SummaryIn a cluster randomized trial, family practice physicians completed a 2-hour online tutorial followed by a 2-hour interactive workshop, both of which included videos, reflective exercises, and decision aids designed to support them in engaging in shared decisionmaking with patients presenting with signs of an acute respiratory infection. Known as DECISION+2, this program is a streamlined version of a more comprehensive package (DECISION+) that featured two additional workshops, periodic written reminders, and feedback on the degree of decisional conflict in patients versus physicians. The streamlined program reduced use of antibiotics for acute respiratory infections and allowed patients to take a more active role in decisionmaking, without having a negative impact on patient outcomes. The earlier, more comprehensive program also reduced antibiotic use, and generated high levels of physician satisfaction and greater agreement between physicians and patients on their level of comfort with the decision.Strong: The evidence consists primarily of a cluster randomized trial that included 181 patients consulting with physicians in five family medicine practices that participated in the DECISION+2 program to 178 patients consulting with physicians in four similar family practices that did not. Additional evidence comes from a smaller trial of the more comprehensive DECISION+ program that involved two participating family medicine groups and two similar control-group sites.
Developing OrganizationsUniversité Laval, Department of Family Medicine and Emergency Medicine
Date First Implemented2007
The trial of DECISION+ ran from November 2007 to April 2008; the second, larger trial of DECISION+2 ran from November 2010 through April 2011.
Problem AddressedFamily practice physicians frequently prescribe antibiotics for acute respiratory infections (ARIs) suspected to be viral in nature, though such treatment is not effective and can lead to development of resistance to antibiotics. They do so in large part because patients or their parents request antibiotics (or the physician believes that they want them). Shared decisionmaking (SDM) can help change patient and parent perceptions of the benefits of antibiotics, yet relatively few physicians engage their patients in this process.
- Overuse of antibiotics for ARIs: Relatively few ARIs are bacterial in nature and hence responsive to antibiotics. Bacterial infections account for only 38 percent of acute rhinosinusitis cases and 5 to 15 percent of acute pharyngitis cases in adults, and for only 6 to 18 percent of all ARI cases in children.1,2 However, physicians prescribe antibiotics in roughly two-thirds (between 63 and 67 percent) of cases in which patients present with symptoms of an ARI.3,4,5 Even in ARI cases likely to be bacterial in nature (e.g., acute rhinosinusitis lasting for more than 10 days, acute otitis media in children), the effectiveness of antibiotics in accelerating recovery is modest and has to be balanced with the risk of side effects, such as diarrhea and allergies.
- Driven by patient/parent perceptions: Despite efforts to educate the public, the message to avoid use of antibiotics for viral infections has not fully reached patients and parents, as illustrated below:
- Patient misperceptions: In a survey of more than 10,000 adults, 27 percent believed that taking antibiotics for a cold could prevent a more serious illness from developing, 32 percent believed that antibiotics accelerated recovery, and nearly half (48 percent) expected their physician to prescribe antibiotics for a cold. A slightly higher percentage of respondents with children shared each of these beliefs/attitudes. In addition, more than half of respondents (58 percent) did not know about the possible health dangers of inappropriate antibiotic use.6
- Parental pressure: One study found that physicians prescribe antibiotics to children nearly two-thirds of the time (62 percent) if they believe parents expect them to do so, but only 7 percent of the time if they do not.7
- Leading to increased resistance to antibiotics: Antimicrobial resistance is a large, rapidly growing problem throughout the world, with recent antibiotic use being a primary risk factor for the development of such resistance.6 Antibiotics will generally be less effective in treating future bacterial infections for those who develop resistance, which can be especially problematic for children who need access to effective antibiotics throughout their lives.8
- Unrealized potential of SDM: With SDM, clinicians educate patients on the best evidence related to the risks and benefits of available options; then physicians and patients jointly decide on the appropriate course of action, with the goal of making more informed decisions. Yet relatively few physicians engage their patients in this process, because they frequently lack the knowledge, educational materials, or time to do so.
Description of the Innovative ActivityIn a cluster randomized trial, family practice physicians completed a 2-hour online tutorial followed by a 2-hour interactive workshop, both of which included videos, reflective exercises, and decision aids designed to support them in engaging in SDM with patients presenting with signs of an ARI. Known as DECISION+2, this program is a streamlined version of a more comprehensive package that featured two additional workshops and feedback to physicians on their degree of decisional conflict versus that of patients. (See Planning and Development Process section for more details.) Key elements of the program include the following:
- Online self-tutorial: Participants in the trial had a month to complete a 2-hour online program with five modules that addressed key components of the clinical decisionmaking process for ARIs in primary care.9
- Introduction: This module introduced physicians to the SDM process for ARIs.
- Diagnostic probabilities: This module taught the most common signs and symptoms of ARIs, diagnostic probabilities, and how to use diagnostic tools.
- Treatment: This module focused on the effects of antibiotics in treating ARIs, integrating concepts of probability associated with these effects. It also discussed how to select the appropriate antibiotic if the decision to prescribe one has been made.
- Effective communication of risks and benefits: This module emphasized the essential elements of effective communication to patients about their treatment options, including associated benefits and risks. It also introduced a tool to assist with such communication.
- Promoting active patient participation: This module focused on questions that physicians can ask to elicit patient preferences and values, including their concerns related to the benefits and risks of taking or not taking antibiotics.
- Interactive workshop: After completing the online tutorial, participating physicians attended a 2-hour inperson workshop designed to reinforce and apply the concepts from the online tutorial. The earlier version of the program included three separate 3-hour workshops, held approximately 4 to 6 weeks apart (see the Planning and Development section for more information). Led by trained physicians with substantial experience in SDM and based on learning principles from medical education, the workshop focused on estimating the probability of encountering viral and bacterial ARIs, the scientific evidence on the risks and benefits of various treatment options, strategies for communicating these risks and benefits to patients, and ways to elicit patient values and preferences and foster their participation in the decisionmaking process.9
- Decision support and other tools: Both the online tutorial and workshop featured videos, reflective exercises, and decision support tools to assist physicians in engaging patients in SDM and in communicating to patients the probability of their having an ARI and the risks and benefits of treatment.9 In the workshop, these tools served to stimulate interactive discussions facilitated by workshop leaders.
- Videos of patient–physician interactions: Participating physicians watched videos of simulated patient–physician consultations for each targeted type of infection—acute rhinosinusitis, acute bronchitis, acute pharyngitis, acute otitis media—with depictions of both usual care and SDM.
- Reflective exercises: The tutorial and workshop both featured reflective exercises about facilitators and barriers to using SDM.
- Decision support tools: During the tutorial and workshop, physicians learned to use decision support tools designed to facilitate SDM with patients, with separate tools available for each of the four targeted infections. Physicians were also encouraged to practice using the tools with patients. At the conclusion of the program, attendees received an integrated tool covering all targeted infections, along with a booklet and manuals summarizing the content from the tutorial and workshop. The six sections in the integrated tool are outlined below:
- Questions to ask the patient about his or her symptoms and signs
- Graphical data to assist doctors in estimating the likelihood of a bacterial versus viral infection based on the signs and symptoms
- Easy-to-comprehend graphical displays and explanations of the odds of a bacterial versus viral infection to be used with the patient
- Graphical displays describing the risks and benefits of using and not using antibiotics, given the odds outlined above
- Tools to help patients elucidate their values and preferences regarding these risks and benefits
- Questions ensure that patients feel comfortable with the decision, including whether they have an adequate understanding of the potential risks and benefits and their preferences related to them
- Periodic reminders: The streamlined, more recent version of the program did not include any reminders to physicians about engaging in SDM. However, the earlier trial of the more comprehensive program featured periodic one-page reminders and biweekly program bulletins, developed by workshop leaders, that reiterated the importance of engaging in SDM with patients, emphasized the value of the decision support tools in doing so, and shared recent findings relevant to antibiotic use with ARIs. Six to 8 weeks after completing the workshop, physicians in the earlier trial also received a postcard (written to themselves at the workshop) reminding them of the need to implement various components of SDM in their practice.
- Onsite support: During both trials, a full-time, onsite research professional worked at each participating practice, with the primary job of recruiting patients to participate and collect data related to program evaluation. In addition, these individuals made sure that physicians had the decision support tools available during consultations with patients presenting with ARI symptoms. (In the absence of the study, this onsite support would not be available, or office staff would have to play this role.) Also, in the earlier trial, the onsite researchers distributed the written reminder materials described above to physicians, encouraging them to engage in SDM with patients.
References/Related ArticlesLégaré F, Labrecque M, Cauchon M, et al. Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial. CMAJ. 2012. Early release available at: www.cmaj.ca on August 13, 2012. [PubMed]
Légaré F, Labrecque M, LeBlanc A, et al. Training family physicians in shared decision making for the use of antibiotics for acute respiratory infections: a pilot clustered randomized controlled trial. Health Expect. 2011 Mar;14 Suppl 1:96-110. [PubMed]
Légaré F, Labrecque M, Leblanc A, et al. Does training family physicians in shared decision making promote optimal use of antibiotics for acute respiratory infections? Study protocol of a pilot clustered randomised controlled trial. BMC Fam Practice; 2007 Nov 29;8:65. [PubMed]
Leblanc A, Légaré F, Labrecque M, et al. Feasibility of a randomised trial of a continuing medical education program in shared decision-making on the use of antibiotics for acute respiratory infections in primary care: the DECISION+ pilot trial. Implement Sci. 2011 Jan 18;6:5. [PubMed]
Légaré F, Labrecque M, Godin G, et al. Training family physicians and residents in family medicine in shared decision making to improve clinical decisions regarding the use of antibiotics for acute respiratory infections: protocol for a clustered randomized controlled trial. BMC Fam Pract. 2011 Jan 26;12:3. [PubMed]
Contact the InnovatorFrance Légaré, MD, PhD, CCFP, FCFP
Michel Labrecque, MD
Department of Family and Emergency Medicine
Canada G1L 3L5
Innovator DisclosuresLégaré and Labrecque reported that the Université Laval received grant funding from Fonds de la Recherche en Santé du Québec (the provincial health funding agency in Québec) and Conseil du Médicament to support the two trials testing different versions of this program.
ResultsThe DECISION+2 program reduced use of antibiotics for ARIs and allowed patients to take a more active role in decisionmaking, without having a negative impact on patient outcomes. The more comprehensive DECISION+ program also reduced antibiotic use, and generated high levels of physician satisfaction and greater agreement between physicians and patients on their level of comfort with the decision.
Strong: The evidence consists primarily of a cluster randomized trial that included 181 patients consulting with physicians in five family medicine practices that participated in the DECISION+2 program to 178 patients consulting with physicians in four similar family practices that did not. Additional evidence comes from a smaller trial of the more comprehensive DECISION+ program that involved two participating family medicine groups and two similar control-group sites.
- Less immediate antibiotic use: Only 27.2 percent of the 181 patients with suspected ARI who consulted with physicians in practices that participated in the Decision+2 program reported using antibiotics immediately after the consultation, significantly below the 52.2 percent of patients that reported using antibiotics after seeing a physician in the control group.9 These findings confirm the results of the earlier (smaller) DECISION+ trial, which also found that patients of participating medical groups were less likely to use antibiotics immediately after the consultation.10
- More active patient role in decisionmaking: Patients of physicians participating in the DECISION+2 program reported taking a more active role in decisionmaking than did those of physicians who did not participate.9
- No impact on patient outcomes or other metrics: In the DECISION+2 trial, patient outcomes 2 weeks after the initial consultation were similar in both groups of patients. In addition, the program did not have a statistically significant impact on other evaluated metrics, including regret over the decision or intent to engage in SDM in the future.9
- High levels of physician satisfaction: In the earlier pilot test of DECISION+, the vast majority (94 percent) of participating physicians expressed high levels of satisfaction with the workshops, as indicated by answers in the top two categories of a four-point scale ("highly satisfied" or "satisfied"). Satisfaction with individual components of the workshops also tended to be quite high.10
- Greater agreement on level of comfort with decision: In the DECISION+ trial (which included feedback to physicians on their degree of decisional conflict versus that of patients), the correlation in average score on the Decisional Conflict Scale between physicians and patients was greater for participating clinics than control-group clinics, suggesting that participating physicians and their patients were more likely to have similar levels of comfort with the decision made.10
Context of the InnovationLocated in Québec, Université Laval offers a full range of undergraduate and graduate programs to both full- and part-time students, including programs in medicine and nursing. Physician researchers within the Department of Family Medicine and Emergency Medicine became interested in addressing overuse of antibiotics in the mid-2000s, after the Conseil du medicament du Québec (now known as the Institut national d’excellence en santé et en services sociaux, or INESSS) issued a report identifying five major areas of nonoptimal medication use. Based on this report, Fonds de la Recherche en Sante du Quebec, the provincial health funding agency in Québec, issued a call for grant applications to test ideas on how to reduce medication overuse. With substantial experience in SDM and in working with primary care physicians, the researchers adapted work from previous projects to create a program founded on SDM principles targeted at antibiotic use. Their proposal, which was approved for funding, called for testing a program to train family physicians in SDM and provide them with clinical tools to facilitate its routine use with patients.
Planning and Development ProcessKey steps included the following:
- Recruiting participating physicians: Program developers generated a list of family medicine groups in the Quebec City area and contacted the physician leader at each by phone. During the call, they provided information about the program and faxed a one-page summary describing it. Group leaders could choose to participate or decline during the call, or could request an inperson meeting to learn more about the program.
- Developing workshops and decision support tools: Local opinion leaders and experts in medical education expanded an existing 90-minute workshop on SDM to create three 180-minute sessions that included all components of the conceptual framework underlying the program. They designed the workshops so that family physicians could qualify for reimbursement under provincial regulations related to continuing medical education (CME), which allow for reimbursement for inperson sessions that last at least 3 hours. This effort included creation of the clinical vignettes depicting usual care and SDM and the decision support tools. To develop the tools, researchers consulted the scientific evidence and adapted materials from the Ottawa Personal Decision Guide11 (a generic decision aid) and the SURE tool,12 which assesses comfort level with a decision.
- Conducting initial trial, with ongoing program modifications: Developers conducted an initial pilot study of the original DECISION+ program between November 2007 and April 2008 at four family medicine groups.10 Throughout the pilot, program developers elicited participant feedback on the workshops and tools during debriefing sessions, and then modified them based on this feedback as appropriate.
- Making further modifications based on focus group: After the first study, researchers held a formal focus group with participating physicians to get further feedback on the workshops and tools. The physicians felt the workshops took too much time, and suggested development of a shorter, more focused, less theoretical program going forward. In fact, only 46 percent of providers in the trial participated in all three workshops.9 In response, program developers adapted the program, creating the 2-hour, Web-based tutorial followed by a 2-hour onsite workshop. Known as DECISION+2, the revamped program does not meet current CME requirements for physicians to be reimbursed for attendance. However, program developers expect these rules to be changed to accommodate online education in the near future.
- Enhancing workshop leader training: During the first trial, the program developers led the workshops. These individuals had expertise in both teaching and SDM and were intimately familiar with the curriculum and tools since they had created them. After the first 6 months of the initial DECISION+ trial, physicians in the control-group practices also attended the workshops and received the accompanying materials, with sessions being led by less experienced individuals. The program had less of an impact in these practices, with developers hypothesizing that suboptimal workshop facilitation contributed to the gap in results. Consequently, they revamped the workshop format to allow skilled trainers to cover more sites and decided to use fewer trainers going forward. They also created a train-the-trainer workshop.
- Conducting larger randomized trial of streamlined program: Between November 2010 and April 2011, researchers tested DECISION+2 with family physicians and residents in nine practice sites. As described earlier, the revamped program included the online tutorial and the new workshop format, along with onsite reminders about SDM. It did not include written reminders or feedback on Decisional Conflict Scale scores.
Resources Used and Skills Needed
- Staffing: Upfront development of the workshop curriculum and associated materials required the work of a small group of physician researchers with substantial expertise in SDM over a period of several months. Ongoing operation of the program requires no new staff, as primary care doctors participate in the workshops and review and practice using the tools as part of their regular duties.
- Costs: Information on program-related costs is not available.
Funding SourcesFonds de la Recherche en Santé du Québec; Conseil du Médicament
Fonds de Recherche du Québec-Santé (FRQS); Institut national d’excellence en santé et en services sociaux (INESSS) and Fonds de Recherche du Québec-Santé (FRQS); Institut national d’excellence en santé et en services sociaux (INESSS) provided funding for the two trials.
Tools and Other ResourcesA summary of the current version of the training sessions and decision support tools is available at: http://decision.chaire.fmed.ulaval.ca/index.php?id=66&L=2. Those interested in gaining access to complete program materials should contact the program developers.
More information on INESSS is available at: http://www.inesss.qc.ca/index.php?id=50&L=1.
Getting Started with This Innovation
- Sell program as “intersection” of patient-centered care, evidence-based medicine: Both organizational leaders and frontline physicians face tremendous pressures to implement patient-centered care and to follow evidence-based medicine. Use of SDM with patients satisfies both demands, as it helps to engage the patient in informed decisionmaking based on evidence relevant to that decision.
- Adapt existing resources to local environment: Rather than developing program materials from scratch, would-be adopters should consider adapting the existing curriculum and decision support tools to their local environment. (Information on how to access these materials can be found in the Tools and Other Resources section.)
- Keep time commitment to a minimum: As noted, less than half of physicians in the DECISION+ trial attended all three workshops, which in total represented a 9-hour time commitment. In contrast, nearly three-quarters of participating physicians completed the online tutorial (72.8 percent) and the one-time 2-hour workshop (73.5 percent) included in DECISION+2, with nearly two-thirds (63.6 percent) completing both.9
- Carefully choose and train workshop leaders: Program success depends in large part on the effectiveness of those leading the workshops; they must be experienced in SDM, familiar with the curriculum and tools, and skilled in teaching physicians. Use of the Web-based tutorial can help standardize the approach to training.
- Schedule workshop during lunch: Non-salaried physicians may be reluctant to attend sessions at times that take them away from seeing patients. To get around this problem, schedule the workshop during lunch. To encourage attendance, provide meals and/or refreshments and emphasize the potential to earn CME credit (if applicable).
- Make program interactive and easily accessible: Surveys and focus groups of family practice physicians suggest that they will be more likely to participate in continuing professional development programs perceived as being interactive and easy to access.13
Sustaining This Innovation
- Embed program into organizational mission and structures: Programs will be more likely to survive if they relate directly to an organization’s mission and become embedded in its existing structures. Many organizations have made patient-centered care and/or evidence-based medicine a formal part of their mission and vision statements and have embedded these principles in existing structures. For example, in the DECISION+2 trial, program developers worked with several practices with residency programs that have made these concepts a formal part of the curriculum. Consequently, SDM has essentially become a permanent fixture within these organizations, as it provides residents an opportunity to practice these principles with patients.
- Update workshop and tool content: The evidence related to use of antibiotics periodically changes, and program-related materials must be updated whenever new, important findings emerge. To that end, someone should be charged with regularly reviewing the literature and proposing updates as needed based on new findings.
- Consider embedding reminders in electronic records: Organizations that use electronic medical records may be able to embed real-time reminders about use of SDM and related decision support tools into these systems, thus ensuring their availability and ease of use at the point of care. Surveys and focus groups of family practice physicians suggest that educational programs that include integrated decision support tools will be more likely to attract their participation.13
1 Alberta Clinical Practice Guideline Working Group. Guideline for the Diagnosis and Treatment of Acute Pharyngitis. Alberta, Canada: Alberta Clinical Practice Guidelines Program, 1999.
2 Agency for Healthcare Research and Quality (AHRQ). Update on Acute Bacterial Rhinosinusitis. In: Ip S, Fu L, Balk E, et al., editors. Evidence Report/Technology Assessment. Rockville, MD: U.S. Department of Health and Human Services, 2005. p. 153.
Nash DR, Harman J, Wald ER, et al. Antibiotic prescribing by primary care physicians for children with upper respiratory tract infections. Arch Pediatr Adolesc Med. 2002;156:1114-19. [PubMed]
Linder JA, Stafford RS. Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989-1999. JAMA. 2001;286:1181-6. [PubMed]
Dosh SA, Hickner JM, Mainous AG, et al. Predictors of antibiotic prescribing for nonspecific upper respiratory infections, acute bronchitis, and acute sinusitis. An UPRNet study. Upper Peninsula Research Network. J Fam Pract. 2000;49:407-14. [PubMed]
Vanden Eng J, Marcus R, Hadler JL, et al. Consumer attitudes and use of antibiotics. Emerg Infect Dis. 2003;9(9):1128-35. [PubMed]
Mangione-Smith R, Wong L, Elliott MN, et al. Measuring the quality of antibiotic prescribing for upper respiratory infections and bronchitis in 5 US health plans. Arch Pedatric Adolesc Med. 2005;159:751-7. [PubMed]
Légaré F, Labrecque M, Cauchon M, et al. Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial. CMAJ. 2012. Early release available at: www.cmaj.ca
on August 13, 2012. [PubMed]
Légaré F, Labrecque M, LeBlanc A, et al. Training family physicians in shared decision making for the use of antibiotics for acute respiratory infections: a pilot clustered randomized controlled trial. Health Expect. 2011 Mar;14 Suppl 1:96-110. [PubMed]
Légaré F, Kearing S, Clay K, et al. Are you SURE?: Assessing patient decisional conflict with a 4-item screening test. Can Fam Physician; 2009. [PubMed]
Allaire AS, Labrecque M, Giguere A, et al. What motivates family physicians to participate in training programs in shared decision making? J Contin Educ Health Prof. 2012;32(2):98-107. [PubMed]
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Service Delivery Innovation Profile
Original publication: November 21, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: December 05, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.