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By training in shared decision-making, providers can empower patients to become more engaged in their own treatment.
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What is SHAREd DECISION-MAKING?
Patients who engage in and own their health do better. Shared Decision-Making, or SDM, is an engagement model that places patients at the forefront of their healthcare decisions and improves outcomes. In the SDM process, doctors help patients understand their health and give an evidence-based presentation of the treatment options available. Patients are in the driver’s seat throughout the decision-making process, and doctors inform patients of the facts, risks, and rewards without regard to their subjective preferences. Patients whose doctors are trained in SDM practices report greater satisfaction and less decisional regret than those whose doctors are not. Continuing medical education (CME) is instrumental in helping doctors develop and maintain their skills, and as SDM tools continue to be developed CME providers play a leading role in ensuring that providers have access to them.
More about CME and Shared Decision-Making
SDM is a cornerstone of patient-centered care that can be practiced every day by clinicians and the patients they see. At a basic level, it involves patients and their healthcare providers together identifying the right course of action for that patient. SDM places patient preferences at the center of the decision-making process, ensuring that patients’ wishes are fulfilled. Late-stage cancer patients, for example, may have differing preferences: one patient may value being comfortable in their final days, while another may value living long enough to attend their grandchild’s graduation or wedding. SDM processes help patients and doctors factor those values into care selection and bolster patient buy-in as treatment moves forward.
A key component of SDM is the incorporation of clinical evidence in the decision-making process, placing patients and providers on firm footing when making their decisions. Treatment options are presented with evidence about outcomes, allowing patients and providers to make informed decisions about the right path. Options are frequently presented with the help of decision aids, which are developed by experts in the field and give clinicians and patients a roadmap for the SDM process. The appropriateness of a given treatment differs by patient, and using clinical evidence to inform the decision-making process fosters a clear-eyed choice.
A key component of SDM is the incorporation of clinical evidence in the decision-making process, placing patients and providers on firm footing when making their decisions. Treatment options are presented with evidence about outcomes, allowing patients and providers to make informed decisions about the right path. Options are frequently presented with the help of decision aids, which are developed by experts in the field and give clinicians and patients a roadmap for the SDM process. The appropriateness of a given treatment differs by patient, and using clinical evidence to inform the decision-making process fosters a clear-eyed choice.
What Does the Government Do?
Multiple federal agencies are involved with researching, developing, and promoting SDM processes. A selection of them is below.
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The Agency for Healthcare Research and Quality (AHRQ) has developed its SHARE framework to educate providers on how to share risks, benefits, and other considerations with patients. SHARE is a five-step process in which providers (1) seek patient participation, (2) help patients explore and compare options, (3) assess patient values and preferences, (4) reach a decision, and (5) evaluate the decision. In addition to tools, AHRQ has created a curriculum for teaching the framework. AHRQ also has a set of success stories from the use of its SHARE framework.
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The Substance Abuse and Mental Health Resources Administration (SAMHSA) and the Health Resources Services Administration (HRSA) maintain a resource center through their joint Center for Integrated Health Solutions dedicated to SDM. They promote AHRQ’s SHARE framework and offer tools to aid in SDM, such as a personal health record tool that patients can use to maintain a log of their health information and share it with providers.
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The Patient-Centered Outcomes Research Institute (PCORI) conducts and funds research into patient-centered care, including SDM. As of November 2017, PCORI has 54 grants totaling $125 million for research into SDM and associated tools. PCORI’s research has spanned a number of different conditions, with cancer and cardiovascular disease being the most studied. The Institute has also funded studies into helping low health literacy populations participate in SDM.
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The Centers for Medicare and Medicaid Services (CMS) has made shared decision-making mandatory for some services related to preference-sensitive conditions. For example, clinicians must now participate in an SDM interaction with patients prior to moving forward with the implantation of implantable cardioverter-defibrillators. They must also participate in an SDM interaction for some lung cancer screenings and for prophylactic left atrial appendage closure. These pilots may pave the way for CMS to mandate SDM for more services, and potentially ones that are less complex than the three for which CMS has mandated SDM.
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What can CME do?
Researchers have found that providers trained in SDM processes involve their patients more in choosing care strategies. In turn, those patients experience less decisional regret and better care outcomes. A study published in the peer-reviewed journal Blood demonstrated that clinicians who undergo CME training in SDM are more likely to incorporate patient preferences in their decision-making processes and were also more likely to choose an expert-recommended course of action. Of 1,253 clinician participants in the study, 45 percent more clinicians indicated that they would consider patient preferences in their decision-making processes after taking a CME course on SDM. Additionally, when considering courses of action for patients in a scenario, the share of clinicians who chose what experts have agreed is the optimal treatment for that patient nearly doubled, from 47 percent to 90 percent.
Another study published in the Annals of Family Medicine found that for physicians who received CME relating to shared decision-making related to cardiovascular disease risk, patient satisfaction was greatly improved. Teaching clinicians to use a simple decision aid to facilitate shared decision-making resulted in significantly less decisional regret on the part of patients while also not contributing negatively to their cardiovascular disease risk.
In addition to helping reduce difficult interventions, the use of shared decision-making tools and decision aids can also help reduce costs. A study of a health system in Washington State showed that the introduction of such tools resulted in fewer elective surgeries and lower costs. Their use was associated with 26 percent fewer hip replacement surgeries, 38 percent fewer knee replacements, and 12-21 percent lower costs over a six-month period. Incorporating patient preferences leads not only to better outcomes from the patient’s perspective, but for the health system in general. Similarly, researchers found in an article published in the Journal of the American Medical Association that the use of SDM-focused patient decision aids led to a better decision-making process and did not carry adverse effects for either the patient or for the health system.
Another study published in the Annals of Family Medicine found that for physicians who received CME relating to shared decision-making related to cardiovascular disease risk, patient satisfaction was greatly improved. Teaching clinicians to use a simple decision aid to facilitate shared decision-making resulted in significantly less decisional regret on the part of patients while also not contributing negatively to their cardiovascular disease risk.
In addition to helping reduce difficult interventions, the use of shared decision-making tools and decision aids can also help reduce costs. A study of a health system in Washington State showed that the introduction of such tools resulted in fewer elective surgeries and lower costs. Their use was associated with 26 percent fewer hip replacement surgeries, 38 percent fewer knee replacements, and 12-21 percent lower costs over a six-month period. Incorporating patient preferences leads not only to better outcomes from the patient’s perspective, but for the health system in general. Similarly, researchers found in an article published in the Journal of the American Medical Association that the use of SDM-focused patient decision aids led to a better decision-making process and did not carry adverse effects for either the patient or for the health system.
Selected Resources
Many states require physicians to complete CME in order to maintain their licenses. A focus on SDM is one way that doctors can fulfill their requirements while building a base of knowledge in patient-centric, collaborative medicine. CME programs are developed by a number of businesses and non-profit organizations, and many are independently evaluated to ensure their utility and accuracy.
CME Coalition is pleased to connect healthcare professionals to a variety of organizations who develop SDM resources. These resources span from CME products that provide instruction on SDM processes and their use to decision aids that structure SDM, supporting patient-centered care.
CME Coalition is pleased to connect healthcare professionals to a variety of organizations who develop SDM resources. These resources span from CME products that provide instruction on SDM processes and their use to decision aids that structure SDM, supporting patient-centered care.
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