Putting Patients at the Center: An Overview of Shared Decision-Making and CME

What is Shared Decision-Making?

Patient-provider shared decision-making (SDM) is a process whereby decisions about screening, treatment goals, or a treatment plan are made in a collaborative way. Clinicians provide trustworthy information in accessible formats about a set of options and negotiate a decision that integrates the patient’s personal context, concerns, and values.1

Foundational for shared decision-making is for the healthcare provider to develop a trusting relationship with the patient. Establishing what role the patient wants to play in the decision-making process is also key to the process, as well as regularly evaluating the process. A variety of tools exist that can be utilized in the SDM process, each with its own objectives and characteristics.2 Using patient decision aids, which are tools explaining why a decision needs to be made, presenting options and associated benefits/risks, and supporting clarification of patient values and preferences, is recommended to facilitate meaningful SDM conversations.

The Value of SDM

For providers, applying the principles of SDM helps them build a collaborative relationship with patients, where the patient feels more knowledgeable about their condition and treatment choices. On the patient side, engaging in SDM may help patients better understand their health conditions, feel better informed about various treatment options, more confidently engage in dialogue with their provider team, and reduce decisional conflict. SDM helps patients and their providers agree upon a healthcare plan, and when patients participate in healthcare decisions, they are more likely to follow through with that plan.3

Challenges of SDM when Managing Psoriatic Arthritis

This collaborative approach to decision-making between patients and their providers applies to situations when there is more than one reasonable option for the treatment of psoriatic disease.

Many treatment options are available for managing psoriatic arthritis (PsA), which makes it critical to implement SDM. Intentional conversations allow the clinician and the patient to discuss the efficacy and safety profile across therapeutic options, while also providing the opportunity for the clinician to understand the priorities and preferences of the patient and navigate treatment decisions with those in mind.  Unfortunately, these conversations are not being consistently utilized in PsA care. A study exploring the perspectives of patients with PsA showed that many patients experienced frustration about decisions that were made by their rheumatologist or dermatologist without their involvement, and some patients recognized a lack of evidence or information they were aware of when trying different treatments.2 Some barriers to SDM mentioned by clinicians are lack of time and low confidence in their ability to communicate risks effectively. Patients also experience barriers, such as unawareness of having a choice, low confidence to participate, a belief of having a lack of knowledge, and uncertainty about which questions to ask. At the same time, clinicians often do not take patients’ perspectives into account and do not accurately assess (and often underestimate) the extent to which the patient wants to be involved in decisions.3,4 A systematic review of 38 studies of barriers to and facilitators of SDM implementation found physicians’ perceived time constraints, perceptions that SDM cannot be applied because of patients’ characteristics, and the nature of the clinical situation to be the three most common barriers to physician involvement in SDM.5 Clinicians’ lack of training in SDM contributes to suboptimal use of SDM in practice.6-8

Can Continuing Medical Education on SDM Improve Discussion about Treatment Options for PsA?

Highly interactive, multicomponent online interventions have the strongest supporting evidence of effectiveness when compared to other online interventions.4 To help effectively educate providers on the skills needed for effective SDM conversations, Forefront Collaborative recently developed an online CME activity. With this interactive exercise, our goal is to promote increased competency and confidence in applying effective SDM in routine clinical practice.

In this experience, learners are first introduced to the key elements of SDM and the Three-Talk Model5 approach. This model describes the following conversational steps:

Team Talk

Next, learners watch two video examples of patient-provider SDM and assess the observed behaviors using the OPTION 5 tool. The five behaviors to assess include:

  • The clinician points out the need to make a decision and defines it.
  • The clinician affirms they will support the patient to become informed about the options and deliberate on the decision.
  • The clinician gives information about the options comparing the pros and the cons
    and checks understanding.
  • The clinician encourages the patient to reflect on and share their personal treatment goals including what aspects of the options are most important.
  • The clinician integrates the patient’s preferences as the decision is made.

As learners score the conversation, they receive immediate feedback from an expert, detailing the expert’s rating and reasoning for their rating. This immediate feedback allows the learner to reflect on their own assessment of SDM behaviors and improve their understanding of SDM.

While this activity was just recently launched in September 2022, early learner feedback shows it as being effective. Based on evaluation responses (N=177), more than half (53%) gained new knowledge or skills and 9% changed their attitude related to SDM. 67% strongly agreed or agreed that the SDM exercise enhanced their learning experience. One learner noted this as an “excellent training resource.”  70% felt more confident in engaging patients with PsA in SDM, and 32% planned to change their practice of communication with patients about treatment goals and options for PsA.

This experience was developed for PsA education; however, shared decision-making is applicable to many different therapeutic areas. Connect with us to discuss the value and application of shared decision-making education to other therapeutic areas.

REFERENCES:

    1. Elwyn G, Durand MA, Song J, et al. A three-talk model for shared decision making: multistage consultation process. BMJ. 2017;359:j4891.
    2. Ahmad M, Abu Tabar N, Othman EH, Abdelrahim Z. Shared Decision-Making Measures: A Systematic Review. Qual Manag Health Care. 2020;29(2):54-66.
    3. Xu Y, et al. Am Health Drug Benefits. 2018;11:408-417.
    4. Sumpton D, Oliffe M, Kane B, et al. Patients’ perspectives on shared decision-making about medications in psoriatic arthritis: an interview study. Arthritis Care Res (Hoboken).
    5. Elwyn G, Dehlendorf C, Epstein RM, Marrin K, White J, Frosch DL. Shared decision making and motivational interviewing: achieving patient-centered care across the spectrum of health care problems. Ann Fam Med. 2014;12(3):270-275.
    6. Volk RJ, Shokar NK, Leal VB, et al. Development and pilot testing of an online case-based approach to shared decision-making skills training for clinicians. BMC Med Inform Decis Mak. 2014;14:95.
    7. Legare F, Witteman HO. Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health Aff (Millwood). 2013;32(2):276-284.
    8. Elwyn G, Barr PJ, Grande SW, Thompson R, Walsh T, Ozanne EM. Developing CollaboRATE: a fast and frugal patient-reported measure of shared decision making in clinical encounters. Patient Educ Couns. 2013;93(1):102-107.
    9. Godolphin W. Shared decision-making. Healthc Q. 2009;12 Spec No Patient:e186-190.
    10. Legare F, Stacey D, Turcotte S, et al. Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database Syst Rev. 2014;9(9):CD006732.
    11. Lam-Antoniades M, Ratnapalan S, Tait G. Electronic continuing education in the health professions: an update on evidence from RCTs. J Contin Educ Health Prof. 2009;29(1):44-51.
    12. Elwyn G, Grande SW, Barr P. Observer OPTION 5 Manual: Measuring shared decision making by assessing recordings or transcripts of encounters from clinical settings.: The Dartmouth Institute for Health Policy and Clinical Practice; 2018.