Quebec University Hospital Research Centre, St-Franois dAssise Hospital, Qubec City, QC, Canada.
Patient. 2012;5(1):1-19. doi: 10.2165/11592180-000000000-00000.
Shared decision making is the process in which a healthcare choice is made jointly by the health professional and the patient. Little is known about what patients view as effective or ineffective strategies to implement shared decision making in routine clinical practice.
This systematic review evaluates the effectiveness of interventions to improve health professionals' adoption of shared decision making in routine clinical practice, as seen by patients.
We searched electronic databases (PubMed, the Cochrane Library, EMBASE, CINAHL, and PsycINFO) from their inception to mid-March 2009. We found additional material by reviewing the reference lists of the studies found in the databases; systematic reviews of studies on shared decision making; the proceedings of various editions of the International Shared Decision Making Conference; and the transcripts of the Society for Medical Decision Making's meetings.
In our study selection, we included randomized controlled trials, controlled clinical trials, controlled before-and-after studies, and interrupted time series analyses in which patients evaluated interventions to improve health professionals' adoption of shared decision making. The interventions in question consisted of the distribution of printed educational material; educational meetings; audit and feedback; reminders; and patient-mediated initiatives (e.g. patient decision aids).
Two reviewers independently screened the studies and extracted data. Statistical analyses considered categorical and continuous process measures. We computed the standardized effect size for each outcome at the 95% confidence interval. The primary outcome of interest was health professionals' adoption of shared decision making as reported by patients in a self-administered questionnaire.
Of the 6764 search results, 21 studies reported 35 relevant comparisons. Overall, the quality of the studies ranged from 0% to 83%. Only three of the 21 studies reported a clinically significant effect for the primary outcome that favored the intervention. The first study compared an educational meeting and a patient-mediated intervention with another patient-mediated intervention (median improvement of 74%). The second compared an educational meeting, a patient-mediated intervention, and audit and feedback with an educational meeting on an alternative topic (improvement of 227%). The third compared an educational meeting and a patient-mediated intervention with usual care (p = 0.003). All three studies were limited to the patient-physician dyad.
To reduce bias, future studies should improve methods and reporting, and should analyze costs and benefits, including those associated with training of health professionals.
Multifaceted interventions that include educating health professionals about sharing decisions with patients and patient-mediated interventions, such as patient decision aids, appear promising for improving health professionals' adoption of shared decision making in routine clinical practice as seen by patients.
共同决策是医疗保健选择由医疗保健专业人员和患者共同做出的过程。对于在常规临床实践中实施共同决策的有效或无效策略，患者认为哪些策略有效或无效，人们知之甚少。
本系统评价评估了干预措施对改善健康专业人员在常规临床实践中采纳共同决策的效果，这是患者所见的效果。
我们从其成立到 2009 年 3 月中旬，在电子数据库（PubMed、Cochrane 图书馆、EMBASE、CINAHL 和 PsycINFO）中进行了搜索。我们还通过查看数据库中发现的研究的参考文献列表、共同决策研究的系统评价、各届国际共同决策会议的记录以及医学决策协会会议的记录找到了更多材料。
在我们的研究选择中，我们纳入了随机对照试验、对照临床试验、对照前后研究和中断时间序列分析，其中患者评估了改善健康专业人员采纳共同决策的干预措施。所讨论的干预措施包括分发印刷教育材料、教育会议、审核和反馈、提醒以及患者介导的举措（例如患者决策辅助工具）。
两名评审员独立筛选研究并提取数据。统计分析考虑了分类和连续过程测量。我们在 95%置信区间内计算了每个结果的标准化效应大小。主要结果是患者在自我管理问卷中报告的健康专业人员对共同决策的采用。
在 6764 条搜索结果中，有 21 项研究报告了 35 项相关比较。总体而言，研究的质量从 0%到 83%不等。只有 3 项 21 项研究报告的主要结果具有临床意义，对干预措施有利。第一项研究比较了教育会议和患者介导的干预措施与另一种患者介导的干预措施（中位数改善 74%）。第二项研究比较了教育会议、患者介导的干预措施和审核与反馈与关于替代主题的教育会议（改善 227%）。第三项研究比较了教育会议和患者介导的干预措施与常规护理（p=0.003）。所有三项研究都仅限于医患二人组。
为了减少偏倚，未来的研究应改进方法和报告，并分析成本和收益，包括与健康专业人员培训相关的成本和收益。
多方面的干预措施，包括教育卫生专业人员与患者共同决策以及患者介导的干预措施，例如患者决策辅助工具，似乎有望改善患者眼中常规临床实践中卫生专业人员对共同决策的采用。
