April is National Minority Health Month, a national initiative led by the U.S. Department of Health and Human Services that is designed to find ways to ensure that all patients have equal access to healthcare regardless of their race or ethnic background.
To help raise awareness of health care disparities that continue to affect racial and ethnic minorities, let’s take a look at the concept of shared decision making and how a new study from Massachusetts General Hospital provides insights into how to empower minority patients and improve their quality of care. The study was conducted by a research team led by Margarita Alegria, PhD, Chief of the Disparities Research Unit at Massachusetts General Hospital.
Shared decision making
According to the National Learning Consortium, shared decision making (SDM) is a process in which clinicians and patients work together to make decisions and select tests, treatments, and care plans that balance risks and expected outcomes with patient preferences and values.
While this patient-centered approach has gained attention in recent years, there have been multiple barriers to large scale implementation of SDM, particularly in patients from racial and ethnic minorities.
On the clinician side, few doctors are trained in and have the skills to encourage patient involvement in decisions about their care.
Many patients do not understand the concept of SDM, or do not feel comfortable with taking an active role in care decisions. This is especially true in ethnic/racial minority populations; research has shown that minority patients are less likely than white patients to state concerns, seek information, or feel trust in their providers.
The DECIDE Intervention
These ethnic and racial disparities were echoed in the results from previous work by Alegria that tested a SDM intervention known as DECIDE.
The DECIDE intervention employs a six-step process that is designed to help patients and clinicians arrive at care decisions by working collaboratively:
D – decide the problem
E – explore the questions
C – closed or open-ended questions
I – identify the who, why, or how of the problem
D – direct questions to your health care professional
E- enjoy a shared solution
The results of the previous studies found that a patient-focused DECIDE intervention (DECIDE-PA) improved patient activation and self-management in behavioral health care settings, but minority patients were more likely than white patients to express concern that becoming activated threatened their relationships with their clinicians. The study authors defined activation as the development of knowledge, skills, and beliefs that enable thoughtful action and active participation in decisions.
Given these findings, a team of researchers — including investigators from Massachusetts General Hospital — sought to test if pairing a clinician-focused DECIDE intervention (DECIDE-PC) with the patient focused intervention (DECIDE-PA) within a minority patient population would be effective for improving SDM and quality of care.
The team conducted a randomized clinical trial in Massachusetts behavioral health clinics. 74 clinicians were randomized to either usual care or DECIDE-PC which consisted of a workshop and as many as six coaching telephone calls to promote improved communication.
A total of 312 patients seeking behavioral health services were randomized to receive either standard care or an intervention with DECIDE-PA, which involved three 60-minute sessions focused on educating patients about their role in clinical visits, and providing them with the skills and confidence to understand and ask questions about their treatment options.
The patients were 42% Latino, 36% non-Latino white, 11% non-Latino black, and 11% Asian; corresponding percentages among the clinicians were 20%, 58%, 5%, and 16%.
Clinician and patient outcomes were assessed at baseline, at two months, and at four to six months.
The research team used a variety of assessment tools: SDM was evaluated using a team of coders who filled out an assessment tool based on audio recordings of clinician-patient interactions. Participating clinicians and patients also filled out a survey evaluating SDM. Lastly, patients received an assessment to evaluate their subjective rating of care.
The study found that the clinician intervention significantly increased SDM as rated by the coders, but not as assessed by clinicians or patients. The authors hypothesize this may be because it’s challenging for clinicians to detect changes in their interactions during clinical visits. They suggest clinicians listen to audiotaped sessions before and after coaching to recognize their changes.
The patient intervention significantly increased patient-perceived quality of care but not SDM. The team found that the more DECIDE-PA training sessions the patients attended, the greater the perceived quality, particularly when their clinicians also received more coaching sessions. The authors suggest the patient intervention didn’t improve SDM because some of the trainings were conducted by telephone, and the intervention was skills-based with a focus on asking questions, identifying resources, and communicating preferences rather than teaching patients explicitly about SDM.
This study was the first of its kind to investigate the effectiveness of patient and clinician interventions to improve SDM in behavioral healthcare among an ethnically and racially diverse patient group. The findings highlight how even a simple intervention can help to improve communication and quality of care.
Although the tested intervention wasn’t entirely successful, the lessons learned can help inform future SDM trainings. The research team’s next step is to streamline the training and work to successfully disseminate the interventions to new clinical sites.