Shared decision-making is an approach in which patients and clinicians work together to make informed healthcare decisions that align with the patients’ preferences and values. It is often evoked in contexts where there is choice between two or more treatment options.
The Agency for Healthcare Research and Quality (AHRQ) wanted an updated version of its SHARE Approach that would teach clinicians how to engage in more effective shared decision-making, and enable them to use shared decision-making more broadly.
A team of researchers at the University of Colorado School of Medicine won the contract to revise AHRQ’s shared decision-making clinician training program. Laura Scherer, PhD, associate professor of medicine and associate director of the Patient-Centered Decisions Core at ACCORDS, led the team.
The CU team created an updated version of the program that is more user-friendly and has expanded to address the complex problem-solving that often occurs when managing multiple chronic conditions.
“For patients with multiple chronic conditions, sometimes you have to make tradeoffs about treatments based on a patient's preferences, values, and life goals,” Scherer says. “We have to consider the health outcomes they want to achieve when treatments for their chronic conditions conflict.”
Broad adoption of shared-decision making
The SHARE Approach includes five elements to promote dialogue with patients:
- Seek your patient’s participation
- Help your patient explore and compare treatment options
- Assess your patient’s values and preferences
- Reach a decision with your patient
- Evaluate your patient’s decision
The CU researchers were tasked with updating the SHARE Approach training program, and the way in which that program taught the applicability of shared decision-making.
“A huge barrier is that clinicians oftentimes don't recognize the broad context in which it could be applicable,” Scherer says. “We’ve also observed confusion between motivational interviewing, goal-directed care, and shared decision-making.”
Motivational interviewing is a technique to elicit a person's preferences and their background perspectives to persuade them to do something.
Shared decision-making employs some of the same conversational strategies, but with a goal to help the patient consider their options, with less of a push toward one choice. It can be difficult for a clinician to balance their own clinical position and opinions while still engaging in shared decision-making.
The revised version of the SHARE Approach includes strategies for making patient-centered recommendations.
Improving implementation
The original SHARE Approach program was created in 2015 but faced barriers in implementation, due to limited resources including time and cost.
Previously delivered through a train-the-trainer model, the program took eight hours for practice leaders to complete before taking their learnings back to their clinic.
Based on feedback from initial stakeholders, the researchers cut the training down to four hours and removed some of the tedious academic components to reach every member of the practice who sees patients.
Robyn Wearner, MA, BS, RD, senior instructor of family medicine, traveled throughout Colorado to implement the program in 12 primary care and cardiology practices.
Due to the cost of traveling to each clinic, Scherer knew that sustainability would play an important role in disseminating the program broadly.
Dan Matlock, MD, MPH, professor of medicine and director of the Patient-Centered Decisions Core, and Christopher Knoepke, PhD, assistant research professor in the Division of Cardiology, collaborated with Scherer on the study structure.
They created an instructional video series to ensure the new model could be easily implemented in practices. Matlock, Knoepke, and Scherer each recorded a training video to convey the basics of shared decision-making. They also updated supplemental resources for advanced training activities that practices could facilitate themselves.
Benefits to patients and physicians
During three levels of evaluation, Scherer and her team engaged both patient and clinician stakeholders. The thorough method of investigating the potential benefits of the SHARE Approach involved surveying participants at various stages.
Clinicians were surveyed after completing the training, and researchers saw a significant improvement in clinician judgements.
“They were confident in using shared decision-making. After the training, they said it was more important to take patients’ preferences into account,” Scherer says.
In later levels of evaluation, surveys were conducted months after clinicians completed the training. The surveys were filled out by patients and clinicians to measure their perceptions of the shared decision-making that had occurred in the appointment.
A subset of those surveyed had their appointments recorded. Research assistants used a shared decision-making scoring rubric to score the conversations.
Scherer says that the audio recordings showed an improvement in shared decision-making scores. The effect of the training wasn’t immediate, but the scores and surveys displayed an improvement over time.
“The takeaway is that the clinicians like the training, and they subjectively felt it was useful in helping them with shared decision-making,” Scherer says. “It's now online, and I would love for it to be implemented across the country.”
