Date of Award

January 2021

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Jason L. Schwartz

Abstract

Recent guidelines and recommendations from prevention advisory groups endorsing shared clinical decision-making reflect an emerging trend among public health bodies such as the Advisory Committee on Immunization Practices (ACIP). These efforts build on the support and demonstrated benefits of shared decision-making initially associated with clinical care. But when applied to prevention and public health, endorsements of shared clinical decision-making (SCDM) over traditional recommendations introduce numerous challenges and complexities.

To study the implications, opportunities, and challenges posed by this approach to prevention recommendations, a narrative literature review of shared clinical decision-making recommendations was conducted with specific focus on the background, origins, expansion, and consequences of SCDM-based recommendations as utilized by the ACIP. In order to understand how SCDM guidelines are interpreted and implemented in a real-world setting, a secondary analysis was conducted regarding serogroup B meningococcal (MenB) vaccines, which protect against a rare but serious disease and was recommended based on shared clinical decision making by the ACIP for adolescents and young adults aged 16-23 years without specified risk factors. The vaccination policies of 373 U.S. 4-year colleges and universities regarding MenB vaccination for undergraduate students were reviewed, and a chi-square test of independence was performed to examine if institutional classification (liberal arts college or R1 university) was associated with vaccination policies.

The results of this study show that shared clinical decision-making recommendations reframe traditional approaches to evidence-based prevention, affect insurance coverage and patient access to preventive services, and influence patient-provider discussions and subsequent patient decision-making. Additionally, the study of college and university MenB vaccination policies—which found that of the 348 colleges or universities providing information on vaccination policies, 165 (47.4%) did not mention MenB vaccines, 46 (13.2%) mentioned MenB vaccination as an option for students without providing a recommendation, 127 (36.5%) recommended or suggested vaccination, and 10 (2.9%) required vaccination, with institution type significantly associated with vaccination policy (p<0.001)—highlight the disparate interpretations of and approaches to the ACIP’s shared clinical decision-making recommendation. In sum, for this relatively new class of SCDM-focused recommendations to be most effective, additional efforts are needed to better inform providers, engage patients, facilitate equitable access, and, overall, enhance evidence-based approaches to prevention among public health policy-makers, expert advisory committees, providers, colleges and universities, and patients alike.

Comments

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