Patient shared decision making

Under a shared decision making (SDM) process, health care practitioners and patients work together to make joint decisions about a patient’s care, informed by the patient’s preferences and values. SDM requires that patients be educated about and understand the risks and benefits of their options; education is often through decision aids such as pamphlets, videos, and computerized tools. SDM is an important part of patient-centered care (Cochrane-Legare 2014*).

Expected Beneficial Outcomes (Rated)

  • Improved patient knowledge

  • Improved patient decision making

  • Improved patient-provider communication

Other Potential Beneficial Outcomes

  • Improved mental health

  • Reduced use of expensive procedures

Evidence of Effectiveness

There is strong evidence that patient shared decision making (SDM) using decision aids improves patients’ knowledge of treatment options (Cochrane-Stacey 2017*, O’Neill 2017*, Volk 2016*, Austin 2015*, Durand 2014, Knops 2013*, O’Brien 2009*), increases their involvement in the decision making process (Cochrane-Stacey 2017*, O’Neill 2017*, Ivlev 2017, Blyer 2016*, Nathan 2016, Austin 2015*, Shay 2015*, Durand 2014, Knops 2013*, O’Brien 2009*), and improves patient-provider communication (Cochrane-Stacey 2017*, Nathan 2016, Mead 2013*).

Decision aids improve patient participation in their treatment decisions (Cochrane-Stacey 2017*), help patients make difficult decisions (Cochrane-Stacey 2017*, O’Brien 2009*, O’Neill 2017*, Shay 2015*, Knops 2013*, Woodhouse 2017*), and reduce anxiety related to treatment (Mead 2013*, Dugas 2012*, Joosten 2008*, O’Brien 2009*) and screenings (Nathan 2016). Using probabilities in decision aids, especially expressed in numbers, improves the accuracy of the level of risk patients perceive (Cochrane-Stacey 2017*). Computerized aids appear as effective as aids delivered in person (Sheehan 2012*).

SDM has been shown to be particularly effective for patients making long-term decisions, patients with chronic health problems (Joosten 2008*), seriously ill patients in palliative care (Austin 2015*), and patients with atrial fibrillation who are at risk of strokes (O’Neill 2017*). SDM can also increase knowledge regarding colorectal cancer screening (Volk 2016*), reduce decision conflict and anxiety regarding decisions for cancer screening (Nathan 2016), and support women’s decisions related to pregnancy and birth (Dugas 2012*). Allowing time to build rapport and trust with providers using SDM may improve patients’ mental health (Cochrane-Legare 2014*, Zisman-Ilani 2017*).

Use of decision aids has been shown to reduce the frequency of prostate-specific antigen (PSA) screening, major elective surgeries (Cochrane-Stacey 2017*) and other invasive procedures (Knops 2013*), and to reduce antibiotic use for respiratory infections (Cochrane-Tonkin-Crine 2017*, Blyer 2016*). SDM may improve asthma management and increase satisfaction for asthmatic patients and their parents (Cochrane-Kew 2017*). SDM also appears to improve quality of life for patients during cancer treatment (Kashaf 2015*) and can increase patient satisfaction overall (Shay 2015*).

SDM has been shown to improve patient-provider communication for racial and ethnic minorities (Nathan 2016, Mead 2013*). Individuals with low incomes or low literacy levels appear to benefit more from SDM than peers with higher incomes or levels of education (Durand 2014). Educational meetings, feedback, learning materials, and decision aids (Cochrane-Legare 2014*), along with policies to support use, may help health care providers adopt SDM (Williams 2017*).  

The impact of patient shared decision making on health care costs is unclear. Some studies show lower costs or no additional costs (Cochrane-Stacey 2017*, Walsh 2014*), while others suggest per person savings ranging from $8 to $3,068 (Walsh 2014*).

Impact on Disparities

Likely to decrease disparities

Implementation Examples

The Agency for Healthcare Research and Quality’s (AHRQ’s) SHARE Approach promotes patient shared decision making (SDM) and trains health care providers to engage their patients in the decision making process (AHRQ-SHARE). The Mayo Clinic’s Shared Decision Making National Resource Center also supports implementation of SDM and includes decision aids for conditions such as osteoporosis, depression, rheumatoid arthritis, and diabetes (Mayo Clinic-SDM). Dartmouth-Hitchcock’s Center for Shared Decision Making was the first center in the US focused primarily on SDM; it includes Patient Support Corps volunteers to assist patients prior to and during appointments (Dartmouth-Hitchcock-SDM). 

Implementation Resources

Healthwise-SDM - Healthwise. Care transformation: Uncover the voice of patients with shared decision making (SDM).

Mayo Clinic-SDM - Mayo Clinic. Shared Decision Making National Resource Center. Decision aids, resources, toolkits, and training opportunities for shared decision making (SDM).

Citations - Evidence

* Journal subscription may be required for access.

Cochrane-Stacey 2017* - Stacey D, Légaré F, Col NF, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews. 2017;(1):CD001431.

O’Neill 2017* - O’Neill ES, Grande SW, Sherman A, Elwyn G, Coylewright M. Availability of patient decision aids for stroke prevention in atrial fibrillation: A systematic review. American Heart Journal. 2017;191:1-11.

Volk 2016* - Volk RJ, Linder SK, Lopez-Olivo MA, et al. Patient decision aids for colorectal cancer screening: A systematic review and meta-analysis. American Journal of Preventive Medicine. 2016;51(5):779-791.

Austin 2015* - Austin CA, Mohottige D, Sudore RL, Smith AK, Hanson LC. Tools to promote shared decision making in serious illness: A systematic review. JAMA Internal Medicine. 2015;175(7):1213-1221.

Durand 2014 - Durand M-A, Carpenter L, Dolan H, et al. Do interventions designed to support shared-decision making reduce health inequalities? A systematic review and meta-analysis. PLOS ONE. 2014;9(4):e94670.

Knops 2013* - Knops AM, Legemate DA, Goossens A, Bossuyt PMM, Ubbink DT. Decision aids for patients facing a surgical treatment decision: A systematic review and meta-analysis. Annals of Surgery. 2013;257(5):860-866.

O’Brien 2009* - O’Brien MA, Whelan TJ, Villasis-Keever M, et al. Are cancer-related decision aids effective? A systematic review and meta-analysis. Journal of Clinical Oncology. 2009;27(6):974–85.

Ivlev 2017 - Ivlev I, Hickman EN, McDonagh MS, Eden KB. Use of patient decision aids increased younger women’s reluctance to begin screening mammography: A systematic review and meta-analysis. Journal of General Internal Medicine. 2017;32(7):803-812.

Blyer 2016* - Blyer K, Hulton L. College students, shared decision making, and the appropriate use of antibiotics for respiratory tract infections: A systematic literature review. Journal of American College Health. 2016;64(4):334-341.

Nathan 2016 - Nathan AG, Marshall IM, Cooper JM, Huang ES. Use of decision aids with minority patients: A systematic review. Journal of General Internal Medicine. 2016;31(6):663-676.

Shay 2015* - Shay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Medical Decision Making. 2015;35(1):114-131.

Mead 2013* - Mead EL, Doorenbos AZ, Javid SH, et al. Shared decision-making for cancer care among racial and ethnic minorities: A systematic review. American Journal of Public Health. 2013;103(12):e15-e29.

Woodhouse 2017* - Woodhouse KD, Tremont K, Vachani A, et al. A review of shared-decision making and patient decision aids in radiation oncology. Journal of Cancer Education. 2017;32(2):238-245.

Dugas 2012* - Dugas M, Shorten A, Dubé E, et al. Decision aid tools to support women’s decision making in pregnancy and birth: A systematic review and meta-analysis. Social Science & Medicine. 2012;74(12):1968–78.

Joosten 2008* - Joosten EAG, DeFuentes-Merillas L, de Weert GH, et al. Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychotherapy and Psychosomatics. 2008;77(4):219–26.

Sheehan 2012* - Sheehan J, Sherman KA. Computerised decision aids: A systematic review of their effectiveness in facilitating high-quality decision-making in various health-related contexts. Patient Education and Counseling. 2012;88(1):69–86.

Cochrane-Legare 2014* - Légaré F, Ratté S, Stacey D, et al. Interventions for improving the adoption of shared decision making by healthcare professionals. Cochrane Database of Systematic Reviews. 2014;(5):CD006732.

Zisman-Ilani 2017* - Zisman-Ilani Y, Barnett E, Harik J, Pavlo A, O’Connell M. Expanding the concept of shared decision making for mental health: Systematic search and scoping review of interventions. Mental Health Review Journal. 2017;22(3):191-213.

Cochrane-Tonkin-Crine 2017* - Tonkin-Crine SK, Tan PS, van Hecke O, et al. Clinician-targeted interventions to influence antibiotic prescribing behaviour for acute respiratory infections in primary care: An overview of systematic reviews. Cochrane Database of Systematic Reviews. 2017;(9):CD012252.

Cochrane-Kew 2017* - Kew KM, Malik P, Aniruddhan K, Normansell R. Shared decision-making for people with asthma. Cochrane Database of Systematic Reviews. 2017;(10):CD012330.

Kashaf 2015* - Kashaf MS, McGill E. Does shared decision making in cancer treatment improve quality of life? A systematic literature review. Medical Decision Making. 2015;35(8):1037-1048.

Williams 2017* - Williams N, Fleming C, Doubleday A. Patient and provider perspectives on shared decision making: A systematic review of the peer-reviewed literature. Journal of Comparative Effectiveness Research. 2017;6(8):683-692.

Walsh 2014* - Walsh T, Barr PJ, Thompson R, et al. Undetermined impact of patient decision support interventions on healthcare costs and savings: Systematic review. BMJ. 2014;348:g188.

Citations - Implementation Examples

* Journal subscription may be required for access.

AHRQ-SHARE - Agency for Healthcare Research and Quality (AHRQ). The SHARE Approach: 5 essential steps of Shared Decision Making. 2017.

Mayo Clinic-SDM - Mayo Clinic. Shared Decision Making National Resource Center. Decision aids, resources, toolkits, and training opportunities for shared decision making (SDM).

Dartmouth-Hitchcock-SDM - Dartmouth-Hitchcock. Center for Shared Decision Making. Decision support toolkits, resources, and e-learning courses.

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