Background
Over the last years, there has been a shift in physician-patient communication away from the paternalistic model of decision-making towards shared processes between physicians and patients [
1,
2]. In the paternalistic model of decision-making, the physician is characterized as information keeper, who makes decisions for the patient in the intention to know what is best for the patient [
1]. Shared decision-making (SDM) is defined as a collaborative process that allows a patient and his/her provider(s) to make health care decisions together based on shared clinical and psychosocial information and the best available evidence [
3].In the course of this process, the provider(s) support(s) the patient to engage in deliberation about the different diagnostic or treatment options in order to come to a shared and informed decision in concordance with the patient’s informed preferences [
3].
To evaluate whether SDM has been implemented in health care, the physicians’ communicative skills for sharing information and for involving patients in the decision-making process have to be assessed. Therefore, the development and psychometric testing of observer rating scales that evaluate whether SDM took place is essential to allow standardised evaluation of physician-patient communication.
Although preferences for participation in decision-making differ between patients with different diagnoses, most patients want to be involved if more than one treatment option exists [
4‐
6]. SDM is positively associated with patient outcomes (e.g., knowledge, satisfaction, decisional conflict, trust) [
7]. Despite patients’ preferences for SDM and its positive effects on patient outcomes, it is still not well implemented in routine practice [
5,
8]. The discrepancy between patients seeking involvement and physicians obstructing this involvement can be analysed from a patient’s, a physician’s and an observer’s point of view [
9,
10]. Observer rating can provide a general estimate of the involvement of both parties and permits an objective assessment of the SDM process in a consultation. Several observer rating scales exist in English, e.g. the Observer OPTION
12,the Rochester Participatory Decision Making Scale, the Brief Decisison Support Analysis Tool, and the Decision Analysis System for Oncology [
10].
So far the Observer OPTION
12 (OPTION scale - observing patient involvement) is the only internationally widely used observer measure available in German language [
10]. Until now the Observer OPTION
12 is a frequently applied observer measure to assess SDM. The Observer OPTION
12 can be used by trained observers to assess SDM during a consultation, in communication trainings or in research using recorded consultations. In the development of new scales Observer OPTION
12 has been often used as a comparator scale to assess validity [
11,
12]. Despite its wide use, psychometric testing of Observer OPTION
12 revealed a great variation in reliability across different studies [
13], and the necessity for improvements concerning specific items. Several items of Observer OPTION
12 (mainly focusing on the degree of exploration of the patient’s preferences and checking the patient’s understanding) were rarely observed (i.e. mainly rated 0) or not specific for SDM [
14]. Other items were revised or combined [
14]. This led to the development of Observer OPTION
5 as a shorter and revised version of Observer OPTION
12 [
14]. For the development of Observer OPTION
5 published models were analysed to identify the core components of a conceptual framework of SDM. By using this framework, which includes data from an observational study of clinical practice in Canada and the existing experience of using Observer OPTION
12, Observer OPTION
5 was developed [
14]. Observer OPTION
5 focuses on the core aspects of SDM and is shorter with only 5 items. Thus, the scale may be less time-consuming and easier to implement in clinical settings [
14]. Furthermore, the scale also assesses patient contribution to the decision-making process unlike the Observer OPTION
12, which only assesses the physician’s contribution to the process. Both measures are described in more detail in the
Methods section.
Psychometric testing of the English version of Observer OPTION
5 showed adequate concurrent validity with Observer OPTION
12 (
r = 0.61), intra-rater reliability (
r = 0.93) and inter-rater agreement (ICC = 0.67) [
15]. A Dutch version reached comparable results with good inter-rater agreement (k = 0.68) and a positive correlation with Observer OPTION
12 (
r = 0.71) [
16]. Based on results of these prior studies on the English and Dutch versions, we hypothesised that the German Observer OPTION
5 version would reach comparable results [
15,
16].
This study aimed to establish a German version of Observer OPTION5 and to test its psychometric characteristics.
Discussion
In this study a German version of the Observer OPTION
5 scale was developed and psychometrically tested. As part of a secondary data analysis, audio recordings of primary care consultations were evaluated independently by two raters with the German Observer OPTION
5. Comparable results to the English and Dutch version were hypothesised [
15,
16]. The testing of the German version of Observer OPTION
5 showed excellent inter- and intra-rater reliability on the total score levels (0.82 and 0.83). On the item level, the inter-rater and intra-rater reliabilities were moderate to excellent (0.45–0.86). No item was rated higher than three (=skilled effort), leading to a left-skewed distribution, which is comparable to the first psychometric testing of Observer OPTION
5 [
15]. This result might be influenced by the physician sample, as none of the participating physicans had any particular training in SDM. A systematic review on studies using Observer OPTION
12 found similarly low ratings in untrained healthcare providers [
22].
The results regarding reliability are comparable to the first psychometric testing of the original English version of Observer OPTION
5 (ICC = 0.67) [
15] and the psychometric testing of the Dutch version (k = 0.68) [
16]. These high inter-rater reliability results (ICC = 0.82) in this study compared to inter-rater agreement (ICC = 0.67) in the first Observer OPTION
5 testing of the English version [
15] may be due to differences in the determination of the relevant decision. In the study at hand, mostly one main decision was dealt with in the consultations. In other studies, vague or many decisions within one consultation may cause lower inter-rater agreement, because raters might not focus on the same issue. The assessment of concurrent validity of the German Observer OPTION
5 scale compared to Observer OPTION
12 showed a moderately positive correlation. While the concurrent validity using a correlation to Observer OPTION
12 (
r = 0.47) is a bit lower than in the two other studies (
r = 0.61;
r = 0.71) [
15,
16], we still found a significant moderate positive correlation [
24], which is in line with our hypothesis. The comparatively smaller correlation might be influenced by the low variance in the Observer OPTION
5 scores, which is known to deteriorate measures of association (also referred to as the ‘restriction of range’ problem).
These psychometric results indicate that the German version of Observer OPTION
5 is a reliable and valid rating scale. It is the shortest available observer rating scale for SDM. This scale can be used to assess SDM in physician-patient-communication and to evaluate physicians’ communication skills. Furthermore, as suggested by Barr and colleagues [
15], the Observer OPTION
5 could possibly be used in communication trainings for physicians as a feedback tool to improve physicians’ SDM skills. However, further research the measure’s potential use as training tool is necessary.
A main strength of this study was the widespread assessment of psychometric properties including inter-rater, intra-rater and concurrent validity of the newly adapted German Observer OPTION5. Since testing showed positive agreement between the German Observer OPTION5 scale and the previous Observer OPTION12 scale, the German Observer OPTION5 was shown to be feasible for use as an observer rating scale in German speaking countries.
A limitation of this study is that the evaluated data showed low variance. The items were mostly rated with no effort (0) or minimal effort (1). Nevertheless, this study reached good psychometric results for inter-rater agreement, intra-rater agreement and concurrent validity. Furthermore, the psychometric properties of the German version of Observer OPTION
5 were tested in an primary care setting with encounters focussing mainly on three chronic conditions. Generalizability beyond this setting is limited. Whenever a measure is used in a different setting, a different patient group or a different country psychometric properties should be re-established [
25]. Future studies should investigate other psychometric properties like responsiveness in order to establish a scale that can be used in intervention studies in the future. It would also be important to test Observer OPTION
5 with a sample of physicians trained in SDM, in order to assess whether this leads to a higher variation of items distribution than in the present study.