Top Things to Know: Shared Decision Making and Cardiovascular Health
Published: August 14, 2023
Prepared by Katherine A. Sheehan, PhD, Science and Medicine Advisor
- Historically, clinical care has been delivered in an authoritarian approach rather than a patient-centered one. The emergence of patient-centered care models in cardiovascular (CV) care represents both a conceptual and pragmatic shift geared toward patients and their families as central members of the health care team.
- Shared decision making (SDM) is an important strategy to improve CV care by enhancing patient involvement in health care decisions, patient-clinician communication, and patient-centered care. SDM is defined as a communication process where patients and clinicians collaborate to choose and agree upon tests, treatments, and care plans that most align with an individual patient’s preferences and values.
- SDM is a fundamental part of effective communication and respect, reflecting professional health care values, yet consistently enacting it in a complex health system with limited time and resources remains a challenge.
- This scientific statement traces the development of SDM through support by the 2010 US Affordable Care Act, reviews the clinical evidence for its implementation and effectiveness as well as critically examining models of SDM, and puts forward strategies for improving implementation and uptake of SDM to improve CV health outcomes and equity.
- The primary goal of SDM is to ensure the patient is given the necessary knowledge and tools to make the best decisions about their own health, while minimizing decisional regret or conflict, with assistance and expertise from their clinicians. The National Quality Forum (NQF) identified three key components: 1) Clearly communicated, unbiased medical evidence about risks and benefits of the medical intervention and reasonable alternatives, including no intervention; 2) Clinical expertise provided in a way that tailors the evidence for individual patients; and 3) Inclusion of patient values, goals, preferences, including treatment burdens, in the decision process.
- Models of SDM generally focus on describing treatment options, making the decision, and choice awareness and may use decision support tools to provide information to the patient and structure the process. Guidance for model formulation and decision aid validation in diverse cohorts is needed as SDM becomes more integrated into value-based care.
- Measures and instruments of SDM are evaluated, including CollaboRATE, and The Control Preference Scale, for features such as patient preferences, and clinician or observer perspective. While most showed satisfactory to excellent reliability, information on measurement error, content validity, responsiveness and interpretability is lacking.
- Strategies to promote SDM practices are presented in this statement, including educating clinicians on communication techniques, engaging multidisciplinary teams, incorporating trained decision coaches, and using decision aid tools to support patients in their CV care decisions.
- The 2019 ACC/AHA Guideline on Primary Prevention of CVD recommends SDM as a best practice to guide discussions to reduce atherosclerotic CVD risk based on the pooled cohort equation. Because this model relies on data that may not equally reflect some racial and ethnic cohorts, suggestions are given to help optimize these results as well as increase racial and ethnic group equity.
- Clinical SDM for CV health care is a rapidly evolving and complex field of CV science. This statement synthesizes the state of the science and highlights important areas for focus and attention. Communications between patients and clinicians and the decision-making process must be evidence based and optimized for alignment with patients’ goals and needs.
Citation
Dennison Himmelfarb CR, Beckie TM, Allen LA, Commodore-Mensah Y, Davidson PM, Lin G, Lutz B, Spatz ES; on behalf of the American Heart Association Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Quality of Care and Outcomes Research; Council on Hypertension; Council on the Kidney in Cardiovascular Disease; Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Lifestyle and Cardiometabolic Health; Council on Peripheral Vascular Disease; Council on Epidemiology and Prevention; and Stroke Council. Shared decision-making and cardiovascular health: a scientific statement from the American Heart Association [published ahead of print August 14, 2023]. Circulation. doi: 10.1161/CIR.0000000000001162