title: Patients' perceptions of sharing in decisions: a systematic review of interventions to enhance shared decision making in routine clinical practice.
abstract: BACKGROUND
  Shared decision making is the process in which a healthcare choice is made jointly by the health professional and the patient. Little is known about what patients view as effective or ineffective strategies to implement shared decision making in routine clinical practice.
  
  
  OBJECTIVE
  This systematic review evaluates the effectiveness of interventions to improve health professionals' adoption of shared decision making in routine clinical practice, as seen by patients.
  
  
  METHODS
  We searched electronic databases (PubMed, the Cochrane Library, EMBASE, CINAHL, and PsycINFO) from their inception to mid-March 2009. We found additional material by reviewing the reference lists of the studies found in the databases; systematic reviews of studies on shared decision making; the proceedings of various editions of the International Shared Decision Making Conference; and the transcripts of the Society for Medical Decision Making's meetings.
  
  
  METHODS
  In our study selection, we included randomized controlled trials, controlled clinical trials, controlled before-and-after studies, and interrupted time series analyses in which patients evaluated interventions to improve health professionals' adoption of shared decision making. The interventions in question consisted of the distribution of printed educational material; educational meetings; audit and feedback; reminders; and patient-mediated initiatives (e.g. patient decision aids).
  
  
  METHODS
  Two reviewers independently screened the studies and extracted data. Statistical analyses considered categorical and continuous process measures. We computed the standardized effect size for each outcome at the 95% confidence interval. The primary outcome of interest was health professionals' adoption of shared decision making as reported by patients in a self-administered questionnaire.
  
  
  RESULTS
  Of the 6764 search results, 21 studies reported 35 relevant comparisons. Overall, the quality of the studies ranged from 0% to 83%. Only three of the 21 studies reported a clinically significant effect for the primary outcome that favored the intervention. The first study compared an educational meeting and a patient-mediated intervention with another patient-mediated intervention (median improvement of 74%). The second compared an educational meeting, a patient-mediated intervention, and audit and feedback with an educational meeting on an alternative topic (improvement of 227%). The third compared an educational meeting and a patient-mediated intervention with usual care (p = 0.003). All three studies were limited to the patient-physician dyad.
  
  
  CONCLUSIONS
  To reduce bias, future studies should improve methods and reporting, and should analyze costs and benefits, including those associated with training of health professionals.
  
  
  CONCLUSIONS
  Multifaceted interventions that include educating health professionals about sharing decisions with patients and patient-mediated interventions, such as patient decision aids, appear promising for improving health professionals' adoption of shared decision making in routine clinical practice as seen by patients.
authors.affiliation: Quebec University Hospital Research Centre, St-Franois dAssise Hospital, Qubec City, QC, Canada. France.Legare@mfa.ulaval.ca
authors.forename: France
authors.initials: F
authors.lastname: Légaré
authors.forename: Stéphane
authors.initials: S
authors.lastname: Turcotte
authors.forename: Dawn
authors.initials: D
authors.lastname: Stacey
authors.forename: Stéphane
authors.initials: S
authors.lastname: Ratté
authors.forename: Jennifer
authors.initials: J
authors.lastname: Kryworuchko
authors.forename: Ian D
authors.initials: ID
authors.lastname: Graham
mesh_terms: D003661:Decision Support Techniques; D006801:Humans; D007318:Inservice Training / Q000458:organization & administration*; D007858:Learning; D010353:Patient Education as Topic / Q000458:organization & administration; D010358:Patient Participation / Q000379:methods*; D010465:Perception; D010817:Physician-Patient Relations