PERFECTLY ACCOMPLISHED SHARED DECISION MAKING: A CALL TO CONSIDER A WIDER RANGE OF CONSEQUENCES

Purpose:

Research on shared decision making (SDM) has focused on a limited set of proximal outcomes; we aimed to elucidate a wider range of consequences to guide future research.

Methods:

We purposively reviewed published research that has examined key aspects of SDM. We used existing outcomes as the starting point for building a conceptual map that assumes, as its inception point, the accomplishment of exemplary shared decision making. We met as a group, face-to-face and virtually, on multiple occasions, to delineate individual, patient, organization, and system level consequences of SDM. We imagined a range of consequences, plausible or otherwise, negative and positive, intended and unintended, shorter and longer term. Our goal was to imagine the possibilities rather than to judge them good or bad.

Results:

We grouped outcomes into those that were proximal, distal and distant to an SDM process. We did not define clear time-limits and acknowledge that divisions may be arbitrary and blurry. The table shows potential outcomes for each time horizon at the individual, organization and healthcare system levels, assuming an ideal SDM process.

Level	Time Horizon
	Proximal	Distal	Distant
Individual	Patients: achieve informed decisions, form realistic expectations, gain knowledge, lower decisional conflict, make different choices. Professionals: achieve a sense of excellence, intrinsic reward.	Patients: greater activation, more information seeking and greater desire for engagement in decisions. Lower decisional regret and anxiety about disease risk. Professionals:  less burnout, more professionalism.	Increased utilization of low risk, effective healthcare interventions. Lower utilization of high risk, marginal benefit interventions. Greater patient engagement in self-management, self-care, healthy lifestyle behaviors.
Organization	Higher patient experience scores, higher decision quality.	Less workforce  distress. Fewer medical liability lawsuits.	Changing demand for clinical intervention requires shifts in workforce composition, more supportive care, less interventional care.
Healthcare System		Greater skepticism toward advertising, of drugs, interventions and services. Reduction in malpractice litigation.	Changing utilization patterns, leads to change in capacity planning. Improved population health. Social influence, community/family consequences of SDM.

Conclusions:

Combining an extended time horizon and analysis by individual, organizational and system levels facilitated recognition of a more comprehensive set of potential consequences of shared decision making than previously specified. This framework enables generation of a wider set of testable hypotheses and systematic generation of larger body of relevant evidence.