title: How does decision complexity affect shared decision making? An analysis of patient-provider antiretroviral initiation dialogue.
abstract: This study analyzed patient-provider dialogue regarding anti-retroviral therapy (ART) initiation, assessing the degree to which shared decision making (SDM) occurred.
  
  
  
  We analyzed 24 audio-recorded dialogues between 14 HIV providers and their patients regarding ART initiation. We coded transcribed dialogues for seven SDM elements. We stratified dialogues into three levels of decision complexity (basic, intermediate, complex) based on patient CD4 counts and evaluated SDM criteria fulfillment at each level of decision complexity.
  
  
  
  There were five basic, twelve intermediate, and seven complex decisions in our sample. While only two met the defined criteria for SDM, the mean number of SDM elements present increased with each level of decision complexity. Discussion of the clinical issue requiring the decision occurred most frequently (88%), while discussion of pros/cons (13%), patient's understanding (21%), and decision alternatives (29%) occurred least frequently.
  
  
  
  While few dialogues met the defined SDM criteria, providers are having conversations that respond to decision complexity. Clinicians should be aware that discussion of pros/cons, alternatives, and uncertainties are frequently skipped, even when these elements are clearly relevant, as in complex decisions. In addition, rhetorical questions to assess patient preferences and understanding are insufficient to fully engage patients in SDM.
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address: wcallon1@jhmi.edu.
authors.forename: Wynne
authors.initials: W
authors.lastname: Callon
authors.affiliation: Portland VA Medical Center, Portland, OR, USA; Department of Medicine, Oregon Health Sciences University, Portland, OR, USA.
authors.forename: Somnath
authors.initials: S
authors.lastname: Saha
authors.affiliation: Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
authors.forename: Ira B
authors.initials: IB
authors.lastname: Wilson
authors.affiliation: Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
authors.forename: Michael Barton
authors.initials: MB
authors.lastname: Laws
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Michele
authors.initials: M
authors.lastname: Massa
authors.affiliation: Department of Medicine, Oregon Health Sciences University, Portland, OR, USA.
authors.forename: P Todd
authors.initials: PT
authors.lastname: Korthuis
authors.affiliation: Saint-Lukes Roosevelt, New York, NY, USA.
authors.forename: Victoria
authors.initials: V
authors.lastname: Sharp
authors.affiliation: Department of Medicine, Wayne State University, Detroit, MI, USA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Cohn
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Richard D
authors.initials: RD
authors.lastname: Moore
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Mary Catherine
authors.initials: MC
authors.lastname: Beach
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D003142:Communication; D003657:Decision Making; D003661:Decision Support Techniques; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D008875:Middle Aged; D010358:Patient Participation; D057240:Patient Preference; D010817:Physician-Patient Relations
chemical_list: D044966:Anti-Retroviral Agents
keywords: Antiretroviral initiation; HIV/AIDS; Patient-provider communication; Shared decision making