Background
Methods
Design
Protocol
Eligibility criteria
Inclusion criteria | Excluded full texts (N = 306) | |
I1 | The full text is accessible. | 2 |
I2 | Context: the language of the full text is English or German. | 0 |
I3 | Concept: the main subject of the full text is shared decision-making (SDM) or decision aids or other decision support interventions. | 33 |
I4 | Concept: the full text reports on the results of a project, quality improvement program, or study that aims to implement SDM or decision aids or other decision support interventions in routine healthcare through a certain implementation strategy or effort. | 157 |
I5 | Concept: the full text reports on the role of experienced organizational- and/or system-level characteristics that influenced the implementation of SDM, decision aids, or other decision support interventions. | 10 |
Exclusion criteria | ||
E1 | Context: the full text is an opinion piece, commentary, editorial, analysis article, or letter, i.e., does not report on a primary data collection. | 61 |
E2 | Context: the full text is a systematic review, a scoping review or a structured literature review. | 22 |
E3 | Context: the full text is a study protocol. | 21 |
Search strategy
Study selection process
Data extraction
Methodological quality appraisal
Synthesis
Results
Included studies
Project ID | Author (year) | Country | Study design* | Setting | Context | Implemented intervention | Implementation strategy |
---|---|---|---|---|---|---|---|
P1 | Abrines-Jaume et al. (2016) [47] | UK | Quality improvement study | Outpatient, inpatient, community, and outreach | Child and adolescent mental health | SDM in general | Teams were encouraged to try a range of tools to support SDM and received cross-site learning events every 3 months including information and materials, group discussions, and action learning sets as part of the Closing the Gap program. They also received regular site meetings and phone and email guidance. |
P2 | Andrews et al. (2016) [68] Berg et al. (2011) [69] Friedberg et al. (2013) [70] | USA | n/r (descriptive implementation study) | Specialty and primary care in an academic medical center | Orthopedics, breast cancer, hip and knee osteoarthritis, prostate cancer, cancer screening, spine conditions, heart/chronic/other | Decision aids and other form of decision support | When indicated, individual’s treatment preferences, questions, and other decision-making data were shared with their clinician and recorded in their electronic medical record (EMR). Shared decision-making summaries (dashboards) were reported to departments at regular intervals in an effort to systematically monitor and evaluate the use of decision support programs in clinical care. |
P3 | Arterburn et al. (2016) [71] Conrad et al. (2011) [55] Hsu et al. (2013) [52] Hsu et al. (2013) [72] King and Moulton (2013) [51] | USA | Mixed-methods case study | Specialty care in an integrated health system | Focus on decisions regarding surgical treatments: breast cancer and DCIS, hip and knee osteoarthritis, chronic low back pain, living better with chronic pain, colon cancer screening, depression, diabetes, PSA testing | Decision aids | Senior project management consultants worked with service line leaders to develop implementation agreements and process flow diagrams for each service line. Once a draft distribution process was generated, the project managers met with frontline providers and staff to introduce the DAs, the distribution process and answer questions. Process revisions were based on provider reactions and suggestions. Once an implementation process was agreed upon, a “go-live” date was set, after which the project managers visited each clinic site at least once to monitor implementation processes and progress. Sites experiencing challenges received additional visits and calls as necessary. DAs were distributed using an existing service that supplies educational materials to patients via US mail. The DVD versions of the DAs could be ordered for patients by clinical staff using the electronic health record. Patients could also view the DA online via the patient portal, and providers could embed a link to the video DA in the patient’s after-visit summary. In treatment decision for which the time between a patient’s initial appointment and the procedure was very short, the DAs could also be distributed in the office. Process was monitored using twice-monthly distribution reports given to clinical leaders. In the second year, these reports included more specific numbers for individual clinicians. |
P4 | Belkora (2011) [73] Belkora et al. (2008) [74] Belkora et al. (2011) [75] Belkora et al. (2012) [48] Belkora et al. (2015) [76] | USA | Quality improvement study | Breast care center (in an NCI designated comprehensive care center) | Breast cancer | Decision aids and other form of decision support | Long-term project with multiple iterations. Implementations consisted of consultation planning, recording, summarizing services in which support staff assisted patients in communicating with their providers before a visit (question brainstorming) and during a visit (audio recording). Improvements on this service consisted of adjusting the scheduling system and workflow of decision support, mailing DAs to patients at home, and making follow-up calls |
P5 | Belkora et al. 2008 [77] | USA | Post-implementation qualitative study | Community clinics and community resource centers | Breast cancer | Other form of decision support | One-time Consultation Planning training workshops included lectures, structured role playing, and group discussion sessions. |
P6 | Brackett et al. (2010) [78] | USA | n/r (descriptive implementation study) | Primary care in one academic medical center and one Veteran’s Affairs Medical Center | Prostate cancer and colorectal cancer screening | Decision aids | Four methods were compared: (1) automatic pre-visit mailing to all potentially eligible patients, (2) letter mailed to all potentially eligible patients offering pre-visit DA (3) eligible patients offered DA at checkout from primary care visit (4) clinician prescribes DA to eligible patients during primary care visit |
P7 | Clay et al. (2013) [79] Friedberg et al. (2013) [70] | USA | n/r (descriptive implementation study) | Academic medical center department of orthopedics | Orthopedics | Decision aids | Embedding decision aid into new EMR to systematically and automatically deliver DA to the right patient at the right time. |
P8 | Elwyn and Thomson (2013) [80] King et al. (2013) [58] Lloyd et al. (2013) [81] Lloyd and Joseph-Williams (2016) [82] | UK | Service development/quality improvement program | NHS hospitals and primary and secondary care teams | Head and neck cancer, breast cancer, pediatric tonsillectomy, obstetrics, urological problems, ear, nose and throat, knee osteoarthritis, statins, managing mood disorders, sexual health and contraception, upper respiratory tract infection, managing carpal tunnel syndrome, smoking cessation, menorrhagia, long-term care, benign prostatic hyperplasia | SDM in general | Making good decisions in collaboration (MAGIC) improvement program: an approach that integrates shared decision-making into routine care through training in shared decision-making and the use of decision support tools, peer support for clinicians, and support for patients to become more engaged in their care. This program has been implemented at several sites and is adapted for best use in the context of each site. |
P9 | Elwyn et al. (2012) [83] | UK | Post-implementation mixed-methods study | NHS healthcare professionals | Knee osteoarthritis, amniocentesis, breast cancer, benign prostatic hyperplasia, localized prostate cancer | Decision aids | Tools were made available on NHS Direct’s web platform and patients were directed to tools by staff. |
P10 | Feibelmann et al. (2011) [84] | USA | n/r (descriptive implementation study) | Cancer centers, hospitals, private practices, and resource centers | Breast cancer | Decision aids | Letters were mailed to providers at sites. Sites could fax or mail back a request for a sample program and then sign a participant agreement to receive copies of decision aids to use with patients. Various implementation techniques were used at individual sites. |
P11 | Fortnum et al. (2015) [85] | Australia | n/r (descriptive implementation study) | Renal units | End-stage kidney disease | Decision aids | Decision aid PDFs were made available nationally (downloadable from Kidney Health Australia and Kidney Health New Zealand websites). Education was provided to over 2000 ANZ health professionals through teleconferences, webinar, website distribution, state workshops, unit visits, conference presentations, and email. |
P12 | Frosch et al. (2011) [50] Uy et al. (2014) [86] | USA | n/r (descriptive implementation study) | Primary care offices and community health centers | First prostate and colon cancer screening then expanded to various contexts with 24 different decision aids available | Decision aids | The initial implementation practices received evidence-based brochure decision support interventions (DESIs). The goal was to provide the DESIs to patients at the time of an office visit and to review before the consultation with the physician. In an expansion of this implementation individual practices selected DESIs to provide to patients. Phase 1: during a patient visit, physician or staff would assess appropriateness of DA prescription then eligible patients received package with DA to take home and review before follow up-appointment. The exact logistics of DA distribution were established by practices individually. Weekly “academic detailing” visits were conducted with a member of the research team to identify barriers and develop potential solutions. Phase 2: introduction of a financial incentive to compensate for time spent prescribing DAs and inclusion/exclusion criteria (to ensure that only eligible patients receive the DA) and phone survey instead of questionnaire. |
P13 | Friedberg et al. (2013) [70] Frosch (2011) [73] Lin et al. (2013) [87] May et al. (2013) [88] Tietbohl et al. (2015) [89] | USA | Case study (descriptive implementation study) | Primary care clinics in an integrated health system | Various contexts: 16 different decision aids available | Decision aids | The project team collaborated with clinics to tailor decision aid distribution methods to individual clinic workflows. Each clinic had a physician and staff champion responsible for promoting the program. The leadership team at each clinic, which included both physicians and leaders of clinical support staff, selected decision aid topics for distribution from the list of available tools. Project team members engaged in academic detailing visits and social marketing efforts to promote distribution of the decision aids. |
P14 | Garden (2008) [59] Wirrman and Askham (2006) [90] | UK | n/r (descriptive implementation study) | Urology departments | Early localized prostate cancer or benign prostatic hyperplasia | Decision aids | Nurse specialists were trained to implement Decision Support Aids and Decision Quality Assessment Forms to patients (implemented at different points in the care pathway at different sites). |
P15 | Holmes-Rovner et al. (2000) [91] | USA | Mixed-methods feasibility study | Hospital community health education centers, cardiology education and research departments, and health education libraries | Breast cancer and ischemic heart disease | Decision aids | To ensure local acceptance of the programs and to fit the program into existing routines, hospitals were asked to identify study coordinators who would work with local physicians and nurses to implement the programs. Participating clinicians were asked to review decision aid and complete survey prior to distributing to patients. Clinicians received reminders and study coordinators repeatedly discussed the DAs with them. |
P16 | Holmes-Rovner et al. (2011) [92] | USA | Retrospective post-then-pre design | Internal medicine and family medicine clinics | Stable coronary artery disease | SDM in general | The complex decision support system called Shared Decision Making Guidance Reminders in Practice (SDM-GRIP) consisted of: (1) provider training (2) patient education. To facilitate discussion in the clinical encounter, a dedicated SDM provider visit was established, and an encounter decision guide (EDG) was given to patients. The EDG provided an evidence summary and decision pages to record choices arrived at in the clinical encounter. |
P17 | Julian et al. (2011) [93] | USA | n/r (descriptive implementation study) | Comprehensive breast care center | Breast cancer, DCIS | Decision aids and other form of decision support | A nurse navigator coordinated patient care and provided decision aids to women. |
P18 | Korsen et al. (2011) [73] | USA | n/r (descriptive implementation study) | Primary care in an integrated health system | PSA testing, colorectal cancer screening, diabetes, acute low back pain, chronic low back pain, depression, menopause, advance directives | Decision aids | Implementation included (1) pre-visit, visit-based, and post-visit distribution models, (2) use of EHR for DA referral, (3) various trainings, workshops, and presentations at different sites |
P19 | Friedberg et al. (2013) [70] Lewis et al. (2011) [73] Lewis et al. (2013) [57] Miller et al. (2012) [94] | USA | n/r (descriptive implementation study) | Primary care clinic | PSA testing and weight loss surgery | Decision aids | The focus was on automated DVD DA delivery through EHR and social marketing campaign. Five delivery models were used: (1) mailing DAs prior to visit (2) using Patient Health Survey to identify eligible patients and allow them to request a DA, (3) requesting DAs by physician (4) distributing DAs within chronic disease management program (5) pre-visit online screening for DA eligibility |
P20 | McGrail et al. (2016) [95] | USA | n/r (descriptive implementation study) | One primary care clinic, one general hospital | Statins, anticoagulation in patients with atrial fibrillation, osteoporosis and knee osteoarthritis, urinary incontinence | SDM in general | The SHARE approach “train-the-trainer” workshop was followed by training sessions for residents and medical group staff. |
P21 | Mollicone et al. (2013) [96] | USA | n/r (descriptive implementation study) | Specialty care center | Chronic kidney disease | SDM in general | Treatment Options Program (TOPs) consists of free classes offered locally, nationwide, by trained FMCNA personnel to educate patients and family members about the options for treatment. Follow up calls encourage patients to discuss options with their doctors and participate in their care. |
P22 | Friedberg et al. (2013) [70] Morrissey and Elwyn (2013) [97] Morrissey and Michels (2011) [98] | USA | n/r (descriptive implementation study) | Primary care | Benign prostatic hyperplasia, prostate cancer, breast cancer, depression, uterine fibroids, chronic low back pain, chronic pain, menopause | Decision aids and other form of decision support | Three models for implementation were used: (1) patient referred from primary care or specialist for care coordination/navigation which included face to face visit with DA (2) provider teed up SDM conversation in exam room and handed patient off to nurse who provided information and DA (3) patient requested DA and care coordinator follows up with a call for discussion |
P23 | Newsome et al. (2012) [60] | USA | Post-implementation qualitative study | Family medicine clinics | Cancer screening, chronic illness care | Decision aids | Physicians used the DAs in clinical practice and medical assistants were involved in distribution of DAs (details not specified, reported in a separate publication). |
P24 | Pasternack et al. (2011) [99] | Finland | n/r (descriptive implementation study) | Breast cancer screening providers | Breast cancer screening | Decision aids | Letter templates with invitation to screening and short decision aid on the back where made available to all breast cancer screening facilities and municipalities in the country. The short DA was put on the back of the letter to avoid extra costs for the providers, who usually just send out the invitation. A website contained a more in depth decision aid. The service providers received information on legislation, the new letter templates, and posters for the waiting rooms. |
P25 | Sepucha and Simmons (2011) [73] Sepucha et al. (2016) [100] Simmons et al. (2016) [101] | USA | n/r (descriptive implementation study) | Primary care clinics | Various contexts: 40 different decision aids available | Decision aids | Clinicians were able to order DAs through the electronic medical record (EMR). The EMR application then generated a note in the patient’s chart documenting that the material has been sent. The distribution and inventory of DA were managed centrally. The DAs were available in several formats (e-mail message with a link to access the DA online; DVD and booklet in the mail). Early on DA prescription was done in a visit by the clinician, but the SDM implementation team worked with clinicians and administrators to automatize prescriptions. Some years into the implementation program, a short 1 h training module was delivered to clinicians to increase familiarity with the DAs, show them ordering in EMR and discuss implementation challenges. They received CME points for training. Further into the implementation program, patients received the opportunity to order DAs themselves (patient-directed ordering). There were no mandates or long-term financial incentives or penalties associated with using or not using DAs |
P26 | Silvia et al. (2008) [102] Silvia and Sepucha (2006) [103] | USA | Post-implementation qualitative study | Community resource centers, community hospitals, academic centers, community oncology center | Breast cancer | Decision aids | Providers and resource centers across the country were informed about the availability of the programs through letters and e-mail. Interested sites received free copies and were left to decide themselves how to use them. |
P27 | Stacey et al. (2006) [104] | Canada | n/r (descriptive implementation study) | Call center | Various health issues; birth control methods, breast versus bottle feeding, male newborn circumcision, wisdom teeth removal, and treatment of miscarriage most common | Decision aids and other form of decision support | Interventions included an online auto tutorial, skill-building workshop, decision support protocol, and feedback on quality of decision support provided to simulated callers |
P28 | Stacey et al. (2008) [105] | Australia | Pre-post test study | Cancer call center | Cancer | Other form of decision support | Interventions included a decision support tutorial, skill-building workshop, and decision coaching protocol. Supervisors were trained in decision support, a trainer workshop was held for supervisory staff members, and the director of the cancer helpline addressed workshop participants to validate that decision support is an important part of their call center role. |
P29 | Stacey et al. (2015) [106] | Canada | Prospective pragmatic observational trial | Cystic fibrosis clinics | Adults with cystic fibrosis considering referral for lung transplant | Decision aids and other form of decision support | Implementation strategy was based on results of prior barriers survey. It consisted of training (workshop and online tutorial), easy access to decision aids, and conference calls for ongoing support. Patients completed DA on their own and discussed results with provider at a subsequent encounter, and a summary was included in the clinic record. |
P30 | Stapleton et al. (2002) [107] | UK | Post-implementation qualitative study | Women’s homes, maternity clinics | Antenatal care and maternity services | Decision aids | Leaflets were provided as part of a cluster randomized controlled trial. Health professionals received a training session in how to use them. |
P31 | Swieskowski (2011) [73] | USA | n/r (descriptive implementation study) | Primary care clinics | Acute and chronic low back pain, diabetes, women’s health issues, knee and hip osteoarthritis, cardiac conditions, spinal care, end of life care, PSA testing | Decision aids | Potential patients were identified by pre-visit chart review and DAs were prescribed by providers or health coaches during the visit. Follow-up decision support was provided by the physician or the health coach at a follow-up visit. |
P32 | Tapp et al. (2014) [53] | USA | Process improvement study | Primary care practices | Asthma | SDM in general | A community based participatory research approach was used to form an advisory board (including patients, physician champions, other healthcare professionals, administrative staff) that met monthly to tailor intervention to needs of each practice (e.g., adapting intervention to delivery by different types of staff members, adapting material for use by Spanish-speaking, low literacy and pediatric population, decide on roll out schedule). All practices started with kick-off meeting, then discussion rounds around logistics, training sessions (including use of decision support materials), regular follow-up meetings. |
Characteristics influencing SDM implementation
Organizational-level characteristics
Characteristics | Descriptions# | Project IDs* |
---|---|---|
Organizational leadership | ||
2003 corporate mission and vision statement | Degree to which the description of the organization’s core purpose and vision for the future supports SDM | P3, P8, P13, P25, P27, P28 |
Encouragement | Degree to which leaders in organization proactively support SDM | P1, P2, P3, P4, P5, P8, P12, P13, P14, P25, P26, P27, P31 |
Performance measurement and feedback | Use of results of performance measurement or quality indicator metrics to indicate room for improvement | P2, P3, P7, P8, P13, P16, P18, P25, P27, P28, P32 |
Organizational culture | Degree to which an organization’s culture supports SDM | P2, P3, P8, P12, P13, S14 |
Autonomy of staff | Degree of flexibility that healthcare providers (HCPs) have to achieve organizational goals | P1, P3, P8, P26 |
Shared views and goals | Degree to which team members share the same views and goals | P4, P8, P9, P13, P21, P31 |
Organizational teamwork | ||
Communication | How information is shared within and between teams | P7, P8, P12, P13, P22, P32 |
Coordination of care | Deliberate organization of care by HCPs from different specialties | P3, P7, P12, P13, P14, P16, P26, P32 |
Organizational resources | Availability of resources | P12, P22, P26 |
Time | Amount of time HCPs have per patient/patient visit | P1, P3, P5, P8, P9, P10, P12, P13, P14, P15, P19, P26, P27, P28, P29, P30, P31, P32 |
Financial resources | Amount of money available for certain activities within organization | P2, P3, P4, P5, P11, P14, P19, P31 |
Space | Amount of room available for certain activities within organization | P4, P5, P8, P26 |
Workforce | Availability and assignment of employees for certain activities within organization | P3, P4, P5, P8, P10, P12, P14, P18, P19, P22, P23, P27, P31, P32 |
Organizational priorities | Degree to which other aspects of care delivery conflict or align with SDM | P2, P3, P4, P5, P8, P9, P10, P12, P13, P14, P18, P19, P26, P27, P31 |
Organizational workflows | ||
Patient information dissemination strategies | Availability of methods to disseminate information to patients and compatibility of workflows with decision aid distribution processes | P2, P3, P4, P5, P6, P8, P12, P13, P14, P17, P22, P24, P25, P26, P27, P28, P29, P31 |
Scheduling routines and timeframes | Degree to which scheduling (e.g., of appointments or for procedures) and time frame available until decision is needed impacts SDM | P3, P4, P6, P8, P10, P12, P13, P14, P15, P21, P22, P26, P29 |
Electronic health record (EHR) | Availability of an EHR to be used in SDM (e.g., documentation of process) | P2, P3, P6, P7, P8, P13, P14, P17, P18, P19, P20, P23, P27, P31 |
System-level characteristics
Characteristics | Descriptions# | Project IDs* |
---|---|---|
Incentives | ||
Payment model | Impact of payment models on the use of SDM | P2, P3, P8, P13, P15, P16, P21, P26, P31, P32 |
Accreditation/certification criteria | Degree to which SDM is included as a criterion in accreditation/certification standards for healthcare institutions | P3 |
Policies and guidelines | ||
Legislation | Degree to which state or national legislation requires the use of SDM/decision support | P3, P14, P19, P21, P29 |
Practice guidelines | Degree to which relevant practice guidelines support the use of SDM | P2, P3, P9, P26, P27, P28 |
Quality indicators | Degree to which quality indicators support the use of SDM | P3, P8, P13, P15 |
Culture of healthcare delivery | Degree to which the culture of healthcare delivery supports SDM | P13, P14, P16, P22 |
HCP education and licensing | Degree to which HCP initial and continuing education and licensing includes SDM training | P3, P8, P10, P13, P14, P16, P23, P25, P26, P31 |
Strategies to address organizational- and system-level characteristics
Characteristics | Strategies described |
---|---|
Organizational-level strategies | |
Organizational leadership | |
Corporate mission and vision statement | Develop and promote a strong consistent message about importance of SDM [72] Make the value of SDM clear to physicians [83] |
Encouragement | Provide personal testimonials from leaders [51] Support healthcare professionals (HCPs) in learning SDM skills, e.g., by protecting time to get trained [7, 47, 51, 58] Show interest by doing site visits to clinics/teams implementing SDM [7] Share success stories in grand rounds [58] |
Performance measurement and feedback | |
Organizational culture | Foster a well-organized and amicable work environment [50] |
Autonomy of staff | |
Shared views and goals | Address relational dynamics of healthcare teams before SDM implementation [89] Hold regular meeting to share goals and successes [54] |
Organizational teamwork | |
Communication | |
Coordination of care | Have a patient navigator [102] |
Organizational resources | |
Time | Tailor interaction length guidelines for type of interaction [104] |
Financial resources | Obtain funding for SDM activities [90] Have access to high quality decision aids at low or no cost [52] |
Space | Use offices instead of clinical exam rooms for delivering decision support [74] |
Workforce | Reorganize workforce responsibilities from over utilized to underutilized staff [74] Salaried physicians for which SDM is part of employment obligations [51] |
Organizational priorities | |
Organizational workflows | |
Patient information dissemination strategies | Automate decision aid distribution, e.g., pre-visit [78], based on triggers [70], send by mail [58, 75, 90] Keep decision aids/tools accessible in exam rooms and workspaces [7, 86, 87] and make them easily available electronically [7, 58, 105] Offer in-office viewing of decision aids as well as other options (e.g., lending them to patients) [52] Align delivery of decision aids with other aspects of care (e.g., obtaining informed consent) [91] Partner with resource centers to deliver decision support [77] Clarify the place that decision aids have in the clinical pathway [103] Make decision aids available via a state-run website [51] Create protocols to prompted staff members to prescribe decision aid corresponding to the reason for referral [70] |
Scheduling routines and time frames | |
Electronic health record (EHR) | |
System-level strategies | |
Incentives | |
Payment model | |
Accreditation/certification criteria | Revise accreditation/certification criteria by adding the implementation of SDM as criterion/quality indicator [51] |
Policies and guidelines | |
Legislation | Create state legislation that fosters SDM (e.g., comparable to Washington state: enhanced legal protection when doing SDM) [51, 56, 57] Create legislation that encourages healthcare organization structures that support SDM [51] |
Practice guidelines | |
Quality indicators | Make the use of decision aids a quality of care indicator/list SDM as performance metric [55, 87, 91] Health plans could collect and distribute SDM performance data [51] Use a national set of measures [58] |
Culture of healthcare delivery | Promote culture of patient engagement in medical school [59] |
Education and licensing |