Shared decision-making: How to choose best approach

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There are many benefits to shared decision-making with patients. Informed patients make better decisions and have more meaningful and frank health discussions with their physicians, but there are as many barriers to an open conversation and shared decision between doctor and patient as there are benefits.

A study published July 22 in Circulation: Cardiovascular Quality and Outcomes highlighted the strengths and weaknesses behind two types of shared decision-making, out-of-visit and in-visit, and explored how both could be used to strengthen patient-provider communication in the future. In-visit shared decision-making involved a decision aid directed discussion. Out-of-visit shared decision-making provided patients with literature, videos and other materials to review on their own, either on-site or at home.

Both give patients more information about options regarding particular healthcare decisions. Examples included elective cardiovascular surgery and use of statins.

Shared decision-making has become increasingly supported by legislature at the federal, state and local level. Aspects of the Patient Protection and Affordable Health Care Act supported research into shared decision-making. However, the biggest hurdle for shared decision-making models seemed to be clinicians themselves.

According to Erik P. Hess, MD, MSc, from the Mayo Clinic in Rochester, Minn., and colleagues, part of what made a shared decision-making model a success involved getting clinicians on board, showing them the benefits of getting patients involved in the decision process and getting them to understand that patients often do want to be involved. Two surveys referenced by Hess et al noted that the majority of patients queried (approximately 68 to 70 percent) wanted to be involved actively in their healthcare, providing at least an equal voice to the treatment decision process.

Comparatively, almost one quarter of patients in the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) and Prospective Registry Evaluating Myocardial Infarction: Events and Recovery Acute Myocardial Infarction (PREMIER AMI) registries wanted decisions to be theirs alone, without a physician. This is a far cry from what some clinicians have expressed: the belief that patients want them to decide what’s best. Patient reluctance to disagree only exacerbates this perception.

When shared decision-making involved language barriers, complex decision-making and health literacy levels, clinicians were challenged to allocate enough time in a visit for education and shared decision-making models.

Further, when out-of-visit models were used, space and resource allocation were occasional confounders to adoption.

However, when clinicians were involved in the development of shared decision-making materials and statistical models could be provided on the benefits to them and their patients, many of their concerns could be allayed. With the provision of open and safe environments to start and maintain dialogue between patients and providers, meaningful discussions could be had on treatment options and involvement appeared to increase patient adherence to medications and behavioral modifications.

While no research at present has explored the combination of in-visit and out-of-visit models, Hess et al recommended future research address this as an option to get the best of both methods and the most out of shared decision-making.