This study examined how satisfaction with decision-making around screening mammography was related to navigation patterns of a CDST and concurrent linguistic features of patient-provider verbal communication. Findings from our study suggest that linguistic dimensions of the encounter and behavioral data gathered in CDST log files are both associated with patients’ SDM satisfaction. Specifically, whereas the amount of communication (i.e., speaker word count) and provider affect words showed no association with satisfaction, patient satisfaction was associated with the rate at which providers used quantitative language. Patient question asking was negatively associated with overall decision-making satisfaction. Regarding CDST use, our findings suggest that more clicks within the tool were negatively associated with SDM satisfaction, whereas looping back through pages in the tool was positively associated with SDM satisfaction. Moreover, patients felt more satisfied when high click counts occurred with looping, whereas patients felt less satisfied when high click counts occurred without looping.
These findings are consistent with prior studies in highlighting the importance of quantitative information in facilitating decision-making [15, 16]. Many CDSTs, including the tool evaluated in this study, describe breast cancer risks with precise numbers or graphical presentations, which can help patients understand probabilities [9, 14] and make informed decisions . Our study suggests that providers’ verbal communication may also play an important complementary role in SDM, with the use of quantifiers likely reflecting efforts to reinforce the quantitative risk information relayed in the CDST, helping patients better understand screening options. While our study provides preliminary evidence of the importance of using quantifiers in SDM accompanying CDST use, future study may explore the effectiveness of specific types of quantitative information, as prior work suggests that different ways of communicating numbers (e.g., odds ratio, absolute risk difference, relative risk) are associated with differing levels of comprehension and satisfaction [33, 34].
Other findings are not consistent with the prior literature. Past studies suggest positive associations between word count, as a proxy of depth of the interaction, and patient satisfaction, whereas we did not find any such association. However, past studies have not been conducted in the context of using CDSTs, and it is possible that word count might work differently in this context. For example, gestures may play a role in communication when using a CDST (e.g., pointing to information or buttons on the screen), relatively brief utterances could prompt important actions in the tool (e.g., requests to run through the sequence again), or too much verbal communication concurrent with tool use could disrupt or distract processing information conveyed in the tool. This interplay of communication volume and tool use warrants further research.
Likewise, regarding affect words, we did not find a significant relationship to SDM satisfaction, which could perhaps reflect the sample in this study, with most patients having completed mammography before. Most patients therefore have prior experience weighing potential affective consequences of outcomes like false positives or cancer diagnoses. For such patients, perhaps discussing up-to-date quantitative information that clarifies their personal risks and benefits from mammography is of greater value.
Surprisingly, whereas we had hypothesized that question asking would indicate patients’ active involvement in SDM and associate with higher satisfaction, we found that patients who asked more questions tended to feel less satisfied overall, less clear about their values, and less certain about their decision at follow-up. These negative associations need to be further explored but could suggest that information was not clearly conveyed, or that clinicians did not adequately address patients’ questions. Prior studies showed that the extent to which patients ask questions is contingent on the clinicians’ communication style . Moreover, patients who receive adequate answers from their clinicians show better psychological adjustment than those who do not . A review of transcripts revealed that patients asked a variety of questions seeking to clarify information presented by the tool (e.g., "What is normal? What are the other normal timelines?"), as well as questions related to issues that were not addressed in the tool, such as insurance coverage (e.g., “I don't think insurance pays for them yearly—they do?"), and coordination and scheduling of mammography (e.g., “Is there any way to coordinate getting that with having to do a physical or some other reason that I'm coming in… So—and I can coordinate those two visits?”). However, further study is needed to systematically examine the types of questions patients ask and the adequacy of answers they receive.
Our findings also suggest that looping in a CDST may play an important role in SDM. Specifically, we found that the relationship between clicks within the CDST and SDM satisfaction varied based upon looping in the system. With fewer clicks, SDM outcomes were not related to the extent of provider looping in the CDST. However, with more clicks, patients reported better SDM outcomes when clinicians looped through more scenarios and worse outcomes without looping. This finding may relate to prior work showing that more clicks in the EHR are associated with lower patient satisfaction [29, 30]. Our results show that clicks may not be helpful even if they ostensibly occur in the context of providers and patients navigating a CDST together, perhaps because the provider lacks knowledge of how to efficiently use the tool, or because certain types of engagement with navigating the tool may distract from patient-centered communication. However, directed use of the CDST, such as when clicks occurred as providers looped through multiple scenarios, may help patients feel more satisfied, more supported, and perceive more effectiveness about their decision.
To improve the process of navigating CDSTs, it may be important to identify where and when clicks occur in the tool. Higher clicks may be important markers of a challenging decision process or a provider’s lack of experience with the tool , perhaps capturing struggles to make sense of the information provided or find the best choice.
These findings can inform SDM provider training to optimize CDST use in clinical encounters. There may be value in providing proper training before large scale implementation of SDM supported by CDSTs, as it is possible that inexperience with a CDST could lead to inefficient use that detracts from SDM. Moreover, it may be beneficial to educate clinicians on verbal communication skills relevant to SDM, such as how to verbalize information in quantitative terms (e.g., risk and associated outcomes) to accompany the visual displays in the CDST, provide adequate answers to questions, and verbally engage patients while simultaneously managing data in the CDST . Moreover, clinicians’ training could offer additional experience and guidance with interface elements to reduce unnecessary clicks and save valuable time during the visit.
These findings also have implications for the design of CDSTs. To improve patient satisfaction, the digital interface must be user-friendly for the patient as well as the clinician [47, 48]. Our study suggests looking to click counts to potentially identify specific user interface elements where the CDST could be improved to further ease navigation. Designers may also consider how the tool can help patients to raise questions and find satisfactory answers. These findings also suggest potential opportunities to automatically monitor encounters and to intervene on possible decisional conflict. For example, if a provider’s use of the CDST involves many clicks but few loops, the CDST creator could provide additional resources or tips for navigating the tool.
Limitations and directions for future research
Our study has several limitations. First, we cannot draw conclusions about the causal relationships among the measured variables. We assessed relationships between linguistic patterns and tool use and SDM satisfaction while controlling for potential confounding variables, but there may be additional unmeasured factors that contribute to the observed relationships. For example, patients’ health literacy should likely be a covariate .
Second, more work may be needed to distinguish activities in the CDST that predict SDM in different ways, including examining when and why clinicians clicked on different parts of the interface, and whether certain patterns drove the negative association between click count and patients’ SDM satisfaction. There may also be particular types of loops that are helpful or unhelpful, based on the specific scenarios explored.
Additional limitations relate to generalizability. As the participants are all from one geographic region, it would be beneficial to replicate this study in other locations. Our study also has a large proportion of patients who had a college education or higher, which may limit the ability to generalize to others. Our patient sample was also entirely women, and all but one of the providers in our study were women. Past work suggests that gender can shape clinical interactions, and it would likely also have implications for how decision aid tools can be effectively used. For example, some work suggests that women are more motivated than men to participate actively in SDM , and that they may have higher information needs during SDM than men . In addition, patterns of verbal communication during clinical encounters are known to vary based on the gender dynamics of the provider-patient dyad, with some research suggesting that female/female dyads are, on average, more verbally communicative during visits . These patterns of findings may be consistent with a high importance of concurrent verbal communication to reinforce CDST use among women, including disambiguating and elaborating on the information a tool provides. Furthermore, since the providers in this study were early adopters, future work may examine uses of CDSTs and SDM outcomes when providers have less experience with CDSTs or are slower to adopt them. Finally, our study examined tool use in the absence of formal training, and future studies may examine whether formal training (which has been developed for BCaRE-DA since data collection) could potentially change use patterns and SDM satisfaction.
As far as future directions, time is an important element to consider in relation to any CDST. Time in clinical settings can be understood as the available length of consultation time and the time constraints perceived by the provider and the patients . Limited time can result in providers being more directive and less likely to encourage patients to ask questions , and some scholars and practitioners argue that time constraint is therefore the main barrier to SDM . Thus, CDSTs that can efficiently support SDM are much needed. The present research did not consider the association between time using the tool and SDM satisfaction due to data limitations, nor did it consider its connection to total word count, but this is a high priority area for future investigation. If the CDSTs are helpful in SDM but take too much time to use in the context of clinic visits, one solution may involve promoting tool use outside of clinical visits, when patients have extra time to navigate and reflect on their decisions. For instance, future work might consider complementary tools or modules that a patient can use independently. Before a clinical encounter, such tools could summarize key information and allow for patients to identify questions and prioritize discussion topics to cover in clinical encounters . After an encounter, such tools could provide methods to seek further information or to connect with peers or professionals for social support [21, 52].
Very limited work has addressed heterogeneity in uses of CDSTs, and how this predicts satisfaction with decision-making. As such, this study provides an important but preliminary step toward understanding these issues. Future work should seek to confirm these findings with a larger sample size that provides increased power.