“Many miles to go …”: a systematic review of the implementation of patient decision support interventions into routine clinical practice

Abstract

BackgroundTwo decades of research has established the positive effect of using patient-targeted decision support interventions: patients gain knowledge, greater understanding of probabilities and increased confidence in decisions. Yet, despite their efficacy, the effectiveness of these decision support interventions in routine practice has yet to be established; widespread adoption has not occurred. The aim of this review was to search for and analyze the findings of published peer-reviewed studies that investigated the success levels of strategies or methods where attempts were made to implement patient-targeted decision support interventions into routine clinical settings.MethodsAn electronic search strategy was devised and adapted for the following databases: ASSIA, CINAHL, Embase, HMIC, Medline, Medline-in-process, OpenSIGLE, PsycINFO, Scopus, Social Services Abstracts, and the Web of Science. In addition, we used snowballing techniques. Studies were included after dual independent assessment.ResultsAfter assessment, 5322 abstracts yielded 51 articles for consideration. After examining full-texts, 17 studies were included and subjected to data extraction. The approach used in all studies was one where clinicians and their staff used a referral model, asking eligible patients to use decision support. The results point to significant challenges to the implementation of patient decision support using this model, including indifference on the part of health care professionals. This indifference stemmed from a reported lack of confidence in the content of decision support interventions and concern about disruption to established workflows, ultimately contributing to organizational inertia regarding their adoption.ConclusionsIt seems too early to make firm recommendations about how best to implement patient decision support into routine practice because approaches that use a ‘referral model’ consistently report difficulties. We sense that the underlying issues that militate against the use of patient decision support and, more generally, limit the adoption of shared decision making, are under-investigated and under-specified. Future reports from implementation studies could be improved by following guidelines, for example the SQUIRE proposals, and by adopting methods that would be able to go beyond the ‘barriers’ and ‘facilitators’ approach to understand more about the nature of professional and organizational resistance to these tools. The lack of incentives that reward the use of these interventions needs to be considered as a significant impediment.

Recent Patterns in Shared Decision Making for Prostate-Specific Antigen Testing in the United States

“…23,24 There are multilevel barriers to implementing shared decision making, including competing demands during primary care physician visits [25][26][27] and lack of system-level support, such as automated prompts. 28,29 These barriers may be more prominent in limited-resource settings and could partly account for the disparities in shared decision making associated with educational attainment.…”

A Model of Organizational Context and Shared Decision Making: Application to LGBT Racial and Ethnic Minority Patients

“…While there is little evidence that SDM requires more time, in practice, than usual care, 28 increased time with patients has sometimes been associated with greater patient participation in SDM. 28,31,32 Minority patients may require additional time or sensitivity to build trust if they are not receiving care as frequently or have had prior negative experiences. 39 Organizations can streamline SDM by preparing patients before the encounter or by finding other ways to distribute SDM across the visit.…”

Physicians as Part of the Solution? Community-Based Participatory Research as a Way to Get Shared Decision Making into Practice

“…1,2 Yet, despite the high level of interest among policy makers, the challenge of how to promote and implement SDM into routine care remains unsolved. [3][4][5] Seen by many as the pinnacle of patient-centered care, SDM is a process in which physicians and patients collaborate, using the best available evidence, in order to make informed treatment decisions.…”

“…Indeed, a recent systematic review of attempts to introduce these types of tools finds that clinicians are reluctant to use them, making it challenging to introduce innovative tools into current health care systems. 5 It is possible that traditional decision support interventions, such as those used primarily outside the clinical encounter, have more trouble fitting into current workflows, while the effectiveness of more innovative methods, developed for use inside the clinical encounter, remains unconfirmed. Adding to the challenge is the lack of incentives, either extrinsic (payments or performance reports) or intrinsic (enhanced status or esteem), to support the adoption of these approaches.…”