Is shared decision making always appropriate for a Choosing Wisely approach?

Shared decision making and health literacy international expert Kirsten McCaffery* says while shared decision making is important for good quality patient-centred care and can play an important role in helping reduce unnecessary, low value care, we also need to think carefully about the difference between shared decision making and evidence-based decision making, and when to use the former.

Professor McCaffery, from the Sydney School of Public Health, University of Sydney, is a keynote speaker at today’s Choosing Wisely forum in Wellington. The Choosing Wisely campaign encourages health professionals to question current practice and discuss the potential risks and benefits of tests, treatments and procedures with consumers. Consumers are encouraged to ask health professionals whether they really need a particular intervention.

Prof McCaffery says people sometimes confuse shared decision making with evidence-based decision making.

'The challenge is applying shared decision making to Choosing Wisely to reduce inappropriate care. We need to think carefully about what we’re trying to achieve and what shared decision making actually is.

'Shared decision making can be done in many different ways – with patient decision aids, coaching, questions, but in essence it is really a process by which we set out the options for patients, give them the evidence as best we can and then support them to choose what they want to do and help them make the choice that fits their preferences and values. Even if that choice is for a low-value test or treatment option. This can be really important in some circumstances.

'However, if we believe the harms of one option vastly outweighs any benefits and we are trying to reduce low-value care, we might want to consider evidence-based decision making where we clearly lay out the evidence, listen to a person’s values and preferences, but ultimately give them a recommendation. For example, ‘We don’t recommend this imaging test because there will be little benefit, but a risk of harm’. Importantly, this is not denying someone a test – it is expressing an opinion on the balance of benefits and harms.

'The question is, when do we do shared decision making and when do we do evidence-based decision making alone and give people a clear recommendation?'

'There may also be some situations where we want to make policy decisions higher up the line that certain options shouldn’t be made available. This can be very contentious with patients and the community, but perhaps we need to have a suite of options for managing or reducing low-value care? Shared decision making is one strategy to help reduce unnecessary tests and treatments, but it’s only one, and we may want to think of alternative strategies.'

She says both options need education and improvements in health literacy for the public and health care providers.

'The Choosing Wisely message of doing less is counter intuitive and needs investment in public and patient communication to help people to understand it. There is a lot of work needed to help people understand there can be real harm doing low-value tests and treatment.

'Typically, we know patients in the community don’t understand, for instance, that imaging and unnecessary testing can cause harm. We can’t expect the community to come on board without some education.'

She says we also need to think of the pressures on providers to change practice.

'Providers often say they respond to patients’ expectations and demands. We can’t just expect providers to stop ordering tests without providing any support and strategies to manage patient demand.

'Saying that, we know providers often do a poor job at telling patients about the harms of any tests or treatments – this needs to change and we also know they can do a better job at talking to patients about their values and preferences. We need to support providers to improve communication skills in these key areas.”

*Professor Kirsten McCaffery is a National Health and Medical Research Council (NHMRC) Professorial Research Fellow; Director of Research and Director, Sydney Health Literacy Lab, Sydney School of Public Health, University of Sydney. Kirsten has an international reputation in shared decision making and health literacy. She is co-founder of Wiser Healthcare – a research collaboration of over 30 researchers across the Universities of Sydney, Bond and Monash.