Implementation of shared decision making in cardiovascular care: past, present, and future.

D espite recent health policy recommendations supporting shared decision making (SDM), a rapidly growing evidence base supporting the desirable effects of tools to facilitate SDM, availability of SDM tools specifically designed for cardiovascular care (Table 1), 1 and recent advocacy for SDM in cardiovascular guidelines, 2,3 SDM has not been widely incorporated into routine clinical practice. Although tools that summarize the best scientific evidence to support decision making, communicate risk, and prompt clarification of patients' values and preferences may be necessary to support SDM, they are insufficient in and of themselves to routinize SDM. This lack of uptake of SDM may reflect many challenges associated with incorporating complex interventions into healthcare delivery. In this article, we describe the main approaches to SDM published in the literature to date, highlight barriers and facilitators relevant to each approach, and suggest future work that is needed to facilitate implementation of SDM in cardiovas-cular practice. Investigators have designed and tested patient decision aids that are delivered at different points along the continuum of medical care. Out-of-visit decision aids seek to activate and empower patients by informing them of their treatment options outside the context of the clinical encounter. One factor that influenced the development of out-of-visit approaches to SDM was data demonstrating regional variation in treatment driven, in part, by differences in physician preferences rather than the health status of patients. 4 An example of one such decision aid is the Living with Coronary Heart Disease program developed by the Informed Medical Decisions Foundation. 5 This decision aid helps patients with stable coronary heart disease distinguish between treatments that relieve symptoms (eg, angioplasty and stenting) and choices they can make to decrease their future risk of acute myocardial infarction (AMI), such as smoking cessation, exercise, and dietary changes. It also includes information about the pathophysiology of coronary heart disease and resources for understanding the available treatment options. The decision aid is available as a DVD, a booklet, and a web-based program. Health coaching, an augmented out-of-visit approach to SDM, has trained health coaches review materials with patients before the clinical encounter. 6 This may better prepare patients to participate in decision making and enhance their ability to express their values and preferences. In-visit decision aids are designed to be delivered by cli-nicians during the clinical encounter. One example of an in-visit decision aid is PCI Choice, a concise paper-based decision aid designed to guide …