What Works in Implementing Patient Decision Aids in Routine Clinical Settings? A Rapid Realist Review and Update from the International Patient Decision Aid Standards Collaboration

Abstract

Background Decades of effectiveness research has established the benefits of using patient decision aids (PtDAs), yet broad clinical implementation has not yet occurred. Evidence to date is mainly derived from highly controlled settings; if clinicians and health care organizations are expected to embed PtDAs as a means to support person-centered care, we need to better understand what this might look like outside of a research setting. Aim This review was conducted in response to the IPDAS Collaboration’s evidence update process, which informs their published standards for PtDA quality and effectiveness. The aim was to develop context-specific program theories that explain why and how PtDAs are successfully implemented in routine healthcare settings. Methods Rapid realist review methodology was used to identify articles that could contribute to theory development. We engaged key experts and stakeholders to identify key sources; this was supplemented by electronic database (Medline and CINAHL), gray literature, and forward/backward search strategies. Initial theories were refined to develop realist context-mechanism-outcome configurations, and these were mapped to the Consolidated Framework for Implementation Research. Results We developed 8 refined theories, using data from 23 implementation studies (29 articles), to describe the mechanisms by which PtDAs become successfully implemented into routine clinical settings. Recommended implementation strategies derived from the program theory include 1) co-production of PtDA content and processes (or local adaptation), 2) training the entire team, 3) preparing and prompting patients to engage, 4) senior-level buy-in, and 5) measuring to improve. Conclusions We recommend key strategies that organizations and individuals intending to embed PtDAs routinely can use as a practical guide. Further work is needed to understand the importance of context in the success of different implementation studies.

Systematic Development of Patient Decision Aids: An Update from the IPDAS Collaboration

“…Health professionals who agree with use of a decision aid, serve as champions on the development teams, and engage meaningfully throughout the development process are seen as enablers of successful implementation in clinical practice. 2,6…”

Preliminary testing of a patient decision aid for patients with relapsing-remitting multiple sclerosis

“…These aspects have been shown to be important for implementation of PtDAs. 34 The online PtDA allowed participants to rate their preferences and treatment goals interactively sorting the treatments in accordance to what would most likely be preferred – potentially reducing the amount of information that patients would have to read. To our knowledge, this is the first RRMS patient decision aid that has tested the preliminary efficacy.…”

A patient decision aid for mild asthma: Navigating a new asthma treatment paradigm

“…Previous studies have demonstrated that implementation of decision aids in real world practice is extremely challenging, with half of authors reporting no uptake following trial result publication [66]. One key enabler to real-world use is to devise the process of integration into care concurrently with the development of the actual decision aid, with end-users [66,67]. An important early finding at our face validation stage was that although providers wished to be engaged at the point of decision-making, the depth of information required for patients necessitated a tool length which could not practically be used at the point-of-care.…”

“…A future research study of real-world implementation should include a process evaluation, assessment of barriers and facilitators to use, and measurement of impacts on shared decision-making, patient-provider communication, and ICS adherence. However, based on findings from this study and existing literature on strategies for implementation of shared decision-making tools into routine clinical settings [67], including promising results from integration into electronic health records [73], our next step will be to integrate both tools into the evidence-based Electronic Asthma Management System (eAMS) [46] and evaluate impact. This patient-and provider-facing, electronic health record-integrated system will be leveraged to prompt eligible patients to complete the decision aid prior to the clinical visit, and prompt providers to use the conversation aid during that visit.…”