Impact of Shared Decision-Making
on Doctor/Patient Relationship
IndustryView | 2015
Shared decision-making (SDM) is a collaborative care model where health care professionals and patients work together to decide on the best treatment option. To learn how SDM can be used to improve relationships with patients, Software Advice conducted a survey to measure patient preferences for medical decision-making. We also consulted with experts in the field to gain their insight.
Imagine the average medical visit: The clinician has a full schedule. The patient doesn’t know what questions to ask, or perhaps is worried they’ll sound uninformed. A treatment plan is decided upon, but without much input from the patient, who will be directly involved—and impacted—in executing it.
According to Dr. Victor Montori, an endocrinologist and researcher with a decade of experience in SDM from the Mayo Clinic’s Knowledge and Evaluation Research (KER) Unit, the average office visit is a lot like the scenario described above. It can be difficult for patients to bring their own views to the table without physicians actively eliciting them.
Susan Mende is the senior program officer at the Robert Wood Johnson Foundation, an organization that provides grant funding for SDM programs at some of the country’s largest research hospitals. She agrees with Montori’s assessment of the average office visit, pointing out that patients can be hesitant to ask about other treatment options and the risks and benefits of such options.
“I don’t think that they ask for ... something that’s tailored specifically to them,” she explains. Instead, she says, most patients listen to their physician's advice and accept whatever treatment is given.
SDM, however, provides an alternative: It’s a guided method of interaction between patient and clinician, where the patient directs the conversation and the clinician asks questions about their lifestyle and how different treatment options will affect them.
SDM decision aids, which include demonstration cards (for example, comparing several different medications for treating diabetes) and patient opinion surveys, can help guide the conversation between patient and caregiver. These decision aids may soon become integrated into digital patient charting (more on this later).
To learn more, Software Advice investigated how patients would prefer to make decisions about their health, given the option to collaborate with their clinician. These findings will help providers understand how the use of SDM can positively impact their relationships with patients.
Respondents were first asked how they would prefer to make treatment decisions, in the event that they were ill or injured and there was more than one medically acceptable treatment available. A resounding majority—68 percent—say they would prefer to decide on treatment collaboratively, along with their physician.
Although most respondents express an interest in collaborative decision-making, not all medical decisions can be made jointly. Decisions that are candidates for SDM, Montori explains, are those without a “right” or “wrong” answer—rather, there are several treatment options that are medically acceptable, and thus the patient is able to decide which option is the best fit for their needs and lifestyle.
An example of a decision well-suited for SDM would be choosing between multiple medication types for managing diabetes. A more technical decision that only has one correct answer, such as choosing to treat an infection with antibiotics, would not be suited for SDM.
Going back to our survey results, 24 percent of respondents say they would prefer to express their opinion, but allow their physician to make the final decision. For these patients, as well as SDM patients, Mende says that motivational interviewing—where patients are asked questions about their goals and motivations—can help physicians discover how new treatments may contribute to positive changes in their patients’ health.
In order to give the patients in our survey an accurate representation of what SDM looks like in practice, we asked them to watch the following video, provided by Montori, in which he demonstrates the use of his SDM decision-aid cards for diabetes.
After watching the video, 40 percent of patients in our sample say they have participated in a similar SDM appointment with a physician, with 21 percent having done so within the last year. For patients who have not used SDM, the video was able to provide a real-life example upon which to base the rest of their responses.
SDM is intended to improve patient engagement when making choices about their health care. To establish a baseline, we first wanted to examine how effective patients feel their current physician is, based on four key objectives that SDM targets for improvement:
Overall, patients in our sample say their current physician is most effective at listening to their concerns and encouraging questions: 51 and 50 percent, respectively, say their provider does this “very effectively.” This effectiveness drops slightly when it comes to providing and explaining multiple treatment options, which 42 and 37 percent, respectively, say their provider does “very effectively.”
Next, we broke down the data to compare the differences in effectiveness between SDM and non-SDM providers. We discovered that patients who report participating in an SDM appointment with their physician (40 percent of the total sample) also report higher levels of effectiveness.
This gap in reported effectiveness is most visible when it comes to listening to patient concerns: 59 percent of SDM patients say their physician listens to their concerns “very effectively,” compared to 45 percent of non-SDM patients.
This improved ability to listen to patient needs and build the relationship between patient and provider is a key benefit of SDM, Montori explains.
“I know that when the magic SDM creates happens, the [decision aids] become irrelevant,” he says. “It’s two humans, having an interaction of deep caring and collaboration.”
Research on SDM’s impact on patient satisfaction levels has been mixed; in fact, many simply say that more research needs to be done. As such, we decided to ask patients how participating in SDM impacts their satisfaction with their medical care.
A combined 89 percent report that participating in SDM would “significantly” (56 percent) or “somewhat” (33 percent) improve their satisfaction with their medical care. Only 8 percent say that this would not have an impact.
Similarly, a combined 87 percent of patients say that using an SDM model “significantly” or “somewhat” improves (or would improve) how involved they feel with their medical care. Conversely, only a combined 2 percent say that using SDM would make them feel “somewhat” or “significantly less involved” in their care.
One of the main goals of SDM (and patient-centered care in general) is to help the patient feel more involved in treatment decisions by reviewing the options with their provider. Allowing patients to actively participate in this discussion places them and their concerns at the center of the conversation—and, as our findings demonstrate, improves how they feel about their overall medical care.
Some research suggests that the use of SDM may improve patients’ adherence to their treatment plans. To establish a baseline, we first wanted to investigate how well patients in our sample adhered to their most recent plan.
A majority of respondents (52 percent) report that they followed their treatment plan perfectly and consistently. Another 33 percent say they “occasionally” deviated from their prescribed treatment, but were able to get back on track successfully.
Patients were also asked about the impact SDM has (or would have, for those who have not used it) on their adherence to a treatment plan. A combined 76 percent of patients say that participating in SDM would have a positive impact on their likelihood to adhere to a treatment plan, while only 1 percent report that SDM would have a negative impact on this.
While these findings are encouraging, Montori points out that paying attention to the source of information and the specific patient population studied is key to any discussion of adherence and SDM. In his research, he says, initial studies showed that self-reported treatment plan adherence did improve with the use of SDM. However, in later studies, researchers looked at pharmacy records to determine whether patients were following their plans by picking up prescribed medications—and these records suggested the opposite.
This discrepancy is likely due to the inherent bias involved with self-reporting, as well as issues of honesty in patients’ disclosing personal information on research forms.
Additionally, Montori explains, patients who are enrolled in clinical trials are already active participants in their care. These patients may already have high levels of treatment-plan adherence before SDM is introduced, making it challenging to show an improvement.
While there is not yet conclusive evidence that SDM improves adherence, Montori says the fact that patients perceive that it does is a positive sign. At the very least, this is another indicator that SDM contributes to improved patient engagement.
Finally, we wanted to gauge patients’ interest in using SDM by asking how likely they would be to switch from a provider who doesn’t offer SDM to one who does (with all else being equal). A combined 47 percent say they would be “extremely” or “very likely” to make the switch to gain access to an SDM model of care. A mere 6 percent are “not at all likely” to switch providers.
These findings reflect significant patient interest in SDM. However, with many recent pieces of health care legislation supporting and incentivizing SDM models of care, patients may not have to switch providers to get the care they want.
The Affordable Care Act (ACA), for example, supports the move towards value-based care, in which provider reimbursement is tied to patient outcomes. In other words, physicians are being encouraged to pursue decision-making strategies that improve patients’ overall health. Medicare is also beginning to increase reimbursement for higher-quality services over the mere quantity of services provided.
Finally, we asked patients what—if anything—would discourage them from participating in SDM with a physician. (Patients were allowed to select more than one option.)
Forty-six percent of patients report that they have “no concerns” related to SDM. Of course, since some patients have no personal experience with SDM, this may not accurately reflect how a patient would feel after participating in the process. Still, this finding is encouraging for physicians considering adopting an SDM model of care.
Twenty percent of patients cite a distrust of their own decision-making abilities as a main concern with SDM. However, as Montori argues, a lack of experience with making their own medical decisions could be the root of these patients’ distrust. As more patients experience SDM, more may come to trust their own judgment.
For the 18 percent concerned with the ability to understand potentially complex clinical information, providing patients with easy-to-understand educational materials can help boost their confidence. Providers could also allow a trusted family member or friend to participate in the decision-making process, at the patient’s discretion.
“You give the patient confidence because you are providing them with the right kind of information at the right time and at the right level,” says Mende of the Robert Wood Johnson Foundation. He adds that with SDM, multiple visits are often required to fully educate each patient.
In this report, we find that SDM may help providers deliver more effective care when it comes to providing and explaining treatment options, listening to patient concerns and encouraging patient questions. Patients also report higher levels of satisfaction and involvement under this model, and nearly half are “extremely” or “very likely” to switch to a provider who offers SDM.
Our experts also weighed in on best practices for physicians looking to implement SDM in their own practice. Here are a few of their tips:
For Montori, one of the big issues is how to ensure that physicians have the right tools to use SDM methods properly. Two of his current research projects focus on this goal, which includes working with electronic health records (EHR) companies to integrate SDM into digital workflows.
Until those projects come to fruition, physicians looking to implement SDM technology can try decision support products, such as WiserCare or CommonGround: programs designed to review treatment options and facilitate conversations between clinicians and patients.
Based on our survey and the information provided by our experts, we predict that SDM has a bright future ahead, as it continues to help improve the quality of treatment discussions and connections between patients and physicians.
Fifty-two percent of our survey respondents are male, and almost half (47 percent) are between the ages of 25 and 34.
To collect the data in this report, we conducted a two-day online survey of 17 questions and gathered a total of 386 responses. Software Advice performed and funded this research independently. We would like to thank Dr. Montori for his time, materials, collaboration on survey design and valuable insight into the use of SDM.
Results are representative of our survey sample, not necessarily the population as a whole. Sources attributed and products referenced in this article may or may not represent client vendors of Software Advice, but vendor status is never used as a basis for selection. Expert commentary solely represents the views of the individual. Chart values are rounded to the nearest whole number.
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