Defense Date


Document Type


Degree Name

Doctor of Philosophy


Social and Behavioral Health

First Advisor

Jennifer Elston Lafata


Introduction: Shared decision making (SDM) has been advocated as an optimal approach to medical decision-making. Yet, little is known about how patients perceive SDM and whether patient-defined SDM is associated with patient outcomes. Methods: This three-manuscript dissertation used a mixed-methods approach including a systematic literature review and both qualitative and quantitative research methods. The aims were to: (1) systematically review the patient outcomes studied in relation to SDM and identify under what measurement contexts SDM is associated with which types of patient outcomes; (2) use in-depth, qualitative interviews to develop a conceptual model of patient-defined SDM and compare this to recent decisions that patients labeled as shared; and (3) apply the model of patient-defined SDM to the context of colorectal cancer screening. Results: Study 1 found that 39 studies measured SDM and evaluated it with a patient outcome, and only 43% of patient outcomes assessed were significantly associated with SDM. Patient reports of SDM were most likely to be associated with outcomes. Study 2 found that patients’ conceptual definition of SDM included four components: exchange of information, active listening, patient-self advocacy, and a personalized physician recommendation. Patient descriptions of recent decisions labeled as shared ranged from very simple recommendations through complex interactions, with the only commonality among shared decisions being that the patient and physician ultimately agreed. Study 3 found that the most commonly observed component of patient-defined SDM was patient self-advocacy (76%) and least common was a personalized physician recommendation (23%). Only 9% visits contained all four patient-defined SDM components. In adjusted models, physician provision of information around the process and potential side effects of colorectal cancer screening was associated with an increase in screening. There were differences in screening rates by the patient’s initial verbal response to the physician recommendation with those who initially refused being least likely to be screened (40%) and patients who did not verbalize a response to the recommendation being most likely to be screened (70%). Discussion: Findings across the three studies highlight the complexity of studying and measuring SDM and emphasize the importance of the patient’s perspective on SDM.


© The Author

Is Part Of

VCU University Archives

Is Part Of

VCU Theses and Dissertations

Date of Submission

September 2013