Mini-review
Barriers and facilitators to implementing shared decision-making in clinical practice: Update of a systematic review of health professionals’ perceptions

https://doi.org/10.1016/j.pec.2008.07.018Get rights and content

Abstract

Objective

To update a systematic review on the barriers and facilitators to implementing shared decision-making in clinical practice as perceived by health professionals.

Methods

From March to December 2006, PubMed, Embase, CINHAL, PsycINFO, and Dissertation Abstracts were searched. Studies were included if they reported on health professionals’ perceived barriers and facilitators to implementing shared decision-making in practice. Quality of the included studies was assessed. Content analysis was performed with a pre-established taxonomy.

Results

Out of 1130 titles, 10 new eligible studies were identified for a total of 38 included studies compared to 28 in the previous version. The vast majority of participants (n = 3231) were physicians (89%). The three most often reported barriers were: time constraints (22/38) and lack of applicability due to patient characteristics (18/38) and the clinical situation (16/38). The three most often reported facilitators were: provider motivation (23/38) and positive impact on the clinical process (16/38) and patient outcomes (16/38).

Conclusion

This systematic review update confirms the results of the original review.

Practice implications

Interventions to foster implementation of shared decision-making in clinical practice will need to address a range of factors.

Introduction

With the increased emphasis on engagement of patients as partners in their care as evidenced by research priorities of national funding agencies [1] there is a rapidly growing body of new knowledge regarding new decision-making models. Consequently, shared decision-making, defined as a decision-making process jointly shared by patients and their health care providers, is attracting increased interest. Nonetheless, shared decision-making has not yet been widely adopted by health care professionals. This is why in 2004–2005, we sought to systematically review studies that reported on health professionals’ perceived barriers and facilitators to implementing shared decision-making in their clinical practice [2].

Systematic reviews are “scientific tools which can be used to summarise, appraise, and communicate the results and implications of otherwise unmanageable quantities of research.” It is of particular value in bringing together a number of separately conducted studies, sometimes with conflicting findings, and synthesizing their results [3]. Systematic reviews are deemed essential for identifying effective interventions but also for identifying important gaps in knowledge that need to be prioritized in future studies. However, systematic reviews are most useful if they are up to date. The updating process of systematic reviews is defined as “a discrete event aiming to search for and identify new evidence to incorporate into a previously completed systematic review [4], [5].” Indeed, as science evolves with the accumulation of new research and publications, there may be reversal of the evidence concerning an intervention previously considered to be effective or new interventions proven to be effective. Ignoring these changes could undermine the validity of existing systematic reviews. For example, within 2 years of their publication, it is estimated that only 3% of systematic reviews published in peer-reviewed journals had been updated thus suggesting an important lack of rigour in the robustness of the existing knowledge [4]. Based on evidence, experts have recently pointed out that “The first step in assessing whether or not a given systematic review is up to date is to consider: (1) the age of the review, (2) the availability of new relevant trials, and (3) the number of participants in the new trials. The second step is to assess the importance of the topic by ascertaining the burden of disease and pace of development of the field [4], [5]. Therefore, in line with these recommendations, this paper reports on the update of our systematic review on the barriers and facilitators to implementing shared decision-making in clinical practice as perceived by health professionals [2].

Section snippets

Search strategy

Covering the period from March to December 2006, PubMed, Embase, CINHAL, PsycINFO, and Dissertation Abstracts were searched.

Selection criteria

A study was eligible for inclusion in the review if: (1) it reported on original collection of data and (2) participants included health professionals, including those in training programs who are responsible for patient care (residents, fellows, and other pre-licensure healthcare professionals) [6] and (3) results included perceived barriers and/or facilitators to shared

Included studies

Out of the new 1130 titles that were identified over the 9-month period we covered, 10 new eligible studies were identified for a total of 38 included studies compared to 28 in the previous version [2]. However, the following results include the aggregated findings from the previous review and this review. This means that overall, for all years available, from PubMed, Embase, CINHAL, PsycINFO and Dissertation Abstracts, we screened a total of 10,710 references (9580 + 1130) and assessed the full

Discussion

Results of this updated systematic review on the barriers and facilitators to implementing shared decision-making in clinical practice as perceived by health professionals are important because they inform researchers, educators and clinicians interested in shared decision-making on two key aspects: (1) how rapidly the knowledge base of this relatively new research field is growing and (2) what factors will need to be addressed for implementing shared decision-making in clinical practice

Conflict of interest

All authors declare that they have no conflicting financial interests.

Two of the authors of this review, IG and FL, are the authors of two of the included studies.

Acknowledgements

Dr. Légaré is funded by a Tier 2 Canada Research Chair in Implementation of Shared Decision-Making in Primary Care. The study sponsor had no involvement in the study design, the collection, analysis and interpretation of data; in the writing of the manuscript; nor in the decision to submit the manuscript for publication.

Contributors: FL conceived the study, supervised SR and KG, validated the methods, validated the article selection, analysed the results, and wrote the first draft of the paper.

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