Michael Barry: Aligning incentives to support shared decision making in the United States

mike_barryShared decision making (SDM) between clinicians and patients is riding high in clinical and health policy circles in the United States. SDM is featured in several sections of the Affordable Care Act, and has been included as an element in the Accountable Care Organizations and the Comprehensive Primary Care Initiative, supported by the Center for Medicare and Medicaid Services to test new, more effective and efficient models of healthcare. The American Medical Association and the influential advocacy group AARP have jointly published policies calling for shared decision making between physicians and patients. Shared decision making has also been the subject of legislation at the state level, most notably in Washington state, where the legislation offers clinicians using decision aids some added protection from medical malpractice claims and has led to a large successful implementation at Group Health Cooperative, a large, innovative prepaid group practice.

Patient decision aids are tools that support shared decision making, and help make it practical in the busy world of clinical medicine. The latest update of the Cochrane meta-analysis of randomized trials of decision aids for treatment or screening decisions, just presented at the International Shared Decision Making meeting, now includes over 100 RCTs. Collectively, these trials show decision aids improve patient knowledge, reduce decisional conflict relating to feeling uninformed or unclear about values, and reduce proportions of people remaining undecided or passive in decision making. Exposure to decision aids was associated with fewer patients choosing elective invasive surgeries and PSA tests for prostate cancer screening. Ironically, the evidence for the use of decision aids is often stronger than the evidence for many of the interventions addressed by decision aids; for example, robotic surgery for men with a diagnosis of early stage prostate cancer.

However, patients facing fateful, preference-sensitive decisions cannot yet count on getting an optimal SDM experience. On 23-24 May, the Informed Medical Decisions Foundation and the Gordon and Betty Moore Foundation cosponsored a meeting of key stakeholders including patients, patient advocates, clinicians, employers, health systems leaders, insurers, government representatives, and researchers to enumerate the barriers to SDM and how to overcome them. Reports of organizations working hard to implement SDM were featured.

The group supported a definition of shared decision making proposed by Angela Coulter, a keynote speaker, as a process in which care providers and patients work together to select tests, treatments and care plans, based on clinical evidence and the patient’s informed preferences. Barriers identified included a culture in medicine that still favors clinicians making decisions for patients and patients playing a passive role, insufficient infrastructure in health systems to make SDM routine, inadequate SDM knowledge and skills among clinicians, and payment mechanisms that still favor providing more medical interventions rather than discussing which interventions are most appropriate for an individual. Attendees worked with the meeting organizers on a call to action addressing how different stakeholders can help to overcome these barriers. The action plan can be found here.

Michael J Barry, MD is the president of the Informed Medical Decisions Foundation.

The author has completed the ICMJE uniform disclosure at www.icmje.org/coi_disclosure.pdf and declares a grant from the Gordon and Betty Moore Foundation for the meeting described in the article; MB receives salary support as president and board member of the nonprofit Informed Medical Decisions Foundation. The Foundation receives royalty and project payments from Health Dialog.