Results Summary
What was the research about?
Shared decision making, or SDM, is a process in which patients and doctors work together to make healthcare decisions. SDM may improve the quality of care a patient receives. But it isn’t common in behavioral health care, which supports mental, emotional, and social well-being.
The research team wanted to improve the level of SDM and quality of care for patients receiving behavioral health care. They offered training for behavioral health providers on skills related to SDM. The team also offered training for patients on taking an active role in their care.
What were the results?
In recorded clinic visits with patients, providers who took the training scored better on a measure of SDM than those who didn’t take the training. Providers who went to more training sessions scored better than providers who went to fewer sessions.
Patients who had the training rated the quality of their care higher than patients who didn’t have training. Patients who had more training sessions rated the quality of care higher than patients who had fewer sessions. When both providers and patients had the training and went to more sessions, patients rated the quality of care even higher.
Who was in the study?
The study included 74 behavioral health providers, such as therapists and social workers. Of these providers, 58 percent were white, and 76 percent were women. Providers worked at health clinics in Massachusetts.
The study also included 312 patients receiving care from the providers in the study. Of these patients, 36 percent were non-Latino white, 11 percent were non-Latino black, 11 percent were Asian, and 42 percent were Latino. In addition, 68 percent of patients were women.
What did the research team do?
The research team assigned providers to one of two groups by chance. One group had a 12-hour, in-person training program about how to work with patients to make treatment decisions. During the program, trained coaches used lectures, videos, and role-playing to teach providers about SDM. In addition, coaches offered providers up to six training sessions on SDM. Coaches also gave providers feedback about their SDM skills using one or two recorded patient visits. For the other group of providers, the team recorded patient visits but didn’t offer training or feedback.
Also in this study, the research team assigned patients to one of two groups by chance. One group received three training sessions on talking with their providers about treatment. Each session lasted one hour. The other group received no training.
To measure SDM, the research team listened to audio recordings of clinic visits. Providers and patients also filled out surveys about SDM after the visit. Patients filled out surveys about quality of care at the start of the study and again one to two and four to six months later.
The research team looked at whether the number of training or coaching sessions attended improved providers’ SDM skills or changed how patients perceived the quality of care.
What were the limits of the study?
Providers who joined the study were those who were interested in taking part in a workshop or training. Most providers in the study were women. Results may be different for male providers. Future studies could test the training with providers from different backgrounds.
How can people use the results?
Behavioral healthcare centers can use these results when thinking about whether and how to train providers and patients to improve SDM and the quality of care.
Professional Abstract
Objective
To compare the effectiveness of an intervention for behavioral health providers (DECIDE-PC) and another for patients (DECIDE-PA) on improving shared decision making (SDM) and quality of care
Study Design
| Design Elements | Description |
|---|---|
| Design | Randomized controlled trial |
| Population | 74 behavioral health providers and 312 patients enrolled in behavioral health treatment |
| Interventions/ Comparators |
Provider: DECIDE-PC versus usual care Patient: DECIDE-PA versus usual care |
| Outcomes |
Primary: level of SDM Secondary: patients’ perceptions of quality of care |
| Timeframe | 6-month follow-up for primary outcome |
In this randomized controlled trial, researchers examined whether a training program for behavioral health providers, DECIDE-PC, and another for their patients, DECIDE-PA, was more effective at improving SDM than usual care. The study included 74 providers from 13 community health clinics in Massachusetts and 312 patients receiving behavioral healthcare treatment from these providers.
Researchers randomly assigned providers to receive DECIDE-PC training or continue providing usual care. DECIDE-PC coached behavioral health providers in communication and therapeutic alliance to improve SDM. Providers received up to six coaching sessions based on audio recordings of their clinical encounters. In addition, coaches led a 12-hour, interactive workshop on taking the patient perspective into account, avoiding stereotypes, and collaborating with patients in treatment decisions.
Researchers randomized up to nine patients from each provider to receive either DECIDE-PA or usual care. DECIDE-PA encouraged patients to take an active role in their care. A trained care manager held three individual one-hour sessions with each patient in person or by phone. Sessions covered how to ask questions and communicate with providers about treatment.
Among providers, 58% were non-Latino white and 76% were female. Among patients, 36% were non-Latino white, 11% were non-Latino black, 11% were Asian, and 42% were Latino. In addition, 68% were female.
Researchers recorded patient-provider encounters and blind-coded them using an observer-rated measure of SDM. Each patient and provider also completed a follow-up SDM assessment. To measure perceptions of quality of care, researchers surveyed patients prior to randomization, then one to two months and four to six months later. The surveys assessed therapeutic bond in treatment and quality of patient-provider communication.
Next, researchers examined the relationship between the number of sessions a provider (DECIDE-PC) or patient (DECIDE-PA) attended and the level of SDM and patients’ perceptions of quality of care.
An advisory board including patients, providers, and researchers gave input on study design and advised on recruiting participants.
Results
Shared decision making. Providers who received the DECIDE-PC training scored higher on coder-measured SDM than providers who did not receive training (p<0.05). Provider and patient survey responses about SDM were the same for providers who received training and those who did not.
Patient perceptions of quality of care. Patients who received DECIDE-PA rated quality of care higher than patients who did not receive training (p<0.05); they rated quality of care even higher if both the patient and the provider had received the combined interventions. When both patients and providers received the combined interventions and attended more sessions, patients rated the quality of care even higher (p<0.05).
Number of coaching sessions. Providers who took part in more DECIDE-PC coaching sessions had higher blind-coded ratings of SDM (p<0.01) but did not have higher survey-based SDM assessments. Patients who completed more DECIDE-PA coaching sessions gave higher ratings for perceived quality of care (p<0.01).
Limitations
Convenience sampling may have resulted in selection bias because only providers who were interested in participating may have agreed to do so. The provider sample included mostly women; results may not be generalizable to men.
Conclusions and Relevance
DECIDE-PC and DECIDE-PA improved measures of the level of SDM and patients’ perceived quality of care. More training or coaching sessions may further improve ratings of SDM and patient evaluations of care.
Future Research Needs
Future research could include providers with diverse backgrounds.
Final Research Report
View this project's final research report.
Journal Citations
Results of This Project
Related Journal Citations
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:
- Reviewers noted that the report discussed focus groups without providing an explanation for how researchers conducted the groups or a report of the findings from them. Researchers removed the allusion to focus groups. They plan to publish qualitative results from those groups separately after a more-complete analysis.
- Reviewers noted that patients and providers who participated in the study were not fully representative, with providers younger than average and patients more educated than average. The researchers acknowledged this and explained that this bias reflected the providers and patients who expressed interest in participating in the study.
- Reviewers suggested that the weak intervention effects observed on outcomes could be the consequence, at least in part, of the specific scale used to measure shared decision making . The researchers agreed and explained that they chose this scale because it tries to avoid bias by using a third-party observer for assessing shared decision making, rather than self-reports by patients or providers. The researchers added that a newer version of the scale which has fewer questions, takes less time, and focuses on eliciting patient preferences may improve analyses in future studies.
Conflict of Interest Disclosures
Project Information
Key Dates
Study Registration Information
^Margarita Alegria, PhD, was affiliated with the Cambridge Health Alliance when this project was initially funded.