Implementation of Evidence-Based Medicine in Primary Care Through the Use of Encounter Shared Decision Making Tools: The ShareEBM Pragmatic Trial

BACKGROUND While decision aids have been proven effective to facilitate patient-centered discussion about evidence-based health information in practice and enable shared decision making (SDM), a chasm remains between the promise and the use of these SDM tools in practice. AIMS To promote evidence-based patient-centered care in primary care by using encounter SDM tools for medication management of chronic conditions. METHODS We conducted a mixed methods study centered around a practice-based, multi-centered pragmatic randomized trial comparing active implementation (active) to passive dissemination (passive) of a web-based toolkit, ShareEBM, to facilitate the uptake in primary care of four SDM tools designed for use during clinical encounters. These tools supported collaborative decisions about medications for chronic conditions. ShareEBM included activities and tactics to increase the likelihood that encounter SDM tools will be routinized in practice. Study team members worked closely with practices in the active arm to actively integrate and promote the use of SDM tools; passive arm practices received no support from the study team. The embedded qualitative evaluation included clinician phone interviews (n=10) and site observations (n=5) for active practices, and exit focus groups for all practices (n=11). RESULTS Eleven practices and 62 clinicians participated in the study. Clinicians in the active arm used SDM tools in 621 encounters (Mean [SD]: 21 [25] encounters per clinician, range: 0-93) compared to 680 in the passive arm (Mean [SD]: 20 [40] encounters per clinician, range: 0-156, p=0.4). Six of 29 (21%) clinicians in the active arm and 14 of 33 (42%) in the passive arm did not use any tools (p=0.1). Clinicians’ views covered four major themes: general views of using encounter SDM tools, perceived impact on patients, strategies used, and how encounter SDM tools are incorporated into practice flow. CONCLUSION Neither active nor passive implementation of a toolkit improved the uptake and use of encounter SDM tools in primary care. Overcoming clinician reluctance to consider using encounter SDM tools, their seamless integration into the electronic and practice workflows, and ongoing feedback about the quality of their use during encounters appear necessary to implement their use in primary care practices. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial NCT02136199 ### Funding Statement This study was funded by the Agency for Healthcare and Quality Research (Grant R24HS022008). The Agency for Healthcare and Quality Research had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Mayo Clinic Institutional Review Board approved study procedures (14-002055). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The SDM encounter tools can be freely accessed on the Mayo Clinic Shared Decision Making National Resource Center website (). The ShareEBM activities and tactics can be requested from the authors. De-identified data can be requested and provided to investigators upon alignment with and approval from Mayo Clinic Ethics Committee and legal authorities.