Objective: The aim of the study was to utilize a Filipino version of the 9-Item Shared Decision Making Questionnaire (SDM Q-9) to evaluate the extent to which a shared decision making process is implemented in the General Internal Medicine outpatient clinic of the Philippine General Hospital from the patient’s perspective.
Methodology: The English version of the SDM Q-9 was translated into Filipino and validated through focus group discussions (FGDs). The validated questionnaire was then fielded to patients who were consulting at the General Internal Medicine outpatient clinic of the Philippine General Hospital over 1 week.
Results: Two hundred thirty-six of 476 invited patients participated in the survey. The majority of the participants agreed that the different steps of the shared decision making process were being practiced in the General Internal Medicine outpatient clinic. More patients (6%) disagreed that identification of preferences, negotiation, and making a shared decision were done compared to the other steps of SDM (3%).
Conclusion: Based on their responses to the SDM Q-9 questionnaire, patients consulting at the General Internal Medicine outpatient clinic of the Philippine General Hospital agreed that shared decision making was being practiced in their clinical encounters with their respective physicians. Identification of preferences, negotiation and making a shared decision may need strengthening.
Keywords: Shared decision making, SDM, questionnaire, Philippines, primary care.
Citation: Mendoza MJ, Sacdalan DB, Palileo-Villanueva LA. Shared decision making at the general internal medicine outpatient clinic of the Philippine General Hospital: patient’s perspective. J Participat Med. 2016 Nov 3; 8:e14.
Published: November 3, 2016.
Competing Interests: The authors have declared that no competing interests exist.
Shared Decision Making (SDM) is an active and collaborative process of clinical decision making involving the patient and health care professional. It is a prototype of current models of patient-centered care, and emphasizes the special role of the patient as an active participant in his or her own health care rather than merely as a passive recipient.  An important prerequisite for SDM is the mutual exchange of information between the health practitioner and the patient. A growing body of evidence suggests that patient involvement in decision making helps improve their knowledge and healthcare experience and results in a more streamlined health service utilization and expenditure.  The goal of SDM is to ensure that patients and health practitioners arrive at medical decisions that are consistent with the former’s values and preferences. Moreover, the sense of sharing in the medical decision making process positively correlates with a patient’s satisfaction with the decision that is eventually made. 
Much of the care patients receive is based on the ability of the individual physician to provide it, rather than on widely agreed standards of best practice or patient’s preferences for treatment. In recent years, there has been a growing clamor for physicians to involve their patients in the medical decision making process citing ethical as well as economic (ie, cost-effectiveness) considerations in support of this change.
Since the 1980s, SDM has been advocated as an important component of good patient care, if not as an outright requirement of routine patient care.  However, the understanding of SDM varies across geographic, cultural, and economic boundaries.  Among developing countries, there is little experience with SDM and, within Asia in particular, there is limited knowledge about how to integrate SDM into everyday clinical practice. 
The SDM Q-9 is a six-point scale, nine-item questionnaire widely used as an instrument for measuring the extent to which a patient is encouraged to participate by his or her physician in the decision making process. It is based on the SDM model of Elwyn and colleagues and theories from psychology and decision analysis modification of the original OPTION scale.The SDM Q-9 can be used to gauge the effectiveness of interventions aimed at the implementation of SDM and as a quality indicator in health services assessment.  The original German version has been shown to have good acceptability, reliability and validity, and has since been translated into different languages including English, Korean, Persian, Spanish and Dutch.  In addition, it offers the possibility of comparing research results across countries particularly for the purposes of pooling data.
At present there are few published studies on this subject in the Philippines. The aim of this study is to utilize a Filipino version of the SDM Q-9 to measure the process of SDM at an outpatient clinic in a tertiary public university hospital in Manila, Philippines.
Phase I: Instrument Development
The authors translated the English version of the SDM Q-9 questionnaire to Filipino. This form was then back-translated by a third party to ensure fidelity to the original questionnaire. A total of three focus group discussions (FGDs) were conducted to determine comprehensibility and acceptability of the language used in the translated questionnaire. Input from participants was used to guide revisions until an acceptable version of each statement was reached.
The preliminary questionnaire was pretested at the General Internal Medicine outpatient clinic among a sample of participants similar in characteristics to the target population of the survey. No further changes were found necessary after pretesting. The pretested questionnaire was used in the survey.
The Philippine General Hospital, a tertiary care facility, is the teaching hospital of the University of the Philippines Manila. Its General Internal Medicine outpatient clinic services up to 225 patients per day (100 new and 125 continuity patients) and is attended by General Internal Medicine residents. New patients are seen for walk-in consultation and referrals from other clinics within the hospital for co-management or preoperative evaluation. Continuity patients are those that have been seen at least once before at the outpatient clinic, or those that have been previously admitted in the hospital and are seen for the first time at the clinic.
The questionnaire was pretested at the General Internal Medicine outpatient clinic for half a day in order to identify problems with the conduct of the survey. Pretesting at the clinic did not result in any changes in the questionnaire; however the venue for fielding was moved from the originally planned conference room adjacent to the main clinic to within the main clinic to facilitate distribution and retrieval of the questionnaires from respondents by the research team. A trained research assistant administered the pretested questionnaire at the General Internal Medicine outpatient clinic over a period of 5 weekdays (Tuesday to Monday), from 8 am to 5 pm.
Patients were invited to participate in the survey after their consultation with their physicians and prior to their discharge from the clinic by the clinic nurse. The residents who cared for the patients were not made aware of their patients’ participation in the study. Patients who were illiterate and those who refused to participate were excluded from the study. All the participants were assigned a control number and asked to fill-out an information sheet together with the SDM Q-9 questionnaire. A research assistant assisted those who had impaired vision (e.g. cataract, presbyopia) by reading the questions to them. Once completed, the forms were secured and filed for later encoding. All patient forms were secured in the investigators’ office to protect confidentiality.
Data Encoding and Analysis.
Data were encoded using Microsoft Excel™ software. Descriptive statistics (frequencies, mean, standard deviation) were computed. The mode and median for each item of the SDM Q-9 were also determined.
Two hundred thirty-six of the 476 patients (49.58%) seen at the General Internal Medicine outpatient clinic during the 1-week fielding took part in the study. The main reasons for nonparticipation were the emergent nature of some of the patient’s cases (they had to be brought to the emergency room for appropriate care), time constraints (patients had other appointments or clinics to visit), and refusal to answer the questionnaire. The mean age of the participants was 54 years (sd 13.41 years). Characteristics of the study participants are shown in the Table.
Descriptive Analyses of the SDM Q-9 Items
Figure 1 shows the frequency distribution of the responses to the SDM Q-9 questionnaire. A majority of the participants agreed that the different steps of the shared decision making process were being practiced in the General Internal Medicine outpatient clinic. More than 60% of the respondents answered “Completely Agree” for items 1, 3, 4, 5 and 9. Meanwhile, less than 60% responded with “Completely Agree” for items 2, 6, 7 and 8.
More than 6% of the respondents disagreed with items 6, 7 and 8. For item 6 in particular, almost 5% of the patients answered “Completely Disagree.” This is more than twice the average of the “Completely Disagree” scores compared to the other items. These three items accounted for the actual decision making steps in the physician-patient encounter.
Since treatment decisions would most likely occur during the initial clinic visit, a post-hoc analysis of the responses of new (walk-in) patients was performed to see how these patients viewed the practice of SDM in the clinic. The frequency distribution of the responses was also determined for this particular subgroup (Figure 2). More than 60% of new (walk-in) patients answered “Completely Agree” for items 4, 5 and 9. On the other hand, more than 9% of the respondents disagreed that they observed items 6, 7 and 8. Moreover, item 6, which covered the “asking for preferred option step” in SDM received the lowest degree of agreement among respondents.
Shared decision making is a process that requires the participation of physician and patient as partners and is regarded as an indicator of high quality of care. This nine-item questionnaire outlines the steps of SDM as they progress from the recognition of the need for decision making to the identification of options and formulation of a decision and finally to the agreement regarding how this decision is implemented.
The initial hypothesis of the investigators was that several areas for improvement would be identified (ie questions in the SDM Q-9 that would have lower scores); and thus would serve as foci for active interventions aimed at improving service delivery at the clinic. This was in light of the challenges that pervade the outpatient clinic, namely a high patient load, overlapping responsibilities of physicians, and time-constraints, to name a few. In addition, studies of patient perception and satisfaction in other developing countries in Asia have reported lower marks being given to public sector outpatient departments in contrast to their private sector counterparts.  The results showed that the majority of respondents gave satisfactory ratings with respect to all nine items of the SDM Q-9 questionnaire. This result was unexpected, but not improbable. We put forth several explanations for these results.
First would be social desirability bias. In this study, we tried to minimize social desirability bias by employing a third party research assistant not involved in the care of patients in the General Internal Medicine outpatient clinic to assist participants in answering the questionnaire. The translated SDM Q-9 itself was self-administered and no identifying information was obtained from patients using the questionnaire. Nevertheless, it was likely that because the survey was conducted within the clinic premises and in close proximity to their physicians, patients tended to give more favorable responses in the SDM Q-9. This was despite re-assurances that all responses would be kept confidential and would not in any way affect the future care of respondents.
One method to determine the extent of social desirability bias in the completion of a questionnaire would be to apply the 33-item Marlowe-Crowne Social Desirability Scale to each respondent. Notably, this could prove to be cumbersome and as such the more succinct derivatives of this tool such as the thirteen-item questionnaire developed by Reynolds might be better options.  Aside from those mentioned earlier, other measures to ensure respondent anonymity such as the use of drop boxes located at a separate site for submissions or adopting a mail return system would be of value in minimizing the effects of this type of bias.
Second would be non-response bias. The study population represented less than half of the patients seen during the period under study. Reasons for nonparticipation were summarized earlier in the Results section of this paper. What could not be determined was how the responses of these patients could affect the results of the study. To directly address this, non-responders could be contacted to obtain a response although this approach would potentially be prone to social desirability and recall biases.
Third, Hölzel and colleagues noted that higher age (mean 62.1 years) and lower educational attainment tended to decrease involvement preference in medical decision making. This study had 60% of the sample belonging to older age brackets (ie, older than 51 years). Moreover, 59.3% had attained an elementary or secondary degree. It was possible that these participants exhibited a low involvement preference and as a direct corollary to this, and harbored lower expectations concerning their involvement in the decision making process regarding their health. In this light, it could be understood why they perceived their experience as highly satisfactory.
An item analysis was performed to determine if certain patterns would emerge. More patients disagreed that items 6 (identification of preferences), 7 (negotiation), and 8 (shared decision) were being performed in the clinic relative to the other items. These items, when examined closely, corresponded to the process of SDM wherein patient participation should be highly encouraged, and where actual decision-sharing occurred.
The steps outlined by the SDM Q-9 represent a theoretical construct instead of an actual schematic with clear-cut limits between points. This arises in part from the lack of a consensus with respect to the definition of the SDM process.  Furthermore, the lack of consensus may in fact be born of the observation that in practice, SDM is more fluid than rigorous; that is, steps are more likely to overlap rather than proceed one after the next during the course of a clinical encounter. In such a case, it may be difficult to differentiate between each step as they occur together and as such one or two steps may be regarded as absent when in fact they are being performed.
Limitations for this study were the following: first, the population studied was composed mainly of patients more than 51 years of age and were from lower socioeconomic strata, who were consulting at a public tertiary hospital. This means that the results of the study might not be applicable to populations with different characteristics (eg, private clinics, younger, more educated patients). Second, baseline knowledge of shared decision making among patients was not established. A lack of understanding of this topic would influence responses to the questionnaire. Third, constraints regarding location of survey administration might have influenced its results (ie, response bias).
Conclusion and Practice Implications
Unlike in the West, shared decision making is as yet an emerging concept in Southeast Asian countries including the Philippines. This study is the first to translate and field the SDM Q-9 questionnaire in Filipino. The SDM Q-9 is a tool used to assess the level of implementation of shared decision making in the clinics from the patient’s perspective. By using this tool in the General Internal Medicine outpatient clinic of a tertiary teaching hospital in Manila the authors were able to observe that patients agreed that shared decision making was being practiced in their clinical encounters with their respective physicians; however it was also noted that more patients disagreed with items corresponding to decision making steps in the SDM process compared to the others. This suggested that these steps may need to be strengthened.
To improve the practice of SDM, physicians should be trained on how to execute the different steps. Likewise, SDM can also be incorporated into clinical practice guidelines (CPGs). Patient education about SDM could also make them want to become more involved in decisions concerning their health.
Recommendations for Research
It would be worthwhile to see the perceptions of physicians with regard to shared decision making in their respective practices and to compare these to those of their respective patients. Determination of patient preferences with respect to their role in the decision making process in the medical clinic is also worthwhile to undertake as this will open the way for the development of a tool that is more culturally appropriate to determine the extent of SDM among Filipinos.
S1. Frequency distribution of the patients’ responses per SDM Q-9 item.
S2. Appendix. Frequency distribution of new (walk-in) patients’ responses per SDM Q-9 item.
For the Filipino version of the Appendix, please email firstname.lastname@example.org.
The authors thank all the patients and support groups who participated in the focus group discussions and answered the questionnaires. We express our gratitude to our research assistants, Ms. Genoveva Nethercott and Ms. Rachel Cabrega for all the help and lastly, Jonnel Poblete, MD for the back-translation which ensured that the investigators’ initial translation is faithful to the original SDM Q-9 English version.
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Copyright: © 2016 Marvin Jonne Mendoza, Danielle Benedict Sacdalan, and Lia Aileen Palileo-Villanueva. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the authors, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.