Description of the condition
Shared decision making
Shared decision making is the process of enabling a health professional and patient to make a joint decision about treatment or management based on the best available evidence and the patient's values and preferences (Charles 1997). It is one of the most important ways of bringing evidence to the point of clinical decisions and an effective strategy for reducing the overuse of ineffective treatments (Elwyn 2012). It is rapidly gaining recognition by health policy makers, health professionals and consumer groups.
Shared decision making for acute respiratory infections
The diagnostic uncertainty associated with acute respiratory infections (ARIs) and the trade-off between the benefits and harms of antibiotics mean that shared decision making can provide an important opportunity for making better clinical decisions (Butler 2001). It can enable health professionals and patients to choose appropriate treatment or management options, including the decision to not use an antibiotic. Systematic reviews conclude that antibiotics have modest benefit for reducing symptom duration or complications in patients with several ARIs, including sore throat (Spinks 2011), acute otitis media (Venekamp 2013), sinusitis (Ahovuo-Saloranta 2011) and bronchitis (Smith 2011), and no benefit for laryngitis (Gonzales 2001) or colds (Kenealy 2013). The limited benefits of antibiotics for ARIs are often outweighed by unnecessary exposure to common adverse reactions (e.g. rash, abdominal pain, diarrhoea and vomiting - although they are not well documented), increased healthcare costs and contribution to the growing problem of antibiotic resistance (Steinman 2009). Nevertheless, ARIs are one of the most common reasons for primary care consultations and account for approximately 75% of antibiotic prescriptions (Gill 2006; Gonzales 1997; Gonzales 2001), despite ARIs being predominantly viral and self limiting (Gonzales 2001).
The threat of antibiotic resistance
Antibiotic use creates biological pressure on selected bacterial populations to develop resistance (WHO 2012). Unnecessary prescribing of antibiotics for self limiting or viral infections and excessive use of broad spectrum antibiotics in place of narrower spectrum drugs are modifiable factors that contribute to resistance (WHO 2012). Influences on clinician's prescribing behaviours include clinical uncertainty and fear of disease progression; inadequate physician knowledge (Altiner 2012); underestimation of antibiotic resistance in clinical practice (Wood 2013) and perceived patient expectations for an antibiotic (Arroll 2002). Antibiotic prescribing for ARIs also creates a 'vicious cycle' by encouraging primary care patients to re-consult for similar conditions and reinforcing expectations for an antibiotic prescription (Butler 1998). Patients who are prescribed an antibiotic for a respiratory infection can develop bacterial resistance to that antibiotic for up to 12 months (Chung 2007; Costelloe 2010). The transient effect of antibiotic prescribing is sufficient to sustain a high level of antibiotic resistance in the community (Chung 2007). The development and spread of antibiotic resistance is an evolving global threat to public health (WHO 2012). The rational use of antibiotics is one of the most important strategies for preserving the therapeutic benefit of antibiotic treatment (WHO 2001; WHO 2012).
Description of the intervention
Shared decision making is the pinnacle of patient-centred care (Groves 2010). It describes health professionals and patients discussing the best available evidence for management options and a decision process in which patients are supported to choose options in accordance with their values and preferences (Makoul 2006). Some of the skills required of health professionals to facilitate shared decision making include proficient communication and rapport building skills as well as access to the best available evidence.
How the intervention might work
Shared decision making supports the principle of patient autonomy and the right to self determination (Elwyn 2012), and has been shown to improve patients' satisfaction with decisions and concordance of decisions with their values (Spatz 2012). As part of shared decision making, the potential benefits and harms of interventions, and the likelihood of each, are considered and discussed. Many patients elect for conservative treatment options after participating in shared decision making (Elwyn 2012). As shared decision making involves eliciting patients' expectations, clarifying any misperceptions and discussing the likely benefits and harms of interventions, this process may result in greater explicit consideration of the benefit-harm trade-off for antibiotics for ARIs, by both patients and health professionals. Antibiotic prescribing for ARIs may reduce as a result.
Why it is important to do this review
Several related Cochrane systematic reviews have been undertaken. Arnold and Straus (Arnold 2005) reviewed the effectiveness of interventions to improve antibiotic stewardship (including the decision to prescribe an antibiotic, and the type, dose and duration of antibiotic therapy) in outpatient care. However, broad inclusion criteria and subsequent heterogeneity of the identified interventions limited the generalisability of practice recommendations. Importantly, this review also did not focus on, or explicitly consider, shared decision making interventions for inclusion. The review by Stacey 2011 assessed the effectiveness of decision aids for people facing treatment or screening decisions. Decision aids are only one tool used to facilitate shared decision making in clinical care. Shared decision making may be enabled through methods other than, or in addition to, decision aids. Similarly, the review by Kinnersley 2007 evaluated the effect of interventions to encourage patient health communication and information seeking delivered prior to the primary care consultation, and shared some but not all components necessary for shared decision making to occur. Legare 2010 assessed the effectiveness of interventions to facilitate health professionals' uptake of shared decision making. However, these interventions were not restricted to a specific health condition and ARIs did not feature among the included studies. The growing interest in shared decision making for potential improvement in treatment decisions and patient outcomes is evident from Cochrane systematic reviews in other clinically important areas and diverse settings, including mental health (Duncan 2010) and paediatric oncology (Coyne 2013). Therefore, the effect of shared decision making on antibiotic prescribing for ARIs in primary care is an important addition to this body of literature. Moreover, shared decision making has become used as a means of reducing prescribing among primary care doctors (e.g. NPS MedicineWise, Australia) based on the assumption that people shown the evidence are less likely to demand antibiotics for common ARIs.