Task Force Working Group Encourages Patient-Provider Partnership in Making Decisions About Preventive Care

12/15/2003

From: Barbara Najar, 301-427-1399 or bnajar@ahrq.gov, Farah Englert, 301-427-1865 or fenglert@ahrq.gov, both of Agency for Healthcare Research and Quality

In shared decision-making, the patient becomes an active partner with the clinician in clarifying acceptable medical options and choosing a preferred course of clinical care. As defined by the working group, shared decision-making is a process in which both the patient and clinician share information, participate in the decision making process, and agree on a course of action. Shared decision-making also assumes that individual patients have weighed their own values about the potential benefits and harms of receiving or not receiving a medical service, and it allows patients to be as involved in the decision- making process as they wish to be. Shared decision-making offers a way to individualize preventive services recommendations according to patients' special needs and preferences when some patients may benefit from an intervention but others may not.

The working group's paper, "Shared Decision-making About Screening and Chemoprevention: A Suggested Approach from the U.S. Preventive Services Task Force," was written because Task Force recommendations are made for average-risk populations and are not designed to be a one-size-fits-all prescription for preventive care. Individuals may weigh the benefits and harms of various preventive services differently, and shared decision-making may be useful in a variety of situations, including the following:

-- Shared decision-making helps patients and clinicians decide whether to use a preventive service that has a net benefit but also has potential for harm. An example is aspirin therapy, which helps prevent heart disease but can also cause stomach bleeding in some patients.

-- Shared decision-making is valuable in deciding which of several equally acceptable screening options are appropriate for a patient. An example is colorectal cancer screening, in which five screening choices are available, including flexible sigmoidoscopy and colonoscopy.

-- Shared decision-making is also valuable when new scientific evidence has caused a reversal of previous recommendations, such as the recent recommendation against use of hormone replacement therapy. In light of this, doctors and their patients might want to discuss whether patients should use hormone replacement therapy to relieve symptoms of menopause on a short-term basis.

"Shared decision-making is a powerful tool," said AHRQ Director Carolyn Clancy, M.D. "Whether we mean preventive services or high- quality, safe health care, a good dialogue between patients and providers makes good sense all around."

Neither the working group nor the Task Force followed their customary process of conducting a systematic review of the scientific evidence, and no formal recommendation was made. The working group found few systematic studies that evaluated shared decision-making and noted that many areas require further research. The report does, however, include commentary on the current thinking and evidence regarding shared decision-making.

While there is no evidence that shared decision-making improves health outcomes, it is supported by a combination of ethical and practical arguments. Some patients may not want to participate in shared decision-making because they are confused about medical terminology and uncomfortable with taking an active role in making medical decisions. Other patients who don't read well or who have poor math skills may also hesitate to participate in shared decision-making. Encouragement by clinicians and their assistants is essential in helping these patients understand the value of participating in decision-making about their medical care.

For clinicians, shorter office visits, lack of reimbursement, and lack of interest and training in interviewing techniques may prevent shared decision-making. To address some of these concerns, the working group encouraged clinicians and health plans to adopt a systematic approach that is likely to improve the quality of their interactions with patients. Decision aids such as pamphlets, computer programs, audio-guided workbooks, videotapes, videodiscs, decision boards, and Web-based tools that health plans and delivery systems share with patients and clinicians may be helpful, the working group noted. Informed decision-making, in which an individual obtains and considers information about preventive services from any source, such as the Internet, without benefit of consultation with a clinician, is addressed in a separate paper by the Centers for Disease Control and Prevention's Task Force on Community Preventive Services. That paper also is published in the January 2004 issue of AJPM.

The working group paper on shared decision-making was developed in conjunction with members of CDC's Community Task Force. The authors of shared decision-making, researchers at RTI International and the University of North Carolina at Chapel Hill and several members of the U.S. Preventive Services Task Force, also met with other experts and clinicians, to discuss the issue.

The paper can be found at http://www.ahrq.gov/clinic/3rduspstf/shared/sharedba.htm on Monday, December 15.