Clarifying values: an updated review

Abstract

BackgroundConsensus guidelines have recommended that decision aids include a process for helping patients clarify their values. We sought to examine the theoretical and empirical evidence related to the use of values clarification methods in patient decision aids.MethodsBuilding on the International Patient Decision Aid Standards (IPDAS) Collaboration’s 2005 review of values clarification methods in decision aids, we convened a multi-disciplinary expert group to examine key definitions, decision-making process theories, and empirical evidence about the effects of values clarification methods in decision aids. To summarize the current state of theory and evidence about the role of values clarification methods in decision aids, we undertook a process of evidence review and summary.ResultsValues clarification methods (VCMs) are best defined as methods to help patients think about the desirability of options or attributes of options within a specific decision context, in order to identify which option he/she prefers. Several decision making process theories were identified that can inform the design of values clarification methods, but no single “best” practice for how such methods should be constructed was determined. Our evidence review found that existing VCMs were used for a variety of different decisions, rarely referenced underlying theory for their design, but generally were well described in regard to their development process. Listing the pros and cons of a decision was the most common method used. The 13 trials that compared decision support with or without VCMs reached mixed results: some found that VCMs improved some decision-making processes, while others found no effect.ConclusionsValues clarification methods may improve decision-making processes and potentially more distal outcomes. However, the small number of evaluations of VCMs and, where evaluations exist, the heterogeneity in outcome measures makes it difficult to determine their overall effectiveness or the specific characteristics that increase effectiveness.

Recommendations for Providers on Person-Centered Approaches to Assess and Improve Medication Adherence

“…This care is meant to encourage value concordance-in this case, the match between the treatment that is selected and the treatment that is most desirable to the patient in terms of timing, duration of a therapy, or potential physical, emotional, and social effects. 19 As payment and delivery system models evolve to hold healthcare organizations and clinicians accountable for poor patient outcomes and downstream costs (e.g., via bundled payments and accountable care organizations), there is an increasing business case and need to identify methods to improve medication adherence by including patient-centered care.We seek to provide methods and tools that healthcare providers might use to advance communication with their patients and ultimately to improve appropriate medication use. To accomplish this, we explore how healthcare providers can partner with patients to improve adherence by using personcentered approaches-defined as those that consider the whole person 20 -including motivational interviewing,…”

“…This care is meant to encourage value concordance-in this case, the match between the treatment that is selected and the treatment that is most desirable to the patient in terms of timing, duration of a therapy, or potential physical, emotional, and social effects. 19 As payment and delivery system models evolve to hold healthcare organizations and clinicians accountable for poor patient outcomes and downstream costs (e.g., via bundled payments and accountable care organizations), there is an increasing business case and need to identify methods to improve medication adherence by including patient-centered care.…”

An Individualized Approach to Cancer Screening Decisions in Older Adults: A Multilevel Framework

“…18 and access to care and to screening tests 19 are among the factors that influence patient decisions regarding cancer screening. 20,21 Patient preferences and values are not always clear. 22 For example, patients over the age of 80 who consider screening might place greater value on years of life with higher quality than on more years of life but with lower quality, and their preference not to be screened is very clearly defined.…”

“…1 For example, they may recommend screening for patients whom they perceive to be in good health, and recommend against screening-or choose not to discuss cancer screening--with those in poor health. 27 Clinicians may also be influenced by the patient's living situation and family support, 21 the patient's personality and previous screening behavior, 21 and the proximity to sites for cancer treatment. 17,27 When clinicians are uncertain of the ratio of benefit to harm of cancer screening, 17,28 decision making can be challenging.…”

“…22 For example, patients over the age of 80 who consider screening might place greater value on years of life with higher quality than on more years of life but with lower quality, and their preference not to be screened is very clearly defined. 20,21 In addition, the desire to live longer might motivate screening, 14 while preparation for the end of life might preclude cancer screening. 14,15,17 In general, however, life expectancy does not seem to weigh heavily in patients' screening decisions.…”