title: Real life clinic visits do not match the ideals of shared decision making.
abstract: OBJECTIVE
  To use observation to understand how decisions about higher-risk treatments, such as biologics, are made in pediatric chronic conditions.
  
  
  METHODS
  Gastroenterology and rheumatology providers who prescribe biologics were recruited. Families were recruited when they had an outpatient appointment in which treatment with biologics was likely to be discussed. Consent/assent was obtained to video the visit. Audio of the visits in which a discussion of biologics took place were transcribed and analyzed. Our coding structure was based on prior research, shared decision making (SDM) concepts, and the initial recorded visits. Coded data were analyzed using content analysis and comparison with an existing model of SDM.
  
  
  RESULTS
  We recorded 21 visits that included discussions of biologics. In most visits, providers initiated the decision-making discussion. Detailed information was typically given about the provider's preferred option with less information about other options. There was minimal elicitation of preferences, treatment goals, or prior knowledge. Few parents or patients spontaneously stated their preferences or concerns. An implicit or explicit treatment recommendation was given in nearly all visits, although rarely requested. In approximately one-third of the visits, the treatment decision was never made explicit, yet steps were taken to implement the provider's preferred treatment.
  
  
  CONCLUSIONS
  We observed limited use of SDM, despite previous research indicating that parents wish to collaborate in decision making. To better achieve SDM in chronic conditions, providers and families need to strive for bidirectional sharing of information and an explicit family role in decision making.
authors.affiliation: Division of Adolescent Medicine, Center for Innovation in Chronic Disease Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; University of Cincinnati College of Medicine, Cincinnati, OH. Electronic address: ellen.lipstein@cchmc.org.
authors.forename: Ellen A
authors.initials: EA
authors.lastname: Lipstein
authors.affiliation: Division of Adolescent Medicine, Center for Innovation in Chronic Disease Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
authors.forename: Cassandra M
authors.initials: CM
authors.lastname: Dodds
authors.affiliation: Division of Adolescent Medicine, Center for Innovation in Chronic Disease Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; University of Cincinnati College of Medicine, Cincinnati, OH.
authors.forename: Maria T
authors.initials: MT
authors.lastname: Britto
mesh_terms: D000293:Adolescent; D000328:Adult; D000553:Ambulatory Care; D002648:Child; D002675:Child, Preschool; D002908:Chronic Disease; D003657:Decision Making; D005260:Female; D005762:Gastroenterology; D006801:Humans; D007223:Infant; D008297:Male; D010358:Patient Participation; D018802:Patient-Centered Care; D010817:Physician-Patient Relations; D010820:Physicians; D012219:Rheumatology; D055815:Young Adult