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• W2276015904 abstract "HomeCirculation: Cardiovascular Quality and OutcomesVol. 9, No. 12015 ACC/AHA Focused Update of Secondary Prevention Lipid Performance Measures Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUB2015 ACC/AHA Focused Update of Secondary Prevention Lipid Performance MeasuresA Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures WRITING COMMITTEE MEMBERS Joseph P. DrozdaJr, MD, FACC, Chair, T. Bruce FergusonJr, MD, FACC, FAHA, Hani Jneid, MD, FACC, FAHA, FSCAI, Harlan M. Krumholz, MD, SM, FACC, Brahmajee K. Nallamothu, MD, FACC, Jeffrey W. Olin, DO, FACC, FAHA, MSVM and Henry H. Ting, MD, MBA, FACC, FAHA ACC/AHA TASK FORCE ON PERFORMANCE MEASURES Paul A. Heidenreich, MD, MS, FACC, FAHA, Chair, Nancy M. Albert, PhD, CCNS, CCRN, CCA, FAHA, Paul S. Chan, MD, MSc, FACC, Lesley H. Curtis, PhD, T. Bruce FergusonJr, MD, FACC, FAHA, Gregg C. Fonarow, MD, FACC, FAHA, P. Michael Ho, MD, PhD, FACC, FAHA, Sean O’Brien, PhD, Andrea M. Russo, MD, FACC, Randal J. Thomas, MD, FACC, FAHA, Henry H. Ting, MD, MBA, FACC, FAHA and Paul D. Varosy, MD, FACC WRITING COMMITTEE MEMBERS Search for more papers by this author , Joseph P. DrozdaJrJoseph P. DrozdaJr Search for more papers by this author , T. Bruce FergusonJrT. Bruce FergusonJr Search for more papers by this author , Hani JneidHani Jneid Search for more papers by this author , Harlan M. KrumholzHarlan M. Krumholz Search for more papers by this author , Brahmajee K. NallamothuBrahmajee K. Nallamothu Search for more papers by this author , Jeffrey W. OlinJeffrey W. Olin Search for more papers by this author and Henry H. TingHenry H. Ting Search for more papers by this author ACC/AHA TASK FORCE ON PERFORMANCE MEASURES Search for more papers by this author , Paul A. HeidenreichPaul A. Heidenreich Search for more papers by this author , Nancy M. AlbertNancy M. Albert Search for more papers by this author , Paul S. ChanPaul S. Chan Search for more papers by this author , Lesley H. CurtisLesley H. Curtis Search for more papers by this author , T. Bruce FergusonJrT. Bruce FergusonJr Search for more papers by this author , Gregg C. FonarowGregg C. Fonarow Search for more papers by this author , P. Michael HoP. Michael Ho Search for more papers by this author , Sean O’BrienSean O’Brien Search for more papers by this author , Andrea M. RussoAndrea M. Russo Search for more papers by this author , Randal J. ThomasRandal J. Thomas Search for more papers by this author , Henry H. TingHenry H. Ting Search for more papers by this author and Paul D. VarosyPaul D. Varosy Search for more papers by this author Originally published14 Dec 2015https://doi.org/10.1161/HCQ.0000000000000014Circulation: Cardiovascular Quality and Outcomes. 2016;9:68–95Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2015: Previous Version 1 Table of ContentsPreamble 691. Introduction 691.1. Rationale for Update 691.2. Structure and Membership of the Writing Committee 691.3. Disclosure of Relationships With Industry and Other Entities 702. Methodology 702.1. Target Population and Care Period 702.2. Literature Review 702.3. Definition and Selection of Measures 703. 2015 Acc/Aha Focused Update of Secondary Prevention Lipid Performance Measures 703.1. Gaps in Care 703.2. Broader Denominator (ASCVD)–Unique to This PM Set 704. General Discussion 724.1. Patient-Centered PMs and SDM 724.2. “Prescribed” Versus “Offered” 734.3. Prescription Versus Adherence 744.4. Exceptions and Exclusions 754.5. Method of Reporting 764.6. Limitations and Unintended Consequences 765. Future Directions 765.1. Improved Information Systems for Capturing Clinical Data 765.2. Measures of SDM and Shared Accountability 775.3. Conclusion and Summary 77References 78Appendix A. 2015 ACC/AHA Focused Update of Secondary Prevention Lipid Performance Measures: Performance Measure Set 80Appendix B. Author Relationships With Industry and Other Entities (Relevant) 90Appendix C. Peer Reviewer Relationships With Industry and Other Entities 91Appendix D. 2015 ACC/AHA Focused Update of Secondary Prevention Lipid Performance Measures: Summary Analysis Table 95PreambleAmerican College of Cardiology (ACC)/American Heart Association (AHA) performance measures can serve as vehicles to accelerate appropriate translation of scientific evidence into clinical practice. Performance measures cover a subset of the most important recommended care practices and are considered appropriate for public reporting or use in pay for performance programs. Other measures of care that are not considered appropriate for public reporting or payment modification may be used as quality or test metrics for internal quality improvement. As defined by the ACC/AHA, quality metrics are those measures that have been developed to support self-assessment and quality improvement at the provider, hospital, and/or healthcare system level. These metrics may not meet all specifications of formal performance measures.1 In certain cases, an ACC/AHA performance measure writing committee may identify particular measures as quality metrics for the purposes of pilot testing with the potential of later promotion to performance measurement. Specific criteria for performance measures have been published2,3 by the ACC/AHA and include an important gap in care and a clear path to improve care. Recently, value was added as an exclusion criterion,4 where a care practice deemed to be of poor value by an ACC/AHA guideline would not be considered as a performance measure. The ACC/AHA Task Force on Performance Measures has historically focused on process of care measures under the control of individual providers. However, writing committees may also create structural or outcome measures when they meet the ACC/AHA performance measurement criteria.A goal of the ACC/AHA Task Force on Performance Measures is to rapidly create or update a performance measure when there are changes to a relevant ACC/AHA clinical guideline. Whenever possible, the ACC/AHA attempt to create relevant performance measures immediately following the publication of a guideline. However, the ACC/AHA believe that it is important to balance speed in measure development with a thorough review by stakeholders, content experts, and other interested parties using a public comment period. The goal is to have up-to-date and valid measures that can be used by all interested members of the healthcare system to evaluate and improve the quality of cardiovascular care.Paul A. Heidenreich, MD, MS, FACC, FAHAChair, ACC/AHA Task Force on Performance Measures1. IntroductionThe “2015 ACC/AHA Focused Update of Secondary Prevention Lipid Performance Measures” Writing Committee (the writing committee) was charged with updating the current lipid performance measures (PMs) based on the new recommendations in the “2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults” (the Cholesterol Guideline).5 In this measure set, the writing committee presents 5 PMs (Appendix A) 3 of which are intended for ambulatory settings and 2 for hospital (inpatient) settings. Four are revisions of lipid management measures appearing in 4 existing measure sets: “ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 Performance Measures for Adults With Peripheral Artery Disease”6; “ACC/AHA 2008 Performance Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction”7; “ACC/AHA/SCAI/AMA-PCPI/NCQA 2013 Performance Measures for Adults Undergoing Percutaneous Coronary Intervention”8; and “ACCF/AHA/AMA-PCPI 2011 Performance Measures for Adults With Coronary Artery Disease and Hypertension.”9 These measure sets for percutaneous coronary intervention (PCI), coronary artery disease (CAD), peripheral artery disease (PAD), and ST-elevation myocardial infarction (STEMI)/non–ST-elevation myocardial infarction (NSTEMI) are summarized in Table 1. The fifth measure is new and applies to the population of patients with clinical atherosclerotic cardiovascular disease (ASCVD) as defined in the 2013 guideline.5Table 1. ACC/AHA Secondary Prevention Lipid PMs to Be UpdatedMeasureDescription2013 PCI Lipid Performance Measures8Percentage of patients ≥18 y of age for whom PCI is performed and who are prescribed optimal medical therapy at discharge2011 CAD Lipid Performance Measures9Percentage of patients ≥18 y of age with a diagnosis of CAD seen within a 12-mo period who have an LDL-C result <100 mg/dL OR patients who have an LDL-C result ≥100 mg/dL and have a documented plan of care to achieve an LDL-C <100mg/dL, including at a minimum the prescription of a statin2010 PAD Lipid Performance Measures6Percentage of patients ≥18 y of age with PAD who were prescribed a statin and whose LDL-C is <100 mg/dL2008 STEMI/NSTEMI Lipid Performance Measures7Percentage of patients with STEMI/NSTEMI who are ≥18 y of age with documented LDL-C level in the hospital record or documented LDL-C testing done during the hospital stay or planned for after dischargeACC/AHA indicates American College of Cardiology/American Heart Association; CAD, coronary artery disease; LDL-C, low-density lipoprotein cholesterol; NSTEMI, non–ST-elevation myocardial infarction; PAD, peripheral artery disease; PCI, percutaneous coronary intervention; PM, performance measure; and STEMI, ST-elevation myocardial infarction.1.1. Rationale for the UpdateTo ensure that ACC/AHA PMs for cardiovascular disease fulfill their intended purposes, remain relevant, and are fully aligned with current clinical practice guidelines, the ACC/AHA Task Force on Performance Measures (the Task Force) requires a transparent and consistent process that will allow focused updates to individual PMs when needed. This may occur when new guideline recommendations are released, when the Task Force receives feedback from end users of the measures about critical implementation problems, or when unintended adverse consequences associated with implementation of the measure(s) are detected. The current writing effort used the Cholesterol Guidelines’ recommendations,5 which are significantly different from those of the prior Adult Treatment Panel III guidelines and emphasize administration of high-intensity statin therapy instead of achievement of low-density lipoprotein cholesterol (LDL-C) targets.1.2. Structure and Membership of the Writing CommitteeThe members of the writing committee included clinicians specializing in interventional cardiology and general cardiology, as well as persons with expertise in development of guidelines and development, implementation, and testing of PMs. Chairs for each of the previously published PMs (Table 1) were selected for the current writing effort.1.3. Disclosure of Relationships With Industry and Other EntitiesThe Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that could arise as a result of relationships with industry or other entities (RWI). Detailed information on the ACC/AHA policy on RWI can be found online. All members of the writing committee, as well as those selected to serve as peer reviewers of this document, were required to disclose all current relationships and those existing within the 12 months before initiation of this writing effort. ACC/AHA policy also requires that the writing committee co-chairs and at least 50% of the writing committee have no relevant RWI.Any writing committee member who develops new RWI during his or her tenure on the writing committee is required to notify staff in writing. These statements are reviewed periodically by the Task Force and members of the writing committee. Author and peer reviewer RWI relevant to the document are included in the appendixes (see Appendix B for relevant writing committee RWI and Appendix C for relevant peer reviewer RWI). Additionally, to ensure complete transparency, the writing committee members’ comprehensive disclosure information, including RWI not relevant to the present document, is available as an online supplement. Disclosure information for the Task Force is also available online.The work of the writing committee was supported exclusively by the ACC and AHA without commercial support. Members of the writing committee volunteered their time for this effort. Meetings of the writing committee were confidential and attended only by committee members and staff from the ACC and AHA.2. MethodologyThe development of PM systems involves identification of a set of measures targeting a specific patient population observed over a particular period. To achieve this goal, the Task Force has outlined a set of mandatory sequential steps.2 The following sections outline how these steps were applied by the present writing committee.2.1. Target Population and Care PeriodThe target population for the ASCVD PM reflects the ACC/AHA Cholesterol Guidelines5 population and consists of patients ages 18 to 75 years. In the focused update of the 4 existing lipid PMs, the target population consists as well of patients ages 18 to 25 years, representing a change from the age range previously specified in each measure set. This change was felt to be necessary in order to maintain consistency with the Class of Recommendation I, Level of Evidence A recommendation in the guidelines for treatment of patients with clinical ASCVD. Additionally, the writing committee developed exclusion criteria for the measures where appropriate in order to further specify the target population.2.2. Literature ReviewThe writing committee used the Cholesterol Guidelines5 as a primary source for deriving the measures. The writing committee also carried out a literature review to assess contemporary gaps in care.2.3. Definition and Selection of MeasuresThe writing committee focused on developing these measures against the ACC/AHA attributes of PMs. Each measure was constructed in a way to ensure it was evidence based, desirable in regard to measure selection, feasible to implement, and consistent with accountability (Table 2). After the peer review and public comment period, the writing committee reviewed and discussed the comments and made further refinements in the measure set. The writing committee evaluated the potential measures against the ACC/AHA attributes of PMs (Table 2) to reach consensus on which measures should be advanced for inclusion in the final measure set; the Summary Analysis Table (Appendix D) captures this evaluation process. The majority of the writing committee believed that the 5 measures in the set fulfilled the PM attributes.Table 2. ACC/AHA Task Force on Performance Measures Attributes for PMs1. Evidence BasedHigh-impact area that is useful in improving patient outcomesa) For structural measures, the structure should be closely linked to a meaningful process of care that in turn is linked to a meaningful patient outcome.b) For process measures, the scientific basis for the measure is well established and the process should be closely linked to a meaningful patient outcome.c) For outcome measures, the outcome should be clinically meaningful. If appropriate, PMs based on outcomes should adjust for relevant clinical characteristics by using appropriate methodology and high-quality data sources.2. Measure SelectionMeasure definitiona) The patient group to whom the measure applies (denominator) and for whom conformance is achieved is clearly defined and clinically meaningful.Measure exceptions and exclusionsb) Exceptions and exclusions are supported by evidence.Reliabilityc) The measure is reproducible across organizations and delivery settings.Face validityd) The measure appears to assess what it is intended to assess.Content validitye) The measure captures most meaningful aspects of care.Construct validityf) The measure correlates well with other measures of the same aspect of care.3. Measure FeasibilityReasonable effort and costa) Data required for the measure can be obtained with reasonable effort and cost.Reasonable periodb) Data required for the measure can be obtained within the period allowed for data collection.4. AccountabilityActionablea) Those held accountable can affect the care process or outcome.Unintended consequences avoidedb) The likelihood of negative unintended consequences with the measure is low.Adapted with permission from Normand et al.10ACC/AHA indicates American College of Cardiology/American Heart Association; and PM, performance measure.3. 2015 ACC/AHA Focused Update of Secondary Prevention Lipid Performance Measures3.1. Gaps in CareEach of the original writing committees that developed the measures revised in this update identified secondary prevention performance gaps in the patient populations that were the subjects of their measure sets. There is evidence that these gaps are ongoing, although the published studies deal primarily with prescription of medication.A study from the REACH (Reduction of Atherothrombosis for Continued Health) Registry found that only 83% of ambulatory patients with known ASCVD were receiving lipid-lowering agents.11 A prospective study by Rabus and colleagues of 73 patients with angiographically diagnosed CAD found that only 44% received prescriptions for statins.12 Reports from the National Cardiovascular Data Registry PINNACLE Registry of ambulatory patients with CAD revealed that only 66.5% (103 830 of 156 145) were receiving optimal medical therapy (OMT), including statins,13 that 77.8% (30 160 of 38 775) were prescribed statins,14 and that uninsured patients were 6% less likely to receive lipid-lowering therapy.15 Additionally, the study by Maddox and colleagues found substantial variation in prescription patterns by practice site.13,15 Shah and colleagues reported that, among 292 patients from Olmstead County, MN, with incident acute myocardial infarction (MI), only 44% were still taking statins 3 years after their infarction.16 Interestingly, a study by Borden and colleagues17 involving patients in the National Cardiovascular Data Registry CathPCI Registry failed to show any significant improvement in the prescription of OMT after PCI following publication of the results of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) study, which had demonstrated no incremental advantage of PCI over OMT on outcomes other than angina-related quality of life in stable CAD. Among all 467 211 patients (173 416 before [37.1%] and 293 795 after [62.9%] the COURAGE trial) who met the study criteria, the use of OMT at discharge following PCI before and after the COURAGE trial was 63.5% (95% confidence interval, 63.3% to 63.7%) and 66.0% (95% confidence interval, 65.8% to 66.1%), respectively (P<0.001).The extent to which statin treatment is initiated as a result of a shared decision-making (SDM) process between patient and clinician has not been systematically assessed but is likely small. Additionally, there is minimal information available about the statin doses being used in practice, although there are reasons for concern that many patients are being undertreated. It is common practice among clinicians to use the smallest dose of a medication necessary to achieve a therapeutic target and minimize the chance of adverse effects. Even PMs such as those revised in this focused update exclude the requirement for therapy in patients who have achieved goals. A study of 38 775 patients in the PINNACLE Registry by Arnold and colleagues revealed findings consistent with undertreatment of patients with CAD.14 They found that 6573 (17.0%) patients were not receiving any lipid-lowering therapy. Cholesterol levels were available for 3365 of these patients, 1794 (53.3%) of whom had LDL-C levels <100 mg/dL, consistent with clinicians either failing to treat or discontinuing lipid-lowering therapy when patient LDL-C levels met the previously recommended therapeutic target. In a secondary analysis of the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status (TRIUMPH) study, only 23% of 4271 patients discharged alive following an acute MI were on maximal statin therapy, with substantial variability across hospitals.18 Finally, a study in the Get With The Guidelines Registry of 65 396 patients with acute coronary syndromes (ACS) who were discharged with lipid-lowering agents found that only 38.3% were discharged with intensive lipid-lowering therapy.19 An editorial challenged measure developers to track the use of effective drug therapy, including dose.20 The current measures are designed therefore not only to promote the use of statins as recommended by the Cholesterol Guidelines5 but also to emphasize the importance of high-intensity dosing.3.2. Broader Denominator (ASCVD)–Unique to This PM SetThe target population for the ASCVD PM includes women and men between 18 and 75 years of age who have clinical ASCVD, which includes the following: ACS, history of MI, stable or unstable angina, coronary (including PCI) or other arterial revascularization, stroke, transient ischemic attack, or PAD. Although this patient population seems heterogeneous, it encompasses a variety of patients who all share presumed atherosclerosis21 as a common pathophysiology. Atherosclerosis is a chronic diffuse disease involving a myriad of arterial beds with intermittent acute clinical manifestations, predominantly occurring as a result of superimposed thrombosis, plaque progression, spasm, embolism, or a combination of the above. Other pathophysiological processes can contribute to the creation of stenosis or aneurysms in the arterial circulation; however, atherosclerosis remains the most common pathophysiology.Patients with clinical ASCVD represent 1 of 4 major groups identified by the writing committee of the Cholesterol Guidelines.5 For these patients, treatment with a 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitor, commonly known as a statin, is clearly beneficial. According to the Cholesterol Guidelines,5 patients with clinical ASCVD were identified by using the inclusion criteria from randomized clinical trials (RCTs) in secondary prevention. In addition, the potential for reduction of risk for ASCVD with statins in these patients clearly exceeds the potential for adverse effects.22The Cholesterol Treatment Trialists provided a comprehensive assessment of the benefits observed with statins.23 They undertook meta-analyses of individual participant data from 26 RCTs and demonstrated reduction in all-cause mortality, which was largely attributable to significant reductions in deaths due to CAD and other cardiac causes.23 The majority of studies in the aforementioned report included patients with known ASCVD. Of the 26 RCTs included, 5 trials (39 612 subjects, all of whom had CAD) compared more versus less intensive statin regimens. The trials demonstrated that more intensive regimens produced a highly significant 15% further reduction in major vascular events, driven by reductions in coronary death or nonfatal MI, coronary revascularization, and ischemic stroke.23 The investigators also found no significant effects observed on deaths due to cancer or other nonvascular causes or on cancer incidence, even at low LDL-C concentrations.23The aforementioned report was a meta-analysis of RCTs.23 Concerns about the quality and quantity of safety reporting in RCTs have been raised previously, and many researchers find the reporting of risks in RCTs to be largely inadequate.24–26 Data from RCTs should generally be supplemented by evidence from effectiveness studies to inform best clinical practice.27On extensive examination of clinical studies from the literature, the current clinical evidence does not support the notion that titrating lipid therapy to achieve proposed low LDL-C levels is beneficial or safe. Conversely, compelling evidence supports near-universal empirical statin therapy for patients at high cardiovascular risk regardless of their LDL-C levels.28 Thus, many argued to abandon the paradigm of treating patients to LDL-C targets and instead replace it with a more tailored treatment approach (ie, personalized care), which aims not only to improve patient outcomes but also reduce harms and costs caused by overtreating patients at low risk.29,30For patients with ACS, which includes unstable angina, NSTEMI, and STEMI, the general period of assessment is the inpatient hospitalization or related emergency department visit. For other patients (non-ACS patients), the PM is intended to assess the care for patients at the practitioner level in an ambulatory care setting for the primary purpose of quality improvement. For these non-ACS patients, the outpatient care period is defined as the care provided in an outpatient setting within the time under evaluation, which is usually 12 months.There are important potential exceptions for routine initiation of statin treatment. For primary prevention, the Cholesterol Guidelines expert panel determined that, despite the high level of risk for cardiovascular disease in patients with a higher New York Heart Association class of heart failure or receiving hemodialysis, the available evidence suggests that initiation of statin therapy might not achieve a significant risk reduction.31–33 In recognizing this, the expert panel made no recommendations about the initiation or discontinuation of statins in these populations, allowing for physician judgment in individual patients.5 Additional exceptions and exclusions related to secondary prevention measures are discussed in a separate section of this report.Historically, the Task Force has developed separate sets of PMs in discrete patient populations, including patients with STEMI and NSTEMI,7 PAD,6 CAD,9 and those undergoing PCI.8 These separate seminal documents, each inclusive of a PM pertaining to statin therapy in its corresponding population, may generally be more useful in specialty care quality improvement programs. Although the writing committee is adhering to this philosophy in revising the lipid PMs for each of these 4 specific populations, it is taking a novel approach in creating a new PM that applies to the much broader population of patients with ASCVD. This PM is concordant with the Cholesterol Guidelines,5 which was based on evidence from RCTs and their meta-analyses showing risk reduction among the variety of patients with clinical ASCVD, including those with ischemic cerebrovascular events. The writing committee believes that primary care clinicians and specialists concerned with secondary prevention of ASCVD will find these new PMs easy to use in the clinical setting. The 5 updated measure sets are summarized in Table 3.Table 3. 2015 ACC/AHA Focused Update of Secondary Prevention Lipid PMsPMDescriptionPADPercentage of patients 18–75 y of age with PAD who were offered moderate- to high-intensity statinSTEMI/NSTEMIPercentage of patients 18–75 y of age with AMI who were offered moderate- to high-intensity statin at hospital dischargePCIPercentage of patients 18–75 y of age for whom PCI was performed who were offered optimal medical therapy at dischargeCADPercentage of patients 18–75 y of age with CAD who were offered moderate- to high-intensity statinASCVDPercentage of patients 18–75 y of age with clinical ASCVD who were offered moderate- to high-intensity statinACC/AHA indicates American College of Cardiology/American Heart Association; AMI, acute myocardial infarction; ASCVD, atherosclerotic cardiovascular disease; CAD, coronary artery disease; NSTEMI, non-ST elevation myocardial infarction; PAD, peripheral artery disease; PCI, percutaneous coronary intervention; PM, performance measure; and STEMI, ST elevation myocardial infarction.4. General Discussion4.1. Patient-Centered PMs and SDMThe recommendation to initiate statins for secondary prevention is based on strong evidence in which benefit far exceeds risk.34 However, better patient outcomes are realized only if patients agree with, act on, and adhere to the recommendation for 5 to 10 years. The importance of clinician-patient discussions about statin therapy is specifically emphasized in the Cholesterol Guidelines.5 Among patients who are prescribed statins for secondary prevention, most initiate treatment, but up to half discontinue statins at 1 to 2 years’ follow-up.16,35 Therefore, a PM that represents only the number of patients prescribed statins in the numerator divided by the number of patients eligible to receive statins for secondary prevention in the denominator is inadequate and does not reflect quality of care. Rather, a measure that reflects the proportion of patients who participated in SDM would promote patient participation in the treatment plan, potentially increasing adherence to guideline-recommended care and improving patient-centered outcomes.SDM: What Is It?The SDM approach aims to promote a process whereby patients and clinicians together make a choice about treatments that incorporates 2 perspectives: 1) clinicians recommending treatments based on strong evidence in which benefit exceeds risk, and 2) patients deliberating on how treatments fit with their preferences, values, and personal context.36 In this framing, the clinician is the expert on evidence-based medicine and guidelines, and the patient is the expert on his or her preferences, values, and personal context. SDM mitigates the power differential between these 2 experts and acknowledges that both perspectives contribute equal weight to decision making. By incorporating patient preferenc" @default.
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