Option Grids: Shared Decision Making Made Easier

Introduction to Option Grids and Shared Decision Making

  • Implementing shared decision making (SDM) into routine care is challenging despite increasing health policy interest.
  • Clinicians cite barriers such as lack of tools and time.
  • Decision support tools (decision aids) designed for independent patient use have not been consistently implemented.
  • Innovations are more likely to be adopted if they:
    • Confer advantage.
    • Fit into existing workflows.
    • Do not conflict with existing priorities, targets, and incentives.
  • Integrating tools into clinical pathways that involve:
    • Portraying options.
    • Supporting patients in weighing pros and cons.
    • Engaging families.
  • …is more demanding than simply recommending treatment.
  • Despite evidence from over 86 randomized trials showing positive effects of patient decision support tools (increased knowledge, improved risk perception, preference-congruent choices, reduced elective surgery rates), implementation remains a challenge.
  • Implementing SDM requires more than just embedding decision support tools; it also necessitates developing positive attitudes among health professionals, who cite barriers such as time constraints, patient disinterest, unsuitable tool design, and conflicting priorities.

Brief Tools for Face-to-Face Encounters as a Solution

  • While most research focuses on extensive patient decision support tools (booklets, videos, websites), brief tools also exist, though less studied.
  • Examples of brief tools:
    • Decision boards (Whelan et al., 1990s).
    • Bar charts for risk communication (Elwyn & Edwards).
    • 'Issues cards' for prioritizing discussion topics (Montori et al.).
  • Brief tools facilitate dialogue about options but aren't comprehensive.
  • Advantages of brief tools:
    • Impact on dialogue.
    • Improved awareness of options.
    • Tangible changes in communication (turn-taking, body language).
  • Brief tools can initiate SDM in clinical encounters, with referral to more extensive resources for further information and family discussion, as described in a recent model of shared decision making.
  • Option Grids are designed for use specifically in clinical encounters.

Methods: Option Grids Defined

  • An Option Grid is a summary of options in a table format, limited to one page.
  • It uses Frequently Asked Questions (FAQs) derived from patient concerns as table rows.
  • Features of options are presented in columns for horizontal comparison.
  • Information is intentionally limited, requiring judgments about which questions and options to include.
  • Typically lists 6-8 FAQs and compares a maximum of 2-3 options.
  • Steps to achieve brevity:
    • Decisions about information relevance based on 'what matters most' to patients.
    • Meticulous editing for concise, accessible, and clear language.
  • The Option Grid can be read in a few minutes by someone with a reading age of 10-12 years, or read aloud by the health professional.
  • The one-page format facilitates local printing and digital formats (video, mobile applications).
  • Development requires access to evidence synthesis (e.g., NICE reviews) and rigorous assimilation and ranking of patient concerns, incorporating clinician perspectives.
  • Further details about the development process are available from the Option Grid Collaborative [21].

Origin of Option Grids

  • The format was inspired by a popular table comparing treatment options on the Bresdex breast cancer decision support website.
  • Tables summarizing pros and cons of treatment options were also produced at Newcastle [24].
  • The tools were used in the Making Good Decisions in Collaboration (MAGIC) program [23] in seven clinical teams over 18 months.
  • Observations, field notes, and semi-structured interviews (n = 52) were conducted by the facilitator (AL) during implementation, focusing on the use of Option Grids.
  • These data form the basis for discussions and summaries of key findings from testing a new approach to facilitating shared decision making.

Theoretical Background: Bounded Rationality

  • The approach draws on the work of the ABC Group in Berlin [20].
  • Gigerenzer’s group has demonstrated that heuristics (rules of thumb) are an efficient method to arrive at good decisions when we are faced with complex information tasks and are the naturally occurring approaches to human decision making.
  • Their research demonstrates that by using rules of thumb, which they have described as 'fast and frugal heuristics', we arrive at decisions that are as good as, and often significantly better, than methods which draw on more complicated methods such as in-depth reasoning or decision analysis – methods that assume ‘unbounded rationality’ [25].
  • Many decision researchers based their analyses on assumptions of unbounded rationality, where information is processed in a 'rational' way with access to perfect information and limitless computation.
  • Real-world decision making, especially in clinical encounters, is more 'bounded' and uncertain.
  • The concept of bounded rationality has gained prominence recently, with recognition of its applicability to clinical practice [26].
  • Option Grids are based on the assumption that decisions are made with limited information and time, and that supporting decisions requires brief, focused information.
  • Option Grids provide comparison points based on key attributes (organized by FAQs).

Results: How to Use Option Grids

Observed key steps based on observations and workshops with clinicians:

  • Describe:
    • Explain that the Grid initiates a conversation about options.
    • Highlight that it is organized as a table for comparison, using questions from other patients.
  • Check:
    • Ask if patients prefer to read it themselves or have the comparisons vocalized.
  • Handover:
    • Give the Option Grid to patients with a pen for marking questions or noting issues.
  • Create space:
    • Ask permission to perform other tasks if patients want to read in silence, removing observation pressure.
  • Ask:
    • Encourage questions and discussion.
  • Gift:
    • Tell patients to take the Option Grid as a memory aid and for discussion with others, encouraging them to seek further information.
  • The clinician will need to establish whether patients are willing to read the Grid.
  • If not, the clinician could use the Grid structure as the basis for their comparison of options.
  • Either way, the grid should still be given to the patient so that both patients and clinicians collaborate as they view the content.
  • Patients typically take about 3 minutes to read an Option Grid - sometimes less time than a verbal explanation.
  • Clinicians suggest asking permission to do another task (e.g., computer notes) to alleviate pressure while patients read.
  • The clinician should remain silent until the patient indicates that they have read the Option Grid.

Handover Effect

  • Interviews and observations confirmed that handing the Option Grid to patients impacts communication.
  • From a sociological perspective, patients receive a representation of institutional knowledge, endorsed by the clinician.
  • It makes options visible and enables comparison in relation to personal questions and preferences.
  • Clinicians felt the handover step achieves:
    • Respect: Signals respect for patients as contributors to decision-making.
    • Power transfer: Shifts the interactional relationship, emphasized by providing a pen for annotation, symbolizing ownership and participation.

Clinician Views on the Value of Option Grids

  • Feedback from the MAGIC program (using Option Grids for breast cancer, tonsillectomy, head and neck cancer, cholesterol-lowering therapies) showed the tools provide:
    • Standardization
    • Visualization
    • Operationalization
  • Standardization:
    • Option Grids standardize information provision and make consultations easier.
    • Quote: “We have always done this – give information to patients – but now it’s in a more organised fashion . . . everybody will use the same Grid, so all the patients will have the same information” (surgeon, multi-disciplinary head and neck cancer team).
  • Visualization:
    • The tool helps patients visualize differences between treatment options.
    • Quote: “. . . patients can now actually see for themselves the actual differences in the choices they have, on a piece of paper. Previously they had to imagine it. Now they can actually see it on a piece of paper . . . This visualisation . . . makes things easier for them to understand” (breast surgeon, multi- disciplinary breast cancer team).
  • Operationalization:
    • It acts as an aide-mémoire for experienced staff and a training tool for junior staff.
    • Quote: “When I started, . . . I always used to ask the nurse, did I forget anything . . . But if you have an Option Grid in front of you it gives you the points you have to go through, then you know you haven’t missed anything. So it’s a very good training tool for juniors as well . . . it gives them confidence that they’ve covered all the points” (breast surgeon, multi- disciplinary breast cancer team).

Examples of Option Grids in Practice (Box 1):

  • Case 1: High Cholesterol: A 48-year-old man, concerned about family history, opted for lifestyle changes after reading an Option Grid and realizing statins weren't free of side effects.
  • Case 2: Breast Cancer: A 50-year-old woman used an Option Grid to compare mastectomy to lumpectomy, noting differences in local cancer recurrence rate and the side effects of radiotherapy, which influenced her decision.
  • Case 3: Early Vocal Cord Cancer: A 60-year-old man underlined issues for discussion on an Option Grid, emphasizing the importance of communication with his family over survival at any cost, aiding in preference clarification.

Discussion and Conclusion

  • The quality improvement project in UK NHS teams used a new tool (Option Grid) to facilitate shared decision making.
  • It fits a conceptual model [19] calling for brief tools in clinical encounters and more elaborate tools for independent use.
  • Option Grids stimulate choice talk and support option talk, providing a visible platform for decision talk (shared decision making).
  • Clinicians are enthusiastic about using Option Grids to accomplish shared decision making.

Practice Implications

  • Clinicians want support to develop communication skills and tools for patient involvement.
  • Using Option Grids seems to challenge the claim that patients