The expressions "doctor's orders" or "the doctor knows best" may bring about images of a physician who curtly dictates the most appropriate treatment, leaving little time for a patient to fully grasp their condition or possible treatment options and ask questions. In other words, an image of a hierarchical, perhaps antiquated, doctor-patient relationship from a time when questioning a doctor could suggest a lack of trust or respect. It is another shifting piece of an evolving health care landscape.

As health information has become more accessible, the average patient often now arrives at appointments with an understanding of their condition, treatment options and preferences. Navigating this new dynamic requires clinicians who are better prepared to talk with patients about their illnesses, discuss risks and benefits of therapies, and help make the eventual treatment decision with the patient.

Over the past two decades, shared decision-making has become a buzzword and, more importantly, a component of the overall goal of creating a health care system that delivers better outcomes, reduces costs and improves population health. The Institute of Medicine's 2001 landmark report, Crossing the Quality Chasm outlined six aims of a high-quality health care system – including patient-centered care, defined as "care that is respectful of and responsive to individual patient preferences, needs and values." Patient-centered care happens only when the clinician understands the patient's goals and makes shared decision-making a priority of routine practice.

Since the publication of the 2001 report, policies have encouraged clinicians to adopt shared decision-making. The 2010 Affordable Care Act includes a provision that would certify tools that facilitate shared decision-making interactions between clinicians and patients. In addition, as of August 2018, the Centers for Medicare and Medicaid Services (CMS) has issued three coverage decisions, including two for cardiovascular procedures, that require a shared decision-making encounter as a condition of reimbursement.

CMS efforts to integrate shared decision-making into patient care "may be reflecting an underlying trend in medicine to recognize that health care is ultimately about patients. Medical decisions about their care are better when patients are engaged in the process," said Larry A. Allen, MD, FACC, who co-chaired an intensive session, Shared Decision-Making for the Clinician: From Buzz to Bedside, last March at ACC.18 in Orlando.

Research has shown benefits of shared decision-making go beyond creating a more patient-centered environment. For example, a 2017 Cochrane review of 105 studies found that patients exposed to shared decision-making were more knowledgeable about their options, had more accurate risk perceptions and were more likely to make decisions that were reflective of their values.

What is less clear, however, is what constitutes a successful shared decision-making encounter that enables patients to make an informed choice that honors their personal values and preferences. The National Quality Forum in 2017 outlined several components of effective shared decision-making:

• Patients should leave a shared decision-making encounter with accurate, unbiased information about their condition and the risks and benefits of treatment options – including the option to decline treatment.
• The clinician should tailor their explanations for each patient and make an effort to understand the patient's values, preferences and goals.

"Health care professionals need to understand the goals of their patients and vice versa, which establishes reasonable expectations for both the patient and the physician," said Martha Gulati, MD, MS, FACC, editor-in-chief of ACC's patient-facing CardioSmart program, in a 2017 letter in the Journal of the American Journal of Cardiology (JACC). "The goals established in such a collaborative manner will improve patient satisfaction and empower patients to have some control of a chronic condition – living with their disease but on their terms."

Communication For Effective Shared Decision-Making

The art of navigating a complex, difficult medical decision while keeping the patient's wishes at the center can be a difficult task. If clinicians are to be successful in practicing patient-centered care – that is, ensuring decision-making is in fact shared with the patient – there must be an increase in provider training on effective patient communication and a deeper understanding of how decision aids and other tools can support shared decision-making efforts.

In its 2012 Health Policy Statement on Patient-Centered Care in Cardiovascular Medicine, the ACC called on clinicians to educate patients on their condition, treatment options and goals through easy-to-understand educational materials. The report also called for an increase in shared decision-making, enhanced clinician-patient communication, and collaborative care planning and goal setting.

Since then, shared decision-making has been incorporated into several clinical policy documents including both the updated Expert Consensus Systems of Care document on operator and institutional recommendations and requirements for TAVR and the new bradycardia guideline (read article here) released this year. Additionally, the policy statement has served as a catalyst for focused development and implementation of ACC tools and resources to help clinicians incorporate shared decision-making discussions with patients into routine practice (see sidebar).

Decision aids are one such tool that explain conditions and treatment options and guide conversations between patients and clinicians. A 2016 study in BMJ reported that chest pain patients who used a decision aid were more engaged in their care. The study enrolled 898 adults who presented to the emergency department for chest pain and were being considered for admission to undergo further cardiovascular testing.

The patients were randomly assigned to receive usual care or review a web-based shared decision-making tool. Patients in the shared decision-making group were more involved in the admission decision and were more likely to decide against admission. After 30 days, there were no adverse cardiovascular events among patients in the shared decision-making group.

By providing information for patients to be active participants in their care, shared decision-making tools provide a means for patients and clinicians to chart the best course of action together. As Gulati wrote in the 2017 JACC letter, "Treating each person needs to always be the priority over simply treating the disease."

Looking to the future, the ACC's next Strategic Plan will continue to build on shared decision-making efforts as part of the goal to advance quality, equity and value of cardiovascular care. The College's new Core Values also focus on supporting and educating patients in shared decision-making as part of improving overall cardiovascular care and patient outcomes.

"We've come a long way since our 2012 health policy statement," said ACC Immediate Past President Mary Norine Walsh, MD, MACC. "The importance of integrating patients' goals, life experiences and perceptions of their disease into a plan that ultimately improves care and outcomes is no longer at question. I'm proud of the College for embedding patient-centered care into the fabric of its next Strategic Plan. Nothing is more patient-centered than involving our patients directly in decisions about their care and charting the path forward together."

Keywords: ACC Publications, Cardiology Magazine, Aortic Valve Stenosis, Atrial Fibrillation, Bradycardia, Caregivers, Centers for Medicare and Medicaid Services, U.S., Chest Pain, Consensus, Decision Making, Decision Support Techniques, Emergency Service, Hospital, Health Policy, Heart Failure, Life Change Events, Medicaid, Medicare, Patient Care, Patient Preference, Patient Protection and Affordable Care Act, Patient Satisfaction, Patient-Centered Care, Physician-Patient Relations, Risk Assessment, Transcatheter Aortic Valve Replacement

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