A qualitative study on how to (better) integrate shared decision-making and decision support tools into clinical practice guidelines

Background: While clinical practice guidelines (CPGs) are essential to support evidence-based healthcare, CPG recommendations are based on population estimates. As such, they cannot account for individual patient preferences and circumstances. This calls for the application of shared decision-making (SDM) – an approach where patients and healthcare professionals make decisions together, based on the best available evidence and in line with patient preferences. However, implementation of SDM in practice remains limited. The integration of SDM and decision support tools (DSTs) into CPGs can help to increase awareness of SDM among healthcare professionals, but remains inconsistent and insufficient. Objective: We explored expert knowledge and experience to identify strategies for (better) integrating SDM and DSTs into CPGs. Our specific research questions were: (1) How to identify CPG recommendations for which SDM is most relevant? And (2) what factors in CPG development hinder or facilitate the consideration of SDM and the development of DSTs? Methods: This qualitative study was waived by the ethics committee of the Brandenburg Medical School. We followed the consolidated criteria for reporting qualitative research (COREQ) checklist to report our study. We conducted semi-structured interviews with CPG and SDM experts who were purposively recruited until we reached data saturation. We contacted experts through the Guidelines International Network, supplemented by reaching out to additional CPG organizations and authors of articles identified in a previous study on a similar topic via email. We iteratively developed an interview guide, which was pilot-tested in three interviews. All interviews were digitally recorded, transcribed, and then analyzed by Mayring’s qualitative content analysis using MAXQDA software. Results: In March and April 2024, we conducted interviews with 16 experts in CPG development, methodology, and SDM from 12 different countries. For question (1), experts proposed a variety of factors that indicate SDM relevance for a recommendation (e.g. multiple reasonable options), contraindicate it (e.g. emergency), or were discussed ambivalently (e.g. strength of recommendation). They suggested using the CPG scoping phase or qualitative methods as strategies for selecting SDM-relevant recommendations. For question (2), they discussed the CPG development group, the underlying methodology, resources, and the culture of the CPG group as both hindering and facilitating factors. While they attributed an important role to patient partners in enabling person-centered CPG development that can foster consideration of SDM, they noted that CPG and DST development processes remain separate, with one group unaware of the other. A lack of methodological guidance for a linked development of CPGs and DSTs, a lack of resources and expertise, as well as a lack of a supportive culture towards SDM were reported as barriers. Implications for research and practice: The identified strategies can serve as a starting point for CPG organizations to explore ways for considering SDM in the CPG development process, taking into account facilitating and hindering circumstances in their specific context. To foster the link between CPGs and SDM, CPG and DST development groups should merge or work in collaboration, while CPG and SDM communities need to work towards closer collaboration at an overarching level.