(CCSP099) EVALUATION OF SHARED DECISION-MAKING INCORPORATION IN MAJOR INTERNATIONAL CARDIOVASCULAR GUIDELINES: A SYSTEMATIC REVIEW

Background: Shared decision-making (SDM) is an essential aspect of the ethical provision of care, yet prior reviews have indicated that SDM is seldom promoted within clinical guidelines. However, these reviews are limited in their scope and characterizations of SDM. The objectives of this study were to characterize the promotion and facilitation of SDM in pharmacotherapeutic recommendations within contemporary international cardiovascular guidelines.

METHODS AND RESULTS: We conducted a systematic review of clinical practice guidelines from the American College of Cardiology (ACC), Canadian Cardiovascular Society (CCS), European Society of Cardiology (ESC), from 2012-2022. We included the latest full guideline along with any subsequent updates for each condition. We quantified the proportion of pharmacotherapy recommendations that incorporated SDM, and characterized them based on domains of directness (1-3; extent SDM was incorporated directly and impartially into the recommendation’s text) and facilitation (A-D; extent decision aids or quantified benefits/harms were provided) using the Supporting Higher Patient Autonomy in Recommendations (SHARE) framework developed by the authors. Additional analyses compared the proportion of SDM recommendations across cardiovascular societies and categories, as well as over time.
From 65 guidelines and updates, 2,655/7,499 (35%) recommendations addressed pharmacotherapy, of which 170 (6%) included SDM. Only 5/170 (3%) of SDM recommendations were SHARE grade 1A (impartial recommendations for SDM supported by a decision aid), whereas 114/170 (67%) were SHARE grade 3D (SDM mentioned only in supporting text and without any tools or information to facilitate SDM). By category, general cardiology guidelines contained the highest proportion of pharmacotherapy recommendations incorporating SDM (10%), whereas heart failure and myocardial disease guidelines contained the least (3%). The proportion of pharmacotherapy recommendations incorporating SDM was comparable across societies (ACC: 8%, CCS: 9%, ESC: 5%), with no trend for change over time.

Conclusion: Across cardiovascular guidelines by the ACC, CSS, and ESC over the past decade, only 6% of pharmacotherapy recommendations incorporated any SDM, with two-thirds of these mentioning SDM only in supporting text and without any tools or information to facilitate SDM. Guidelines should move beyond merely advocating for consideration of patient preferences by providing the tools necessary to support patients and clinicians in meaningfully engaging in SDM.