Written by Victor M. Montori, MD and Jon C. Tilburt, MD
Lee and Emanuel raise the profile of the shared decision making (SDM) provisions in the Patient Protection and Affordable Care Act. We concur that those provisions should spur research and development in SDM. However, their claims, that we already know how to implement SDM and that it is time for pay-for-performance for use of certified decision aids, are both premature and misguided.
Studies of decision aids implemented outside clinical visits show improvements in patient knowledge about the available options and about their risks and benefits, but not in actual sharing of decision making. Decision aids for use by patients and clinicians during the visit may work better. Video data from hundreds of recorded visits show a stark difference: patients in decision aid visits are better informed and participate more in making decisions. Patients and clinicians end up more comfortable with decisions they made together. In-visit decision aids galvanize patients and clinicians around a shared a purpose – to make the best possible evidence-based decision given the patient's values, preferences, goals, and context. Yet, getting this degree of patient engagement does not happen with the flip of a switch and routine implementation remains untested.
Lee and Emanuel rightly point out the potential utilitarian benefits of SDM, particularly about surgical decisions. However, in so doing they jeopardize the patient-centered vision at the core of SDM. Moreover, their economic claim of cost-savings overreaches the current state of the evidence, making their SDM-linked pay for performance proposal premature. Research on SDM implementation is green, clinicians and patients are not ready, training and tools are just evolving. Thus, we support the law's push for research and development. Their proposal is also dangerous. A focus on cost containment and pay for performance can corrupt the journey toward implementing SDM for all: we fear that the next time a clinician pulls out a decision aid, the clinician will be thinking about reimbursement while the patient wonders whether the clinician has her back.