Background/Purpose

The purpose of the study was to improve communication and shared decision-making (SDM) between clinicians and parents of patients with juvenile idiopathic arthritis (JIA), and patients with JIA, regarding the choice of medication.  SDM aims to ensure medication choices match families’ goals and preferences.  A treatment plan that is a good fit may be more reliably implemented at home, leading to better health outcomes.  This project aimed to develop reliable care processes within a subset of centers in the Pediatric Rheumatology Care & Outcomes Improvement Network (PR-COIN) to 1) identify patients with JIA facing a decision to start or switch medicine, 2) provide SDM support during visits with our JIA ‘medication discussion cards’ that we developed and 3) measure the outcomes that accrue.  Tests of implementation strategies across sites followed the Model for Improvement. 

Methods

Volunteer PR-COIN sites employed iterative Plan-Do- Study-Act cycles to reliably implement the materials.  To track the quality of interaction and the fidelity of use with the SDM cards, sites collected a short, voluntary, anonymous survey from parents after the visit.  The post-visit survey contained information from two validated scales: 1) CollaboRATE is a 3-item measure of SDM (scale range 0 -100).  2) SURE is a 4-item measure of unmet decision support needs (scale range 0-4). The survey also contained 3 parent-report items that we developed with yes/no response options to assess the extent to which the decision aid cards were used as intended during the visit, or “fidelity of use.” The first fidelity item asks parents “Did you discuss starting or switching medicine to treat your child’s arthritis?”  The second item shows a picture of the cards and asks “Did your clinician show you the tool (pictured) during your visit?” The third item asks, “If “yes”, did your clinician ask you to pick the first topic to discuss?” Outcomes were tracked on run charts including: proportion of eligible patient visits where ‘JIA medication discussion cards’ were used, percent of card use visits with cards used as intended. Separate run charts depict the weekly mean score for each proximal decisional outcome measure. 

Results

78 surveys were collected from 3 sites from March – June 2014.  Decision aid cards were used in 33% of visits where a parent reported a medication start/switch.  Cards were used as intended during 71% of visits.  There was a ceiling effect with both outcome measures.  CollaboRATE scores were 100 for all but 3 parents, one who reported card use and two who did not.  75 of 78 parents had maximal SURE scores; the two parents with the greatest number of unmet decisional needs did not report use of the cards. 

Conclusion

Uptake of decision aid cards was achieved in approximately 1/3 of visits where a parent reported a medication start or switch.  When cards were used, there was moderate fidelity (71%) to intended use.  Due to ceiling effects it was difficult to estimate if the use of cards was associated with improved proximal decisional outcomes.  Next steps are to collect a different measure of decisional quality and expand the number of sites assessing outcomes, including a control site. We will develop and test new approaches with PDSAs to increase reliability and fidelity of use.

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« Back to 2014 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/towards-reliable-implementation-and-optimal-use-of-medication-decision-aid-cards-for-shared-decision-making-in-juvenile-idiopathic-arthritis/