The SDM 3 Circle Model: A Literature Synthesis and Adaptation for Shared Decision Making in the Hospital
Patient engagement through shared decision-making (SDM) is increasingly seen as a key component for patient safety, patient satisfaction, and quality of care. Current SDM models do not adequately account for medical and environmental contexts, which may influence medical decisions in the hospital. We identified leading SDM models and reviews to inductively construct a novel SDM model appropriate for the inpatient setting. A team of medicine and pediatric hospitalists reviewed the literature to integrate core SDM concepts and processes and iteratively constructed a synthesized draft model. We then solicited broad SDM expert feedback on the draft model for validation and further refinement. The SDM 3 Circle Model identifies 3 core categories of variables that dynamically interact within an “environmental frame.” The resulting Venn diagram includes overlapping circles for (1) patient/family, (2) provider/team, and (3) medical context. The environmental frame includes all external, contextual factors that may influence any of the 3 circles. Existing multistep SDM process models were then rearticulated and contextualized to illustrate how a shared decision might be made. The SDM 3 Circle Model accounts for important environmental and contextual characteristics that vary across settings. The visual emphasis generated by each “circle” and by the environmental frame direct attention to often overlooked interactive forces and has the potential to more precisely define, promote, and improve SDM. This model provides a framework to develop interventions to improve quality and patient safety through SDM and patient engagement for hospitalists.
© 2017 Society of Hospital Medicine
Model Development and Expert Review
The draft model and a standardized set of questions (supplementary Appendix A) were then emailed to all first and last authors of the reviewed studies (Table 2). Expert responses were compiled, coded, and analyzed independently by 3 coauthors. Inductive coding techniques and a constant comparative approach were used to code the qualitative data.32 Preliminary findings were shared among the 3 reviewers and discussed until consensus was reached on emerging themes and implications for the new SDM model and multistep SDM pathway. A master list of suggested revisions was shared with the larger authorship team and the model was refined accordingly.
RESULTS
Two previously published systematic reviews25,26 identified 494 articles, 161 conceptual definitions of SDM, and over 30 separate key concepts. The additional PubMed search garnered 1957 publications (with many overlapping from the systematic reviews). A manual search of the systematic reviews and PubMed abstracts identified 16 unique and complete decision-making models for further review. Hand searches of their citations yielded an additional 6 models for a total of 22 models.3,4,13,23,33-51 The majority of excluded articles described specific decision aids and small clinical studies, focused on only one step of the decision-making process, or were not otherwise relevant. The first (SR) and senior authors (JS) reviewed the 22 models for SDM relevance, generalizability, and content saturation, yielding a final sample of 9 SDM models. A subsequent Google Scholar search did not identify any new SDM models but 2 SDM theory papers1,52 and 2 commentaries53,54 were selected based on influence (ie, number of citations), expert recommendation, or coverage of a novel aspect of SDM. A total of 15 studies (9 SDM models + 6 reviews; Table 2) were used by our development team to create a synthesized SDM model. A 10th SDM model55 and 3 additional descriptive and normative studies8,56,57 were later added based on expert feedback and incorporated into our final SDM 3 Circle Model.
Expert Feedback
Twenty-one of 27 (78%) SDM expert authors responded to our e-mail request for feedback. The majority (62%) agreed with the basic elements of the model, including the environmental frame and the 3 domains. Some respondents viewed SDM as strictly a process between patient and provider independent of the disease, leading to refinement of the medical context category. Several experts emphasized the importance of SDM “set-up,” which includes the elicitation of patient preferences in how decisions are made and the extent of patient and/or surrogate involvement.
Several respondents identified time constraints (N = 2), acuity of disease (N = 3), and presence of multiple teams (N = 6) to be the significant factors distinguishing inpatient from outpatient SDM. For some experts, “team” referred to the interprofessional care team, whereas others referred to it as the collaboration among attending physicians and trainees. Experts noted that although the intensity and frequency of inpatient interactions could promote SDM, higher patient acuity and the urgency of decisions could negatively influence SDM and/or the patient’s ability to participate. Similarly, the presence of other team members may either impede or promote SDM by either contributing to miscommunication or bringing well-trained SDM experts to the bedside. Financial impact on patients and resource constraints were also noted as relevant. All of these elements have been incorporated into the final SDM 3 Circle Model and multistep SDM Pathway (Supplemental Appendix A and B).
The SDM 3 Circle Model
The SDM 3 Circle Model comprises 3 categories of SDM barriers and facilitators that intersect within the environmental frame of an inpatient ward or other setting: (1) provider/team, (2) patient/family, and (3) medical context. A Venn diagram visually represents the conceptual overlaps and distinctions among these categories that are all affected by the environment in which they occur (Supplemental Appendix A).
The patient/family circle mirrors prior SDM models that address the role of patient preferences in making decisions,3,4,12 with the explicit addition of the roles of families and surrogates as either decision-makers or influencers. This circle includes personal characteristics, such as cognitions (eg, beliefs, attitudes), emotions (eg, anxiety, hope), behaviors (eg, adherence, assertiveness), illness history (ie, subjective experience and understanding of one’s own medical history), and related social features (eg, culture, education, literacy, social supports).
Patient factors are not static over time or context. They occur within an environmental setting and are likely to be influenced by concurrent provider and medical variables (the second and third circles). Disease exacerbation leading to hospitalization or transfer to a subacute facility could dramatically shift the calculus a patient uses to determine preferences or activate dormant family dynamics. Strong provider-patient rapport (the overlap of patient and provider factors) may influence the development of trust and subsequent decisions.9 The type of disease or symptom presentation (circle 3–medical context) may further influence patient factors due to stigma, perceived vulnerability, or assumed prognosis.
The provider/team circle includes both individual and team-based factors falling into similar categories as the patient/family domain, such as cognitions, behavior, and social features; however, these factors include both personal (eg, the provider’s personal history, values, and beliefs) and professional (eg, past medical training, decision-making style, past experiences treating a disease) characteristics. Decisions may involve an interprofessional team representing a broad range of personalities and professional values. Decisions and decision-making processes may change over time as team composition changes, as level of provider expertise varies, or as environmental, patient, or disease/illness factors influence providers and teams.
Medical context includes factors related to the disease and the potential ways to evaluate or manage it. Examples of disease factors include acuity, symptoms, course, and prognosis. Most obviously, disease factors will influence the content of risk-benefit discussions but may also affect the SDM process through disease stigma or cultural assumptions about etiology. Disease evaluation factors include the psychometrics of a diagnostic screen, invasive and noninvasive testing, or a range of different preventive or therapeutic interventions. Treatment variables include the available options, costs, and risk of complications. Medical context variables evolve as evidence-based medicine and biomedical knowledge increase and new treatment options emerge.
Each of the 3 circles operates within the same environmental frame, such as an inpatient medicine ward, which itself operates within a hospital and the broader healthcare system. This frame exerts overt and subtle influences on providers, patients, and even the medical context. Features of the environmental frame include culture (eg, values, preferences, social norms), university versus community setting, incentives, formularies, quality improvement campaigns, regulations, and technology use.
The dynamic interactivity of the environmental frame and the 3 circles inform the process of SDM and highlight key differences that may occur between care settings. Certain features may predominate in different situations, but all will influence and be influenced by features of other circles during the course of SDM.
