As the patient-facing roles of pharmacists increase in practice, pharmacists need to develop effective consultation skills. This includes a patient-centred approach and shared decision making (SDM). For effective SDM, patients should be well-informed about options, evaluate the benefits versus risks and integrate these with their values. The discrete choice experiment (DCE) is a tool which structures a decision problem into an attribute-based framework and asks individuals to value options in a series of choices, highlighting the concept of trade-offs inherent in healthcare decisions. They have been used extensively to value patient experiences in healthcare, including pharmacy services. The mechanism underlying a DCE gives it a potential role as a decision aid tool (DAT)
This study aims to employ DCE methodology to develop and pilot a personalized computer-based decision aid tool (DAT) to facilitate shared decision making (SDM) within a pharmacist-led consultation. The context will be the management of non- malignant chronic pain.
The study objectives are to:
- Identify existing DATs on non-malignant chronic pain.
- Define and characterise attributes and associated levels that are important in the management of non-malignant chronic pain.
- Develop a multimedia information package on chronic pain and available treatment based on a patient information booklet produced by the Scottish Intercollegiate Guidelines Network (SIGN).
- Design a personalised DCE to assess patients’ preferences for management of chronic pain based on findings from 1.
- Develop the DAT intervention tool by programming 2 and 3 into a computer-based application, thus generating information on the relative importance of attributes, trade-offs and utility/benefit scores for different treatment options.
- Conduct pilot testing of the DAT intervention tool to assess its usability.
- Conduct a pilot randomised trial to assess the acceptability of the DAT intervention tool, recruitment and retention rates, patient satisfaction with the pharmacist-patient interaction, and test outcome measures.
- Develop a protocol for a definitive study.
The context is the management of chronic pain, a condition of high prevalence in which pharmacists are increasingly involved. In practice, the success of pain interventions (pharmacological and non-pharmacological) is assessed by reductions in pain intensity. This may not be the most important outcome to patients. Our research has shown that pain management involves patients making trade-offs between reductions in pain intensity, medication side effects, physical activity, and competing external (e.g. social and employment) goals. Further, each individual will have different experiences, health needs, expectations and treatment preferences. Thus SDM is crucial in chronic pain management.
This study will be conducted in three phases:
Phase 1 – literature review and qualitative interviews with patients, pharmacists and doctors to confirm what is important in the delivery of chronic pain treatment, and inform the DAT development.
Phase 2 – development and pre-testing of the DAT. The DAT will include multimedia information about chronic pain and a personalised-DCE component programmed to provide real-time feedback. Usability of the tool will be evaluated using think-aloud and eye-tracking methods as well as being user-tested in practice with five patient-pharmacist pairs. Necessary modifications will be made following the evaluation.
Phase 3 – a pilot randomised trial will assess the acceptability of the DAT, recruitment and retention rates, and patient satisfaction with the pharmacist-patient interaction, and test outcome measures. Ten pharmacists will be recruited and, in collaboration with GPs, each will recruit four patients with chronic pain. Pharmacists will be randomised to one of two groups; control group pharmacists will deliver care based on standard practice, while intervention group pharmacists will use the DAT. Randomisation will be at pharmacist level to minimise contamination. Update training on pain management (and how to use the DAT) will be provided prior to the trial. Outcomes of the intervention will be measured using the Decisional Conflict Scale (to capture decision making processes and satisfaction with choice), the Chronic Pain Grade (as measure of pain and functioning), Personal Well-being Scale and EQ-5D (to capture quality of life).
The study will produce a refined DAT tool for use in pharmacy, and by other healthcare professions, a training programme and a protocol for the conduct of a definitive RCT.