User-centered design and the development of patient decision aids: protocol for a systematic review

Improving a Web-Based Tool to Support Older Adults to Stay Independent at Home: Qualitative Study

Background

Older adults desire to stay independent at home for as long as possible. We developed an interactive website to inform older adults and caregivers about ways to achieve this.

Objective

This study aimed to perform an in-depth exploration among potential end users about how to improve the interactive website to better inform older adults and caregivers about ways to stay independent at home.

Methods

To complement the results of a quantitative survey on the usability and acceptability of the website before implementation, we conducted a qualitative descriptive study. Using multiple recruitment strategies, we recruited a purposeful sample of older adults (aged ≥65 years) and caregivers of older adults struggling to stay independent at home. We conducted face-to-face or telephonic interviews in either English or French. In addition, we collected sociodemographic characteristics, other characteristics of participants (eg, health, digital profile, and perception of retirement homes), and experiences with using the website (factors facilitating the use of the website, barriers to its use, and suggestions for improvement). Interviews were audio recorded, transcribed verbatim, and thematically analyzed by two researchers.

Results

We recruited 15 participants, including 5 older adults (mean age 75 years, SD 6) and 10 caregivers (mean age 57 years, SD 14). The mean interview time was 32 min (SD 14). Most older adults had either mobility or health problems or both, and many of them were receiving home care services (eg, blood pressure measurement and body care). Overall, participants found the website easy to navigate using a computer, reassuring, and useful for obtaining information. Barriers were related to navigation (eg, difficult to navigate with a cellphone), relevance (eg, no specific section for caregivers), realism (eg, some resources presented are not state funded), understandability (eg, the actors’ accents were difficult to understand), and accessibility (eg, not adapted for low digital literacy). Suggestions for improvement included a needs assessment section to direct users to the support appropriate to their needs, addition of information about moving into residential care, a section for caregivers, distinction between state-provided and private support services, simpler language, expansion of content to be relevant to all of Canada, and video subtitles for the hearing impaired.

Conclusions

Users provided a wealth of information about the needs of older adults who were facing a loss of autonomy and about what such a website could usefully provide. The request for less generic and more personalized information reflects the wide range of needs that electronic health innovations, such as our interactive website, need to address. After integrating the changes suggested, the new website—Support for Older Adults to Stay Independent at Home (SUSTAIN)—will be implemented and made available to better assist older adults and caregivers in staying independent at home.

Development and Field Testing of a Long-Term Care Decision Aid Website for Older Adults: Engaging Patients and Caregivers in User-Centered Design

BACKGROUND AND OBJECTIVES

Decisions about long-term care and financing can be difficult to comprehend, consider, and communicate. In a previous needs assessment, families in rural areas requested a patient-facing website; however, questions arose about the acceptability of an online tool for older adults. This study engaged older adults and family caregivers in (a) designing and refining an interactive, tailored decision aid website, and (b) field testing its utility, feasibility, and acceptability.

RESEARCH DESIGN AND METHODS

Based on formative work, the research team engaged families in designing and iteratively revising paper drafts, then programmed a tailored website. The field test used the ThinkAloud approach and pre-/postquestionnaires to assess participants' knowledge, decisional conflict, usage, and acceptability ratings.

RESULTS

Forty-five older adults, family members, and stakeholders codesigned and tested the decision aid, yielding four decision-making steps: Get the Facts, What Matters Most, Consider Your Resources, and Make an Action Plan. User-based design and iterative storyboarding enhanced the content, personal decision-making activities, and user-generated resources. Field-testing participants scored 83.3% correct on knowledge items and reported moderate/low decisional conflict. All (100%) were able to use the website, spent an average of 26.3 min, and provided an average 87.5% acceptability rating.

DISCUSSION AND IMPLICATIONS

A decision aid website can educate and support older adults and their family members in beginning a long-term care plan. Codesign and in-depth interviews improved usability, and lessons learned may guide the development of other aging decision aid websites.

Towards Inclusive Healthcare Delivery: Potentials and Challenges of Human-Centred Design in Health Innovation Processes to Increase Healthy Aging

National healthcare systems need to adjust services and operations to accommodate the needs of complex, aging populations living with multimorbidity and polypharmacy. This paper suggests the use of a human-centred design as a method to engage older adults and key professionals in innovation processes aiming to design person-centred healthcare services and improve quality of life in older adults. We outline three innovation phases and highlight how such processes can create engagement and new insights on how life experiences of older adult's shape preferences, beliefs, and habits. It is important to incorporate these insights into the design of successful strategies for ensuring age-friendly healthcare services. Our viewpoint is contextualised through a small-scale case study focusing on polypharmacy in older adults. From this case study, we extracted three challenges to producing co-designed health research: recruitment, time and resources, and funding. We discuss how to address these challenges. We argue for the involvement of older adults and professional stakeholders at an early stage in the design process to align expectations and to increase the likelihood of successful implementation of healthcare innovations that improve the quality of life for older adults.

Parents' Perceptions of the Acceptability of Evidence-Based Interventions to Support Transition From Neonatal to Rehabilitation Services

BACKGROUND

Parents of children born preterm with a disability often experience profound psychological distress with transition from neonatal to rehabilitation services. Four interventions were found effective to support parents throughout this critical transition period whereby parental stress can threaten the child's development.

PURPOSE

To examine parents' perceptions of the acceptability of four evidence-based interventions to support their transition.

METHODS

A quantitative design using survey methods was employed with 24 parents with experience in transition to rehabilitation services. Each participant rated the acceptability of the interventions using the Treatment Perception and Preference scale. Descriptive statistics and repeated measures analysis of variance were used for data analysis.

RESULTS

Mean overall acceptability scores differed across the four interventions (p = .042); the difference was of moderate size (η² = .11). Parents perceived psychoeducation and narrative therapy as most acceptable, followed by website consultation with healthcare providers and parent support program, then parent self-help program.

CONCLUSIONS

Psychoeducation and narrative therapy should be accessible to parents experiencing transition from neonatal to rehabilitation services.

Advancing nursing participation in user-centred design

BACKGROUND

What is the role of nursing in the digital health transformation of the 21st century? The answer to this critical question may rely on how prepared nursing is to enter into design processes associated with this evolution.

AIMS

The purpose of this paper is to introduce foundational terminology and tools to support increased nursing participation in user-centred design. Situated within a six-step design process, this includes a new analytic framework combining the disciplinary expertise of computer science with the nursing methodology Interpretive Description.

METHODS

The analytic framework and recommended research process were developed over the course of two projects each employing a similar collaborative mixed-methods design. Primary methodological drivers were drawn from the software development life-cycle and Interpretive Description in these digital health intervention studies.

RESULTS

Using aspects of software development practice, an analytic framework was conceived as part of an interdisciplinary research process allowing nurses to integrate their disciplinary expertise in user-centred digital design. The framework allows nurses to parse collected data into a robust set of functional and non-functional requirements for software developers while still engaging in a fulsome interpretive analysis.

CONCLUSION

There is a need for nursing to occupy a more significant role in the advancement of technology innovation in healthcare. However, a lack of familiarity with design-thinking and associated practical experience impedes nursing voices in this area. Tools and processes are introduced to enhance an existing nursing methodology as a means to extend our disciplinary design capacity.

Mobile Health in Urology: The Good, the Bad and the Ugly

Our aim is to present the current position of mobile health (mHealth) and the delivery of healthcare services via mobile communication devices in urology. We conducted a literature review of urology mHealth papers on PubMed. Results indicate that mHealth is becoming ubiquitous in contemporary healthcare systems. Although its potential has been shown, urology lags behind other areas, representing just 0.1% of the 300,000 available medical apps in the Apple App Store and Google Play Store. Furthermore, there is a lack of expert healthcare professional involvement in app development. To avoid harm, it is critical that the scientific accuracy, patient privacy, and user safety of urology mHealth applications are assured. This is because there is no globally enforced medical app regulation, compulsory scientific guidelines, nor mandatory industry standards. Urologists, either individually or via scientific organizations, should have a pivotal position in the design, development, review, certification, and recommendation of apps. mHealth holds great potential in urology, as it can aid multiple stakeholders: citizens, patients, healthcare professionals, health organizations, and public authorities (e.g., Ministry of Health). Even though it is mostly used to improve existing medical activities at present, the future will include revolutionary and ground-breaking technology solutions. This innovative field should be seen by urologists as an opportunity to provide greater care to our patients and better tools and knowledge to our peers.

Information Priorities for Deciding on Treatment of Pelvic Organ Prolapse

OBJECTIVE

The objective of this study was to elicit information priorities from women considering treatment for pelvic organ prolapse (POP).

STUDY DESIGN

This is a cross-sectional study of women before and after treatment of stage II or higher POP. Women were recruited either at the conclusion of their initial evaluation (before treatment) or at postoperative or pessary maintenance visits (after treatment). Women completed a written survey that used a Likert scale to rank potentially frequently asked questions (FAQs) that could be important information to use in decision making for POP.

RESULTS

Among the 100 women surveyed, 32 women wanted to pursue surgical options and 18 women wanted to pursue nonsurgical treatment options in the before treatment group. In the after treatment group, 35 women had undergone surgery and 15 women were using a pessary.Overall, women ranked FAQs about treatment success (overall Likert score, 1.11±0.35), quality of life after treatment (1.18±0.41), and complications and side effects (1.20±0.57) as the most important information when making a decision. Women were least concerned with FAQs regarding cost (2.39±1.48), impact on sexual function (2.21±1.4), and impact on hormones (2.20±1.27).

CONCLUSIONS

Women with POP identified the most important FAQs related to treatment success and complications, quality of life, and understanding how the treatment works. This information will be used to develop a comprehensive decision aid for women considering treatment options for POP.

Social rhythm therapy-A potentially translatable psychosocial intervention for bipolar disorder

INTRODUCTION

The aim of this paper was to present Social Rhythm Therapy, which has been modified from Interpersonal and Social Rhythm Therapy, by drawing on implementation science to describe a process that for integrating this into routine clinical practice.

METHOD

On the basis of the principles of user-centred design, we aimed to modify an existing psychosocial therapy for bipolar disorder to make this readily translatable into a range of clinical practice models which could be further modified based on feedback from end users.

RESULTS

Social Rhythm Therapy has been adapted from Interpersonal and Social Rhythm Therapy which has demonstrated efficacy in research settings. The adaptation was developed in order to facilitate implementation of some of the key components in routine clinical practice. It is short, relatively simple, easily learned and intended to be flexible.

CONCLUSIONS

Social rhythm therapy for bipolar disorder has many characteristics which may make it translatable into clinical practice in different settings. There is a need for studies into the clinical effectiveness of this intervention that has been modified from an evidence-based intervention.

Aligning implementation and user-centered design strategies to enhance the impact of health services: results from a concept mapping study

BACKGROUND

Innovative approaches are needed to maximize fit between the characteristics of evidence-based practices (EBPs), implementation strategies that support EBP use, and contexts in which EBPs are implemented. Standard approaches to implementation offer few ways to address such issues of fit. We characterized the potential for collaboration with experts from a relevant complementary approach, user-centered design (UCD), to increase successful implementation.

METHOD

Using purposive and snowball sampling, we recruited 56 experts in implementation (n = 34) or UCD (n = 22). Participants had 5+ years of professional experience (M = 10.31), worked across many settings (e.g., healthcare, education, human services), and were mostly female (59%) and white (73%). Each participant completed a web-based concept mapping structured conceptualization task. They sorted strategies from established compilations for implementation (36 strategies) and UCD (30 strategies) into distinct clusters, then rated the importance and feasibility of each strategy.

RESULTS

We used multidimensional scaling techniques to examine patterns in the sorting of strategies. Based on conceptual clarity and fit with established implementation frameworks, we selected a final set of 10 clusters (i.e., groups of strategies), with five implementation-only clusters, two UCD-only clusters, and three trans-discipline clusters. The highest-priority activities (i.e., above-average importance and feasibility) were the trans-discipline clusters plus facilitate change and monitor change. Implementation and UCD experts sorted strategies into similar clusters, but each gave higher importance and feasibility ratings to strategies/clusters from their own discipline.

CONCLUSIONS

In this concept mapping study, experts in implementation and UCD had perspectives that both converged (e.g., trans-discipline clusters, which were all rated as high-priority) and diverged (e.g., in importance/feasibility ratings). The results provide a shared understanding of the alignment between implementation science and UCD, which can increase the impact and sustainability of EBP implementation efforts. Implications for improved collaboration among implementation and UCD experts are discussed.

Identifying Barriers and Enablers to Attending Diabetic Retinopathy Screening in Immigrants to Canada From Ethnocultural Minority Groups: Protocol for a Qualitative Descriptive Study

Background

Immigrants to Canada belonging to ethnocultural minority groups are at increased risk of developing diabetes and complications, including diabetic retinopathy, and they are also less likely to be screened and treated. Improved attendance to retinopathy screening (eye tests) has the potential to reduce permanent complications, including blindness.

Objective

This study aims to identify the barriers and enablers of attending diabetic retinopathy screening among ethnocultural minority immigrants living with diabetes in Quebec and Ontario, Canada, to inform the development of a behavior change intervention to improve diabetic retinopathy screening attendance.

Methods

The research question draws on the needs of patients and clinicians. Using an integrated knowledge translation approach, the research team includes clinicians, researchers, and patient partners who will contribute throughout the study to developing and reviewing materials and procedures, helping to recruit participants, and disseminating findings. Using a convenience snowball strategy, we will recruit participants from three target groups: South Asian and Chinese people, and French-speaking people of African descent. To better facilitate reaching these groups and support participant recruitment, we will partner with community organizations and clinics serving our target populations in Ontario and Quebec. Data will be collected using semistructured interviews, using topic guides developed in English and translated into French, Mandarin, Hindi, and Urdu, and conducted in those languages. Data collection and analysis will be structured according to the Theoretical Domains Framework (TDF), which synthesizes predominant theories of behavior change into 14 domains covering key modifiable factors that may operate as barriers or enablers to attending eye screening. We will use directed content analysis to code barriers and enablers to TDF domains, then thematic analysis to define key themes within domains.

Results

This study was approved for funding in December 2017, and the research ethics board approved the conduct of the study as of January 13, 2018. Data collection then began in April 2018. As of August 28, 2018, we have recruited 22 participants, and analysis is ongoing, with results expected to be published in 2020.

Conclusions

Findings from this study will inform the codevelopment of theory-informed, culturally- and linguistically-tailored interventions to support patients in attending retinopathy screening.

International Registered Report Identifier (IRRID)

DERR1-10.2196/15109

Designing clinical practice feedback reports: three steps illustrated in Veterans Health Affairs long-term care facilities and programs

Background

User-centered design (UCD) methods are well-established techniques for creating useful artifacts, but few studies illustrate their application to clinical feedback reports. When used as an implementation strategy, the content of feedback reports depends on a foundational audit process involving performance measures and data, but these important relationships have not been adequately described. Better guidance on UCD methods for designing feedback reports is needed. Our objective is to describe the feedback report design method for refining the content of prototype reports.

Methods

We propose a three-step feedback report design method (refinement of measures, data, and display). The three steps follow dependencies such that refinement of measures can require changes to data, which in turn may require changes to the display. We believe this method can be used effectively with a broad range of UCD techniques.

Results

We illustrate the three-step method as used in implementation of goals of care conversations in long-term care settings in the U.S. Veterans Health Administration. Using iterative usability testing, feedback report content evolved over cycles of the three steps. Following the steps in the proposed method through 12 iterations with 13 participants, we improved the usability of the feedback reports.

Conclusions

UCD methods can improve feedback report content through an iterative process. When designing feedback reports, refining measures, data, and display may enable report designers to improve the user centeredness of feedback reports.

Important Considerations for Design and Implementation of Decision Aids for Shared Medical Decision Making

INTRODUCTION

Decision aids are software or paper-based tools that enable patients and health care practitioners to work together to make optimal treatment decisions. Although there are decades of favorable research for the use of decision aids, there is wide variation in their development and implementation.

OBJECTIVE

To review the literature and provide a summary of best practices for the design, implementation, and assessment of decision aids.

METHODS

A literature search and screening process was employed with a focus on systematic review articles. The resulting articles were synthesized and summarized into recommendations regarding the optimal design, implementation, and appraisal of shared decision-making tools.

RESULTS

Designers of decision aids should initially focus on engagement by involving health care practitioners and patients to ensure the decision aids are pertinent to the situation and not perceived as time consuming. The International Patient Decision Aids Standards help ensure quality in design. Patients should be able to select information in a manner that suits them and view it in a way that allows them to evaluate trade-offs. In reporting of statistical risks, format bias should be avoided through careful and consistent choice of format and by adding visual representations. Decision aids should be tested in real settings with iterative improvements. For appraisal of the implemented decision aids, consider using the Control Preference and Decisional Conflict scales.

DISCUSSION

Further research is recommended regarding optimal engagement of users with decision aids and exploration of the distinct opportunities that computerized decision aids and online patient communities may present.

CONCLUSION

Decision aids can be a valuable tool for shared medical decision making. Their quality and usefulness can be maximized by involving users in their creation and by attending to key considerations in their design, implementation, and appraisal.

Developing the family support tool: An interactive, web-based tool to help families navigate the complexities of surrogate decision making in ICUs

INTRODUCTION

Although family members of incapacitated, critically ill patients often struggle in the role of surrogate decision maker, there are no low-cost, easily-scaled interventions to address this problem.

AIM OF THE STUDY

To develop and pilot-test the Family Support Tool, an interactive, web-based tool to help individuals navigate the complexities of surrogate decision making in ICUs.

MATERIAL AND METHODS

We used a mixed methods, user-centered process to create the Family Support Tool, including: 1) creation of a preliminary design by an expert panel; 2) engagement of a key stakeholder panel to iteratively refine the preliminary design; 3) user testing of a low-fidelity prototype of the tool by 6 former ICU surrogates; 4) creation of a web-based prototype; and 5) user testing of the web-based prototype with 14 surrogates and ICU physicians, including semi-structured interviews and quantitative measurement of usability, acceptability, and perceived effectiveness.

RESULTS

The initial design contained a collection of videos and exercises designed to help individuals understand the surrogate's role and think through the patient's values and preferences. Based on family stakeholders' feedback about the emotional overwhelm they experience early in an ICU stay, we redesigned the tool to be viewed in sections, with the first section focused on decreasing surrogates' emotional distress, and later sections focused on helping surrogates prepare for family meetings. Surrogates actively making decisions in the ICU judged the final tool to be highly usable (mean summary score 83.5, correlating to 95th percentile when normalized to devices of its type), acceptable (mean 4.2 +/- 0.5 out of 5), and effective (mean 4.3 +/- 0.6 out of 5). All surrogates reported the tool helped them consider goals of care and all indicated they would recommend the tool to a friend.

CONCLUSIONS

We successfully developed a web-based tool to help individuals navigate the complexities of surrogate decision making in ICUs that has high potential for scalability. Surrogates judged the tool to be usable, acceptable, and effective. These data support proceeding to test the tool in a pilot randomized clinical trial.

Considering Breast Reconstruction after Mastectomy: A Patient Decision Aid Video and Workbook

Supplemental Digital Content is available in the text.

Women report difficulty understanding and personalizing breast reconstruction information during the complex and time-limited period of cancer treatment planning. Patient decision aids can help patients become well informed, form realistic expectations, prepare to communicate with the surgical team, and be more satisfied with their decision-making process.

Co-creation of a post-traumatic brain injury sexuality information toolkit: a patient-oriented project

AIM

Different studies and two clinical practice guidelines emphasize the necessity to provide patients undergoing rehabilitation with information about commonly occurring changes in sexuality following traumatic brain injury (TBI). The purpose of this study was to co-create information resources for individuals with moderate to severe TBI and their partners to consult during rehabilitation.

METHODS

An iterative user-centered design was used, combining focus group and individual interviews. A convenience sample of individuals with TBI and life partners was constituted.

RESULTS

The needs and expectations of these participants in terms of form and content of an information toolkit on post-TBI sexuality were explored. The subjects that matched the interests and needs of participants were numerous and supported by the literature. Contrasting with existing written resources, the participants' views oriented the creation process toward the development of a toolkit including five audiovisual presentations, a double-sided information sheet, and a checklist.

CONCLUSIONS

A similar approach of co-creation could be used to develop other information packs aimed at patients with other disabilities. The created material is expected to be a usable and useful tool for individuals with TBI, which can support clinicians in addressing the subject of sexuality.Implications for rehabilitationThe central role held by individuals with moderate to severe traumatic brain injury, in identifying the sexuality related topics to be addressed and the form of resources to be created, led to a better understanding of their needs.This patient-centered research brought solutions to difficulties related to the understanding of health information, prevalent among patients.This patient-oriented project highlights the necessity for adequacy between the health information provided by rehabilitation professionals and the capacity of their patients' to seek for, process, and understand its content.

Communicating laboratory results to patients and families

People are increasingly able to access their laboratory results via patient portals. The potential benefits provided by such access, such as reductions in patient burden and improvements in patient satisfaction, disease management, and medical decision making, also come with potentially valid concerns about such results causing confusion or anxiety among patients. However, it is possible to clearly convey the meaning of results and, when needed, indicate required action by designing systems to present laboratory results adapted to the people who will use them. Systems should support people in converting the potentially meaningless data of results into meaningful information and actionable knowledge. We offer 10 recommendations toward this goal: (1) whenever possible, provide a clear takeaway message for each result. (2) Signal whether differences are meaningful or not. (3) When feasible, provide thresholds for concern and action. (4) Individualize the frame of reference by allowing custom reference ranges. (5) Ensure the system is accessible. (6) Provide conversion tools along with results. (7) Design in collaboration with users. (8) Design for both new and experienced users. (9) Make it easy for people use the data as they wish. (10) Collaborate with experts from relevant fields. Using these 10 methods and strategies renders access to laboratory results into meaningful and actionable communication. In this way, laboratories and medical systems can support patients and families in understanding and using their laboratory results to manage their health.

The Benefits and Challenges of Using Patient Decision Aids to Support Shared Decision Making in Health Care

Shared decision making (SDM) and patient-centered care require patients to actively participate in the decision-making process. Yet with the increasing number and complexity of cancer treatment options, it can be a challenge for patients to evaluate clinical information and make risk-benefit trade-offs to choose the most appropriate treatment. Clinicians face time constraints and communication challenges, which can further hamper the SDM process. In this article, we review patient decision aids (PDAs) as a means of supporting SDM by presenting clinical information and risk data to patients in a format that is accessible and easy to understand. We outline the benefits and limitations of PDAs as well as the challenges in their development, such as a lengthy and complex development process and implementation obstacles. Lastly, we discuss future trends and how change on multiple levels-PDA developers, clinicians, hospital administrators, and health care insurers-can support the use of PDAs and consequently SDM. Through this multipronged approach, patients can be empowered to take an active role in their health and choose treatments that are in line with their values.

Measurement properties of self-report pedestrians' road crossing behavior questionnaires constructed based on the theory of planned behavior: protocol for a systematic review

BACKGROUND

Pedestrians' unsafe crossing behavior exposes them at risk of trauma and death and puts a tremendous burden on the health care system. The theory of planned behavior (TPB) is one of the leading theoretical models used to develop pedestrians' road crossing behavior questionnaires, yet the quality of measurement properties of them has not been evaluated. The aim of the proposed systematic review is to evaluate the quality of measurement properties of the questionnaires constructed based on the TPB to predict pedestrians' road crossing behavior.

METHODS

We will include studies validating or evaluating one or more psychometric properties of the self-reported questionnaire employing the TPB for predicting pedestrians' road crossing behavior. A comprehensive search strategy will be formulated based on the components of review aim. The databases of MEDLINE, Embase, PubMed, Cochrane Library, PsycINFO, PsycARTICLES, and ProQuest, also grey literature and the reference lists of the included studies, will be searched. A hand search for the relevant journals and Google Scholar will be conducted. COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) Risk of Bias checklist will be used to evaluate the measurement properties of the included questionnaires. First, we will assess standards for the methodological quality of each study. Then, each scale or subscale of a questionnaire will be rated using the updated criteria for good measurement property. We will quantitatively pool or qualitatively summarize the results and will evaluate them against the criteria for good measurement properties. Finally, we will grade the pooled or summarized evidence using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach and provide recommendations for the most appropriate instrument.

DISCUSSION

The proposed systematic review will evaluate the measurement properties of self-report pedestrians' road crossing behavior questionnaires constructed based on the TPB. The findings will help researchers in selecting the appropriate TPB-based instrument for pedestrians' road crossing behavior.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017047793.

Development and validation of a patient decision aid for prostate Cancer therapy: from paternalistic towards participative shared decision making

BACKGROUND

Patient decision aids (PDAs) can support the treatment decision making process and empower patients to take a proactive role in their treatment pathway while using a shared decision-making (SDM) approach making participatory medicine possible. The aim of this study was to develop a PDA for prostate cancer that is accurate and user-friendly.

METHODS

We followed a user-centered design process consisting of five rounds of semi-structured interviews and usability surveys with topics such as informational/decisional needs of users and requirements for PDAs. Our user-base consisted of 8 urologists, 4 radiation oncologists, 2 oncology nurses, 8 general practitioners, 19 former prostate cancer patients, 4 usability experts and 11 healthy volunteers.

RESULTS

Informational needs for patients centered on three key factors: treatment experience, post-treatment quality of life, and the impact of side effects. Patients and clinicians valued a PDA that presents balanced information on these factors through simple understandable language and visual aids. Usability questionnaires revealed that patients were more satisfied overall with the PDA than clinicians; however, both groups had concerns that the PDA might lengthen consultation times (42 and 41%, respectively). The PDA is accessible on http://beslissamen.nl/ .

CONCLUSIONS

User-centered design provided valuable insights into PDA requirements but challenges in integrating diverse perspectives as clinicians focus on clinical outcomes while patients also consider quality of life. Nevertheless, it is crucial to involve a broad base of clinical users in order to better understand the decision-making process and to develop a PDA that is accurate, usable, and acceptable.

Development and evaluation of decision aids for people considering taking part in a clinical trial: a conceptual framework

Ethical requirements of informed consent stipulate that patients approached to participate in a clinical trial be provided with written information that must cover key aspects of the trial. For consent to be deemed “informed”, potential participants should be provided with a range of information about the trials (e.g., the trial aims, the anticipated benefits and potential risks of the trial, and their right to withdraw consent at any time). However, it is well documented that simple provision of this information does not ensure that participants make truly informed decisions. Decision aids, tools that have been shown in a treatment and screening context to support better-quality decisions, are emerging as a possible vehicle to support decision making about trial participation. However, information on how they should best be developed and evaluated in a clinical trial context is lacking. Therefore, this article, drawing on theoretical and empirical insights, outlines a framework for the development and evaluation of decision aids for people considering taking part in a clinical trial.

User-testing an interactive option grid decision aid for prostate cancer screening: lessons to improve usability

OBJECTIVE

To user-test a web-based, interactive Option Grid decision aid 'prostate-specific antigen (PSA) test: yes or no?' to determine its usability, acceptability and feasibility with men of high and low health literacy.

DESIGN

A semi-structured interview study.

SETTING

Interviews were conducted at a senior centre, academic hospital or college library in New Hampshire and Vermont.

PARTICIPANTS

Individuals over 45 years of age with no history of prostate cancer who voluntarily contacted study authors after viewing local invitations were eligible for inclusion. Twenty interviews were conducted: 10 participants had not completed a college degree, of which eight had low health literacy, and 10 participants had high health literacy.

INTERVENTION

An interactive, web-based Option Grid patient decision aid for considering whether or not to have a PSA test.

RESULTS

Users with lower health literacy levels were able to understand the content in the tool but were not able to navigate the Option Grid independent of assistance. The tool was used independently by men with high health literacy. In terms of acceptability, the flow of questions and answers embedded in the tool did not seem intuitive to some users who preferred seeing more risk information related to age and family history. Users envisioned that the tool could be feasibly implemented in clinical workflows.

CONCLUSION

Men in our sample with limited health literacy had difficulty navigating the Option Grid, thus suggesting that the tool was not appropriately designed to be usable by all audiences. The information provided in the tool is acceptable, but users preferred to view personalised risk information. Some participants could envision using this tool prior to an encounter in order to facilitate a better dialogue with their clinician.

ETHICS APPROVAL

The study received ethical approval from the Dartmouth College Committee for the Protection of Human Subjects (STUDY00030116).

Decision aids that facilitate elements of shared decision making in chronic illnesses: a systematic review

BACKGROUND

Shared decision making (SDM) is a patient-centered approach in which clinicians and patients work together to find and choose the best course of action for each patient's particular situation. Six SDM key elements can be identified: situation diagnosis, choice awareness, option clarification, discussion of harms and benefits, deliberation of patient preferences, and making the decision. The International Patient Decision Aid Standards (IPDAS) require that a decision aid (DA) support these key elements. Yet, the extent to which DAs support these six key SDM elements and how this relates to their impact remain unknown.

METHODS

We searched bibliographic databases (from inception until November 2017), reference lists of included studies, trial registries, and experts for randomized controlled trials of DAs in patients with cardiovascular, or chronic respiratory conditions or diabetes. Reviewers worked in duplicate and independently selected studies for inclusion, extracted trial, and DA characteristics, and evaluated the quality of each trial.

RESULTS

DAs most commonly clarified options (20 of 20; 100%) and discussed their harms and benefits (18 of 20; 90%; unclear in two DAs); all six elements were clearly supported in 4 DAs (20%). We found no association between the presence of these elements and SDM outcomes.

CONCLUSIONS

DAs for selected chronic conditions are mostly designed to transfer information about options and their harms and benefits. The extent to which their support of SDM key elements relates to their impact on SDM outcomes could not be ascertained.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42016050320 .

Reducing complexity of patient decision aids for community-based older adults with dementia and their caregivers: multiple case study of Decision Boxes

OBJECTIVES

To identify patient decision aids' features to limit their complexity for older adults with dementia and their family caregivers.

DESIGN

Mixed method, multiple case study within a user-centred design (UCD) approach.

SETTING

Community-based healthcare in the province of Quebec in Canada.

PARTICIPANTS

23 older persons (aged 65+ years) with dementia and their 27 family caregivers.

RESULTS

During three UCD evaluation-modification rounds, participants identified strengths and weaknesses of the patient decision aids' content and visual design that influenced their complexity. Weaknesses of content included a lack of understanding of the decision aids' purpose and target audience, missing information, irrelevant content and issues with terminology and sentence structure. Weaknesses of visual design included critics about the decision aids' general layout (density, length, navigation) and their lack of pictures. In response, the design team implemented a series of practical features and design strategies, comprising: a clear expression of the patient decision aids' purpose through simple text, picture and personal stories; systematic and frequent use of pictograms illustrating key points and helping structure patient decision aids' general layout; a glossary; removal of scientific references from the main document; personal stories to clarify more difficult concepts; a contact section to facilitate implementation of the selected option; GRADE ratings to convey the quality of the evidence; a values clarification exercise formatted as a checklist and presented at the beginning of the document to streamline navigation; involvement of a panel of patient/caregiver partners to guide expression of patient priorities; editing of the text to a sixth grade reading level; UCD process to optimise comprehensiveness and relevance of content and training of patients/caregivers in shared decision-making.

CONCLUSIONS

The revised template for patient decision aids is designed to meet the needs of adults living with dementia and their caregivers better, which may translate into fewer evaluation-modification rounds.

Developing a Conversation Aid to Support Shared Decision Making: Reflections on Designing Anticoagulation Choice

Patient-centered care requires that treatments respond to the problematic situation of each patient in a manner that makes intellectual, emotional, and practical sense, an achievement that requires shared decision making (SDM). To implement SDM in practice, tools-sometimes called conversation aids or decision aids-are prepared by collating, curating, and presenting high-quality, comprehensive, and up-to-date evidence. Yet, the literature offers limited guidance for how to make evidence support SDM. Herein, we describe our approach and the challenges encountered during the development of Anticoagulation Choice, a conversation aid to help patients with atrial fibrillation and their clinicians jointly consider the risk of thromboembolic stroke and decide whether and how to respond to this risk with anticoagulation.

End-user views of an electronic encounter decision aid linked to routine depression screening

OBJECTIVE

Our aim was to gather community stakeholder input to inform the development of a digital system linking depression screening to decision support.

METHODS

Views and feature requirements were identified through (1) focus groups with patients and consumers with depression, and interviews with primary care clinicians and (2) usability sessions where patients and consumers used the current version of encounter decision aid (eDA) in a primary care waiting room. Qualitative data were analyzed using the framework method.

RESULTS

We conducted six focus groups with 15 participants, seven clinician interviews and 10 usability sessions. Patients were comfortable completing the Patient Health Questionnaire (PHQ-9) and receiving the electronic eDA in clinic. They felt this would allow patients to prepare for their visit and instill a sense of agency. Participants were comfortable receiving the PHQ-9 results and a subsequent eDA on a tablet in the waiting room.

CONCLUSION

Patients with and without depression, as well as clinicians, viewed linking the PHQ-9, results, and eDA positively. Patients were comfortable doing this in the clinic waiting room.

PRACTICE IMPLICATIONS

Linking depression decision support to screening was viewed positively by patients and clinicians, and could help overcome barriers to shared decision-making implementation in this population.

Evaluating Mobile Health Apps for Customized Dietary Recording for Young Adults and Seniors: Randomized Controlled Trial

BACKGROUND

The role of individual-tailored dietary recording in mobile phone health apps has become increasingly important in management of self-health care and population-based preventive service. The development of such mobile apps for user-centered designing is still challengeable and requires further scientific evidence.

OBJECTIVE

This study aims to conduct a randomized trial to assess the accuracy and time efficiency of two prototypes for dietary recoding utilization related to the input method of food intake.

METHODS

We first present an innovative combinatorial concept for dietary recording to account for dish variation. One prototype was a self-chosen tab app that featured choosing each food ingredient to synthesize an individual dish, whereas the other was an autonomous exhaustive list app that provided one selection from a comprehensive list of dish items. The concept included commercially available choices that allowed users to more accurately account for their individual food selection. The two mobile apps were compared in a head-to-head parallel randomized trial evaluation. Young adults (n=70, aged 18-29) and older adults (n=35, aged 55-73) were recruited and randomized into two groups for accuracy and response time evaluation based on 12 types of food items in use of the developed self-chosen tab and autonomous exhaustive list apps, respectively.

RESULTS

For the trials based on the self-chosen tab (53 participants) and autonomous exhaustive list groups (52 participants), the two prototypes were found to be highly accurate (>98%). The self-chosen tab app was found to be more efficient, requiring significantly less time for input of 11 of 12 items (P<.05). The self-chosen tab users occasionally neglected to select food attributes, an issue which did not occur in the autonomous exhaustive list group.

CONCLUSIONS

Our study contributes through the scientific evaluation of the transformation step into prototype development to demonstrate that a self-chosen tab app has potentially better opportunity in effectiveness and efficiency. The combinatorial concept offers potential for dietary recording and planning which can account for high food item variability. Our findings on prototype development of diversified dietary recordings provide design consideration and user interaction for related further app development and improvement.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN86142301; http://www.isrctn.com/ ISRCTN86142301 (Archived by WebCite at http://www.webcitation.org/74YLEPYnS).

Integrating implementation and user-centred design strategies to enhance the impact of health services: protocol from a concept mapping study

BACKGROUND

Innovative approaches are needed to maximise the uptake and sustainment of evidence-based practices in a variety of health service contexts. This protocol describes a study that will seek to characterise the potential of one such approach, user-centred design (UCD), which is an emerging field that seeks to ground the design of an innovation in information about the people who will ultimately use that innovation. The use of UCD to enhance strategies for implementation of health services, although promising, requires a multidisciplinary perspective based on a firm understanding of how experts from each discipline perceives the interrelatedness and suitability of these strategies.

METHOD

This online study will use a combination of purposive and snowball sampling to recruit a sample of implementation experts (n = 30) and UCD experts (n = 30). These participants will each complete a concept mapping task, which is a mixed-method conceptualisation technique that will allow for identification of distinct clusters of implementation and/or UCD strategies. The research team has selected a set of implementation strategies and UCD strategies that each participant will sort and rate on dimensions of importance and feasibility. Data analyses will focus on describing the sample, identifying related clusters of strategies, and examining the convergences, divergences, and potential for collaboration between implementation science and UCD.

DISCUSSION

By leading to a better understanding of the overlap between implementation science and UCD, grounded within established theoretical frameworks, this study holds promise for improving the impact and sustainability of evidence-based health services in community settings.

Electronically Verified Use of Internet-Based, Multimedia Decision Aids by Adolescents With Type 1 Diabetes and Their Caregivers

Decision aids (DAs) are central to shared decision making (SDM) interventions, yet little is known about patients' actual DA use. Adequate utilization of DAs could optimize SDM effectiveness. Electronic DAs enable more objective tracking and analysis of actual DA utilization than do paper DAs. This report is part of an ongoing randomized controlled SDM trial enrolling adolescents with type 1 diabetes and their caregivers (n = 153) who were considering use of an insulin pump or continuous glucose monitor. Extensive stakeholder engagement guided creation of two online DAs. After completing baseline measures, 133 dyads were randomized to SDM (access to the pertinent DA) or Usual Care (clinic routines for preparing candidates for adopting these devices). Utilization data showed that 80% of caregivers and 66% of youths logged into a DA at least once; youths and caregivers, respectively, dedicated a mean of 44.7 and 55.0 minutes to website use and viewed 72.2% and 77.4% of the DA content. Median total duration from enrollment to last DA logout was 48.2 days for adolescents and 45.6 days for caregivers. Bivariate comparisons showed that non-Hispanic, Caucasian females from households with higher socioeconomic status were significantly more likely to login to the assigned DA at least once. Hierarchical multiple regression showed that adolescent males with lower levels of health literacy demonstrated fewer DA logins (F = 2.59; P < 0.009), but identified no significant predictors of adolescents' or caregiver' duration of DA use or proportion of DA content viewed. Future SDM trials should seek to promote DA use, especially by non-White adolescents, perhaps with direct assistance with the initial DA login. Trials employing electronic DAs should routinely report and analyze utilization data.

Design Thinking in Health Care

Introduction

Applying Design Thinking to health care could enhance innovation, efficiency, and effectiveness by increasing focus on patient and provider needs. The objective of this review is to determine how Design Thinking has been used in health care and whether it is effective.

Methods

We searched online databases (PubMed, Medline, Web of Science, CINAHL, and PyscINFO) for articles published through March 31, 2017, using the terms “health,” “health care,” or “healthcare”; and “Design Thinking,” “design science,” “design approach,” “user centered design,” or “human centered design.” Studies were included if they were written in English, were published in a peer-reviewed journal, provided outcome data on a health-related intervention, and used Design Thinking in intervention development, implementation, or both. Data were collected on target users, health conditions, intervention, Design Thinking approach, study design or sample, and health outcomes. Studies were categorized as being successful (all outcomes improved), having mixed success (at least one outcome improved), or being not successful (no outcomes improved).

Results

Twenty-four studies using Design Thinking were included across 19 physical health conditions, 2 mental health conditions, and 3 systems processes. Twelve were successful, 11 reported mixed success, and one was not successful. All 4 studies comparing Design Thinking interventions to traditional interventions showed greater satisfaction, usability, and effectiveness.

Conclusion

Design Thinking is being used in varied health care settings and conditions, although application varies. Design Thinking may result in usable, acceptable, and effective interventions, although there are methodological and quality limitations. More research is needed, including studies to isolate critical components of Design Thinking and compare Design Thinking–based interventions with traditionally developed interventions.

Development of a Path to Home Mobile App for the Geriatric Rehabilitation Program at Bruyère Continuing Care: Protocol for User-Centered Design and Feasibility Testing Studies

Background

As the population ages, the need for appropriate geriatric rehabilitation services will also increase. Pressures faced by hospitals to reduce length of stay and reduce costs have driven the need for more complex care being delivered in the home or community setting. As a result, a multifaceted approach that can provide geriatric rehabilitation patients with safe and effective person- and family-centered care during transitions from hospital to home is required. We hypothesize that a technology-supported person- and family-centered care transition could empower geriatric rehabilitation patients, engage them in shared decision making, and ultimately help them to safely manage their personalized needs during care transitions from hospital to home.

Objective

The purpose of this study is to design and test the feasibility of a novel Path to Home mobile app to manage the personalized needs of geriatric rehabilitation patients during their transitions from hospital to home.

Methods

This study will consist of (1) codesigning a patient- and provider-tailored mobile app, and (2) feasibility pilot testing of the mobile app to manage the needs of geriatric rehabilitation patients when leaving the hospital. In phase 1, we will follow a user-centered design process integrated with a modern agile software development methodology to iteratively codesign the personalized care transition Path to Home mobile app. In phase 2, we will conduct a single-arm feasibility pilot test with geriatric rehabilitation patients using the personalized care transition Path to Home mobile app to manage their needs during the transition from hospital to home.

Results

The project was funded in May 2018, and enrollment and data analysis are underway. First results are expected to be submitted for publication in 2019.

Conclusions

Our findings will help validate the use of this technology for geriatric rehabilitation patients discharged from the hospital to home. Future research will more rigorously evaluate the health and economic benefits to inform wide-scale adoption of the technology.

Registered Report Identifier

RR1-10.2196/11031

Agile research to complement agile development: a proposal for an mHealth research lifecycle

Mobile health (mHealth) technology is increasingly being used, but academic evaluations supporting its use are not keeping pace. This is partly due to the disconnect between the traditional pharmaceutical approach to product evaluation, with its incremental approach, and the flexible way in which mHealth products are developed. An important step to addressing these problems lies in establishing agile research methods that complement the agile development methodologies used to create modern digital health applications. We describe an mHealth research model that mirrors traditional clinical research methods in its attention to safety and efficacy, while also accommodating the rapid and iterative development and evaluation required to produce effective, evidence-based, and sustainable digital products. This approach consists of a project identification stage followed by four phases of clinical evaluation: Phase 1: User Experience Design, Development, & Alpha Testing; Phase 2: Beta testing; Phase 3: Clinical Trial Evaluation; and Phase 4: Post-Market Surveillance. These phases include sample gating questions and are adapted to accommodate the unique nature of digital product development.

Availability of researcher-led eHealth tools for pain assessment and management: barriers, facilitators, costs, and design

INTRODUCTION

Numerous eHealth tools for pain assessment and management have been developed and evaluated with promising results regarding psychometric properties, efficacy, and effectiveness. Although considerable resources are spent on developing and evaluating these tools with the aim of increasing access to care, current evidence suggests they are not made available to end users, reducing their impact and creating potential research waste.

METHODS

This study consisted of 2 components: (1) a systematic review of eHealth tools for pediatric pain assessment and/or management published in the past 10 years, and (2) an online survey, completed by the authors of identified tools, of tool availability, perceived barriers or facilitators to availability, grant funding used, and a validated measure of user-centeredness of the design process (UCD-11).

RESULTS

Ninety articles (0.86% of citations screened) describing 53 tools met inclusion criteria. Twenty-six survey responses were completed (49.06%), 13 of which (50.00%) described available tools. Commonly endorsed facilitators of tool availability included researchers' beliefs in tool benefits to the target population and research community; barriers included lack of infrastructure and time. The average cost of each unavailable tool was $314,425.31 USD ($3,144,253.06 USD total, n = 10). Authors of available tools were more likely to have followed user-centered design principles and reported higher total funding.

CONCLUSION

Systemic changes to academic and funding structures could better support eHealth tool availability and may reduce potential for research waste. User-centered design and implementation science methods could improve the availability of eHealth tools and should be further explored in future studies.

Tailoring and evaluating an intervention to improve shared decision-making among seniors with dementia, their caregivers, and healthcare providers: study protocol for a randomized controlled trial

Background

The increasing prevalence of Alzheimer’s disease and other forms of dementia raises new challenges to ensure that healthcare decisions are informed by research evidence and reflect what is important for seniors and their caregivers. Therefore, we aim to evaluate a tailored intervention to help healthcare providers empower seniors and their caregivers in making health-related decisions.

Methods

In two phases, we will: (1) design and tailor the intervention; and (2) implement and evaluate it. We will use theory and user-centered design to tailor an intervention comprising a distance professional training program on shared decision-making and five shared decision-making tools dealing with difficult decisions often faced by seniors with dementia and their caregivers. Each tool will be designed in two versions, one for clinicians and one for patients. We will recruit 49 clinicians and 27 senior/caregiver to participate in three cycles of design-evaluation-feedback of each intervention components. Besides think-aloud and interview approaches, users will also complete questionnaires based on the Theory of Planned Behavior to identify the factors most likely to influence their adoption of shared decision-making after exposure to the intervention. We will then modify the intervention by adding/enhancing behavior-change techniques targeting these factors. We will evaluate the effectiveness of this tailored intervention before/after implementation, in a two-armed, clustered randomized trial. We will enroll a convenience sample of six primary care clinics (unit of randomization) in the province of Quebec and recruit the clinicians who practice there (mostly family physicians, nurses, and social workers). These clinics will then be randomized to immediate exposure to the intervention or delayed exposure. Overall, we will recruit 180 seniors with dementia, their caregivers, and their healthcare providers. We will evaluate the impact of the intervention on patient involvement in the decision-making process, decisional comfort, patient and caregiver personal empowerment in relation to their own healthcare, patient quality of life, caregiver burden, and decisional regret.

Discussion

The intervention will empower patients and their caregivers in their healthcare, by fostering their participation as partners during the decision-making process and by ensuring they make informed decisions congruent with their values and priorities.

Trial registration

ClinicalTrials.org, NCT02956694. Registered on 31 October 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2697-1) contains supplementary material, which is available to authorized users.

Pregnant women's views on how to promote the use of a decision aid for Down syndrome prenatal screening: a theory-informed qualitative study

Background

For pregnant women and their partners, the decision to undergo Down syndrome prenatal screening is difficult. Patient decision aids (PtDA) can help them make an informed decision. We aimed to identify behaviour change techniques (BCTs) that would be useful in an intervention to promote the use of a PtDA for Down syndrome prenatal screening, and to identify which of these BCTs pregnant women found relevant and acceptable.

Methods

Using the Behaviour Change Wheel and the Theoretical Domains Framework, we conducted a qualitative descriptive study. First, a group of experts from diverse professions, disciplines and backgrounds (eg. medicine, engineering, implementation science, community and public health, shared decision making) identified relevant BCTs. Then we recruited pregnant women consulting for prenatal care in three clinical sites: a family medicine group, a birthing centre (midwives) and a hospital obstetrics department in Quebec City, Canada. To be eligible, participants had to be at least 18 years old, having recently given birth or at least 16 weeks pregnant with a low-risk pregnancy, and have already decided about prenatal screening. We conducted three focus groups and asked questions about the relevance and acceptability of the BCTs. We analysed verbatim transcripts and reduced the BCTs to those the women found most relevant and acceptable.

Results

Our group of experts identified 25 relevant BCTs relating to information, support, consequences, others’ approval, learning, reward, environmental change and mode of delivery. Fifteen women participated in the study with a mean age of 27 years. Of these, 67% (n = 10) were pregnant for the first time, 20% (n = 3) had difficulty making the decision to take the test, and 73% had made the decision with their partner. Of the 25 BCTs identified using the Behaviour Change Wheel, the women found the following 10 to be most acceptable and relevant: goal setting (behaviour), goal setting (results), problem solving, action plan, social support (general), social support (practical), restructuring the physical environment, prompts/cues, credible sources and modelling or demonstration of the behaviour.

Conclusions

An intervention to promote PtDA use among pregnant women for Down syndrome prenatal screening should incorporate the 10 BCTs identified.

Impacts of online and group perinatal education: a mixed methods study protocol for the optimization of perinatal health services

Background

Prenatal education is a core component of perinatal care and services provided by health institutions. Whereas group prenatal education is the most common educational model, some health institutions have opted to implement online prenatal education to address accessibility issues as well as the evolving needs of future parents. Various studies have shown that prenatal education can be effective in acquisition of knowledge on labour and delivery, reducing psychological distress and maximising father’s involvement. However, these results may depend on educational material, organization, format and content. Furthermore, the effectiveness of online prenatal education compared to group prenatal education remains unclear in the literature. This project aims to evaluate the impacts of group prenatal education and online prenatal education on health determinants and users’ health status, as well as on networks of perinatal educational services maintained with community-based partners.

Methods

This multipronged mixed methods study uses a collaborative research approach to integrate and mobilize knowledge throughout the process. It consists of: 1) a prospective cohort study with quantitative data collection and qualitative interviews with future and new parents; and 2) a multiple case study integrating documentary sources and interviews with stakeholders involved in the implementation of perinatal information service networks and collaborations with community partners. Perinatal health indicators and determinants will be compared between prenatal education groups (group prenatal education and online prenatal education) and standard care without these prenatal education services (control group).

Discussion

This study will provide knowledge about the impact of online prenatal education as a new technological service delivery model compared to traditional group prenatal education. Indicators related to the complementarity of these interventions and those available in community settings will refine our understanding of regional perinatal services networks. Results will assist decision-making regarding service organization and delivery models of prenatal education services.

Protocol version

Version 1 (February 9 2018).

Standards for UNiversal reporting of patient Decision Aid Evaluation studies: the development of SUNDAE Checklist

BACKGROUND

Patient decision aids (PDAs) are evidence-based tools designed to help patients make specific and deliberated choices among healthcare options. The International Patient Decision Aid Standards (IPDAS) Collaboration review papers and Cochrane systematic review of PDAs have found significant gaps in the reporting of evaluations of PDAs, including poor or limited reporting of PDA content, development methods and delivery. This study sought to develop and reach consensus on reporting guidelines to improve the quality of publications evaluating PDAs.

METHODS

An international workgroup, consisting of members from IPDAS Collaboration, followed established methods to develop reporting guidelines for PDA evaluation studies. This paper describes the results from three completed phases: (1) planning, (2) drafting and (3) consensus, which included a modified, two-stage, online international Delphi process. The work was conducted over 2 years with bimonthly conference calls and three in-person meetings. The workgroup used input from these phases to produce a final set of recommended items in the form of a checklist.

RESULTS

The SUNDAE Checklist (Standards for UNiversal reporting of patient Decision Aid Evaluations) includes 26 items recommended for studies reporting evaluations of PDAs. In the two-stage Delphi process, 117/143 (82%) experts from 14 countries completed round 1 and 96/117 (82%) completed round 2. Respondents reached a high level of consensus on the importance of the items and indicated strong willingness to use the items when reporting PDA studies.

CONCLUSION

The SUNDAE Checklist will help ensure that reports of PDA evaluation studies are understandable, transparent and of high quality. A separate Explanation and Elaboration publication provides additional details to support use of the checklist.

Building an Informed Consent Tool Starting with the Patient: The Patient-Centered Virtual Multimedia Interactive Informed Consent (VIC)

Patient safety and quality of care are at risk if the informed consent process does not emphasize patient comprehension. In this paper, we describe how we designed, developed, and evaluated an mHealth tool for advancing the informed consent process. Our tool enables the informed consent process to be performed on tablets (e.g., iPads) utilizing virtual coaching with text-to-speech automated translation as well as an interactive multimedia elements (e.g., graphics, video clips, animations, presentations, etc.). We designed our tool to enhance patient comprehension and quality of care, while improving the efficiency of obtaining patient consent. We present the Used-Centered Design approach we adopted to develop the tool and the results of the different methods we used during the development of the tool. Also, we describe the results of the usability study which we conducted to evaluate the effectiveness, efficiency, and user satisfaction with our mHealth App to enhance the informed consent process. Using the UCD approach we were able to design, develop, and evaluate a highly interactive mHealth App to deliver the informed consent process.

Agile Acceptance Test-Driven Development of Clinical Decision Support Advisories: Feasibility of Using Open Source Software

Background

Moving to electronic health records (EHRs) confers substantial benefits but risks unintended consequences. Modern EHRs consist of complex software code with extensive local configurability options, which can introduce defects. Defects in clinical decision support (CDS) tools are surprisingly common. Feasible approaches to prevent and detect defects in EHR configuration, including CDS tools, are needed. In complex software systems, use of test–driven development and automated regression testing promotes reliability. Test–driven development encourages modular, testable design and expanding regression test coverage. Automated regression test suites improve software quality, providing a “safety net” for future software modifications. Each automated acceptance test serves multiple purposes, as requirements (prior to build), acceptance testing (on completion of build), regression testing (once live), and “living” design documentation. Rapid-cycle development or “agile” methods are being successfully applied to CDS development. The agile practice of automated test–driven development is not widely adopted, perhaps because most EHR software code is vendor-developed. However, key CDS advisory configuration design decisions and rules stored in the EHR may prove amenable to automated testing as “executable requirements.”

Objective

We aimed to establish feasibility of acceptance test–driven development of clinical decision support advisories in a commonly used EHR, using an open source automated acceptance testing framework (FitNesse).

Methods

Acceptance tests were initially constructed as spreadsheet tables to facilitate clinical review. Each table specified one aspect of the CDS advisory’s expected behavior. Table contents were then imported into a test suite in FitNesse, which queried the EHR database to automate testing. Tests and corresponding CDS configuration were migrated together from the development environment to production, with tests becoming part of the production regression test suite.

Results

We used test–driven development to construct a new CDS tool advising Emergency Department nurses to perform a swallowing assessment prior to administering oral medication to a patient with suspected stroke. Test tables specified desired behavior for (1) applicable clinical settings, (2) triggering action, (3) rule logic, (4) user interface, and (5) system actions in response to user input. Automated test suite results for the “executable requirements” are shown prior to building the CDS alert, during build, and after successful build.

Conclusions

Automated acceptance test–driven development and continuous regression testing of CDS configuration in a commercial EHR proves feasible with open source software. Automated test–driven development offers one potential contribution to achieving high-reliability EHR configuration. Vetting acceptance tests with clinicians elicits their input on crucial configuration details early during initial CDS design and iteratively during rapid-cycle optimization.

Increasing Vaccination: Putting Psychological Science Into Action

Vaccination is one of the great achievements of the 20th century, yet persistent public-health problems include inadequate, delayed, and unstable vaccination uptake. Psychology offers three general propositions for understanding and intervening to increase uptake where vaccines are available and affordable. The first proposition is that thoughts and feelings can motivate getting vaccinated. Hundreds of studies have shown that risk beliefs and anticipated regret about infectious disease correlate reliably with getting vaccinated; low confidence in vaccine effectiveness and concern about safety correlate reliably with not getting vaccinated. We were surprised to find that few randomized trials have successfully changed what people think and feel about vaccines, and those few that succeeded were minimally effective in increasing uptake. The second proposition is that social processes can motivate getting vaccinated. Substantial research has shown that social norms are associated with vaccination, but few interventions examined whether normative messages increase vaccination uptake. Many experimental studies have relied on hypothetical scenarios to demonstrate that altruism and free riding (i.e., taking advantage of the protection provided by others) can affect intended behavior, but few randomized trials have tested strategies to change social processes to increase vaccination uptake. The third proposition is that interventions can facilitate vaccination directly by leveraging, but not trying to change, what people think and feel. These interventions are by far the most plentiful and effective in the literature. To increase vaccine uptake, these interventions build on existing favorable intentions by facilitating action (through reminders, prompts, and primes) and reducing barriers (through logistics and healthy defaults); these interventions also shape behavior (through incentives, sanctions, and requirements). Although identification of principles for changing thoughts and feelings to motivate vaccination is a work in progress, psychological principles can now inform the design of systems and policies to directly facilitate action.

Evaluating the Usability and Usefulness of a Mobile App for Atrial Fibrillation Using Qualitative Methods: Exploratory Pilot Study

BACKGROUND

Atrial fibrillation (AFib) is the most common form of heart arrhythmia and a potent risk factor for stroke. Nonvitamin K antagonist oral anticoagulants (NOACs) are routinely prescribed to manage AFib stroke risk; however, nonadherence to treatment is a concern. Additional tools that support self-care and medication adherence may benefit patients with AFib.

OBJECTIVE

The aim of this study was to evaluate the perceived usability and usefulness of a mobile app designed to support self-care and treatment adherence for AFib patients who are prescribed NOACs.

METHODS

A mobile app to support AFib patients was previously developed based on early stage interview and usability test data from clinicians and patients. An exploratory pilot study consisting of naturalistic app use, surveys, and semistructured interviews was then conducted to examine patients' perceptions and everyday use of the app.

RESULTS

A total of 12 individuals with an existing diagnosis of nonvalvular AFib completed the 4-week study. The average age of participants was 59 years. All participants somewhat or strongly agreed that the app was easy to use, and 92% (11/12) reported being satisfied or very satisfied with the app. Participant feedback identified changes that may improve app usability and usefulness for patients with AFib. Areas of usability improvement were organized by three themes: app navigation, clarity of app instructions and design intent, and software bugs. Perceptions of app usefulness were grouped by three key variables: core needs of the patient segment, patient workflow while managing AFib, and the app's ability to support the patient's evolving needs.

CONCLUSIONS

The results of this study suggest that mobile tools that target self-care and treatment adherence may be helpful to AFib patients, particularly those who are newly diagnosed. Additionally, participant feedback provided insight into the varied needs and health experiences of AFib patients, which may improve the design and targeting of the intervention. Pilot studies that qualitatively examine patient perceptions of usability and usefulness are a valuable and often underutilized method for assessing the real-world acceptability of an intervention. Additional research evaluating the AFib Connect mobile app over a longer period, and including a larger, more diverse sample of AFib patients, will be helpful for understanding whether the app is perceived more broadly to be useful and effective in supporting patient self-care and medication adherence.

Pathways: patient-centred decision counselling for women at risk of cancer-related infertility: a protocol for a comparative effectiveness cluster randomised trial

INTRODUCTION

National guidelines recommend that all reproductive-age women with cancer be informed of their fertility risks and offered referral to fertility specialists to discuss fertility preservation options. However, reports indicate that only 5% of patients have consultations, and rates of long-term infertility-related distress remain high. Previous studies report several barriers to fertility preservation; however, initial success has been reported using provider education, patient decision aids and navigation support. This protocol will test effects of a multicomponent intervention compared with usual care on women's fertility preservation knowledge and decision-making outcomes.

METHODS AND ANALYSIS

This cluster-randomised trial will compare the multicomponent intervention (provider education, patient decision aid and navigation support) with usual care (consultation and referral, if requested). One hundred newly diagnosed English-speaking women of reproductive age who are at risk of cancer-related infertility will be recruited from four regional oncology clinics.The Pathways patient decision aid website provides (1) up-to-date evidence and descriptions of fertility preservation and other family-building options, tailored to cancer type; (2) structured guidance to support personalising the information and informed decision-making; and (3) a printable summary to help women prepare for discussions with their oncologist and/or fertility specialist. Four sites will be randomly assigned to intervention or control groups. Participants will be recruited after their oncology consultation and asked to complete online questionnaires at baseline, 1 week and 2 months to assess their demographics, fertility preservation knowledge, and decision-making process and quality. The primary outcome (decisional conflict) will be tested using Fisher's exact test. Secondary outcomes will be assessed using generalised linear mixed models, and sensitivity analyses will be conducted, as appropriate.

ETHICS AND DISSEMINATION

The University of Texas MD Anderson Cancer Center provided approval and ongoing review of this protocol. Results will be presented at relevant scientific meetings and submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03141437; Pre-results.

Development of a decision aid for cardiopulmonary resuscitation and invasive mechanical ventilation in the intensive care unit employing user-centered design and a wiki platform for rapid prototyping

BACKGROUND

Upon admission to an intensive care unit (ICU), all patients should discuss their goals of care and express their wishes concerning life-sustaining interventions (e.g., cardiopulmonary resuscitation (CPR)). Without such discussions, interventions that prolong life at the cost of decreasing its quality may be used without appropriate guidance from patients.

OBJECTIVES

To adapt an existing decision aid about CPR to create a wiki-based decision aid individually adapted to each patient's risk factors; and to document the use of a wiki platform for this purpose.

METHODS

We conducted three weeks of ethnographic observation in our ICU to observe intensivists and patients discussing goals of care and to identify their needs regarding decision making. We interviewed intensivists individually. Then we conducted three rounds of rapid prototyping involving 15 patients and 11 health professionals. We recorded and analyzed all discussions, interviews and comments, and collected sociodemographic data. Using a wiki, a website that allows multiple users to contribute or edit content, we adapted the decision aid accordingly and added the Good Outcome Following Attempted Resuscitation (GO-FAR) prediction rule calculator.

RESULTS

We added discussion of invasive mechanical ventilation. The final decision aid comprises values clarification, risks and benefits of CPR and invasive mechanical ventilation, statistics about CPR, and a synthesis section. We added the GO-FAR prediction calculator as an online adjunct to the decision aid. Although three rounds of rapid prototyping simplified the information in the decision aid, 60% (n = 3/5) of the patients involved in the last cycle still did not understand its purpose.

CONCLUSIONS

Wikis and user-centered design can be used to adapt decision aids to users' needs and local contexts. Our wiki platform allows other centers to adapt our tools, reducing duplication and accelerating scale-up. Physicians need training in shared decision making skills about goals of care and in using the decision aid. A video version of the decision aid could clarify its purpose.

eHealth and mHealth in prostate cancer detection and active surveillance

eHealth and mobile health (mHealth) offer patients, healthcare providers, researchers, and policy makers new potential to improve wellness, practice prevention and reduce suffering from diseases. While the eHealth market is growing to an expected US $26 billion, its potential in the field of Urology is still underused. Research has shown that currently only 176 apps (of the 300,000 medical apps available) were found in the Apple App Store and Google Play Store, of which 20 were prostate cancer related. Three good examples of eHealth/mHealth applications are the Rotterdam Prostate Cancer Risk Calculator (RPCRC) website and app, the Prostate cancer Research International Active Surveillance (PRIAS) website and the Follow MyPSA app for men on active surveillance for prostate cancer: they are tools with a clear vision that offer true added value in daily clinical practice and which positively influence healthcare beyond borders. To increase the uptake of eHealth applications in the coming years, it is important to involve professionals in their design and development, and to guarantee the safety and privacy of its users and their data.

User-Centered Design, Experience, and Usability of an Electronic Consent User Interface to Facilitate Informed Decision-Making in an HIV Clinic

Health information exchange is the electronic accessibility and transferability of patient medical records across various healthcare settings and providers. In some states, patients have to formally give consent to allow their medical records to be electronically shared. The purpose of this study was to apply a novel user-centered, multistep, multiframework approach to design and test an electronic consent user interface, so patients with HIV can make more informed decisions about electronically sharing their health information. This study consisted of two steps. Step 1 was a cross-sectional, descriptive, qualitative study that used user-centric design interviews to create the user interface. This informed Step 2. Step 2 consisted of a one group posttest to examine perceptions of usefulness, ease of use, preference, and comprehension of a health information exchange electronic consent user interface. More than half of the study population had college experience, but challenges remained with overall comprehension regarding consent. The user interface was not independently successful, suggesting that in addition to an electronic consent user interface, human interaction may also be necessary to address the complexities associated with consenting to electronically share health information. Comprehension is key factor in the ability to make informed decisions.

Deciding How to Stay Independent at Home in Later Years: Development and Acceptability Testing of an Informative Web-Based Module

Background

Seniors with loss of autonomy may face decisions about whether they should stay at home or move elsewhere. Most seniors would prefer to stay home and be independent for as long as possible, but most are unaware of options that would make this possible.

Objective

The study aimed to develop and test the acceptability of an interactive website for seniors, their caregivers, and health professionals with short interlinked videos presenting information about options for staying independent at home.

Methods

The approach for design and data collection varied, involving a multipronged, user-centered design of the development process, qualitative interviews, and end-user feedback to determine content (ie, needs assessment) in phase I; module development (in English and French) in phase II; and survey to test usability and acceptability with end users in phase III. Phase I participants were a convenience sample of end users, that is, seniors, caregivers, and professionals with expertise in modifiable factors (eg, day centers, home redesign, equipment, community activities, and finances), enabling seniors to stay independent at home for longer in Quebec and Alberta, Canada. Phase II participants were bilingual actors; phase III participants included phase I participants and new participants recruited through snowballing. Qualitative interviews were thematically analyzed in phase II to determine relevant topics for the video-scripts, which were user-checked by interview participants. In phase III, the results of a usability questionnaire were analyzed using descriptive statistics.

Results

In phase I, interviews with 29 stakeholders, including 4 seniors, 3 caregivers, and 22 professionals, showed a need for a one-stop information resource about options for staying independent at home. They raised issues relating to 6 categories: cognitive autonomy, psychological or mental well-being, functional autonomy, social autonomy, financial autonomy, and people involved. A script was developed and evaluated by participants. In phase II, after 4 days in a studio with 15 bilingual actors, 30 videos were made of various experts (eg, family doctor, home care nurse, and social worker) presenting options and guidance for the decision-making process. These were integrated into an interactive website, which included a comments tool for visitors to add information. In phase III (n=21), 8 seniors (7 women, mean age 75 years), 7 caregivers, and 6 professionals evaluated the acceptability of the module and suggested improvements. Clarity of the videos scored 3.6 out of 4, length was considered right by 17 (separate videos) and 13 participants (all videos together), and 18 participants considered the module acceptable. They suggested that information should be tailored more, and that seniors may need someone to help navigate it.

Conclusions

Our interactive website with interlinked videos presenting information about options for staying independent at home was deemed acceptable and potentially helpful by a diverse group of stakeholders.

The Pathways fertility preservation decision aid website for women with cancer: development and field testing

PURPOSE

To improve survivors' awareness and knowledge of fertility preservation counseling and treatment options, this study engaged survivors and providers to design, develop, and field-test Pathways: a fertility preservation patient decision aid website for young women with cancer©.

METHODS

Using an adapted user-centered design process, our stakeholder advisory group and research team designed and optimized the Pathways patient decision aid website through four iterative cycles of review and revision with clinicians (n = 21) and survivors (n = 14). Field-testing (n = 20 survivors) assessed post-decision aid scores on the Fertility Preservation Knowledge Scale, feasibility of assessing women's decision-making values while using the website, and website usability/acceptability ratings.

RESULTS

Iterative stakeholder engagement optimized the Pathways decision aid website to meet survivors' and providers' needs, including providing patient-friendly information and novel features such as interactive value clarification exercises, testimonials that model shared decision making, financial/referral resources, and a printable personal summary. Survivors scored an average of 8.2 out of 13 (SD 1.6) on the Fertility Preservation Knowledge Scale. They rated genetic screening and having a biological child as strong factors in their decision-making, and 71% indicated a preference for egg freezing. Most women (> 85%) rated Pathways favorably, and all women (100%) said they would recommend it to other women.

CONCLUSIONS

The Pathways decision aid is a usable and acceptable tool to help women learn about fertility preservation.

IMPLICATIONS FOR CANCER SURVIVORS

The Pathways decision aid may help women make well-informed values-based decisions and prevent future infertility-related distress.