There is significant policy interest and an established ethical imperative for involving patients in decisions about their healthcare [1, 2]. In some medical conditions there is clear evidence that a treatment is highly effective, and the need for comparing alternative approaches is negligible. However, in many other conditions the balance of benefit to harm of a range of treatment options may be much less obvious, and the choice of treatment will be dependent on the preferences of the individual patient, in consultation with their practitioner. In such situations, shared decision making (SDM), an approach where clinicians and patients make decisions together using the best available evidence, is appropriate .
Patient decision support interventions, often called decision aids, have been developed to support SDM between practitioners and patients. These tools differ from traditional information resources in several ways: they make options explicit rather than imply a preferred choice; they use the best available evidence to be clear about benefits and harms; and many are interactive, making use of media such as the web and DVDs. Evidence suggests that patients who participate in SDM with the help of these tools are more knowledgeable about treatment options, make decisions that are more consistent with their own attitudes toward benefits and harms, and have more informed discussions with their practitioners [3, 4].
Despite wide policy interest, the promotion of SDM has not led to sustained use in routine practice . A significant problem has been the narrow interpretation of SDM, as if the provision of tools alone could somehow automatically lead to better communication between clinicians and patients about treatment options . The reality is that these approaches do not seem to work well [7, 8]. Professionals resist their use in practice, and are ambivalent about the idea of sharing decisions with patients [9, 10]. Practical barriers include the time required to implement SDM supported by decision aids in routine practice, consequently causing disruption to clinic workflows. Typically, the tools have been quite extensive and can take time for a patient to read or view them, as well as requiring a degree of technical and health literacy . They are costly to develop and producers often have commercial pay walls, which limit their accessibility .
Little is known about using patient decision support tools in populations that are ethnically diverse or socio-economically disadvantaged. Very few tools have been specifically designed for low-literacy populations [12, 13]. Decision tools have predominantly been developed in English and often contain information that may be difficult for people with lower levels of literacy, and for those who do not have English as their first language .
Work to address the implementation challenges faced by decision aids has resulted in the development of brief decision making tools designed to be used in the clinical encounter called Option Grids . Drawing on decision theories that refer to heuristics or “rules of thumb” , Option Grids are one-page evidence-based summaries of the available condition-specific treatment or screening options, presented in a tabular format, listing patients’ essential trade-offs or frequently asked questions [5, 16, 17]. The underpinning theory and rationale for Option Grids, their development process and guidance for their use in the clinical encounter, is reported elsewhere [5, 16]. Option Grids are deliberately brief, free of clinical jargon, and can be read by an individual with a reading age of 10 to 12 years. Formatted to one page and hosted on an open access website (http://www.optiongrid.org), they can be downloaded and printed with minimal cost .
The Option Grid website (http://www.optiongrid.org) currently hosts 28 Option Grids and considerable interest has been shown in them by the medical community, with thousands of Option Grid downloads since the website’s inception in 2012. Evidence from an implementation study suggests that clinicians find these short tools helpful as they remove the burden of having to talk extensively about options, and they notice that this structured information exchange takes either less, or no additional, time . Patient comprehension is facilitated by a layout that displays the alternative options side-by-side for easy comparison. Patients are enabled to raise relevant personal issues, picking the frequently asked questions as their starting point .
The interest from the clinical community in these tools indicates their wish to explore the feasibility of Option Grids for supporting SDM, but evidence from controlled studies of their effects in day-to-day clinical situations is currently lacking. We therefore developed a controlled trial to test the efficacy of an Option Grid in facilitating SDM. A concurrent qualitative evaluation will explore patients’, physiotherapists’ and interpreters’ views on the acceptability of using Option Grids in clinical encounters.
The primary objective is to assess the impact of the Option Grid (for OA of the knee) on SDM in routine encounters, in comparison to usual care where the Option Grid was not provided. Secondary objectives are to: assess the impact of Option Grids on patient decision making preferences in a clinical setting; examine whether these tools lead to good outcomes for physiotherapists and patients; evaluate the feasibility of using Option Grids in routine clinical practice; assess whether these tools can also be used with groups disadvantaged by language and literacy barriers and the extent of their reach; and evaluate whether there is willingness among practitioners to embed these tools into clinical pathways.