Commentary on “Enhancing Success of Medicare’s Shared Decision Making Mandates Using Implementation Science: Examples Applying the Pragmatic Robust Implementation and Sustainability Model (PRISM)”

Nov 15,2020 | Leila Kahwati Commentary

In this issue’s newsletter, we highlight an article by Matlock and colleagues that discusses the use of implementation science to understand the challenges associated with implementing shared decision making in clinical practice. The Centers for Medicare and Medicaid Services (CMS) has mandated shared decision making using a decision aid for reimbursement of computerized tomography (CT) for lung cancer screening, left atrial appendage closure for atrial fibrillation, and for the use of implantable cardiac defibrillators for certain abnormal heart rhythms. Although research suggests that decision aids can support shared decision-making by improving communication, knowledge and by reducing decisional conflict and regret, it an open question whether robust shared decision making with decision aids outside of a controlled research setting can occur in routine practice, particularly when mandated. The authors cite a recent systematic review of decision aid implementation that identified many implementation barriers.  As a primary care clinician for more than 20 years, I know firsthand how mandates, no matter how well-intentioned, can quickly devolve into a ‘check the box’ exercise in the rush of a busy clinic day.

In this article, the authors use the Pragmatic Robust Implementation and Sustainability Model (PRISM) framework to discuss how principles of implementation science can be used to plan for implementation of shared decision making generally, and more specifically to the CMS mandates for shared decision making in the three conditions listed above. PRISM also offers a framework for evaluation of these mandates. A key recommendation from the authors to developers of future decision aids is to balance between designing aids for maximal effectiveness versus designing aids that may be more pragmatic to implement, thus maximizing reach, adoption, and sustainability. In summary, this article offers suggestions for researchers and policymakers on how to apply principles of implementation science to bridge research to practice from both sides of the divide.

Read the full abstract