Implementing shared decision-making: consider all the consequences

Abstract

BackgroundThe ethical argument that shared decision-making is “the right” thing to do, however laudable, is unlikely to change how healthcare is organized, just as evidence alone will be an insufficient factor: practice change is governed by factors such as cost, profit margin, quality, and efficiency. It is helpful, therefore, when evaluating new approaches such as shared decision-making to conceptualize potential consequences in a way that is broad, long-term, and as relevant as possible to multiple stakeholders. Yet, so far, evaluation metrics for shared decision-making have been mostly focused on short-term outcomes, such as cognitive or affective consequences in patients. The goal of this article is to hypothesize a wider set of consequences, that apply over an extended time horizon, and include outcomes at interactional, team, organizational and system levels, and to call for future research to study these possible consequences.Main argumentTo date, many more studies have evaluated patient decision aids rather than other approaches to shared decision-making, and the outcomes measured have typically been focused on short-term cognitive and affective outcomes, for example knowledge and decisional conflict. From a clinicians perspective, the shared decision-making process could be viewed as either intrinsically rewarding and protective, or burdensome and impractical, yet studies have not focused on the impact on professionals, either positive or negative. At interactional levels, group, team, and microsystem, the potential long-term consequences could include the development of a culture where deliberation and collaboration are regarded as guiding principles, where patients are coached to assess the value of interventions, to trade-off benefits versus harms, and assess their burdens—in short, to new social norms in the clinical workplace. At organizational levels, consistent shared decision-making might boost patient experience evaluations and lead to fewer complaints and legal challenges. In the long-term, shared decision-making might lead to changes in resource utilization, perhaps to reductions in cost, and to modification of workforce composition. Despite the gradual shift to value-based payment, some organizations, motivated by continued income derived from achieving high volumes of procedures and contacts, will see this as a negative consequence.ConclusionWe suggest that a broader conceptualization and measurement of shared decision-making would provide a more substantive evidence base to guide implementation. We outline a framework which illustrates a hypothesized set of proximal, distal, and distant consequences that might occur if collaboration and deliberation could be achieved routinely, proposing that well-informed preference-based patient decisions might lead to safer, more cost-effective healthcare, which in turn might result in reduced utilization rates and improved health outcomes.

A Systematic Literature Review of Shared Decision Making in Cancer Care (Preprint)

“…Additionally, this systematic review adhered to the PRISMA guidelines, [43,44] and the internal validity of the included studies was rated as acceptable or high. Finally, findings in cancer care were consistent with those reported across other disease areas, [23,28,49] indicating that the lack of qualitative and quantitative assessment of SDM interactions is not unique to cancer care and needs to be considered broadly across future SDM intervention studies.…”

“…Outcomes that were more distal to the intervention or decision-such as changes in symptoms, HRQoL, or functional status and well-being-were infrequently assessed, usually did not achieve statistical significance, and may indicate that study designs focused on a single patient-clinician interaction are not well suited to capturing outcomes outside of immediate decision making. Given that more distal outcomes are often most relevant to patients themselves and represent key indicators of high quality of care, [49] optimal study designs for longitudinal (multiple-touch point) SDM interventions as well as measuring more distal outcomes are an area in need of further research. Furthermore, the lack of consistency in the tools used to assess the 81 unique outcomes identified in this study complicates comparisons across studies.…”

“…The relationship between the number of SDM elements included in each study and the number of statistically-significant outcomes was examined using Spearman's rank correlation. Study outcomes were also grouped along a proximal-to-distal continuum similar to that proposed by Elwyn and colleagues [49] (online supplement).…”

Psychiatric service staff perceptions of implementing a shared decision-making tool: a process evaluation study

“…While few in number, implementation studies on SDM interventions in Sweden have suggested the importance of expanding the decision-making process beyond single encounters (Hultberg & Rudebeck, 2017) and beyond simply educating the patient in self-care (Herlitz, Munthe, Törner, & Forsander, 2016). Results from somatic care studies suggest that successful implementation of SDM requires continuity of care and that the user is offered concrete opportunities to participate as an equal in the decision-making process (Elwyn, Frosch, & Kobrin, 2015). Basic prerequisites for successful implementation of SDM in psychiatric care settings are considered to consist of the following factors; (a) attending staff have the ability and are willing to include the user in decisions (skills and attitude) (b) the user is willing and has the ability to actively participate in the decisions (c) additional information and decision support is available to facilitate the SDM process (Hamann, Kruse, Schmitz, Kissling, & Pajonk, 2010; O’Connor et al, 2007).…”

Rationale for using a double-wavelength (940 nm + 2780 nm) laser in endodontics: literature overview and proof-of-concept

“…The goal of decision-making in healthcare is to choose the interventions that are most likely to deliver the outcomes that are of most interest to patients while preventing possible harmful outcomes [134]. With this manuscript, the aim was to demonstrate that laser-technology is in far expansion within the endodontic field and that with double-wavelength lasers, clinicians should expect to achieve highly predictable outcomes and less iatrogenic complications even in the most complicated endodontic scenarios such as in multi-rooted teeth with unfavourable anatomies, associated with AP.…”