Generalized shared decision making approaches and patient problems. Adapting AHRQ’s SHARE Approach for Purposeful SDM

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Highlights

  • General SDM approaches e.g. AHRQ’s SHARE don’t account for patient problems.

  • We related the 5 SHARE steps and Purposeful SDM’s problem specific modes of SDM.

  • SDM terms, concepts and practices vary significantly with kinds of patient problems.

  • SDM practice may be supported by adapting general SDM approaches to problems.

Abstract

Objective

Generalized shared decision making (SDM) describes the involvement of patients in choosing options. However, there are many situations in which patients and clinicians make decisions together that don’t focus on choosing between options, e.g. problem-solving dialysis and insulin use while traveling. Poor uptake associated with clinicians’ perception that SDM doesn’t apply to clinical situations they face may reflect the lack of adaptation of generalized SDM approaches to patients’ problems. The Purposeful SDM schema published in 2019 identifies problems for which different kinds of SDM are appropriate.

Methods

The U.S. Agency for Healthcare Research and Quality developed SHARE as a generalized SDM approach. We sought to adapt SHARE to the different problems that patients face using a matrix to relate SHARE steps and Purposeful SDM modes and describe changes in generalized concepts and practices of SDM across these modes.

Results

Many SHARE communicative behaviors applied across modes, although the meaning of SDM terms and practices, e.g. patients involved as problem solvers versus experts, varied substantially.

Conclusion

Aspects of SHARE require adaptation to different patient problems.

Practice implications

SDM in education, practice, and tools may be supported by adapting generalized SDM approaches to patients’ problems.

Introduction

Shared decision making (SDM) is a patient-centered approach to making health care decisions that are individualized to the patient and incorporate their values and preferences. Investments in implementation toolkits, cultural interventions, clinician training, decision aids, guidelines, and policy enforcement have not resulted in widespread adoption of SDM [1], and its success in clinical practice has been mixed [2,3]. Well-documented barriers persist to the uptake of interventions to promote SDM and patient involvement [[4], [5], [6]].

A primary barrier to the adoption and implementation of SDM in practice is clinician perception that SDM is not pertinent to the decisions they are making with patients [5]. The issue of the pertinence of SDM to clinical problems was raised in the 2019 Purposeful SDM schema [7]. This work proposes that what patients and clinicians are trying to achieve together and how they interact and make decisions is significantly determined by the problem that makes decision making necessary (Box 1). It suggests that there are several kinds of SDM each pertinent to the need to resolve different kinds of patient problems (Table 1).

Generalized models of SDM [[9], [10], [11]] have helpfully identified essential communicative elements of SDM, e.g. describing the pros and cons of options, that are useful in training clinicians in how to do SDM. However, less guidance is given to how these behaviors should change when clinicians apply them to the different problems and situations that they encounter with their patients. Our intention is to begin to conceptually and practically relate generally accepted elements of SDM, to different kinds of problems for which shared decisions are made. We use the established United States Agency for Healthcare Research and Quality’s (AHRQ) SHARE Approach as an instance of a generalized SDM model.

In 2015 AHRQ, released the SHARE Approach [12], a generalized SDM model that streamlined the nine essential steps of SDM identified by Makoul and Clayman [13] into five steps, each represented by a letter of the SHARE mnemonic (Seek, Help, Assess, Reach, Evaluate). The SHARE Approach model is supported by a training workshop curriculum for clinicians emphasizing how to carry out each step of SDM [14] (Appendix 1), basic communication skills, and the use of comparative clinical effectiveness evidence and tools to inform decisions. Payers, health systems, and clinicians have adopted the SHARE Approach to improve communication and patient engagement and implement value-based care initiatives and evidence-based guidelines [15].

The SHARE Approach model, and others like it [[9], [10], [11]], describe best or effective general communication and inter-personal practices to help patients with their clinicians choose between evidence-based options, which often are in equipoise. However, there are many occasions where patients and clinicians need to make decisions together that do not principally focus on choosing among known options, e.g. the ALS case in Box 1 [7,[16], [17], [18], [19]]. The SHARE Approach and similar models that focus on general communicative and interpersonal behaviors, do not currently account for variation in the patient problems that guide decision making. We theoretically and practically related the generalized SHARE Approach model to each kind of problem identified through Purposeful SDM.

Section snippets

Method

We developed a matrix (Table 2) that sets the five steps of SHARE against the four modes of Purposeful SDM. Within the cells of the matrix we explored differences in the terms, concepts, methods, and warrants for SDM arising at each intersection. The matrix was first populated by I.G.H., reflected upon from a clinical perspective by V.M.M., and from an AHRQ SHARE perspective by A.K.F. and A.S.B. Discussion and modification of the matrix continued until it was deemed by the authors to be

Results

All accounts of SDM, implicitly or explicitly, deal in some way with a problem that leads to decision making (problem), different ways of addressing that problem (options), the involvement of people in decision making (roles and communication), the interactions between them in addressing the problem (deliberation), the desires (desires) at play, and the final action taken (decision) [23]. All of these elements are present in some way in the SHARE Approach and each mode of Purposeful SDM. The

Discussion

Patients and a broad range of clinicians make decisions together in response to many kinds of problems. General models of SDM such as SHARE were developed in response to limited kinds of decisional situations. The matrix provides a structure for adapting SHARE to the broader reality of clinical practice in order to help patients and clinicians with more individualized and caring conversations that are responsive to the problems that patients are experiencing. Through this, clinical perception

Funding

This publication was supported by Grant Number UL1 TR002377 from the National Center for Advancing Translational Sciences (NCATS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Disclaimer

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the US Department of Health and Human Services.

Authorship

I.G.H and A.K.F led the writing of this manuscript. All authors contributed to the discussions in which the four modes of Purposeful SDM were related to the five SHARE steps. All authors contributed revisions and approved the final version of this paper.

Acknowledgements

The authors are grateful to the conference participants at the International Conference on Communication in Healthcare in San Diego who joined in conversation following the presentation of this work.

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