Shared Decision-Making in Endocrinology: A Vital Clinical Tool

Shared decision-making is a patient-centered approach incorporating a deliberative dialogue between the physician and patient that facilitates more understanding and helps pin-point the best treatment option.

Commentary by Juan P. Brito, MBBS
Male physician speaking with patient and familyA physician should always work in the best interest of his or her patient, using evidence-based practices to make important clinical decisions. However, finding the right treatment option can be a challenge. There may be limitations to the research, patients may have relevant personal preferences, and it may be unclear how well a treatment option will fit into a patient’s daily life.

  • Shared decision-making is a patient-centered approach incorporating a deliberative dialogue between the physician and patient that facilitates more understanding and helps pin-point the best treatment option.

An article published in Lancet Diabetes Endocrinology detailed evidence on how shared decision-making may improve patient outcomes and satisfaction. However, it still is not an approach widely accepted by physicians, according to corresponding author Juan P. Brito, MBBS, of the Mayo Clinic in Rochester, Minnesota.

There can be various reasons why this happens Dr. Brito said, including clinicians not having the tools available for shared decision-making, not working within an environment that promotes this approach, or not considering the patient’s values as relevant. A lack of shared decision-making can be a serious problem, though, with possible ethical and clinical implications.

What Is Shared Decision-Making?
“Shared decision-making is an approach for better care. It is most useful when patients have two or more medically reasonable courses of action that differ in important aspects,” said Dr. Brito.

Patient preference can be essential to a clinical decision, considering that evidence-based medicine does not always delineate a superior treatment option.1 The potential differences in costs, benefits, and risks/harms of treatment choices can make the patient an intrinsic stakeholder in the clinical process.

Patients need to be involved with their health care, edified about their options, and ensured the autonomy they deserve concerning their health choices.2 Even when the best option is clear, physicians may have to find out how well the treatment can fit within a patient’s personal circumstances.

Shared Decision-Making in Endocrinology
There are numerous instances where patients with endocrine disorders face difficult diagnostic and treatment dilemmas. Noticeably, 60% of all recommendations in current endocrine guidelines are based on low or very low quality evidence.3,4 In these instances, more than one option may be available to patients, and clinicians can benefit from explaining the pros and cons of these options to their patients.

One of the most universal examples is finding the right form of diabetes treatment. Utilizing decision tools is a desirable method for reaching clinical decisions in collaboration with the patient. “Unfortunately, we do not have tools for all the decisions that must be made. In the absence of a decision aid, clinicians are still encouraged to use shared decision-making,” said Dr. Brito, who recommends a 3-step approach:

  • Step 1: Create choice awareness
  • Step 2: Discuss treatment options in detail
  • Step 3: Discuss the patient’s values and preferences and decide what is best

Granted, there are some clear medical decisions where the distribution of patient preference is low, such as the use of steroids for adrenal insufficiency or insulin for diabetic ketoacidosis, but there are many other endocrine clinical situations where shared decision-making can be implemented:

  • Choosing the best add-on treatment after metformin fails to achieve glycemic control in a patient with type 2 diabetes
  • Choosing a first-line drug for painful diabetic neuropathy
  • Choosing a treatment course for a patient with Graves’ disease

Available Resources, Decision Aids
Physicians and patients need to start their dialogue from a common ground of evidence-based information, which can be difficult. The majority of patients do not have medical degrees, and they may be overwhelmed by the complexities of details to different treatment courses.

Decision aids help patients by providing a fair and balanced presentation of the facts, enabling them to understand the relative merits of available options,5 something that seems to improve patient outcomes, especially to more disadvantaged patients with lower literacy and socioeconomic status.6

Future Directions for Shared Decision-Making
Today, shared decision-making is becoming more recognized as a valuable approach to patient-centered care, having been endorsed by organizations like the American Diabetes Association and the Endocrine Society.7-9 However, according to the authors of the Lancet article, more clinical practice guidelines should provide indication(s) for when the shared decision-making approach is applicable, especially considering the guidelines’ proclivity to low or very low quality evidence recommendations.3,4

There is also a need to raise awareness and promote more research into the applicability and efficacy of shared decision-making, such as the 2 year follow-up study currently testing a diabetes decision aid utilized in over 40 general practices.10

Endocrine practices also can benefit from the development and testing of more shared decision-making models for a variety of other endocrine disorders. To this aim, the not-for profit MAGIC project (Making GRADE the Irresistible Choice) could be a valuable initiative, as it enables researchers to create decision aids using a structured database of evidence based on the GRADE methodology.

“It clearly is a step towards the application and dissemination of tools meant to facilitate conversations of benefits, harms and values between clinicians and patients, having graphical interfaces of the effect estimates underlying a single recommendation,” stated Dr. Brito.

April 14, 2016

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