Strategy 6I: Shared Decisionmaking

Contents

6.I.1. The Problem
6.I.2. The Intervention
6.I.3. Benefits of This Intervention
6.I.4. Implementation of This Intervention
References

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Shared Decisionmaking
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6.I.1. The Problem

Although patients are far more informed than they were even 20 or 30 years ago, some people express frustration and dissatisfaction with their care because they do not feel like they have adequate (if any) input into the decisions that clinicians are making about their health and their lives. One element of this problem is that patients often do not know enough about their treatment options to make informed decisions. In particular, they may not understand the evidence base underlying the decisions they are being offered.

Another contributing factor is that providers are not always supportive of patient involvement in the decisionmaking process. In some cases, clinicians are supportive of the concept but do not know how to make it happen.

Complicating the decisionmaking process is the fact that decisions related to preventive testing, diagnostic work-ups, and treatment options are often driven by physicians' preferences (which may be shaped by medical training, local norms, or personal experience) rather than scientific evidence. The resulting variations in care across the country are tremendous and well-documented. (For evidence of geographic variations, consult the Dartmouth Atlas.) However, the only preference driving variations should be that of the patient. This is a core principle behind shared decisionmaking.

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6.I.2. The Intervention

Shared decisionmaking is a model of patient-centered care that enables and encourages people to play a role in the medical decisions that affect their health. It operates under two premises:

• First, consumers armed with good information can and will participate in the medical decisionmaking process by asking informed questions and expressing personal values and opinions about their conditions and treatment options.
• Second, clinicians will respect patients' goals and preferences and use them to guide recommendations and treatments.

While some critics of shared decisionmaking maintain that patients are not able or willing to make their own health care decisions, there is considerable evidence that patients want more information and greater involvement in decisionmaking in partnership with their doctors.^1-3 The innovation of shared decisionmaking is the use of evidence-based tools, known as patient decision aids, to inform patients and help them set their own goals and clarify their values.

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6.I.3. Benefits of This Intervention

Improved quality of medical consultations has been found to have a positive effect on the quality of treatment decisions, the quality of patient-physician communication, and the satisfaction of both patients and physicians. Specifically, research on the impact of this intervention has found:

• Consumer participation can increase patient satisfaction and lead to better health outcomes.^4-6
• Patients who are empowered to make decisions about their health that better reflect their personal preferences often experience more favorable health outcomes such as decreased anxiety, quicker recovery and increased compliance with treatment regimens.⁷
• Greater consumer involvement in decisionmaking leads to lower demand for health care resources.⁸

Since this approach was first developed in the early 1980s, there has been considerable evidence gathered on the efficacy of patient decision aids. These tools increase knowledge, improve risk estimates, increase patient's involvement in decisions, and help clarify treatment preferences.⁹ Research also suggests that the use of decision aids can increase the richness of discussions between physician and patient. In one study, both patients and physicians benefited from an increased level of understanding that allowed discussions to focus on the critical risk/benefit tradeoffs rather than simply describing treatment alternatives.¹⁰

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6.I.4. Implementation of This Intervention

The aim of shared decisionmaking is to ensure that:

• Patients understand their options and the pros and cons of those options.
• Patient's goals and treatment preferences are used to guide decisions.

A key step in shared decisionmaking is making sure that patients are fully informed about their medical condition and their options. Consumers have access to a variety of sources for such information, including physicians, friends and family, Web sites, and printed materials such as pamphlets and journal articles. Patient decision aids go beyond that kind of information to explain the issues fairly and clearly, highlighting the pros and cons of each option, and providing support for users to clarify and express their personal goals and preferences. Good decision aids, whether Web-, video- or paper-based, are balanced and do not encourage one treatment approach over the others. They can be used before, during and after visits for medical care,¹¹ and may be applied to a variety of medical conditions as well as general preventive medicine. Educational applications may also be used to prepare patients for various procedures or explain what they need to know after surgery.¹²

The challenge for patient decision aids is keeping pace with rapidly changing developments, including new treatment alternatives and new information concerning treatment efficacy and complications.¹³ Keeping the decision aids up-to-date is a major enterprise.¹⁴ International standards for the development of these types of patient decision aids provide guidance for developers as well as for potential users to evaluate the quality of available decision aids, including those developed by commercial companies.¹⁵

A related element of the shared decisionmaking model is that patients must take some responsibility for identifying and availing themselves of information and speaking up to share their concerns, goals, and questions with their health care team. This may involve reviewing information before or after a visit, and perhaps completing an assessment of their understanding and goals. It may also involve working with a coach or attending a support group or educational program offered in the community.

Another important step in shared decisionmaking is for the clinician to involve the patient in the decisionmaking process. While the right of patients to be informed decisionmakers is well accepted, it is not always well implemented.¹⁶ Shared decisionmaking requires a "modification of the relationship between patient and provider and recognition of the ability of the patients to participate in making choices that affect their lives."¹⁷ Thus, one key to success lies in training physicians and other members of the care team to:

• Communicate about risks and benefits clearly.
• Elicit patients' goal and treatment preferences.
• Respect patient's values, preferences, and expressed needs when making recommendations for care.¹⁸

Clinical decision support tools, such as risk calculators, can play a useful role in the shared decisionmaking process. It is also helpful to use a team approach to shared decisionmaking that involves nurses, health coaches, and case managers, so that informing patients and respecting their goals and preferences happens in all interactions.

A final element to consider is an assessment of the extent to which patients are meaningfully involved in decisionmaking for medical tests and treatments. Specifically, organizations implementing shared decisionmaking can follow-up with patients to determine whether they understood that they had options, how much the risks and benefits of each option was discussed, and whether their preferences were discussed. This kind of feedback can help to identify where the process of shared decisionmaking may be lacking and how it can be improved.

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References

1. Deber RB, Kraetschmer N, Irvine J. What role do patients wish to play in treatment decision making? Arch Intern Med 1996;156(13):1414-20.
2. Guadagnoli E, Ward P. Patient participation in decision-making. Soc Sci Med 1998;47(3):329-39.
3. Coulter A. The autonomous patient: ending paternalism in medical care. London: Nuffield Trust; 2002.
4. Greenfield S, Kaplan S, Ware JE Jr. Expanding patient involvement in care. Effects on patient outcomes. Ann Intern Med 1985;102(4):520-8.
5. Greenfield S, Kaplan SH, Ware JE Jr., et al. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988;3(5):448-57.
6. Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989;27(3 Suppl):S110-27.
7. Guadagnoli E, Ward P. Patient participation in decision-making. Soc Sci Med 1998;47(3):329-39.
8. Devine EC and Cook TD. A meta-analytic analysis of effects of psychoeducational interventions on length of postsurgical hospital stay. Nurs Res 1983;32(5):267-74.
9. Onel E, Hamond C, Wasson JH, et al. Assessment of the feasibility and impact of shared decision making in prostate cancer. Urology 1998;51(1):63-6.
10. Mechanic D. Issues in promoting health. Soc Sci Med 1999;48(6):711-8.
11. Onel E, Hamond C, Wasson JH, et al. Assessment of the feasibility and impact of shared decision making in prostate cancer. Urology 1998;51(1):63-6.
12. Mechanic D. Issues in promoting health. Soc Sci Med 1999;48(6):711-8.
13. Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. Washington, DC, National Academy Press; 2001.
14. Deber RB, Kraetschmer N, Irvine J. What role do patients wish to play in treatment decision making? Arch Intern Med 1996;156(13):1414-20.
15. Towle A, Godolphin W. Framework for teaching and learning informed shared decision making. BMJ 1999;319(7212):766-71.
16. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC, National Academy Press; 2001.
17. Deber RB, Kraetschmer N, Irvine J. What role do patients wish to play in treatment decision making? Arch Intern Med 1996;156(13):1414-20.
18. Towle A, Godolphin W. Framework for teaching and learning informed shared decision making. BMJ1999;319(7212):766-71.

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