns (2015), http://dx.doi.org/10.1016/j.pec.2015.04.004
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Table 1 Characteristics of participating and non-participating patients. Demographic variables mean (SD)
Patients recorded n = 194 (38%)
Eligible but not includeda n = 106 (21%)
Eligibility unknownb n = 93 (18%)
Ineligiblec n = 115 (23%)
Age (years) Gestation (weeks) IMD
31.2 (5.9) 26.9 (8.9) 15.0 (12.8)
31.5 (7.3) 27.6 (8.8) 14.7 (13.1)
31.3 (6.0) 26.8 (9.5) 14.6 (11.6)
30.2 (6.9) 25.4 (12.9) 15.9 (13.6)
a b c
Eligible patients that were not included - patients that did not consent and consented but were not recorded, including patient who had incomplete consent form Eligibility unknown patients - patients that were not approached because the staff members did not consent Ineligible patients - patients that did not receive information prior to the appointment, were under age, unable to consent in English or did not attend.
attending these clinics are 31 years old, 27 weeks gestation and have a mean index of multiple deprivation (IMD) of 15. Table 1 demonstrates that there was very little difference in patient age, gestation or deprivation between the participating and nonparticipating groups. Table 2 shows the frequency of the 73 decisions, classified according to the five major categories and 14 subcategories. The most common decisions were regarding time of follow up
Table 2 Decision number by category and subcategory. Decision category
Decision subcategory example decision
Number of decisions (%)
Delivery (dDC)
Delivery Mode of delivery—vaginal or caesarean section Subtotal
127 (22)
Care structure (cDC)
Investigations (iDC)
Medication (mDC)
Other (oDC)
Total
Referrals/appointments outside of obstetrics Referral to another hospital speciality—i.e., haematology Appointments Decision about postnatal follow-up Day assessment unit appointments Appointment for foetal heart monitoring Admission Elective admission Subtotal Blood tests Requesting additional/non-routine blood tests Examination Decision whether to have a stretch and sweep Scans Decision for additional foetal growth scans Other tests Decision for carbon monoxide reading Subtotal
127 (22) 26 (4)
185 (32) 20 (3) 3 (1) 234 (40)
Table 3 Associations between patient, consultation, decision and doctor variables and the outcome Decisions with Choice (DWC). Exposure variable
25 (4)
19 (3)
45 (8)
40 (6.8) 129 (22)
Medication Decision to alter prescription of established medication Other therapy Decision whether to perform external cephalic version Concurrent problems Whether to operate on gynaecological condition Subtotal
66 (11)
Postnatal care Decision for prolonged observation on labour ward Employment Decisions about working (including shift patterns) Subtotal
13 (2)
585 (100)
appointment (23%), mode of delivery (7%) and gestation of delivery (7%). Most consultations contained a care structure decision (85%), with half containing an investigation (52%) or delivery decision (50%). Across the 194 audio recorded consultations, 585 decisions were made. The mean number of decisions per consultation was 3.0 (SD 1.5, range 0 to 8). In 75% of decisions (439 out of 585) only one option was verbalised and hence no choice was offered. A choice between two different options was offered in 23% of decisions and the remaining 2% had between three and eight different options. The Decisions with Choice variable (DWC) was zero in 86 of the 194 consultations (44%). This indicates that no choice was offered or no decisions were made (but only two consultations (1%) contained no decisions). The mean decisions with choice (DWC) was 26% (SD 29). Table 3 shows that none of the patient variables were associated with the DWC variable. There was some evidence of an association between DWC and consultation length; consultations where mode of delivery and care structure were discussed; and the doctors specialist register and college membership status.
12 (2)
2 (0)
80 (14)
2 (0)
15 (3)
Patient variables Age (years) Gestation (weeks) Index of Multiple Deprivation Consultation variables Total number of decisions Appointment—New/ follow up Length of consultation (mins) Decision variables Delivery (dDC) Care structure (cDC) Investigations (iDC) Medication (mDC) Others (oDC) Doctor variables Female gender UK graduate Senior/career grade On specialist register Royal College membership Member vs non-member Fellow vs non-member
Unadjusted
Adjusted
Coefficient
Coefficient
95% Confidence interval
p-value
0.30 0.49 0.02
0.06 0.10 0.07
(0.61, 0.73) (0.48, 0.67) (0.38, 0.24)
0.87 0.74 0.66
0.99
2.16
(6.96, 2.64)
0.38
2.63
3.61
(13.99, 6.77)
0.50
0.89
0.86
(0.06, 1.66)
0.03
16.59 22.50 4.91 1.85 0.64
12.06 14.50 5.11 2.26 0.79
(1.91, 22.20) (26.93, 2.06) (15.14, 4.91) (7.81, 12.33) (17.27, 18.85)
0.02 0.02 0.32 0.66 0.93
2.24 18.35 8.87 1.47
0.38 4.61 9.04 18.16
(11.48, 10.71) (19.10, 28.33) (23.75, 5.67) (7.31, 29.00)
0.95 0.70 0.23 <0.01
14.57
1.62
(14.20, 17.44)
0.04
1.71
20.17
(37.91, 2.43)
Please cite this article in press as: Garrard F, et al. Decisions, choice and shared decision making in antenatal clinics: An observational study. Patient Educ Couns (2015), http://dx.doi.org/10.1016/j.pec.2015.04.004
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Doctors initiated 80% of all the discussions that lead to a decision, with the remainder being patient (15%) and midwife (5%) initiated. The options both of doing nothing and deferring the decision were also infrequently offered (15% and 2% of decisions respectively). If decisions were deferred (8%), this was frequently done without offering the option to the patient (6% of decisions, 75% of deferred decisions). 4. Discussion and conclusions 4.1. Discussion This study aimed to describe the decisions made in a secondary care obstetric clinic; including the options offered to women and the factors associated with more than one option (choice) being offered. We identified 73 different types of decision with the time of next appointment, mode and gestation of delivery being most common. Almost half of all the consultations included no patient choice and patient choice was positively associated with longer consultations, delivery decisions and doctors on the specialist register or with Royal College membership. To our knowledge, this is the first study to document the decisions made in an antenatal clinic. This study is also novel in its investigation of patient choice and potential associations with patient, doctor, decision and consultation characteristics. Robust methods were used to analyse hierarchical data and account for the clustering of data within doctors and clinics. Audio recording avoided any influence from having an observer physically present during the consultation, but pausing of the recording during ultrasound scanning will have affected the consultation length variable and may meant decisions were missed. The clinics in this setting had few UK graduates, nonRCOG members or male doctors; which may not reflect other clinical settings. Although the analysis accounted for clustering at the doctor level, a single doctor contributed over a third of the recordings. The general clinic was also under-represented, which may weigh data towards more specialist clinics. When the results are placed in context, it appears UK antenatal clinics make a similar number of decisions per consultation to American internists, surgeons and family physicians, with a similar proportion initiated by the doctor [7,8]. However more care structure (appointment, referrals and admissions) and fewer medication decisions were made in UK obstetric consultations. This study demonstrated that choice was more common when management decisions (delivery) were discussed, when compared with Braddock’s work on informed decision making [7]. Other studies in pregnant women have shown less patient involvement and satisfaction with decisions relating to investigations (foetal monitoring) [9], but we found weak evidence of any such association. Compared to other studies in pregnant women, we identified a much lower overall level of choice [9]. This could be due to methodological differences or because the present study was performed in secondary care, where options may be restricted for clinical reasons. In fact 40% of all the decisions identified by this study were care structure decisions (referrals, admission and appointments), which may have limited options for practical logistic reasons. We are unable to determine whether options weren’t available or just not being offered. However, we found that the type of decision being made and the seniority of the consulting doctor are associated with choice. The single centre nature of this study limits the generalisability of the results and further work is required to investigate the factors associated with patient choice. Given the nature of maternity care, it is important to remember that decisions may be made or options explored longitudinally, i.e. over a series of consultations [19]. Further work needs to explore the multidisciplinary decisions made across the whole pregnancy.
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4.2. Conclusion Although equipoise decisions have been described as common [8], this study suggests they form less than 25% of antenatal decisions. However, decisions were often deferred without offering this option to the patient, which would imply that there might be more options available than are offered to the patient. If doctor seniority does influence practice, then there may be scope for supporting healthcare professionals to offer options, through education, guidance and decision support aids. If patient self care is to be encouraged through SDM, then these may need to focus on identifying, exploring and offering options. 5. Practice implication Prior to implementing universal shared decision making, current practices need to be understood and any pre-conditions addressed. This study demonstrated that options are not always available, but it was beyond its scope to explore the impact of patient demand or clinical need, maternal or foetal, on the offering of choice. It is likely that for some patients, certain options may not be available because they are clearly suboptimal or unsafe. There may also be other pressures on the choices available, such as local policies and national targets. It is possible that those making acute or care management decisions may offer less choice, but deliver clinically appropriate care in the context of limited options. Elwyn et al argued that shared decision making shouldn’t be reserved only for those situations where ‘‘genuine choice’’ exists, because the process of involvement is still important and patients’ desire for information and involvement is often underestimated [20,21]. Indeed at the core of shared decision making is mutual involvement and information sharing between the healthcare professional and patient, and not all SDM models include equipoise as a prerequisite [19,22,23]. It is therefore important that we do not simply improve our decision making practice for decisions very amenable to the model, but work collaboratively with patients to find novel options and make shared plans. One possible outcome of our findings could be the development of an intervention to improve physician awareness of and engagement with SDM. This is crucial if there is to be ‘‘no decision about me, without me’’[4]. Disclosure of interests Nil Contribution to authorship The study was designed by FG with input from all other authors. FG carried out the data collection, supervised by HN. FG conducted the data coding and analysis, with input from HN (face validity of decision categories), MR (reliability of coding) and AM (statistical analysis). The paper was drafted by FG, and authors contributed to and approved the final submission. Ethical approval This study was reviewed and approved by the South West 5 Regional Ethics Committee, reference number: 10/H0107/59. Funding The Health Foundation, as part of their Shine Programme, sponsored this study. The funding body had no involvement in the design or conduct of this study.
Please cite this article in press as: Garrard F, et al. Decisions, choice and shared decision making in antenatal clinics: An observational study. Patient Educ Couns (2015), http://dx.doi.org/10.1016/j.pec.2015.04.004
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Acknowledgments Many thanks to the doctors, midwives and patients who took part in this project. Prof. Montgomery and Dr. Ridd supervised this research as part of an MSc by Research at the University of Bristol (Dr. Garrard). The Health Foundation, as part of their Shine Programme, sponsored this project. Dr. Narayan who locally supervised the project also received this funding. References [1] Towle A. Physician and Patient Communication Skills: Competencies For Informed Shared Decision-Making. Informed Shared Decision-Making Project: Internal Report. Vancouver: University of British Columbia; 1997. [2] Elwyn G, Edwards A, Kinnersley P, Grol R. Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices. Br J Gen Pract 2000;50:892–9. [3] Legare F, Stacey D, Pouliot S, Gauvin FP, Desroches S, Kryworuchko J, et al. Interprofessionalism and shared decision-making in primary care: a stepwise approach towards a new model. J Interprof Care 2011;25:18–25. [4] Department of Health. Equity and Excellence: Liberating the NHS. London: Department of Health/UK Government; 2010. [5] Coulter A. Do patients want a choice and does it work? Brit Med J 2010;341:c4989. [6] Da Silva D. Helping People Share Decision: A Review Of Evidence Considering Whether Shared Decision Making Is Worthwhile. London: The Health Foundation; 2012. [7] Braddock 3rd CH, Fihn SD, Levinson W, Jonsen AR, Pearlman RA. How doctors and patients discuss routine clinical decisions. Informed decision making in the outpatient setting. J Gen Intern Med 1997;12:339–45. [8] Braddock 3rd CH, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice: time to get back to basics. J Amer Med Assoc 1999;282:2313–20. [9] O’Cathain A, Thomas K, Walters SJ, Nicholl J, Kirkham M. Women’s perceptions of informed choice in maternity care. Midwifery 2002;18:136–44. [10] Weill medical college of Cornell University. Age calculator, hhttp://www-users.med.cornell.edu/spon/picu/calc/agecalc.htmi; 2000 [accessed 14.04.11].
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Please cite this article in press as: Garrard F, et al. Decisions, choice and shared decision making in antenatal clinics: An observational study. Patient Educ Couns (2015), http://dx.doi.org/10.1016/j.pec.2015.04.004
PEC-5027; No. of Pages 6 Patient Education and Counseling xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Medical Decision Making
Decisions, choice and shared decision making in antenatal clinics: An observational study Francesca Garrard a,*, Matthew Ridd b, Harini Narayan c, Alan A. Montgomery d a
School of Acute Care Common Stem, Severn Deanery, Bristol, UK Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK c The Great Western Hospital, Swindon, UK d Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 30 May 2014 Received in revised form 3 April 2015 Accepted 4 April 2015
Objective: The UK Government has prioritised shared decision making (SDM) and choice in maternity services, but no studies have explored the breadth of antenatal decisions or the feasibility of this aspiration. This study aimed to describe the decisions made, investigate the factors associated with choice and explore SDM practice. Methods: Cross-sectional audio-recording of consultations in a UK district general hospital. Multi-level regression models were used to investigate associations between choice and doctor, patient, consultation and decision variables. Results: 585 decisions were documented with a mean of 3.0 (SD 1.5) per consultation. No choice was offered in 75% of decisions. Choice was associated with the decision topic, consultation length, Royal College membership status and presence on the specialist register. Conclusions: Without a choice, it will be challenging for a patient and their healthcare profession to truly share decisions. Practice Implications: If universal SDM is the aim, then further work is required to understand the factors impacting choice availability and SDM, while engaging and supporting healthcare professionals to offer options and share decisions with patients. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Shared decision making Choice Option Decisions Antenatal Obstetrics Maternity
1. Introduction Shared decision making has been described as a middle ground between paternalism and informed choice. It involves the health care professional and patient exchanging information, discussing different options and making a decision together [1–3]. In 2010, the UK government prioritised shared decision making and choice, particularly in maternity services [4]. This reflected the belief that sharing decisions with patients was not only an ethical obligation, but would improve patient satisfaction, understanding and adherence. Within a culture of promoting patient engagement and selfcare, it aimed to improve health outcomes and reduce health costs. A key model of shared decision making proposed by Elwyn et al includes a list of competencies, which are shown in Box 1 [2]. Elwyn’s model emphasises that shared decision making is
* Corresponding author at: School of Acute Care Common Stem, Severn Deanery, Deanery House, Vantage Business Park, Old Gloucestershire Road, Hambrook, Bristol, BS16 1GW, UK. E-mail address: [email protected] (F. Garrard).
dependent on having a choice between equally valid options, known as equipoise [2]. In these decisions professionals are unable to have a clear preference based on research evidence. These decisions have been described as ‘‘common’’ but their frequency has never been formally described [5]. A number of studies suggest that shared decision making is associated with improved patient satisfaction, but there is limited evidence of an impact on treatment adherence or clinical outcomes [6]. There has also been little research documenting the range of decisions made within medical consultations or the factors affecting patient choice. Braddock et al. have demonstrated that American community consultations contain a mean of 3.2 decisions (range 1–8). Most decisions in this study were of basic or intermediate complexity (94%), and were initiated by doctors (86%) [7,8]. When O’Cathain et al surveyed women in Wales, 54% felt they had made informed antenatal and postnatal choices, but informed choice varied between decisions (foetal monitoring 31%, foetal screening 73%) and was associated with patient characteristics [9]. In order to establish if shared decision making is feasible, it is important to understand whether the decisions being made commonly involve multiple options.
http://dx.doi.org/10.1016/j.pec.2015.04.004 0738-3991/ß 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Garrard F, et al. Decisions, choice and shared decision making in antenatal clinics: An observational study. Patient Educ Couns (2015), http://dx.doi.org/10.1016/j.pec.2015.04.004
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Box 1. Competencies for shared decision making
Implicit or explicit involvement of patients in decision making process. Explore ideas, fears and expectations of the problem and possible treatments. Portrayal of equipoise and options. Identify preferred format and provide tailor-made information. Checking process: understanding of information and reactions (e.g. ideas, fears and expectations of possible options). Checking process: acceptance of process and decision making role preference, involving the patient to the extent they desire to be involved. Make, discuss or defer decisions. Arrange follow-up. Based on competencies included in Elwyn G, Edwards A, Kinnersley P, Grol R. Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices. Br J Gen Pract 2000 Nov;50(460):892–9. [Research Support, Non-U.S. Gov’t].
Therefore, we aimed to describe the decisions made in a secondary care obstetric clinic; including the options offered to women and the factors associated with more than one option (choice) being offered. 2. Methods This was a cross-sectional study, which took place in the obstetric outpatient department of a southwest UK district general hospital. This service runs approximately 7500 antenatal appointments per year and is staffed by six consultants, five Obstetrics and Gynaecology trainees, six career grade doctors (non-consultant staff grade doctors) and two locums (temporary staff), each with a midwife. All women attending clinics during the study period were recruited, if they were able to provide written consent; not previously taken part; and at least 18 years old. However, they were excluded if they did not receive the posted information leaflet; or if the midwives, doctors or any friends or family attending with them did not provide written consent. As this was an exploratory study a formal sample size was not determined, but we aimed to recruit as many women as possible over a two-week period. This was extended to enrol more women from clinics with low recruitment rates and data were collected between January and March 2011. This descriptive study observed medical consultations via audio recording and coded the decisions made and options available, in each consultation. The participants were blinded to the exact outcomes of the study. They were informed that the study was investigating communication skills, in order to prevent any change in decision making behaviour. Midwives and doctors were given information leaflets prior to the start of the study and consented before each clinic. Where staff members notified the research team that they didn’t wish to take part, their patients were not approached. Prior to the start of each clinic, recording equipment was set up in the consulting room and the patient lists were labelled with study numbers. Patients were approached as they checked in for their appointment and patients who consented were given a card. If the patient had a card then the doctor would start recording, and read out the study number from their patient list before carrying on the consultation as normal. All recordings were checked prior to coding and a few were excluded
because they were incomplete. One researcher coded all the consultations (FG) and a second researcher (MR) rated a sample of thirteen recordings (one from each doctor), to assess inter-rater reliability of the classification system and choice variable. Anonymous data on gestation, age and deprivation (index of multiple deprivation score) were collected for all patients who were booked to attend the clinics, to allow a comparison between participants and non-participants [10–13]. The IMD is a geographically based deprivation score produced by the UK Government that includes data on areas such as income, employment, education, housing and child poverty. Across the UK, the IMD ranges from 0.53 to 87.8, with higher scores indicating more deprivation. Across the hospitals local authority, the mean IMD is 17.2 (SD 13.6). For participants, consultation duration and type (first or follow up appointment) were also collected. Doctors were asked to provide basic demographic data; including grade, membership status and general medical council (GMC) number. The GMC number was used to obtain publically available data in place of graduation and presence on the specialist register [14]. In joint obstetrician–physician clinics, the obstetricians’ demographic data were used for analysis. Decisions were defined as ‘‘a verbalised choice or deferment of choice that could alter the patient’s current or planned management.’’ This was based on Braddock’s original definition, but adapted to include deferment as a valid outcome [2,7,8]. Care was taken to distinguish between decision-making and information giving. Information giving occurred when women asked a question and the doctor responded with advice, but there was no commitment to a particular course of action and hence a decision was not made. In the absence of any known system for classifying obstetric decisions by topic, the authors developed a categorisation system de novo. While listening to the consultations, decisions were identified and sorted into sub-categories, until no new decisions were found. Each time a decision was identified, it was either matched with an existing decision (and coded similarly) or it was added as a new decision under a sub-category. For the purposes of analysis, the subcategories were grouped into five decision categories (DCs): Delivery; Care Structure (appointments, referrals and admissions); Investigations; Medication and other therapy; and Other. Each consultation was reported as a binary variable (category discussed or not discussed) for each of these five categories. The number of different options that were offered and available to be chosen were counted per decision. Where the option of doing nothing was offered, this was counted. However, options that were excluded by the healthcare professionals as impractical or unsafe did not count (see Fig. 1). Each decision was converted into a binary variable indicating that a choice between multiple options was or was not offered. The number of decisions with choice was divided by the total number of decisions in the consultation and reported as a percentage. This percentage was called the decisions with choice (DWC) variable and formed the study’s primary outcome. The secondary outcome measures included the number of decisions per consultation, who initiated the decision discussion and the range of decisions made. They also included the proportion of decisions where the option to do nothing or defer the decision was offered, and the proportion of decisions that were deferred. Basic descriptive statistics (percentages, means and standard deviation) were used to analyse and present the decisions made. Agreement between the two raters was assessed using a Bland– Altman plot. This scatter plot compares the pair mean with the pair difference for each observation [15]. In doing so, it uses the pair mean as an estimate for the unknown true value and the mean difference as an estimate of bias [16,17]. The Bland-Altman compares points in relation to a horizontal line at a mean difference of 0, which indicates perfect agreement. In normally distributed data, 95% of observations should lie within two
Please cite this article in press as: Garrard F, et al. Decisions, choice and shared decision making in antenatal clinics: An observational study. Patient Educ Couns (2015), http://dx.doi.org/10.1016/j.pec.2015.04.004
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Invalid opons (Not included) Only one opon was menoned or The opons were discussed and clearly discussed. Asking the paent for consent available to be chosen when decisions or approval on a single opon ie “is that were made. ok?” was not counted as a choice. Paent adds an opon, which is not Doctor dismissed an opon as invalid, excluded as invalid by the doctor and and explicitly said this to the paent. It was considered when the final decision was not considered when the decision was made. was finally made. Direcon of management was enrely dependent on clinical course, so that no The paent was offered a single opon alternaves were available to the but had a clear choice of whether to paent. For example, the mode of accept or reject it. The opon had to be delivery of twins in an otherwise normal phrased so that either choosing or pregnancy was enrely dependent on rejecng the intervenon would be valid. the posion of the leading twin. If the In this situaon the paent was offered a leading twin was breech then the doctor choice between doing nothing and the told the paent she would need a proposed course of acon. caesarean secon, but if the leading twin was head-down then a vaginal delivery could be considered. Discussion between different opons Where mulple opons are discussed and their exclusion involved the paent. between healthcare professionals, but This represents a process of choosing only one was offered to the paent. As such, only the offered opon would be between valid opons and therefore each opon was counted. defined as valid or available. Valid opons (Included)
Fig. 1. Examples of valid and invalid options.
standard deviations of the mean observed differences and lines of agreement can be plotted at these limits [18]. It also allows assessment of whether the degree of agreement between raters is constant across the range of mean scores. The Bland–Altman plot
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demonstrated a small mean difference (0.07) and 95% limits of agreement from 0.7 to 0.6, indicating good agreement between the two raters. The two raters also agreed on 63% of the decision category (DC) variables. The associations between patient, doctor, decision and consultation variables and the decisions with choice (DWC) variable were investigated using multilevel regression models. The total number of decisions per consultation was included as a covariate. Both intra-class correlation coefficients (ICC) and a likelihood ratio test revealed that the clinic level did not significantly alter the output (clinic ICC 0.01 and doctor ICC 0.11, clinic only model ICC 0.05). Therefore a two level model was used to allow for clustering at the doctor level only. A Wald test was used to give a global p value for the association between DWC and membership status. 3. Results Fifteen doctors (13 obstetricians and 2 physicians) were invited to take part and three obstetricians (or their midwife colleague) did not consent. Consultations in 9 of the 43 eligible clinics were not audio-recorded because the staff did not provide consent. Overall the number of recordings reflects clinic attendance, but the previous caesarean section and poor obstetric history clinics were over-represented; and the general clinic was under-represented. The median contribution of each doctor was 17 recordings (range 5 to 66). The recordings are generally representative of the number of women seen by each doctor, although one doctor contributed over a third of recordings. Of the 508 booked women, 38% (194 participants) were included in the study (see Fig. 2). On average the patients
Fig. 2. Flow diagram of patient recruitment.
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Table 1 Characteristics of participating and non-participating patients. Demographic variables mean (SD)
Patients recorded n = 194 (38%)
Eligible but not includeda n = 106 (21%)
Eligibility unknownb n = 93 (18%)
Ineligiblec n = 115 (23%)
Age (years) Gestation (weeks) IMD
31.2 (5.9) 26.9 (8.9) 15.0 (12.8)
31.5 (7.3) 27.6 (8.8) 14.7 (13.1)
31.3 (6.0) 26.8 (9.5) 14.6 (11.6)
30.2 (6.9) 25.4 (12.9) 15.9 (13.6)
a b c
Eligible patients that were not included - patients that did not consent and consented but were not recorded, including patient who had incomplete consent form Eligibility unknown patients - patients that were not approached because the staff members did not consent Ineligible patients - patients that did not receive information prior to the appointment, were under age, unable to consent in English or did not attend.
attending these clinics are 31 years old, 27 weeks gestation and have a mean index of multiple deprivation (IMD) of 15. Table 1 demonstrates that there was very little difference in patient age, gestation or deprivation between the participating and nonparticipating groups. Table 2 shows the frequency of the 73 decisions, classified according to the five major categories and 14 subcategories. The most common decisions were regarding time of follow up
Table 2 Decision number by category and subcategory. Decision category
Decision subcategory example decision
Number of decisions (%)
Delivery (dDC)
Delivery Mode of delivery—vaginal or caesarean section Subtotal
127 (22)
Care structure (cDC)
Investigations (iDC)
Medication (mDC)
Other (oDC)
Total
Referrals/appointments outside of obstetrics Referral to another hospital speciality—i.e., haematology Appointments Decision about postnatal follow-up Day assessment unit appointments Appointment for foetal heart monitoring Admission Elective admission Subtotal Blood tests Requesting additional/non-routine blood tests Examination Decision whether to have a stretch and sweep Scans Decision for additional foetal growth scans Other tests Decision for carbon monoxide reading Subtotal
127 (22) 26 (4)
185 (32) 20 (3) 3 (1) 234 (40)
Table 3 Associations between patient, consultation, decision and doctor variables and the outcome Decisions with Choice (DWC). Exposure variable
25 (4)
19 (3)
45 (8)
40 (6.8) 129 (22)
Medication Decision to alter prescription of established medication Other therapy Decision whether to perform external cephalic version Concurrent problems Whether to operate on gynaecological condition Subtotal
66 (11)
Postnatal care Decision for prolonged observation on labour ward Employment Decisions about working (including shift patterns) Subtotal
13 (2)
585 (100)
appointment (23%), mode of delivery (7%) and gestation of delivery (7%). Most consultations contained a care structure decision (85%), with half containing an investigation (52%) or delivery decision (50%). Across the 194 audio recorded consultations, 585 decisions were made. The mean number of decisions per consultation was 3.0 (SD 1.5, range 0 to 8). In 75% of decisions (439 out of 585) only one option was verbalised and hence no choice was offered. A choice between two different options was offered in 23% of decisions and the remaining 2% had between three and eight different options. The Decisions with Choice variable (DWC) was zero in 86 of the 194 consultations (44%). This indicates that no choice was offered or no decisions were made (but only two consultations (1%) contained no decisions). The mean decisions with choice (DWC) was 26% (SD 29). Table 3 shows that none of the patient variables were associated with the DWC variable. There was some evidence of an association between DWC and consultation length; consultations where mode of delivery and care structure were discussed; and the doctors specialist register and college membership status.
12 (2)
2 (0)
80 (14)
2 (0)
15 (3)
Patient variables Age (years) Gestation (weeks) Index of Multiple Deprivation Consultation variables Total number of decisions Appointment—New/ follow up Length of consultation (mins) Decision variables Delivery (dDC) Care structure (cDC) Investigations (iDC) Medication (mDC) Others (oDC) Doctor variables Female gender UK graduate Senior/career grade On specialist register Royal College membership Member vs non-member Fellow vs non-member
Unadjusted
Adjusted
Coefficient
Coefficient
95% Confidence interval
p-value
0.30 0.49 0.02
0.06 0.10 0.07
(0.61, 0.73) (0.48, 0.67) (0.38, 0.24)
0.87 0.74 0.66
0.99
2.16
(6.96, 2.64)
0.38
2.63
3.61
(13.99, 6.77)
0.50
0.89
0.86
(0.06, 1.66)
0.03
16.59 22.50 4.91 1.85 0.64
12.06 14.50 5.11 2.26 0.79
(1.91, 22.20) (26.93, 2.06) (15.14, 4.91) (7.81, 12.33) (17.27, 18.85)
0.02 0.02 0.32 0.66 0.93
2.24 18.35 8.87 1.47
0.38 4.61 9.04 18.16
(11.48, 10.71) (19.10, 28.33) (23.75, 5.67) (7.31, 29.00)
0.95 0.70 0.23 <0.01
14.57
1.62
(14.20, 17.44)
0.04
1.71
20.17
(37.91, 2.43)
Please cite this article in press as: Garrard F, et al. Decisions, choice and shared decision making in antenatal clinics: An observational study. Patient Educ Couns (2015), http://dx.doi.org/10.1016/j.pec.2015.04.004
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Doctors initiated 80% of all the discussions that lead to a decision, with the remainder being patient (15%) and midwife (5%) initiated. The options both of doing nothing and deferring the decision were also infrequently offered (15% and 2% of decisions respectively). If decisions were deferred (8%), this was frequently done without offering the option to the patient (6% of decisions, 75% of deferred decisions). 4. Discussion and conclusions 4.1. Discussion This study aimed to describe the decisions made in a secondary care obstetric clinic; including the options offered to women and the factors associated with more than one option (choice) being offered. We identified 73 different types of decision with the time of next appointment, mode and gestation of delivery being most common. Almost half of all the consultations included no patient choice and patient choice was positively associated with longer consultations, delivery decisions and doctors on the specialist register or with Royal College membership. To our knowledge, this is the first study to document the decisions made in an antenatal clinic. This study is also novel in its investigation of patient choice and potential associations with patient, doctor, decision and consultation characteristics. Robust methods were used to analyse hierarchical data and account for the clustering of data within doctors and clinics. Audio recording avoided any influence from having an observer physically present during the consultation, but pausing of the recording during ultrasound scanning will have affected the consultation length variable and may meant decisions were missed. The clinics in this setting had few UK graduates, nonRCOG members or male doctors; which may not reflect other clinical settings. Although the analysis accounted for clustering at the doctor level, a single doctor contributed over a third of the recordings. The general clinic was also under-represented, which may weigh data towards more specialist clinics. When the results are placed in context, it appears UK antenatal clinics make a similar number of decisions per consultation to American internists, surgeons and family physicians, with a similar proportion initiated by the doctor [7,8]. However more care structure (appointment, referrals and admissions) and fewer medication decisions were made in UK obstetric consultations. This study demonstrated that choice was more common when management decisions (delivery) were discussed, when compared with Braddock’s work on informed decision making [7]. Other studies in pregnant women have shown less patient involvement and satisfaction with decisions relating to investigations (foetal monitoring) [9], but we found weak evidence of any such association. Compared to other studies in pregnant women, we identified a much lower overall level of choice [9]. This could be due to methodological differences or because the present study was performed in secondary care, where options may be restricted for clinical reasons. In fact 40% of all the decisions identified by this study were care structure decisions (referrals, admission and appointments), which may have limited options for practical logistic reasons. We are unable to determine whether options weren’t available or just not being offered. However, we found that the type of decision being made and the seniority of the consulting doctor are associated with choice. The single centre nature of this study limits the generalisability of the results and further work is required to investigate the factors associated with patient choice. Given the nature of maternity care, it is important to remember that decisions may be made or options explored longitudinally, i.e. over a series of consultations [19]. Further work needs to explore the multidisciplinary decisions made across the whole pregnancy.
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4.2. Conclusion Although equipoise decisions have been described as common [8], this study suggests they form less than 25% of antenatal decisions. However, decisions were often deferred without offering this option to the patient, which would imply that there might be more options available than are offered to the patient. If doctor seniority does influence practice, then there may be scope for supporting healthcare professionals to offer options, through education, guidance and decision support aids. If patient self care is to be encouraged through SDM, then these may need to focus on identifying, exploring and offering options. 5. Practice implication Prior to implementing universal shared decision making, current practices need to be understood and any pre-conditions addressed. This study demonstrated that options are not always available, but it was beyond its scope to explore the impact of patient demand or clinical need, maternal or foetal, on the offering of choice. It is likely that for some patients, certain options may not be available because they are clearly suboptimal or unsafe. There may also be other pressures on the choices available, such as local policies and national targets. It is possible that those making acute or care management decisions may offer less choice, but deliver clinically appropriate care in the context of limited options. Elwyn et al argued that shared decision making shouldn’t be reserved only for those situations where ‘‘genuine choice’’ exists, because the process of involvement is still important and patients’ desire for information and involvement is often underestimated [20,21]. Indeed at the core of shared decision making is mutual involvement and information sharing between the healthcare professional and patient, and not all SDM models include equipoise as a prerequisite [19,22,23]. It is therefore important that we do not simply improve our decision making practice for decisions very amenable to the model, but work collaboratively with patients to find novel options and make shared plans. One possible outcome of our findings could be the development of an intervention to improve physician awareness of and engagement with SDM. This is crucial if there is to be ‘‘no decision about me, without me’’[4]. Disclosure of interests Nil Contribution to authorship The study was designed by FG with input from all other authors. FG carried out the data collection, supervised by HN. FG conducted the data coding and analysis, with input from HN (face validity of decision categories), MR (reliability of coding) and AM (statistical analysis). The paper was drafted by FG, and authors contributed to and approved the final submission. Ethical approval This study was reviewed and approved by the South West 5 Regional Ethics Committee, reference number: 10/H0107/59. Funding The Health Foundation, as part of their Shine Programme, sponsored this study. The funding body had no involvement in the design or conduct of this study.
Please cite this article in press as: Garrard F, et al. Decisions, choice and shared decision making in antenatal clinics: An observational study. Patient Educ Couns (2015), http://dx.doi.org/10.1016/j.pec.2015.04.004
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Acknowledgments Many thanks to the doctors, midwives and patients who took part in this project. Prof. Montgomery and Dr. Ridd supervised this research as part of an MSc by Research at the University of Bristol (Dr. Garrard). The Health Foundation, as part of their Shine Programme, sponsored this project. Dr. Narayan who locally supervised the project also received this funding. References [1] Towle A. Physician and Patient Communication Skills: Competencies For Informed Shared Decision-Making. Informed Shared Decision-Making Project: Internal Report. Vancouver: University of British Columbia; 1997. [2] Elwyn G, Edwards A, Kinnersley P, Grol R. Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices. Br J Gen Pract 2000;50:892–9. [3] Legare F, Stacey D, Pouliot S, Gauvin FP, Desroches S, Kryworuchko J, et al. Interprofessionalism and shared decision-making in primary care: a stepwise approach towards a new model. J Interprof Care 2011;25:18–25. [4] Department of Health. Equity and Excellence: Liberating the NHS. London: Department of Health/UK Government; 2010. [5] Coulter A. Do patients want a choice and does it work? Brit Med J 2010;341:c4989. [6] Da Silva D. Helping People Share Decision: A Review Of Evidence Considering Whether Shared Decision Making Is Worthwhile. London: The Health Foundation; 2012. [7] Braddock 3rd CH, Fihn SD, Levinson W, Jonsen AR, Pearlman RA. How doctors and patients discuss routine clinical decisions. Informed decision making in the outpatient setting. J Gen Intern Med 1997;12:339–45. [8] Braddock 3rd CH, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice: time to get back to basics. J Amer Med Assoc 1999;282:2313–20. [9] O’Cathain A, Thomas K, Walters SJ, Nicholl J, Kirkham M. Women’s perceptions of informed choice in maternity care. Midwifery 2002;18:136–44. [10] Weill medical college of Cornell University. Age calculator, hhttp://www-users.med.cornell.edu/spon/picu/calc/agecalc.htmi; 2000 [accessed 14.04.11].
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Please cite this article in press as: Garrard F, et al. Decisions, choice and shared decision making in antenatal clinics: An observational study. Patient Educ Couns (2015), http://dx.doi.org/10.1016/j.pec.2015.04.004