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      Supporting shared decision-making for older people with multiple health and social care needs: a realist synthesis

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          Abstract

          Background

          Health-care systems are increasingly moving towards more integrated approaches. Shared decision-making (SDM) is central to these models but may be complicated by the need to negotiate and communicate decisions between multiple providers, as well as patients and their family carers; this is particularly the case for older people with complex needs.

          Objectives

          To provide a context-relevant understanding of how models to facilitate SDM might work for older people with multiple health and care needs and how they might be applied to integrated care models.

          Design

          Realist synthesis following Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) publication standards.

          Participants

          Twenty-four stakeholders took part in interviews.

          Data sources

          Electronic databases including MEDLINE (via PubMed), The Cochrane Library, Scopus, Google and Google Scholar (Google Inc., Mountain View, CA, USA). Lateral searches were also carried out. All types of evidence were included.

          Review methods

          Iterative stakeholder-driven, three-stage approach, involving (1) scoping of the literature and stakeholder interviews ( n = 13) to develop initial programme theory/ies, (2) systematic searches for evidence to test and develop the theories and (3) validation of programme theory/ies with stakeholders ( n = 11).

          Results

          We included 88 papers, of which 29 focused on older people or people with complex needs. We identified four theories (context–mechanism–outcome configurations) that together provide an account of what needs to be in place for SDM to work for older people with complex needs: understanding and assessing patient and carer values and capacity to access and use care; organising systems to support and prioritise SDM; supporting and preparing patients and family carers to engage in SDM; and a person-centred culture of which SDM is a part. Programmes likely to be successful in promoting SDM are those that create trust between those involved, allow service users to feel that they are respected and understood, and engender confidence to engage in SDM.

          Limitations

          There is a lack of evidence on interventions to promote SDM in older people with complex needs or on interprofessional approaches to SDM.

          Conclusions

          Models of SDM for older people with complex health and care needs should be conceptualised as a series of conversations that patients, and their family carers, may have with a variety of different health and care professionals. To embed SDM in practice requires a shift from a biomedical focus to a more person-centred ethos. Service providers are likely to need support, both in terms of the way services are organised and delivered and in terms of their own continuing professional development. Older people with complex needs may need support to engage in SDM. How this support is best provided needs further exploration, although face-to-face interactions and ongoing patient–professional relationships are key.

          Future work

          There is a need for further work to establish how organisational structures can be better aligned to meet the requirements of older people with complex needs. This includes a need to define and evaluate the contribution that different members of health and care teams can make to SDM for older people with complex health and care needs.

          Study registration

          This study is registered as PROSPERO CRD42016039013.

          Funding

          The National Institute for Health Research Health Services and Delivery Research programme.

          Related collections

          Most cited references121

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          Patient-centredness: a conceptual framework and review of the empirical literature.

          A 'patient-centred' approach is increasingly regarded as crucial for the delivery of high quality care by doctors. However, there is considerable ambiguity concerning the exact meaning of the term and the optimum method of measuring the process and outcomes of patient-centred care. This paper reviews the conceptual and empirical literature in order to develop a model of the various aspects of the doctor-patient relationship encompassed by the concept of 'patient-centredness' and to assess the advantages and disadvantages of alternative methods of measurement. Five conceptual dimensions are identified: biopsychosocial perspective; 'patient-as-person'; sharing power and responsibility; therapeutic alliance; and 'doctor-as-person'. Two main approaches to measurement are evaluated: self-report instruments and external observation methods. A number of recommendations concerning the measurement of patient-centredness are made.
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            Where is the evidence? A systematic review of shared decision making and patient outcomes.

            Despite widespread advocacy for shared decision making (SDM), the empirical evidence regarding its effectiveness to improve patient outcomes has not been systematically reviewed. The purpose of this study was to systematically review the empirical evidence linking patient outcomes and SDM, when the decision-making process has been explicitly measured, and to identify under what measurement perspectives SDM is associated with which types of patient outcomes (affective-cognitive, behavioral, and health). PubMed (through December 2012) and hand search of article bibliographies. Studies were included if they empirically 1) measured SDM in the context of a patient-clinician interaction and 2) evaluated the relationship between SDM and at least 1 patient outcome. Study results were categorized by SDM measurement perspective (patient-reported, clinician-reported, or observer-rated) and outcome type (affective-cognitive, behavioral, or health). Thirty-nine studies met inclusion criteria. Thirty-three used patient-reported measures of SDM, 6 used observer-rated measures, and 2 used clinician-reported measures. Ninety-seven unique patient outcomes were assessed; 51% affective-cognitive, 28% behavioral, and 21% health. Only 43% of assessments (n = 42) found a significant and positive relationship between SDM and the patient outcome. This proportion varied by SDM measurement perspective and outcome category. It was found that 52% of outcomes assessed with patient-reported SDM were significant and positive, compared with 21% with observer-rated and 0% with clinician-reported SDM. Regardless of measurement perspective, SDM was most likely to be associated with affective-cognitive patient outcomes (54%), compared with 37% of behavioral and 25% of health outcomes. The relatively small number of studies precludes meta-analysis. Because the study inclusion and exclusion criteria required both an empirical measure of SDM and an assessment of the association between that measure and a patient outcome, most included studies were observational in design. SDM, when perceived by patients as occurring, tends to result in improved affective-cognitive outcomes. Evidence is lacking for the association between empirical measures of SDM and patient behavioral and health outcomes. © The Author(s) 2014.
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              What are the core elements of patient-centred care? A narrative review and synthesis of the literature from health policy, medicine and nursing.

              To identify the common, core elements of patient-centred care in the health policy, medical and nursing literature. Healthcare reform is being driven by the rhetoric around patient-centred care yet no common definition exists and few integrated reviews undertaken. Narrative review and synthesis. Key seminal texts and papers from patient organizations, policy documents, and medical and nursing studies which looked at patient-centred care in the acute care setting. Search sources included Medline, CINHAL, SCOPUS, and primary policy documents and texts covering the period from 1990-March 2010. A narrative review and synthesis was undertaken including empirical, descriptive, and discursive papers. Initially, generic search terms were used to capture relevant literature; the selection process was narrowed to seminal texts (Stage 1 of the review) and papers from three key areas (in Stage 2). In total, 60 papers were included in the review and synthesis. Seven were from health policy, 22 from medicine, and 31 from nursing literature. Few common definitions were found across the literature. Three core themes, however, were identified: patient participation and involvement, the relationship between the patient and the healthcare professional, and the context where care is delivered. Three core themes describing patient-centred care have emerged from the health policy, medical, and nursing literature. This may indicate a common conceptual source. Different professional groups tend to focus on or emphasize different elements within the themes. This may affect the success of implementing patient-centred care in practice. © 2012 Blackwell Publishing Ltd.
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                Author and article information

                Journal
                Health Services and Delivery Research
                Health Serv Deliv Res
                National Institute for Health Research
                2050-4349
                2050-4357
                August 2018
                August 2018
                : 6
                : 28
                : 1-84
                Affiliations
                [1 ]Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
                [2 ]Centre for Health Service Studies, University of Kent, Canterbury, UK
                [3 ]Social Care Workforce Research Unit, King’s College London, London, UK
                [4 ]Research Department of Primary Care and Population Health, University College London Medical School (Royal Free Campus), London, UK
                [5 ]Tower Hamlets Clinical Commissioning Group, The Tredegar Practice, London, UK
                [6 ]The Preference Laboratory, The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, NH, USA
                Article
                10.3310/hsdr06280
                29291720
                6a8fc798-a3da-4929-a5b5-d2c0165b907e
                © 2018

                Free to read

                http://www.nationalarchives.gov.uk/doc/non-commercial-government-licence/non-commercial-government-licence.htm

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