This document provides an introduction to shared decision making (SDM) and patient decision aids. It defines SDM as a process where patients are involved in making an informed, values-based choice between medically reasonable options. The document outlines the six steps to SDM and explains how patient decision aids can support the process by providing balanced information about conditions, treatments, and patient stories. It also reviews evidence that SDM increases patient knowledge and involvement in decisions, improves risk perception, and reduces decisional conflict and uncertainty.

1. Introduction to Shared Decision
Making and Patient Decision Aids
Richard Wexler, MD
Chief Medical Officer
February, 2012

2. What is Shared Decision Making?
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3. Shared Decision Making (SDM)
“the process of interacting with patients who wish to be
involved in arriving at an informed, values-based choice
among two or more medically reasonable alternatives”¹
Informed Values-Based
• There is a choice • What’s important to the patient
• The options
• The benefits and harms
of the options
Information
The Clinician The Patient
¹A.M. O'Connor et al, “Modifying
Unwarranted Variations In Health Care:
Shared Decision Making Using Patient
Decision Aids” Health Affairs, 7 October, 3
2004

4. A Word on Taxonomy
Preference-Sensitive
Effective Care
• Strong evidence base Care
supports care • Evidence supports more
• Benefit-to-harm ratio high than one approach
• All with need should receive • Treatment/testing options
involve significant trade
offs
• Personal
values, preferences and life
circumstances should drive
decisions
SDM Sweet Spot 4

5. A Schematic of Shared Decision Making
Options Patient Lens
Goals and Concerns Benefits
Benefits
Risks
Risks
A
Decision
B Benefits Benefits Deliberate Decision
to Make
Risks Risks
C
Benefits Benefits
Unique Life
Risks Circumstances Risks
© Informed Medical Decisions Foundation. All Rights Reserved. 2012 5

6. Six Steps to SDM
1. Invite patient to participate
2. Present options
3. Provide information on benefits and risks
4. Assist patient in evaluating options based on their goals and
concerns
5. Facilitate deliberation and decision making
6. Assist with implementation
Benefits and Patient Deliberate and
Invite Options Implementation
Risks Preferences Decide
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7. Patient Decision Aids: Tools to Facilitate SDM
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8. Supported by
Patient Decision Aids
Options Patient Lens
Goals and Concerns Benefits
Benefits
Risks
Risks
A
Decision
B Benefits Benefits Deliberate Decision
to Make
Risks Risks
C
Benefits Benefits
Unique Life
Risks Circumstances Risks
© Informed Medical Decisions Foundation. All Rights Reserved. 2012 8

9. Patient Decision Aids
• Information about a specific condition
• Evidence organized around specific decisions
• Accessible—charts, graphs
• Balanced
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10. Patient Decision Aids
• Encourage patients to interpret evidence in
context of their own goals and concerns
• Include patient stories
• Encourage patients to make decisions with
physician
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11. Patient Decision Aids: Development Process
• Literature review
• Patient interviews and focus groups help
identify:
• issues most important to patients
• common misconceptions
• Provider interviews and focus groups help
identify:
• decision points and treatment options
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12. Patient Decision Aids: Development Process
• An evidence summary is produced by
Foundation research associates, working with
medical editors
• Medical editors are generalists and free from
industry conflicts
• Summary is reviewed by clinical advisors,
who are specialists
• Editor has final control
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13. Patient Decision Aids: Development Process
From evidence
summary, a decision aid
is produced which
includes
text, graphics, and often
video.
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14. Patient Decision Aids: Evaluation Process
What Who When
• Clinical accuracy • Patients • Draft scripts, interview
• Balance • Medical editors material, graphical
presentations
• Viewer acceptability • Clinical advisors
• Rough cut
• Foundation and Health
• “Final” version
Dialog staff
incorporates feedback
• Clinical reviewers from evaluation process
• Reviewed at 6 months
for clinical accuracy
• Evaluated every 2 years
for accuracy, balance
and relevance
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15. Why Bother with SDM?
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16. Why Bother with SDM?
• No fateful decision in the face of avoidable
ignorance
• Doctors aren’t very good at diagnosing
patient preferences
• If doctors get it wrong, patients will still listen
• It’s a patient safety issue
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17. No Fateful Decision in the Face of Avoidable
Ignorance
The DECISIONS Study
Nationwide telephone survey
Conducted by University of Michigan
The Decisions Study. Medical Decision Making 2010; 30 supplement 1
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18. DECISIONS Study Findings
• Patients often not knowledgeable about the
basic benefits and risks of their treatment
• Patients usually not asked for their
preferences about treatment
• Providers discuss pros of treatments more
than cons
• Providers advise “do it” 65-95% of the time
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19. Doctors Aren’t Very Good at Diagnosing
Patient Preferences
Karen Sepucha
• Identified key facts and goals for 14 decisions
• Surveyed providers and patients
• How important was each item
• Identify the 3 most important items
Sepucha KR, et al. Pt Education and
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Counseling. 2008;73:504-10.

20. Top Three Goals and Concerns for Breast
Cancer Decisions
Condition: Goal Pat Prov p
Keep your breast? 7% 71% P<0.01
Live as long as possible? 59% 96% P=0.01
Look natural without clothes 33% 80% P=0.05
Avoid using prosthesis 33% 0% P<0.01
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21. If Doctors Get It Wrong,
Patients Will Still Listen
Sepucha KR, et al. Pt Education and
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Counseling. 2008;73:504-10.

22. Is Doing What the Doctor Thinks Best a Top
Priority?
Decision Pat Prov p
BCA surgery 86% 14% P<0.01
Hip replacement 84% 40% P<0.01
Knee replacement 78% 35% P<0.01
Menopause 60% 21% P=0.02
PSA 59% 21% P=0.03
Spinal Stenosis 46% 5% P<0.01
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23. It’s a Patient Safety Issue
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24. Patient Safety
How do we describe operating on a patient
who would say NO to surgery if
Wrong Site Surgery alternatives, risks and benefits were well
understood?
Wrong Patient Surgery
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25. Is SDM Effective?
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26. Cochrane Review
Review of 86 randomized trials evaluating
patient decision aids
• Increase patient knowledge
• Increase patient involvement in decision
making
• Increase the proportion of patients with
accurate risk perceptions (patients have more
realistic expectations)
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27. Cochrane Review
• Increase the consistency between patient
decisions and patient values
• Reduce decisional conflict related to feeling
uninformed or unclear about personal values
• Reduce the proportion of patients who
remain undecided
• Reduce the choice of major elective surgery in
favor of more conservative options
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28. Thank you!
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