July 2, 2019

Decision aids that facilitate elements of shared decision making in chronic illnesses

By Kirsten Fleming

Submitted by Thomas Wieringa

Shared decision making (SDM) is a patient-centered approach in which clinicians and patients work together to find and choose the best course of action for each patient’s particular situation [1]. This approach is pertinent to the care of patients with chronic conditions [2]. Six key elements of shared decision making can be identified [1-4]:

  1. situation diagnosis (understanding the patient’s situation and establishing the aspects require action)
  2. choice awareness (indicating that multiple options are available and highlighting the
  3. importance of the patient’s preferences in deciding on the course of action)
  4. option clarification (explaining the available options)
  5. discussion of harms and benefits (explaining the harms and benefits of each option)
  6. deliberation of patient preferences (discussing the preferences of the patient)
  7. making the decision (clinician and patient making together the decision)

Decision aids
SDM can be facilitated by decision aids that have been developed for use by clinicians and patients, either during or in preparation of the clinical encounter [5-7]. Decision aids can help patients choose an option that is congruent with their values, reduce the proportion of patients remaining undecided and/or who play a passive role in the decision-making process, and improve patient knowledge, decisional conflict, and patient-clinician communication [7-11].

The International Patient Decision Aid Standards (IPDAS) Collaboration developed a minimal set of standards for qualifying a tool as a decision aid, which require that a decision aid support all key elements but making the decision [12].

Systematic review
We conducted a systematic review to assess the extent to which decision aids support the six key SDM elements and how this relates to their impact.

We found 24 articles reporting on 23 RCTs of 20 DAs (10 DAs for cardiovascular disease, two DAs for respiratory diseases, and eight DAs for diabetes). With the exception of one, all studies have an unclear or high risk of bias for all outcomes assessed in this review. The option clarification element (included in 20 of 20 DAs; 100%) and the harms and benefits discussion (included in 18 of 20 DAs; 90%; unclear in two DAs) are the elements most commonly clearly included in the DAs. The other elements are less common and more uncertainty is present whether these elements are included, especially with regard to choice awareness (uncertain in 14 out of 20 DAs; 70%). All elements were clearly supported in four DAs (20%). We found no association between the presence of these elements and SDM outcomes.

Conclusion
Thus, despite the IPDAS minimal set of qualifying criteria, our systematic review showed that decision aids for cardiovascular diseases, chronic respiratory diseases, and diabetes mostly support the option clarification and the discussion of harms and benefits elements of SDM, while the other SDM elements are less often incorporated.

Future research
Possibly, some SDM elements may be left out of decision aids by design. This choice may depend on what features were thought most important by the developers (e.g., patient education, risk communication, preference elicitation, or patient empowerment). The importance of incorporation of SDM elements in decision aids may be situation-dependent, but the way this works is unclear. Therefore, future research should clarify this situation-dependence and eventually inform possible reconsideration of the IPDAS minimum standards for decision aid qualification. The relationship between the extent to which decision aids support SDM elements and outcomes is yet unknown and should be studied in future research as well.

The full paper was published in Systematic Reviews and can be found here: https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-019-1034-4.

Thomas Wieringa is a post-doc researcher at the department of Epidemiology at the University Medical Center Groningen (UMCG), the Netherlands. He did his PhD, focused on shared decision making and patient-reported outcomes in type 2 diabetes, at the VU University Medical Center. He visited and collaborated with the Knowledge and Evaluation Research (KER) Unit of the Mayo Clinic in the context of his PhD.

References

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  2. Montori VM, Gafni A, Charles C. A shared treatment decision-making approach between patients with chronic conditions and their clinicians: The case of diabetes. Health Expectations. 2006;9(1):25-36.
  3. Kunneman M, Engelhardt EG, Ten Hove FL, Marijnen CA, Portielje JE, Smets EM, et al. Deciding about (neo-) adjuvant rectal and breast cancer treatment: Missed opportunities for shared decision making. Acta Oncologica. 2016;55(2):134-9.
  4. Stiggelbout AM, Pieterse AH, De Haes JCJM. Shared decision making: Concepts, evidence, and practice. Patient Education and Counseling. 2015;98(10):1172-9.
  5. IPDAS Collaboration. What are patient decision aids? http://ipdas.ohri.ca/what.html (2017). Accessed 30 Oct 2018.
  6. Montori VM, Kunneman M, Brito JP. Shared decision making and improving health care: The answer is not in. JAMA: Journal of the American Medical Association. 2017;318(7):617-8.
  7. Stacey D, Légaré F, Lewis K, Barry MJ, Bennett CL, Eden KB, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews. 2017;(4):CD001431.
  8. Durand MA, Carpenter L, Dolan H, Bravo P, Mann M, Bunn F, et al. Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis. PloS One. 2014;9(4):e94670.
  9. Légaré F, Turcotte S, Stacey D, Ratté S, Kryworuchko J, Graham ID. Patients' perceptions of sharing in decisions. The Patient - Patient-Centered Outcomes Research. 2012;5(1):1-19.
  10. Dwamena F, Holmes-Rovner M, Gaulden CM, Jorgenson S, Sadigh G, Sikorskii A, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. The Cochrane Library. 2012;(12):CD003267.
  11. Joosten EA, DeFuentes-Merillas L, De Weert GH, Sensky T, Van Der Staak CPF, de Jong CA. Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychotherapy and Psychosomatics. 2008;77(4):219-26.
  12. 12.           Joseph-Williams N, Newcombe R, Politi M, Durand M-A, Sivell S, Stacey D, et al. Toward minimum standards for certifying patient decision aids: A modified Delphi consensus process. Medical Decision Making. 2014;34(6):699-710.

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