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Systematic review
Impact of decision aids used during clinical encounters on clinician outcomes and consultation length: a systematic review
  1. Claudia Caroline Dobler1,2,
  2. Manuel Sanchez2,
  3. Michael R Gionfriddo3,
  4. Neri A Alvarez-Villalobos2,4,
  5. Naykky Singh Ospina2,5,
  6. Gabriela Spencer-Bonilla2,
  7. Bjorg Thorsteinsdottir1,6,
  8. Raed Benkhadra1,
  9. Patricia J Erwin7,
  10. Colin P West8,9,
  11. Juan P Brito2,
  12. Mohammad Hassan Murad1,
  13. Victor M Montori2
  1. 1 Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
  2. 2 Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
  3. 3 Center for Pharmacy Innovation and Outcomes, Geisinger, Forty Fort, Pennsylvania, USA
  4. 4 Facultad de Medicina y Hospital Universitario, Unidad de Investigación Clínica, Universidad Autonoma de Nuevo León, Monterrey, Mexico
  5. 5 Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, Florida, USA
  6. 6 Division of Primary Care Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
  7. 7 Medical Library, Mayo Clinic, Rochester, Minnesota, USA
  8. 8 Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
  9. 9 Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Dr Claudia Caroline Dobler, Mayo Clinic, Evidence-Based Practice Center, Rochester, MN 55905, USA; dobler.claudia{at}mayo.edu

Abstract

Background Clinicians’ satisfaction with encounter decision aids is an important component in facilitating implementation of these tools. We aimed to determine the impact of decision aids supporting shared decision making (SDM) during the clinical encounter on clinician outcomes.

Methods We searched nine databases from inception to June 2017. Randomised clinical trials (RCTs) of decision aids used during clinical encounters with an unaided control group were eligible for inclusion. Due to heterogeneity among included studies, we used a narrative evidence synthesis approach.

Results Twenty-five papers met inclusion criteria including 22 RCTs and 3 qualitative or mixed-methods studies nested in an RCT, together representing 23 unique trials. These trials evaluated healthcare decisions for cardiovascular prevention and treatment (n=8), treatment of diabetes mellitus (n=3), treatment of osteoporosis (n=2), treatment of depression (n=2), antibiotics to treat acute respiratory infections (n=3), cancer prevention and treatment (n=4) and prenatal diagnosis (n=1). Clinician outcomes were measured in only a minority of studies. Clinicians’ satisfaction with decision making was assessed in only 8 (and only 2 of them showed statistically significantly greater satisfaction with the decision aid); only three trials asked if clinicians would recommend the decision aid to colleagues and only five asked if clinicians would use decision aids in the future. Outpatient consultations were not prolonged when a decision aid was used in 9 out of 13 trials. The overall strength of the evidence was low, with the major risk of bias related to lack of blinding of participants and/or outcome assessors.

Conclusion Decision aids can improve clinicians’ satisfaction with medical decision making and provide helpful information without affecting length of consultation time. Most SDM trials, however, omit outcomes related to clinicians’ perspective on the decision making process or the likelihood of using a decision aid in the future.

  • health services research
  • shared decision making
  • communication

http://dx.doi.org/10.1136/bmjqs-2018-008022

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    Introduction

    Shared decision making (SDM) is considered an essential element of patient-centred care, yet its implementation into routine clinical practice has proven to be difficult.1 SDM refers to a process of deliberation in which clinician and patient work together to achieve the best possible healthcare choice aligned with the patients’ values and preferences.2 3

    Despite evidence that decision aids improve patients’ knowledge and clarify patients’ values,4 the uptake of encounter decision aids for SDM among clinicians and their integration into routine clinical care is low.1 5 6 Most of the barriers to widespread implementation of SDM are commonly encountered with any clinical practice changes.7 8 These include time constraints with competing priorities taking precedence and uncertainty about the value of the proposed change.9 Clinicians may also have concerns about the lack of applicability of SDM due to patient characteristics and the clinical situation.1 6

    System approaches (as opposed to reliance on individual clinicians) have been identified as potential facilitators to implementation of SDM into mainstream clinical practice.1 5 It is likely that some system approaches, such as implementation of encounter decision aids into the electronic medical record system, would support uptake of this intervention by clinicians. In addition, however, it seems essential to address and overcome clinicians’ concerns in order to achieve widespread implementation of SDM. This includes concerns that SDM takes too much time or that decision aids for SDM do not address the needs of all patients, in particular that they may not address the perceived different needs of elderly people, immigrants and patients with low health literacy in general.10

    Measured outcomes in trials to assess the impact of decision aids for SDM have usually been patient-reported and have focused on patients’ experience and satisfaction with the decision making process.4 Clinicians’feedback is, however, also important, as clinicians’ satisfaction with the way that the process of SDM using an encounter decision aid affects the clinical encounter can be a strong incentive for sustained uptake of encounter decision aids alongside other incentives such as achieving appropriate medical decisions and satisfaction with the decision making process. Ideally, decision aids, particularly those designed for use in the clinical encounter, will facilitate constructive engagement and collaborative deliberation betweenpatientsand clinicians about healthcare options, increasing both patients’ and clinicians’ satisfaction with the clinical encounter.

    It is unknown how the experience of using an encounter decision aid for SDM may change the perception and acceptability of these tools among clinicians. To date, there is no systematic evaluation of whether physicians who have used encounter decision aids for SDM have been satisfied by this experience and how they judge the SDM tool’s helpfulness and impact on the decision making process. We were thus interested to evaluate and compare opinions about decision aids for use during the clinical encounter in clinicians who had used these tools in randomised controlled trials (RCTs) and those who had not. Consequently, we performed a systematic review to determine clinician outcomes in RCTs of encounter decision aids for SDM.

    Methods

    Literature search

    We reviewed all studies included in the Cochrane review entitled ‘Decision aids for people facing health treatment or screening decisions’ published in April 2017 (literature search conducted on 24 April 2015).4 The Cochrane review captured trials of decision aids for people facing health treatment or screening decisions. The majority of studies in the Cochrane review used decision aids outside of medical encounters, while our study included decision aids used during the medical encounter, and we focused on clinician outcomes. We updated the search using the following electronic bibliographic databases: Ovid Embase, Ovid Medline, PubMed, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register), Health Technology Assessment Database, NHS Economic Evaluation Database, PsycInfo and EBSCO CINAHL.

    The literature search was conducted by an experienced research librarian (PJE). Databases were searched from the date of inception to 1 June 2017. We also searched the reference lists of relevant papers.

    Eligibility criteria

    Study types

    As we were interested in the comparative effectiveness of encounter decision aids, we included RCTs of encounter decision aids that compared a decision aid intervention to at least one control and measured at least one clinician outcome. Further, we included studies of any design nested within an RCT design (eg, a second analysis of the original trial), if they met the other study inclusion criteria and reported relevant outcomes not mentioned in the parent study. We included articles reported in any language.

    Participants

    To be included, studies needed to report on adults making decisions about screening or treatment options for themselves, a child or an incapacitated significant other. Participating clinicians could have been any healthcare professional (nurse, physician, physician assistant, dietician and so on) in any type of healthcare setting (inpatient or outpatient).

    Interventions

    Encounter decision aids were defined as any communication or support tool that facilitated a SDM process including patients and clinicians deliberating available healthcare options. The decision aid had to include at least one component designed for use during the patient-clinician encounter. Decision aids only used before or after the clinical encounter were excluded.

    Control

    Control groups were usual care or alternative interventions without the use of a decision aid. Studies that only compared different types of decision aids were excluded.

    Outcome measures

    We aimed to include studies that measured clinician-reported or clinician-important outcomes in the following a priori defined categories: (1) clinicians’ satisfaction with: (i) the clinical encounter in general, (ii) the decision-making process or any component of it (eg, knowledge transfer, patient participation and engagement, decisional comfort/conflict), (iii) the decision aid (eg, plan to use the decision aid again, recommend it to others) and (iv) the decision made; (2) efficiency in terms of the length of the clinical consultation and (3) personal and professional well-being including: (i) mood and burnout indicators and (ii) satisfaction with the practice of clinical care.

    Study selection and data extraction

    All references identified in the literature search were independently screened by two reviewers using DistillerSR software (Evidence Partners, Ottawa, Ontario, Canada). All studies that were identified for full text review based on abstract and title were reviewed by two independent reviewers. Disagreements were resolved through discussion. Data were extracted from included articles by two independent research team members using a standardised data extraction form. All extracted data were cross-checked by the first author. The processes for study screening and data extraction from included studies were pilot-tested by having study reviewers and data extractors independently conduct preliminary study screening and data extraction on selected articles. Extracted data included: study name and authors, year of publication, study location(s), topic area, number of patients and clinicians in intervention and control groups, number of clinical encounters, characteristics of clinician participants, description of the intervention, description of the comparator, quantitative and qualitative clinician outcomes.

    Analysis

    Due to high heterogeneity among included studies, we conducted narrative evidence syntheses. We grouped outcome categories and assessed results within each category without quantitative pooling.

    Risk of bias assessment

    The methodological quality of the studies (ie, risk of bias) was appraised by two independent reviewers using the original Cochrane Collaboration’s risk of bias tool.11

    We reported our systematic review and meta-analysis according to the PRISMA guidelines.12 A review protocol with a priori defined outcome categories was developed before study selection commenced.

    Results

    Studies included in the Cochrane review on decision aids (n=105) and citations identified with an updated search resulted in 6702 unique citations, from which 218 full-text articles were reviewed after consideration of title and abstract (figure 1). Twenty-five papers met the inclusion criteria including 22 RCTs and 3 qualitative or mixed-methods studies nested in an RCT, together representing 23 unique trials (online supplementary file 1).13–37 One study was excluded because it had no comparator group without decision aid.38 There were three nested qualitative studies and nine RCTs included in our review that were not included in the Cochrane review, the majority of which were published after April 2015, the date of the literature search for the Cochrane review.

    Supplemental material

    Figure 1
    Figure 1

    Flow diagram of study selection.

    Study characteristics

    The characteristics of the included trials are summarised in online supplementary file 1 in the supplementary file. Ten trials were conducted in the USA, followed by the UK with three and Canada with two studies. One study each was conducted in Spain, Greece, Germany, the Netherlands and Australia. Three trials were international multicentre RCTs. Trials evaluated healthcare decisions for cardiovascular prevention and treatment (n=8), treatment of diabetes mellitus (n=3), treatment of osteoporosis (n=2), treatment of depression (n=2), antibiotics to treat acute respiratory infections (n=3), cancer prevention and treatment (n=4) and prenatal diagnosis (n=1). In three trials, SDM interventions were multifaceted programmes (including an encounter decision aid).

    Risk of bias assessment

    Table 1 gives an overview of the risk of bias assessment of all included studies. The major source of risk of bias in trials was the lack of blinding of participants.

    View this table:
    Table 1

    Risk of bias assessment in individual randomised controlled trials

    Clinicians’ satisfaction with decision aid and decision making process

    Clinicians’ satisfaction with the decision aid and decision making was measured as a quantitative outcome in the decision aid group and the control group in eight studies of which two showed statistically significant greater satisfaction in the decision aid group and six showed no difference between groups. Of the eight studies, six measured satisfaction as a continuous outcome, of which one showed greater satisfaction among clinicians in the intervention group, and five showed no difference between clinicians in different groups (table 2).

    View this table:
    Table 2

    Comparative (decision aid vs usual care) continuous outcomes

    A study on a decision aid for treatment of depression reported clinician satisfaction with decision making as dichotomous outcome and found a significantly higher proportion of clinicians being satisfied or extremely satisfied in the intervention compared with the control group (76.3% vs54.0%; relative risk (RR) 1.64, 95% CI 1.25 to2.16).28 A study on a decision aid for diabetes medication that used five categories of different levels of satisfaction found no significant difference between groups (intervention vs control group: completely satisfied: 34.7% vs 17.7%, very satisfied: 50.0%vs59.8%, somewhat satisfied: 9.2%vs17.7%, poorly satisfied: 5.1% vs 4.9%, not at all satisfied: 1.0 vs 0%; p=0.87) (figure 2).23

    Figure 2
    Figure 2

    Summary of quantitative comparative outcomes (decision aid vs control group). SDM, shared decision making.

    Clinicians perceived the decision aid as useful when it was easy to use and implement into routine clinical care.22 32 One study reported that clinicians felt proud to have additional tools for patients to view and take home.14 Many clinicians reported that patients were more satisfied with care after using the decision aid. These clinicians recognised that the decision aid may have an added value.14

    Added value from the use of a decision aid reported by clinicians included that the decision aid positively challenged patients’ preconceived ideas;14 22 32 contained useful information25 and increased patients’ and clinicians’ knowledge;22 32 enhanced communication by providing visual representations of choices;14 reduced clinicians’ burden to produce accurate representations by hand by providing graphical contents, giving clinicians more time to engage in meaningful discussions with patients;14 provided scientific evidence for issues discussed in the consultation;32 reassured patients;25 helped to frame the ‘usual care’/no-intervention option in a more positive light (eg, non-antibiotic prescribing decisions with a positive message about symptom relief);32 facilitated more structured and coherent consultations;22 32 provided reminders of specific topic to cover in the discussion;32 motivated patients and/or involved them in the choice to be made;25 32 assisted in the elicitation of patient preferences14 and led to a greater recognition among clinicians of the importance of actively engaging patients in treatment decisions.14

    Clinicians’ concerns about encounter decision aids were that they felt obliged to discuss options that were not relevant (eg, medically not possible) for some patients because they were included in the decision aid;25 information in decision aids was sometimes worrying for patients or difficult to understand;25 patients had other priorities during the encounter than discussing the decision aid;25 they did not perceive the decision aid as motivating for behavioural change;25 they had to give up feelings of competence and comfort with their own familiar routines;14 decision aids would add time to their clinics if they were not simple and straightforward14 and informing the patient before the visit (as opposed to using an encounter decision aid) may save time during the clinical encounter and potentially improve the conversation.14

    Knowledge transfer

    Knowledge transfer was assessed in one study.23 The majority of clinicians in the intervention group asked to assess the knowledge transfer using the decision aid judged it as very easy (48%) or easy (39%).23

    Decisional conflict/comfort

    Decisional conflict was reported as a comparative continuous outcome in three studies. Clinicians in the decision aid group were less conflicted with the decisions made than clinicians in the control group in two studies and there was no difference between groups in one study (table 2). One study reported decisional conflict as dichotomous outcome and found no statistically significant difference between groups. The proportion of clinicians with 2.5 or more on the Decisional Conflict Scale (1=low decisional conflict, 5=very high decisional conflict) was 4.6% (range 0%–6.1%) in the decision aid group and 1.1% (range 0% to 2.4%) in the control group (adjusted RR 3.4; 95% CI 0.3 to 38.0) (figure 2).30

    Helpfulness of the shared information

    Three studies assessed helpfulness of the information in the intervention and control group. Results from all studies indicated that clinicians found the information in the decision aid group more helpful than in the control (mean difference 0.64, 95% CI 0.18 to 1.0927 (table 2); 70% vs 35% of clinicians judged information as helpful26 and a significantly higher proportion (54.1%) of clinicians in the intervention group who judged the information as extremely helpful compared with the control (33.7%) (figure 2).15

    Two studies that assessed how helpful clinicians in the intervention group found the information contained in the decision aid (but did not assess the outcome in the comparator group) revealed that 98% and 86% of clinicians, respectively, found the information helpful.16 24 Some clinicians reported that the decision aid helped influence the healthcare decision.22

    Intention to use decision aid/SDM making in the future/for other decisions

    Of three studies that measured intention to use a decision aid/SDM in the future as comparative continuous outcome, one found a significantly higher proportion of clinicians in the intervention intending to use a decision aid/SDM for other decisions and two did not show any significant differences between intervention groups and controls (table 2). Of two studies using dichotomous and categorical outcomes respectively, one found a significantly higher proportion of clinicians in the intervention intending to use a decision aid/SDM for other decisions (67% vs 41%, RR 1.6; 95% CI 1.01 to 2.6),26 but the other found no statistically significant difference between groups (three categories of answers for intention to use a decision aid/ SDM in future: ‘yes’, ‘not sure’, ‘no’ with 62.9% vs 43.8% ‘yes’ answers in the intervention and control group, respectively) (figure 2).15

    Four studies assessed intention to use a decision aid/SDM in the future in the intervention group only and found that 63%,16 90%,24 94%23 and 100%14 of clinicians, respectively, intended to use a decision aid/SDM in the future.

    Would recommend decision aid/SDM to other clinicians

    Three studies assessed whether clinicians would recommend the use of decision aids/SDM to colleagues in the intervention and control group and all found that clinicians in the intervention group were more likely to recommend use of a decision aid/SDM to other clinicians (mean difference 1.09, 95% CI 0.57 to 1.6127 (table 2); 74% vs 30% of clinicians would recommend decision aids/SDM26 and a significantly higher proportion (62.7%) of clinicians in the intervention group who would recommend decision aids/SDM compared with the control (41.9%) when given a choice between ‘yes’ (would recommend), ‘no’ and ‘not sure’.15

    Intention to follow clinical practice guidelines

    The outcomes of two studies did not show any significant difference regarding intention to follow clinical practice guidelines between intervention groups and controls (table 2).

    Disruption to flow of consultation

    Disruption to the flow of a consultation was assessed in one study, which showed that 77% of clinicians in the decision aid group thought that the use of a decision aid was not disruptive and even potentially beneficial, while 15% found it neither disruptive nor beneficial and 8% found it potentially disruptive.14

    Length of the clinical consultation

    Of thirteen studies conducted in an outpatient setting that measured length of the consultation, nine found no significant difference in consultation time between intervention and control groups. Three studies reported a longer and one study a shorter consultation time in the decision aid group (table 2, figure 2).

    One of the reviewed studies, which evaluated reasons why some of the clinicians in the intervention group did not use the assigned encounter decision aid in 19% of all consultations, showed that clinicians’ perception that they do not have enough time was the main reason for not using a decision aid (38.5% of all clinician responses).23 Length of consultation was not measured in this study, and therefore it remains unclear whether use of a decision aid indeed prolonged consultation time in this study.

    In a large multicentre study of the chest pain decision aid located in emergency departments, short conversations lasted longer in the intervention than in the control group (mean of 4.4. min vs 3.1 min).15

    Personal and professional wellbeing

    None of the studies assessed mood or burnout indicators for clinicians or the impact of encounter decision aids on clinicians’ satisfaction with the practice of clinical care and professional fulfilment.

    Discussion

    This systematic review and meta-analysis, which evaluated the impact of encounter decision aids on clinician outcomes and consultation length, found that the use of decision aids can improve satisfaction with medical decision making and provide helpful information without negatively affecting other measures of clinician satisfaction and length of consultation time. Clinicians reported added value from the use of a decision aid, for example, by positively challenging patients’ preconceived ideas, by providing visual representations of choices and by facilitating more structured and coherent consultations. Clinicians’ concerns included that they had to step out of their comfort zone when using new decision aids, that decision aids would add time to their clinics and that they felt obliged to discuss options that were not relevant for some patients because they were included in the decision aid. Clinicians who had used a decision aid were more likely to recommend the use of a decision aid or SDM to other clinicians. However, included studies together contributed to inferences warranting only low confidence (because of selection of clinicians into trials and sparse data), and clinician outcomes are only captured in a minority of SDM trials.

    Limitations of our review include that the number of clinician participants was relatively small in most included studies, and due to the nature of the intervention, clinicians were not blinded to the use of a decision aid, possibly resulting in bias. Most importantly, this review summarises results from RCTs, and thus the views captured are of clinicians who volunteered and enrolled patients into these trials. Measured outcomes did not correct for the possibility that clinicians might not have used the decision aids as intended (low fidelity). Evidence from a participant-level meta-analysis including six RCTs of decision aids for SDM showed that clinicians often did not use encounter decision aids as instructed.39 Also, randomisation was not always performed at the level of clinician/clinician group and randomisation at the level of clinical encounter or patient could have resulted in ‘contamination’ of outcomes reported by clinicians who had used the decision aid with a prior patient. This would be expected to have biased results towards no difference.

    While we included qualitative outcomes from RCTs and nested studies, the major goal of our review was to assess the comparative effectiveness of encounter decision aids for clinician outcomes. For an in-depth exploration of clinicians’ views on SDM and the use of decision aids, a systematic review of the qualitative literature would be necessary.

    A major barrier to implementing the use of encounter decision aids into routine clinical care is clinicians’ perception that using a decision aid is time consuming and therefore often not feasible within the time constraints already placed on them.40 The results of our systematic review do not support these concerns, demonstrating that the duration of outpatient consultations did not significantly differ whether an encounter decision aid was used or not in 9 out of 13 studies. Three studies reported a longer and one study a shorter consultation time in the decision aid group.

    A recent Cochrane review on decision aids for healthcare decisions, which included 105 studies (of which 89 (84.8%) examined a decision aid used by the patient in preparation for the consultation, not during the clinical encounter) identified 10 (7 using an encounter decision aid) that evaluated the effect of a decision aid compared with usual care on consultation length.4 In the Cochrane review, the median consultation length was 24 min (range 3.8–68.3) vs 21 min (range 4.2–65.7) in the decision aid versus usual care groups, respectively (difference of 2.6 min longer in the decision aid group). There was no significant difference in consultation length in eight studies, but consultation length was significantly longer in two studies (which both used encounter decision aids; one study additionally employed the time-consuming standard gamble method to elicitate patient values in the decision aid group).19 37

    Only one study evaluated the duration of clinical encounters in emergency departments.15 The significantly longer duration of clinician-patient encounters in the decision aid group compared with usual care in this study (mean of 4.4 vs 3.1 min) can likely be explained by the small amount of absolute time spent on these conversations, which, in standard care, likely often focus just on informing the patient rather than having a discussion.

    A study (not included in our systematic review because it was not a randomised trial) in which clinicians were interviewed before and after the use of a decision aid for knee osteoarthritis described a clear learning curve among clinicians as they became increasingly familiar with the tool and confident to use it.40 Clinicians overcame their initial concerns that the decision aid would lead to an increase in encounter duration, would present evidence that differs from current clinical practice, would overload patients with information and lead to inappropriate patient demands. For example, they learnt how to make the tool workable by personalising the decision aid to a patient’s circumstances.

    None of the clinician-reported outcomes related to the a priori chosen outcome domain of clinicians’ personal and professional well-being. We previously speculated that improving interactions with patients in clinical encounters using SDM could potentially lead to improved physician well-being by creating more meaningful human connections and thus providing deeper professional satisfaction for clinicians,41 but this has not been examined in RCTs to date.

    The recently published Standards for Universal reporting of patient Decision Aid Evaluations (SUNDAE Checklist) acknowledge the important role of health professionals in any decision making process by recommending the description of characteristics of participating health professionals in reports of evaluation studies of patient decision aids.42 43

    We recommend that clinician outcomes be included in all future trials of decision aids in addition to patient outcomes. Including clinician outcomes that reflect satisfaction with the human connection made with patients during clinical encounters, and evaluating whether encounters that incorporate decision aids for SDM are considered more professionally satisfying than standard care, could provide new insights into factors that are relevant for clinician well-being.

    In the USA, the Centers for Medicare and Medicaid Services have mandated SDM for certain interventions including lung cancer screening and implantation of a left atrial appendage closure device (as an alternative to long-term oral anticoagulation in patients with non-valvular atrial fibrillation). As mandated SDM is likely to increase in the future in an effort to provide patient-centred care, it is important that regulators do not alienate clinicians by ignoring their input.

    Conclusion

    Among clinicians who have used decision aids for SDM in clinical encounters, there is good acceptance of this intervention. Importantly, consultation times in outpatient settings were not prolonged in the majority of studies when an encounter decision aid was used. Using decision aids for SDM can be mutually beneficial for patients as well as clinicians. Clinician outcomes in SDM trials have been rarely captured and deserve more attention.

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    Footnotes

    • Contributors CCD, MRG, CPW, GS-B, JPB and VMM developed the study protocol. PJE performed the literature search. CCD, MS, MRG, NAA-V, NSO, GS-B, BT, RB and VMM reviewed studies for inclusion and/or performed data extraction. MHM helped with data analysis. CCD drafted the manuscript. All authors reviewed and contributed to versions of the manuscript and approved the final submission.

    • Funding CCD was supported by a fellowship of the National Health and Medical Research Council (APP1123733). BT was supported by a National Institute on Aging grant K23AG051679 and the Norman S. Coplon Extramural Grant Program of Satellite Healthcare, a not-for-profit renal care provider.

    • Disclaimer The sponsors had no role in manuscript design, data interpretation or writing of the manuscript.

    • Competing interests MRG has conducted consulting work around shared decision making for Pfizer with travel costs and honoraria paid to his institution. MRG was also paid by Hillcrest Medical Center (Tulsa, OK) to speak on SDM at a continuing medical education event with travel costs and an honorarium paid to his institution; no other relationships or activities that could appear to have influenced the submitted work.

    • Patient consent Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement No additional data available.