Primary care faces hurdles on shared decisionmaking: study

An eight-site demonstration project has revealed some of the biggest challenges facing primary-care practices seeking to implement shared decisionmaking, according to a study in the February issue of Health Affairs.

Launched in July 2009 and led by the Boston-based Informed Medical Decisions Foundation, the demonstration project supported and followed early adopters as they planned and put in place a number of decision aids to better engage patients in their care.

The practices faced numerous obstacles, including inadequate clinical information systems that lacked the ability to identify which patients should receive decision aids or the ability to capture whether patients' views were considered in subsequent care, according to the study, authored by researchers from the foundation and RAND Corp., and based on interviews with demonstration participants.

“No participating site reported having an information system that included tools for tracking whether patients actually received care concordant with their decisions,” the authors said in the study,

Time-challenged and overworked physicians presented another hurdle, the study found. When physicians were tasked with choosing who should receive decision aids, only 10% to 30% of patients facing a decision actually received them, the authors said. Lack of provider training also hindered shared decisionmaking efforts, the study found. Many physicians said they were already effectively engaging patients in their care, despite evidence to the contrary.

Despite those challenges, two factors consistently eased implementation: automatic triggers for decision aid distribution and participation by non-physician team members.

“Given the difficulty of implementing shared decision making in primary care, accountable care organizations recognized by Medicare may fail to meaningfully engage patients and change patterns of care in their initial attempts to satisfy Medicare's final rule requirements,” the authors wrote in the study. “To meet this challenge, we recommend that such organizations carefully plan their implementation of shared decision making and make substantial long-term investments in information systems, provider training and process reengineering.”