How to integrate shared decision-making into your practice

An online listing of publicly available decision aids is maintained by the Ottawa Hospital Research Institute,³⁴ which reviews decision-aid quality by objective criteria in addition to providing direct links to resources.³⁵ EBSCO health’s DynaMed Decisions also maintains a list of shared decision-making tools (https://decisions.dynamed.com/).

Effectiveness of decision aids

There is a robust body of research focused on decision aids for SDM. An example is a 2017 Cochrane review that concluded SDM facilitated by decision aids significantly improved patient engagement and satisfaction and increased patient knowledge, accuracy in risk perception, and congruency in making value-aligned care choices. Beyond decision aids, studies show SDM practices increase patient knowledge, engagement, and satisfaction, particularly among low-literacy or disadvantaged groups.^4,36,37

Barriers to implementation

Clinicians frequently cite time constraints as a barrier to successfully implementing SDM in practice, although studies that explicitly compare the time/cost of SDM to “usual care” are limited.³⁸ A Cochrane review of 105 studies evaluating the use of decision aids vs usual care found that only 10 studies examined the effects of decision aids on the length of the office visit.³ Two of these studies (one evaluating decision aids for prenatal diagnostic screening and the other for atrial fibrillation) found a median increase in visit length of 2.6 minutes (24 vs 21; 7.5% increase); the other 8 studies reported no increase in visit length.³

Avoid oversaturating patients with data, maintain a focus on patient values, and engage in a 2-way discussion that considers the unique mix of patient preferences and circumstances.

Studies focusing on the time impact of using SDM in an office visit, rather than decision aids as a proxy for SDM, are few. A study by Braddock et al³⁹ assessed the elements of SDM, measuring the quality and the time-efficiency of 141 surgical decision-making interactions between patients and 89 orthopedic surgeons. Researchers found 57% of the discussions had elements of SDM sufficient to meet a “reasonable minimum” standard (eg, nature of the decision, patient’s role, patient’s preference). These conversations took 20 minutes compared to a median of 16 minutes for a more typical conversation.³⁹ The study used audiotaped interviews, which were coded and scored based on the presence of SDM elements; treatment choice, outcomes of the choices, and satisfaction were not reported. A separate study by Loh et al⁵ looking at SDM in primary care for patients with depression sought to determine whether patient participation in the decision-making process improved treatment adherence, outcomes, and patient satisfaction without increasing consultation time. This study, which included 23 physicians and 405 patients, found improved participation and satisfaction outcomes in the intervention group and no difference in consultation time between the intervention and control groups.⁵

Care costs appear similar

The impact of SDM on cost and patient-­centered clinical outcomes is not well defined. One study by Arterburn et al⁴⁰ found decision aids and SDM lowered the rates of elective surgery for hip and knee arthritis, as well as associated health system costs. However, other studies suggest this phenomenon likely varies by demographic, demonstrating that certain populations with a generally lower baseline preference for surgery on average chose surgery more often after SDM interventions.^41,42 Evidence does support patient acceptability and efficacy for SDM in longitudinal care when the approach is incorporated into decisions over multiple visits or long-term decisions for chronic conditions.⁴ Studies comparing patient groups receiving decision aids to usual care have shown similar or lower overall care costs for the decision-aid group.³

Continue to: Limitations to the evidence