Shared Decision-Making and High-Level Support

Shared decision-making (SDM) is a process of communication in which clinicians and patients work together to make informed healthcare decisions that align with what matters most to patients and their individual concerns, preferences, goals, and values.

Among the many organizations promoting the universal adoption of shared decision-making is the influential National Quality Forum, which endorses quality measures and strategies to reduce costs and improve patient care. In 2018, it published a National Quality Partners Playbook that called shared decision-making a “healthcare imperative.”(1) The Forum’s focus on shared decision-making reflects the need to improve patient-centered — or person-centered — care. The playbook identifies three components for true shared decision-making:

• Clear, accurate, and unbiased medical evidence about reasonable alternatives, including no medical intervention, and the risks and benefits of each.

• Clinician expertise in communicating and tailoring the evidence for individual patients.

• Patient values, goals, informed preferences, and concerns, which may include treatment burdens.

The playbook states: “SDM can become a standard of care for all patients regardless of setting or diagnosis, but that can only happen when patients and families understand the importance of their input and engagement in healthcare decisions, and clinicians understand the importance of involving patients in decisions — and when both are supported in doing so.”

The National Quality Partners Shared Decision Making Action Team identified six fundamentals that healthcare organizations must embrace to implement shared decision-making(1):

1. Promote leadership and culture.

2. Enhance patient education and engagement.

3. Provide healthcare team knowledge and training.

4. Take concrete actions for implementation.

5. Track, monitor, and report [findings].

6. Establish accountability for organizations, clinicians, and patients.

Daniel Matlock, MD, MPH, director of the Colorado Program for Patient-Centered Decisions at the University of Colorado Anschutz Medical Campus, suggests that for most health systems, shared decision-making is more of a buzzword than an organizational imperative.

“People want to say, ‘Oh yeah, we do shared decision-making; our care is very patient-centered,’” Matlock says. “OK, then have you talked to your docs? Did you measure how patient-centered they are? Most of the successful examples of widespread shared decision-making are one-offs, often in clinical settings,” he says. “I can count them on one hand because that’s how few and far between they are.”

Still, health systems working under the fee-for-service business model find it hard to justify implementing a process that might reduce utilization. “There’s a lot of data supporting shared decision-making, and there’s a lot of pull from patients to have more of this,” Matlock says. “But I’m still trying to figure out what is the value proposition for a hospital — there’s not a great one from a financial perspective.”

That may be changing, however. The Centers for Medicare & Medicaid Services recently mandated shared decision-making as a condition for payment for implantable defibrillators for some patients, as well as left atrial appendage closure devices and lung cancer screening using low- dose computed tomography. Shared decision-making also may help health systems succeed in value-based payment arrangements. For example, UCLA Health contracts with an insurer using an alternative payment model that incentivizes the health system to reduce care gaps.(2)

Excerpted from Physician Leadership: More Valuable Than Ever —A White Paper from the American Association for Physician Leadership by Peter B. Angood, MD, FRCS(C), FACS, MCCM, FAAPL(Hon).

REFERENCES

1. National Quality Forum. National Quality Partners™ Shared Decision Making Action Team. NQF website. https://www.qualityforum.org/National_Quality_Partners_Shared_Decision_Making_Action_Team_.aspx

2. Butcher L. Shared Decision-Making Needs More Leadership. Physician Leadership Journal. 2022;9(3):40–42. https://www.physicianleaders.org/articles/doi/10.55834/plj.7122014777

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