The promotion of shared decision-making is a central policy initiative in the Patient Protection and Affordable Care Act and a key component of person-centered medicine. Yet, as interest increases, disturbing distortions of shared decision-making have occurred. Fueled by a desire to reduce healthcare costs, reduce litigation and improve cost-effectiveness, the underlying rationale for shared decision-making risks being overshadowed. Some portray shared decision-making as a method to bend the cost curve, but opponents claim it is a ploy to ration care to patients [1]. Both these positions misrepresent the underpinning principles.The imperative for shared decision-making rests on the principles of good clinical practice, respecting patients' right to know that their informed preferences should be the basis for professional actions. Technologic advances have led to the proliferation of multiple treatment options while evidence-based medicine has contributed to our understanding that many therapies have marginal benefits. Shared decision-making aims to make the trade-offs between harms and benefits evident to patients rather than ration care. Overutilization arguably arises out of undue corporate influence on the promotion of marginally efficacious therapies with distorted claims of benefit. Other methods should be used to tackle these wider challenges, while the practice of shared decision-making would help medical professionals re-align themselves with patients' informed preferences and, in so doing, place patients, not making or saving money, at the center of care.

BACKGROUND Studies have shown that self-monitoring of blood pressure (BP) is effective when combined with co-interventions, but its efficacy varies in the presence of some co-morbidities. This study examined whether self-monitoring can reduce clinic BP in patients with hypertension-related co-morbidity. METHODS A systematic review was conducted of articles published in Medline, Embase, and the Cochrane Library up to January 2018. Randomized controlled trials of self-monitoring of BP were selected and individual patient data (IPD) were requested. Contributing studies were prospectively categorized by whether they examined a low/high-intensity co-intervention. Change in BP and likelihood of uncontrolled BP at 12 months were examined according to number and type of hypertension-related co-morbidity in a one-stage IPD meta-analysis. RESULTS A total of 22 trials were eligible, 16 of which were able to provide IPD for the primary outcome, including 6,522 (89%) participants with follow-up data. Self-monitoring was associated with reduced clinic systolic BP compared to usual care at 12-month follow-up, regardless of the number of hypertension-related co-morbidities (−3.12 mm Hg, [95% confidence intervals −4.78, −1.46 mm Hg]; P value for interaction with number of morbidities = 0.260). Intense interventions were more effective than low-intensity interventions in patients with obesity (P < 0.001 for all outcomes), and possibly stroke (P < 0.004 for BP control outcome only), but this effect was not observed in patients with coronary heart disease, diabetes, or chronic kidney disease. CONCLUSIONS Self-monitoring lowers BP regardless of the number of hypertension-related co-morbidities, but may only be effective in conditions such obesity or stroke when combined with high-intensity co-interventions.