The SDM 3 Circle Model: A Literature Synthesis and Adaptation for Shared Decision Making in the Hospital
Patient engagement through shared decision-making (SDM) is increasingly seen as a key component for patient safety, patient satisfaction, and quality of care. Current SDM models do not adequately account for medical and environmental contexts, which may influence medical decisions in the hospital. We identified leading SDM models and reviews to inductively construct a novel SDM model appropriate for the inpatient setting. A team of medicine and pediatric hospitalists reviewed the literature to integrate core SDM concepts and processes and iteratively constructed a synthesized draft model. We then solicited broad SDM expert feedback on the draft model for validation and further refinement. The SDM 3 Circle Model identifies 3 core categories of variables that dynamically interact within an “environmental frame.” The resulting Venn diagram includes overlapping circles for (1) patient/family, (2) provider/team, and (3) medical context. The environmental frame includes all external, contextual factors that may influence any of the 3 circles. Existing multistep SDM process models were then rearticulated and contextualized to illustrate how a shared decision might be made. The SDM 3 Circle Model accounts for important environmental and contextual characteristics that vary across settings. The visual emphasis generated by each “circle” and by the environmental frame direct attention to often overlooked interactive forces and has the potential to more precisely define, promote, and improve SDM. This model provides a framework to develop interventions to improve quality and patient safety through SDM and patient engagement for hospitalists.
© 2017 Society of Hospital Medicine
Evolving models of medical care emphasize the importance of shared decision-making (SDM) on practical and ethical grounds.1-3 SDM is a cognitive, emotional, and relational process in which provider and patient collaborate in a decision after discussing the options, evidence, and potential benefits and harms, while considering the patient’s values, preferences, and circumstances.4 Categories of decisions include information gathering, pharmacotherapy, therapeutic procedures, consultations and referrals, counseling and precautions (eg, behavior modification, goals of care, end-of-life care), and care transitions (eg, transfer or discharge to home).5 Decisions span the continuum of urgency and may be anticipatory or reactive.6 The patient’s environment7,8 and the provider-patient relationship9 have been explicitly incorporated into the ideal SDM process.
SDM has been conceptually and empirically linked with evidence-based practice,1 although the relationship between SDM and clinical outcomes is less clear.10,11 SDM is desired by patients12 and may bolster patient satisfaction, trust, and adherence.13,14 Limited evidence suggests SDM could reduce inappropriate treatments and testing,15 decrease adverse events,16 and promote greater patient safety,17-19 but more well-designed studies are needed.
Provider, patient, and contextual factors influence the extent to which SDM occurs. Providers commonly cite time constraints and perceived lack of applicability to certain clinical scenarios or settings.19 Providers may also lack training and competency in SDM skills.2 Patients may be reluctant to disagree with their provider or fear being mislabeled as “difficult.”20 When faced with high stakes or emotionally charged decisions, patients’ surrogates may prefer to have the provider serve as the sole decision-maker.21 Contextually, there may be limited evidence, high clinical stake, or a number of equally beneficial (or harmful) options.22,23
Current SDM models guide clinicians in determining when and how to engage in SDM, yet models vary widely. For example, Elwyn’s model emphasizes the ethical imperative for SDM and outlines 3 SDM steps: introduce choice, describe options, and help patients explore preferences and make decisions.3 Using a multimodal review and clinician-driven feedback, Legaré’s “IP-SDM” (Interprofessional Shared Decision Making) model illustrates the roles of the interprofessional team and emphasizes the influence of environmental factors on decision-making.24 Recent systematic reviews of SDM models have attempted to identify common elements, language, and processes.2,25,26
This study reviews leading SDM models to construct a more environmentally and contextually sensitive model that is appropriate for the hospital setting. Although developed with hospital medicine in mind, a synthesized model that attends to environmental and systems context, provider/team factors, patient factors, and disease/medical variables is highly relevant in any setting where SDM occurs.
METHODS
We constructed a model that is appropriate for SDM across the care continuum through the following 3-part, iterative group process: (1) a comprehensive literature review of existing SDM models, (2) synthesis and inductive development of a new draft model, and (3) modification of the new model using feedback from SDM experts.
Narrative Literature Review
We performed a structured, comprehensive literature review 29 to compare and contrast existing SDM models and frameworks. Leading models and key concepts were first identified using 2 systematic reviews 25,26 and a comprehensive review.2 In order to extend the search to 2016 and include any overlooked articles, a PubMed search was performed using the terms “shared decision-making” or “medical decision-making” AND “model” or “theory” or “framework” for English-language articles from inception to 2016. The search was repeated using Google Scholar to verify results and obtain the number of citations per article as a proxy for impact and saturation. In order to minimize possible search error or selection bias, reference lists in high-impact publications were hand searched to identify additional articles. All abstracts were manually reviewed by 2 independent authors for relevance and later inclusion in our group iterative process. A priori inclusion criteria were limited to provider-patient SDM (ie, not clinical reasoning or making decisions in general) and complete descriptions of a conceptual model or framework. Additional publications suggested by experts (eg, perspective pieces or terminology summaries) were also reviewed.
