This application is core to AHRQ's Comparative Effectiveness Research (CER) and Value Portfolios, in that it is fundamentally focused on improving the extent to which clinicians actually use up-to-date, evidence-based information about treatment options when it is provided to their patients. Localized prostate cancer treatment is paradigmatic of a preference sensitive decision;patients need to understand the trade-offs and reach a mutually acceptable decision with the treating physician. Prostate cancer treatment remains both troubling and controversial, due to the lack of survival gain obtainable by active treatment and the large differences in urinary, sexual and bowel side effects among treatment options. Due to these quality of life concerns, shared decision making (SDM) is widely recommended. To date, SDM for this and other preference sensitive decisions has been largely addressed through providing patients with decision aids (DAs). However, successful implementation of SDM requires information and collaborative conversations between patients and physicians about treatment decisions as well as a DA. DA studies in early stage prostate cancer have found discrepancies between patient treatment preferences before and after meeting with their physicians. To date, however, research has not adequately described the transaction between physicians and patients who have reviewed a DA. The objective of the application is to describe, from audio recordings of actual clinical encounters, how urologists present treatment choices, to measure the degree to which shared decision making occurs, and to evaluate the impact of SDM on patient decisions. The study is a mixed methods secondary data analysis of transcripts of audio-recorded conversations between urologists following a biopsy showing early stage prostate cancer. The parent study, a randomized trial of two decisions aids, was conducted in four Veterans Administration (VA) health system sites. The patient population is highly diverse, varying by region of the US, and by race and income of patients. The parent study recruited over 1,000 men, one-third of whom had early stage prostate cancer.
Specific Aims are to:
Aim 1 : To describe and evaluate urologists'presentation of treatment choices to DA prepared early stage prostate cancer patients in actual decision encounters.
Aim 2 : To describe, evaluate, and model the impact of shared decision making on patient decisions. Our working hypothesis is that more SDM in the encounter will increase concordance between patient treatment preferences from pre-encounter to post-encounter as a result of the patient-physician interaction. The study will have a critical impact in two major areas. One is to evaluate the extent to which physicians fulfill their responsibility to inform patients of the benefits and risks of their treatment options and evaluate the impact on patient decisions. The second is to suggest new theoretical directions and practical strategies for SDM implementation on the ground, leading directly to new approaches to physician training programs.
Deciding on prostate cancer treatment is troubling and controversial, because there are no treatments that improve overall survival, but there are large differences in side effects. The project will analyze audio recordings of doctor visits and patient surveys collected in a previous study to 1) better understand how doctors and patients decide on treatment when patients are well informed and 2) to evaluate the impact of the amount of shared decision making in the doctor visit on patients'decisions.