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The design of a low literacy decision aid about rheumatoid arthritis medications developed in three languages for use during the clinical encounter.

Barton JL, Koenig CJ, Evans-Young G, Trupin L, Anderson J, Ragouzeos D, Breslin M, Morse T, Schillinger D, Montori VM, Yelin EH - BMC Med Inform Decis Mak (2014)

Bottom Line: The final tool organized data using icons and plain language for 12 RA medications across 5 issues: frequency of administration, time to onset, cost, side effects, and special considerations.The tool successfully created a conversation between clinician and patient, and garnered high acceptability from clinicians.The process of collaboratively developing an RA decision aid designed to promote shared decision making resulted in a graphically-enhanced, low literacy tool.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, University of California, San Francisco, CA, USA. Jennifer.Barton@va.gov.

ABSTRACT

Background: Shared decision-making in rheumatoid arthritis (RA) care is a priority among policy makers, clinicians and patients both nationally and internationally. Demands on patients to have basic knowledge of RA, treatment options, and details of risk and benefit when making medication decisions with clinicians can be overwhelming, especially for those with limited literacy or limited English language proficiency. The objective of this study is to describe the development of a medication choice decision aid for patients with rheumatoid arthritis (RA) in three languages using low literacy principles.

Methods: Based on the development of a diabetes decision aid, the RA decision aid (RA Choice) was developed through a collaborative process involving patients, clinicians, designers, decision-aid and health literacy experts. A combination of evidence synthesis and direct observation of clinician-patient interactions generated content and guided an iterative process of prototype development.

Results: Three iterations of RA Choice were developed and field-tested before completion. The final tool organized data using icons and plain language for 12 RA medications across 5 issues: frequency of administration, time to onset, cost, side effects, and special considerations. The tool successfully created a conversation between clinician and patient, and garnered high acceptability from clinicians.

Conclusions: The process of collaboratively developing an RA decision aid designed to promote shared decision making resulted in a graphically-enhanced, low literacy tool. The use of RA Choice in the clinical encounter has the potential to enhance communication for RA patients, including those with limited health literacy and limited English language proficiency.

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Final set of five issue cards and a cover page (F) for a tri-fold copy of the cards given to patients at the end of their clinic visit. (A) Considerations, (B) Cost, (C), How Soon?, (D) How Often?, (E) cover page, (F) Side Effects.
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Fig6: Final set of five issue cards and a cover page (F) for a tri-fold copy of the cards given to patients at the end of their clinic visit. (A) Considerations, (B) Cost, (C), How Soon?, (D) How Often?, (E) cover page, (F) Side Effects.

Mentions: Several changes were made to this final deck in response to feedback from multiple stakeholders. Clinicians were extremely concerned about the amount of time it would take to review all eight issue cards (including the goals and combination therapy card) however they did note that the cards pushed them to consider patient preference as well as their own which they acknowledged promoted patient-centered care (their default was to tell the patient which drug they preferred, as opposed to eliciting patient preferences; the cards helped initiate that conversation). Patients reported some difficulty reading lighter color text on top of color, but liked the icons and calendar depictions. In cognitive interviews, it became clear that the goals card generated tangential conversations which distracted patients and providers from the task at hand. The combination card did not add to the conversations and it was deemed by our decision aid expert to be a “doctor” card in that it was information the doctor could easily convey in a sentence and was not an issue of importance to the patient. With respect to time, visits during the initial prototype testing varied from 30 to 60 minutes. We attributed some of this to a lengthy introduction of the tool to patients as well as a greater number of issue cards in the deck (Deck #2 - 8 cards). Three cards were then eliminated from the deck (goals, benefits, combination therapy) and a more stream-lined approach to using the cards in the clinic was developed. With these adjustments, visit length on average was 33 minutes (range 12-57 minutes) and often did not take longer than a visit without the tool. One user reported an increase visit time of 2 minutes with the tool. Clinicians were asked to start the conversation about choosing a medication with three main issue cards (how often, how soon and cost), and if patients asked questions about side effects or raised concerns related to special considerations, those cards would be pulled into the conversation. Thus the team arrived at a final set of five issue cards to be used in the clinical encounter (Figure 6). The final tool was translated and back-translated [40] into Spanish and Chinese by a professional translation agency (Figure 7).Figure 6


The design of a low literacy decision aid about rheumatoid arthritis medications developed in three languages for use during the clinical encounter.

Barton JL, Koenig CJ, Evans-Young G, Trupin L, Anderson J, Ragouzeos D, Breslin M, Morse T, Schillinger D, Montori VM, Yelin EH - BMC Med Inform Decis Mak (2014)

Final set of five issue cards and a cover page (F) for a tri-fold copy of the cards given to patients at the end of their clinic visit. (A) Considerations, (B) Cost, (C), How Soon?, (D) How Often?, (E) cover page, (F) Side Effects.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4363399&req=5

Fig6: Final set of five issue cards and a cover page (F) for a tri-fold copy of the cards given to patients at the end of their clinic visit. (A) Considerations, (B) Cost, (C), How Soon?, (D) How Often?, (E) cover page, (F) Side Effects.
Mentions: Several changes were made to this final deck in response to feedback from multiple stakeholders. Clinicians were extremely concerned about the amount of time it would take to review all eight issue cards (including the goals and combination therapy card) however they did note that the cards pushed them to consider patient preference as well as their own which they acknowledged promoted patient-centered care (their default was to tell the patient which drug they preferred, as opposed to eliciting patient preferences; the cards helped initiate that conversation). Patients reported some difficulty reading lighter color text on top of color, but liked the icons and calendar depictions. In cognitive interviews, it became clear that the goals card generated tangential conversations which distracted patients and providers from the task at hand. The combination card did not add to the conversations and it was deemed by our decision aid expert to be a “doctor” card in that it was information the doctor could easily convey in a sentence and was not an issue of importance to the patient. With respect to time, visits during the initial prototype testing varied from 30 to 60 minutes. We attributed some of this to a lengthy introduction of the tool to patients as well as a greater number of issue cards in the deck (Deck #2 - 8 cards). Three cards were then eliminated from the deck (goals, benefits, combination therapy) and a more stream-lined approach to using the cards in the clinic was developed. With these adjustments, visit length on average was 33 minutes (range 12-57 minutes) and often did not take longer than a visit without the tool. One user reported an increase visit time of 2 minutes with the tool. Clinicians were asked to start the conversation about choosing a medication with three main issue cards (how often, how soon and cost), and if patients asked questions about side effects or raised concerns related to special considerations, those cards would be pulled into the conversation. Thus the team arrived at a final set of five issue cards to be used in the clinical encounter (Figure 6). The final tool was translated and back-translated [40] into Spanish and Chinese by a professional translation agency (Figure 7).Figure 6

Bottom Line: The final tool organized data using icons and plain language for 12 RA medications across 5 issues: frequency of administration, time to onset, cost, side effects, and special considerations.The tool successfully created a conversation between clinician and patient, and garnered high acceptability from clinicians.The process of collaboratively developing an RA decision aid designed to promote shared decision making resulted in a graphically-enhanced, low literacy tool.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, University of California, San Francisco, CA, USA. Jennifer.Barton@va.gov.

ABSTRACT

Background: Shared decision-making in rheumatoid arthritis (RA) care is a priority among policy makers, clinicians and patients both nationally and internationally. Demands on patients to have basic knowledge of RA, treatment options, and details of risk and benefit when making medication decisions with clinicians can be overwhelming, especially for those with limited literacy or limited English language proficiency. The objective of this study is to describe the development of a medication choice decision aid for patients with rheumatoid arthritis (RA) in three languages using low literacy principles.

Methods: Based on the development of a diabetes decision aid, the RA decision aid (RA Choice) was developed through a collaborative process involving patients, clinicians, designers, decision-aid and health literacy experts. A combination of evidence synthesis and direct observation of clinician-patient interactions generated content and guided an iterative process of prototype development.

Results: Three iterations of RA Choice were developed and field-tested before completion. The final tool organized data using icons and plain language for 12 RA medications across 5 issues: frequency of administration, time to onset, cost, side effects, and special considerations. The tool successfully created a conversation between clinician and patient, and garnered high acceptability from clinicians.

Conclusions: The process of collaboratively developing an RA decision aid designed to promote shared decision making resulted in a graphically-enhanced, low literacy tool. The use of RA Choice in the clinical encounter has the potential to enhance communication for RA patients, including those with limited health literacy and limited English language proficiency.

Show MeSH
Related in: MedlinePlus