A0623 - Barriers and Facilitators to Shared Decision-Making Implementation in the Management of Esophageal Diseases: A Mixed Methods Study

Sunday, October 23, 2022

5:00 PM – 7:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

SA

Sudharshan Achalu, BA

Stanford University
Redwood City, CA

Sudharshan Achalu, BA¹, Rani Berry, MD¹, George Triadafilopoulos, MD², John O. Clarke, MD¹, Afrin N. Kamal, MD, MS¹
¹Stanford University, Redwood City, CA; ²Stanford University School of Medicine, Redwood City, CA

Introduction: Shared decision-making (SDM) is a model in which properly informed patients partake in decision-making as physicians incorporate patient goals/preferences. Despite growing recognition that SDM may improve health outcomes, physician implementation has not yet been routine. To increase acceptance and implementation, we must first explore physicians’ views on SDM. To formally study gastroenterologists’ perspectives on the potential barriers and facilitators of SDM implementation in the management of esophageal disease.

Methods: Surveys and semi-structured interviews were conducted with a national panel of gastroenterologists focusing on esophageal disease, recruited from the Esophageal Virtual Collaborative. All panelists completed an investigator-developed survey capturing beliefs and practice patterns on SDM. In addition, 50% of them were invited for interviews to explore barriers (e.g., factors inhibiting) and facilitators (e.g., factors promoting) to SDM implementation. An interview guide was created from literature review. Interviews were recorded, transcribed, and independently coded by 2 reviewers. The Theoretical Domain Framework (TDF) was applied to identify barriers/facilitators in SDM implementation to guide possible intervention.

Results: Thirty-three gastroenterologists completed the survey (75% male; median age 29.5 years). Over 75% of them agreed in the promotion of SDM if the patients’ symptoms are severe (75.8%) and that the use of partnership building language is essential to SDM (72.7%). Interview transcripts with 16 of these gastroenterologists were independently coded into TDF domains with strong inter-rater reliability (Cohen’s Kappa = 0.77). Four domains were the most relevant to barriers and facilitators: 1) environmental context and resources; 2) memory, attention, and decision processes; 3) knowledge; and 4) skills. Of 533 beliefs identified, most common beliefs on barriers and facilitators included: 1) low patient health literacy; 2) clinic time constraints; 3) patient fear/anxiety, and: 1) physician communication skills (e.g., joint discussion of treatment options); 2) communication aids (e.g., Question Prompt Lists); and 3) illustrations (e.g., diagrams) to improve understanding, respectively.

Discussion: We identified gastroenterologist beliefs on barriers/facilitators to SDM implementation when managing esophageal disease. Our early data will help design studies/strategies for behavior change interventions.

Figure: Work flow specific to the qualitative methods

Barriers / Facilitators	Theme	Beliefs	Corroborating Interview Quote
Barriers	Time	I believe time constraints in clinic are a barrier to SDM	“I imagine, probably the biggest barrier is time. It's a lot easier to just tell a patient what to do. I mean if I just tell them, you know you're going to take a PPI, now goodbye, that takes about 10 seconds. If I lay out every option and explain all the pros and cons of every option. the adverse effects and possible drug interactions and implications of everything, that will take more than 30 minutes.”
	Patient Characteristics	I believe low patient health care literacy is a barrier to SDM	“I think the biggest barriers are really trying to break down complex medical pathology and tests for a lay person with various ranges of medical literacy and insight. So, trying to make patients exactly understand what the options are for testing and treatment is always the challenge.”
	Patient Characteristics	I believe patient fear/anxiety is a barrier to SDM	“There are patients who are just intimidated by the medical personnel and environment, and they just don't feel comfortable asking questions, mostly because of their insecurities or fearful of portraying that they do not understand.
Facilitators	Physician Communication	I believe drawing diagrams with images facilitates SDM	“I'll try to maximize their understanding, asking if they have questions, at multiple points along the way, and stopping to do that. I think diagrams are helpful as well. When we're talking about shared decision-making, graphics can be helpful in ensuring that patients understand options and complex treatments”
	Physician Communication	I believe the use of question prompt lists (QPL) facilitates SDM	“I think that this absolutely has the potential to be effective, particularly for people with limited healthcare literacy, or for those who with new diagnosis, [or] for those who have not previously searched the Internet. I think that QPLs are really helpful because they allow patients to think and focus on the disease and their symptoms that matter to them the most.”
	Physician Communication	I believe informing patients about treatment options facilitates SDM	“First part of SDM is to explain thoroughly the disease process to the patient, so they understand to some degree the pathophysiology and why the available treatments could be effective. I think it's important to go through all the risks and benefits of each of those treatment proposals. And then it's important to ask the patient what they think about the various decisions.”

Table: Relevant barriers and facilitators following gastroenterologist interviews

Disclosures:

Sudharshan Achalu indicated no relevant financial relationships.

Rani Berry indicated no relevant financial relationships.

George Triadafilopoulos indicated no relevant financial relationships.

John Clarke: Alnylam – Advisory Committee/Board Member. Castle Biosciences – Advisory Committee/Board Member. Isothrive – Advisory Committee/Board Member. Medtronic – Advisory Committee/Board Member. Regeneron – Advisory Committee/Board Member. Sanofi – Advisory Committee/Board Member.

Afrin Kamal indicated no relevant financial relationships.

Sudharshan Achalu, BA¹, Rani Berry, MD¹, George Triadafilopoulos, MD², John O. Clarke, MD¹, Afrin N. Kamal, MD, MS¹. A0623 - Barriers and Facilitators to Shared Decision-Making Implementation in the Management of Esophageal Diseases: A Mixed Methods Study, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.