Decision analysis for newly diagnosed hypertensive patients: a qualitative investigation

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Abstract

This study adopted a qualitative approach to explore patients’ views on the usefulness of a decision analytic decision aid (DA). Semi-structured interviews were conducted with 15 newly diagnosed hypertensive patients who had been recruited for a factorial randomised controlled trial of two decision aids. Issues investigated included respondents’ attitudes to information, their views on the nature of their relationship with their general practitioner (GP) (paternalistic, shared or consumerist), the ease of use and potential wider application of the computerised decision aid and its influence upon their decision-making about whether or not to begin anti-hypertensive treatment. Views on the decision aid were favourable. For the majority, the decision aid appeared to confirm and/or clarify their stated preferences towards medicine-taking. Occasionally it could provoke a major shift in a respondent’s attitude to medicine-taking, while in a few it had no discernible effect. While views on the decision aid were favourable, it was difficult to determine whether this was due to the individualised cardiovascular risk information it provided or the decision analytic process itself.

Introduction

Decision aids (DA) are tools to facilitate patient involvement [1] in decisions about their health care and can be seen as one way of operationalising the principles of informed shared decision-making [2]. This shared model of treatment decision-making promotes active patient involvement in the decision-making process [3] and can be seen as an approach distinct from the traditional paternalistic model of doctor–patient interactions. The goals of decision aids vary; they can clarify patients’ goals or may communicate risk, improve patient knowledge or facilitate various behavioural outcomes such as compliance with treatment [4]. A systematic review revealed that decision aids increase knowledge, lower the uncertainty surrounding the decision-making process and allow more active patient participation in decision-making [1]. Decision aids have been developed in many therapeutic areas including atrial fibrillation [5], hormone replacement therapy [6] and benign prostatic hyperplasia [7].

When assessing the effectiveness of decision aids, the traditional approach has been to use a variety of quantitative outcome measures such as patient uncertainty surrounding decision-making (the Decisional Conflict Scale), patient knowledge, anxiety, compliance with treatment, functional status, symptom resolution or satisfaction [8], [9], [10], [11], [12]. A qualitative approach can complement such quantitative outcomes by enabling a broader perspective on how patients view a decision aid. Few studies have, however, adopted a combined qualitative and quantitative approach [13]. In a recent randomised controlled trial we investigated whether a decision analytic decision aid was associated with changes in decisional conflict, knowledge, anxiety, treatment intentions and actual treatment choice in newly diagnosed hypertensive patients [14]. This study found that patients who received the decision aid had lower decisional conflict, greater knowledge about hypertension and no increase in state anxiety than those who did not receive the decision aid. The present qualitative study builds upon the quantitative findings to explore patients’ perceptions of the decision aid, to include the role of information in guiding patient decision-making, their views on the decision aid’s use and potential wider application in general practice and its impact upon their decision-making on whether or not to take tablets.

Section snippets

Methods

Fifteen follow-up interviews were conducted with participants from the main trial [14]. To be eligible for the trial, patients had to be between 30 and 80 years old, not currently taking anti-hypertensive medication and to have had a sustained raised blood pressure at a level where their general practitioner (GP) was considering initiating pharmacological treatment. The presence of cardiovascular disease was not an explicit exclusion criteria. Two interventions were investigated: a computerised

Attitudes to information

One of the aims of the interviews was to explore how respondents viewed their relationship with their general practitioner and whether they wanted a shared, as opposed to paternalistic, decision-making style in their doctor–patient interactions. This issue was approached by asking respondents whether they liked to sit and discuss issues with their doctor or whether they preferred to be told what to do. A few respondents felt they were able to discuss issues with their doctor, but most either

Discussion and conclusion

Semi-structured interviews were conducted with 15 newly diagnosed hypertensive patients to explore respondents’ perceptions of a decision analytic decision aid, including their views on where to access additional clinical information, the decision aid’s ease of use and the decision aid’s effect upon their preferences for taking medication. Respondents’ information-seeking attitudes featured prominently, with most seeking additional clinical information from friends, family, leaflets, books or

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    Fourth, included studies either did not have an experimental design or were subject to a high risk of bias, affecting confidence in observed effect estimates [66]. In addition, due to the design of included studies, it was difficult to determine what components of the decision analysis intervention (i.e., provision of information, preference elicitation exercises, review of decision analysis model output) were useful or if any of the observed benefits were due to patients’ desire for more support and/or information, regardless of the format [46]. While we focused on formal decision analytic models (i.e., decision trees and Markov models) for this review, there exist other types of decision models that have been used to incorporate patient preferences and probability of outcomes in clinical decision-making [67–69].

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