Mancini Brittney, Siar Joshua, Valentine Kathrene Diane, Simmons Leigh, Leavitt Lauren, Sepucha Karen
Massachusetts General Hospital, Boston MA, USA.
Medical College of Georgia AU/UGA Medical Partnership University of Georgia Health Sciences Campus Winnie Davis Hall, Athens, GA, USA.
Med Decis Making. 2025 May 28:272989X251340704. doi: 10.1177/0272989X251340704.
BackgroundEffective shared decision making (SDM) in health care involves thorough discussions of options, pros, cons, and patient preferences. While SDM is recommended for engaging adults aged 76 to 85 y in colorectal cancer (CRC) screening decisions, the extent of SDM documentation in clinical notes remains unclear.ObjectiveThis study aimed to evaluate the current state of SDM documentation in clinical notes regarding CRC screening discussions for adults aged 76 to 85 y. It also sought to assess the impact of an SDM training intervention on documentation quality and compare documented SDM elements with physician- and patient-reported SDM.MethodsData from 465 patient participants and 58 primary care physicians in a multisite cluster randomized trial were analyzed. Physicians in the intervention arm underwent a 2-h SDM skills training and received support tools, including an electronic health record SmartPhrase. Coders analyzed clinical notes using content analysis to identify SDM elements. Linear multilevel models and multilevel partial correlations were used for analysis.ResultsOverall, SDM Note scores were low ( = 0.80, = 0.99). The intervention arm exhibited higher SDM Note scores than the comparator arm did (adjusted mean 1.02 v. 0.66; = 0.006), with more frequent documentation of stool-based tests (52% v. 33%; = 0.02) and colonoscopy cons (28% v. 8%; = 0.001). No significant differences were observed in patient preference documentation. SDM Note scores correlated moderately with patient- and physician-reported SDM.ConclusionDocumentation of CRC screening discussions with older adults lacks comprehensive SDM elements. The intervention improved SDM documentation, particularly regarding alternative screening options and potential cons. Given the limited documentation of SDM even after a training intervention, attention to more robust SDM documentation, including patient preferences and discussion of stopping CRC screening, is needed.HighlightsShared decision-making (SDM) documentation in clinical notes is limited for discussions on colon cancer screening among older adults.SDM training improves SDM documentation of screening options for colorectal cancer, specifically documentation of stool-based testing and the downsides of screening options.SDM documentation in clinical notes is related to patient and provider reports of SDM.
背景
医疗保健中的有效共同决策（SDM）涉及对各种选择、利弊及患者偏好进行全面讨论。虽然推荐采用SDM来促使76至85岁的成年人参与结直肠癌（CRC）筛查决策，但临床记录中SDM的记录程度仍不明确。
目的
本研究旨在评估临床记录中关于76至85岁成年人CRC筛查讨论的SDM记录现状。还试图评估SDM培训干预对记录质量的影响，并将记录的SDM要素与医生和患者报告的SDM进行比较。
方法
对一项多中心整群随机试验中465名患者参与者和58名初级保健医生的数据进行了分析。干预组的医生接受了为期2小时的SDM技能培训，并获得了包括电子健康记录智能短语在内的支持工具。编码人员使用内容分析法分析临床记录以识别SDM要素。采用线性多级模型和多级偏相关进行分析。
结果
总体而言，SDM记录分数较低（ = 0.80， = 0.99）。干预组的SDM记录分数高于对照组（调整后均值为1.02对0.66； = 0.006），基于粪便检测的记录更频繁（52%对33%； = 0.02），结肠镜检查缺点的记录也更频繁（28%对8%； = 0.001）。在患者偏好记录方面未观察到显著差异。SDM记录分数与患者和医生报告的SDM呈中度相关。
结论
与老年人进行的CRC筛查讨论记录缺乏全面的SDM要素。该干预改善了SDM记录，特别是关于替代筛查选项和潜在缺点的记录。鉴于即使经过培训干预，SDM记录仍然有限，需要关注更完善的SDM记录，包括患者偏好以及关于停止CRC筛查的讨论。
要点
临床记录中关于老年人结肠癌筛查讨论的共同决策（SDM）记录有限。
SDM培训改善了结直肠癌筛查选项的SDM记录，特别是基于粪便检测的记录以及筛查选项的缺点记录。
临床记录中的SDM记录与患者和提供者报告的SDM相关。
