THE ROLE OF PATIENT VALUE AND PATIENT-CENTRED
CARE IN HEALTH SYSTEMSis, buy-in from the top and throughout the organisation, and a lot of training. You need tools and the
right environment. If any one of these is missing, you are not going to succeed.”
An advisory board member insisted that an
essential element of making health systems
truly patient-centred is to “make shared
decision-making real. It is a radical idea.”Unfortunately for something so important,
no single, accepted definition exists. A
2007 literature review found that roughly
a quarter of studies of the topic either did
not bother defining shared decision-making
or did so in an idiosyncratic way.^26 Later, in
2015 another analysis noted that the varying
definitions across the literature made it
difficult to say much about its impact.^27
This has implications beyond the analytical.
Axel Mühlbacher, professor of health
economics and healthcare management
at the Institut Gesundheitsökonomie und
Medizinmanagement (Health Economics and
Healthcare Management Institute) in Germany
notes that shared decision-making is lacking
“a single, systematic approach toward how
communication about patients’ preferences
between doctors and patients should be
organised.”Discussions of the concept therefore inevitably
need to fall back on the technique of calling
something a duck if it walks and quacks like
one. What, then, are this bird’s attributes?At a minimum, as one study^28 put it, three
elements are essential:
recognising and acknowledging that adecision is required;
knowing and understanding the best
available evidence; and
incorporating the patient’s values and
preferences into the decision.This, however, could describe a kind of
advanced version of informed consent where
the clinician diagnoses a condition and then
presents a menu of options from which
the patient can choose based on whatever
considerations seem relevant.Shared decision-making is much more,
explains Alan Balch, CEO of the US National
Patient Advocate Foundation. “It should start
with a conversation about what matters to
you as a person. What are your goals? What is
your work and social environment like? What
elements of quality of life are important to
you?” The doctor, like a good service provider in
other sectors, should then indicate what sorts
of treatments might best meet that individual
patient’s needs, bounded by treatment
guidelines and incorporating cost of care into
the discussion.Rather than an asymmetry of knowledge
giving power to one side in the conversation,
both bring something to the discussion, adds
Mr Balch. “The patient is the expert on what
is important to them. The healthcare provider
should have expertise around the medical
science and how it could be used. CombiningBox: A radical duck: What is shared decision-making?
- N Moumjid et al, “Shared decision making
in the medical encounter: are we all
talking about the same thing?” Medical
Decision Making, 2007. - L Shay and J Lafata, “Where is the
evidence? A systematic review of shared
decision making and patient outcomes,”
Medical Decision Making, 2015. - France Légaré and Holly Witteman,
“Shared Decision Making: Examining Key
Elements And Barriers To Adoption Into
Routine Clinical Practice,” Health Affairs,
2013.