Shared Decision Making
Science and Action
Dr Jones is a 55-year-old surgeon with class I angina. Her exercise stress echocardiogram shows mild ischemia involving 2 segments of the inferior wall, and diagnostic coronary angiography demonstrates a right coronary artery discrete, mid-80% stenosis. She is meeting with her cardiologist to decide whether to pursue percutaneous coronary intervention (PCI) with a drug-eluting stent or continue her current medications (aspirin, atorvastatin, metoprolol, and nitrates). Current research evidence suggests that PCI and medical therapy have comparable outcomes for death and myocardial infarction, as well as similar relief of angina symptoms at 1-year follow-up.1 PCI might achieve more rapid relief of symptoms but with some risk for bleeding, stent thrombosis, and restenosis. This risk is not present with medications; however, these might take longer to titrate and achieve improvement of symptoms and have their own potential side effects.2,3 How should Dr Jones, the patient, decide between PCI and medical therapy?
Spatz and Spertus4 have described the primary challenge facing American health care in the 21st century as the need to improve evidence-based, cost-effective, and patient-centered care. Although healthcare organizations and clinicians study, measure, and improve gaps in evidence-based and cost-effective care, patient-centered care lacks comparable science and action. Spatz and Spertus4 have proposed shared decision making (SDM) as the path forward to achieve patient-centered care and have introduced a series of articles in Circulation: Cardiovascular Quality and Outcomes to describe the state of the science in SDM, design and test tools for SDM, implement SDM in clinical practice, understand measurement and outcomes of SDM, and promote policy and accountability in SDM. In this introductory article, we address the following questions:
Why do we need SDM?
How should we do SDM?
How should we measure SDM?
How should we promote SDM?
What are the future directions …