Research Activities, August 2013
Conference papers explore shared decisionmaking between clinicians and patients
In September 2011, AHRQ convened a conference of health care and health communication experts to explore the challenges of differing levels of evidence in promoting shared decisionmaking between clinicians and patients and to propose strategies for addressing these challenges. These strategies are needed to assist clinicians in addressing clinical uncertainty in a positive and constructive fashion. Conference speakers explored various aspects of uncertainty that focused on: communicating precision and uncertainty in clinical evidence, eliciting patients’ values and preferences in decisionmaking, and supporting shared decisions when clinical evidence is low.
The following eight papers that evolved from the AHRQ-sponsored conference (Contract No. 290-08-10015) were published in a special supplement to the February 2013 Medical Care Research and Review 70(1).
Braddock, C.H., III. "Supporting shared decision making when clinical evidence is low," pp. 129S-140S.
This paper examines shared decisionmaking (SDM) and its relevance to all clinical decisionmaking under conditions of clinical uncertainty. It emphasizes the potential for using SDM to empower patients to become more fully engaged in understanding the strength of the evidence and what it means in terms of the choices the patient faces, drawing on the concept of gist (general impression) knowledge and the role that it can play in the decisionmaking process.
Epstein, R.M., and Gramling, R.E. "What is shared in shared decision making? Complex decisions when the evidence is unclear," pp. 94S-112S.
The authors examine issues around clinical decisionmaking when evidence is unclear or inadequate. They also discussed when other factors, such as clinical complexity and nonclinical influences (e.g., family input, religious beliefs), create further challenges that may be amenable to resolution through varied strategies, including health systems reorientation.
Fraenkel, L. "Incorporating patients’ preferences into medical decision making," pp. 80S-93S.
This paper focuses on patient values and strategies for bringing them into the decisionmaking process. Strategies include discussions of current methods for engaging patients (e.g., conjoint analysis, best-worst scaling) and implications for point-of-care decision support.
Han, P.K.J. "Conceptual, methodological, and ethical problems in communicating uncertainty in clinical evidence," pp. 14S-36S.
The author offers an overview of conceptual, methodological, and ethical problems in communicating uncertainty in clinical evidence. He argues that the key to managing uncertainty constructively involves greater conceptual clarity and use of consistent representational methods that can be integrated into patient-centered interventions in ways that help patients cope with uncertainties.
Llewellyn-Thomas, H.A., and Crump, R.T. "Decision support for patients: Values clarification and preference elicitation," pp. 50S-79S.
This paper explores the need for values clarification (VC) and preference elicitation (PE) as integral components of the full decision support process, including positing a wider catalogue of approaches to VC/PE.
McCullough, L.B. "The professional medical ethics model of decision making under conditions of clinical uncertainty." pp. 141S-158S.
The author applies principles integral to the medical ethics model to decisionmaking under conditions of clinical uncertainty. He emphasizes specific virtues implicit in the roles of the decisionmakers (i.e., integrity on the part of the clinical professional and prudence on the part of the patient), since these virtues impact decision dynamics and outcomes.
Politi, M.C., Lewis, C.L., and Frosch, D.L. "Supporting shared decisions when clinical evidence is low," pp. 113S-128S.
This paper discusses applications of SDM that extend beyond situations in which equipoise between treatment options and or clinical outcomes exist to suggest applications of SDM in situations in which evidence is low or conflicting. The authors conclude with recommendations about priority areas for future research, including studies to assess effective management of uncertainty in clinical settings—a topic largely unexplored through formal research.
Zikmund-Fisher, B.J. "The right tool is what they need, not what we have: A taxonomy of appropriate levels of precision in patient risk communication," pp. 37S-49S.
The author examines the need for improved precision in patient risk communication, presenting a taxonomy of seven distinct risk concepts and discussing how patient acceptance of a health risk message varies across the seven conceptual areas.