The false promises of shared decision making in rehabilitation

In the recent years, Shared Decision Making (SDM) has been increasingly advocated as an ideal model of treatment decision-making during the medical encounter, as it has been shown to increase benefits for both clinicians and the health-care system (1).  But does SDM result in better outcomes for patients with painful musculoskeletal conditions?  In this article, we’ll address the “5 W’s” of SDM.

WHAT is Shared Decision Making (SDM)?

Although many definitions of SDM exist, all converge to a similar notion: SDM is a dynamic process by which the healthcare professional (not limited to the physician) and the patient influence each other in making health related choices or decisions (2). In 2015, a comprehensive review SDM for  multiple health-related pathologies suggested that outcomes associated with the cognitive-affective domain exhibit stronger effects, whereas non-cognitive health related outcomes (e.g., function) yield the smallest effects (3).

WHO integrated SDM in our healthcare systems?          

The concept of SDM has been advocated for more than 40 years and is highly supported within infrastructures of health-care systems.  The Agency of Healthcare Research and Quality advocates for a shared approach to care and a five-step process, which involves exploring and comparing the benefits, harms, and risks of each option, through meaningful dialogue about what matters most to the patient. Other initiatives have also embraced this approach, such as the Patient-Centered Outcomes Research Institute (PCORI), as well as decision-makers, through the Affordable Care Act, which urges the implementation of SDM in health care systems (1).

WHEN should we use SDM in the context of musculoskeletal rehabilitation?

It is well recognized that painful musculoskeletal conditions, are one of the leading reasons for lower quality of life and represent a major burden (4). Although SDM is often embedded in today’s health care reality, the true effects of SDM (ie: added-value over “standard” client-centered care practice) on patient reported outcomes in the context of musculoskeletal rehabilitation are less known.  To shed light on SDM’s influence on health related outcomes in patients presenting with musculoskeletal conditions, I was part of a systematic review of studies comparing SDM with a control intervention (with SDM as the manipulated variable), and which included one or more of the following outcome measures: well-being, costs, health related pain or disability measures, or quality of life.  Not a single study investigated the true effect (effectiveness) of SDM on patient reported outcomes in a musculoskeletal pain population, despite the reality that SDM has been advocated for many years. We only found one study which explored the effect of a decision aid (educational brochure that could be part of a decision process) on patient satisfaction and physical outcomes in a sample of patients with non-specific low back pain.  Although these authors found comparable satisfaction levels, they reported worse outcomes (pain/physical aspects) and lower cost-effectiveness for the intervention arm (5)!

The top 3 reasons WHY to remain skeptical to SDM’s integration in musculoskeletal rehabilitation

  1. Decision aids are underdeveloped in rehabilitation: One tactic to implement an ideal application of the SDM approach is by the use of decision aids (educational material), which will stimulate the exchange of information between both parties, and will then drive SDM.  However, in musculoskeletal rehabilitation, decision-aids are i) scarce, ii) described to be in their developmental phase and iii) seen as premature to implement in clinical practice (7). Furthermore, in the short term, they are likely to remain scarce since we don’t fully understand our own intervention effects.
  2. SDM’s fundamentals relate to potentially harmful treatment options: SDM is recommended in the context of management of persistent pain related to the musculoskeletal diseases (6).  However, this recommendation made by the American Pain Society mostly concerned the decision making process between invasive therapies (surgery) and interdisciplinary rehabilitation, two approaches with radically different levels of potential harm and risk.  It is when confronted by such decisions that the SDM process might better serve the patient and the health care system.  However, rehabilitation involves a very low probability of harm, such as increase mortality risk, compared to surgical or pharmacological options.
  3. Conundrum of pain science: A tenant of SDM involves the assumption that delivering the patient preference will lead to improved outcomes.  However, patients and health care professionals are not always on the same page – if patient and therapist do not share a common understanding of pain, the SDM process should be questioned. For example, with chronic pain, patients with maladaptive thoughts or detrimental behaviors may demand care that is detrimental to their own progression. In pain management, evidence supports adoption exercises and active approaches.  However, these options are often at the opposite end of the desirability spectrum by the patient.  In such circumstances, SDM could have a negative influence on outcomes as both patient/therapist can be off the track, and select/offer a non-optimal treatment.

WHERE to go from this point?

There are recognized potential benefits of SDM in a patient-centered care approach, as it explicitly gives a voice to individuals and offers them more control towards the healthcare they choose to receive. However, one can argue that further investigation of this concept is necessary before wholesale implementation and assumption of superiority, especially in chronic pain management, where there are often more questions than answers.  One could also recommend more emphasis on gaining an accurate perspective and common understanding as a meaningful way to enhance outcomes.  In this particular context, maybe “soft skills” like therapeutic alliance (8) and better communication/education strategies (9) might represent interesting options in the meantime.

About Yannick Tousignant-Laflamme

yannick-tousignant-laflamme

Pr Tousignant-Laflamme is a registered physical therapist and researcher interested in developing and evaluating new ways to improve pain management in rehabilitation. His research program focuses on the treatment of chronic pain conditions, such as chronic back pain and complex regional pain syndrome (CRPS) as well as the development of pain assessment tools. His current research program focuses on three key areas of pain management: 1) Self-management programs; 2) Appraisal of therapeutic approach; 3) Development and validation of assessment tools. Finally, he has numerous research collaborations aimed to develop and validate various tools for measuring pain in vulnerable populations (ie: elderly, critical care).

References

[1] Oshima Lee E, Emanuel EJ. Shared decision making to improve care and reduce costs. The New England journal of medicine [Internet]. 2013;368(1):6–8. Available from: http://www.nejm.org/doi/full/10.1056/NEJMp1209500\nhttp://www.nejm.org/doi/pdf/10.1056/NEJMp1209500\nhttp://www.ncbi.nlm.nih.gov/pubmed/23281971

[2] Legare F, Witteman HO. Shared decision making: examining key elements and barriers to adoption into routine clinical practice. Health Aff (Millwood). 2013;32(2):276–84.

[3] Shay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Medical decision making : an international journal of the Society for Medical Decision Making [Internet]. 2015 Jan [cited 2016 Aug 31];35(1):114–31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25351843

[4] Palazzo C, Ravaud J-F, Papelard A, Ravaud P, Poiraudeau S, Vos T, et al. The Burden of Musculoskeletal Conditions. Chopra A, editor. PLoS ONE [Internet]. Public Library of Science; 2014 Mar 4 [cited 2016 Aug 31];9(3):e90633. Available from: http://dx.plos.org/10.1371/journal.pone.0090633

[5] Patel S, Ngunjiri A, Hee SW, Yang Y, Brown S, Friede T, et al. Primum non nocere: shared informed decision making in low back pain–a pilot cluster randomised trial. BMC musculoskeletal disorders [Internet]. BioMed Central; 2014 [cited 2016 Sep 26];15:282. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25146587

[6] Chou R, Loeser JD, Owens DK, Rosenquist RW, Atlas SJ, Baisden J, et al. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine [Internet]. 2009;34(10):1066–77. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19363457

[7] Gross DP, Armijo-Olivo S, Shaw WS, Williams-Whitt K, Shaw NT, Hartvigsen J, et al. Clinical Decision Support Tools for Selecting Interventions for Patients with Disabling Musculoskeletal Disorders: A Scoping Review. Journal of occupational rehabilitation [Internet]. 2016 Sep [cited 2016 Sep 6];26(3):286–318. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26667939

[8] Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, et al. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Physical therapy [Internet]. 2014 Apr [cited 2016 Apr 15];94(4):477–89. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24309616

[9] Louw A, Puentedura EJ, Zimney K, Schmidt S. Know Pain, Know Gain? A Perspective on Pain Neuroscience Education in Physical Therapy. Journal of Orthopaedic & Sports Physical Therapy [Internet]. JOSPT, Inc. JOSPT, 1033 North Fairfax Street, Suite 304, Alexandria, VA 22134-1540 ; 2016 Mar [cited 2016 Sep 2];46(3):131–4. Available from: http://www.jospt.org/doi/10.2519/jospt.2016.0602

Commissioning Editor Neil O’Connell

Comments

  1. Thank you Pr Tousignant-Laflamme for this excellent summary of Shared Decision Making in the context of rehab. This is a new area of research for me and I am not extensively familiar with the literature on this topic. I have also not read the Patel 2016 article referred to in this review, but my instict to be a dissenter makes me think that the educational brochure is not an accurate surrogate for shared decision making, and hence, not surprising that it did not result in improved self-report outcomes…isn’t the evidence fairly robust that education/informed advice alone is a less effective strategy than motivational interviewing/collaborative care?
    So-perhaps one interpretation of the findings could be that the context of the delivery was not accurately modeled upon a “shared decision making platform”?
    Could you also elaborate on the idea that the central tenant of the SDM model is that delivering the patient preference will lead to improved outcomes? Again, not extensively familiar with the SDM literature, but I am familiar with the MI principles of information exchange (Miller and Rollnick), which perhaps share some overlap to what you were referring to?
    For example, using an MI informed “hat”, the clinician would view the exchange of information between clinician and client/patient as…

    1. I have some expertise, and patients are the experts on themselves
    2. I find out what information patients want and need
    3. I match information to patient needs and strengths
    4. Patients can tell me what kind of info is helpful
    5. Advice that champions patient needs and autonomy is helpful

    I do find these principles helpful in my practice and perhaps more in-line with the spirit of the SDM model?

    I’ve also enclosed a link of the principles that underlie the SDM model in action, at least per the Stanford MedX teaching/learning platform:

    http://www.everyoneincluded.org/

    Hope this provides for a platform for further discussion.

    Best
    Nick

  2. great review of studies and thanks for pointing out what is missing. It will help PT providers “defend” the hands on, mind on, approaches that often yield success.

  3. This is a very nice post. I am particularly concerned about the “behind the scenes” elements of SDM and how this has been championed in the United States with PCORI and Obama-care. It is my perception that this is another example of jumping in with both feet despite not knowing whether the outcome is better or not. At a minimum, it should have been studied appropriately. I’ve seen similar results with discrete-patient choice options: the patient satisfaction seems to be better but the outcome is not. Nice work Yannick.

  4. It is possible for patients to ruin their own chances of a successful outcome if they come in with rigid expectations about how the therapist should do his job (eg. “I’ve always had ultrasound to my elbow when it plays up like this” – the subtext is very clear). Such patients believe that unless they are directing every aspect of the treatment, it will fail. I think it’s one of the hardest clinical dilemmas to handle smoothly.

    It’s all very well to say “just do the ultrasound”, but have you considered what it means to acquiesce to such controlling behaviour? It simply feeds the mistrust and fear.

    Ideally, the patient’s job is a simple one – find out whom you trust, stop Googling your symptoms and let go. Most people manage to do this very well, but chronic pain patients have a lot more fear and so the level of difficulty skyrockets.

    Peter Elias Reply:

    What you describe and correctly object to is DDM (dictated decision making) and is the antithesis of SDM. Shared means shared. DDM is a problem regardless of who is dictating. It is possible for both (either) clinicians or patients to diminish the chance of a good outcome through rigid expectations (this is what worked with my last patient, this is what worked with my previous episode) or inability/unwillingness to listen (premature or inaccurate diagnosis, lack of understanding of patient goals and resources, refusal to listen to clinician explaining options with pro/con information).

    EG Reply:

    Got it. Seems like this is a process better suited to medicine, where risk-reward ratios for different options can be evaluated in a consultative way.

    In Physio, we have no proven techniques (other than confidence and rapport), so we can’t really advise patients in a way that’s going to make sense to them.