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Table 2 Included implementation projects

From: Organizational- and system-level characteristics that influence implementation of shared decision-making and strategies to address them — a scoping review

Project ID Author (year) Country Study design* Setting Context Implemented intervention Implementation strategy
P1 Abrines-Jaume et al. (2016) [47] UK Quality improvement study Outpatient, inpatient, community, and outreach Child and adolescent mental health SDM in general Teams were encouraged to try a range of tools to support SDM and received cross-site learning events every 3 months including information and materials, group discussions, and action learning sets as part of the Closing the Gap program. They also received regular site meetings and phone and email guidance.
P2 Andrews et al. (2016) [68]
Berg et al. (2011) [69]
Friedberg et al. (2013) [70]
USA n/r (descriptive implementation study) Specialty and primary care in an academic medical center Orthopedics, breast cancer, hip and knee osteoarthritis, prostate cancer, cancer screening, spine conditions, heart/chronic/other Decision aids and other form of decision support When indicated, individual’s treatment preferences, questions, and other decision-making data were shared with their clinician and recorded in their electronic medical record (EMR). Shared decision-making summaries (dashboards) were reported to departments at regular intervals in an effort to systematically monitor and evaluate the use of decision support programs in clinical care.
P3 Arterburn et al. (2016) [71]
Conrad et al. (2011) [55]
Hsu et al. (2013) [52]
Hsu et al. (2013) [72]
King and Moulton (2013) [51]
USA Mixed-methods case study Specialty care in an integrated health system Focus on decisions regarding surgical treatments: breast cancer and DCIS, hip and knee osteoarthritis, chronic low back pain, living better with chronic pain, colon cancer screening, depression, diabetes, PSA testing Decision aids Senior project management consultants worked with service line leaders to develop implementation agreements and process flow diagrams for each service line. Once a draft distribution process was generated, the project managers met with frontline providers and staff to introduce the DAs, the distribution process and answer questions. Process revisions were based on provider reactions and suggestions. Once an implementation process was agreed upon, a “go-live” date was set, after which the project managers visited each clinic site at least once to monitor implementation processes and progress. Sites experiencing challenges received additional visits and calls as necessary. DAs were distributed using an existing service that supplies educational materials to patients via US mail. The DVD versions of the DAs could be ordered for patients by clinical staff using the electronic health record. Patients could also view the DA online via the patient portal, and providers could embed a link to the video DA in the patient’s after-visit summary. In treatment decision for which the time between a patient’s initial appointment and the procedure was very short, the DAs could also be distributed in the office. Process was monitored using twice-monthly distribution reports given to clinical leaders. In the second year, these reports included more specific numbers for individual clinicians.
P4 Belkora (2011) [73]
Belkora et al. (2008) [74]
Belkora et al. (2011) [75]
Belkora et al. (2012) [48]
Belkora et al. (2015) [76]
USA Quality improvement study Breast care center (in an NCI designated comprehensive care center) Breast cancer Decision aids and other form of decision support Long-term project with multiple iterations. Implementations consisted of consultation planning, recording, summarizing services in which support staff assisted patients in communicating with their providers before a visit (question brainstorming) and during a visit (audio recording). Improvements on this service consisted of adjusting the scheduling system and workflow of decision support, mailing DAs to patients at home, and making follow-up calls
P5 Belkora et al. 2008 [77] USA Post-implementation qualitative study Community clinics and community resource centers Breast cancer Other form of decision support One-time Consultation Planning training workshops included lectures, structured role playing, and group discussion sessions.
P6 Brackett et al. (2010) [78] USA n/r (descriptive implementation study) Primary care in one academic medical center and one Veteran’s Affairs Medical Center Prostate cancer and colorectal cancer screening Decision aids Four methods were compared: (1) automatic pre-visit mailing to all potentially eligible patients, (2) letter mailed to all potentially eligible patients offering pre-visit DA (3) eligible patients offered DA at checkout from primary care visit (4) clinician prescribes DA to eligible patients during primary care visit
P7 Clay et al. (2013) [79]
Friedberg et al. (2013) [70]
USA n/r (descriptive implementation study) Academic medical center department of orthopedics Orthopedics Decision aids Embedding decision aid into new EMR to systematically and automatically deliver DA to the right patient at the right time.
P8 Elwyn and Thomson (2013) [80]
King et al. (2013) [58]
Lloyd et al. (2013) [81]
Lloyd and Joseph-Williams (2016) [82]
UK Service development/quality improvement program NHS hospitals and primary and secondary care teams Head and neck cancer, breast cancer, pediatric tonsillectomy, obstetrics, urological problems, ear, nose and throat, knee osteoarthritis, statins, managing mood disorders, sexual health and contraception, upper respiratory tract infection, managing carpal tunnel syndrome, smoking cessation, menorrhagia, long-term care, benign prostatic hyperplasia SDM in general Making good decisions in collaboration (MAGIC) improvement program: an approach that integrates shared decision-making into routine care through training in shared decision-making and the use of decision support tools, peer support for clinicians, and support for patients to become more engaged in their care. This program has been implemented at several sites and is adapted for best use in the context of each site.
P9 Elwyn et al. (2012) [83] UK Post-implementation mixed-methods study NHS healthcare professionals Knee osteoarthritis, amniocentesis, breast cancer, benign prostatic hyperplasia, localized prostate cancer Decision aids Tools were made available on NHS Direct’s web platform and patients were directed to tools by staff.
P10 Feibelmann et al. (2011) [84] USA n/r (descriptive implementation study) Cancer centers, hospitals, private practices, and resource centers Breast cancer Decision aids Letters were mailed to providers at sites. Sites could fax or mail back a request for a sample program and then sign a participant agreement to receive copies of decision aids to use with patients. Various implementation techniques were used at individual sites.
P11 Fortnum et al. (2015) [85] Australia n/r (descriptive implementation study) Renal units End-stage kidney disease Decision aids Decision aid PDFs were made available nationally (downloadable from Kidney Health Australia and Kidney Health New Zealand websites). Education was provided to over 2000 ANZ health professionals through teleconferences, webinar, website distribution, state workshops, unit visits, conference presentations, and email.
P12 Frosch et al. (2011) [50]
Uy et al. (2014) [86]
USA n/r (descriptive implementation study) Primary care offices and community health centers First prostate and colon cancer screening then expanded to various contexts with 24 different decision aids available Decision aids The initial implementation practices received evidence-based brochure decision support interventions (DESIs). The goal was to provide the DESIs to patients at the time of an office visit and to review before the consultation with the physician. In an expansion of this implementation individual practices selected DESIs to provide to patients. Phase 1: during a patient visit, physician or staff would assess appropriateness of DA prescription then eligible patients received package with DA to take home and review before follow up-appointment. The exact logistics of DA distribution were established by practices individually. Weekly “academic detailing” visits were conducted with a member of the research team to identify barriers and develop potential solutions. Phase 2: introduction of a financial incentive to compensate for time spent prescribing DAs and inclusion/exclusion criteria (to ensure that only eligible patients receive the DA) and phone survey instead of questionnaire.
P13 Friedberg et al. (2013) [70]
Frosch (2011) [73]
Lin et al. (2013) [87]
May et al. (2013) [88]
Tietbohl et al. (2015) [89]
USA Case study (descriptive implementation study) Primary care clinics in an integrated health system Various contexts: 16 different decision aids available Decision aids The project team collaborated with clinics to tailor decision aid distribution methods to individual clinic workflows. Each clinic had a physician and staff champion responsible for promoting the program. The leadership team at each clinic, which included both physicians and leaders of clinical support staff, selected decision aid topics for distribution from the list of available tools. Project team members engaged in academic detailing visits and social marketing efforts to promote distribution of the decision aids.
P14 Garden (2008) [59]
Wirrman and Askham (2006) [90]
UK n/r (descriptive implementation study) Urology departments Early localized prostate cancer or benign prostatic hyperplasia Decision aids Nurse specialists were trained to implement Decision Support Aids and Decision Quality Assessment Forms to patients (implemented at different points in the care pathway at different sites).
P15 Holmes-Rovner et al. (2000) [91] USA Mixed-methods feasibility study Hospital community health education centers, cardiology education and research departments, and health education libraries Breast cancer and ischemic heart disease Decision aids To ensure local acceptance of the programs and to fit the program into existing routines, hospitals were asked to identify study coordinators who would work with local physicians and nurses to implement the programs. Participating clinicians were asked to review decision aid and complete survey prior to distributing to patients. Clinicians received reminders and study coordinators repeatedly discussed the DAs with them.
P16 Holmes-Rovner et al. (2011) [92] USA Retrospective post-then-pre design Internal medicine and family medicine clinics Stable coronary artery disease SDM in general The complex decision support system called Shared Decision Making Guidance Reminders in Practice (SDM-GRIP) consisted of: (1) provider training (2) patient education. To facilitate discussion in the clinical encounter, a dedicated SDM provider visit was established, and an encounter decision guide (EDG) was given to patients. The EDG provided an evidence summary and decision pages to record choices arrived at in the clinical encounter.
P17 Julian et al. (2011) [93] USA n/r (descriptive implementation study) Comprehensive breast care center Breast cancer, DCIS Decision aids and other form of decision support A nurse navigator coordinated patient care and provided decision aids to women.
P18 Korsen et al. (2011) [73] USA n/r (descriptive implementation study) Primary care in an integrated health system PSA testing, colorectal cancer screening, diabetes, acute low back pain, chronic low back pain, depression, menopause, advance directives Decision aids Implementation included (1) pre-visit, visit-based, and post-visit distribution models, (2) use of EHR for DA referral, (3) various trainings, workshops, and presentations at different sites
P19 Friedberg et al. (2013) [70]
Lewis et al. (2011) [73]
Lewis et al. (2013) [57]
Miller et al. (2012) [94]
USA n/r (descriptive implementation study) Primary care clinic PSA testing and weight loss surgery Decision aids The focus was on automated DVD DA delivery through EHR and social marketing campaign. Five delivery models were used: (1) mailing DAs prior to visit (2) using Patient Health Survey to identify eligible patients and allow them to request a DA, (3) requesting DAs by physician (4) distributing DAs within chronic disease management program (5) pre-visit online screening for DA eligibility
P20 McGrail et al. (2016) [95] USA n/r (descriptive implementation study) One primary care clinic, one general hospital Statins, anticoagulation in patients with atrial fibrillation, osteoporosis and knee osteoarthritis, urinary incontinence SDM in general The SHARE approach “train-the-trainer” workshop was followed by training sessions for residents and medical group staff.
P21 Mollicone et al. (2013) [96] USA n/r (descriptive implementation study) Specialty care center Chronic kidney disease SDM in general Treatment Options Program (TOPs) consists of free classes offered locally, nationwide, by trained FMCNA personnel to educate patients and family members about the options for treatment. Follow up calls encourage patients to discuss options with their doctors and participate in their care.
P22 Friedberg et al. (2013) [70]
Morrissey and Elwyn (2013) [97]
Morrissey and Michels (2011) [98]
USA n/r (descriptive implementation study) Primary care Benign prostatic hyperplasia, prostate cancer, breast cancer, depression, uterine fibroids, chronic low back pain, chronic pain, menopause Decision aids and other form of decision support Three models for implementation were used: (1) patient referred from primary care or specialist for care coordination/navigation which included face to face visit with DA (2) provider teed up SDM conversation in exam room and handed patient off to nurse who provided information and DA (3) patient requested DA and care coordinator follows up with a call for discussion
P23 Newsome et al. (2012) [60] USA Post-implementation qualitative study Family medicine clinics Cancer screening, chronic illness care Decision aids Physicians used the DAs in clinical practice and medical assistants were involved in distribution of DAs (details not specified, reported in a separate publication).
P24 Pasternack et al. (2011) [99] Finland n/r (descriptive implementation study) Breast cancer screening providers Breast cancer screening Decision aids Letter templates with invitation to screening and short decision aid on the back where made available to all breast cancer screening facilities and municipalities in the country. The short DA was put on the back of the letter to avoid extra costs for the providers, who usually just send out the invitation. A website contained a more in depth decision aid. The service providers received information on legislation, the new letter templates, and posters for the waiting rooms.
P25 Sepucha and Simmons (2011) [73]
Sepucha et al. (2016) [100]
Simmons et al. (2016) [101]
USA n/r (descriptive implementation study) Primary care clinics Various contexts: 40 different decision aids available Decision aids Clinicians were able to order DAs through the electronic medical record (EMR). The EMR application then generated a note in the patient’s chart documenting that the material has been sent. The distribution and inventory of DA were managed centrally. The DAs were available in several formats (e-mail message with a link to access the DA online; DVD and booklet in the mail). Early on DA prescription was done in a visit by the clinician, but the SDM implementation team worked with clinicians and administrators to automatize prescriptions. Some years into the implementation program, a short 1 h training module was delivered to clinicians to increase familiarity with the DAs, show them ordering in EMR and discuss implementation challenges. They received CME points for training. Further into the implementation program, patients received the opportunity to order DAs themselves (patient-directed ordering). There were no mandates or long-term financial incentives or penalties associated with using or not using DAs
P26 Silvia et al. (2008) [102]
Silvia and Sepucha (2006) [103]
USA Post-implementation qualitative study Community resource centers, community hospitals, academic centers, community oncology center Breast cancer Decision aids Providers and resource centers across the country were informed about the availability of the programs through letters and e-mail. Interested sites received free copies and were left to decide themselves how to use them.
P27 Stacey et al. (2006) [104] Canada n/r (descriptive implementation study) Call center Various health issues; birth control methods, breast versus bottle feeding, male newborn circumcision, wisdom teeth removal, and treatment of miscarriage most common Decision aids and other form of decision support Interventions included an online auto tutorial, skill-building workshop, decision support protocol, and feedback on quality of decision support provided to simulated callers
P28 Stacey et al. (2008) [105] Australia Pre-post test study Cancer call center Cancer Other form of decision support Interventions included a decision support tutorial, skill-building workshop, and decision coaching protocol. Supervisors were trained in decision support, a trainer workshop was held for supervisory staff members, and the director of the cancer helpline addressed workshop participants to validate that decision support is an important part of their call center role.
P29 Stacey et al. (2015) [106] Canada Prospective pragmatic observational trial Cystic fibrosis clinics Adults with cystic fibrosis considering referral for lung transplant Decision aids and other form of decision support Implementation strategy was based on results of prior barriers survey. It consisted of training (workshop and online tutorial), easy access to decision aids, and conference calls for ongoing support. Patients completed DA on their own and discussed results with provider at a subsequent encounter, and a summary was included in the clinic record.
P30 Stapleton et al. (2002) [107] UK Post-implementation qualitative study Women’s homes, maternity clinics Antenatal care and maternity services Decision aids Leaflets were provided as part of a cluster randomized controlled trial. Health professionals received a training session in how to use them.
P31 Swieskowski (2011) [73] USA n/r (descriptive implementation study) Primary care clinics Acute and chronic low back pain, diabetes, women’s health issues, knee and hip osteoarthritis, cardiac conditions, spinal care, end of life care, PSA testing Decision aids Potential patients were identified by pre-visit chart review and DAs were prescribed by providers or health coaches during the visit. Follow-up decision support was provided by the physician or the health coach at a follow-up visit.
P32 Tapp et al. (2014) [53] USA Process improvement study Primary care practices Asthma SDM in general A community based participatory research approach was used to form an advisory board (including patients, physician champions, other healthcare professionals, administrative staff) that met monthly to tailor intervention to needs of each practice (e.g., adapting intervention to delivery by different types of staff members, adapting material for use by Spanish-speaking, low literacy and pediatric population, decide on roll out schedule). All practices started with kick-off meeting, then discussion rounds around logistics, training sessions (including use of decision support materials), regular follow-up meetings.
  1. UK United Kingdom, USA United States of America, SDM shared decision-making, DCIS ductal carcinoma in situ, PSA prostate-specific antigen, NCI National Cancer Institute, NHS National Health Service,
  2. *Study design: as reported in publication; if not reported (n/r), authors categorized based on study description in brackets