How to integrate shared decision-making into your practice

A proposed framework for identifying whether SDM or motivational interviewing is appropriate is featured in the FIGURE. In their paper, Elwyn et al²⁹ further define and discuss the distinguishing features and roles of SDM and behavioral support interventions, such as motivational interviewing.

Tools to facilitate SDM conversations

Decision aids

SDM has historically been operationalized for study through the use of decision aids: formally structured materials describing, in detail, the available treatment options under consideration, including the relative risks and benefits. Frequently, such tools are framed from a patient perspective, with digestible information presented in a multimedia format (eg, visual risk representations of “1 out of 10” in an icon array vs “10%”), leveraging effective risk communication strategies (eg, absolute risk rates vs relative risks and “balanced framing”). For instance, the physician would note that 1 out of 10 patients have an outcome and 9 out of 10 do not.

Additional information on risk communication skills is available at the Agency for Healthcare Research and Quality’s webpage on the SHARE approach (www.ahrq.gov/health-literacy/professional-training/shared-decision/tool/resource-5.html).³⁰ Decision aids have been shown to enhance health literacy, increase patient knowledge and understanding, and promote the frequency of “values-concordant” choices.³

Point-of-care decision support

A more recent trend in SDM is increased development and use of point-of-care decision support tools that emphasize information reflecting individual patient circumstances (eg, leveraging heart risk calculators to individualize risk conversations when considering statins for primary prevention of heart disease based on lipids and other demographic factors). An advantage to using such tools is that they provide “just-in-time” detailed and personalized evidence-based information, guiding the discussion and minimizing the need for an extensive advance review of each topic by emphasizing the “key facts.” To ensure effective use of SDM tools, avoid oversaturating patients with data, maintain a focus on patient values, and engage in a 2-way discussion that considers the unique mix of preferences and circumstances.

Proprietorship of tools and decision aids

Until recently, SDM materials were compiled primarily within not-for-profit entities such as the Informed Medical Decisions Foundation, which became a division of Healthwise in 2014.² In recent years, there has been an increasing trend of for-profit companies acquiring or developing their own decision aids and decision-support tools, eg, EBSCO Health (Option Grid³¹ and Health Decision³²) and Wolters Kluwer (EMMI³³). The extensive work of curating SDM and educational tools to keep up with best medical evidence is costly, and the effort to defray costs can give rise to potential conflicts of interest. Therefore, the interests of the creators of such tools—whether commercial or academic—should always be considered when evaluating the use of a given decision-support tool.

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