Patient and provider perspectives on shared decision making: a systematic review of the peer-reviewed literature

Researchers found that pros of tests or treatments are often more likely to be discussed than cons, and often providers do not ask patients whether they want a test or treatment that may not be necessary. Via a survey of a national sample of adults 40 years or older, Fowler et al. [10] found that for each of ten common tests, medications and procedures, “patients reported more discussion of the pros than of the cons”. Similarly, Hoffman et al. [11] found that “most discussion with providers addressed pros of [breast, colorectal and prostate cancer] screening…but few similarly addressed cons”. We found similar findings elsewhere. For example, via a survey of 412 patients who received an implantable cardioverter defibrillator, Green et al. [12] found that some respondents reported not being told of the option not to get an implantable cardioverter defibrillator, and/or did not remember being asked if they wanted one. Similarly, researchers surveying patients who underwent vascular procedures found that only about half of respondents indicated they were offered a choice [13].

Across varied clinical settings, patient demographics such as race and gender also have been shown to have a bearing on decision-making processes and related outcomes. Among women with early stage, nonmetastatic breast cancer considering adjuvant chemotherapy or hormone therapy, Shelton et al. [14] found that black patients had the lowest ratings for communication with their oncologists and involvement in the decision-making process. Similarly, among male veterans receiving outpatient care at a Veterans Affairs Medical Center in Miami, whites expressed more satisfaction with their current role in decision making than did African Americans [15]. Researchers have also demonstrated that gender may be an important factor in SDM processes and outcomes. In their analyses of results from a national survey of adults who made cancer screening decisions, Hoffman et al. [11] found that among adults who made a colorectal cancer screening decision, most men reported that their provider explained the patient could choose whether to have the test and asked if the participant wanted the test, compared with smaller majorities of women. Similarly, most men making a prostate cancer screening decision reported the provider asked if the participant wanted the test versus a smaller majority of women making a breast cancer screening decision. On the other hand, results from a survey of patients with depression and providers treating patients with depression indicated ratings of SDM were more likely to be higher if the survey respondent was female [16].

Adding to the complexity of SDM processes and potential factors affecting them is patient knowledge of tests and treatments. Analyzing results from a sample drawn from a national survey of adults making decisions about ten common cancer screenings and blood pressure or cholesterol medications, Fairfield et al. [17] found overall knowledge scores were low across the study sample (adults 40 years or older); respondents also reported poor decision processes. Via a study of 1041 men deciding whether to undergo prostate-specific antigen testing after viewing a decision aid, researchers found that men with higher knowledge were ‘more likely to lean against’ screening (the US Preventive Services Task Force recommends against routine prostate-specific antigen testing) and ‘less likely to be unsure’ about their decision [18].

Patient perceptions of disease risk, disease-related mortality risk and effectiveness of treatments or screenings have also been found to influence exchange of treatment-related information and patient preferences. Hoffman et al. found, via a survey of adults facing cancer screening decisions, that patient perception of being at average/high risk for cancer was a factor highly associated with decision confidence. However, in another study of adults faced with the same decisions, they found most participants greatly overestimated risks of a cancer diagnosis and mortality [19].

Unsurprisingly, given that providers are the most important and often most trusted source of information for patients making medical decisions (e.g., [13,19,20]), provider knowledge and beliefs about the efficacy of tests and treatments as well as their perceptions of patient preferences also influence the scope of SDM in clinical practice. Volk et al. [21] found that “compared with physicians who ordered prostate cancer screening without discussion, physicians who discussed harms and benefits with patients and then let them decide were more likely to endorse beliefs that scientific evidence does not support screening, that patients should be told about the lack of evidence, and that patients have a right to know the limitations of screening”. The researchers also found that such physicians “were also less likely to endorse the belief that there was no need to educate patients because they wanted to be screened” [21]. Additionally, physician demographics such as specialty (e.g., family physicians vs internists) and physicians’ beliefs about their patients’ aversion to ambiguous scientific information predicted attitudes toward communicating such ambiguity [22]. When physicians felt their patients would respond negatively to ambiguous information, Portnoy et al. [22] found that such physicians ‘were more likely to think that they should decide what is best for their patients’.

Given the number and scope of patient and provider factors potentially clouding decision-making processes, it is important to note that our review includes studies indicating that patients and providers utilizing SDM processes have the potential to improve patient knowledge regarding the decisions they make as well as patient satisfaction with confidence in both the decision-making process and decisions made. Bozic et al. [23] found significantly more patients who were assigned to an SDM intervention reached an informed decision compared with a control group, and also ‘reported higher confidence in knowing what to ask their doctor’. Fowler et al. [24] found that patients with more knowledge and those who reported more involvement in decision making more frequently had their decision match their stated goals and concerns. Further, patients whose stated goals were met “reported more confidence in their decisions and feeling more positively about how the treatment turned out” [24].