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Factors associated with level of shared decision making in Malaysian primary care consultations
Journal Pre-proof Factors Associated with Level of Shared Decision Making in Malaysian Primary Care Consultations Yew Kong Lee, Yee Yang Chor, Mae-Yen Tan, Yi Chen Ngio, Ai Wie Chew, Han Wei Tiew, Mohamed Reza Syahirah, Chirk Jenn Ng
PII:
S0738-3991(19)30549-X
DOI:
https://doi.org/10.1016/j.pec.2019.12.005
Reference:
PEC 6475
To appear in:
Patient Education and Counseling
Received Date:
29 May 2019
Revised Date:
27 November 2019
Accepted Date:
9 December 2019
Please cite this article as: Lee YK, Chor YY, Tan M-Yen, Ngio YC, Chew AW, Tiew HW, Syahirah MR, Ng CJ, Factors Associated with Level of Shared Decision Making in Malaysian Primary Care Consultations, Patient Education and Counseling (2019), doi: https://doi.org/10.1016/j.pec.2019.12.005
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
TITLE: Factors Associated with Level of Shared Decision Making in Malaysian Primary Care Consultations AUTHORS: Yew Kong Leeac, Yee Yang Chora, Mae-Yen Tanb, Yi Chen Ngioa, Ai Wie Chewa, Han Wei Tiewa, Mohamed Reza Syahiraha, Chirk Jenn Nga a Department of Primary Care, University of Malaya, Kuala Lumpur, Malaysia b School of Medicine, University of Glasgow, Glasgow, UK c Corresponding author at: Dr Lee Yew Kong of
Primary of Lumpur,
Highlights
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First use of the OPTION tool to measure shared decision-making in an Asian setting Overall shared decision-making score was lower than scores published elsewhere Increased consultation time was significantly associated with a better SDM score Scores for the ethnic majority were better than for the minorities.
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Care, Malaya, Malaysia
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Department University Kuala [email protected]
ABSTRACT Objective
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To measure the level of shared decision-making (SDM) in primary care consultations in Malaysia, a multicultural, middle-income developing country. Methods
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A cross-sectional study was conducted in an urban, public primary care clinic. Convenience sampling was used to recruit participants, and audio-recorded consultations were scored for SDM levels by two independent raters using the OPTION tool. Univariate and multivariate analysis was conducted to determine factors significantly associated with SDM levels. Results
199 patients and 31 doctors participated. Mean consultation time was 14.3 minutes (+ SD 5.75). Patients’ age ranged from 18-87 years (median age of 57.5 years). 52.8% of patients were female, with three main ethnicities (Malay, Chinese, Indian). The mean OPTION score was found to be 7.8 (+ SD 3.31) out of 48. After a multivariate analysis, only patient ethnicity (β= -0.142, p<0.05) and increased consultation time (β=0.407, p<0.01) were associated with higher OPTION scores. Conclusions
Patients in Malaysia experience extremely poor levels of SDM in general practice. Higher scores were associated with increased consultation time and patient ethnicity. Practice implications Malaysian general practitioners should aim to develop and practice cultural competency skills to avoid biased SDM practice towards certain ethnicities. Keywords: shared decision making; Malaysia; consultation; primary care 1. Introduction Shared decision making (SDM) involves patients and doctors making values-based decisions together in a collaborative manner [1]. SDM practice in actual consultations is poor in Western contexts [2] and the situation would likely be worse in Asia, where patients are often confined to passive roles [3].
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In Asia, it is often assumed that patients would prefer a passive role due to strict social hierarchies that elevate authority figures including doctors. This assumption has been challenged by studies from Japan, Malaysia, South Korea, Thailand, China and India which report that more than 50% of patients desire active or shared decision making with their doctors [4,5]. However, a study on Malaysian doctors found that they often underestimated patients’ desire to engage in SDM [5].
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Little is known on levels of SDM in actual consultations in understudied developing, Asian countries such as Malaysia. Malaysia is an upper-middle income developing country [6] with a multi-ethnic and multi-lingual society [7]. Situational analyses of SDM in Malaysia has reported gaps in research, practice, policies and laws, and that cultural components of language issues, paternalism, strong family involvement, religious beliefs and complementary medicine are important to consider when practicing SDM in this setting [3,8]. This study aimed to measure the actual level of SDM practice in primary care consultations in Malaysia.
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2. Material and methods
A cross-sectional study was conducted between March- May 2016 at the urban, outpatient primary care clinic of the University Malaya Medical Centre, Kuala Lumpur.
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Clinical consultations between patients and doctors who agreed to participate were audio-recorded. Patients were chosen by convenience sampling of patients above the age of 18 who were fluent in Malay, Mandarin or English. Consultation variables were reason for consultation, and consultation duration. Patient and doctor sociodemographic data was collected. The OPTION instrument was used to measure SDM [9]. OPTION is the most widely used SDM measurement tool [10,2] and scores 12 aspects of physician consultation behavior (related to framing a decision, listing options, eliciting values and deliberating the choice) using a 5-point score ranging from 0 (no evidence of SDM-related behaviour) to 4 (high standard of behaviour) [9]. The tool is highly reliable with inter-rater intraclass correlation coefficient of 0.62, inter-agreement kappa scores of 0.71 and Cronbach’s alpha of 0.79 [9]. Two raters scored each consultation using an OPTION scoresheet. In cases of multimorbidity, raters identified the primary issue (the issue discussed most in the consultation) so that a single issue was used to score the consultation. Inter-rater reliability was calculated using
Cohen’s Kappa. Demographic variables were analyzed descriptively. Rater scores were averaged and totaled across the 12 items to produce an average OPTION score per consultation. Univariate analyses was used to determine the patient and clinical consultation variables independently associated with OPTION score; variables with a p<0.25 were then entered into a multiple linear regression model. Doctor variables were not included in analysis as the sample size was too small (n=31). Analysis was conducted using SPSS v18.0. Ethics approval for the study was obtained from the University of Malaya Medical Research Ethics Committee (Reference: MREC 201732-4996). 3. Results
Table 1. Participant demographics n (%)
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57.5 (39.2-68.0), 18-87 39 (19.6) 42 (21.1) 118 (59.3)
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PATIENTS (n=199) Age (n=192) Median (Interquartile range), Range (years) Age groups (n=199) <35 36-54 >55 Gender (n=199) Male Female Ethnicity (n=199) Malay Chinese Indian Others Marital Status (n=199) Single Married Divorced/ Widow Educational Level (n=198) Primary education Secondary education Technical/ vocational/ diploma Tertiary education Total Household Income (n=179) <999 1000-2999 3000-4999 >5000
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A total of 199 patients and 31 doctors participated (Table 1). Consultation times ranged from 3 minutes 52 seconds to 37 minutes 41 seconds (Mean= 14.3 minutes, SD + 5.75). Patients presented with a wide range of conditions including fevers, falls, numbness, gastric, giddiness, piles, infections, and follow-up for chronic diseases (diabetes, hypertension, cholesterol, stroke); follow-up consultations (n=100) to new presenting conditions (n=99) were almost equal.
94 (47.2) 105 (52.8) 65 (32.7) 67 (33.7) 51 (25.6) 16 (8.0) 39 (19.6) 129 (64.8) 31 (15.6) 30 (15.2) 77 (38.9) 48 (24.2) 43 (21.7) 34 (19.0) 68 (38.0) 37 (20.7) 31 (17.3)
Retired Consultation time (n=198) Mean, (SD), Range (minutes) Type of consultation (n=199) New Consultation Review Consultation DOCTORS (n=31) Age (n=31) Median, (SD), Range Gender (n=31) Male Female Position (n=31) Medical officer Lecturer/ Family Medicine Specialist
9 (5.0) 14.3 (SD 5.75), 4 -38 99 (49.7) 100 (50.3)
33.0 (SD 3.79), 30-49
28 3
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11 (35.5) 20 (64.5)
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Inter-rater reliability was good with a Cohen’s kappa of 0.838. The mean SDM score was 7.80 (SD + 3.31) out of 48. Items which required exploring the patients’ values and preferences scored the lowest (Item 3: “patients preferred approach to receiving information” Mean= 0.03 (SD + 0.12); Item 10: “patients preferred level of involvement in decision making” Mean= 0.12 (SD + 0.27); Item 6: “patients expectations about how the problem is to be managed” Mean= 0.35 (SD + 0.47)), while items related to doctor-centred behaviour of directing the consultation interaction scored the highest (Item 1: “clinician draws attention to an issue” Mean = 1.41 (SD + 0.56), Item 12: “clinician indicates the need to revisit the decision” Mean =1.26 (SD + 0.64) , Item 9: “clinician offers patient a chance to ask questions” Mean = 1.21 (SD + 0.43)).
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In univariate analysis, only ethnicity (Malay, Mean = 8.67 (SD = + 3.34), followed by Indian Mean = 7.64 (SD = + 3.70) , Chinese, Mean = 7.45 (SD = + 2.98) and Others, Mean = 6.31 (SD = + 2.46), p = 0.034), and longer consultation time (r=0.423, p<0.001) were significantly associated with a higher OPTION score. For multiple linear regression, four factors with a p-value <0.25 (gender, ethnicity, educational level and consultation time) were entered into the regression model. Only ethnicity and consultation time were associated with higher OPTION scores (Table 2).
R2 value
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Table 2. Multiple linear regression
.203 Standardized coefficients (β)
p value
Patient’s Ethnicity
-.142
.039
Patient’s Education Level
.074
.318
Patients Total Household Income
.052
.486
Rounded up duration of consultation .407
.000
Jo
Variables
4. Discussion & Conclusion
4.1. Discussion The mean SDM score (7.8, SD 3.31) in our study is lower than that reported in studies elsewhere. In a systematic review of 33 articles, the average OPTION score was 23 on a scale of 100 [2]. In contrast, the average OPTION score in our setting was 16.3 when converted to a scale of 100. One reason could be the general practice setting of our study as medical specialists and non‐physicians have better OPTION scores than general practitioners possibly due to longer consultation times [2]. Besides that, this survey involved patients in an outpatient clinic and in many of these cases, SDM opportunities may be few as acute conditions are easily treated while chronic disease follow-ups are a quick review with little emphasis on exploring other patient concerns [11]. Poor service orientation (i.e. a lack of interpersonal manners and communication skills) is an acknowledged issue with primary care practice in Malaysia [12] and SDM training should be considered in primary care professional development programs.
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Similar to studies elsewhere, increased consultation time was associated with a better SDM score in our study [2]. Focus should be on unpacking how longer consultations make SDM more possible by allowing time for patient-initiated SDM cues and rapport building [13]. Doctors in our setting should also be trained on practising SDM as an ethos or elemental process (e.g. the OPTION Talk model of team-, option- and decision- talk) instead of a stepby-step model which can take up more time [14].
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In this study, the majority ethnic group (Malays) have the highest SDM scores, followed by Indians and Chinese. This pattern is similar to US studies where the minority (non-white) population experienced less participatory consultation styles in race-discordant consultations [15,16], with language barriers acknowledged as a factor [15]. Language barriers are an issue in Malaysia [17] as each ethnic group has its own mother tongue [7]. Studies of non-native language consultations have shown that physicians tend to miss patient’s subtle voicing of concerns and preferences [18]. Formalized, longitudinal training involving cultural competency and communication skills, alongside SDM training is needed to address this issue [19].
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The highest and lowest item scores reveal that while doctors are best at establishing a consultation direction (Item 1, 12 and 9), they are poorest at exploring patients’ preferences and values (Item 3, 10, 6). Couet et al report similar patterns in their review [2] where they further observe that items that are part of routine clinical behaviours are consistently present (identifying the problem, providing opportunities for questions, and indicating need to review/ defer) while items that require tailoring to the patient are largely absent (assessing the patient’s preferred approach and eliciting preferred involvement). The primary care context provides further challenges to tailoring as patients often present with multimorbidity for which preference elicitation can be time-consuming [11,20]. Doctors may try to tackle all issues, which could make the consultation more doctor-centred and limit SDM. Thus, rather than revisiting all issues at each consultation, prioritisation of which issue to address is necessary. There are a number of limitations. The first is rating bias where the low OPTION score might be due to observer bias. However, the scoring manual provides clear descriptions for scoring, and care was taken to ensure that all raters understood the scoring criteria by pilot-testing a few consultations to resolve uncertainties. Secondly, the observer effect may have affected doctor’s consultation behaviour. Care was taken to avoid this having the research assistant leave the room during the consultation. 4.2. Conclusion In conclusion, this study found the involvement of patients in SDM among the primary care doctors in Malaysia to be much lower compared to other studies. This highlights the
challenge of establishing a novel way of working and interacting among a relatively naïve SDM population. Factors associated with higher SDM were longer consultation time and ethnicity. 4.3. Practice implications In Malaysia’s multicultural setting, doctors should aim to formally develop and practice cultural competency skills to avoid biased SDM practice towards certain ethnicities. The low scores for items exploring patient values and preferences suggest that doctors should explore cultural issues (such as family involvement, religious health beliefs, and use of complementary medicine with patients) which may affect SDM practice in Malaysian consultations. Conflicts of interest
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There are no conflicts of interest to declare. The study was self-funded.
References [1] C. Charles, A. Gafni, T. Whelan, Shared Decision-Making in the Medical Encounter: What Does it Mean? (Or it Takes at Least Two to Tango), Soc Sci Med. 44 (1997) 681-92. [2] N. Couet, S. Desroches, H. Robitaille, H. Vaillancourt, A. Leblanc, S. Turcotte, G. Elwyn, F. Legare, Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument, Health Expect. 18 (2013) 542-61. [3] C.J. Ng, P.Y. Lee, Y.K. Lee, B.H. Chew, J.P. Engkasan, Z.I. Irmi, N.S. Hanafi, S.F. Tong, An overview of patient involvement in healthcare decision-making: a situational analysis of the Malaysian context, BMC Health Serv Res. 13 (2013) 408. [4] D.L. Alden, M.Y. Merz, J. Akashi, Young adult preferences for physician decision-making style in Japan and the United States, Asia Pac J Public Health. 24 (2012) 173-84.
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[5] R. Ambigapathy, Y.C. Chia, C.J. Ng, 2016. Patient involvement in decision-making: a cross-sectional study in a Malaysian primary care clinic. BMJ Open. 6, e010063. [6] Ivtzan, I., et al, Linking religion and spirituality with psychological well-being: examining self-actualisation, meaning in life, and personal growth initiative, J Relig Health. 52 (2013) 915-29.
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[7] Central Intelligence Agency, The World Factbook: Malaysia, 2019. https://www.cia.gov/llibrary/publications/the-world-factbook/geos/my.html. (Accessed 18 April 2019).
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[8] Y.K. Lee, C.J. Ng, The state of shared decision making in Malaysia, Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) 123-124 (2017) 66–68.
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[9] G. Elwyn, A. Edwards, M. Wensing, K. Hood, C. Atwell, R. Grol, Shared decision making: developing the OPTION scale for measuring patient involvement, Qual Saf Health Care. 12 (2003) 93-9.
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[10] J. Nicolai, M. Moshagen, W. Eich, C. Bieber, The OPTION scale for the assessment of shared decision making (SDM): methodological issues, Z Evid Fortbild Qual Gesundhwes. 106 (2012) 264-71. [11] Y.K. Lee, C.J. Ng, W.Y. Low, Addressing unmet needs of patients with chronic diseases: Impact of the VISIT website during consultations, J Eval Clin Prac. 23 (2017) 1281-8.
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[12] K. Ganasegeran, W. Perianayagam, R. Abdul Manaf, S.A. Ali Jadoo, S.A.R. Al-Dubai, 2015. Patient Satisfaction in Malaysia's Busiest Outpatient Medical Care. ScientificWorldJournal. 2015, 714754.
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[13] M. Truglio-Londrigan, J.T. Slyer, Shared Decision-Making for Nursing Practice: An Integrative Review, Open Nurs J. 12 (2018) 1-14. [14] G. Elwyn, D. Frosch, R. Thomson, N. Joseph-Williams, A. Lloyd, P. Kinnersley, E. Cording, D. Tomson, C. Dodd, S. Rollnick, A. Edwards, M. Barry, Shared decision making: a model for clinical practice, J Gen Intern Med. 27 (2012) 1361-7. [15] L. Cooper-Patrick, J.J. Gallo, J.J. Gonzales, H.T. Vu, N.R. Powe, C. Nelson, D.E. Ford, Race, Gender, and Partnership in the Patient-Physician Relationship, JAMA. 282 (1999) 5839.
[16] M.Y. Lin, N.R. Kressin, Race/ethnicity and Americans' experiences with treatment decision making, Patient Educ Couns. 98 (2015) 1636-1642. https://doi.org/10.1016/j.pec.2015.07.017 [17] G. Vimala, S. Omar, Interpersonal Communication skill Barrier Faced by Cardiology Doctors at National Heart Centre Malaysia, International Journal of Academic Research in Business and Social Sciences. 6 (2016) 355-369. http://dx.doi.org/10.6007/IJARBSS/v6i6/2202 [18] A.M.D. Landmark, J. Svennevig, J. Gerwing, P. Gulbrandsen, Patient involvement and language barriers: Problems of agreement or understanding?, Patient Educ Couns. 100 (2017) 1092-102. [19] S.T. Hawley, A.M. Morris, Cultural challenges to engaging patients in shared decision making, Patient Educ Couns. 100 (2017) 18-24.
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[20] D. Mangin, G. Stephen, V. Bismah, C. Risdon, Making patient values visible in healthcare: a systematic review of tools to assess patient treatment priorities and preferences in the context of multimorbidity, BMJ Open. 6 (2016).
PII:
S0738-3991(19)30549-X
DOI:
https://doi.org/10.1016/j.pec.2019.12.005
Reference:
PEC 6475
To appear in:
Patient Education and Counseling
Received Date:
29 May 2019
Revised Date:
27 November 2019
Accepted Date:
9 December 2019
Please cite this article as: Lee YK, Chor YY, Tan M-Yen, Ngio YC, Chew AW, Tiew HW, Syahirah MR, Ng CJ, Factors Associated with Level of Shared Decision Making in Malaysian Primary Care Consultations, Patient Education and Counseling (2019), doi: https://doi.org/10.1016/j.pec.2019.12.005
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
TITLE: Factors Associated with Level of Shared Decision Making in Malaysian Primary Care Consultations AUTHORS: Yew Kong Leeac, Yee Yang Chora, Mae-Yen Tanb, Yi Chen Ngioa, Ai Wie Chewa, Han Wei Tiewa, Mohamed Reza Syahiraha, Chirk Jenn Nga a Department of Primary Care, University of Malaya, Kuala Lumpur, Malaysia b School of Medicine, University of Glasgow, Glasgow, UK c Corresponding author at: Dr Lee Yew Kong of
Primary of Lumpur,
Highlights
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First use of the OPTION tool to measure shared decision-making in an Asian setting Overall shared decision-making score was lower than scores published elsewhere Increased consultation time was significantly associated with a better SDM score Scores for the ethnic majority were better than for the minorities.
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Care, Malaya, Malaysia
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Department University Kuala [email protected]
ABSTRACT Objective
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To measure the level of shared decision-making (SDM) in primary care consultations in Malaysia, a multicultural, middle-income developing country. Methods
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A cross-sectional study was conducted in an urban, public primary care clinic. Convenience sampling was used to recruit participants, and audio-recorded consultations were scored for SDM levels by two independent raters using the OPTION tool. Univariate and multivariate analysis was conducted to determine factors significantly associated with SDM levels. Results
199 patients and 31 doctors participated. Mean consultation time was 14.3 minutes (+ SD 5.75). Patients’ age ranged from 18-87 years (median age of 57.5 years). 52.8% of patients were female, with three main ethnicities (Malay, Chinese, Indian). The mean OPTION score was found to be 7.8 (+ SD 3.31) out of 48. After a multivariate analysis, only patient ethnicity (β= -0.142, p<0.05) and increased consultation time (β=0.407, p<0.01) were associated with higher OPTION scores. Conclusions
Patients in Malaysia experience extremely poor levels of SDM in general practice. Higher scores were associated with increased consultation time and patient ethnicity. Practice implications Malaysian general practitioners should aim to develop and practice cultural competency skills to avoid biased SDM practice towards certain ethnicities. Keywords: shared decision making; Malaysia; consultation; primary care 1. Introduction Shared decision making (SDM) involves patients and doctors making values-based decisions together in a collaborative manner [1]. SDM practice in actual consultations is poor in Western contexts [2] and the situation would likely be worse in Asia, where patients are often confined to passive roles [3].
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In Asia, it is often assumed that patients would prefer a passive role due to strict social hierarchies that elevate authority figures including doctors. This assumption has been challenged by studies from Japan, Malaysia, South Korea, Thailand, China and India which report that more than 50% of patients desire active or shared decision making with their doctors [4,5]. However, a study on Malaysian doctors found that they often underestimated patients’ desire to engage in SDM [5].
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Little is known on levels of SDM in actual consultations in understudied developing, Asian countries such as Malaysia. Malaysia is an upper-middle income developing country [6] with a multi-ethnic and multi-lingual society [7]. Situational analyses of SDM in Malaysia has reported gaps in research, practice, policies and laws, and that cultural components of language issues, paternalism, strong family involvement, religious beliefs and complementary medicine are important to consider when practicing SDM in this setting [3,8]. This study aimed to measure the actual level of SDM practice in primary care consultations in Malaysia.
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2. Material and methods
A cross-sectional study was conducted between March- May 2016 at the urban, outpatient primary care clinic of the University Malaya Medical Centre, Kuala Lumpur.
Jo
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Clinical consultations between patients and doctors who agreed to participate were audio-recorded. Patients were chosen by convenience sampling of patients above the age of 18 who were fluent in Malay, Mandarin or English. Consultation variables were reason for consultation, and consultation duration. Patient and doctor sociodemographic data was collected. The OPTION instrument was used to measure SDM [9]. OPTION is the most widely used SDM measurement tool [10,2] and scores 12 aspects of physician consultation behavior (related to framing a decision, listing options, eliciting values and deliberating the choice) using a 5-point score ranging from 0 (no evidence of SDM-related behaviour) to 4 (high standard of behaviour) [9]. The tool is highly reliable with inter-rater intraclass correlation coefficient of 0.62, inter-agreement kappa scores of 0.71 and Cronbach’s alpha of 0.79 [9]. Two raters scored each consultation using an OPTION scoresheet. In cases of multimorbidity, raters identified the primary issue (the issue discussed most in the consultation) so that a single issue was used to score the consultation. Inter-rater reliability was calculated using
Cohen’s Kappa. Demographic variables were analyzed descriptively. Rater scores were averaged and totaled across the 12 items to produce an average OPTION score per consultation. Univariate analyses was used to determine the patient and clinical consultation variables independently associated with OPTION score; variables with a p<0.25 were then entered into a multiple linear regression model. Doctor variables were not included in analysis as the sample size was too small (n=31). Analysis was conducted using SPSS v18.0. Ethics approval for the study was obtained from the University of Malaya Medical Research Ethics Committee (Reference: MREC 201732-4996). 3. Results
Table 1. Participant demographics n (%)
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57.5 (39.2-68.0), 18-87 39 (19.6) 42 (21.1) 118 (59.3)
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PATIENTS (n=199) Age (n=192) Median (Interquartile range), Range (years) Age groups (n=199) <35 36-54 >55 Gender (n=199) Male Female Ethnicity (n=199) Malay Chinese Indian Others Marital Status (n=199) Single Married Divorced/ Widow Educational Level (n=198) Primary education Secondary education Technical/ vocational/ diploma Tertiary education Total Household Income (n=179) <999 1000-2999 3000-4999 >5000
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A total of 199 patients and 31 doctors participated (Table 1). Consultation times ranged from 3 minutes 52 seconds to 37 minutes 41 seconds (Mean= 14.3 minutes, SD + 5.75). Patients presented with a wide range of conditions including fevers, falls, numbness, gastric, giddiness, piles, infections, and follow-up for chronic diseases (diabetes, hypertension, cholesterol, stroke); follow-up consultations (n=100) to new presenting conditions (n=99) were almost equal.
94 (47.2) 105 (52.8) 65 (32.7) 67 (33.7) 51 (25.6) 16 (8.0) 39 (19.6) 129 (64.8) 31 (15.6) 30 (15.2) 77 (38.9) 48 (24.2) 43 (21.7) 34 (19.0) 68 (38.0) 37 (20.7) 31 (17.3)
Retired Consultation time (n=198) Mean, (SD), Range (minutes) Type of consultation (n=199) New Consultation Review Consultation DOCTORS (n=31) Age (n=31) Median, (SD), Range Gender (n=31) Male Female Position (n=31) Medical officer Lecturer/ Family Medicine Specialist
9 (5.0) 14.3 (SD 5.75), 4 -38 99 (49.7) 100 (50.3)
33.0 (SD 3.79), 30-49
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11 (35.5) 20 (64.5)
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Inter-rater reliability was good with a Cohen’s kappa of 0.838. The mean SDM score was 7.80 (SD + 3.31) out of 48. Items which required exploring the patients’ values and preferences scored the lowest (Item 3: “patients preferred approach to receiving information” Mean= 0.03 (SD + 0.12); Item 10: “patients preferred level of involvement in decision making” Mean= 0.12 (SD + 0.27); Item 6: “patients expectations about how the problem is to be managed” Mean= 0.35 (SD + 0.47)), while items related to doctor-centred behaviour of directing the consultation interaction scored the highest (Item 1: “clinician draws attention to an issue” Mean = 1.41 (SD + 0.56), Item 12: “clinician indicates the need to revisit the decision” Mean =1.26 (SD + 0.64) , Item 9: “clinician offers patient a chance to ask questions” Mean = 1.21 (SD + 0.43)).
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In univariate analysis, only ethnicity (Malay, Mean = 8.67 (SD = + 3.34), followed by Indian Mean = 7.64 (SD = + 3.70) , Chinese, Mean = 7.45 (SD = + 2.98) and Others, Mean = 6.31 (SD = + 2.46), p = 0.034), and longer consultation time (r=0.423, p<0.001) were significantly associated with a higher OPTION score. For multiple linear regression, four factors with a p-value <0.25 (gender, ethnicity, educational level and consultation time) were entered into the regression model. Only ethnicity and consultation time were associated with higher OPTION scores (Table 2).
R2 value
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Table 2. Multiple linear regression
.203 Standardized coefficients (β)
p value
Patient’s Ethnicity
-.142
.039
Patient’s Education Level
.074
.318
Patients Total Household Income
.052
.486
Rounded up duration of consultation .407
.000
Jo
Variables
4. Discussion & Conclusion
4.1. Discussion The mean SDM score (7.8, SD 3.31) in our study is lower than that reported in studies elsewhere. In a systematic review of 33 articles, the average OPTION score was 23 on a scale of 100 [2]. In contrast, the average OPTION score in our setting was 16.3 when converted to a scale of 100. One reason could be the general practice setting of our study as medical specialists and non‐physicians have better OPTION scores than general practitioners possibly due to longer consultation times [2]. Besides that, this survey involved patients in an outpatient clinic and in many of these cases, SDM opportunities may be few as acute conditions are easily treated while chronic disease follow-ups are a quick review with little emphasis on exploring other patient concerns [11]. Poor service orientation (i.e. a lack of interpersonal manners and communication skills) is an acknowledged issue with primary care practice in Malaysia [12] and SDM training should be considered in primary care professional development programs.
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Similar to studies elsewhere, increased consultation time was associated with a better SDM score in our study [2]. Focus should be on unpacking how longer consultations make SDM more possible by allowing time for patient-initiated SDM cues and rapport building [13]. Doctors in our setting should also be trained on practising SDM as an ethos or elemental process (e.g. the OPTION Talk model of team-, option- and decision- talk) instead of a stepby-step model which can take up more time [14].
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In this study, the majority ethnic group (Malays) have the highest SDM scores, followed by Indians and Chinese. This pattern is similar to US studies where the minority (non-white) population experienced less participatory consultation styles in race-discordant consultations [15,16], with language barriers acknowledged as a factor [15]. Language barriers are an issue in Malaysia [17] as each ethnic group has its own mother tongue [7]. Studies of non-native language consultations have shown that physicians tend to miss patient’s subtle voicing of concerns and preferences [18]. Formalized, longitudinal training involving cultural competency and communication skills, alongside SDM training is needed to address this issue [19].
Jo
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The highest and lowest item scores reveal that while doctors are best at establishing a consultation direction (Item 1, 12 and 9), they are poorest at exploring patients’ preferences and values (Item 3, 10, 6). Couet et al report similar patterns in their review [2] where they further observe that items that are part of routine clinical behaviours are consistently present (identifying the problem, providing opportunities for questions, and indicating need to review/ defer) while items that require tailoring to the patient are largely absent (assessing the patient’s preferred approach and eliciting preferred involvement). The primary care context provides further challenges to tailoring as patients often present with multimorbidity for which preference elicitation can be time-consuming [11,20]. Doctors may try to tackle all issues, which could make the consultation more doctor-centred and limit SDM. Thus, rather than revisiting all issues at each consultation, prioritisation of which issue to address is necessary. There are a number of limitations. The first is rating bias where the low OPTION score might be due to observer bias. However, the scoring manual provides clear descriptions for scoring, and care was taken to ensure that all raters understood the scoring criteria by pilot-testing a few consultations to resolve uncertainties. Secondly, the observer effect may have affected doctor’s consultation behaviour. Care was taken to avoid this having the research assistant leave the room during the consultation. 4.2. Conclusion In conclusion, this study found the involvement of patients in SDM among the primary care doctors in Malaysia to be much lower compared to other studies. This highlights the
challenge of establishing a novel way of working and interacting among a relatively naïve SDM population. Factors associated with higher SDM were longer consultation time and ethnicity. 4.3. Practice implications In Malaysia’s multicultural setting, doctors should aim to formally develop and practice cultural competency skills to avoid biased SDM practice towards certain ethnicities. The low scores for items exploring patient values and preferences suggest that doctors should explore cultural issues (such as family involvement, religious health beliefs, and use of complementary medicine with patients) which may affect SDM practice in Malaysian consultations. Conflicts of interest
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There are no conflicts of interest to declare. The study was self-funded.
References [1] C. Charles, A. Gafni, T. Whelan, Shared Decision-Making in the Medical Encounter: What Does it Mean? (Or it Takes at Least Two to Tango), Soc Sci Med. 44 (1997) 681-92. [2] N. Couet, S. Desroches, H. Robitaille, H. Vaillancourt, A. Leblanc, S. Turcotte, G. Elwyn, F. Legare, Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument, Health Expect. 18 (2013) 542-61. [3] C.J. Ng, P.Y. Lee, Y.K. Lee, B.H. Chew, J.P. Engkasan, Z.I. Irmi, N.S. Hanafi, S.F. Tong, An overview of patient involvement in healthcare decision-making: a situational analysis of the Malaysian context, BMC Health Serv Res. 13 (2013) 408. [4] D.L. Alden, M.Y. Merz, J. Akashi, Young adult preferences for physician decision-making style in Japan and the United States, Asia Pac J Public Health. 24 (2012) 173-84.
ro of
[5] R. Ambigapathy, Y.C. Chia, C.J. Ng, 2016. Patient involvement in decision-making: a cross-sectional study in a Malaysian primary care clinic. BMJ Open. 6, e010063. [6] Ivtzan, I., et al, Linking religion and spirituality with psychological well-being: examining self-actualisation, meaning in life, and personal growth initiative, J Relig Health. 52 (2013) 915-29.
-p
[7] Central Intelligence Agency, The World Factbook: Malaysia, 2019. https://www.cia.gov/llibrary/publications/the-world-factbook/geos/my.html. (Accessed 18 April 2019).
re
[8] Y.K. Lee, C.J. Ng, The state of shared decision making in Malaysia, Z. Evid. Fortbild. Qual. Gesundh. wesen (ZEFQ) 123-124 (2017) 66–68.
lP
[9] G. Elwyn, A. Edwards, M. Wensing, K. Hood, C. Atwell, R. Grol, Shared decision making: developing the OPTION scale for measuring patient involvement, Qual Saf Health Care. 12 (2003) 93-9.
na
[10] J. Nicolai, M. Moshagen, W. Eich, C. Bieber, The OPTION scale for the assessment of shared decision making (SDM): methodological issues, Z Evid Fortbild Qual Gesundhwes. 106 (2012) 264-71. [11] Y.K. Lee, C.J. Ng, W.Y. Low, Addressing unmet needs of patients with chronic diseases: Impact of the VISIT website during consultations, J Eval Clin Prac. 23 (2017) 1281-8.
ur
[12] K. Ganasegeran, W. Perianayagam, R. Abdul Manaf, S.A. Ali Jadoo, S.A.R. Al-Dubai, 2015. Patient Satisfaction in Malaysia's Busiest Outpatient Medical Care. ScientificWorldJournal. 2015, 714754.
Jo
[13] M. Truglio-Londrigan, J.T. Slyer, Shared Decision-Making for Nursing Practice: An Integrative Review, Open Nurs J. 12 (2018) 1-14. [14] G. Elwyn, D. Frosch, R. Thomson, N. Joseph-Williams, A. Lloyd, P. Kinnersley, E. Cording, D. Tomson, C. Dodd, S. Rollnick, A. Edwards, M. Barry, Shared decision making: a model for clinical practice, J Gen Intern Med. 27 (2012) 1361-7. [15] L. Cooper-Patrick, J.J. Gallo, J.J. Gonzales, H.T. Vu, N.R. Powe, C. Nelson, D.E. Ford, Race, Gender, and Partnership in the Patient-Physician Relationship, JAMA. 282 (1999) 5839.
[16] M.Y. Lin, N.R. Kressin, Race/ethnicity and Americans' experiences with treatment decision making, Patient Educ Couns. 98 (2015) 1636-1642. https://doi.org/10.1016/j.pec.2015.07.017 [17] G. Vimala, S. Omar, Interpersonal Communication skill Barrier Faced by Cardiology Doctors at National Heart Centre Malaysia, International Journal of Academic Research in Business and Social Sciences. 6 (2016) 355-369. http://dx.doi.org/10.6007/IJARBSS/v6i6/2202 [18] A.M.D. Landmark, J. Svennevig, J. Gerwing, P. Gulbrandsen, Patient involvement and language barriers: Problems of agreement or understanding?, Patient Educ Couns. 100 (2017) 1092-102. [19] S.T. Hawley, A.M. Morris, Cultural challenges to engaging patients in shared decision making, Patient Educ Couns. 100 (2017) 18-24.
Jo
ur
na
lP
re
-p
ro of
[20] D. Mangin, G. Stephen, V. Bismah, C. Risdon, Making patient values visible in healthcare: a systematic review of tools to assess patient treatment priorities and preferences in the context of multimorbidity, BMJ Open. 6 (2016).