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Turkson-Ocran RAN, Ogunwole SM, Hines AL, Peterson PN. Shared Decision Making in Cardiovascular Patient Care to Address Cardiovascular Disease Disparities. J Am Heart Assoc 2021; 10:e018183. [PMID: 34612050 PMCID: PMC8751878 DOI: 10.1161/jaha.120.018183] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | - S Michelle Ogunwole
- Department of Medicine The Johns Hopkins University School of Medicine Baltimore MD.,The Johns Hopkins Center for Health Equity Baltimore MD
| | - Anika L Hines
- Department of Medicine The Johns Hopkins University School of Medicine Baltimore MD.,The Johns Hopkins Center for Health Equity Baltimore MD.,Department of Health Behavior and Policy Virginia Commonwealth University School of Medicine Richmond VA
| | - Pamela N Peterson
- Division of Cardiology University of Colorado, Anschutz Medical Campus Aurora CO.,Division of Cardiology Denver Health Medical Center Denver CO
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Kamath CC, Giblon R, Kunneman M, Lee AI, Branda ME, Hargraves IG, Sivly AL, Bellolio F, Jackson EA, Burnett B, Gorr H, Torres Roldan VD, Spencer-Bonilla G, Shah ND, Noseworthy PA, Montori VM, Brito JP. Cost Conversations About Anticoagulation Between Patients With Atrial Fibrillation and Their Clinicians: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2116009. [PMID: 34255051 PMCID: PMC8278261 DOI: 10.1001/jamanetworkopen.2021.16009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
IMPORTANCE How patients with atrial fibrillation (AF) and their clinicians consider cost in forming care plans remains unknown. OBJECTIVE To identify factors that inform conversations regarding costs of anticoagulants for treatment of AF between patients and clinicians and outcomes associated with these conversations. DESIGN, SETTING, AND PARTICIPANTS This cohort study of recorded encounters and participant surveys at 5 US medical centers (including academic, community, and safety-net centers) from the SDM4AFib randomized trial compared standard AF care with and without use of a shared decision-making (SDM) tool. Included patients were considering anticoagulation treatment and were recruited by their clinicians between January 30, 2017, and June 27, 2019. Data were analyzed between August and November 2019. MAIN OUTCOMES AND MEASURES The incidence of and factors associated with cost conversations, and the association of cost conversations with patients' consideration of treatment cost burden and their choice of anticoagulation. RESULTS A total of 830 encounters (out of 922 enrolled participants) were recorded. Patients' mean (SD) age was 71.0 (10.4) years; 511 patients (61.6%) were men, 704 (86.0%) were White, 303 (40.9%) earned between $40 000 and $99 999 in annual income, and 657 (79.2%) were receiving anticoagulants. Clinicians' mean (SD) age was 44.8 (13.2) years; 75 clinicians (53.2%) were men, and 111 (76%) practiced as physicians, with approximately half (69 [48.9%]) specializing in either internal medicine or cardiology. Cost conversations occurred in 639 encounters (77.0%) and were more likely in the SDM arm (378 [90%] vs 261 [64%]; OR, 9.69; 95% CI, 5.77-16.29). In multivariable analysis, cost conversations were more likely to occur with female clinicians (66 [47%]; OR, 2.85; 95% CI, 1.21-6.71); consultants vs in-training clinicians (113 [75%]; OR, 4.0; 95% CI, 1.4-11.1); clinicians practicing family medicine (24 [16%]; OR, 12.12; 95% CI, 2.75-53.38]), internal medicine (35 [23%]; OR, 3.82; 95% CI, 1.25-11.70), or other clinicians (21 [14%]; OR, 4.90; 95% CI, 1.32-18.16) when compared with cardiologists; and for patients with an annual household income between $40 000 and $99 999 (249 [82.2%]; OR, 1.86; 95% CI, 1.05-3.29) compared with income below $40 000 or above $99 999. More patients who had cost conversations reported cost as a factor in their decision (244 [89.1%] vs 327 [69.0%]; OR 3.66; 95% CI, 2.43-5.50), but cost conversations were not associated with the choice of anticoagulation agent. CONCLUSIONS AND RELEVANCE Cost conversations were common, particularly for middle-income patients and with female and consultant-level primary care clinicians, as well as in encounters using an SDM tool; they were associated with patients' consideration of treatment cost burden but not final treatment choice. With increasing costs of care passed on to patients, these findings can inform efforts to promote cost conversations in practice. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02905032.
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Affiliation(s)
- Celia C. Kamath
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Rachel Giblon
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Marlene Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Alexander I. Lee
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Megan E. Branda
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Colorado School of Public Health, Anschutz Medical Campus, University of Colorado, Denver, Aurora
| | - Ian G. Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Angela L. Sivly
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | | | - Elizabeth A. Jackson
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham
| | - Bruce Burnett
- Thrombosis Clinic and Anticoagulation Services, Park Nicollet Health Services, St Lois Park, Minnesota
| | - Haeshik Gorr
- Division of General Internal Medicine, Hennepin Health, Minneapolis, Minnesota
| | - Victor D. Torres Roldan
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | | | - Nilay D. Shah
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Peter A. Noseworthy
- Robert D. and Patricia E. Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, Minnesota
- Heart Rhythm Services, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Victor M. Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Juan P. Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota
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Schott SL, Berkowitz J, Dodge SE, Petersen CL, Saunders CH, Sobti NK, Xu K, Coylewright M. Personalized, Electronic Health Record-Integrated Decision Aid for Stroke Prevention in Atrial Fibrillation: A Small Cluster Randomized Trial and Qualitative Analysis of Efficacy and Acceptability. Circ Cardiovasc Qual Outcomes 2021; 14:e007329. [PMID: 34107740 DOI: 10.1161/circoutcomes.120.007329] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Shared decision-making in cardiology is increasingly recommended to improve patient-centeredness of care. Decision aids can improve patient knowledge and decisional quality but are infrequently used in real-world practice. This mixed-methods study tests the efficacy and acceptability of a decision aid integrated into the electronic health record (Integrated Decision Aid [IDeA]) and delivered by clinicians for patients with atrial fibrillation considering options to reduce stroke risk. We aimed to determine whether the IDeA improves patient knowledge, reduces decisional conflict, and is seen as acceptable by clinicians and patients. METHODS A small cluster randomized trial included 6 cardiovascular clinicians and 66 patients randomized either to the IDeA (HealthDecision) or usual care (clinician discretion) during a clinical encounter when stroke prevention treatment options were discussed. The primary outcome was patient knowledge of personalized stroke risk. Exploratory outcomes included decisional conflict, values concordance, trust, the presence of a shared decision-making process, and patient knowledge related to time spent using the IDeA. Additionally, we conducted semistructured interviews with clinicians and patients who used the IDeA were conducted to assess acceptability and predictions of future use. RESULTS The IDeA significantly increased patients' knowledge of their stroke risk (odds ratio, 3.88 [95% CI, 1.39-10.78]; P<0.01]). Patients had less uncertainty about their final decision (P=0.04). There were no significant differences in values concordance, trust in clinician or shared decision-making. Despite training, each clinician used the IDeA differently. Qualitative analysis revealed patients prefer using the IDeA earlier in their diagnosis. Clinicians were satisfied with the IDeA, yet varied in the contexts in which they planned to use it in the future. CONCLUSIONS Using an Integrated Decision Aid, or IDeA, increases patient knowledge and lessens uncertainty for decision-making around stroke prevention in atrial fibrillation. Qualitative data provide insight into potential implementation strategies in real-world practice.
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Affiliation(s)
- Stacey L Schott
- Division of Cardiology, Johns Hopkins University School of Medicine (S.L.S.)
| | - Julia Berkowitz
- Geisel School of Medicine at Dartmouth, Hanover, NH (J.B.).,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (J.B., C.L.P., C.H.S., M.C.)
| | - Shayne E Dodge
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH (S.E.D., K.X., M.C.)
| | - Curtis L Petersen
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (J.B., C.L.P., C.H.S., M.C.)
| | - Catherine H Saunders
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (J.B., C.L.P., C.H.S., M.C.)
| | - Navjot Kaur Sobti
- Division of Cardiology, Department of Medicine, New York Presbyterian Hospital, Weill Cornell Medicine (N.K.)
| | - Keren Xu
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH (S.E.D., K.X., M.C.)
| | - Megan Coylewright
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (J.B., C.L.P., C.H.S., M.C.).,Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH (S.E.D., K.X., M.C.)
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Crijns HJGM, Prinzen F, Lambiase PD, Sanders P, Brugada J. The year in cardiovascular medicine 2020: arrhythmias. Eur Heart J 2021; 42:499-507. [PMID: 33388752 DOI: 10.1093/eurheartj/ehaa1091] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/08/2020] [Accepted: 12/19/2020] [Indexed: 12/12/2022] Open
Abstract
of the progress in arrhythmias in 2020. RACE4 and ALL-IN indicated that integrated nurse-led care improves outcomes in AF patients.3,4 The same was reported for early rhythm control therapy15 and cryoablation as initial AF treatment.25,26 Subcutaneous ICD was non-inferior to classical transvenous ICD therapy in PRAETORIAN.54 One mechanistic study showed that autoantibodies against misexpressed actin, keratin, and connexin-43 proteins create a blood-borne biomarker profile enhancing diagnosis of Brugada syndrome.50 Another mechanistic study indicated that transseptal LV pacing yields similar improvement in contractility as His bundle pacing whilst being more easy to execute.44 In PRE-DETERMINE a simple-to-use ECG risk score improved risk prediction in patients with ischemic heart disease possibly enhancing appropriate ICD therapy in high risk patients.58.
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Affiliation(s)
- Harry J G M Crijns
- Department of Cardiology and Cardiovascular Research Centre Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Frits Prinzen
- Department of Physiology and Cardiovascular Research Centre Maastricht (CARIM), University of Maastricht, Maastricht, The Netherlands
| | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Josep Brugada
- Cardiovascular Institute, Hospital Clinic, Pediatric Arrhythmia Unit, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
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Torres Roldan VD, Brand-McCarthy SR, Ponce OJ, Belluzzo T, Urtecho M, Espinoza Suarez NR, Toloza FJK, Thota AD, Organick PW, Barrera F, Liu-Sanchez C, Jaladi S, Prokop L, Ozanne EM, Fagerlin A, Hargraves IG, Noseworthy PA, Montori VM, Brito JP. Shared Decision Making Tools for People Facing Stroke Prevention Strategies in Atrial Fibrillation: A Systematic Review and Environmental Scan. Med Decis Making 2021; 41:540-549. [PMID: 33896270 PMCID: PMC8191170 DOI: 10.1177/0272989x211005655] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Shared decision making (SDM) tools can help implement guideline recommendations for patients with atrial fibrillation (AF) considering stroke prevention strategies. We sought to characterize all available SDM tools for this purpose and examine their quality and clinical impact. METHODS We searched through multiple bibliographic databases, social media, and an SDM tool repository from inception to May 2020 and contacted authors of identified SDM tools. Eligible tools had to offer information about warfarin and ≥1 direct oral anticoagulant. We extracted tool characteristics, assessed their adherence to the International Patient Decision Aids Standards, and obtained information about their efficacy in promoting SDM. RESULTS We found 14 SDM tools. Most tools provided up-to-date information about the options, but very few included practical considerations (e.g., out-of-pocket cost). Five of these SDM tools, all used by patients prior to the encounter, were tested in trials at high risk of bias and were found to produce small improvements in patient knowledge and reductions in decisional conflict. CONCLUSION Several SDM tools for stroke prevention in AF are available, but whether they promote high-quality SDM is yet to be known. The implementation of guidelines for SDM in this context requires user-centered development and evaluation of SDM tools that can effectively promote high-quality SDM and improve stroke prevention in patients with AF.
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Affiliation(s)
- Victor D Torres Roldan
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sarah R Brand-McCarthy
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Oscar J Ponce
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Tereza Belluzzo
- General Medicine, Charles University in Prague, Medical Faculty of Hradec Králové, Hradec Kralove, Czech Republic
| | - Meritxell Urtecho
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nataly R Espinoza Suarez
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Freddy J K Toloza
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anjali D Thota
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paige W Organick
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Francisco Barrera
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic (KER Unit Mexico), School of Medicine, Universidad Autonoma de Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | | | - Soumya Jaladi
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Larry Prokop
- Department of Library-Public Services, Mayo Clinic, Rochester MN, USA
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA.,Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation
| | - Ian G Hargraves
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Peter A Noseworthy
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Victor M Montori
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Juan P Brito
- Knowledge and Evaluation Research (KER) Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Kapoor A, Andrade A, Hayes A, Mazor K, Possidente C, Nolen K, Hegeman-Dingle R, McManus D. Usability, Perceived Usefulness, and Shared Decision-Making Features of the AFib 2gether Mobile App: Protocol for a Single-Arm Intervention Study. JMIR Res Protoc 2021; 10:e21986. [PMID: 33625361 PMCID: PMC7946587 DOI: 10.2196/21986] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 12/23/2020] [Accepted: 01/15/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Centers for Disease Control and Prevention has estimated that atrial fibrillation (AF) affects between 2.7 million and 6.1 million people in the United States. Those who have AF tend to have a much higher stroke risk than others. Although most individuals with AF benefit from anticoagulation (AC) therapy, a significant majority are hesitant to start it. To add, providers often struggle in helping patients negotiate the decision to start AC therapy. To assist in the communication between patients and providers regarding preferences and knowledge about AC therapy, different strategies are being used to try and solve this problem. In this research study, we will have patients and providers utilize the AFib 2gether app with hopes that it will create a platform for shared decision making regarding the prevention of stroke in patients with AF receiving AC therapy. OBJECTIVE The aim of our study is to measure several outcomes related to encounters between patients and their cardiology providers where AFib 2gether is used. These outcomes include usability and perceived usefulness of the app from the perspective of patients and providers. In addition, we will assess the extent and nature of shared decision making. METHODS Eligible patients and providers will evaluate the AFib 2gether mobile app for usability and perceived usefulness in facilitating shared decision making regarding understanding the patient's risk of stroke and whether or not to start AC therapy. Both patients and providers will review the app and complete multiple questionnaires about the usability and perceived usefulness of the mobile app in a clinical setting. We will also audio-record a subset of encounters to assess for evidence of shared decision making. RESULTS Enrollment in the AFib 2gether shared decision-making study is still ongoing for both patients and providers. The first participant enrolled on November 22, 2019. Analysis and publishing of results are expected to be completed in spring 2021. CONCLUSIONS The AFib 2gether app emerged from a desire to increase the ability of patients and providers to engage in shared decision making around understanding the risk of stroke and AC therapy. We anticipate that the AFib 2gether mobile app will facilitate patient discussion with their cardiologist and other providers. Additionally, we hope the study will help us identify barriers that providers face when placing patients on AC therapy. We aim to demonstrate the usability and perceived usefulness of the app with a future goal of testing the value of our approach in a larger sample of patients and providers at multiple medical centers across the country. TRIAL REGISTRATION ClinicalTrials.gov NCT04118270; https://clinicaltrials.gov/ct2/show/NCT04118270. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/21986.
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Affiliation(s)
- Alok Kapoor
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Andreza Andrade
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Anna Hayes
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Kathleen Mazor
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | | | - Kim Nolen
- Medical Affairs, Pfizer Inc, New York, NY, United States
| | | | - David McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
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Rao BR, Merchant FM, Howard DH, Matlock D, Dickert NW. Shared Decision-Making for Implantable Cardioverter-Defibrillators: Policy Goals, Metrics, and Challenges. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2021; 49:622-629. [PMID: 35006064 PMCID: PMC9060309 DOI: 10.1017/jme.2021.85] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Shared decision-making has become a new focus of health policy. Though its core elements are largely agreed upon, there is little consensus regarding which outcomes to prioritize for policy-mandated shared decision-making.
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