Patient Education and Counseling 95 (2014) 281–287

A classification model of patient engagement methods and assessmentof their feasibility in real-world settings

Stuart W. Grande a, Marjan J. Faber b, Marie-Anne Durand c, Rachel Thompson a,Glyn Elwyn a,d,e,*a The Dartmouth Center for Health Care Delivery Science, Dartmouth College, Hanover, USAb Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlandsc School of Psychology, University of Hertfordshire, UKd The Cochrane Institute for Primary Care and Public Health, Cardiff University, Cardiff, UKe The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, USA

A R T I C L E I N F O

Article history:

Received 14 September 2013

Received in revised form 19 December 2013

Accepted 26 January 2014

Keywords:

Patient engagement

Patient–provider communication

Review

Methods

Clinical encounter

A B S T R A C T

Objective: Examine existing reviews of patient engagement methods to propose a model where the focus

is on engaging patients in clinical workflows, and to assess the feasibility of advocated patient

engagement methods.

Methods: A literature search of reviews of patient engagement methods was conducted. Included

reviews were peer-reviewed, written in English, and focused on methods that targeted patients or

patient–provider dyads. Methods were categorized to propose a conceptual model. The feasibility of

methods was assessed using an adapted rating system.

Results: We observed that we could categorize patient engagement methods based on information

provision, patient activation, and patient–provider collaboration. Methods could be divided by high and

low feasibility, predicated on the extent of extra work required by the patient or clinical system. Methods

that have good fit with existing workflows and that require proportional amounts of work by patients are

likely to be the most feasible.

Conclusion: Implementation of patient engagement methods is likely to depend on finding a ‘‘sweet-

spot’’ where demands required by patients generate improved knowledge and motivate active

participation.

Practice implications: Attention should be given to those interventions and methods that advocate

feasibility with patients, providers, and organizational workflows.

� 2014 Elsevier Ireland Ltd. All rights reserved.

Contents lists available at ScienceDirect

Patient Education and Counseling

jo ur n al h o mep ag e: w ww .e lsev ier . co m / loc ate /p ated u co u

1. Introduction

In the US, as elsewhere, there is growing policy support forengaging patients [1–5]. Health care payers and insurers, likeUnitedHealth, realizing the untapped benefits that might follow,also advocate for patient engagement [6]. Yet, while policy interestis high, the work required to implement patient engagementmethods remains a perennial challenge [7]. Barriers to adoption,like workload pressures and complex organizational systems, arenumerous and difficult to overcome [8,9]. As a consequence, efforts

* Corresponding author at: The Dartmouth Center for Health Care Delivery

Science, Dartmouth College, 37 Dewey Field Road, Hanover, NH 03755, USA.

Tel.: +1 603 646 2295; fax: +1 603 646 1269.

E-mail address: glynelwyn@gmail.com (G. Elwyn).

0738-3991/$ – see front matter � 2014 Elsevier Ireland Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.pec.2014.01.016

to engage patients in clinical settings have met resistance in realworld settings [10].

Patient engagement has often been conflated with other termslike patient activation and, consequently, there is confusion in theliterature. Hibbard and colleagues define patient activation as‘‘understanding one’s role in the care process and having theknowledge, skill and confidence to manage one’s health and healthcare’’ [4]. Patient engagement has multiple definitions [3,11], buthas broadly been defined as the process of actively involving and

supporting patients in health care and treatment decision making

activities [2,3,12,13]. Patient engagement can target professionals,patients, the organizational environment, and the interventionitself [14]. The literature on patient engagement recognizes policylevel tensions where efforts to communicate risk and involvepatients in their care [15] are seen as critical to improving qualityand costs of patient care [5,13]; yet, many of these broaderreflections on patient engagement have made it increasingly

S.W. Grande et al. / Patient Education and Counseling 95 (2014) 281–287282

difficult to identify what, where, and how methods to engagepatients can be introduced into routine clinical settings. To addressthis knowledge gap, we concentrate our attention on methods toengage patients, specifically, in clinical settings (i.e., the first levelof engagement–direct care [3]).

The arguments in favor of engaging patients are numerous andinclude those derived from the ethical principles of enhancingagency and respecting autonomy [16]. Although not alwaysreferred to as patient engagement explicitly, the practice ofengaging patients using decision support tools has been shown tohave many positive outcomes, including reduced decisionalconflict [17,18], improved treatment adherence to asthmapharmacotherapy [19], improved likelihood of receiving guide-line-concordant depression care and improved symptoms [20],improved confidence in dealing with breathing problems andclinical care for patients with COPD [21], and enhanced healthstatus [22]. However, despite this evidence of benefit, manymethods fail to be implemented in routine clinical settings [7,23].We observe that there has been insufficient attention given to thisissue and suggest that it is time to assess the feasibility ofadvocated methods, especially in real world settings [24].

The purpose of this article is to assess the feasibility ofsuggested patient engagement methods in order to understandhow implementation might be improved. Assessing feasibility ofpatient engagement methods in clinical practice, as for anyinnovation, requires an understanding of barriers to implementa-tion [25]. Barriers to the implementation of shared decisionmaking, one of many forms of patient engagement methods,include provider perceptions of lack of time [9] and limitedapplicability of the approach for some patients and clinical settings[9]. It is reasonable to assume that these cited barriers would alsoapply to other forms of patient engagement. While some reviewsreport the effectiveness of patient engagement methods, there areonly a few examples of successful implementation strategies[23,26]. Given this mismatch between aspiration and reality, wehave three objectives in this study: (1) to describe existing reviewsof patient engagement methods; (2) to propose a model of patientengagement methods where the focus is on patient engagement inclinical workflows; and (3) to assess the feasibility of advocatedpatient engagement methods.

2. Method

We define patient engagement methods as tools or strategies,applied as part of the clinical workflow, that support patientsthrough a process of being involved as partners in their own healthcare and decision making activities.

2.1. Search for reviews of patient engagement methods

Drawing from our definition of patient engagement, wesearched the literature for existing reviews of patient engagementmethods. We searched three databases (PubMed, Medline, andGoogle Scholar) using the following key words: patient, engage-ment, activation, communication, clinical encounter, shareddecision making, intervention, and reviews.

2.2. Selection of reviews of patient engagement methods

We included reviews of patient engagement methods pub-lished in English in peer-reviewed journals. We excluded whitepapers, reports, and individual primary studies. Reviews had toinclude patient engagement methods targeted at patients (eitheralone or as part of the patient–provider dyad). Reviews were notincluded if they featured studies that targeted providers alone (e.g.,provider training). Provider-targeted reviews of methods were

excluded strictly for the purposes of clarity and scope. Two raters(SG and MF) independently checked the reviews for eligibility.

2.3. Working toward a model of patient engagement

We extracted data about the salient characteristics of reportedpatient engagement methods. We explored the timing of eachmethod relative to the clinical encounter, how many individualswere involved in the delivery of the method, how the method wasused by patients (directly or indirectly), and in what form themethod was delivered to patients. These patient engagementmethods were then categorized using an iterative process, basedon a constant comparison of salient characteristics that is widelysupported in the literature [27,28].

2.4. Feasibility of patient engagement methods

We assessed the feasibility of the reviewed patient engagementmethods using a customized qualitative rating system. We definedfeasibility as both likely uptake (i.e., acceptability) in routineclinical practice [29], and how successful the method may be whenused within a specific context or setting [30]. Two researchers (SGand MF) qualitatively assessed the feasibility of each method,based on reported findings, using three scoring criteria: (1) howmuch work is required of the patient (patient effort—low,moderate, high, variable), (2) the number of additional humanresources (e.g., time, expertise) likely required to implement themethod (additional human resources—no, yes, variable), and (3)how well the method might fit into usual clinical workflows (builtwithin existing system—poor, fair, good, high). Illustrativeexamples of qualitative assessment criteria from included reviewsof methods were shared and consensus achieved prior toindependent rating by SG and MF. Based on each individualqualitative assessment, overall feasibility of methods was assigneda ‘‘low’’ or ‘‘high’’ rating by two authors (SG and MF). Final ratingvalidation was determined by convergence using investigatortriangulation and reconfirmed by a third independent rater (GE).

3. Results

3.1. Literature review

After applying the inclusion and exclusion criteria, we includedten reviews of patient engagement methods [10,23,31–38]. Weexcluded seven reviews (see Appendix 1).

3.2. Reviews of methods

Table 1 provides details of the included reviews. The patientengagement methods included were extracted from articles from1977 to 2011 that represent decades of research examining methodsto activate and engage patients in and around the clinical encounter.A majority of articles have been published since 1990. The methodsincluded using health coaches to inform and activate patients [37]and a wide variety of patient decision aids [38]—most often in theform of videos and handouts—that were designed to preparepatients and, in some cases, physicians, for the patient–providerconversation. Other methods included the use of educationalmaterials [34] and the use of written materials to help patientscommunicate with physicians and clarify their health needs [35,38].

While some patient engagement strategies that adopt tools toinform patients are effective, findings reveal they work best tosupport, not replace, face-to-face communication within theclinical encounter [32]. Methods that prepare patients forthe clinical encounter, like pre-consultation interviews [33]where clinical or non-clinical staff counsel patients prior to their

Table 1Description of included reviews.

Author Method Description Findings

Coulter [31] Patient engagement Selective review of interventions designed to support

patients to play an effective role in care processes. The

review covers strategies to improve health literacy and to

support shared decision making.

The effectiveness of patient engagement

interventions varies.

Coulter and Ellins [32] Strategies for

informing, educating,

and involving patients

Literature review of 129 systematic reviews on patient

focused interventions for health literacy, clinical decision

making, self care, and patient safety.

Decision aids are most effective when they

augment, not replace, human interaction.

Griffin [33] Interaction between

patients and

practitioners

Systematic review of 35 studies in primary care that aim to

alter the interaction between patients and practitioners.

Examples of interventions include: skills training with

patients, leaflets, help cards, pre-visit interviews, in-

consultation booklets/information provision, and

communication skills training with providers. Some

combinations delivered to both patients and providers.

Interventions show inconsistent findings.

Harrington [23] Improving patient

communication with

doctors

Systematic review of 20 studies that evaluated patients’

communication with doctors in (any setting) and reported

data on impact of intervention, which include the following

behaviors: question asking, raising concerns, and

requesting clarification or checking understanding.

Encouraging patient participation in

consultations leads to greater sense of control

and preference for more active role.

Haywood [34] Patient participation in

consultation process

Structured review of 146 articles examining interventions

to enhance patient participation in the consultation. Patient

targeted interventions include: checklist, coaching,

education material, goal setting, group education, patient-

held record, PROM, questionnaires, and values clarification.

Patient–provider partnership in the

consultation is encouraged.

Kinnersley [35] Question prompt lists Systematic review of interventions to encourage question

asking, include question checklists, coaching and checklists,

videos, and written materials, each designed to assist

patients with getting more appropriate/relevant

information from their providers.

Interventions increased patient question

asking.

Kruijver [36] Patient perceptions of

sharing in decisions

Literature review of communication training programs in

nursing care to assess nurse behavior change and patient

outcomes as well as communication quality and perception

of change in nurse communication behavior.

Limited evidence links nursing behavior change

and patient outcomes.

Rao [10] Interventions designed

to improve

communication

between patients and

providers

Systematic review of 36 studies that focused on

interventions characterized by information, feedback,

modeling, and practice.

Efforts to improve patient–provider

communication through method design need to

be integrated into routine practice.

Stacy [38] Decision Aids Systematic review of 86 studies that evaluated a range of

DA’s including: pamphlets, videos, or web-based tools.

DAs increase knowledge about perceived risk.

Stacey [37] Decision Coaching Systematic review of decision coaching in trials of patient

decision aids (PtDA). Decision coaches are professionals

trained to develop patient confidence and skills to

communicate with providers about health decisions.

Decision coaching improves knowledge but

comparable to PtDA. Impact on quality needs

investigation.

S.W. Grande et al. / Patient Education and Counseling 95 (2014) 281–287 283

exam, communication skills training [36], or question promptsheets [35], show promise, but evidence is mixed or inconclusive.Methods to improve health literacy and shared decision making[31] show some effectiveness, but are often difficult to imple-ment in routine practice [39], where too much is often asked ofpatients [40]. Interventions designed to improve patient–provider communication [10,23] are seen as essential to goodpatient-centered care, yet have not been routinely implementedinto clinical care [41,42].

3.3. Classification model of methods

Based on an examination of the ten included reviews, werecognized that methods can be visualized within a progressivestructure, starting from those designed primarily to providepatients with information to those designed to activate specificbehaviors [2] to those designed to stimulate participation andcatalyze collaboration. This arrangement suggests the idea of steps,where elements are progressively combined, i.e., a classificationmodel (Fig. 1). We describe the methods illustrated in the figure inmore detail below, and use examples to explain the model.

3.3.1. Passive information provision

This category describes methods based on information provi-sion to patients, in passive ways, using either booklets or one-page

leaflets [43], web-based text pages [44], DVDs [45], or other media.The provision of information is characterized by a unidirectionaltransmission of information where the patient’s role is passive, andthe provider is not involved in the delivery of the information.

3.3.2. Information + activation

This category targets patients by encouraging, prompting,coaching, helping, and supporting them to perform specificengagement behavior(s) in the clinical encounter, such as: askingquestions, requesting clarification, and sharing what matters most.Mittler’s [2] definition of ‘‘activation’’ is aligned with this information

and activation group and includes methods focused on skills andmotivation to enact particular communication behaviors with aprovider, e.g., ask questions. This group of methods is quite diverse inboth the level of interaction and delivery type, (i.e., human orcomputer). Within this category, we make a distinction betweenmethods that target self-efficacy (confidence) and those thatemphasize interaction in skill development (preparing to commu-nicate), which we demonstrate in our model by an increase inshading (Fig. 1). One example of a method designed to target apatient’s confidence is a web-based decision aid that generatestailored data and questions explicitly for use in the clinicalencounter [46]. Another is a pre-visit tool designed to helppatients improve their communication with providers byprompting them to ask specific questions prior to meeting with

Fig. 1. Classification model of patient engagement.

S.W. Grande et al. / Patient Education and Counseling 95 (2014) 281–287284

their provider [47]. A final example is a multidimensionalintervention that combines coaching (consultation + planning)and feedback (recording + summarizing) by modifying a patient’spreparation for, and recall of, their clinical visit [48].

3.3.3. Information + activation + collaboration

This category adds a component that attempts to foster genuinepatient–provider dialog, where there are explicit expectations thatthe interaction is one in which two (or more) participants worktogether to share information, views, and perspectives, using toolsthat catalyze engagement. The last grouping of methods builds on

Table 2Feasibility of methods of patient engagement.

Classification Delivery medium and/

or method

Description

Passive information

provision

Text-based information A document with either gener

specific health related informa

(any media)

Audio-visual

information

A/V information describing,

teaching or demonstrating

Combination text-

based and audio-visual

information

Multifaceted information to re

view, and practice

Information + activation Text-based prompts to

action

List of questions prepare patie

give feedback to provider

Human interaction Consultation with professional

pre-visit

Human interaction and

Text-based prompts to

action

Consultation with professional

pre-visit, prepare questions fo

visit, feedback to provider

Text-based information

and Human interaction

A document with either gener

specific health related informa

(any media) completed with

assistance by a professional

pre-visit

Information + Activation

+ Collaboration

Point of care

engagement tools

Tools/Method focused on

supporting, creating, and

maintaining collaboration with

the clinical encounter; may be

designed for multiple points o

engagement, and allow for pat

and provider input

the other groups and introduces collaboration, a two-waycommunication process that supports engagement. Methods ofthis type share the goal of more and better conversations betweena patient and provider, and facilitate communication of evidenceand elicitation of patient preferences at the point of care. Montoriand colleagues [49,50] developed a set of simple ‘‘issue cards’’ toassist providers and diabetic patients in discussing risks, benefits,and concerns related to medication options (with the cards alsoavailable to take home for further discussion with family). Elwyndeveloped Option Grids, one-page decision support tools designedto provide evidence-based answers to patients’ frequently asked

Patient work

required?

Additional human

resources required?

Fit within existing

system?

Overall

feasibility?

al or

tion

Variable No Good High

Variable No Good High

ad, High Variable Poor Low

nts, Low Yes Good High

Moderate Yes Fair Low

r

High Yes Poor Low

al or

tion

High Yes Fair Low

in

f

ient

Moderate No Good High

S.W. Grande et al. / Patient Education and Counseling 95 (2014) 281–287 285

questions about available options, for use by patient and providertogether [51]. Giguere and colleagues developed decision boxes [52],one- or two-page documents for providers to use in the clinicalencounter with patients, as a way to share evidence-based risks andbenefits, and the types of decisions needing to be made. Collectively,we refer to these as point of care engagement tools (POCET).

3.4. Feasibility of patient engagement methods

Our assessment contends that strategies requiring additionalhuman resources, such as a health coach or physician assistant, toimplement patient engagement methods are less feasible becausethey require more changes in usual practice, and are, as confirmedby reviews of barriers to implementation [25,53], likely to be lesssustainable (Table 2). We also suggest that text-based prompts to

action seem to require less patient effort and do not placeadditional workflow burdens on usual practice, though we findthat some additional human resources would be required todistribute materials, collect data, and provide feedback results tophysicians. In cases where patient burden is high, we find overallfeasibility is low (Table 2). Human interaction, while offeringbenefits to patients and families, does require patient time beforethe encounter and a health professional to provide that interaction,and most likely would require additional time, space, and recordsmanagement within the workflow. Point of care engagement tools

(POCET) do require a moderate amount of patient work, butbecause the method leverages existing systems (the clinicalencounter), the provider serves as the only human resource.

4. Discussion and conclusion

4.1. Discussion

Our feasibility assessment of patient engagement methodsdesignated four as having high feasibility and four as having lowfeasibility, based on whether the methods required reasonablelevels of patient work (sufficient but not overwhelming) andwhether realistic investments could be expected of providers andtheir organizations. As we define them, areas of high feasibility takeadvantage of existing workflows and gaps in workflows and/orrequire little, if any, additional human resources, e.g., healthcoaches or clinical staff to support patients to become informed orencouraged to adopt more active approaches. On the other hand,we define low feasibility as methods characterized by: (1)significant patient burden (e.g., a 45-min video or a large bookletof information); (2) poor fit with complex clinical workflows; and(3) additional time and work separate from the hospital or doctorvisit, i.e., the use of coaches. While methods that inform andprompt patients to be engaged are helpful, when used alone theyare unlikely to catalyze a meaningful shift in behavior. The powergradient between patients and providers is too steep to beovercome by methods that do not influence the actual communi-cation process [54–56]. This power gradient is particularlyconsequential for the underserved patient, who may also benefitthe most from these methods of engagement [4,57]. Interventionsthat explicitly influence the patterns of deliberation may be likelyto produce true engagement patterns. To summarize, engagingpatients might not be achieved by only providing information oradvocating patients become more activated. Possible new tech-nologies might augment activation, e.g., avatars, simulations, andvirtual worlds, provided that attitudes and behaviors of providersactualize new patterns of engagement behaviors. In addition, theprofession of medicine is highly institutionalized [58] and providerbehavior is unlikely to change based solely on provider-targetedmethods [14,59]. Therefore, tools that promote the third group ofmethods from the model (inform + activate + collaborate), by

engaging patients and providers in collaboration at the point ofcare, are the most likely to be both feasible and effective.

We were unable to find other articles that have sought tocritically investigate the feasibility of patient engagement methodsand/or to provide a detailed assessment of those methods. Onereview describing ‘‘what is lacking’’ with decision aids, foundfeasibility of decision aids in practice to be under-reported [24].Although recent trial evidence debates the effectiveness of stand-alone decision aids and finds promise in patient–provider targetedinterventions [42], there still remains uncertainty about thefeasibility and use of these methods in routine practice. Wepropose this classification model of patient engagement methodsas a means to re-consider how best to implement patientengagement methods, and as a way to build on the analysis ofmethods proposed by Griffin [33], Haywood [34], and Coulter [31].

A strength of this approach was basing the search for methods onexisting reviews of patient engagement methods so that we couldfocus on our core aim of assessing their feasibility in real worldclinical settings. This article is limited to methods of patientengagement that focused on patients; we did not assess feasibility ofmethods reflective of provider behavior or skill development.Arguably, such an investigation, while potentially informative,necessitates a much larger discussion related to culture change,provider autonomy, and medical education; therefore, such a reviewwas determined to be beyond the scope of this manuscript. Wefurther recognize that unpublished patient engagement methodsthat may be novel, innovative, and currently used in practice, wouldnot be included in a review of published tools or strategies.

4.2. Conclusion

The likelihood of a method being feasible appears to depend onfinding a ‘‘sweet-spot’’ where patients’ learning burden is not sohigh as to overwhelm their capacity to absorb new information andtake on more active roles. Further, levels of patient need andinterest in engagement vary between patients as well as within apatient—one can become more willing to engage once circum-stances have changed—highlighting the need for tailored messagesand methods. Just how effective these kinds of methods might berequires further evaluation. We believe this classification modelillustrates that a graduated approach might be more successful atdelivering better engagement levels.

4.3. Practice implications

Considering widespread policy interest to ‘‘integrate thepatient’s voice into the research process’’ [1], research and practicemight benefit by focusing on patient engagement methods thathave the greatest likelihood for success. This classification modelmay help promote more feasible solutions. Methods that usedsimulation-based tools such as embodied agents (avatars) andvirtual worlds [60] might be considered as fitting into the model,delivering elements of information, activation, and collaboration inintegrated ways that require less face-to-face time with existinghealth professionals. Ultimately, we conclude that tools thataccomplish all three components of patient engagement—inform,activate, and collaborate—are most likely to succeed.

Funding

This work was supported by the Dartmouth Center for HealthCare Delivery Science.

Acknowledgement

We acknowledge the significant contribution of Robin ParadisMontibello, information scientist, in supervising the literaturesearch and collaborating on edits and revisions.

Appendix 1. Excluded reviews

Excluded reviews Description Reasoning

Greenhalgh J, Meadows K. The effectiveness of the use of

patient-based measures of health in routine practice in

improving the process and outcomes of patient care: a

literature review. J Eval Clin Pract 1999;5:401–16.

Literature review of 13 studies that evaluated patient-based

measures of health in practice. Types of interventions

assessed include: individual/group education.

Target patient-based measures of

provider based interventions

Espallargues M, Valderas JM, Alonso J. Provision of feedback on

perceived health status to health care professionals: a

systematic review of its impact. Med Care 2000;38:175–86.

Systematic review that looked at groups or individual

doctors, RCTs, used feedback of information. Reviewed

primary practice, and 6 outpatient practices.

Targeted physicians in primary practice

who receive feedback from patients.

Lewin SA, Skea ZC, Entwistle V, Zwarenstein M, Dick J.

Interventions for providers to promote a patient-centered

approach in clinical consultations. Cochrane Database Syst Rev

2001.

Systematic review of interventions for providers to

promote a patient-centered approach in clinical

consultations.

Targeted interventions to change

provider patient-centered behavior

Marshall S, Haywood K, Fitzpatrick R. Impact of patient-

reported outcome measures on routine practice: a structured

review. J Eval Clin Pract 2005;12:559–68.

Structured review of 38 studies evaluated 25 different

PROMs being used in routine practice. PROMs include self-

reported questionnaires that contain questions related to

health status or quality of life.

Targeted effect of patient reported

measures when fed back to providers

Giguere A, Legare F, Grimshaw J, Turcotte S, Fiander M,

Grudniewicz A, et al. Printed educational materials: effects on

professional practice and healthcare outcomes. Cochrane

Database Syst Rev 2012;10.

Systematic review of studies including those that looked at

printed education material (PEM) as intervention to

improve clinician knowledge, attitudes, and skills and

clinical practice these include: printable documents on

web, mass media, practice guidelines, journal articles, and

monographs).

Targeted the effect of printed education

material on physician behavior

Legare F, Ratte S, Stacey D, Kryworuchko J, Gravel K, Graham ID,

et al. Interventions for improving the adoption of shared

decision making by healthcare professionals. Cochrane

Database Syst Rev 2010;5.

Systematic review of interventions designed to have health

professionals adopt shared decision making including:

decision aids, pamphlet, education meeting, and audit/

feedback.

Targeted effects of professional health

behaviors around adoption of decision

support tools

Legare F, Turcotte S, Stacey D, Ratte S, Kryworuchko J, Graham

ID, et al. Patients’ perceptions of sharing in decisions: a

systematic review of interventions to enhance shared decision

making in routine clinical practice. Patient 2012;5:1–19.

Review, which includes patient evaluated SDM

interventions of provider adoption of SDM by a self-

administered questionnaire. All included studies were

RCTs.

Targeted patient feedback on provider

adoption of shared decision making

S.W. Grande et al. / Patient Education and Counseling 95 (2014) 281–287286

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