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m Added some references research based on barriers to SDM at beginning of implementation section; added some details to end of the Measuring section and to end of Expanding the Field section; added an item to further reading.
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== The implementation of shared decision-making ==
== The implementation of shared decision-making ==


With funding bodies emphasizing [[knowledge translation]], i.e. making sure that scientific research results in changes in practice, researchers in shared decision-making have focussed on ''implementing'' SDM, or making it happen. Many studies explore the development of sound, theory-based training programs and decision aids, and the evaluation of their results. Canada has established a research chair that focusses on implementing shared decision-making in primary care contexts.<ref>Canada Research Chair in Implementation of Shared Decision Making in Primary Care http://www.decision.chaire.fmed.ulaval.ca</ref>
With funding bodies emphasizing [[knowledge translation]], i.e. making sure that scientific research results in changes in practice, researchers in shared decision-making have focussed on ''implementing'' SDM, or making it happen. Based on studies of barriers to shared decision-making as perceived by health professionals <ref name="Légaré, Ratté, Gravel, Graham">{{cite journal|last1=Légaré|first1=F|last2=Ratté|first2=S|last3=Gravel|first3=K|last4=Graham|first4=ID|title=Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals' perceptions|journal=Patient Education and Counseling|date=December 2008|volume=3|issue=73|pages=526-35|doi=10.1016/j.pec.2008.07.018}}</ref> and patients,<ref name=>Joseph-Williams N, Edwards A, Elwyn G.{{cite journal|last1=Joseph-Williams|first1=N.|last2=Edwards|first2=A.|last3=Elwyn|first3=G.|title=Power imbalance prevents shared decision making|journal=BMJ|date=14 May 2014|issue=348:g3178|doi=10.1136/bmj.g3178|url=http://www.bmj.com/content/348/bmj.g3178}}</ref> many researchers are developing sound, theory-based training programs and decision aids, and evaluating their results. Canada has established a research chair that focusses on implementing shared decision-making in primary care contexts.<ref>Canada Research Chair in Implementation of Shared Decision Making in Primary Care http://www.decision.chaire.fmed.ulaval.ca</ref>
Although patients who are involved in decision-making about their health have better outcomes,<ref name="Stacey, Bennet, Barry, Col Eden, et al.">{{cite journal|last=Stacey|first=D|author2=Bennett CL |author3=Barry MJ |author4=Col NF |author5=Eden KB |author6=Holmes-Rovner M |author7=Llewellyn-Thomas H |author8=Lyddiatt A |author9=Légaré F |author10=Thomson R |title=Decision aids for people facing health treatment or screening decisions|journal=Cochrane Database of Systematic Reviews|year=2011|issue=10|page=CD001431|doi=10.1002/14651858.CD001431.pub3 |pmid=19588325}}</ref> healthcare professionals rarely involve them in these decisions.<ref>{{cite journal |author=Couët N, Desroches S, Robitaille H, et al. |title=Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument |journal=Health Expectations |volume= |issue= |pages= | date=March 2013 |pmid=23451939 |doi=10.1111/hex.12054}}</ref> A [[Cochrane Collaboration|Cochrane]] review <ref name="Légaré, Ratté, Stacey, et al.">{{cite journal|last=Légaré|first=F|author2=Ratté, S |author3=Stacey, D |author4=Kryworuchko, J |author5=Gravel, K |author6=Graham, ID |author7= Turcotte, S |title=Interventions for improving the adoption of shared decision making by healthcare professionals.|journal=The Cochrane database of systematic reviews|date=May 12, 2010|issue=5|pages=CD006732|pmid=20464744|doi=10.1002/14651858.CD006732.pub2}}</ref> has synthesized the body of evidence about different interventions that can be used to help healthcare professionals adopt practices to better involve their patients in the process of making decisions about their health. In this review of studies testing interventions to help healthcare professionals adopt practices to better involve their patients in the process of making decisions, five studies were identified. This review found that educational meetings, giving healthcare professionals feedback, giving healthcare professionals learning materials, and using patient decision aids are some techniques that have been tried and might be helpful. However, the review could not determine from the available studies which of these were best. The review <ref name="Légaré, Ratté, Stacey, et al." /> makes some suggestions for how research studies could better evaluate healthcare professionals involving patients in the process of making decisions about their health so that we can understand this better in the future. There is also a need for greater conceptual clarity. Involving patients in decisions is by definition a process that could occur over time and in many encounters. Much of the literature seems to assume that achieving shared decision-making is a matter of giving healthcare professionals enough information.
Although patients who are involved in decision-making about their health have better outcomes,<ref name="Stacey, Bennet, Barry, Col Eden, et al.">{{cite journal|last=Stacey|first=D|author2=Bennett CL |author3=Barry MJ |author4=Col NF |author5=Eden KB |author6=Holmes-Rovner M |author7=Llewellyn-Thomas H |author8=Lyddiatt A |author9=Légaré F |author10=Thomson R |title=Decision aids for people facing health treatment or screening decisions|journal=Cochrane Database of Systematic Reviews|year=2011|issue=10|page=CD001431|doi=10.1002/14651858.CD001431.pub3 |pmid=19588325}}</ref> healthcare professionals rarely involve them in these decisions.<ref>{{cite journal |author=Couët N, Desroches S, Robitaille H, et al. |title=Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument |journal=Health Expectations |volume= |issue= |pages= | date=March 2013 |pmid=23451939 |doi=10.1111/hex.12054}}</ref> A recently updated [[Cochrane Collaboration|Cochrane]] review <ref name="Légaré, Ratté, Stacey, et al.">{{cite journal|last=Légaré|first=F|author2=Ratté, S |author3=Stacey, D |author4=Kryworuchko, J |author5=Gravel, K |author6=Graham, ID |author7= Turcotte, S |title=Interventions for improving the adoption of shared decision making by healthcare professionals.|journal=The Cochrane database of systematic reviews|date=May 12, 2010|issue=5|pages=CD006732|pmid=20464744|doi=10.1002/14651858.CD006732.pub2}}</ref> has synthesized the body of evidence about different interventions that can be used to help healthcare professionals adopt practices to better involve their patients in the process of making decisions about their health. In this review of studies testing interventions to help healthcare professionals adopt practices to better involve their patients in the process of making decisions, five studies were identified. This review found that educational meetings, giving healthcare professionals feedback, giving healthcare professionals learning materials, and using patient decision aids are some techniques that have been tried and might be helpful. However, the review could not determine from the available studies which of these were best. The review <ref name="Légaré, Ratté, Stacey, et al." /> makes some suggestions for how research studies could better evaluate healthcare professionals involving patients in the process of making decisions about their health so that we can understand this better in the future. There is also a need for greater conceptual clarity. Involving patients in decisions is by definition a process that could occur over time and in many encounters. Much of the literature seems to assume that achieving shared decision-making is a matter of giving healthcare professionals enough information.


Training health professionals in shared decision-making attracts the attention of policy makers when it shows potential for addressing chronic problems in healthcare systems such as the overuse of drugs or screening tests. One such program, designed for primary care physicians in Quebec, Canada, showed that shared decision-making can reduce use of antibiotics for acute respiratory problems (ear aches, sinusitis, bronchitis, etc.) which are often caused by viruses and do not respond to antibiotics.<ref>{{cite journal |author=Légaré F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J |title=Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial |journal=CMAJ |volume=184 |issue=13 |pages=E726–34 | date=September 2012 |pmid=22847969 |pmc=3447039 |doi=10.1503/cmaj.120568}}</ref>
Training health professionals in shared decision-making attracts the attention of policy makers when it shows potential for addressing chronic problems in healthcare systems such as the overuse of drugs or screening tests. One such program, designed for primary care physicians in Quebec, Canada, showed that shared decision-making can reduce use of antibiotics for acute respiratory problems (ear aches, sinusitis, bronchitis, etc.) which are often caused by viruses and do not respond to antibiotics.<ref>{{cite journal |author=Légaré F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J |title=Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial |journal=CMAJ |volume=184 |issue=13 |pages=E726–34 | date=September 2012 |pmid=22847969 |pmc=3447039 |doi=10.1503/cmaj.120568}}</ref>
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Harvey Fineberg, Head of the US [[Institute of Medicine]], has suggested that shared decision-making should be shaped by the particular needs and preferences of the patient, which may be to call on a physician to assume full responsibility for decisions or, at the other extreme, to be supported and guided by the physician to make completely autonomous decisions.<ref name="Fineberg">{{cite doi|10.1186/2045-4015-1-6}}</ref> This suggests that, just as with interventions, which need to match the patient's style and preferences, patient's preferences for degree of involvement also need to be taken into account and respected.<ref name="Fineberg"/>
Harvey Fineberg, Head of the US [[Institute of Medicine]], has suggested that shared decision-making should be shaped by the particular needs and preferences of the patient, which may be to call on a physician to assume full responsibility for decisions or, at the other extreme, to be supported and guided by the physician to make completely autonomous decisions.<ref name="Fineberg">{{cite doi|10.1186/2045-4015-1-6}}</ref> This suggests that, just as with interventions, which need to match the patient's style and preferences, patient's preferences for degree of involvement also need to be taken into account and respected.<ref name="Fineberg"/>


=== Measuring shared decision-making ===
== Measuring shared decision-making ==


Several researchers in this field have designed scales for measuring to what extent shared decision-making takes place in the clinical encounter and its effects, from the perspective of patients or healthcare professionals or both, or from the perspective of outside observors.<ref>{{cite journal |author=Scholl I, Koelewijn-van Loon M, Sepucha K, et al. |title=Measurement of shared decision making - a review of instruments |journal=Zeitschrift Für Evidenz, Fortbildung Und Qualität Im Gesundheitswesen |volume=105 |issue=4 |pages=313–24 |year=2011 |pmid=21620327 |doi=10.1016/j.zefq.2011.04.012}}</ref> The purpose of these scales is to explore what happens in shared decision-making and how much it happens, with the goal of applying this knowledge to incite healthcare professionals to practise it.
Several researchers in this field have designed scales for measuring to what extent shared decision-making takes place in the clinical encounter and its effects, from the perspective of patients or healthcare professionals or both, or from the perspective of outside observors.<ref>{{cite journal |author=Scholl I, Koelewijn-van Loon M, Sepucha K, et al. |title=Measurement of shared decision making - a review of instruments |journal=Zeitschrift Für Evidenz, Fortbildung Und Qualität Im Gesundheitswesen |volume=105 |issue=4 |pages=313–24 |year=2011 |pmid=21620327 |doi=10.1016/j.zefq.2011.04.012}}</ref> The purpose of these scales is to explore what happens in shared decision-making and how much it happens, with the goal of applying this knowledge to incite healthcare professionals to practise it. Based on these scales, simple tools are being designed to help physicians better understand their patients’ decision needs. One such tool that has been validated, SURE, is a quick questionnaire for finding out in busy clinics which patients are not comfortable about the treatment decision (decisional conflict). SURE is based on O’Connor’s Decisional Conflict Scale <ref>{{cite journal|last1=O'Connor|first1=AM|title=Validation of a decisional conflict scale|journal=Medical Decision Making|date=1995|volume=15|issue=1|pages=25-30|url=http://www.ncbi.nlm.nih.gov/pubmed/7898294}}</ref>which is commonly used to evaluate patient decision aids.<ref>{{cite journal|last1=Stacey|first1=D|last2=Légaré|first2=F|last3=Col|first3=NF|last4=et al.|title=Decision aids for people facing health treatment or screening decisions|journal=The Cochrane Database of Systematic Reviews|date=2014|volume=1|pages=CD001431|doi=10.1002/14651858.CD001431.pub4|url=http://www.ncbi.nlm.nih.gov/pubmed/24470076}}</ref>The four yes-or-no questions are about being '''S'''ure, '''U'''nderstanding the information, the '''R'''isk-benefit ratio, and sources of advice and '''E'''ncouragement.<ref>{{cite journal|last1=Légaré|first1=F|last2=Kearing|first2=S|last3=Clay|first3=K|last4=et al.|title=[http://www.ncbi.nlm.nih.gov/pubmed/20705870 Are you SURE?: Assessing patient decisional conflict with a 4-item screening test]|journal=Canadian Family Physician|date=2010|volume=56|issue=8|pages=e308-14}}</ref><ref>{{cite journal|last1=Ferron Parayre|first1=A|last2=Labrecque|first2=M|last3=Rousseau|first3=M|last4=et al.|title=[http://www.ncbi.nlm.nih.gov/pubmed/23776141 Validation of SURE, a four-item clinical checklist for detecting decisional conflict in patients]|journal=Medical Decision Making|date=2014|volume=34|issue=1|pages=54-62}}</ref>


== Expanding the field of shared decision-making ==
== Expanding the field of shared decision-making ==


Researchers in shared decision-making are increasingly taking account of the fact that involvement in making healthcare decisions is not always limited to one patient and one healthcare professional in a clinical setting. Often more than one healthcare professional is involved in a decision, such professional teams involved in caring for an elderly person who may have several health problems at once. Some researchers, for example, are focussing on how interprofessional teams might practise shared decision-making among themselves and with their patients.<ref>{{cite journal |author=Légaré F, Stacey D, Pouliot S, et al. |title=Interprofessionalism and shared decision-making in primary care: a stepwise approach towards a new model |journal=Journal of Interprofessional Care |volume=25 |issue=1 |pages=18–25 | date=January 2011 |pmid=20795835 |pmc=3018136 |doi=10.3109/13561820.2010.490502}}</ref> Researchers are also expanding the definition of shared decision-making to include an ill person’s spouse, family caregivers or friends, especially if they are responsible for giving the person medicine, transporting them or paying the bills. Decisions that ignore them may not be based on realistic options or may not be followed through.<ref>{{cite journal |author=Zhang AY, Siminoff LA |title=The role of the family in treatment decision making by patients with cancer |journal=Oncology Nursing Forum |volume=30 |issue=6 |pages=1022–8 |year=2003 |pmid=14603359 |doi=10.1188/03.ONF.1022-1028}}</ref>
Researchers in shared decision-making are increasingly taking account of the fact that involvement in making healthcare decisions is not always limited to one patient and one healthcare professional in a clinical setting. Often more than one healthcare professional is involved in a decision, such professional teams involved in caring for an elderly person who may have several health problems at once. Some researchers, for example, are focussing on how interprofessional teams might practise shared decision-making among themselves and with their patients.<ref>{{cite journal |author=Légaré F, Stacey D, Pouliot S, et al. |title=Interprofessionalism and shared decision-making in primary care: a stepwise approach towards a new model |journal=Journal of Interprofessional Care |volume=25 |issue=1 |pages=18–25 | date=January 2011 |pmid=20795835 |pmc=3018136 |doi=10.3109/13561820.2010.490502}}</ref> Researchers are also expanding the definition of shared decision-making to include an ill person’s spouse, family caregivers or friends, especially if they are responsible for giving the person medicine, transporting them or paying the bills. Decisions that ignore them may not be based on realistic options or may not be followed through.<ref>{{cite journal |author=Zhang AY, Siminoff LA |title=The role of the family in treatment decision making by patients with cancer |journal=Oncology Nursing Forum |volume=30 |issue=6 |pages=1022–8 |year=2003 |pmid=14603359 |doi=10.1188/03.ONF.1022-1028}}</ref> Shared decision-making is also now being applied in areas of healthcare that have wider social implications, such as decisions faced by the frail elderly and their caregivers about staying at home or moving into care facilities.<ref>{{cite journal|last1=Légaré|first1=F|last2=Brière|first2=N|last3=Stacey|first3=D|title=Improving Decision making On Location of Care with the frail Elderly and their caregivers (the DOLCE study): study protocol for a cluster randomized controlled trial|journal=Trials|date=2015|volume=16|issue=1|page=50|doi=doi:10.1186/s13063-015-0567-7|url=http://www.trialsjournal.com/content/16/1/50}}</ref>


==Related gatherings==
==Related gatherings==
Many researchers and practitioners in this field meet every two years at the International Shared Decision Making (ISDM) Conference, which have been held at Oxford in 2001, Swansea in 2003, Ottawa in 2005, Freiburg in 2007, Boston in 2009, Maastricht in 2011, and Lima, Peru in 2013. Shared decision-making is also closely associated with the use of [[decision support interventions]], also known as [[decision aids]]. Much of the research and implementation studies to date are contained in the following publication: ''Shared Decision Making in Healthcare: Evidence-based Patient Choice. 2nd ed. Oxford: Oxford University Press, 2009.<ref name="Elwyn, Edwards">{{cite book |author=Elwyn, Glyn; Edwards, Adrian |title=Shared decision-making in health care: Achieving evidence-based patient choice |publisher=Oxford University Press |year=2009 |isbn=0-19-954627-4 |edition=2nd |url=http://ukcatalogue.oup.com/product/9780199546275.do}}</ref>
Many researchers and practitioners in this field meet every two years at the International Shared Decision Making (ISDM) Conference, which have been held at Oxford in 2001, Swansea in 2003, Ottawa in 2005, Freiburg in 2007, Boston in 2009, Maastricht in 2011, Lima, Peru in 2013, and Sydney, Australia, in 2015.[http://www.isdm-isehc2015.org] Shared decision-making is also closely associated with the use of [[decision support interventions]], also known as [[decision aids]]. Much of the research and implementation studies to date are contained in the following publication: ''Shared Decision Making in Healthcare: Evidence-based Patient Choice. 2nd ed. Oxford: Oxford University Press, 2009.<ref name="Elwyn, Edwards">{{cite book |author=Elwyn, Glyn; Edwards, Adrian |title=Shared decision-making in health care: Achieving evidence-based patient choice |publisher=Oxford University Press |year=2009 |isbn=0-19-954627-4 |edition=2nd |url=http://ukcatalogue.oup.com/product/9780199546275.do}}</ref>


In December 2010 a [[Salzburg Global Seminar]] focused on "The Greatest Untapped Resource in Healthcare? Informing and Involving Patients in Decisions about Their Medical Care." Powerful conclusions emerged among the 58 participants from 18 countries: not only is it ethically right that patients should be involved more closely in decisions about their own medical care and the risks involved, it is practical – through careful presentation of information and the use of decision aids/pathways – and it brings down costs. [[Unwarranted variation|Unwarranted practice variations]] – where one area may have many more interventions than another, but with no better outcomes – are reduced, sometimes dramatically. So why is it that this ‘win-win’ approach is not better understood? Following the seminar the participants created the Salzburg Statement on Shared Decision Making launched in London by the BMJ, one of the world’s leading medical journals, and released it to the press worldwide to stimulate attention and debate.<ref name="Salzburg Global Seminar">{{cite journal |author= |title=Salzburg statement on shared decision making |journal=BMJ |volume=342 |issue= |pages=d1745 |year=2011 |pmid=21427038 |doi=10.1136/bmj.d1745}}</ref>
In December 2010 a [[Salzburg Global Seminar]] focused on "The Greatest Untapped Resource in Healthcare? Informing and Involving Patients in Decisions about Their Medical Care." Powerful conclusions emerged among the 58 participants from 18 countries: not only is it ethically right that patients should be involved more closely in decisions about their own medical care and the risks involved, it is practical – through careful presentation of information and the use of decision aids/pathways – and it brings down costs. [[Unwarranted variation|Unwarranted practice variations]] – where one area may have many more interventions than another, but with no better outcomes – are reduced, sometimes dramatically. So why is it that this ‘win-win’ approach is not better understood? Following the seminar the participants created the Salzburg Statement on Shared Decision Making launched in London by the BMJ, one of the world’s leading medical journals, and released it to the press worldwide to stimulate attention and debate.<ref name="Salzburg Global Seminar">{{cite journal |author= |title=Salzburg statement on shared decision making |journal=BMJ |volume=342 |issue= |pages=d1745 |year=2011 |pmid=21427038 |doi=10.1136/bmj.d1745}}</ref>
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*{{cite journal |author=Towle A, Godolphin W |title=Framework for teaching and learning informed shared decision making |journal=BMJ |volume=319 |issue=7212 |pages=766–71 | date=September 1999 |pmid=10488010 |pmc=1116602 |doi=10.1136/bmj.319.7212.766}}
*{{cite journal |author=Towle A, Godolphin W |title=Framework for teaching and learning informed shared decision making |journal=BMJ |volume=319 |issue=7212 |pages=766–71 | date=September 1999 |pmid=10488010 |pmc=1116602 |doi=10.1136/bmj.319.7212.766}}
*{{cite journal |author=Frosch DL, Kaplan RM |title=Shared decision making in clinical medicine: past research and future directions |journal=American Journal of Preventive Medicine |volume=17 |issue=4 |pages=285–94 | date=November 1999 |pmid=10606197 |doi=10.1016/S0749-3797(99)00097-5}}
*{{cite journal |author=Frosch DL, Kaplan RM |title=Shared decision making in clinical medicine: past research and future directions |journal=American Journal of Preventive Medicine |volume=17 |issue=4 |pages=285–94 | date=November 1999 |pmid=10606197 |doi=10.1016/S0749-3797(99)00097-5}}
*{{cite journal|last1=Légaré|first1=F|last2=Thompson-Leduc|first2=P|title=Twelve myths about decision making|journal=Patient Education and Counseling|date=2014|volume=96|issue=3|pages=281-6|doi=10.1016/j.pec.2014.06.014|url=http://www.ncbi.nlm.nih.gov/pubmed/25034637}}


==External links==
==External links==
* [http://www.decision.chaire.fmed.ulaval.ca Canada Research Chair in Implementation of Shared Decision Making in Primary Care]
* [http://www.decision.chaire.fmed.ulaval.ca Canada Research Chair in Implementation of Shared Decision Making in Primary Care]
* [http://isdm2013.org International Shared Decision Making Conference 2013, Peru]
* [http://www.isdm-isehc2015.org International Society for Evidence Based Health Care (ISEHC) and International Shared Decision-Making (ISDM) Conference in Sydney, 2015]
* [http://www.healthdialog.com Health Dialog - The Shared Decision Making company]
* [http://www.healthdialog.com Health Dialog - The Shared Decision Making company]
* [[:es:Toma de Decisiones Compartidas]]
* [[:es:Toma de Decisiones Compartidas]]

Revision as of 19:07, 13 March 2015

Shared decision-making (SDM) is an approach in which clinicians and patients communicate together using the best available evidence when faced with the task of making decisions. Patients are supported to deliberate about the possible attributes and consequences of options, to arrive at informed preferences in making a determination about the best course of action which respects patient autonomy, as well as ethical and legal norms.

Original definition and scope

One of the first instances where the term shared decision-making was employed was in a report entitled the "President's Commission for the Study of Ethical Problems in Medicine and Biomedical Research."[1] This work built on the increasing interest in patient-centredness and an increasing emphasis on recognising patient autonomy in health care interactions since the 1970s.[2][3]

Charles described a set of principles for shared decision-making, stating “that at least two participants, the clinician and patient be involved; that both parties share information; that both parties take steps to build a consensus about the preferred treatment; and that an agreement is reached on the treatment to implement".[4] These principles rely on an eventual arrival at an agreement but this final principle is not fully accepted by others in the field.[5] The view that it is acceptable to agree to disagree is also regarded as an acceptable outcome of shared decision-making.[6]

Main components

Elwyn described a set of competences for shared decision-making, which are composed of the steps of defining the problem which requires a decision, the portrayal of equipoise and the uncertainty about the best course of action, thereby leading to the requirement to provide information about the attributes of available options and support a deliberation process.[7] An assessment scale to measure the extent to which clinicians involve patients in decision-making has been developed[8] and translated into Dutch, Chinese, French, German, Spanish and Italian.[9] A talk model has been recently proposed, composed of three different phases: team, option and decision talk. In the first of these phases, clinicians' work to create a supportive relationship with the patient as they introduce the idea of recognizing the existence of alternative actions (options) - this is to form a team with the patient and their family. In the second phase, the work is to introduce the options in a clear way, describing and explaining the probabilities of benefits and harms that might be likely - this is option talk. In the last phase, patients' preferences are constructed, elicited and integrated - this is decision talk. A shorter 5-item version of the Observer OPTION measure has been published based on this model. [10]

The National Shared Decision-Making Programme in the UK

The aim of the Right Care Shared Decision-Making Programme is to embed shared decision-making in NHS care. This is part of the wider ambition to promote patient centred care, to increase patient choice, autonomy and involvement in clinical decision-making and make “no decision about me, without me” a reality. The Shared Decision-Making programme is part of the Quality Improvement Productivity and Prevention (QIPP) Right Care programme. In 2012, the programme entered an exciting new phase and, through three workstreams, is aiming to embed the practice of shared decision-making among patients and those who support them, and among health professionals and their educators.[11] One of the components of the National Programme is the work of the Advancing Quality Alliance (AQuA) - [12] who are tasked with creating a receptive culture for shared decision-making with patients and health professionals.[13]

The implementation of shared decision-making

With funding bodies emphasizing knowledge translation, i.e. making sure that scientific research results in changes in practice, researchers in shared decision-making have focussed on implementing SDM, or making it happen. Based on studies of barriers to shared decision-making as perceived by health professionals [14] and patients,[15] many researchers are developing sound, theory-based training programs and decision aids, and evaluating their results. Canada has established a research chair that focusses on implementing shared decision-making in primary care contexts.[16]

Although patients who are involved in decision-making about their health have better outcomes,[17] healthcare professionals rarely involve them in these decisions.[18] A recently updated Cochrane review [19] has synthesized the body of evidence about different interventions that can be used to help healthcare professionals adopt practices to better involve their patients in the process of making decisions about their health. In this review of studies testing interventions to help healthcare professionals adopt practices to better involve their patients in the process of making decisions, five studies were identified. This review found that educational meetings, giving healthcare professionals feedback, giving healthcare professionals learning materials, and using patient decision aids are some techniques that have been tried and might be helpful. However, the review could not determine from the available studies which of these were best. The review [19] makes some suggestions for how research studies could better evaluate healthcare professionals involving patients in the process of making decisions about their health so that we can understand this better in the future. There is also a need for greater conceptual clarity. Involving patients in decisions is by definition a process that could occur over time and in many encounters. Much of the literature seems to assume that achieving shared decision-making is a matter of giving healthcare professionals enough information.

Training health professionals in shared decision-making attracts the attention of policy makers when it shows potential for addressing chronic problems in healthcare systems such as the overuse of drugs or screening tests. One such program, designed for primary care physicians in Quebec, Canada, showed that shared decision-making can reduce use of antibiotics for acute respiratory problems (ear aches, sinusitis, bronchitis, etc.) which are often caused by viruses and do not respond to antibiotics.[20]

While some medical schools (e.g. in Germany, the UK and Canada) already include such training programs in their residency programs, there is increasing demand for shared decision-making training programs by medical schools and providers of continuing professional education (such as medical licensing bodies). A 2012 inventory of existing programs (regularly updated)[21] showed that they vary widely in what they deliver and are rarely evaluated.[22] These observations led to an international effort to list the skills necessary for practising shared decision-making and to prioritize them.[23] The effort generated debate among researchers around what core competencies should be taught and how they should be measured, which brought the discussion back to basic questions: what exactly is shared decision-making, do decisions always have to be shared, and how can it be accurately evaluated?

Harvey Fineberg, Head of the US Institute of Medicine, has suggested that shared decision-making should be shaped by the particular needs and preferences of the patient, which may be to call on a physician to assume full responsibility for decisions or, at the other extreme, to be supported and guided by the physician to make completely autonomous decisions.[24] This suggests that, just as with interventions, which need to match the patient's style and preferences, patient's preferences for degree of involvement also need to be taken into account and respected.[24]

Measuring shared decision-making

Several researchers in this field have designed scales for measuring to what extent shared decision-making takes place in the clinical encounter and its effects, from the perspective of patients or healthcare professionals or both, or from the perspective of outside observors.[25] The purpose of these scales is to explore what happens in shared decision-making and how much it happens, with the goal of applying this knowledge to incite healthcare professionals to practise it. Based on these scales, simple tools are being designed to help physicians better understand their patients’ decision needs. One such tool that has been validated, SURE, is a quick questionnaire for finding out in busy clinics which patients are not comfortable about the treatment decision (decisional conflict). SURE is based on O’Connor’s Decisional Conflict Scale [26]which is commonly used to evaluate patient decision aids.[27]The four yes-or-no questions are about being Sure, Understanding the information, the Risk-benefit ratio, and sources of advice and Encouragement.[28][29]

Expanding the field of shared decision-making

Researchers in shared decision-making are increasingly taking account of the fact that involvement in making healthcare decisions is not always limited to one patient and one healthcare professional in a clinical setting. Often more than one healthcare professional is involved in a decision, such professional teams involved in caring for an elderly person who may have several health problems at once. Some researchers, for example, are focussing on how interprofessional teams might practise shared decision-making among themselves and with their patients.[30] Researchers are also expanding the definition of shared decision-making to include an ill person’s spouse, family caregivers or friends, especially if they are responsible for giving the person medicine, transporting them or paying the bills. Decisions that ignore them may not be based on realistic options or may not be followed through.[31] Shared decision-making is also now being applied in areas of healthcare that have wider social implications, such as decisions faced by the frail elderly and their caregivers about staying at home or moving into care facilities.[32]

Related gatherings

Many researchers and practitioners in this field meet every two years at the International Shared Decision Making (ISDM) Conference, which have been held at Oxford in 2001, Swansea in 2003, Ottawa in 2005, Freiburg in 2007, Boston in 2009, Maastricht in 2011, Lima, Peru in 2013, and Sydney, Australia, in 2015.[1] Shared decision-making is also closely associated with the use of decision support interventions, also known as decision aids. Much of the research and implementation studies to date are contained in the following publication: Shared Decision Making in Healthcare: Evidence-based Patient Choice. 2nd ed. Oxford: Oxford University Press, 2009.[33]

In December 2010 a Salzburg Global Seminar focused on "The Greatest Untapped Resource in Healthcare? Informing and Involving Patients in Decisions about Their Medical Care." Powerful conclusions emerged among the 58 participants from 18 countries: not only is it ethically right that patients should be involved more closely in decisions about their own medical care and the risks involved, it is practical – through careful presentation of information and the use of decision aids/pathways – and it brings down costs. Unwarranted practice variations – where one area may have many more interventions than another, but with no better outcomes – are reduced, sometimes dramatically. So why is it that this ‘win-win’ approach is not better understood? Following the seminar the participants created the Salzburg Statement on Shared Decision Making launched in London by the BMJ, one of the world’s leading medical journals, and released it to the press worldwide to stimulate attention and debate.[34]

See also

References

  1. ^ President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry (1998). "Quality First: Better Health Care for All Americans".
  2. ^ Engel GL (May 1980). "The clinical application of the biopsychosocial model". Am J Psychiatry. 137 (5): 535–44. PMID 7369396.
  3. ^ Levenstein JH (1984). "The patient-centred general practice consultation". South African Family Practice. 5: 276–82.
  4. ^ Charles C, Gafni A, Whelan T (March 1997). "Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango)". Soc Sci Med. 44 (5): 681–92. doi:10.1016/S0277-9536(96)00221-3. PMID 9032835.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  5. ^ Makoul G, Clayman ML (March 2006). "An integrative model of shared decision making in medical encounters". Patient Educ Couns. 60 (3): 301–12. doi:10.1016/j.pec.2005.06.010. PMID 16051459.
  6. ^ Elwyn G, Edwards A, Kinnersley P (June 1999). "Shared decision-making in primary care: the neglected second half of the consultation". Br J Gen Pract. 49 (443): 477–82. PMC 1313449. PMID 10562751.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  7. ^ Elwyn G, Edwards A, Kinnersley P, Grol R (November 2000). "Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices". Br J Gen Pract. 50 (460): 892–9. PMC 1313854. PMID 11141876.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  8. ^ Elwyn G, Hutchings H, Edwards A, Rapport F, Wensing M, Cheung WY, Grol R (March 2005). "The OPTION scale: measuring the extent that clinicians involve patients in decision-making tasks". Health Expect. 8 (1): 34–42. doi:10.1111/j.1369-7625.2004.00311.x. PMID 15713169.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  9. ^ "Option Instrument".
  10. ^ Elwyn G, Tsulukidze M, Edwards A, Légaré F, Newcombe R (November 2013). "Using a 'talk' model of shared decision making to propose an observation-based measure: Observer OPTION 5 Item". Patient Education and Counseling. 93 (2): 265–71. doi:10.1016/j.pec.2013.08.005. PMID 24029581.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  11. ^ "NHS Shared Decision Making Programme". Retrieved 29 December 2012.
  12. ^ "Shared Decision Making". Advancing Quality Alliance (NHS). Retrieved 31 January 2014.
  13. ^ Elwyn G, Rix A, Holt T, Jones D (2012). "Why do clinicians not refer patients to online decision support tools? Interviews with front line clinics in the NHS". BMJ Open. 2 (6). doi:10.1136/bmjopen-2012-001530. PMC 3532981. PMID 23204075.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  14. ^ Légaré, F; Ratté, S; Gravel, K; Graham, ID (December 2008). "Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals' perceptions". Patient Education and Counseling. 3 (73): 526–35. doi:10.1016/j.pec.2008.07.018.
  15. ^ Joseph-Williams N, Edwards A, Elwyn G.Joseph-Williams, N.; Edwards, A.; Elwyn, G. (14 May 2014). "Power imbalance prevents shared decision making". BMJ (348:g3178). doi:10.1136/bmj.g3178.
  16. ^ Canada Research Chair in Implementation of Shared Decision Making in Primary Care http://www.decision.chaire.fmed.ulaval.ca
  17. ^ Stacey, D; Bennett CL; Barry MJ; Col NF; Eden KB; Holmes-Rovner M; Llewellyn-Thomas H; Lyddiatt A; Légaré F; Thomson R (2011). "Decision aids for people facing health treatment or screening decisions". Cochrane Database of Systematic Reviews (10): CD001431. doi:10.1002/14651858.CD001431.pub3. PMID 19588325.
  18. ^ Couët N, Desroches S, Robitaille H; et al. (March 2013). "Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument". Health Expectations. doi:10.1111/hex.12054. PMID 23451939. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  19. ^ a b Légaré, F; Ratté, S; Stacey, D; Kryworuchko, J; Gravel, K; Graham, ID; Turcotte, S (May 12, 2010). "Interventions for improving the adoption of shared decision making by healthcare professionals". The Cochrane database of systematic reviews (5): CD006732. doi:10.1002/14651858.CD006732.pub2. PMID 20464744.
  20. ^ Légaré F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J (September 2012). "Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial". CMAJ. 184 (13): E726–34. doi:10.1503/cmaj.120568. PMC 3447039. PMID 22847969.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  21. ^ An updated list is maintained by the Canada Research Chair in Implementation of Shared Decision Making in Primary Care.http://www.decision.chaire.fmed.ulaval.ca/index.php?id=180&L=2
  22. ^ Légaré F, Politi MC, Drolet R, Desroches S, Stacey D, Bekker H (August 2012). "Training health professionals in shared decision-making: an international environmental scan". Patient Education and Counseling. 88 (2): 159–69. doi:10.1016/j.pec.2012.01.002. PMID 22305195.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  23. ^ Légaré F, Moumjid-Ferdjaoui N, Drolet R; et al. (2013). "Core competencies for shared decision making training programs: insights from an international, interdisciplinary working group". The Journal of Continuing Education in the Health Professions. 33 (4): 267–73. doi:10.1002/chp.21197. PMC 3911960. PMID 24347105. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  24. ^ a b Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1186/2045-4015-1-6, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1186/2045-4015-1-6 instead.
  25. ^ Scholl I, Koelewijn-van Loon M, Sepucha K; et al. (2011). "Measurement of shared decision making - a review of instruments". Zeitschrift Für Evidenz, Fortbildung Und Qualität Im Gesundheitswesen. 105 (4): 313–24. doi:10.1016/j.zefq.2011.04.012. PMID 21620327. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  26. ^ O'Connor, AM (1995). "Validation of a decisional conflict scale". Medical Decision Making. 15 (1): 25–30.
  27. ^ Stacey, D; Légaré, F; Col, NF; et al. (2014). "Decision aids for people facing health treatment or screening decisions". The Cochrane Database of Systematic Reviews. 1: CD001431. doi:10.1002/14651858.CD001431.pub4. {{cite journal}}: Explicit use of et al. in: |last4= (help)
  28. ^ Légaré, F; Kearing, S; Clay, K; et al. (2010). "Are you SURE?: Assessing patient decisional conflict with a 4-item screening test". Canadian Family Physician. 56 (8): e308-14. {{cite journal}}: Explicit use of et al. in: |last4= (help); External link in |title= (help)
  29. ^ Ferron Parayre, A; Labrecque, M; Rousseau, M; et al. (2014). "Validation of SURE, a four-item clinical checklist for detecting decisional conflict in patients". Medical Decision Making. 34 (1): 54–62. {{cite journal}}: Explicit use of et al. in: |last4= (help); External link in |title= (help)
  30. ^ Légaré F, Stacey D, Pouliot S; et al. (January 2011). "Interprofessionalism and shared decision-making in primary care: a stepwise approach towards a new model". Journal of Interprofessional Care. 25 (1): 18–25. doi:10.3109/13561820.2010.490502. PMC 3018136. PMID 20795835. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  31. ^ Zhang AY, Siminoff LA (2003). "The role of the family in treatment decision making by patients with cancer". Oncology Nursing Forum. 30 (6): 1022–8. doi:10.1188/03.ONF.1022-1028. PMID 14603359.
  32. ^ Légaré, F; Brière, N; Stacey, D (2015). "Improving Decision making On Location of Care with the frail Elderly and their caregivers (the DOLCE study): study protocol for a cluster randomized controlled trial". Trials. 16 (1): 50. doi:doi:10.1186/s13063-015-0567-7. {{cite journal}}: Check |doi= value (help)
  33. ^ Elwyn, Glyn; Edwards, Adrian (2009). Shared decision-making in health care: Achieving evidence-based patient choice (2nd ed.). Oxford University Press. ISBN 0-19-954627-4.{{cite book}}: CS1 maint: multiple names: authors list (link)
  34. ^ "Salzburg statement on shared decision making". BMJ. 342: d1745. 2011. doi:10.1136/bmj.d1745. PMID 21427038.

Further reading

External links

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