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 . This approach is pertinent to the care of
patients with chronic conditions . Six key elements of shared decision making
can be identified [1-4]:
- situation diagnosis (understanding the patient’s situation and establishing the aspects require action)
- choice awareness (indicating that multiple options are available and highlighting the
- importance of the patient’s preferences in deciding on the course of action)
- option clarification (explaining the available options)
- discussion of harms and benefits (explaining the harms and benefits of each option)
- deliberation of patient preferences (discussing the preferences of the patient)
- making the decision (clinician and patient making together the decision)
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].
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 .
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.
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
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
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