In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
E alua ion o he Use o Sha ed Decision Making in B eas
Cance : In e na ional Su ey
Ma a Maes-Ca ballo 1,2 , Manuel Ma ín-Díaz 3, Luciano Mignini 4, Khalid Saeed Khan 2,5 ,
Rubén T igue os 6,* and Au o a Bueno-Ca anillas 2,5,7
Ci a ion: Maes-Ca ballo, M.;
Ma ín-Díaz, M.; Mignini, L.; Khan,
K.S.; T igue os, R.; Bueno-Ca anillas,
A. E alua ion o he Use o Sha ed
Decision Making in B eas Cance :
In e na ional Su ey. In . J. En i on.
Res. Public Heal h 2021,18, 2128.
h ps://doi.o g/10.3390/ije ph
18042128
Academic Edi o s: Se ena Ba ello and
Guendalina G a igna
Recei ed: 25 Decembe 2020
Accep ed: 18 Feb ua y 2021
Published: 22 Feb ua y 2021
Publishe ’s No e: MDPI s ays neu al
wi h ega d o ju isdic ional claims in
published maps and ins i u ional a il-
ia ions.
Copy igh : © 2021 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and
condi ions o he C ea i e Commons
A ibu ion (CC BY) license (h ps://
c ea i ecommons.o g/licenses/by/
4.0/).
1Unidad de Pa ología Mama ia del Se icio de Ci ugía Gene al, Complexo Uni e si a io Hospi ala io de
Ou ense, 32005 Ou ense, Spain; [email p o ec ed]
2Depa men o P e en i e Medicine and Public Heal h, Uni e si y o G anada, 18014 G anada, Spain;
[email p o ec ed] (K.S.K.); abueno@ug .es (A.B.-C.)
3Hospi al Básico San a Ana de Mo il, 18600 G anada, Spain; [email p o ec ed]
4Unidad de Mas ología del G upo O oño, 2000 Rosa io, A gen ina; [email p o ec ed]
5CIBER o Epidimiology and Public Heal h (CIBERESP), 28029 Mad id, Spain
6Depa men o Language and Educa ion, Uni e si y o An onio de Neb ija, 28015 Mad id, Spain
7Ins i u o de In es igación Biosani a ia (IBS), 18012 G anada, Spain
*Co espondence: igue [email p o ec ed]
Abs ac :
Objec i es: To assess sha ed decision-making (SDM) knowledge, a i ude and applica ion
among heal h p o essionals in ol ed in b eas cance (BC) ea men . Ma e ials and Me hods: A c oss-
sec ional s udy based on an online ques ionnai e, sen by se e al p o essional socie ies o heal h
p o essionals in ol ed in BC managemen . The e we e 26 ques ions which combined demog aphic
and p o essional da a wi h some i ems measu ed on a Like - ype scale. Resul s: The pa icipa ion
(459/541; 84.84%) and comple ion (443/459; 96.51%) a es we e high. Pa icipan s s ongly ag eed
o ag eed in 69.57% (16/23) o hei esponses. The majo i y s a ed ha hey knew o SDM (mean
4.43 (4.36–4.55)) and we e in a ou o i s implemen a ion (mean 4.58 (4.51–4.64)). They highligh ed
ha SDM p ac ice was no adequa e due o lack o esou ces (3.46 (3.37–3.55)) and ag eed on policies
ha imp o ed i s implemen a ion (3.96 (3.88–4.04)). The main ad an age o SDM o pa icipan s
was pa ien sa is ac ion (38%), and he main disad an age was he pa ien s’ pauci y o knowledge o
unde s and hei disease (24%). The main obs acle indica ed was he lack o ime and esou ces (40%).
Conclusions: New policies mus be designed o adequa e aining o p o essionals in in eg a ing
SDM in clinical p ac ice, p epa ing hem o use SDM wi h adequa e esou ces and ime p o ided.
Keywo ds:
sha ed decision making; b eas cance ; use o sha ed decision making; su ey; longi udi-
nal s udy
1. In oduc ion
B eas cance (BC) is he leading cause o dea h in women [
1
]. Imp o emen s in
diagnosis, he g ea e e icacy o neoadju an he apies and he de elopmen o new
oncoplas ic echniques and oncological managemen ha e educed he agg essi eness o
su gical ea men s and imp o ed he aes he ic and unc ional esul s [
2
]. As BC ea men
is now mo e complex, each case’s ideal app oach equi es a high deg ee o indi idualiza ion,
scien i ic- echnical upda ing, mul idisciplina y coo dina ion, and con inuous e iew o
esul s [3].
The ideal s a egic plan o a BC pa ien will be he one ha bes mee s hei needs and
expec a ions. I s design should be based on an accu a e diagnosis o hei disease and he
pa ien ’s ci cums ances, p e e ences, and alues [
2
,
3
]. So, sha ed decision making (SDM),
“an app oach in which physicians and pa ien s sha e he bes a ailable e idence when aced wi h
he ask o making decisions and whe e pa ien s a e suppo ed in conside ing op ions, o achie e
decisions ollowing hei p e e ences and alues” [
4
], is i ally impo an in BC. I s diagnosis
In . J. En i on. Res. Public Heal h 2021,18, 2128. h ps://doi.o g/10.3390/ije ph18042128 h ps://www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2021,18, 2128 2 o 15
and ea men equi es mul iple high- isk decisions made in a limi ed ime pe iod and,
o en, wi h incomple e e idence, aising he need o mo e signi ican pa ien suppo
du ing hei decision-making p ocess [4].
SDM is a uni e sally suppo ed concep [
5
–
7
] linked o ca e quali y [
8
,
9
]. I inc eases
pa ien sa is ac ion and hei pe cep ion o isk [
10
]. I is a legal obliga ion in la ge pa s o
de eloped coun ies [
11
–
14
] and educes malp ac ice claims [
15
,
16
]. Howe e , i s ac ual
implemen a ion emains low [
17
,
18
]. I is poo ly e lec ed in clinical p ac ice guidelines
and consensus [
19
] and obs acles o i s implemen a ion pe sis [
20
,
21
]. I s main objec-
i e is o espec pa ien s’ au onomy wi hou de imen o hei bene i , p o iding ca e
unde hei alues and p e e ences. This equi es he de elopmen o mul idisciplina y
eams wi h a high scien i ic- echnical le el, excellen coo dina ion, communica ion wi h
he pa ien , and pe manen e iew o he esul s wi hin he amewo k o a con inuous
imp o emen p og am.
The aim o his wo k is o assess he le el o in e es , knowledge and a i ude owa ds
SDM, as well as he pe cep ion o he deg ee o applica ion o SDM by heal h p o essionals
in ol ed in he managemen o BC (including he en i e p ocess sc eening, diagnosis,
ea men and ollow-up).
2. Me hods
The “Checklis o Repo ing he Resul s o In e ne E-Su eys” (CHERRIES) was
used o his s udy, which allows a quali y desc ip ion o he esea ch esul s om su eys
o web en i onmen s [
22
,
23
]. CHERRIES, used o ensu ing comple e desc ip ions o
e-su ey me hodology, is designed o imp o e he quali y o epo s [
22
]. A c oss-sec ional
obse a ional s udy on a con enience sample o BC specialis was conduc ed.
2.1. Measu emen
A ques ionnai e was designed by a g oup o h ee SDM expe s and b eas cance
specialis (MMC, MD, LM) wi h a comp ehensi e heo e ical and p ac ical expe ience
abou his delibe a i e [
24
,
25
]. A li e a u e e iew abou SDM was done o elabo a e and
design a ques ionnai e o be sel -comple ed online (Appendix A), which included b ie
in o ma ion on he s udy’s scope and objec i es and a wa ning o hose membe s o se e al
o hese socie ies no o answe i in duplica e. The su ey was cons uc ed in Spanish
(Spanish and A gen ine a ia ions). Bo h a ian s we e e iewed by na i e au ho s (MMC
o Spanish om Spain and LM o Spanish om A gen ina). No iden i ying da a we e
collec ed. The a iables o in e es we e measu ed on a Like - ype scale [
26
,
27
] wi h
5 esponses, 1 being “s ongly disag ee” and 5 “s ongly ag ee”. The deg ee o knowledge
abou SDM (ques ions 1–5), he opinion abou SDM (ques ions 6–12), he awa eness and
a i ude abou SDM (ques ions 13–15) and he deg ee o cu en and u u e applica ion
o SDM (ques ions 16–23) we e in es iga ed. Finally, h ee open-ended ques ions we e
included, e e ing o he pe cei ed ad an ages, disad an ages and obs acles o i s imple-
men a ion. An a bi a o (ABC) has e iewed his p o o ype ques ionnai e and sugges ed
modi ica ions. P io o dissemina ing he ques ionnai e, a pilo es was ca ied ou on
a sample o 15 specialis s con ac ed di ec ly o assess he ques ions’ unde s anding and
ele ance. Some modi ica ions o imp o ing unde s anding o he su ey ha e been done.
We could no es ima e he esponse o pa icipa ion a e. The comple ion a e was cal-
cula ed om hose who opened he online link. The eal pa icipa ion a e was impossible
due o open dis ibu ion dissemina ion [28,29].
2.2. Pe iod and Scope o he S udy
The in o ma ion was collec ed du ing he mon hs o June, July, Augus and Sep embe
2020 in wo coun ies: Spain and A gen ina. The e e ence popula ion was BC ea men
specialis s, membe s o scien i ic socie ies ela ed o his p ocess (BC sc eening, diagnosis,
ea men and ollow-up): Asociación Española de Ci ujanos (AEC), Sociedad Española
de Senología y Pa ología Mama ia (SESPM), Sociedad A gen ina de Mas ología (SAM),
In . J. En i on. Res. Public Heal h 2021,18, 2128 3 o 15
Sociedad A gen ina de Ci ugía Plás ica, Es é ica y Repa ado a (SACPER), Asociación de
Oncología de Rosa io (AOR) y Asociación de Mas ología de Rosa io (AMAR). The sample
was made up o he membe s o hese socie ies who ecei ed and answe ed he online
su ey. Su eys ha did no answe a leas 25% o he i ems su eyed we e excluded.
2.3. Da a Collec ion
The pa icipa ing scien i ic socie ies sen he su ey by e-mail o he pa ne s’ lis ,
included a link on hei websi es and he possibili y o sha ing his link wi h o he col-
leagues. Two eminde s we e sen a e he ini ial in i a ion; all cons uc ed by he eam
esea che . The esponse was en i ely olun a y and wi hou incen i e. I was adminis e ed
h ough Google Fo ms [
30
], an online su ey pla o m, om 1 June o 31 Oc obe 2020.
The e was no obliga ion o answe all he ques ions, and back acking was allowed o
answe p e ious ques ions. The e was no andom assignmen o ques ions and answe s.
No da a iden i ying he pa icipan s we e s o ed. No minimum comple ion ime was
speci ied a p io i. Pa ially comple ed su eys we e accep ed, p o ided ha a leas 25%
o he ques ions we e answe ed, and a manual e iew was conduc ed o e i y abno mal
esponse pa e ns.
2.4. Da a Analysis
The dis ibu ion o esponses and he a e age alues o each ques ion o he su ey
we e s udied, s a i ying by sex, age, p o essional senio i y, speciali y, ype o hospi al
(public o p i a e) and se ice (wi h o wi hou b eas uni ), and he numbe o pa ien s
a ended annually, by he p o essional and by he hospi al. The esul s we e compa ed using
Chi-squa e es o compa e p opo ions (Table 1), a mean compa ison es o independen
g oups (S uden T- es ) o compa e ac oss wo ca ego ies o a iables (Table 2) o analysis
o he a iance o one ou e (ANOVA wi h Bon e oni co ec ion) o a iables wi h mo e
han wo ca ego ies. S a is ical signi icance was se a p< 0.05. All analyses we e pe o med
wi h he S a a 15.0 s a is ical package (S a aCo p LLC, College S a ion, TX, USA).
Table 1. Desc ip ion o he pa icipan s s a i ied acco ding o hei na ionali y.
A gen ina Spain To al p-Value
Gende
Men 121 (51.27%) 97 (44.10%) 218 (47.80%)
p= 0.125
Women 115 (48.73%) 123 (55.90%) 238 (52.19%)
To al 236 (100%) 220 (100%) 456 (100%)
Age
<35 yo 130 (54.62%) 80 (36.36%) 210 (45.85%)
p= 0.001
35–50 yo 66 (27.73%) 105 (47.73%) 171 (37.35%)
51–65 yo 16 (6.72%) 17 (7.73%) 33 (7.20%)
>65 yo 26 (10.93%) 18 (8.18%) 44 (9.60%)
To al 238 (100%) 220 (100%) 458 (100%)
P o essional ca ee pe iod
MR 0 (0%) 8 (3.63%) 8 (1.75%)
p= 0.001
MAS 169 (71.00%) 127 (57.73%) 296 (64.63%)
Head o Se ice 67 (28.99%) 74 (33.64%) 141 (30.78%)
O he 2 (0.01%) 11 (5%) 13 (2.84%)
To al 238 (100%) 220 (100%) 458 (100%)
Speciali y
Gene al Su ge y 0 (0%) 126 (56.25%) 126 (27.27%)
p= 0.001
Plas ic Su ge y 72 (30.25%) 61 (27.23%) 133 (28.78%)
Mas ology * 122 (51.26%) 0 (0%) 122 (26.41%)
O he s Speciali y 44 (18.49%) 37 (16.52%) 81 (17.54%)
To al 238 (100%) 224 (100%) 462 (100%)
In . J. En i on. Res. Public Heal h 2021,18, 2128 4 o 15
Table 1. Con .
A gen ina Spain To al p-Value
Kind o se ice
B eas Uni 131 (39.70%) 199 (88.83%) 330 (71.42%)
p= 0.001
Wi hou B eas Uni 107 (81.06%) 25 (11.16%) 132 (28.57%)
To al 236 (100%) 224 (100%) 462 (100%)
Hospi al
Public 94 (39.50%) 172 (76.79%) 266 (57.58%)
p= 0.001
P i a e 144 (60.50%) 52 (23.21%) 196 (42.42%)
To al 238 (100%) 224 (100%) 462 (100%)
BC cases/yea /hospi al
<100 106 (44.54%) 54 (24.66%) 160 (35.01%)
p= 0.001
100–149 52 (21.85%) 41 (18.72%) 93 (20.35%)
150–199 30 (12.61%) 32 (14.61%) 62 (13.56%)
200–249 19 (7.98%) 24 (10.96%) 43 (9.40%)
>250 31 (13.02%) 68 (31.05%) 99 (21.66%)
To al 238 (100%) 219 (100%) 457 (100%)
BC cases/yea /doc o
<100 151 (63.44%) 94 (41.96%) 245 (53.03%)
p= 0.001
100–149 42 (17.65%) 48 (21.42%) 90 (19.48%)
150–199 15 (6.30%) 13 (5.80%) 28 (6.06%)
200–249 12 (5.05%) 14 (6.25%) 26 (5.63%)
>250 18 (7.56%) 38 (16.96%) 56 (12.12%)
NSNC 0 (0%) 17 (7.58%) 17 (3.68%)
To al 238 (100%) 224 (100%) 462 (100%)
% o use o he SDM
<33% 49 (20.85%) 19 (8.72%) 68 (15.01%)
p= 0.001
33–66% 53 (22.55%) 28 (12.84%) 81 (17.88%)
>66% 67 (28.51%) 149 (68.35%) 216 (47.69%)
N/A 66 (28.09%) 22 (10.09%) 88 (19.42%)
To al 235 (100%) 218 (100%) 453 (100%)
* Speciali y only ecognized in A gen ina. Abb e ia ions: BC (B eas Cance ), MAS (Medical A ea Specialis ), MR
(Medical Residen ), N/A (no answe ), SDM (sha ed decision-making), yo (yea s old).
Table 2. A e age esponse alues o each su ey ques ion.
Su ey Ques ions Mean (CI 95%) A gen ina Spain p-Value
1I am amilia wi h he concep and a ionale o Sha ed Decision
Making (SDM) 4.43 (4.36–4.50) 4.51 (4.42–4.60) 4.33 (4.22–4.45) p= 0.027
2The SDM is a necessa y su ey o p o ide quali y assis ance. 4.48 (4.42–4.55) 4.45 (4.36–4.54) 4.51 (4.42–4.61) p= 0.289
3
The impo ance o SDM inc eases when he e a e se e al ea men
op ions wi h simila ou comes, whe e he selec ion o one o
ano he op ion depends on he pa ien ’s p e e ences.
4.44 (4.37–4.50) 4.43 (4.34–4.52) 4.44 (4.35–4.54) p= 0.741
4All physicians should ask hei pa ien s exac ly how hey would
like o pa icipa e in decision-making. 4.29 (4.22–4.36) 4.32 (4.22–4.41) 4.26 (4.16–4.36) p= 0.429
5SDM inc eases pa ien sa is ac ion, imp o es cos -e ec i eness
and educes malp ac ice claims. 4.35 (4.28–4.41) 4.34 (4.25–4.27) 4.36 (4.23–4.44) p= 0.708
6SDM is a basic elemen in he physician’s ela ionship wi h b eas
cance (BC) pa ien s. 4.58 (4.51–4.64) 4.79 (4.72–4.85) 4.33 (4.23–4.44) p= 0.001
7All doc o s should in o m hei pa ien s abou he di e en
ea men op ions a ailable o hei heal h p oblem. 4.61 (4.55–4.67) 4.57 (4.48–4.67) 4.66 (4.58–4.73) p= 0.211
8All doc o s should explain all ea men op ions o hei pa ien s,
including he possibili y o no p o iding any ea men a all. 4.62 (4.56–4.69) 4.79 (4.71–4.84) 4.44 (4.32–4.55) p= 0.001
9All doc o s should explain o hei pa ien s he bene i s, isks and
side e ec s o possible ea men s. 4.72 (4.67–4.78) 4.77 (4.71–4.83) 4.67 (4.58–4.75) p= 0.036
In . J. En i on. Res. Public Heal h 2021,18, 2128 5 o 15
Table 2. Con .
Su ey Ques ions Mean (CI 95%) A gen ina Spain p-Value
10 All doc o s should help hei pa ien s unde s and all he
in o ma ion p o ided o hem. 4.52 (4.46–4.59) 4.35 (4.25–4.44) 4.73 (4.66–4.80) p= 0.001
11 All doc o s should ask hei pa ien s which ea men op ion
hey p e e . 4.32 (4.25–4.38) 4.19 (4.11–4.27) 4.46 (4.37–4.55) p= 0.001
12 Mos pa ien s eel ha he doc o is he bes pe son o decide on
he bes ea men op ion. 4.38 (4.31–4.44) 4.57 (4.49–4.65) 4.15 (4.07–4.24) p= 0.001
13 All doc o s should gi e hei pa ien s enough ime o assess he
di e en ea men op ions. 4.38 (4.32–4.45) 4.25 (4.14–4.36) 4.54 (4.46–4.62) p= 0.001
14 All doc o s should choose he ea men op ion oge he wi h
hei pa ien s. 4.29 (4.21–4.37) 4.35 (4.24–4.45) 4.22 (4.11–4.34) p= 0.135
15 All doc o s should ag ee wi h hei pa ien s o moni o
hei p ocess. 3.80 (3.71–3.89) 3.64 (3.53–3.80) 3.98 (3.84–4.11) p= 0.001
16 My Uni has expe ience in he use o SDM in b eas cance . 3.80 (3.71–3.88) 3.65 (3.54–3.76) 3.97 (3.85–4.09) p= 0.001
17 My Uni has a speci ic consul a ion o explain ea men op ions
and acili a e SDM. 3.34 (3.24–3.44) 3.41 (3.29–3.53) 3.26 (3.10–3.42) p= 0.179
18 My Uni has he necessa y ime o p ac ice he p ac ice o MDS in
he ca e o he BC 3.45 (3.35–3.55) 3.63 (3.50–3.76) 3.24 (3.09–3.40) p= 0.001
19
My Uni has he necessa y ma e ials o p ac ice he SDM in he BC
3.46 (3.37–3.55) 3.61 (3.49–3.72) 3.29 (3.15–3.43) p= 0.001
20 My hospi al should p omo e mo e pa ien communica ion and
he BC 3.96 (3.88–4.04) 3.98 (3.87–4.08) 3.93 (3.82–4.05) p= 0.799
21 In gene al, he e should be mo e aining on pa ien
communica ion and BC 4.33 (4.27–4.40) 4.41 (4.33–4.48) 4.25 (4.15–4.35) p= 0.023
22
SDM can be use ul o p i a e heal h ca e, bu i has no applica ion
in public heal h ca e, he pa ien canno decide on he mos
e icien ea men op ion.
2.10 (2.00–2.20) 2.49 (2.34–2.64) 1.65 (1.53–1.76) p= 0.001
23 In he u u e, he e will be an inc easing applica ion o SDM in
BC ca e. 4.33 (4.27–4.40) 4.34 (4.25–4.42) 4.33 (4.23–4.43) p= 0.910
Abb e ia ions: CI (con idence in e al).
3. Resul s
A o al o 541 doc o s iewed he su ey, and o hese, 459 (84.84%) p o ided demo-
g aphic in o ma ion and answe ed a leas 25% o he ques ions and one ques ion based on
con en (pa icipa ion a e). The majo i y o pa icipan s (443/459; 96.51%) comple ed all
ques ions (comple ion a e). The e we e only 5% o unanswe ed ques ions, which was no
signi ican . No pa e n o he unanswe ed ques ions was ound.
3.1. Pa icipan s
Table 1summa ised he socio-demog aphic and p o essional cha ac e is ics o he pa -
icipan s and compa ed hen be ween coun ies. The e was a simila ep esen a ion o bo h
sexes, mos ly unde 50 yea s old, wi h a ious speciali ies dis ibu ion. Mos pa icipan s
belonged o a b eas uni (71.42%; p= 0.001), bu only one hi d wo ked in hospi als wi h
mo e han 200 cases pe yea (31.06%; p= 0.001). When compa ing be ween A gen ina and
Spain, di e ences in age (younge p o essionals in A gen ina) and he speciali y s and ou .
A o al o 51.26% o A gen ine p o essionals we e classi ied as mas ologis s, a speciali y
ha does no exis in Spain and which is eplaced by 56.25% o gene al su geons (
p= 0.001
).
I was mo e equen in Spain han in A gen ina o belong o a b eas uni (88.33% s.
39.70%; p= 0.001) and wo k in a public hospi al (76.79% s. 39.50; p= 0.001).
3.2. Global Analysis o he Su ey and Compa ison be ween Coun ies
Table 2p esen s he esul s o he ques ionnai e. The majo i y esponses we e in
all cases alues 4 “ag ee” and 5 “s ongly ag ee”, excep o ques ion 22. The i s i e
ques ions, abou he deg ee o knowledge o he SDM, ob ained a high conco dance. Only
in he i s case, he e was a sligh ly highe sco e in he A gen ine pa icipan s (4.51 s. 4.33),
bu s ill s a is ically signi ican (p= 0.027). The opinion abou SDM ques ions (ques ions
6-12) e ealed a e y posi i e a i ude abou SDM, which was highe o A gen inean
In . J. En i on. Res. Public Heal h 2021,18, 2128 6 o 15
su geons in e ms o he use ulness o SDM in he ela ionship wi h pa ien s (ques ion
6, 4.79 s. 4.33; p= 0.001), also ob aining a highe sco e in he obliga ion o explain o
pa ien s (ques ion 9, 4.77 s. 4.67; p= 0.036). The Spanish we e mo e willing o help
pa ien s unde s and he in o ma ion (ques ion 10, 4.73 s. 4.35; p= 0.001) and ask abou
hei expec a ions (ques ion 11, 4.46 s. 4.19; p= 0.001).
Conce ning he ques ions ha measu ed a i ude and awa eness abou SDM (ques ions
13–15), ques ion 13, on p o iding su icien ime, also ob ained a high le el o ag eemen ,
g ea e in he Spanish p ac i ione s (4.25 s. 4.54; p= 0.001). All hese esul s a e p esen ed
in Table 2. Ques ion 14, on he join choice o ea men , also go an eno mous ag eemen
bu wi hou signi ican di e ences be ween coun ies (p= 0.135). Howe e , when i comes
o moni o ing he p ocess, ques ion 15, he deg ee o ag eemen dec eased, pa icula ly in
A gen ina (3.80 s. 3.65; p= 0.001). Rega ding he deg ee o cu en and u u e applica ion
o SDM (ques ions 16–23), he su ey ob ained he lowes alues. Ques ion 17, on he
exis ence o a speci ic consul a ion (3.41 s. 3.26; p= 0.179), and ques ions 18 (3.63 s. 3.24;
p= 0.001) and 19 (3.61 s. 3.29; p= 0.001), on he a ailabili y o he necessa y ime and
esou ces espec i ely, go lowe esul s in Spain. The e was high ag eemen on he need
o mo e aining (ques ion 21), signi ican ly highe in A gen ina (4.41 s. 4.25; p= 0.023),
and on he u u e g owing applica ion (ques ion 23). The e was low ag eemen on Spain’s
public and p i a e assis ance han A gen ina (1.65 s. 2.49; p= 0.001).
When he esponses we e s a i ied by sex, he highes sco e ob ained by women
o ques ions 9 (4.80 s. 4.64; p= 0.004), 10 (4.61 s. 4.44;
p= 0.007
) and 11 (4.40 s.
4.23;
p= 0.009
) s ood ou , e ealing a mo e empa he ic a i ude on he pa o he women,
who in u n a e mo e awa e o he need o SDM as a quali y ool, ques ion 2 (p= 0.003).
In con as , men we e mo e likely o conside he doc o he mos app op ia e pe son o
decide, ques ion 12 (p= 0.033). Rega ding age, signi ican di e ences in a ou o younge
p o essionals (doc o s mo e you h ul han 50 yea s old) we e obse ed o ques ions 6–9,
ela ed o a i ude, and o ha e e ing o a u u e applica ion, ques ion 23 (4.41 s. 4.24;
p= 0.041).
When analysing he answe s by speciali y, he highes deg ee o ag eemen o he
specialis s in mas ology conce ning ques ions 1 (knowledge o he undamen als o SDM),
6 (SDM as a basic elemen o he ela ionship wi h he pa ien s), 8 (obliga ion o explain) and
12 ( he pa ien belie es ha he doc o should choose he ea men ) s ood ou . A gen inian
had mo e ime (ques ion 18) and we e mo e p edisposed o ecognise di e ences be ween
public and p i a e ca e (ques ion 22). Plas ic su geons s ood ou o he g ea e ag eemen
ega ding he use ulness o SDM when he e we e se e al al e na i es (ques ion 3) and he
need o explain he di e en ea men op ions (ques ion 7), hei ad an ages and disad-
an ages (ques ion 9), and he need o u he aining (ques ion 21). Finally, he gene al
su geons claimed he need o help pa ien s unde s and he in o ma ion (ques ion 10) and
he necessi y o ime o do so (ques ion 13). Conce ning he exis ence o a B eas Uni ,
he e we e ew signi ican di e ences. Howe e , when he e was one, mo e emphasis was
placed on inco po a ing he pa ien in o he ollow-up p ocess (ques ion 15), and he g ea e
expe ience was highligh ed (ques ion 16). On he o he hand, when no wo king in a b eas
uni , he esul s we e highe o ques ion 6 (SDM as a basic elemen o he ela ionship
wi h pa ien s), 8 (obliga ion o explain) and he need o he join choice o ea men wi h
pa ien s (ques ion 14), bu hey also ag eed ha pa ien s gene ally conside ha i is he
doc o who should decide (ques ion 12).
3.3. Ad an ages, Disad an ages and Main Obs acles o he Implemen a ion o he SDM
Figu e 1a and b shows he main ad an ages and disad an ages o SDM, as epo ed
by pa icipan s. The main ad an ages highligh ed we e pa ien sa is ac ion and g ea e
commi men o ea men (38%), imp o emen in he doc o -pa ien ela ionship, hus in-
c easing con idence in he doc o (36%) and educ ion in pa ien s ess by helping hem o
unde s and hei illness (26%). The main d awback was he lack o pa ien li e acy (24%)
ollowed by he lack o ins i u ional suppo , lack o means, and ime in consul a ion o
In . J. En i on. Res. Public Heal h 2021,18, 2128 7 o 15
implemen i (21%). Conce ning he obs acles, Figu e 2, widely highligh ed he lack o
ime and esou ces o ma e ials (a p ope SDM consul a ion a ailable, aining cou ses o
p ac i ione s,
. . .
) o he implemen a ion o SDM, poin ed ou by 40% o he esponden s.
In . J. En i on. Res. Public Heal h 2021, 18, 2128 7 o 15
(a)
(b)
Figu e 1. (a) Main ad an ages o he use o he SDM e e ed by he pa icipan s; (b) Main disad-
an ages o he use o he SDM e e ed by he pa icipan s (* O he s: lack o uni e sali y, delay in
he pa ien ’s decision and di icul applicabili y.).
Figu e 1.
(
a
) Main ad an ages o he use o he SDM e e ed by he pa icipan s; (
b
) Main disad-
an ages o he use o he SDM e e ed by he pa icipan s (* O he s: lack o uni e sali y, delay in
he pa ien ’s decision and di icul applicabili y).
In . J. En i on. Res. Public Heal h 2021,18, 2128 8 o 15
In . J. En i on. Res. Public Heal h 2021, 18, 2128 8 o 15
Figu e 2. Main Obs acles o he implemen a ions o he SDM
4. Discussion
Mos o he p o essionals who answe ed he su ey had a b oad knowledge and a
a ou able opinion abou SDM. Spanish speaking p ac i ione s we e keene o help he
pa ien unde s and he in o ma ion p ocess and ask abou pa ien expec a ions. Mo e A -
gen ineans hough abou SDM as an essen ial elemen in BC managemen and an obliga-
ion o pu sue. Rega ding he awa eness- aising and a i ude abou SDM, pa icipan s,
mainly Spanish, ag eed on he necessi y o p o iding enough ime o p ac ice SDM and
on he join choice o ea men . Conce ning he cu en and u u e applica ion o SDM,
he e was high ag eemen on he need o mo e aining. The leas ag eemen was ob-
se ed o he necessi y o ag ee wi h pa ien s on he p ocess’s ollow-up and he cu en
and u u e implemen a ion. This was mainly in he a ailabili y o speci ic consul a ions
o ime and esou ces o SDM in he pa icipan se ice. On he o he hand, pa icipan s
highligh ed pa ien sa is ac ion and a mo e signi ican commi men o ea men as he
main ad an age o SDM and he lack o pa ien p epa a ion o unde s and hei illness as
he main d awback. They poin ed ou he lack o ime and esou ces as he main obs acle.
4.1. S eng hs and Limi a ions
The design and p esen a ion o he s udy ha e ollowed he CHERRIES publica ion
guideline [22,23], so necessa y measu es ha e been aken o main ain he quali y equi ed
in his ype o esea ch. The esul s we e unde pinned by he inclusion o a signi ican
numbe o pa icipan s, 459, all om di e en speciali ies and pe iods o p o essional ca-
ee s in Eu ope and La in Ame ica, wi h e y di e en heal h sys ems [31].
The lack o es ablished psychome ics o he su ey could be conside ed a limi a ion.
Howe e , his psychome ic alida ion aimed ypically o adap and alida e an ins u-
men o measu e elemen s o equen ly ambiguous con ex . In ou s udy, knowledge and
a i udes we e measu ed wi hou quan i ying o in eg a ing he esponses in o a complex
index.
The main limi a ion esul s om he pa icipan s’ selec ion bias implici in online su -
eys, which possibly leads o esponses in a ou o SDM. Social desi abili y bias was
inhe en o his kind o su ey. I could ha e led p o essionals o answe based on social
expec a ions a he han hei eal a i udes owa ds SDM [32]. Anonymi y and con iden-
iali y o he answe s we e used o educe i [33]. The e o e, he possible exis ence o a
selec ion and social-desi abili y bias u he ein o ces he esul s ob ained: e en among
Figu e 2. Main Obs acles o he implemen a ions o he SDM.
4. Discussion
Mos o he p o essionals who answe ed he su ey had a b oad knowledge and a
a ou able opinion abou SDM. Spanish speaking p ac i ione s we e keene o help he
pa ien unde s and he in o ma ion p ocess and ask abou pa ien expec a ions. Mo e A -
gen ineans hough abou SDM as an essen ial elemen in BC managemen and an obli-
ga ion o pu sue. Rega ding he awa eness- aising and a i ude abou SDM, pa icipan s,
mainly Spanish, ag eed on he necessi y o p o iding enough ime o p ac ice SDM and
on he join choice o ea men . Conce ning he cu en and u u e applica ion o SDM,
he e was high ag eemen on he need o mo e aining. The leas ag eemen was obse ed
o he necessi y o ag ee wi h pa ien s on he p ocess’s ollow-up and he cu en and
u u e implemen a ion. This was mainly in he a ailabili y o speci ic consul a ions o
ime and esou ces o SDM in he pa icipan se ice. On he o he hand, pa icipan s
highligh ed pa ien sa is ac ion and a mo e signi ican commi men o ea men as he
main ad an age o SDM and he lack o pa ien p epa a ion o unde s and hei illness as
he main d awback. They poin ed ou he lack o ime and esou ces as he main obs acle.
4.1. S eng hs and Limi a ions
The design and p esen a ion o he s udy ha e ollowed he CHERRIES publica ion
guideline [
22
,
23
], so necessa y measu es ha e been aken o main ain he quali y equi ed
in his ype o esea ch. The esul s we e unde pinned by he inclusion o a signi ican
numbe o pa icipan s, 459, all om di e en speciali ies and pe iods o p o essional
ca ee s in Eu ope and La in Ame ica, wi h e y di e en heal h sys ems [31].
The lack o es ablished psychome ics o he su ey could be conside ed a limi a-
ion. Howe e , his psychome ic alida ion aimed ypically o adap and alida e an
ins umen o measu e elemen s o equen ly ambiguous con ex . In ou s udy, knowl-
edge and a i udes we e measu ed wi hou quan i ying o in eg a ing he esponses in o a
complex index.
The main limi a ion esul s om he pa icipan s’ selec ion bias implici in online
su eys, which possibly leads o esponses in a ou o SDM. Social desi abili y bias
was inhe en o his kind o su ey. I could ha e led p o essionals o answe based on
social expec a ions a he han hei eal a i udes owa ds SDM [
32
]. Anonymi y and
con iden iali y o he answe s we e used o educe i [
33
]. The e o e, he possible exis ence
o a selec ion and social-desi abili y bias u he ein o ces he esul s ob ained: e en among
hose p o essionals mos likely o use SDM, he e is a lack o use, and in pa icula o ime
and esou ces.
In . J. En i on. Res. Public Heal h 2021,18, 2128 9 o 15
On he o he hand, sending he su ey by open dis ibu ion made i impossible o
es ima e he eal esponse a e [
28
,
29
]. E-mail dis ibu ion o su eys has a lowe esponse
a es han o he dis ibu ion ou es such as elephone su eys [
29
]. Fo una ely, p e ious
e iews iden i ied smalle - han-an icipa ed di e ences be ween physician esponden s
and non- esponden s and be ween ea ly and la e esponde s [
34
–
36
], sugges ing low
non esponse bias a es [
28
]. The comple ion a e was high, sugges ing ecogni ion o he
impo ance o his issue o quali y heal h p ac ice oday.
The ques ionnai e was alida ed by a pilo es sen o i een BC specialis . We we e
using ques ions o explo e concep s, belie es and a i udes. No o he ools we e ound use-
ul o measu e hese aspec s, so we did no ha e a gold-s anda d o alida e how accu a ely
he selec ed ques ions assess e e y domain (knowledge, opinion, awa eness- aising and
a i ude abou SDM, and cu en o u u e applica ion o i ). Lack o answe a iabili y is
p oblema ic in elemedicine su eys because o i s ha m ul e ec s in esponses sensi i i y
and eliabili y. This ceiling e ec esul ed om high sa is ac ion a ings. Al hough one
p esumed solu ion would be o c ea e a a ing scale wi h mo e signi ican disc imina ion o
esponses in he con inuum scale [
37
], some s udies ha e ound he numbe o a ing poin s
un ela ed o c oss-sec ional eliabili y [
38
,
39
]. The e was no enough e idence o suppo
his s a emen [
37
]. We ha e c ea ed a 5-poin Like scale ha has been demons a ed
assu ance be o e [26,27].
Rega ding compa isons e e ing o 23 i ems as a dependen a iable, we could
suppose ha pa o he di e ences de ec ed migh be due only o chance. This was an
addi ional limi a ion, mainly when he e ec o age, sex, size and se ing o he hospi al
and he pa icipan ’s speciali y has been analyzed o each i em. De e mined pa e ns ha e
no been app ecia ed, and he esul s we e in e p e ed wi h g ea cau ion.
Rega ding pa icipan s’ cha ac e is ics, mos o he pa icipan s did no belong o
b eas uni s. This was possibly due o he high equi emen s necessa y o cons i u e a
b eas uni [
40
], which means ha he e we e no oo many b eas uni s in hospi als in
absolu e numbe s. A mo e decisi e da a we e he numbe o pa ien s ea ed by each
pa icipa ing physician. A o al o 46.97% o he pa icipan s ea ed mo e han 100 pa ien s
pe yea , a signi ican numbe o cases in indi idual e ms and allowed consis ency o he
indings ound in his s udy.
I has also been shown ha pa icipan s unde 50 yea s old we e opene o SDM.
Howe e , i migh p obably in luence ha doc o s unde 50 yea s o age we e mo e amilia
wi h ou su ey’s dis ibu ion ne wo ks. Howe e , a mo e p ecise analysis could obse e
ha mos pa icipan s we e unde 50 yea s o age because hey we e he as majo i y
o ac i e wo ke s in BC oday. In he majo i y o he coun ies, he e i emen age is
con empla ed om 65 yea s. Mo eo e , apa om he ac ha his olde popula ion would
p esumably be less in e es ed in upda ing hei knowledge, i was also less in e es ing o
ou s udy since hey did no ep esen ac i e BC managemen wo k.
4.2. Implica ions
To ou knowledge, his s udy was he i s in e na ional su ey o BC specialis s on
he unde s anding, a i ude and applica ion o SDM. This was su p ising as SDM is an
essen ial componen o quali y heal h ca e [
8
,
9
] and a legal obliga ion in mos de eloped
coun ies [
11
–
13
]. The p ac ice o SDM in cance ca e has been p oposed as a c ucial
elemen o change a sys em’s cou se in c isis owa ds excellence and sus ainabili y [
4
].
I s implemen a ion in BC ca e cons i u es a e y demanding pa h, which implies he
c ea ion o mul idisciplina y eams wi h a high scien i ic- echnical le el, excellen coo di-
na ion, con inui y o ca e and communica ion wi h he pa ien , and a pe sis en e iew
o he esul s o a con inuous imp o emen p og am. Al hough he e a e no p e ious
s udies o he en i onmen al impac ha SDM could cause, i would be logical o hink ha
inc easing he e iciency and quali y o BC managemen would educe he use o esou ces.
This would ul ima ely be one mo e oo hold o impulse he use o SDM. Mo e s udies
should be done o suppo his s a emen .
