Evidence Base
Helping patients make informed medical decisions is the right thing to do. But how do we know it’s beneficial and can be implemented in the real-world setting? We are confident of the benefits of shared decision-making because of the strength of the evidence base and the resounding results of our ongoing demonstration projects.
The scientific literature contains a solid body of evidence demonstrating the many benefits of the use of decision aids and the process of shared decision-making.
• Use of decision aids increases patients’ knowledge about their condition and treatment options. [O’Connor 1999]
• In some cases, patients choose a different treatment option after use of decision aids, suggesting that standard practice may not sufficiently educate patients about the complexities of their medical decisions. [O’Connor 1999]
• Patients whose physicians use decision aids are more likely to choose a less invasive treatment option. [Whelan 2004]
• Patients who use decision aids report less decisional conflict and greater satisfaction with their treatment decision than patients who receive usual care without decision aids, suggesting that shared decision-making empowered them to choose the treatment option that better fit their values. [Whelan 2004]
• Patients who engage in shared decision-making are more likely to disagree with a recommendation for a more invasive treatment option, suggesting that use of decision aids helps clarify patient values and preferences, even when these differ from their physicians’. [Morgan 2000]
Review Of Clinical Trials
A systematic review of randomized controlled trials found that decision aids:
• Increase patient knowledge scores
• Reduce decisional conflict
• Reduce the proportion of patients who remain undecided about their options
• Improve agreement between the medical option selected and the patient’s values
Most of the trials reviewed also found that a smaller proportion of patients select the more invasive option after engaging in shared decision-making. In several trials based in the UK, costs were comparable or lower when decision aids were used rather than usual care, primarily due to lower rates of surgery. [O’Connor 2004]
Our demonstration projects have shown that shared decision-making can be effectively implemented in the busy, time-pressured, clinical setting. The Foundation funds demonstration projects on the real-world implementation of informed medical decision-making in primary care, and specialty care. Through the efforts of health care providers, administrators, and staff at our many demonstration sites, we’ve learned a great deal about the implementation of shared-decision making models, including:
• Optimal implementation strategies differ depending on whether the decision involves testing or treatment.
• The office setting of providers is often not conducive to optimal viewing and understanding of decision aids, because of competing demands for a patient’s attention.
• To achieve high viewing rates, providers and office staff must enthusiastically endorse decision aids.
• Patients in demonstration sites generally rated our decision aids highly, regardless of age, sex, or education.
• Patient knowledge scores increased after viewing decision aids in our demonstration sites.
• Fewer patients remain undecided about their decision after viewing a decision aid.
The scientific literature and our experience with demonstration sites have created a solid evidence base that substantiates the benefits of shared decision-making and the use of decision aids. Our work with demonstration sites has proven that implementation of shared decision-making is feasible, even in the complex, time-pressured reality of current clinical care settings. By funding additional research and continuing our support of demonstration sites, we will extend the understanding of the effective implementation strategies and investigate the cost effectiveness of shared decision-making.
Links:
Primary Care Demonstration Sites
Specialty Care Demonstration Sites
References:
O'Connor AM, Llewellyn-Thomas HA, Flood AB. Modifying unwarranted variations in health care: shared decision making using patient decision aids. Health Aff (Millwood). 2004;Suppl Web Exclusives:VAR63-72.
O'Connor AM, Rostom A, Fiset V, Tetroe J, Entwistle V, Llewellyn-Thomas H, Holmes-Rovner M, Barry M, Jones J. Decision aids for patients facing health treatment or screening decisions: systematic review. BMJ. 1999;319(7212):731-4.
Whelan T, Levine M, Willan A, Gafni A, Sanders K, Mirsky D, Chambers S, O'Brien
MA, Reid S, Dubois S. Effect of a decision aid on knowledge and treatment decision making for breast cancer surgery: a randomized trial. JAMA. 2004;292(4):435-41.
Morgan MW, Deber RB, Llewellyn-Thomas HA, Gladstone P, Cusimano RJ, O'Rourke K, Tomlinson G, Detsky AS. Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease. J Gen Intern Med. 2000;15(10):685-93.