Education, Patient Activation Can Enhance Shared Decision-making

Web-based Intervention Bolsters PSA Screening Discussions, Studies Find

July 17, 2013 11:00 am News Staff

Although many organizations, including the AAFP, recommend against prostate-specific antigen (PSA)-based screening to one degree or another, PSA testing remains a common practice in the United States, with an estimated 40 percent to 50 percent of men ages 50 years and older undergoing screening each year.

[Stock photo of doctor talking to patient about PSA screening]

With organizations such as the U.S. Preventive Services Task Force and the American Urological Association recommending that physicians discuss the pros, cons and uncertainties of PSA screening with their patients, researchers now are looking closely at the shared decision-making model and its relation to screening.

According to a study of men older than 50( in the July/August issue of Annals of Family Medicine, shared decision-making about PSA testing was lacking in both screened and nonscreened men. Nearly two-thirds of more than 3,400 men who participated in the 2010 National Health Interview Survey reported no physician-patient discussion regarding advantages, disadvantages or scientific uncertainty pertaining to PSA screening. That's compared to only 8 percent of respondents who reported discussing all three elements, and slightly less than 28 percent who said they discussed one or two elements (partial shared decision-making).

As for the screening itself, slightly more than 44 percent of respondents reported no PSA screening, nearly 28 percent reported low-intensity (less-than-annual) screening, and about 25 percent reported high-intensity (nearly annual) screening.

Story Highlights
  • Prostate-specific antigen (PSA)-based screening remains a common practice in the United States, with an estimated 40 percent to 50 percent of men 50 and older undergoing screening each year.
  • As organizations tout the shared decision-making model, researchers are looking at ways to improve doctor-patient communication regarding PSA testing
  • Studies published in the Annals of Family Medicine showed that although most American men report little shared decision-making regarding PSA screening, educational interventions may enhance the process.

"Most U.S. men report little shared decision-making with their doctor in regard to PSA screening," said the study authors. "In addition, the lack of shared decision-making is more prevalent in nonscreened than in screened men."

The authors noted that although previous clinical trials have shown decision support reduces the uptake of PSA screening, the most significant finding was that the absence of shared decision-making applied to both screened and nonscreened men.

"Much of (the current policy debate about PSA screening) has focused on PSA screening in the absence of shared decision-making and its potential harm of undesired, unnecessary treatment of screening-detected cancer," said the authors. "Our study, however, suggests that the more prevalent problem is nonscreening in the absence of shared decision-making -- the harm of which is the failure to allow individuals to decide for themselves if screening is beneficial."

Studies Assess Web-based Educational Intervention

Two unrelated studies published in the same issue of Annals examined ways to improve the shared decision-making process.

The first of these studies( -- a cluster randomized controlled trial -- involved both primary care physicians (family physicians and internists) and their patients and compared "usual education" using informational brochures published by the CDC (control group) with physician education alone (M.D.-Ed group) and with physician education accompanied by patient activation (M.D.-Ed+A group). The interventions consisted of two Web-based educational programs: one tailored to physicians and the other to patients.

The study also used unannounced standardized patient visits that were digitally recorded to further explore the quantity and quality of patient-physician communication about PSA screening.

All results for this study were based on self-reporting by participants.

Although researchers failed to detect an interventional impact on the primary outcome of patient-perceived shared decision-making, with patients in all three groups reporting a moderate to high level of shared decision-making, they did find that the interventions had a significant effect on

  • physician attitudes toward screening,
  • the likelihood physicians would engage in prostate cancer screening discussions with patients and
  • the likelihood physicians would be neutral in their final recommendations.

Specifically, patients in the M.D.-Ed+A group were more likely to report having discussed PSA screening with their physicians (65 percent) than were patients in the control group (38 percent). The authors also found differences in physician attitudes when discussing prostate cancer screening -- from a pro screening bias toward neutral counseling -- were still evident at three months postintervention.

As for standardized patient visits, study authors said that although all physicians discussed prostate cancer screening after prompting, 9 percent responded minimally or rescheduled the discussion for a later visit. Most physicians (64 percent) lectured the standardized patient about prostate cancer screening rather than engaging in a two-way discussion (28 percent).

Furthermore, in response to the question, "What would you do if you were me?" 80 percent of control physicians recommended PSA testing compared with 59 percent of M.D.-Ed physicians and 44 percent of M.D.-Ed+A physicians. One-half of M.D.-Ed+A physicians were neutral in counseling about PSA screening compared with 33 percent of M.D.-Ed physicians and 15 percent of control physicians.

The second of the two studies( analyzed audio transcripts of the recorded standardized patient encounters conducted as part of the study described above using a 32-item "transcript abstraction tool"( based on the following three dimensions of shared decision-making:

  • provision of information (e.g., prostate cancer epidemiology, screening options, treatment options);
  • elicitation of patient perspectives (e.g., interest in engaging in shared decision-making, experience with and perspectives on prostate cancer and prostate cancer screening, values or preferences about different screening options); and
  • guiding final decision-making (e.g., whether patients were encouraged to seek input from others or asked if they wanted additional information to help make an informed decision).

Physicians' final screening recommendations (for, against, neither) and ultimate decision whether to order a PSA test also were assessed.

Among findings of the transcript analysis:

  • about one-half of all physicians discussed the epidemiology of prostate cancer and prostate cancer screening;
  • about 90 percent acknowledged shortfalls in PSA screening accuracy, with intervention physicians more likely to discuss other possible drawbacks;
  • only about 25 percent of physicians asked if the patient understood the information presented, and only 13 percent asked whether the patient had any questions;
  • about one-half asked about personal and family histories and direct experiences with prostate cancer and prostate cancer screening; and
  • a great majority of physicians in all three groups did not explicitly involve patients in shared decision-making about prostate cancer screening, although intervention physicians did provide more neutral guidance.

"Our transcript analysis found that whereas some behaviors were similar between physician groups, intervention physicians showed a greater number of patient-centered behaviors, asked about or provided more information about prostate cancer screening, and involved standardized patients more frequently in those discussions," said the authors.

"As consumers are bombarded with direct-to-consumer advertising of clinical tests and drugs, there is a potential growing demand for more care," the authors concluded. "This study shows, however, that when clinicians and patients engage in meaningful discussions around the uses and limitations of at least one technology (PSA tests), utilization of that technology may decrease, potentially decreasing the utilization of other tests with uncertain value."

Balance and Focus Needed to Improve Shared Decision-making

Even so, said the authors of an accompanying editorial(, "shared decision-making is less a discrete act than a skill to be cultivated through repeated application within meaningful relationships." In this broader context, it's important to balance individualized health care and population/public health roles in shared decision-making, as well as to find innovative ways to devote the needed time and resources to a more intensive shared decision-making scenario, such as through use of clinical teams.

"Shared decision-making is such a good idea that we seldom step back to look at the larger picture," said the authors. "Raising our performance means doing exactly that, treating shared decision-making not as an episodic event, but as an ongoing process within patients' lives and the practices of those who care for them."