The OPTION scale for the assessment of shared decision making (SDM): methodological issues

doi:10.1016/j.zefq.2012.03.002

Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen

Volume 106, Issue 4, 2012, Pages 264-271

https://doi.org/10.1016/j.zefq.2012.03.002 Get rights and content

Summary

Background

Promoting patient involvement in medical decision making has become a desirable goal in medical consultations. Reliable and valid measures are necessary to evaluate interventions designed to promote shared decision making and to understand determinants and associations. The OPTION (“observing patient involvement”) scale is the most prominent observation instrument for assessing the extent to which clinicians actively involve patients in decision making.

Objective

This paper discusses psychometric and methodological characteristics of the OPTION scale.

Results

There is little support for the purported unidimensional structure. Although reliabilities are acceptable, results are highly heterogeneous across studies. There is also little evidence concerning validity. In particular, studies mainly failed to support convergent validity. Additional issues pertain to lack of item independence, restriction of range, and failure to consider dyadic aspects.

Conclusions

Given these findings, a number of methodological and conceptual issues still need to be addressed for the effective measurement of patient involvement. Directions for future research are discussed.

Zusammenfassung

Hintergrund

Die Beteiligung von Patienten an medizinischen Entscheidungen ist zu einem wichtigen Qualitätsmerkmal in Konsultationen geworden. Die Evaluation von Interventionen zur Förderung partizipativer Entscheidungsfindung und Forschung zum Verständnis von Determinanten effektiver medizinischer Entscheidungsfindung verlangt reliable und valide Messinstrumente. OPTION ist das am weitesten verbreitete Beobachtungsinstrument zur Erfassung des Ausmaßes, in dem Ärzte ihre Patienten aktiv an der Entscheidungsfindung beteiligen.

Ziel

In dieser Arbeit werden psychometrische und methodologische Aspekte der OPTION-Skala diskutiert.

Ergebnisse

Für die angenommene einfaktorielle Struktur gibt es keine klare Evidenz. Die Reliabilitäten liegen meist im akzeptablen Bereich, sind über verschiedene Studien heterogen. Die Validität ist kaum belegt. Insbesondere die konvergente Validität von OPTION konnte nicht bestätigt werden. Als weitere Probleme werden Abhängigkeiten zwischen Items, geringe Streuung in den OPTION-Werten und die fehlende Berücksichtigung dyadischer Aspekte identifiziert.

Schlussfolgerungen

Die Übersicht verweist auf verschiedene konzeptuelle und psychometrische Probleme, die in zukünftigen Untersuchungen berücksichtigt werden müssen. Es werden Anregungen für weitere Forschungsarbeiten gegeben.

Introduction

The relevance of patient involvement in medical consultations is widely acknowledged [1], [2]. Shared decision making (SDM) appears to be effective in producing better psychological outcomes as well as in increasing patient satisfaction [3], [4], [5]. Given the importance of patient involvement in medical decision making, it is vital that precise measures are developed to evaluate the performance of clinicians with regard to SDM. However, a gold standard is missing, and an appraisal of the appropriateness of existing instruments must be made based on psychometric properties, whereas validity is a matter of debate [6] (and Scholl in this issue).

The OPTION (“observing patient involvement”) scale [7], [8] represents the currently by far most prominent measure. Due to the OPTION scale's role amongst the instruments in the field and its widespread use in evaluating medical decision making processes, a thorough methodological appraisal of the scale is needed. This paper discusses relevant issues in this regard, in particular those relating to factor structure and internal consistency, agreement across raters, validity, and feasibility aspects. We will proceed with a description of the measure, a review of studies that used the OPTION while focussing on factor structure, reliability, and validity, a discussion of other issues (feasibility and utility, restriction of range, item independence, and consideration of dyadic aspects) and finish with an evaluation and recommendations for improvement.

Section snippets

The OPTION scale

OPTION is an observation-based measure which aims to assess the extent to which clinicians involve patients in medical decision making during consultations. OPTION was developed based on a review of instruments, a theoretical framework, and qualitative studies involving patients and general practitioners [7]. The scale consists of 12 items, each assessed on a five-point scale, ranging from “the behaviour is not observed” to “the behaviour is exhibited to a very high standard” [8]¹

Review of studies employing OPTION

Relevant studies were identified through searches of the PsycINFO, PubMed, Science Citation Index, and Social Science Citation Index databases for the years 2003 – 2011 using the search terms “OPTION”, “shared decision making”, and “patient involvement”. Moreover, a forward search was conducted on the basis of articles that cite one of the original studies [5], [8]. Finally, websites of relevant journals were searched for articles in press. This search strategy led to the identification of an

Factor structure and internal consistency

While a unidimensional structure has been claimed by the originators of the OPTION scale, few studies have tested this assumption. In a semi-exploratory principal components analysis (PCA) on the initial version of the scale, a single factor was extracted which explained 35% of the variance [7]. However, neither fit statistics nor eigenvalues were reported, making it impossible to judge whether a different number of factors might better describe the data. Using PCA on the revised OPTION, Elwyn

Agreement across raters

Another important issue concerns whether different raters arrive at similar conclusions when rating the same object. Various measures exist to capture inter-rater reliability, including Cohen's kappa and the Intraclass Correlation Coefficient (ICC). Comparisons of the inter-rater reliabilities reported in different studies are complicated by the fact that different types of ICCs exist [18]. If every rating object is rated by various raters and the scores of the raters are aggregated, mean

Validity

The comparison of the OPTION scale with other scales with similar purposes is important. Given the lack of a gold standard, validity can only be determined indirectly. Demonstration of convergent validity is one reasonable approach. According to Campbell and Fiske [21] and others [22], measurements of the same construct made by different methods should converge. Thus, OPTION should correlate with measures of patient involvement reflecting the patient perspective. With respect to

Feasibility and utility aspects

Discrepancies between raters, usually appearing during OPTION training, have to be discussed until consensus is achieved. The OPTION manual is supposed to provide guidance in this regard by stating concrete rules or examples. However, these clarifications are often incomplete. For instance, for item 12, “The clinician indicates the need to review the decision (or deferment)”, a score of ‘3’ indicates that “The behaviour is performed to a good standard” while a ‘4’ indicates that “The behaviour

Conclusions and recommendations

Patient involvement is an important construct that addresses the broader concept of medical decision making. Medical decision making is a complex process involving many different factors which complicates quantitative assessment. Valid assessment of patient involvement seems to be an elusive goal [43]. In this study, OPTION was selected for a review of methodological issues because it is currently the most prominent measure for the assessment of clinician-patient involvement. Psychometric

Conflict of interest

No conflicts of interest have been declared.

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The OPTION instrument was used to measure SDM [9]. OPTION is the most widely used SDM measurement tool [10,2] and scores 12 aspects of physician consultation behavior (related to framing a decision, listing options, eliciting values and deliberating the choice) using a 5-point score ranging from 0 (no evidence of SDM-related behaviour) to 4 (high standard of behaviour) [9]. The tool is highly reliable with inter-rater intraclass correlation coefficient of 0.62, inter-agreement kappa scores of 0.71 and Cronbach’s alpha of 0.79 [9].
To measure the level of shared decision-making (SDM) in primary care consultations in Malaysia, a multicultural, middle-income developing country.
A cross-sectional study was conducted in an urban, public primary care clinic. Convenience sampling was used to recruit participants, and audio-recorded consultations were scored for SDM levels by two independent raters using the OPTION tool. Univariate and multivariate analysis was conducted to determine factors significantly associated with SDM levels.
199 patients and 31 doctors participated. Mean consultation time was 14.3 min (+ SD 5.75). Patients’ age ranged from 18 to 87 years (median age of 57.5 years). 52.8 % of patients were female, with three main ethnicities (Malay, Chinese, Indian). The mean OPTION score was found to be 7.8 (+ SD 3.31) out of 48. After a multivariate analysis, only patient ethnicity (β= -0.142, p < 0.05) and increased consultation time (β = 0.407, p < 0.01) were associated with higher OPTION scores.
Patients in Malaysia experience extremely poor levels of SDM in general practice. Higher scores were associated with increased consultation time and patient ethnicity.
Malaysian general practitioners should aim to develop and practice cultural competency skills to avoid biased SDM practice towards certain ethnicities.
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Anyway, the use of the OPTION12 scale for training purposes is still controversial. For example, while Goss et al. [28] stated that Option scale can aid “both teaching purposes and research”, according to Nicolai et al. [52] “while OPTION seems well suited for research purposes involving group comparisons, it may have less utility in education, training, and clinical supervision”. The low involvement of our patients by clinicians, may indicate key barriers in using SDM according to previous studies [48,53].
Shared decision-making (SDM) may help to reduce the rate of Cesarean Delivery (CD). The aim of the study was to evaluate the extent to which pregnant women are involved in SDM about the mode of delivery, applying the Italian version of the OPTION¹² scale to obstetric consultations.
Fifty-eight outpatient consultations were rated; statistical associations between OPTION¹² scores and sociodemographic data of both patient and physicians were determined.
The OPTION¹² total scores showed a skewed distribution in the lower range of total scores. Total scores in a percentage basis ranged from 0 to 69, with a mean of 21.2 (±19.84) and a median of 13.5. Mean and median scores for all the 12 OPTION¹² items never reached the minimum skill level.
A low level of patient involvement in deciding between a CD and a Vaginal Delivery (VD) was demonstrated. Interventions aiming at educating obstetricians as well as the adoption of decision aids are requested.
The OPTION¹² scale may prove useful for testing the extent of pregnant women’s involvement in deciding between CD and VD. The awareness of a low patient involvement seems mandatory to improve SDM and may lead to medico-legal protection.
Occupational therapists' shared decision-making behaviors with patients having persistent pain in a work rehabilitation context: A cross-sectional study
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The meetings were not audio-taped, and an live observer rated the encounter [38]. Previous research reported that audio recordings seem to reduce identification of SDM behaviors compared to videos/observations [39,40]. Therefore, we are confident that our scores were not inflated due to the rating method.
In a work rehabilitation context, we assessed occupational therapists’ (OTs) shared decision-making (SDM) behaviors with individuals having persistent pain and explored factors influencing SDM behaviors.
A cross-sectional study that used audio-recordings of work rehabilitation consultations between OTs trained in SDM and a convenient sample of patients. Eligible patients were: off work for ≥12 weeks due to persistent pain associated with a musculoskeletal disorder, starting a work rehabilitation program, and French speaking. Transcripts were analyzed using the Observing Patient Involvement in Shared Decision Making (OPTION) instrument and assessed patients’ decisional conflict and socioeconomic status.
Of 15 OTs trained in SDM, 11 (90% female), provided audiotaped SDM meetings with 37 patients (40.5% female; aged 18–62 years). Their average OPTION score was 53.94 out of 100 (SD = 9.68; range 35.42–70.83), indicating basic skills. Significant factors associated with OPTION scores ( $R_{adjusted}^{2} = 21.7 %$ ) were the interview length (p = 0.008) and level of patient education (p = 0.038).
Basic SDM behaviors were integrated in the practice of OTs trained in SDM.
Evaluating SDM behaviors is a step toward providing OTs with performance feedback toward achieving client-centered care.
Measurement of patient involvement - What do concepts of psychotherapy research contribute?
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The article comments on Shared Decision Making (SDM) research from a different perspective, i.e. psychotherapy research. Psychotherapy research had to face similar challenges, both conceptual as well as methodological. Meanwhile, the generic model of psychotherapy has helped researchers to put single results into a perspective that also might be helpful to the SDM field. Since SDM research increasingly focuses upon process perspectives directed towards the doctor-patient dyad, we propose measures and constructs from interpersonal theory as useful tools to be introduced into SDM research. A selection of these measures and their potential within SDM research is described.
Der Beitrag kommentiert SDM-Forschung aus einer anderen Perspektive, nämlich jener der Psychotherapieforschung. Die Psychotherapieforschung sah sich ähnlichen konzeptuellen wie methodischen Herausforderungen gegenüber, wie sie derzeit im Zusammenhang mit SDM diskutiert werden. Mittlerweile hat beispielsweise ein Allgemeines Modell von Psychotherapie („generic model of psychotherapy“) dazu beigetragen, dass Einzelbefunde besser integriert werden können. Ein analoges Modell könnte für die SDM-Forschung hilfreich sein. Da in diesem Bereich der Forschung mehr und mehr auf Prozessaspekte geachtet wird, die auf dyadische Gesichtspunkte fokussieren, werden als nützliche Hilfsmittel hierfür Instrumente und Konstrukte aus der interpersonalen Theorie vorgeschlagen, die vermehrt in die SDM-Forschung integriert werden könnten. Eine Auswahl dieser Methoden und ihr Potenzial im Kontext von SDM werden skizziert.
Of blind men and elephants: Suggesting SDM-MASS as a compound measure for shared decision making integrating patient, physician and observer views
2012, Zeitschrift fur Evidenz, Fortbildung und Qualitat im Gesundheitswesen
Citation Excerpt :
The next best alternative to MAPPIN'SDM, the expanded Dyadic OPTION system [19], does not comprise an observer scale assessing the SDM performance of the doctor-patient dyad. Moreover, it carries on most of the theoretical shortcomings of its unilateral predecessor [9,27]. Therefore, it would not have been reasonable to build SDMMASS based on components drawn from the OPTION system.
Shared decision making (SDM) between patient and physician is an interpersonal process. Most SDM measures use the view of one party (patient, physician or observer) as a proxy to capture this process although these views typically diverge. This study suggests the compound measure SDM_MASS (SDM Meeting its concept's ASSumptions) integrating these three perspectives in one single index.
SDM_MASS was derived theoretically and compared empirically to unilateral perspectives of patients, physicians and observers by application to a data set of 10 physicians (40 consultations) receiving an SDM training.
The constituting parts of SDM_MASS were highly reliable (Cronbach's alpha .94; interrater reliability .74-.87). Unilateral appraisal of training effects was divergent. SDM_MASS revealed no effect.
SDM_MASS combines noteworthy information about SDM processes from different viewpoints and thereby delivers plausible assessments. It could overcome immanent shortcomings of unilateral approaches. However, it is a complex measure needing further validation.
Shared Decision Making (SDM) zwischen Patient und Arzt ist ein interpersonaler Prozess. Die meisten SDM-Messinstrumente verwenden die Sichtweise einer der Parteien Patient, Arzt und Beobachter als Surrogatparameter für diesen Prozess, obwohl die unilateralen Maße typischerweise divergieren. Diese Studie stellt das SDM-Verbundmaß SDM_MASS (SDM Meeting its concept's ASSumptions) vor, das diese drei Perspektiven in einem einzigen Index bündelt.
SDM_MASS wurde theoretisch hergeleitet und anhand eines bestehenden Datensatzes von 10 Ärzten (40 Konsultationen), die ein SDM-Training durchliefen, mit den unilateralen Perspektiven von Patient, Arzt und Beobachter empirisch verglichen.
Die konstituierenden Teile von SDM_MASS waren hoch reliabel (Cronbach's alpha .94; Interrater-Reliabilität .74 bis .87). Die unilaterale Bewertung von Trainingseffekten war divergent. SDM_MASS offenbarte keinen Effekt.
SDM_MASS kombiniert notwendige Informationen über SDM-Prozesse aus unterschiedlichen Blickwinkeln und liefert damit plausible Ergebnisse. Es könnte immanente Schwächen unilateraler Ansätze überwinden. Allerdings ist es ein in der Anwendung komplexes Maß, das weiterer Validierung bedarf.

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SchwerpunktThe OPTION scale for the assessment of shared decision making (SDM): methodological issuesDie OPTION-Skala zur Erfassung Partizipativer Entscheidungsfindung: methodische Aspekte

Summary

Background

Objective

Results

Conclusions

Zusammenfassung

Hintergrund

Ziel

Ergebnisse

Schlussfolgerungen

Introduction

Section snippets

The OPTION scale

Review of studies employing OPTION

Factor structure and internal consistency

Agreement across raters

Validity

Feasibility and utility aspects

Conclusions and recommendations

Conflict of interest

Social Science & Medicine

Patient Educ Couns

Patient Educ Couns

Patient Education and Counseling

Patient Educ Couns

Patient Educ Couns

Patient Education and Counseling

Patient Educ Couns

Patient Education and Counseling

Patient Educ Couns

Patient Educ Couns

Patient Education and Counseling

Journal of Mathematical Psychology

Social Science & Medicine

Social Science & Medicine

Patient Educ Couns

Patient Educ Couns

Patient Educ Couns

Soc Sci Med

The meaning of patient involvement and participation in health care consultations: A taxonomy

Social Science & Medicine

Patient participation in deciding breast cancer treatment and subsequent quality of life

Med Decis Making

Decisional regret and quality of life after participating in medical decision-making for early-stage prostate cancer

BJU Int

Self-reported use of shared decision-making among breast cancer specialists and perceived barriers and facilitators to implementing this approach

Health Expect

Shared decision making: developing the OPTION scale for measuring patient involvement

Quality and Safety in Health Care

The OPTION scale: measuring the extent that clinicians involve patients in decision making tasks

Health Expectations

Schwerpunkt
The OPTION scale for the assessment of shared decision making (SDM): methodological issuesDie OPTION-Skala zur Erfassung Partizipativer Entscheidungsfindung: methodische Aspekte