Despite the proven efficacy of decision aids as interventions for increasing patient engagement and facilitating shared decision making, they are not used routinely in clinical care. Findings from a project designed to achieve such integration, conducted at five primary care practices in 2010-12, document low rates of distribution of decision aids to eligible patients due for colorectal cancer screening (9.3 percent) and experiencing back pain (10.7 percent). There were also no lasting increases in distribution rates in response to training sessions and other promotional activities for physicians and clinic staff. The results of focus groups, ethnographic field notes, and surveys suggest that major structural and cultural changes in health care practice and policy are necessary to achieve the levels of use of decision aids and shared decision making in routine practice envisioned in current policy. Among these changes are ongoing incentives for use, physician training, and a team-based practice model in which all care team members bear formal responsibility for the use of decision aids in routine primary care. I ncreasing patient engagement has been advocated as a top priority for improving health care quality.1 Providing patients with information about their clinical options and activating patients to participate in informed discussions regarding their care are the foundation of shared decision making and a potential mechanism for increasing patients' engagement in their care.These concepts are particularly relevant when preference-sensitive decisions are being made, such as the choice of method for colorectal cancer screening or of treatment for back pain. In preference-sensitive decisions, more than one available option exists, each of which carries different risks and benefits, and patients' treatment preferences can vary.
3Although many potential pathways may be taken to help facilitate preference-sensitive decisions, the use of decision aids has been a commonly proposed and studied intervention. Decision aids, which are specifically designed to provide patients with the information necessary to engage in shared decision making with their care providers, serve as an adjunct to clinical consultations. They come in a variety of formats, including video, print, and online.The use of decision aids has been shown to increase patients' knowledge of available treatment options and to help clarify patients' preferences. 4 For example, national clinical practice guidelines suggest that the decision to undergo colorectal cancer screening be a shared one between physicians and patients, because multiple efficacious screening methods are available. 2 Studies have shown that patients' preferences for specific methods of colorectal cancer screening vary, and the use of decision aids on this topic has been linked to increases in screening rates. 5 However, there is evidence that despite physi-