Shared Decision-Making is Missing from Many Cardiovascular Guidelines, Analysis Says

Shared decision-making (SDM) is not being incorporated into cardiovascular guidelines as much as it should be, according to an investigation published in JAMA Network Open.

This finding is based on a cross-sectional analysis of 65 guideline documents published by the American College of Cardiology (ACC), Canadian Cardiovascular Society (CCS), or European Society of Cardiology (ESC) between 2012 and 2022.

Using a systematic rating system, the investigators evaluated the quality of SDM incorporation based on 2 criteria. Directness was rated 1-3 to indicate how directly and impartially SDM was incorporated into the recommendation’s text, with 1 being most direct. Facilitation was rated from A to D based on the presence of decision aids or quantified benefits and harms, with A being the best. The cross-sectional study also examined the proportion of recommendations incorporating SDM based on the guideline’s society and category.

Out of 65 total guidelines, 33 incorporated SDM in a general statement or within specific recommendations, and 2655 of 7499 specific recommendations (35%) addressed pharmacotherapy. Of these, only 170 (6%) directly incorporated SDM.

When categorized by specialty, general cardiology guidelines had the highest proportion of pharmacotherapy recommendations incorporating SDM at 10%, while heart failure and myocardial disease guidelines had the lowest at 3%. Interestingly, the proportion of pharmacotherapy recommendations incorporating SDM was relatively consistent across the 3 different societies—8% for ACC, 9% for CCS, and 5% for ESC—with no discernible change over the 10-year period.

Additionally, only a small fraction of SDM recommendations (3%) received a grade of 1A, indicating impartial recommendations supported by decision aids. Meanwhile, a substantial 67% were rated as grade 3D, indicating that SDM was mentioned but not facilitated with tools or information.

Although the overall findings raised concerns about the integration of SDM in cardiovascular guidelines, the authors pointed out 2 specific guidelines that stood out as positive examples. In the ACC 2018 cholesterol guideline, a notable 43% of pharmacotherapy recommendations incorporated SDM—which was approximately 7 times higher than the average—and 32% of these recommendations received a grade A, indicating the provision of decision aids. The CCS 2022 cardiometabolic guideline also offered a summary of findings table that could support SDM by providing estimates of benefits related to patient-oriented efficacy outcomes.

However, despite these few positive notes, the overall findings build upon those of earlier reviews. For instance, a 2007 review of major Canadian guidelines on various health conditions such as diabetes and hypertension found that a mere 0.1% of the total content related to SDM and patient preferences. Further, facilitation of SDM was deemed poor, with essential information either absent or presented in an unbalanced manner.

Similar issues were noted in a 2019 review of osteoporosis guidelines, where only 39% included any statements about patients’ beliefs, values, and preferences. Additionally, a 2020 review of coronary artery disease and diabetes guidelines revealed that only 25% of recommendations included estimates of absolute benefit or harm, with just 3% addressing both aspects.

According to the investigators, these findings underscore the widespread nature of these issues and suggest that improvements in this area have been limited over time.

“The inclusion of broad statements supporting the principles and role of SDM in patient care is an important starting point, and the ACC’s guidelines are leaders in cardiovascular guidelines in this respect,” they said. “Such broad statements serve as acknowledgments of the central role of patient values in decision-making but may not provide the support necessary for busy clinicians who are already faced with serious time constraints in implementing guideline-directed care.”

According to the investigators, there are several potential strategies to enhance SDM integration in future guidelines.

One approach is to modify the wording of recommendations to encourage discussion and present the absolute benefits and harms of interventions. Decision aids can also be integrated into guidelines to assist with SDM. Another option is to follow the example of the United Kingdom’s National Institute for Health and Care Excellence, which has published guidelines specifically addressing how to incorporate SDM into patient care across various conditions and settings.

Alternatively, guideline panels could adopt a simpler approach by identifying recommendations suitable for SDM, particularly weak and conditional recommendations with multiple reasonable options. However, this should not exclude the use of SDM in situations involving strong recommendations. Recommendations promoting SDM should be neutrally phrased, explicitly incorporating patient values and preferences, and ideally referencing any existing evidence regarding patient preferences. Guideline panels can also provide summaries of benefits, harms, and other relevant factors like cost to inform patient decisions, potentially through the use of decision aids or summary tables outlining benefits and harms in absolute terms.

According to the investigators, these steps can collectively contribute to more effective integration of SDM into clinical practice based on guidelines.

Reference

MacDonald BJ, Turgeon RD. Incorporation of shared decision-making in international cardiovascular guidelines, 2012-2022. JAMA Netw Open. 2023;6(9):e2332793. doi:10.1001/jamanetworkopen.2023.32793