Optimizing the design and implementation of question prompt lists to support person‐centred care: A scoping review

Abstract Introduction Question prompt lists (QPLs) are lists of questions that patients may want to discuss with clinicians. QPLs support person‐centred care and have been associated with many beneficial outcomes including improved patient question‐asking, and the amount and quality of the information provided by clinicians. The purpose of this study was to review published research on QPLs to explore how QPL design and implementation can be optimized. Methods We performed a scoping review by searching MEDLINE, EMBASE, Scopus, CINAHL, Cochrane Library and Joanna Briggs Database from inception to 8 May 2022, for English language studies of any design that evaluated QPLs. We used summary statistics and text to report study characteristics, and QPL design and implementation. Results We included 57 studies published from 1988 to 2022 by authors in 12 countries on a range of clinical topics. Of those, 56% provided the QPL, but few described how QPLs were developed. The number of questions varied widely (range 9–191). Most QPLs were single‐page handouts (44%) but others ranged from 2 to 33 pages. Most studies implemented a QPL alone with no other accompanying strategy; most often in a print format before consultations by mail (18%) or in the waiting room (66%). Both patients and clinicians identified numerous benefits to patients of QPLs (e.g., increased patient confidence to ask questions, and patient satisfaction with communication or care received; and reduced anxiety about health status or treatment). To support use, patients desired access to QPLs in advance of clinician visits, and clinicians desired information/training on how to use the QPL and answer questions. Most (88%) studies reported at least one beneficial impact of QPLs. This was true even for single‐page QPLs with few questions unaccompanied by other implementation strategies. Despite favourable views of QPLs, few studies assessed outcomes amongst clinicians. Conclusion This review identified QPL characteristics and implementation strategies that may be associated with beneficial outcomes. Future research should confirm these findings via systematic review and explore the benefits of QPLs from the clinician's perspective. Patient/Public Contribution Following this review, we used the findings to develop a QPL on hypertensive disorders of pregnancy and interviewed women and clinicians about QPL design including content, format, enablers and barriers of use, and potential outcomes including beneficial impacts and possible harms (will be published elsewhere).

5][6] A 2018 meta-analysis of 28 systematic reviews identified multiple strategies that support PCC categorized as communication tools, patient and/or communication skills training, health coaching, counselling, motivational interviewing, physical support, environmental changes and healthcare system processes. 7The meta-analysis found that communication tools were the most frequently used strategy, leading to improved patient knowledge, self-management of health, satisfaction with healthcare experiences and quality of life. 7While there is no widelyaccepted formal definition, in this context, 'communication tools' appear to be resources used by patients, family and/or clinicians to support person-centred discussions during clinical consultations. 8estion prompt lists (QPLs) are an increasingly common tool to promote and support patient-clinician communication, typically consisting of a list of questions that patients may want to ask or discuss with clinicians. 9,10While shared decision-making is a component of PCC, QPLs can be distinguished from other communication tools such as decision aids, which help patients consider values and preferences to engage in shared-decision making. 11QPLs enable patients to voice concerns and uncertainties via question-asking, prompting patient-clinician discussion about any topic relevant to a particular condition or health concern of importance to patients, and not only decisions about treatment or management of a health issue. 9,10QPLs have been used to support the discussion of various medical conditions amongst different populations.For example, an Internet search identified 173 QPLs on a wide range of topics. 12In general, encouraging patients to ask questions reduces their anxiety, and increases their knowledge and satisfaction with healthcare visits. 13QPLs appear to offer many benefits for patients, clinicians and health systems.For example, Brandes et al. conducted a systematic review of 16 studies on QPLs in the oncology setting and found QPLs enhanced patient question asking during consultation, satisfaction with consultation, knowledge and recall of information; and reduced anxiety at follow-up. 9In another systematic review of 10 studies, cancer patients found QPLs more helpful than information sheets and may reduce anxiety at follow-up visits. 14A rapid review of 42 studies on QPLs in health consultations by Sansoni et al.   found that, in addition to the aforementioned benefits, QPL use increased the amount and quality of the information provided to patients by clinicians. 10 prior review characterized QPLs to identify common features,

| Approach
We conducted a scoping review, which is a type of synthesis that examines the current state of research on a particular topic, particularly for topics that are relatively new, research is of mixed design, or concepts or design issues lack clarity, as is the case for QPLs. 15,16We followed the methods initially proposed by Arksey and O'Malley, and refined by Levac et al. 15,17 We did not require institutional review board approval as data were publicly available, and we did not register a protocol because the International Prospective Register of Systematic Reviews does not accept scoping reviews.To optimize rigour, we adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews. 18

| Scoping
We conducted a preliminary search to become familiar with the QPL literature.J. U. R. searched MEDLINE using select search terms employed by authors of prior QPL syntheses including question prompt and question asking. 9,10J. U. R., W. B. B. and A. R. G. jointly reviewed search results to generate eligibility criteria and design a comprehensive search strategy.

| Eligibility
We developed eligibility criteria based on the population, intervention, comparisons, outcomes and time framework, 19 and refined those criteria prospective to screening.Supporting information: Additional  20 This created a preliminary yet detailed QPL definition to facilitate screening (Supporting information: Additional File 1).We included studies that used various terms for QPLs including but not limited to: QPL, question prompt sheet, communication tool, communication aid, frequently asked questions list and commonly asked questions list.Comparisons referred to studies that evaluated single-or multifaceted interventions involving a QPL, where studies aimed to assess QPL use and/or impact alone or compared with other interventions, either before and after, or only after exposure to the QPL.Publication types included English-language empirical studies based on qualitative, quantitative or multiple/mixed methods research design that evaluated a QPL.Outcomes included any reported by authors.No time restriction was applied; we included studies from database inception to the date of search.We excluded studies involving trainee or nonadult populations, and publications in the form of editorials, letters, opinions, protocols, abstracts or proceedings.We excluded studies of patient-generated question lists alone, a very different type of intervention compared with preformed QPLs.We also excluded studies that developed a QPL but did not evaluate its use or impact.Reviews were not eligible but we screened reference lists for eligible primary studies.

| Searching
We developed a comprehensive search strategy (Supporting information: Additional File 2) in conjunction with a medical librarian according to Peer Review of Electronic Search Strategy reporting guidelines. 21

| Data extraction
We developed fields of data extraction based on those used in prior QPL reviews, 9,10 further elaborated by our study purpose, eligibility criteria and WIDER categories, 20 and refined through the data extraction pilot-testing process.Given little prior research that focussed on associating QPL characteristics with impact, we aimed to extract data on a wide range of characteristics.J. U. R., S. D. and A. R. G. independently extracted data from the same four studies, then met to compare and discuss findings, resolve discrepancies and refine the approach to data extraction.This process was repeated for the next six articles, at which time data extraction was congruent.Thereafter, J. U. R. and S. D. extracted data from all remaining studies, consulting with A. R. G. about uncertainties.Periodically, A. R. G. and W. B. B. reviewed data extraction to independently ensure accuracy, consistency and clarity.We extracted data on study characteristics (publication year, country, research design and healthcare issue), how the QPL was developed, QPL characteristics and how the QPL was implemented based on the WIDER reporting recommendations: participants, personnel and QPL content (e.g., clinical topic, questions, number of questions, number of pages), format (e.g., print or online, booklet or brochure), delivery (e.g., how QPL was shared), 20 enablers and barriers to QPL use and impacts including the types of outcomes measured.

| Data analysis
We used summary statistics, text and tables to describe the number of studies by publication year, country, research design and healthcare issue; QPL development processes and implementation strategies, and enablers, barriers and impacts of QPL use.The methodological quality of studies was not assessed as this is not required for scoping reviews. 15,17 listed enablers and barriers of QPLs for patients and clinicians.To identify possible trends that could inform a future systematic review, we mapped QPL characteristics and implementation to impact, categorizing impact as either improved or no change.Impacts included any reported by studies such as the number of questions asked, satisfaction with communication or clinical outcomes.

| Review by stakeholders
Methodologists advocate for engaging stakeholders at the results phase of scoping reviews. 17In line with this recommendation, we used the findings of this review about common and effective characteristics of QPLs to develop a QPL on hypertensive disorders of pregnancy and interviewed women and clinicians to refine QPL design including content and format (will be published elsewhere).

| Search results
The search generated 1141 results.We removed 386 duplicates and discarded 652 ineligible titles/abstracts.We excluded 67 full-text studies because they did not investigate a QPL (n = 43), the population (n = 7), publication type (n = 9) and setting (n = 2) were ineligible, or did not evaluate a QPL (n = 6).Ultimately, we included 57 studies (Figure 1).

| Study characteristics
Supporting Information: Additional File 3 provides data extracted from included studies.  Studs were published from 1988 to 2022, with two-thirds (38, 66.7%) published in the last 10 years.
Studies were led by authors based in 12 countries, most often Australia (18, 31.6%) and the United States (17, 29.8%).Other countries included Germany, Korea, France, Sweden, The Netherlands, Italy, Norway, Japan and Singapore.Most QPLs were based on cancer topics (35, 61.4%).Two (3.5%) studies involved generic QPLs that were meant to prompt patients to ask questions about health topics of interest to them. 26,35Other clinical topics, even for generic QPLs, included heart disease, reproductive health (polycystic ovarian syndrome, menopause), mental health (depression), asthma, arthritis, diabetes, HIV, neurologic health (migraine), dermatologic health (atopic dermatitis) and surgical care (pre-and postoperative procedures).
Regarding research design, a large proportion of studies aimed to evaluate the impact of a QPL using a randomized controlled trial (31, 54.4%).

| QPL development
About half of the studies provided the QPL either in the article or via an accessible Internet link (32, 56.1%).Most studies mentioned some details about how the QPL was developed (43, 75.4%), with many drawing from various sources to acquire content including preexisting QPLs, clinical guidelines, clinical consultation audio recordings or published research.However, in most studies, details about QPL development were vague or implied.For example, 'The QPL group were shown a list of common questions (compiled by the researchers) which they could use for seeking clarification from their surgeons'. 624 | QPL design and implementation

| Views about QPLs
A total of 26 (45.6%) studies assessed patient views about QPLs.

| Enablers and barriers of QPL use
A total of 24 (42.1%)studies reported patient and/or clinician enablers or barriers to QPL use (Table 1).Enablers for patients included having sufficient time to read the QPL before appointments, 26,43,58 translation to the patient's primary language and cultural acceptability of questions 43,58 ; not too many questions or too lengthy ones, 26,31,32,48 clinical contexts involving sensitive topics 34,38,52,58 and when physicians encouraged them to ask questions on the QPL. 26,41,43Patient-reported barriers included the time required to read the QPL, 31,58,66 being accompanied to a consultation, 28,47 if questions were addressed in some manner before QPL use, 58,69,76 not having time to discuss QPL questions or additional questions during the consultation, 66,76 feeling overwhelmed, 33,58 feeling like clinicians disliked patient questionasking, 76 clinicians not being able to answer questions or discuss topics included in the QPL 24,32,33,56,72 and QPLs not being available in a language other than English. 58nablers for clinicians included receiving the QPL before consultations, 44,57 reliable supply of QPLs, 25,57 training on how to use the QPL, 24,32 the QPL is not too lengthy, 44 and reminders for administrative staff to provide QPLs to patients and/or clinicians. 57inician-reported barriers included clinician beliefs about the efficacy and relevance of QPLs, 75 time constraints for consultations with patients, 25,32,57 remembering to use the QPL, 57 lack of knowledge about or difficulty answering QPL questions 24,25,32,55,66 and concerns about perceived negative impacts on patients (e.g., increased anxiety). 24,32,57

| DISCUSSION
This scoping review of 57 studies that evaluated QPLs on a range of clinical topics explored factors that may influence QPL impact including QPL design and implementation.Most (87.7%) studies reported beneficial impacts associated with QPLs.Most often, QPLs increased patient confidence to ask questions and satisfaction with communication or care; and reduced their anxiety about health status or treatment.This was true even for single-page QPLs with few questions unaccompanied by other implementation strategies.
These findings build on prior research based on QPLs.Earlier research on QPLs largely focussed on the oncology setting, 9,10 but this review identified QPLs on a wide range of clinical topics, which in combination with other research, 12 shows that QPLs are relevant to patients with a wide range of health concerns.Prior reviews of QPLs, conducted before 2015, largely focussed on QPL effectiveness. 9,10is review updated prior reviews with current research, and by employing a scoping review approach, and exploring QPL design and implementation, expanded our knowledge of how to potentially optimize QPL effectiveness.By describing their characteristics in detail, this review revealed what constitutes a QPL. 11By focussing specifically on QPLs, this review highlights an important approach for supporting PCC not considered in a prior review of strategies for preparing patients before clinical visits, 81 or a prior review of reviews on strategies to support PCC that identified patient information, involvement in care and empowerment as important strategies but did not discuss how to operationalize them. 7Overall, this study T A B L E 1 Enablers and barriers of QPL use reported by patients and clinicians.

Patients
• Good translation and acceptability of questions 43,58 • Clinical contexts where QPLs support discussion of sensitive topics 34,38,52,58 • Having a sufficient amount of time to read the QPL before a consultation 43,58 • QPLs are a sufficient length-there are not too many questions 26,31,32,48 • QPL provided in an accessible format 26 • QPLs added in appointment software systems, or sent via SMS or mail 26,58 • High information needs 52,55,56 • Physician encouragement 26,41,64 • Time-consuming to read 31,58,66 • Time constraints of consultation 76 • Being accompanied to consultations 14,28 • Questions answered prior to QPL use 58,69,76 • Fear of not being able to discuss questions not provided on QPLs 66,76 • Feeling overwhelmed 33,58 • Perceiving that clinicians dislike question-asking 76 • QPLs not available in languages other than English 58 • QPL questions can cause patient anxiety 32,33,72

Clinicians
• Reliable supply of QPLs or other resources 25,58 • Reminders for administrative staff to provide QPLs to patients 58 • Consultations scheduled for longer time periods 25 • Training on using QPL 24,32 • Clinicians provided with QPLs prior to the consultation 44,58 • QPL is not too long 44 • Time constraints for consultations with patients 25,32,58 • Clinician beliefs on efficacy and relevance of QPLs 76 • Difficulty remembering to use QPL 58 • Difficulty answering certain questions on QPL 25,56 • Concerns about potential negative impacts on patients 24,32,58 • Clinicians lacking knowledge relevant to QPL questions 24,32,67 • Questions on QPL suitable for health setting 32 Abbreviation: QPL, question prompt list.
| 1409 solidified the important role that QPLs can play in person-centred communication and offers guidance to those developing and implementing QPLs.
Analysis of the findings offers insight into considerations for future QPL development.For example, only half of the studies included the QPL, two-thirds described implementation and most offered vague details of how they developed the QPL.All future QPL research should more consistently report QPL design and implementation based on reporting guidelines such as the WIDER criteria. 20ly then can QPL developers, implementers and users fully understand how to optimize QPL development and implementation.
Due to the limited detail about how QPLs were developed in most studies, it is not clear if or how patients were involved in QPL planning.Patient engagement in healthcare planning and improvement is becoming a worldwide standard. 82Patient engagement in designing QPLs represents another approach that could optimize QPL design, use and impact so that they meet patient needs and preferences.It would also be imperative to involve clinicians in planning QPL design and implementation to ensure that questions are clinically relevant and to optimize QPL adoption into clinical routines.One of the included studies that used a two-round Delphi survey to assess acceptability found that most of the questions they rated were deemed acceptable by 96 patients and 26 healthcare professionals. 24In other research studies focussed on clinical decision support systems, which represent possible disruptions to clinical routines similar to QPLs, involving clinicians in system design resulted in significant improvement in awareness and adoption of clinical practices recommended by the system. 83om the patient's perspective, QPLs should be made available in advance of clinical appointments to allow time to review the questions.
A systematic review found that previsit planning techniques targeting patients such as educational websites, telephone calls or selfassessment tools improved patient-provider communication, illness perception and knowledge, perceived involvement in care and patient satisfaction with consultations. 81Patients also expressed concern that clinicians would not be open to using the QPL.A possible implementation strategy to address this risk is to disseminate the QPL to both patients so that they can prepare for appointments, and to clinicians so that they are primed for its use.This strategy is supported by a systematic review that found that interventions to support patient-provider communication are more likely to be adopted and impactful if shared with both groups rather than only one group. 84om the perspective of clinicians, this study found they were most concerned about lacking the knowledge to answer QPL questions and desired training on how to use the QPL.Hence, sharing of QPLs with clinicians might be accompanied by or direct clinicians to educational materials including published articles or clinical guidelines, or a version of the QPL with answers to the questions plus links to additional information on the topic.Another option is for professional societies to endorse the QPL and make it available in conjunction with accredited continuing education.In some included studies, clinicians expressed concern that QPLs might cause anxiety amongst patients.In contrast, patients thought that QPLs would reduce anxiety about health status or treatment.Hence, the implementation of QPLs by clinicians could include evidence of the many benefits of QPLs including reduced patient anxiety amongst others.
These ideas are suggestions to overcome barriers reported in the included T A B L E 2 Reported benefits and harms associated with QPLs.
T A B L E 3 QPL impact by QPL design and implementation.[87] This study also identified knowledge useful to ongoing research.This study featured several strengths.The use of a scoping review approach to integrate the results of studies with different research designs revealed insight into how to optimize QPL development and implementation. 16We employed rigorous scoping review methods 15,17 and complied with standards for the conduct and reporting of scoping reviews and search strategies. 20,21Several limitations should also be noted.As is the case with all syntheses, our literature search strategy may not have identified all relevant studies.The decision to exclude the grey literature and the stringency of screening criteria may have excluded potentially useful studies.While not required of scoping reviews, 15,17 the lack of critical appraisal of included studies means that interpretation and application of the findings must be interpreted with caution.

| CONCLUSION
The purpose of this scoping review was to identify how to optimize QPL design and implementation.We included 57 studies that evaluated QPLs on a wide range of healthcare topics explore patient or clinician views on QPLs and examine other enablers or barriers of QPL use, or how QPLs were operationalized, knowledge needed to guide future development and implementation of QPLs.Lack of such knowledge impedes researchers and others from improving the design, implementation and evaluation of QPLs, limiting the potential of QPLs to support PCC.The purpose of this review was to synthesize published research that evaluated QPLs to explore how the design and implementation of QPLs may optimize QPL use and beneficial outcomes.

File 1
offers detailed eligibility criteria that were needed to distinguish QPLs from a plethora of other types of tools for the purpose of screening.In brief, populations included patients aged 18+, family or caregivers or clinicians of any specialty who employed a QPL during a healthcare visit for any health issue in primary, secondary or tertiary healthcare settings in any country.Interventions involved the use of QPLs, characterized based on the Workgroup for Intervention Development and Evaluation Research (WIDER) recommendations for reporting behaviour change interventions, which we found was needed to understand how QPLs were operationalized to support decisions about inclusion or exclusion.
Preferred Reporting Items for Systematic Reviews and Meta-analyses diagram.| 1407 RAMLAKHAN ET AL.
For example, since patients valued knowing what to ask and thinking of new questions, which in turn reduced anxiety and improved selfefficacy, these are measures that could be evaluated in future QPL research, given that most studies included in this review assessed a number of questions asked.However, further research might engage patients in prioritizing the measures most important to them in terms of QPL benefits.When asked, most clinicians reported the benefits of QPLs for patients.Future research should explore how to enhance the perceived benefits of QPLs for clinicians, and more comprehensively assess the perceived and actual benefits of QPLs amongst clinicians.Few studies purposefully explored the harms of QPL use, so this should be consistently assessed in future research.To confirm the findings of this scoping review, a future systematic review is warranted to more definitively associate QPL design and implementation with beneficial impacts.
published from 1988 to 2022 by authors in 12 countries.Most (88%) studies reported at least one beneficial impact, most commonly patient confidence to ask questions, patient satisfaction with communication or care received; and reduced anxiety amongst patients about health status or treatment.This was true even for single-page QPLs of <20 questions that included the following components: a brief introduction, instructions for use, blank space for writing notes, section headings and developer affiliations; and for QPLs alone, unaccompanied by other implementation strategies, when shared in printed format with patients before consultations (mailed home or in the waiting room) by either researchers, staff or healthcare professionals (e.g., nurse, social worker).To support implementation, clinicians wanted guidance on how to use QPLs.Many studies offered limited detail of QPL development, characteristics and implementation; hence, future research should more consistently do so by employing intervention reporting standards.To confirm these findings, future research should more definitively confirm how QPL design and implementation are associated with QPL impact.