15250-m-cuypers

13 General introduction 1 Medical decision making Historically, most medical decisions were characterized by a strong focus on the disease itself -not the patient suffering from it- and the expertise of the doctor 35 . The more complex the disease or proposed treatment was, the more dominant the voice of the doctor was and, as a result, patients could feel excluded from this process. The exchange of information between a doctor and patient was often limited to the amount that was required to obtain a patient´s informed consent for undergoing treatment. Partly, this paternalistic model existed because many medical conditions only had a single treatment 36 . Fromthe 1980´s onwards awareness increased thatwith advances inmedical treatments, more complexity was introduced in deciding about which treatment would be best. For example, different treatments can have the same expected survival outcome, but may differ in the adverse treatment effects and risks involved. In such situations, a doctor can no longer solely rely on the medical characteristics to determine the best solution. Patient preferences and personal circumstances should then be evaluated to further guide the tradeoff between risks and benefits. Consequently, a more active patient role became necessary 35 . With increasing patient involvement, interest grew to deliver healthcare that is both effective and appropriate. Value-based healthcare was introduced as a term that aimed at optimal patient value while reducing health care costs 37 . An important driver in the developmentofvalue-basedhealthcareconsistedoftheobservationofregionalvariation in treatments for the same disease. Routine clinical practice displayed wide treatment variations which could not be explained by illness severity or patient preferences alone 38. This variation has also been observed in Dutch Pca care 39 . Unwarranted regional variations in clinical practice for the same disease can be an indication for impaired healthcare quality. Care that is delivered does then possibly not reflect the latest scientific guidelines or patient preferences, but health-care provider preferences or financial incentives instead 40, 41 . Shared patient-doctor decisions may help to counter practice variation: When treatments reflect patient preferences, the same variation in treatments should be found across different regions or hospital locations 42, 43 . Shared decision making Shared decision making (SDM) is a key concept throughout this dissertation. Definitions of SDM vary, but all include ‘a balanced presentation of options and outcomes tailored to the individual patient’s risk’ and ‘ active engagement with the patient to help clarify his own values and preference’ 44 . Active engagement does not necessarily mean that