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76Barriers to Routine Use of DAsWhile DAs appear to function well in experimental settings, getting them routinelyused in everyday practice is challenging. An early observational study of DA adoptionby enthusiastic providers found that they were rarely used (Holmes-Rovneret al., 2000). SDM multimedia videos for prostate cancer, breast cancer, and ischemicheart disease were judged by physicians and nurses to be clear and accurate,and to present about the right amount of information in an appropriate amount oftime. Programs were judged to be informative and appropriate for patients to seebefore making a decision. However, the study revealed that clinicians were unconvincedabout patients’ desire to participate in treatment decision-making, and referralvolume to the programs was lower than expected. In seven months across threemedium-sized hospitals, 34 physicians and nurses referred a total of 24 patients tothe programs.A more recent pilot study conducted in the United Kingdom in outpatient settingsfound similar difficulties. In 2004, four National Health Services Hospital Trustsimplemented two SDM videos (benign prostatic hypertrophy [BPH] and early stageprostate cancer) in outpatient urology practices. The intervention consisted of nursetraining for counseling about SDM and decision support, the videos, and decisionquality assessment (DQA) (Wirrmann & Askham, 2006). However, during 12months in four trusts, only 86 patients answered questions on the DQA, indicatinguse of either video. Interviews with patients and health professionals showed thathealth professionals felt a need to carefully screen the patients for whom the informationwas considered appropriate, reflecting a somewhat narrow vision of whenpatient choice might be appropriate. In addition, finding a mechanism for reliablygetting the videos to patients before the consultation was problematic, as was thecase in the prior study. In this particular approach to implementation, specialistnurses were the main counselors and DA implementation staff had an informationand support role. The administrative burden on an already overworked staff was aserious threat to program sustainability.As in the U.S. study, not all patients accepted the decision support program. Ironically,in the U.S. program, when physicians were especially thorough and supportivein their discussions with patients, patients were not interested in spending an hourgetting further education. Only the physician who did not provide extensive information,and who required the patients to view the video before their visits to receivebiopsy results, was able to get consistent patient participation in seeing the video.These studies suggest that physician referral is unlikely to be a reliable mechanismfor patient access to DAs. Better information systems may help with timely and helpfuldelivery of information to both consumers and providers. However, finding theright triggers to such timely support has been elusive to date. In addition, the UnitedKingdom study found what has been found previously in guidelines studies, thatmost providers want a say in designing materials for their local settings. MaterialsShared Decision-Making in Mental Health Care: Practice, Research, and Future Directions