Clinical Notes Contain Limited Documentation of Shared Decision Making for Colorectal Cancer Screening Decisions

Brittney Mancini, Joshua Siar, Kathrene Diane Valentine, Leigh Simmons, Lauren Leavitt and Karen Sepucha
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Brittney Mancini: Massachusetts General Hospital, Boston MA, USA
Joshua Siar: Medical College of Georgia AU/UGA Medical Partnership University of Georgia Health Sciences Campus Winnie Davis Hall, Athens, GA, USA
Kathrene Diane Valentine: Massachusetts General Hospital, Boston MA, USA
Leigh Simmons: Massachusetts General Hospital, Boston MA, USA
Lauren Leavitt: Massachusetts General Hospital, Boston MA, USA
Karen Sepucha: Massachusetts General Hospital, Boston MA, USA

Medical Decision Making, 2025, vol. 45, issue 6, 665-674

Abstract: Background Effective shared decision making (SDM) in health care involves thorough discussions of options, pros, cons, and patient preferences. While SDM is recommended for engaging adults aged 76 to 85 y in colorectal cancer (CRC) screening decisions, the extent of SDM documentation in clinical notes remains unclear. Objective This study aimed to evaluate the current state of SDM documentation in clinical notes regarding CRC screening discussions for adults aged 76 to 85 y. It also sought to assess the impact of an SDM training intervention on documentation quality and compare documented SDM elements with physician- and patient-reported SDM. Methods Data from 465 patient participants and 58 primary care physicians in a multisite cluster randomized trial were analyzed. Physicians in the intervention arm underwent a 2-h SDM skills training and received support tools, including an electronic health record SmartPhrase. Coders analyzed clinical notes using content analysis to identify SDM elements. Linear multilevel models and multilevel partial correlations were used for analysis. Results Overall, SDM Note scores were low ( x ¯ = 0.80, s = 0.99). The intervention arm exhibited higher SDM Note scores than the comparator arm did (adjusted mean 1.02 v. 0.66; P = 0.006), with more frequent documentation of stool-based tests (52% v. 33%; P = 0.02) and colonoscopy cons (28% v. 8%; P = 0.001). No significant differences were observed in patient preference documentation. SDM Note scores correlated moderately with patient- and physician-reported SDM. Conclusion Documentation of CRC screening discussions with older adults lacks comprehensive SDM elements. The intervention improved SDM documentation, particularly regarding alternative screening options and potential cons. Given the limited documentation of SDM even after a training intervention, attention to more robust SDM documentation, including patient preferences and discussion of stopping CRC screening, is needed. Highlights Shared decision-making (SDM) documentation in clinical notes is limited for discussions on colon cancer screening among older adults. SDM training improves SDM documentation of screening options for colorectal cancer, specifically documentation of stool-based testing and the downsides of screening options. SDM documentation in clinical notes is related to patient and provider reports of SDM.

Keywords: Shared Decision Making (SDM); colorectal cancer screening; clinical documentation; older adults; SDM training; SDM process score; content analysis; multilevel modeling (search for similar items in EconPapers)
Date: 2025
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Persistent link: https://EconPapers.repec.org/RePEc:sae:medema:v:45:y:2025:i:6:p:665-674

DOI: 10.1177/0272989X251340704

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