Quantity and quality of shared decision making incorporation across major international cardiology guidelines

Abstract Background/Introduction Shared decision-making (SDM) is a key component of the provision of ethical care, but prior reviews have indicated that clinical practice guidelines poorly promote and facilitate SDM. Purpose To identify and characterize all pharmacotherapy recommendations integrating SDM within contemporary cardiovascular guidelines using a novel classification system. Methods The American College of Cardiology (ACC), Canadian Cardiovascular Society (CCS), and European Society of Cardiology (ESC) digital guideline libraries (2012–2022) were searched for current guidelines, or subsequent updates, that included at least one pharmacotherapy recommendation. We identified all pharmacotherapy recommendations for each guideline. Recommendations that incorporated SDM were rated according to a novel Supporting Higher Patient Autonomy in Recommendations (SHARE) rating framework – which evaluates the quality of SDM incorporation based on directness (1-3; assessing whether SDM was incorporated directly and impartially into the recommendation’s text) and facilitation (A-D; assessing whether decision aids or quantified benefits/harms were provided). Results From 65 guidelines and updates, 2,655 recommendations (35% of total) addressed pharmacotherapy. Of these recommendations, 171 (6%) incorporated SDM. By category, general cardiology guidelines contained the highest proportion of pharmacotherapy recommendations incorporating SDM (10%), whereas heart failure and myocardial disease 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. Only 5/171 (3%) of SDM recommendations met SHARE grade 1A (impartial recommendations for SDM supported by a decision aid), whereas 63% were SHARE grade 3D (SDM mentioned only in supporting text and without any tools or information to facilitate SDM). Conclusions Across guidelines published by three cardiovascular societies over the last decade, few recommendations incorporated SDM in any form, and even fewer adequately facilitated SDM. Guidelines should move away from merely advocating for consideration of patient preferences, and toward facilitating meaningful engagement in SDM.