Value-based Healthcare: Integrating Shared Decision-making into Clinical Practice

Shared decision-making (SDM) is a collaborative process wherein clinicians share their knowledge of conditions, treatment options, and potential harms and benefits, and patients share their preferences, values, and goals before making individualized and confident healthcare decisions together. Patient decision aids have been developed to facilitate SDM, and they have been shown to consistently improve a patient’s knowledge about their condition and treatment options as well as decision quality, resulting in more informed and confident decisions [5, 6]. But why isn’t SDM (and, in particular, why aren’t patient decision aids) in wider use across clinical practice? More importantly, how can we resolve this problem?

The Knowing-Doing Gap

First off, a decade on from a Clinical Orthopaedics and Related Research® column on the prospect and benefits of SDM in orthopaedics, we perceive little has changed in terms of orthopaedic surgeons’ level of engagement with SDM [3]. That is, although most surgeons agree with the rationale behind SDM and many think (and believe) they already “do SDM,” it’s unclear whether they are truly engaging in the process and harnessing the full benefits of this concept. There are several common barriers that get raised.

It Is Unrealistic to Use SDM in my Busy Practice During Short Office Visits

There is a common misconception that SDM and decision aids extend office visit times. This may cause some clinicians to resist the use of decision aids and hesitate before engaging patients fully in the decision-making process. In fact, current evidence shows that the use of patient decision aids does not significantly extend the duration of office visits; rather, both clinicians and patients feel the use of such tools is time well-spent and enhances the care experience all around [4, 11]. Clinicians may also forget that better healthcare decisions are usually made when there is time, space, and opportunity for deliberation rather than forcing decisions over set timeframes.

My Patients Want Me to Make the Decision

Surgeon perceptions of patient preferences and control over decision-making may be misaligned with patient perceptions, despite the availability of PROs and patient decision aids, which are intended to limit this mismatch [1]. Patients may not engage with SDM for a variety of reasons, from power dynamics that lead to poor communication (for example, being afraid to disagree with the doctor’s recommendations) and believing that medical science determines the best approach (the feeling that “doctor knows best”), to not understanding how their goals and preferences get matched to clinical decisions. We also know that the expectation-outcome mismatch in terms of pain relief, functional restoration, and quality of life drives dissatisfaction after procedures such as arthroplasty. However, if effective SDM were the norm, it’s hard to believe that some 20% to 30% of patients would report dissatisfaction after total joint replacement surgery.

Our Resources Are Limited and There’s no Budget for SDM

Even if institutions and care teams are committed to the concept, the reality is that most do not have funding earmarked to support SDM. The dominant fee-for-service payment system in US healthcare strongly incentivizes procedural volume; this undermines SDM, which is rooted in the idea that appropriate care—which may constitute nonsurgical treatment or even simple observation (whatever ultimately leads to outcomes that benefit patients relative to cost)—is the goal and should be valued (and remunerated) as such. Notably, some studies show the use of decision aids reduces utilization in elective surgery, whereas others demonstrate the benefit of these tools in identifying appropriate, informed surgical candidates. Ultimately, SDM and patient decision aids are still currently recognized as a “nice to have” item rather than a value-generating tool, and until there are active efforts to integrate SDM into routine practice and policy reform, through linkage with reimbursement, they may not become commonplace in volume-driven musculoskeletal care.

The Solution: A Structured Approach to SDM

We believe the solution lies in the implementation of a more structured SDM approach where clinics are supported to (1) implement evidence-based decision aids into care pathways; (2) promote use of decision aids and incorporate decision coaching to promote equity; and (3) integrate measurement of the utility and impact of decision aids into patient-reported outcome measurement to drive improvement.

The first component of this approach is to reevaluate your clinical pathway, recognizing that redesigning workflows to systematically engage patients in SDM can offer substantial benefits. We recommend starting by mapping the entire patient care pathway and identifying points at which the team can engage in SDM and coordinate interactions with the patient decision aid. Existing team members (including administrative teams, medical assistants, clinical and nonclinical staff) and technologies (such as information technology and telehealth) can then be assigned to enable SDM activities at relevant points along the pathway. For instance, administrative staff and schedulers can add patient decision aids to the clinic registration process via email or patient portal, and medical assistants or other staff members might follow up with patients via telephone or telehealth after SDM consultations involving the care team. Pathway mapping may also extend to primary care and encompass the referral phase of the pathway. In Canada, trained general practitioners or physiotherapists engage in SDM using a decision aid and personal decision form that documents patient preferences and decisional needs as part of a more-streamlined surgical screening process for joint replacement prior to the orthopaedic consultation [10]. We believe this approach will also reap additional rewards. For instance, a pathway with greater patient touchpoints offers the opportunity to boost capture of patient-reported outcome measures, communicate with patients, and modify, delay, or even avert unnecessary outpatient reviews, reducing costs of care while improving patient experience.

The second component is to promote the routine use of high-quality patient decision aids, and when possible, augment these tools with a decision coach to promote equity. The extensive evidence base demonstrating positive impact of patient decision aids includes recent evidence that such tools can increase trust and enhance patient-reported health outcomes, making their use a high priority for clinics interested in providing patient-centered care. The purpose of “decision coaching” is to promote trusting relationships with patients, provide guidance in the steps of decision-making, and support full participation for all patients [7]. Decision coaches are trained healthcare professionals, including nonclinical team members, who spend time with patients to ensure information is effectively conveyed and understood, questions are identified, and patients’ preferences, values, and needs are recognized while navigating the SDM process and decision aids. For example, at Massachusetts General Brigham, nonclinical staff members have been efficiently trained as decision coaches and assigned to patients to determine their preferred method of colorectal screening using the Ottawa Personal Decision Guide [9]. At the UCSF Breast Care Center, premedical interns manually send decision aids and engage with eligible patients to improve their care experience [2]. Engaging others on the care team using well-established decision coaching programs can support patients during the decision-making window, and using evidence-based decision aids can help make the most of short visits.

The final component involves the measurement of patient decision aid utilization and decision quality. A major part of the knowledge gap is that feedback on performance when using decision aids and SDM is often lacking. We believe this is a foundational element to inform and tailor treatments to patient preferences while also enabling feedback, driving quality improvement, and forming a basis for reimbursement. For instance, Blue Cross Blue Shield of Massachusetts has started to incorporate measurement of decision quality and SDM for select clinical conditions into their Alternative Quality Contracts with health systems, with a view toward using these measures in performance reporting and performance-based payment in the future. We recommend the adoption of short, well-validated measures, such as the Hip or Knee Replacement Decision Quality Index, Shared Decision Making Process survey, and CollaboRATE survey, all of which are National Quality Forum–endorsed measures of SDM [8]. Although some systems have yet to integrate routine measurement of patient outcomes, others have successfully made investments in patient-reported outcome measurement platforms. Adding the typically shorter questionnaires relating to decision-making in these instances should be relatively straightforward. The information provided by these measures can accelerate improvement for providers and systems that do not want to wait until they are forced to by payers. We believe leadership and commitment to SDM and decision coaching (along with further empirical work in this area) will improve patient and provider experience, decision quality, and health outcomes to deliver substantial return on investment [12].

Conclusion

Orthopaedic practices may face a range of clinical and practical barriers in implementing SDM and patient decision aids. A structured SDM approach, focused on redesigning the care pathway to integrate SDM, leveraging decision coaching to augment high-quality patient decision aids and promote equity, and incorporating measures of decision quality related to SDM as part of the patient outcomes measurement platform, can overcome these hurdles. Engaging in this approach should accelerate the path toward patient-centered decision-making and the opportunity for richer conversations, more trusting relationships, and greater likelihood of value-concordant decisions.