Abstract
BackgroundDespite decades of ethical, empirical, and policy support, shared decision-making (SDM) has failed to become standard practice in US cancer care. Organizational and health system characteristics appear to contribute to the difficulties in implementing SDM in routine care. However, little is known about the relevance of the different characteristics in specific healthcare settings. The aim of the study was to explore how organizational and health system characteristics affect SDM implementation in US cancer care.MethodsWe conducted semi-structured interviews with diverse cancer care stakeholders in the USA. Of the 36 invited, 30 (83%) participants consented to interview. We used conventional content analysis to analyze transcript content.ResultsThe dominant theme in the data obtained was that concerns regarding a lack of revenue generation, or indeed, the likely loss of revenue, were a major barrier preventing implementation of SDM. Many other factors were prominent as well, but the view that SDM might impair organizational or individual profit margins and reduce the income of some health professionals was widespread. On the organizational level, having leadership support for SDM and multidisciplinary teams were viewed as critical to implementation. On the health system level, views diverged on whether embedding tools into electronic health records (EHRs), making SDM a criterion for accreditation and certification, and enacting legislation could promote SDM implementation.ConclusionCancer care in the USA has currently limited room for SDM and is prone to paying lip service to the idea. Implementation efforts in US cancer care need to go further than interventions that target only the clinician-patient level. On a policy level, SDM could be included in alternative payment models. However, its implementation would need to be thoroughly assessed in order to prevent further misdirected incentivization through box ticking.
Highlights
Despite decades of ethical, empirical, and policy support, shared decision-making (SDM) has failed to become standard practice in United States (US) cancer care
The results show that SDM implementation in US cancer care will remain unlikely if economic barriers are not removed
In a recent scoping review [11], we identified a range of organizational- and system-level characteristics that influence the implementation of SDM
Summary
Empirical, and policy support, shared decision-making (SDM) has failed to become standard practice in US cancer care. The aim of the study was to explore how organizational and health system characteristics affect SDM implementation in US cancer care. Studies that investigated implementation difficulties have mainly described barriers at the patient and physician levels [9, 10], but few have considered how the structure of the US healthcare system itself may undermine adoption of SDM [11]. This is in line with the implementation science literature in general. As in other areas of healthcare, adoption of SDM in cancer care is slow [8, 16,17,18]
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