The first two articles in this series pointed out we need better and more affordable evidence. Yet, even if affordable high quality evidence is forthcoming it is imperative that patients can make informed decisions and that doctors have the tools to actually inform patients it in practice.
There is, however, growing unease that the current system is not serving patients information needs. Sally Davies, the UK’s Chief Medical Officer (CMO), recently requested a review to restore public trust in the safety and effectiveness of medicines, because patients increasingly see doctors as over-medicating and clinical scientists who are afflicted by conflicts of interest: the CMO therefore considers it is difficult for the public to trust either.
What is clear is that informed patients require an unbiased presentation of reasonable options to consider the benefits and harms of their treatment options. Yet, despite the significant growth in RCTs over the last twenty years there have been few robust studies that have evaluated shared decision making – actually there are none.
A 2015 systematic review of shared decision making strategies, including at least one patient outcome, found 39 studies. But none of these were randomised controlled trials: 28 were cross sectional or before and after surveys, and whilst 8 RCTs were included in the review, the analyses were secondary to the main trial hypotheses, and were therefore conducted irrespective of the group assignment (ie., they weren’t randomised comparisons).
Furthermore, there is a serious under-representation of shared decision-making evidence in many disease areas: fourteen studies in the review were cancer related (10 breast cancer), five each for mental health and diabetes and only two were based in primary care. A further Cochrane systematic review of interventions that aimed to improve the adoption of shared decision making by healthcare professionals found only 5 RCTs, three were done in primary care and two in specialist care.
Hence, it is difficult to advise which strategy, if any, to adopt when it comes to informing patients in real world practice.
While there is little evidence to inform shared decision making strategies there is considerably more evidence for decision aids: over 500 have been developed (an inventory is available here) and 115 randomised trials involving 34,444 participants were included in a recent updated cochrane systematic review. This review concluded that there is ‘high-quality evidence that decision aids improve people’s knowledge regarding options, and reduce their decisional conflict related to feeling uninformed and unclear about their personal values.’ However, there was less evidence for effects on clinical outcomes and adherence to treatments. A further systematic review of the impact of patient decision support interventions and costs and savings including 7 studies and 8 analyses found that there is some evidence patients choose more conservative approaches when they are better informed; but there is little evidence as to whether this generates any actual savings.
When it comes to informing patients needs there is an obvious dearth of information and evidence in the shared decision making space. What we now need to do is divert some, if not a lot (if not all for one year) of the research funds that are going to waste into this extremely important area that affects all of us all of the time in health care
Example of shared decision making strategies by Victor Montori speaking at EvidenceLive in 2016:
Victor Montori – How do we make evidence care?
The campaign starts at EvidenceLive 2016 – with an open meeting to prioritize and explore the potential solutions to better evidence for better decisions.
The next in the series will look at better decisions require treatments that matter.
His research interests span chronic diseases, diagnostics, use of new technologies, improving the quality of research and investigative work with The BMJ on drugs and devices that you might stumble across in the media.
I declare that I have read and understood BMJ Policy on declaration of interests and I hereby declare the following interests: CEBM jointly runs the EvidenceLive conference with The BMJ and is one of the founders of the AllTrials campaign. He has received expenses and payments for his media work and has received expenses from the World Health Organization (WHO) and and holds grant funding from the NIHR, the National School of Primary Care Research, the Wellcome Trust, and the WHO.