Objective: This study aimed to investigate how patients with chronic conditions evaluate telephone health coaching provided by their health insurance company.Methods: A retrospective survey was conducted among coaching participants (n=834). Outcomes included the general evaluation of the coaching, the evaluation of process and effects and the impact on patient-physician communication.Results: Participants' average age was 66.2 years and the majority were women (58.3%). The majority (78.3%) of the insured persons were satisfied with the coaching and 82.3% would recommend it to others. More than half of the participants (53.3%) had learned about new options to influence their health condition. Sub-group differences in the evaluation of the health coaching were found for age, gender and medical condition.Conclusion: Health coaching might be useful in supporting patients with chronic conditions. While the results indicate a general positive appraisal, a possibility for improvement could be a stronger focus on the individual situation and the imparting of specific skills. Target groups might be selected in a specified manner for the coaching, as older participants in need of specific care seem to benefit less from the approach. Longitudinal and controlled studies are needed to investigate clinical effects of health coaching.

Objective: To investigate how a German audience appraises an American video-based decision aid on early stage breast cancer for potential use in Germany.Methods: A German synchronized voice-over version was produced and subject to different focus groups with patients (n = 9), health care providers (n = 7) and German health care experts (n = 15) using an individual questionnaire-based evaluation and a moderated group discussion. Research questions included a general appraisal of the decision aid and the exploration of adaptation needs for use in Germany. Descriptive statistics were calculated and the qualitative data were analyzed applying an inductive approach to categorize the statements.Results: The general appraisal of the decision aid revealed positive results in all groups, especially with regard to comprehensible presentation of information and integration of patients' testimonials. However, cultural differences between the American decision aid and Germany were debated in all groups.Conclusion: Despite a high general interest and positive appraisal of the decision aid, the results of this study suggest that it cannot just be translated and used in another country.Practice implications: The decision aid needs further cultural adaptation and testing in an implementation study before it can be transferred to Germany. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

Objective: To evaluate the effectiveness of a web-based, individually tailored decision aid (Patient Dialogue) on depression or acute low back pain for insurees of a German sickness fund.Methods: Patient Dialogue (PD) was compared to the non-tailored Static Patient Information (SPI) in an online randomized controlled trial (RCT). The primary outcome was decisional conflict; secondary outcomes included knowledge, preparation for decision-making, preference for participation, involvement in decision-making, decision regret, and adherence.Results: Out of 2480 randomized participants, 657 (26.5%) provided analyzable data immediately after using the system. Three months later, data from 131 (5.3%) participants could be included in the analysis. The PD group reported a significantly lower overall decisional conflict than the SPI group (38.7 vs. 45.1; p = 0.028 via multiple imputation estimator). The largest standardized effect (Cohen's d 0.56) resulted from the preparation for decision-making (PD 59.4 vs. SPI 46.8; p < 0.001).Conclusion: PD may be an effective tool to reduce decisional conflict and prepare participants for treatment decision-making. However, the large dropout rate needs to be taken into account.Practice implications: This study shows how a health insurance fund can support shared decision-making and how a decision aid can be evaluated in a RCT under routine care conditions. (C) 2011 Elsevier Ireland Ltd. All rights reserved.

Shared decision making is an approach where clinicians and patients communicate together using the best available evidence when faced with the task of making decisions. The chapter presents an overview of current research that focuses on patient participation, the level to which patients want to be involved in medical decisions, and strategies that assess the measurement of these preferences. While most patients (> 80%) want detailed information and physicians often underestimate this need, some patients clearly indicate a strong preference to participate in decision making. Patients' preferences for participation can vary depending on factors such as age, gender, experience of illness, and relationship with the physician. At present, only a few psychometrically sound instruments are available to measure patients' preferences for participation.

ObjectiveValidation of the German version of the Autonomy-Preference-Index (API), a measure of patients' preferences for decision making and information seeking.MethodsStepwise confirmatory factor analysis was conducted on a sample of patients (n = 1592) treated in primary care for depression (n = 186), surgical and internal medicine inpatients (n = 811) and patients with minor trauma treated in an emergency department (n = 595). An initial test of the model was done on calculation and validation halves of the sample. Both local and global indexes-of-fit suggested modifications to the scale. The scale was modified and re-tested in the calculation sample and confirmed in the validation sample. Subgroup analyses for age, gender and type of treatment setting were also performed.ResultsThe confirmatory analysis led to a modified version of the API with better local and global indexes-of-fit for samples of German-speaking patients. Two items of the sub-scale, 'preference for decision-making', and one item of the sub-scale, 'preference for information seeking', showed very low reliability scores and were deleted. Thus, several global indexes-of-fit clearly improved significantly. The modified scale was confirmed on the validation sample with acceptable to good indices of fit. Results of subgroup analyses indicated that no adaptations were necessary.Discussion and conclusionsThis first confirmatory analysis for a German-speaking population showed that the API was improved by the removal of several items. There were theoretically plausible explanations for this improvement suggesting that the modifications might also be appropriate in English and other language versions.

Abstract Shared decision-making (SDM) was originally described as an approach for physician-patient communication in the context of health decisions for which several treatment options exist (Charles et al., 1997). Positive outcomes of SDM including increased patient knowledge, satisfaction, and treatment adherence have been reported for various “physical” health conditions, but less research has been done on SDM for mental health conditions. Research on SDM in mental health care is a high priority for quality-of-life, autonomy, and health outcomes reasons (Wills and Holmes-Rovner 2006b), and results of early studies are favourable regarding the potential of SDM to improve mental health care (Loh et al., 2007; Swanson et al., 2007). SDM is highly relevant in mental health care due to the presence of multiple treatment decision options and the preferences of many consumers to participate in decision-making (Hamann et al., 2005). With its focus on mutual information sharing and respect for individual preferences, SDM can be an empowerng experience, assisting mental health recovery for people who have encountered stigmatization and discrimination due to mental illness (Pinninti and Bokkala-Pinninti, 2007). In the US, the incorporation of mental health consumer preferences into person-centered treatment focused on recovery is supported by the President’s New Freedom Commission Report (Hogan, 2003). Consumer participation in decision-making is also advocated by international clinical practice guidelines for mental disorders, e.g. in the UK and Germany, as well as training manuals (Härter et al., 2007, Härter et al., 2008, NICE 2002; Lehman et al., 2004). Individual values, explicit negotiation, empowerment, and self-determination are essential values for the treatment of people with mental illness and have been in the focus of psychiatric rehabilitation for decades (Anthony, Cohen and Pierce 1980; Anthony, Cohen and Farkas 1999; Deegan and Drake 2006; Lazare, Eisenthal and Wasserman 1975). SDM is also consistent with a fundamental assumption that rehabilitation is done with the person and not to the person (Schauer, Everett and del Vecchio, 2007).

Objective: To develop and psychometrically test a brief patient-report instrument for measuring Shared Decision Making (SDM) in clinical encounters.Methods: We revised an existing instrument (Shared Decision Making Questionnaire; SDM-Q), including the generation of new items and changing the response format. A 9-item version (SDM-Q-9) was developed and tested in a German primary care sample of 2351 patients via face validity ratings, investigation of acceptance, as well as factor and reliability analysis. Findings were cross-validated in a randomly selected subsample.Results: The SDM-Q-9 showed face validity and high acceptance. Factor analysis revealed a clearly one-dimensional nature of the underlying construct. Both item difficulties and discrimination indices proved to be appropriate. Internal consistency yielded a Cronbach's alpha of 0.938 in the test sample.Conclusion: The SDM-Q-9 is a reliable and well accepted instrument. Generalizability of the findings is limited by the elderly sample living in rural areas of Germany. While the current results are promising, further testing of criterion validity and administration in other populations is necessary.Practice implications: The SDM-Q-9 can be used in studies investigating the effectiveness of interventions aimed at the implementation of SDM and as a quality indicator in health services assessments. (c) 2009 Elsevier Ireland Ltd. All rights reserved.

Die gesetzlichen Rahmenbedingungen für die ärztliche Tätigkeit haben sich durch die Gesundheitsreformen grundlegend verändert. Der vorliegende Sammelband widmet sich dem durch die Reformen hervorgerufenen Wandel im Arbeitsalltag und Selbstverständnis des Arztes sowie im Verhältnis zu seinen Patienten.

Pragmatic randomized trials are important tools for shared decision-making, but no guidance exists on patients' preferences for types of causal information. We aimed to assess preferences of patients and investigators toward causal effects in pragmatic randomized trials.We (a) held three focus groups with patients (n = 23) in Boston, MA; (b) surveyed (n = 12) and interviewed (n = 5) investigators with experience conducting pragmatic trials; and (c) conducted a systematic literature review of pragmatic trials (n = 63).Patients were distrustful of new-to-market medications unless substantially more effective than existing choices, preferred stratified absolute risks, and valued adherence-adjusted analyses when they expected to adhere. Investigators wanted both intention-to-treat and per-protocol effects but felt methods for estimating per-protocol effects were lacking. When estimating per-protocol effects, many pragmatic trials used inappropriate methods to adjust for adherence and loss to follow-up.We made four recommendations for pragmatic trials to improve patient centeredness: (1) focus on superiority in effectiveness or safety, rather than noninferiority; (2) involve patients in specifying a priori subgroups; (3) report absolute measures of risk; and (4) complement intention-to-treat effect estimates with valid per-protocol effect estimates.

In recent years shared decision making (SDM) has gained importance as an appropriate approach for patient-physician communication and health related decision-making. The benefits of SDMconcerning patient satisfaction, treatment adherence or reduction of decisional conflict have been shown in several studies using interventional approaches on both the patients’ and physicians’ side. This article introduces the Ottawa Decision Support Framework (ODSF) as a theory-based guidance for the design and evaluation of SDM interventions such as patient decision aids, training of health professionals or patient education. Its key elements are assessment of decisional needs, provision of decision support and evaluation of decision process and outcome. In addition this article presents an allocation of available psychometric instruments for measuring dimensions of the framework. Most of them stem from Englishspeaking countries and have been translated into German. The Ottawa Decision Support Framework can be used for the development of SDM interventions and associated evaluation strategies. Evaluation measures can be chosen from a variety of instruments, yet many of them still need to show their psychometric quality in further studies.

In recent years shared decision-making (SDM) has gained importance as an appropriate approach to patient-physician communication and decision-making. However, there is a conceptual variety that implies problems of inconsistent measurement, of defining relationships of SDM and outcome measures, and of comparisons across different studies. This article presents the results of a literature search of psychometric instruments measuring aspects of decision-making. Altogether 18 scales were found. The majority covers the patients' perspective and relates to preferences for information and participation, decisional conflict, self-efficacy as well as to the evaluation of decision-making process and outcomes. The scales differ widely in their extent of validation. Although this review is not exhaustive, it presents a variety of available decision-making instruments. Yet, many of them still need to show their psychometric quality for other settings in further studies.

Das Verfahren der partizipativen Entscheidungsfindung (PEF) bezieht die Patienten bei medizinischen Entscheidungen mit ein – ein Ansatz, mit dem bei unterschiedlichen Indikationen eine bessere Therapietreue und größere Behandlungseffekte zu erzielen sind. In einer kontrollierten randomisierten Studie in der Depressionsbehandlung konnte durch die PEF-Intervention eine höhere Patientenbeteiligung und Patientenzufriedenheit erzielt werden. Tat-sächlich waren es genau die Patienten, die stärker an der Entscheidungsfin-dung beteiligt waren, welche die Diagnose und die Behandlung der Depression besser akzeptierten, die Therapie zuverlässiger durchführten und so bes-sere klinische Behandlungsergebnisse erreichten. Aufgrund dieses Erfolgs ist es gerechtfertigt, nicht nur aus ethischen Erwägungen, sondern auch aus empirischen Gründen eine detailliertere Information der Betroffenen wie auch ihre stärkere Beteiligung bei Behandlungsentscheidungen zu fördern. Depressive

Patient participation within the German healthcare system is described at three different levels: the macro level as active patient influence on the regulation of medical care, the meso level in terms of institutions enhancing patient information and counselling, and the micro level focusing on the actual treatment decision-making process in the medical encounter. The main focus of the present publication is on the health care system-specific influences on patient participation in medical decision-making and on the current state of research and implementation of shared decision-making in Germany. We describe institutions promoting patient involvement, their aims and initiatives as well as recent changes in German legislation. Against the background of German health politics’ endorsement of patient participation the German Ministry of Health funded a research consortium with shared decision-making intervention projects in various disease areas. The present state of the intervention projects’ results is outlined as well as subsequently funded transfer projects and future perspectives of research grants. Supported by health politics and the utilisation of scientific evidence shared decision-making's transfer into practice is considered to be relevant to the German health care system.

Patient-centred depression care approaches should better address barriers of insufficient patient information and involvement in the treatment decision process. Additional research is needed to test the effect of increased patient participation on outcomes. The aim of this study was to assess, if patient participation in decision-making via a shared decision-making intervention leads to improved treatment adherence, satisfaction, and clinical outcome without increasing consultation time.Cluster-randomized controlled intervention study based on physician training and patient-centered decision aid compared to usual care in primary care settings in Südbaden region of Germany. Twenty-three primary care physicians treating 405 patients with newly diagnosed depression were enrolled. Patient involvement was measured with the patient perceived involvement in care scale (PICS) and a patient participation scale (MSH-scale). Patient satisfaction was measured by the CSQ-8 questionnaire. Treatment adherence was evaluated by patient and provider self-report. Depression severity and remission outcomes were assessed with the Brief PHQ-D.Physician facilitation of patient participation improved significantly and to a greater extent in the intervention compared to the control group. There was no intervention effect for depression severity reduction. Doctor facilitation of patient participation, patient-rated involvement, and physician assessment of adherence improved only in the intervention group. Patient satisfaction at post-intervention was higher in the intervention group compared to the control group. The consultation time did not differ between groups.A shared decision-making intervention was better than usual care for improving patient participation in treatment decision-making, and patient satisfaction without increasing consultation time. Additional research is needed to model causal linkages in the decision-making process in regard to outcomes.The study results encourage the implementation of patient participation in primary care of depression.