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The paradox of using SDM for de-implementation of low-value care in the clinical encounter
  1. Paula Riganti1,
  2. Karin Silvana Kopitowski1,
  3. Kirsten McCaffery2,
  4. Leti van Bodegom-Vos3
  1. 1 Family and Community Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
  2. 2 Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
  3. 3 Biomedical Data Sciences, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
  1. Correspondence to Dr Paula Riganti, Family and Community Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires, C1199, Argentina; paula.riganti{at}

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In the last decades, researchers, governments and public campaigns have increased awareness about healthcare overuse.1 Low-value care is described as care unlikely to benefit the patient given the harms, costs or available alternatives.2 Clinical practice guidelines with ‘do-not-do’ recommendations and other de-implementation strategies were promoted to reduce it.1 One of these strategies is shared decision making (SDM).3 SDM was traditionally described as an approach to enhance patient involvement in healthcare decisions by communicating evidence-based information about options, their pros and cons, and eliciting patients' preferences to support them to deliberate about those options.4 Currently, some authors consider SDM as a broader concept, a method that adapts to a wider range of situations where patients and clinicians make decisions together using different approaches (not only limited to cases with a fine balance between benefits and harms, where practitioners help to weigh pros and cons with patients' values and preferences).5

Different studies showed that when patients are better informed about the benefits and harms of interventions (eg, surgeries, screening tests, medications), they tend to decline low-value care.3 6 7 These findings might explain why SDM has been promoted to reduce low-value care.3 6–9

Focusing on the conversations between patients, caregivers and clinicians during the clinical encounter, we reflect on why using SDM for de-implementation of low-value care can be paradoxical.

When it is problematic to use SDM for low-value care de-implementation

Both de-implementation of low-value care and SDM are informed by new evidence that contradicts current practice, that is medical reversal,10 but have different purposes and pursue different outcomes (see table 1). De-implementation strategies aim at removing, replacing, reducing or restricting low-value care to solve problems of rising healthcare costs and harms. SDM aims to respond to patients' problems to find the care that best fits the patients' and their families' unique context, aligned …

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  • Twitter @paula_riganti, @lvanbodegomvos

  • Contributors PR, KSK and LvB-V initiated the article and all authors contributed to the writing and revisions.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests KMcC is the current President of the International Society of Shared Decision Making.

  • Provenance and peer review Not commissioned; externally peer reviewed.