Decision aids for people facing health treatment or screening decisions

Exploring patient involvement in healthcare decision making across different education and functional health literacy groups

Education and health literacy potentially limit a person's ability to be involved in decisions about their health. Few studies, however, have explored understandings and experiences of involvement in decision making among patients varying in education and health literacy. This paper reports on a qualitative interview study of 73 men and women living in Sydney, Australia, with varying education and functional health literacy levels. Participants were recruited from a community sample with lower educational attainment, plus an educated sample of University of Sydney alumni. The transcripts were analysed using the 'Framework' approach, a matrix-based method of thematic analysis. We found that participants with different education conceptualised their involvement in decision making in diverse ways. Participants with higher education appeared to conceive their involvement as sharing the responsibility with the doctor throughout the decision-making process. This entailed verifying the credibility of the information and exploring options beyond those presented in the consultation. They also viewed themselves as helping others in their health decisions and acting as information resources. In contrast, participants with lower education appeared to conceive their involvement in terms of consenting to an option recommended by the doctor, and having responsibility for the ultimate decision, to agree or disagree with the recommendation. They also described how relatives and friends sought information on their behalf and played a key role in their decisions. Both education groups described how aspects of the patient-practitioner relationship (e.g. continuity, negotiation, trust) and the practitioner's interpersonal communication skills influenced their involvement. Health information served a variety of needs for all groups (e.g. supporting psychosocial, practical and decision support needs). These findings have practical implications for how to involve patients with different education and literacy levels in decision making, and highlight the important role of the patient-practitioner relationship in the process of decision making.

Treatment, care and support for people co-infected with HIV and hepatitis C: a scoping review

BACKGROUND

Providing care for people who are co-infected with both HIV and hepatitis C virus (HCV) is becoming increasingly complex and requires integrated prevention, screening, support and programming efforts. We undertook a scoping review to provide a summary of the existing evidence base and to identify and assess the quality of treatment guidelines and systematic reviews related to 3 domains of interest: treatment; epidemiology; and care, support, programming and prevention.

METHODS

We searched 7 databases, hand-searched 8 journals and contacted key informants to identify relevant literature. We included all primary research (including systematic reviews and meta-analyses) or treatment guidelines that assessed pegylated interferon and ribavirin for HCV or highly active antiretroviral therapy for HIV treatment, or both. In the epidemiology domain, we included all primary research (including systematic reviews and meta-analyses). Studies that included only people with hemophilia and those conducted in developing countries were excluded. In the care, support, programming and prevention domain, we included all studies and reports that focused on co-infection. Two reviewers independently applied coding criteria and assessed the quality of the treatment guidelines and systematic reviews using the Appraisal of Guidelines Research and Evaluation and A MeaSurement Tool to Assess Reviews instruments.

RESULTS

Our search strategy yielded 1633 unique references. Of these, 227 references met the final inclusion criteria: 114 addressed treatment, 52 epidemiology and 79 care, support, programming or prevention. The references included 9 treatment guidelines: 4 were assessed as "strongly recommend," 3 as "recommend (with provisos or alterations)" and 1 as "would not recommend" (1 could not be located). Of 10 systematic reviews that were located, 7 were assessed as being high quality, 2 as medium quality and 1 as low quality.

CONCLUSION

This quality-assessed inventory of treatment guidelines and systematic reviews can be used by physicians and service providers to rapidly locate research about HIV-HCV co-infection. However, many treatment guidelines and reviews often indicate that treatment of current injection drug users and/or people with mental health issues should proceed on a "case-by-case basis." Therefore, much of the evidence (particularly in the treatment literature) is limited in its scope and applicability to important populations that are vulnerable to HIV or HCV infection or co-infection.

Training physicians in shared decision-making-who can be reached and what is achieved?

OBJECTIVE

To report on experiences with a general shared decision-making (SDM) physician training program offered to physicians throughout Germany.

METHODS

This study enrolled 150 physicians in an 8-h SDM training program. Physicians were assessed with standardized instruments before and after training. Main variables of interest were physician professional attributes, personality characteristics, attitudes, measures of training success (quality rating, knowledge, competency ratings), and variables associated with training success.

RESULTS

The SDM training obtained positive quality ratings, led to an amelioration in an objective SDM knowledge test (p<.001), and highly improved physicians' confidence in their SDM competencies (p<0.001). It attracted experienced, middle-aged (45 years), male and female (46%) physicians, mostly office-based (2/3) general practitioners and internists (2/3). Most physicians (94%) reported positive attitudes towards SDM. They were securely attached (63%) with predominant social career choice motives (46%). Physicians with personality characteristics clashing with the SDM concept benefited mostly from the training.

CONCLUSION

A voluntary SDM training program is attractive to practicing physicians and effective in increasing SDM-related confidence and knowledge.

PRACTICE IMPLICATIONS

Even physicians who are highly motivated to use SDM can improve their skills and benefit from SDM training. The dissemination of SDM training programs should be encouraged.

Healthcare professionals' views on two computer-based decision aids for women choosing mode of delivery after previous caesarean section: a qualitative study

OBJECTIVE

To explore healthcare professionals' views about decision aids, developed by the DiAMOND study group, for women choosing mode of delivery after a previous caesarean section.

DESIGN/METHODS

A qualitative focus group study. Data were analysed thematically.

SETTING

Two city maternity units, surrounding community midwife units and general practitioner (GP) practices in southwest England.

SAMPLE

Twenty-eight healthcare professionals, comprising obstetricians, hospital and community midwives and GPs, who participated in six focus groups.

RESULTS

Participants were generally positive about the decision aids. Most thought they should be implemented during early pregnancy in the community, but should be accessible throughout pregnancy, with any arising questions discussed with an obstetrician nearer to term. Perceived barriers to implementation included service issues (e.g. time pressure, cost and access), computer issues (e.g. computer literacy) and people issues (e.g. women's prior delivery preferences and clinician preference). Facilitators to implementation included access to more standardised and reliable information and empowerment of the user. Self-accessing the aids, increased awareness of decision aids among healthcare professionals and incorporation of aids into usual care were suggested as possible ways to improve implementation success.

CONCLUSIONS

This study gives insight into healthcare professionals' views on the role of decision aids for women choosing a mode of delivery after a prior caesarean section. It highlights potential obstacles to their implementation and ways to address these. Such aids could be a useful adjunct to current antenatal care.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Decision aids prepare people to participate in 'close call' decisions that involve weighing benefits, harms, and scientific uncertainty.

OBJECTIVES

To conduct a systematic review of randomised controlled trials (RCTs) evaluating the efficacy of decision aids for people facing difficult treatment or screening decisions.

SEARCH STRATEGY

We searched MEDLINE (Ovid) (1966 to July 2006); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library; 2006, Issue 2); CINAHL (Ovid) (1982 to July 2006); EMBASE (Ovid) (1980 to July 2006); and PsycINFO (Ovid) (1806 to July 2006). We contacted researchers active in the field up to December 2006. There were no language restrictions.

SELECTION CRITERIA

We included published RCTs of interventions designed to aid patients' decision making by providing information about treatment or screening options and their associated outcomes, compared to no intervention, usual care, and alternate interventions. We excluded studies in which participants were not making an active treatment or screening decision, or if the study's intervention was not available to determine that it met the minimum criteria to qualify as a patient decision aid.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts for inclusion, and extracted data from included studies using standardized forms. The primary outcomes focused on the effectiveness criteria of the International Patient Decision Aid Standards (IPDAS) Collaboration: attributes of the decision and attributes of the decision process. We considered other behavioural, health, and health system effects as secondary outcomes. We pooled results of RCTs using mean differences (MD) and relative risks (RR) using a random effects model.

MAIN RESULTS

This update added 25 new RCTs, bringing the total to 55. Thirty-eight (69%) used at least one measure that mapped onto an IPDAS effectiveness criterion: decision attributes: knowledge scores (27 trials); accurate risk perceptions (11 trials); and value congruence with chosen option (4 trials); and decision process attributes: feeling informed (15 trials) and feeling clear about values (13 trials).This review confirmed the following findings from the previous (2003) review. Decision aids performed better than usual care interventions in terms of: a) greater knowledge (MD 15.2 out of 100; 95% CI 11.7 to 18.7); b) lower decisional conflict related to feeling uninformed (MD -8.3 of 100; 95% CI -11.9 to -4.8); c) lower decisional conflict related to feeling unclear about personal values (MD -6.4; 95% CI -10.0 to -2.7); d) reduced the proportion of people who were passive in decision making (RR 0.6; 95% CI 0.5 to 0.8); and e) reduced proportion of people who remained undecided post-intervention (RR 0.5; 95% CI 0.3 to 0.8). When simpler decision aids were compared to more detailed decision aids, the relative improvement was significant in knowledge (MD 4.6 out of 100; 95% CI 3.0 to 6.2) and there was some evidence of greater agreement between values and choice.In this review, we were able to explore the use of probabilities in decision aids. Exposure to a decision aid with probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.6; 95% CI 1.4 to 1.9). The effect was stronger when probabilities were measured quantitatively (RR 1.8; 95% CI 1.4 to 2.3) versus qualitatively (RR 1.3; 95% CI 1.1 to 1.5).As in the previous review, exposure to decision aids continued to demonstrate reduced rates of: elective invasive surgery in favour of conservative options, decision aid versus usual care (RR 0.8; 95% CI 0.6 to 0.9); and use of menopausal hormones, detailed versus simple aid (RR 0.7; 95% CI 0.6 to 1.0). There is now evidence that exposure to decision aids results in reduced PSA screening, decision aid versus usual care (RR 0.8; 95% CI 0.7 to 1.0) . For other decisions, the effect on decisions remains variable.As in the previous review, decision aids are no better than comparisons in affecting satisfaction with decision making, anxiety, and health outcomes. The effects of decision aids on other outcomes (patient-practitioner communication, consultation length, continuance, resource use) were inconclusive.There were no trials evaluating the IPDAS decision process criteria relating to helping patients to recognize a decision needs to be made, understand that values affect the decision, or discuss values with the practitioner.

AUTHORS' CONCLUSIONS

Patient decision aids increase people's involvement and are more likely to lead to informed values-based decisions; however, the size of the effect varies across studies. Decision aids have a variable effect on decisions. They reduce the use of discretionary surgery without apparent adverse effects on health outcomes or satisfaction. The degree of detail patient decision aids require for positive effects on decision quality should be explored. The effects on continuance with chosen option, patient-practitioner communication, consultation length, and cost-effectiveness need further evaluation.

Importance of evidence grading for guideline implementation: the example of asthma

The goal of evidence-based clinical guidelines is to improve the value of health care by recommending treatments with favorable benefit/harm ratios. Achieving this goal requires use of evidence-grading systems that explicitly address strength of evidence in terms of external validity (generalizability), internal validity, and patient-oriented outcomes. To be clinically useful, guidelines should also incorporate patient preferences, particularly when evidence is weak. The National Heart, Lung and Blood Institute recently published Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3). This special report addresses the extent to which current guidelines adhere to the principles enunciated above by using EPR-3 as the prime example. EPR-3 used an unconventional evidence-grading system that emphasized precision and consistency (statistical significance, large sample sizes, and/or consistency of results) at the expense of patient-oriented outcomes and generalizability (applicability to the general population). EPR-3 did not report information on numbers needed to treat or numbers needed to harm, which are useful in eliciting patient preferences via shared decision making. Asthma guidelines (and others) are limited by lack of a generalizable research base, 3 awed evidence grading, and lack of attention to patient preferences. An evidence-grading system based on applicable populations, patient-oriented outcomes, and shared decision making might improve physician and patient guideline adherence and improve asthma outcomes.

Implementing patient decision support tools: moving beyond academia?

OBJECTIVE

To ascertain the feasibility of implementing three decision support tools (DSTs) for people with rectal cancer within the surgical consultation.

METHODS

Twenty colorectal surgeons participated in a focus group or individual interviews. Colorectal surgeons were also asked to complete a self-administered questionnaire.

RESULTS

All surgeons responded encouragingly to the concept of DSTs. However, for every positive statement an accompanying caveat was made and these were either a criticism of each tool or a barrier to their implementation. Surgeons stated DSTs should be used by patients and surgeons together (80%). The majority (70-75%) thought each tool was 'useful' or 'extremely useful'. However, there were strong views that in their current form the DSTs would not feasible to be used within the surgical consultation. Time restraints, personal and clinical characteristics of the patient, the content of each tool, the potential negative impact on the doctor-patient relationship were noted as real barriers to their implementation.

CONCLUSION

Surgeons have identified a number of barriers that may limit implementation of DSTs into routine clinical practice.

PRACTICE IMPLICATIONS

Feasibility and implementation studies have the potential to provide important information to help guide development, evaluation and implementation of DSTs.

Assessing risk communication in breast cancer: are continuous measures of patient knowledge better than categorical?

OBJECTIVE

To compare the performance of categorical and continuous measures of patient knowledge in the context of risk communication about breast cancer, in terms of statistical and clinical significance as well as efficiency.

METHODS

Twenty breast cancer patients provided estimates of 10-year mortality risk before and after their oncology visit. The oncologist reviewed risk estimates from Adjuvant!, a well-validated and commonly used prognostic model. Using the Adjuvant! estimates as a gold standard, we calculated how accurate the patient estimates were before and after the visit. We used three novel continuous measures of patient accuracy, the absolute bias, Brier, and Kullback-Leibler scores, and compared them to a categorical measure in terms of sensitivity to intervention effects. We also calculated the sample size required to replicate the primary study using the categorical and continuous measures, as a means of comparing efficiency.

RESULTS

In this sample, the Kullback-Leibler measure was most sensitive to the intervention effects (p=0.004), followed by Brier and absolute bias (both p=0.011), and finally the categorical measure (0.125). The sample size required to replicate the primary study was 18 for the Kullback-Leibler measure, 23 for absolute bias and Brier, and 37 for the categorical measure.

CONCLUSIONS

The continuous measures led to more efficient sample sizes and to rejection of the null hypothesis of no intervention effect. However, the difference in sensitivity of the continuous measures was not statistically significant, and the performance of the categorical measure depends on the researcher's categorical cutoff for accuracy. Continuous measures of patient accuracy may be more sensitive and efficient, while categorical measures may be more clinically relevant.

PRACTICE IMPLICATIONS

Researchers and others interested in assessing the accuracy of patient knowledge should weigh the trade-offs between clinical relevance and statistical significance while designing or evaluating risk communication studies.

A knowledge synthesis of patient and public involvement in clinical practice guidelines: study protocol

Background

Failure to reconcile patient preferences and values as well as social norms with clinical practice guidelines (CPGs) recommendations may hamper their implementation in clinical practice. However, little is known about patients and public involvement programs (PPIP) in CPGs development and implementation. This study aims at identifying what it is about PPIP that works, in which contexts are PPIP most likely to be effective, and how are PPIP assumed to lead to better CPGs development and implementation.

Methods and design

A knowledge synthesis will be conducted in four phases. In phase one, literature on PPIP in CPGs development will be searched through bibliographic databases. A call for bibliographic references and unpublished reports will also be sent via the mailing lists of relevant organizations. Eligible publications will include original qualitative, quantitative, or mixed methods study designs reporting on a PPIP pertaining to CPGs development or implementation. They will also include documents produced by CPGs organizations to describe their PPIP. In phase two, grounded in the program's logic model, two independent reviewers will extract data to collect information on the principal components and activities of PPIP, the resources needed, the contexts in which PPIP were developed and tested, and the assumptions underlying PPIP. Quality assessment will be made for all retained publications. Our literature search will be complemented with interviews of key informants drawn from of a purposive sample of CPGs developers and patient/public representatives. In phase three, we will synthesize evidence from both the publications and interviews data using template content analysis to organize the identified components in a meaningful framework of PPIP theories. During a face-to-face workshop, findings will be validated with different stakeholder and a final toolkit for CPGs developers will be refined.

Discussion

The proposed research project will be among the first to explore the PPIP in CPGs development and implementation based on a wide range of publications and key informants interviews. It is anticipated that the results generated by the proposed study will significantly contribute to the improvement of the reconciliation of CPGs with patient preferences and values as well as with social norms.

Video decision support tool for advance care planning in dementia: randomised controlled trial

OBJECTIVE

To evaluate the effect of a video decision support tool on the preferences for future medical care in older people if they develop advanced dementia, and the stability of those preferences after six weeks.

DESIGN

Randomised controlled trial conducted between 1 September 2007 and 30 May 2008. Setting Four primary care clinics (two geriatric and two adult medicine) affiliated with three academic medical centres in Boston.

PARTICIPANTS

Convenience sample of 200 older people (>or=65 years) living in the community with previously scheduled appointments at one of the clinics. Mean age was 75 and 58% were women.

INTERVENTION

Verbal narrative alone (n=106) or with a video decision support tool (n=94).

MAIN OUTCOME MEASURES

Preferred goal of care: life prolonging care (cardiopulmonary resuscitation, mechanical ventilation), limited care (admission to hospital, antibiotics, but not cardiopulmonary resuscitation), or comfort care (treatment only to relieve symptoms). Preferences after six weeks. The principal category for analysis was the difference in proportions of participants in each group who preferred comfort care.

RESULTS

Among participants receiving the verbal narrative alone, 68 (64%) chose comfort care, 20 (19%) chose limited care, 15 (14%) chose life prolonging care, and three (3%) were uncertain. In the video group, 81 (86%) chose comfort care, eight (9%) chose limited care, four (4%) chose life prolonging care, and one (1%) was uncertain (chi(2)=13.0, df=3, P=0.003). Among all participants the factors associated with a greater likelihood of opting for comfort care were being a college graduate or higher, good or better health status, greater health literacy, white race, and randomisation to the video arm. In multivariable analysis, participants in the video group were more likely to prefer comfort care than those in the verbal group (adjusted odds ratio 3.9, 95% confidence interval 1.8 to 8.6). Participants were re-interviewed after six weeks. Among the 94/106 (89%) participants re-interviewed in the verbal group, 27 (29%) changed their preferences (kappa=0.35). Among the 84/94 (89%) participants re-interviewed in the video group, five (6%) changed their preferences (kappa=0.79) (P<0.001 for difference).

CONCLUSION

Older people who view a video depiction of a patient with advanced dementia after hearing a verbal description of the condition are more likely to opt for comfort as their goal of care compared with those who solely listen to a verbal description. They also have more stable preferences over time.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00704886.

'Listen to me, tell me': a qualitative study of partnership in care for people with non-specific chronic low back pain

OBJECTIVE

To investigate and summarize participant experience of exercise programmes for non-specific chronic low back pain and the effects of these experiences on exercise participation and engagement.

SUBJECTS

Three groups of six adults (>18 years) who speak, read and understand English and who had participated in an exercise programme for non-specific chronic low back pain.

METHOD

Qualitative research methods were used and three focus groups were conducted by an experienced facilitator. Each group was guided with a set of pre-determined questions and participants were encouraged to give personal opinions. Transcribed data were read independently by two researchers and analysed thematically according to Grounded Theory.

RESULTS

Preference for partnership in care emerged as a significant theme from all focus group transcripts. The following subthemes emerged: (1) engagement with the health care process; (2) 'listen to me; I know my own body'; (3) 'tell me: explain it to me'. People with non-specific chronic low back pain want an active role in their rehabilitation. They expressed anger and frustration at not being listened to, not being provided with adequate explanations and education and not being given credit for knowing their own bodies. Tension existed between patients' wanting a genuine voice in the partnership and them wanting a care-provider to give explicit diagnosis and best management instruction.

CONCLUSION

A gap exists between care-seeker experiences of, and preferences for, exercise programmes for back pain. Care-seekers consider that care-providers should adopt a willingness to listen and consider care-seeker's experiences when designing exercise programmes.

Patient perspectives with abbreviated versus standard pre-test HIV counseling in the prenatal setting: a randomized-controlled, non-inferiority trial

BACKGROUND

In the US, an unacceptably high percentage of pregnant women do not undergo prenatal HIV testing. Previous studies have found increased uptake of prenatal HIV testing with abbreviated pre-test counseling, however little is known about patient decision making, testing satisfaction and knowledge in this setting.

METHODOLOGY/FINDINGS

A randomized-controlled, non-inferiority trial was conducted from October 2006 through February 2008 at San Francisco General Hospital (SFGH), the public teaching hospital of the City and County of San Francisco. A total of 278 English- and Spanish-speaking pregnant women were randomized to receive either abbreviated or standard nurse-performed HIV test counseling at the initial prenatal visit. Patient decision making experience was compared between abbreviated versus standard HIV counseling strategies among a sample of low-income, urban, ethnically diverse prenatal patients. The primary outcome was the decisional conflict score (DCS) using O'Connor low-literacy scale and secondary outcomes included satisfaction with test decision, basic HIV knowledge and HIV testing uptake. We conducted an intention-to-treat analysis of 278 women--134 (48.2%) in the abbreviated arm (AA) and 144 (51.8%) in the standard arm (SA). There was no significant difference in the proportion of women with low decisional conflict (71.6% in AA vs. 76.4% in SA, p = .37), and the observed mean difference between the groups of 3.88 (95% CI: -0.65, 8.41) did not exceed the non-inferiority margin. HIV testing uptake was very high (97. 8%) and did not differ significantly between the 2 groups (99.3% in AA vs. 96.5% in SA, p = .12). Likewise, there was no difference in satisfaction with testing decision (97.8% in AA vs. 99.3% in SA, p = .36). However, women in AA had significantly lower mean HIV knowledge scores (78.4%) compared to women in SA (83.7%, p<0.01).

CONCLUSIONS/SIGNIFICANCE

This study suggests that streamlining the pre-test counseling process, while associated with slightly lower knowledge, does not compromise patient decision making or satisfaction regarding HIV testing.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00503308.

Cancer informational support and health care service use among individuals newly diagnosed: a mixed methods approach

AIM

To report on the integration of quantitative and qualitative findings to increase understanding of the role of cancer informational support and use of health care services among individuals newly diagnosed with breast or prostate cancer.

METHODS

A mixed methods sequential design was used. First, a quantitative secondary analysis considered self-report data from a large number of individuals newly diagnosed with cancer (n = 250); next, a follow-up, in-depth qualitative inquiry with distinct individuals also newly diagnosed was conducted (n = 20); last, using a quantitative-hierarchical strategy, quantitative and qualitative findings were merged and re-analyzed.

RESULTS

Quantitative analyses showed significant relationships between informational support and health care services. For instance, individuals who received more intense cancer informational support [face-to-face and information technology (IT)] spent more time with nurses. Women with breast cancer as opposed to men with prostate cancer also were found to rely primarily on nurses for cancer information and information on health services available, whereas men relied mostly on their oncologists. In-depth interviews revealed that informational support could be construed as positive, unsupportive, or mixed depending on context. The mixed design analysis documented positive experiences for individuals who reported to be better prepared for consultations and treatments with information provided by more than one source. Negative experiences with physicians were reported by both women and men but the former was about quality of cancer information provided and the latter in terms of quantity.

CONCLUSIONS

A mixed methods approach allowed a deeper understanding of the role of informational support on subsequent use of health care services by individuals with cancer. Further studies may include other types of cancer and diverse background characteristics to clarify how informational support and subsequent use of health services may be jointly determined by these factors.

Randomized trial of a decision aid for BRCA1/BRCA2 mutation carriers: impact on measures of decision making and satisfaction

OBJECTIVE

Genetic testing is increasingly part of routine clinical care for women with a family history of breast cancer. Given their substantially elevated risk for breast cancer, BRCA1/BRCA2 mutation carriers must make the difficult decision whether or not to opt for risk reducing mastectomy. To help BRCA1/2 carriers make this decision, the authors developed a computer-based interactive decision aid that was tested against usual care in a randomized controlled trial.

DESIGN

After the completion of genetic counseling, 214 female (aged 21-75) BRCA1/BRCA2 mutation carriers were randomized to Usual Care (UC; N = 114) or Usual Care plus Decision Aid (DA; N = 100) arms. UC participants received no additional intervention. DA participants were sent the CD-ROM DA to view at home.

MAIN OUTCOME MEASURES

The authors measured final management decision, decisional conflict, decisional satisfaction, and receipt of risk reducing mastectomy at 1-, 6-, and 12-months postrandomization.

RESULTS

Longitudinal analyses revealed that the DA was effective among carriers who were initially undecided about how to manage their breast cancer risk. Within this group, the DA led to an increased likelihood of reaching a management decision (OR = 3.09, 95% CI = 1.62, 5.90; p < .001), decreased decisional conflict (B = -.46, z = -3.1, p <002), and increased satisfaction (B = .27, z = 3.1, p = .002) compared to UC. Among carriers who had already made a management decision by the time of randomization, the DA had no benefit relative to UC.

CONCLUSION

These results demonstrate that BRCA1/BRCA2 mutation carriers who are having difficulty making a breast cancer risk management decision can benefit from adjunct decision support.

Primary care physicians' reported use of pre-screening discussions for prostate cancer screening: a cross-sectional survey

Background

Professional medical organizations recommend individualized patient decision making about prostate cancer screening. Little is known about primary care physicians' use of pre-screening discussions to promote informed decision making for prostate cancer screening. The aim of this study is to explore physicians' use of pre-screening discussions and reasons why physicians would or would not try to persuade patients to be screened if they initially refuse testing.

Methods

Primary care physicians completed a self-administered survey about prostate cancer screening practices for informed decision making.

Results

Sixty-six physicians (75.9%) completed the survey, and 63 were used in the analysis. Thirteen physicians (20.6%) reported not using prescreening discussions, 45 (71.4%) reported the use of prescreening discussions, and 3 (4.8%) reported neither ordering the PSA test nor discussing it with patients. Sixty-nine percent of physicians who reported not having discussions indicated they were more likely to screen African American patients for prostate cancer, compared to 50% of physicians who reported the use of discussions (Chi-square(1) = 1.62, p = .20). Similarly, 91% of physicians who reported not having discussions indicated they are more likely to screen patients with a family history of prostate cancer, compared to 46% of those who reported the use of discussion (Chi-square(1) = 13.27, p < .001). Beliefs about the scientific evidence and efficacy of screening, ethical concerns regarding patient autonomy, and concerns about time constraints differed between physicians who would and would not try to persuade a patient to be tested.

Conclusion

Although guidelines recommend discussing the risks and benefits of prostate cancer screening, physicians report varying practice styles. Future research needs to consider the nature of discussions and the degree to which informed decision making is being achieved in clinical practice.

Long-term health outcomes of a decision aid: data from a randomized trial of adjuvant! In women with localized breast cancer

PURPOSE

Women with localized breast cancer face difficult decisions about adjuvant therapy. Several decision aids are available to help women choose between treatment options. Decision aids are known to affect treatment choices and may therefore affect patient survival. The authors aimed to model the effects of the Adjuvant! decision aid on expected survival in women with early stage breast cancer.

PATIENTS AND METHODS

Data were obtained from a randomized trial of Adjuvant! (n = 395). To calculate the effects of the decision aid on survival, the authors used the Adjuvant! survival predictions as a surrogate endpoint. Data from each arm were entered separately into statistical models to estimate change in survival associated with receiving the Adjuvant! decision aid.

RESULTS

Most women (approximately 85%) chose a treatment option that maximized predicted survival. The effects of the decision aid on outcome could not be modeled because a small number of women (n = 12, 3%) chose treatment options associated with a large (5%-14%) loss in survival. These women-most typically estrogen receptor positive but refusing hormonal therapy-were equally divided between Adjuvant! and control groups and were not distinguished by medical or demographic factors.

CONCLUSIONS

Expected benefit from treatment is a key variable in understanding patient behavior. A small number of women refuse adjuvant treatment associated with large increases in predicted survival, even when they are explicitly informed about the degree of benefit they would forgo. Investigation of the effects of decision aids on cancer survival is unlikely to be fruitful due to power considerations.

Building blocks for meta-synthesis: data integration tables for summarising, mapping, and synthesising evidence on interventions for communicating with health consumers

Background

Systematic reviews have developed into a powerful method for summarising and synthesising evidence. The rise in systematic reviews creates a methodological opportunity and associated challenges and this is seen in the development of overviews, or reviews of systematic reviews. One of these challenges is how to summarise evidence from systematic reviews of complex interventions for inclusion in an overview. Interventions for communicating with and involving consumers in their care are frequently complex. In this article we outline a method for preparing data integration tables to enable review-level synthesis of the evidence on interventions for communication and participation in health.

Methods and Results

Systematic reviews published by the Cochrane Consumers and Communication Review Group were utilised as the basis from which to develop linked steps for data extraction, evidence assessment and synthesis. The resulting output is called a data integration table. Four steps were undertaken in designing the data integration tables: first, relevant information for a comprehensive picture of the characteristics of the review was identified from each review, extracted and summarised. Second, results for the outcomes of the review were assessed and translated to standardised evidence statements. Third, outcomes and evidence statements were mapped into an outcome taxonomy that we developed, using language specific to the field of interventions for communication and participation. Fourth, the implications of the review were assessed after the mapping step clarified the level of evidence available for each intervention.

Conclusion

The data integration tables represent building blocks for constructing overviews of review-level evidence and for the conduct of meta-synthesis. Individually, each table aims to improve the consistency of reporting on the features and effects of interventions for communication and participation; provides a broad assessment of the strength of evidence derived from different methods of analysis; indicates a degree of certainty with results; and reports outcomes and gaps in the evidence in a consistent and coherent way. In addition, individual tables can serve as a valuable tool for accurate dissemination of large amounts of complex information on communication and participation to professionals as well as to members of the public.

Are Cancer-Related Decision Aids Effective? A Systematic Review and Meta-Analysis

Purpose

Decision aids (DAs) have been developed to improve communication between health professionals and patients, and to involve patients in decisions about their health care. Cancer-related decisions can be difficult due to problems in communicating complex information about prognosis and the modest benefits of available treatments. We conducted a systematic review of cancer-related DAs.

Methods

Randomized controlled trials (RCTs) of cancer-related DAs about screening, prevention, and treatment decision making were included. We completed a comprehensive literature search and conducted both qualitative and quantitative analyses. We also conducted a meta regression to explore heterogeneity of effect estimates.

Results

We identified 34 RCTs of DAs in a screening (n = 22 trials) or preventive/treatment (n = 12 trials) context. DAs significantly improved knowledge about screening options when compared to usual practice (weighted average effect size, 0.50; 95% CI, 0.27 to 0.73; P < .0001). A similar effect on knowledge was also found for preventive/treatment options (weighted average effect size, 0.50; 95% CI, 0.31 to 0.70; P < .0001). Overall, general anxiety was not increased in most trials and was significantly reduced in a screening context. Decisional conflict was reduced overall but not when screening and preventive/treatment studies were analyzed separately. There were few differences between different types of DAs.

Conclusion

Cancer-related DAs are effective in increasing patient knowledge compared with usual practice without increasing anxiety particularly in the area of cancer screening. Further research is needed to determine the effectiveness of DAs in the prevention and treatment context.

Impact of an informed choice invitation on uptake of screening for diabetes in primary care (DICISION): trial protocol

Background

Screening invitations have traditionally been brief, providing information only about population benefits. Presenting information about the limited individual benefits and potential harms of screening to inform choice may reduce attendance, particularly in the more socially deprived. At the same time, amongst those who attend, it might increase motivation to change behavior to reduce risks. This trial assesses the impact on attendance and motivation to change behavior of an invitation that facilitates informed choices about participating in diabetes screening in general practice. Three hypotheses are tested:

1. Attendance at screening for diabetes is lower following an informed choice compared with a standard invitation.

2. There is an interaction between the type of invitation and social deprivation: attendance following an informed choice compared with a standard invitation is lower in those who are more rather than less socially deprived.

3. Amongst those who attend for screening, intentions to change behavior to reduce risks of complications in those subsequently diagnosed with diabetes are stronger following an informed choice invitation compared with a standard invitation.

Method/Design

1500 people aged 40–69 years without known diabetes but at high risk are identified from four general practice registers in the east of England. 1200 participants are randomized by households to receive one of two invitations to attend for diabetes screening at their general practices. The intervention invitation is designed to facilitate informed choices, and comprises detailed information and a decision aid. A comparison invitation is based on those currently in use. Screening involves a finger-prick blood glucose test. The primary outcome is attendance for diabetes screening. The secondary outcome is intention to change health related behaviors in those attenders diagnosed with diabetes. A sample size of 1200 ensures 90% power to detect a 10% difference in attendance between arms, and in an estimated 780 attenders, 80% power to detect a 0.2 sd difference in intention between arms.

Discussion

The DICISION trial is a rigorous pragmatic denominator based clinical trial of an informed choice invitation to diabetes screening, which addresses some key limitations of previous trials.

Trial registration

Current Controlled Trials ISRCTN73125647

Contextual factors in shared decision making: a randomised controlled trial in women with a strong suspicion of breast cancer

Decision aids in North American breast cancer outpatients have been shown to assist with treatment decision making and reduce decisional conflict. To date, appropriate delivery formats to effectively increase patient participation in newly diagnosed breast cancer inpatients have not been investigated in the context of German health care provision. The impact of a decision aid intervention was studied in patients (n=111) with a strong suspicion of breast cancer in a randomised controlled trial. The primary outcome variable was decisional conflict. Participants were followed up 1 week post-intervention with a retention rate of 92%. Analyses revealed that the intervention group felt better informed (eta(p)(2)=0.06) but did not experience an overall reduction in decisional conflict as compared with the control group. The intervention had no effect on uptake rates of treatment options, length of consultation with the surgeon, time point of treatment decision making, perceived involvement in decision making, neither decision related nor general patient satisfaction. Patients who received the decision aid intervention experienced a small benefit with regards to how informed they felt about advantages and disadvantages of relevant treatment options. Results are discussed in terms of contextual factors and individual differences as moderators of treatment decision aid effectiveness.

Improving understanding of adjuvant therapy options by using simpler risk graphics

BACKGROUND

To help oncologists and breast cancer patients make informed decisions about adjuvant therapies, online tools such as Adjuvant! provide tailored estimates of mortality and recurrence risks. However, the graphical format used to display these results (a set of 4 horizontal stacked bars) may be suboptimal. The authors tested whether using simpler formats would improve comprehension of the relevant risk statistics.

METHODS

A total of 1,619 women, aged 40-74 years, completed an Internet-administered survey vignette about adjuvant therapy decisions for a patient with an estrogen receptor-positive tumor. Participants were randomized to view 1 of 4 risk graphics, a base version that mirrored the Adjuvant! format, an alternate graph that showed only 2 options (those that included hormonal therapy), a graph that used a pictograph format, or a graph that included both changes. Outcome measures included comprehension of key statistics, time required to complete the task, and graph-perception ratings.

RESULTS

The simplifying format changes significantly improved comprehension, especially when both changes were implemented together. Compared with participants who viewed the base 4-option bar graph, respondents who, instead, viewed a 2-option pictograph version were more accurate when they reported the incremental risk reduction achievable from adding chemotherapy to hormonal therapy (77% vs 51%; P< .001), answered that question more quickly (median time, 28 seconds vs 42 seconds; P< .001), and liked the graph more (mean, 7.67 vs 6.88; P< .001).

CONCLUSIONS

Although most patients will only view risk calculators such as Adjuvant! in consultation with their clinicians, simplifying design graphics could significantly improve patients' comprehension of statistics essential for informed decision making about adjuvant therapies.

Theory-based interventions for contraception

BACKGROUND

The explicit use of theory in research helps expand the knowledge base. Theories and models have been used extensively in HIV-prevention research and in interventions for preventing sexually transmitted infections (STIs). The health behavior field uses many theories or models of change. However, educational interventions addressing contraception often have no stated theoretical base.

OBJECTIVES

Review randomized controlled trials that tested a theoretical approach to inform contraceptive choice; encourage contraceptive use; or promote adherence to, or continuation of, a contraceptive regimen.

SEARCH STRATEGY

We searched computerized databases for trials that tested a theory-based intervention for improving contraceptive use (MEDLINE, POPLINE, CENTRAL, PsycINFO, EMBASE, ClinicalTrials.gov, and ICTRP). We also wrote to researchers to find other trials.

SELECTION CRITERIA

Trials tested a theory-based intervention for improving contraceptive use. We excluded trials focused on high-risk groups. Interventions addressed the use of one or more contraceptive methods. The reports provided evidence that the intervention was based on a specific theory or model. The primary outcomes were pregnancy, contraceptive choice, initiating or changing contraceptive use, contraceptive regimen adherence, and contraception continuation.

DATA COLLECTION AND ANALYSIS

The primary author evaluated abstracts for eligibility. Two authors extracted data from included studies. We calculated the odds ratio for dichotomous outcomes and the mean difference for continuous data. No meta-analysis was conducted due to intervention differences.

MAIN RESULTS

Of 26 trials, 12 interventions addressed contraception (other than condoms), while 14 focused on condom use for preventing HIV or STIs. In 2 of 10 trials with pregnancy or birth data, a theory-based group showed better results. Four of nine trials with contraceptive use (other than condoms) showed better outcomes in an experimental group. For condom use, a theory-based group had favorable results in 14 of 20 trials, but the number was halved in a subgroup analysis. Social Cognitive Theory was the main theoretical basis for 12 trials, and 10 showed positive results. Of the other 14 trials, favorable results were shown for other social cognition models (N=2), motivational interviewing (N=5), and the AIDS Risk Reduction Model (N=2). No major patterns were detected by type of theory, intervention, or target population.

AUTHORS' CONCLUSIONS

Family planning researchers and practitioners could apply the relevant theories and effective interventions from HIV and STI prevention. More thorough use of single theories would help inform the field about what works. Better reporting is needed on research design and intervention implementation.

The impact of thyroid cancer and post-surgical radioactive iodine treatment on the lives of thyroid cancer survivors: a qualitative study

Background

Adjuvant treatment with radioactive iodine (RAI) is often considered in the treatment of well-differentiated thyroid carcinoma (WDTC). We explored the recollections of thyroid cancer survivors on the diagnosis of WDTC, adjuvant radioactive iodine (RAI) treatment, and decision-making related to RAI treatment. Participants provided recommendations for healthcare providers on counseling future patients on adjuvant RAI treatment.

Methods

We conducted three focus group sessions, including WDTC survivors recruited from two Canadian academic hospitals. Participants had a prior history of WDTC that was completely resected at primary surgery and had been offered adjuvant RAI treatment. Open-ended questions were used to generate discussion in the groups. Saturation of major themes was achieved among the groups.

Findings

There were 16 participants in the study, twelve of whom were women (75%). All but one participant had received RAI treatment (94%). Participants reported that a thyroid cancer diagnosis was life-changing, resulting in feelings of fear and uncertainty. Some participants felt dismissed as not having a serious disease. Some participants reported receiving conflicting messages from healthcare providers on the appropriateness of adjuvant RAI treatment or insufficient information. If RAI-related side effects occurred, their presence was not legitimized by some healthcare providers.

Conclusions

The diagnosis and treatment of thyroid cancer significantly impacts the lives of survivors. Fear and uncertainty related to a cancer diagnosis, feelings of the diagnosis being dismissed as not serious, conflicting messages about adjuvant RAI treatment, and treatment-related side effects, have been raised as important concerns by thyroid cancer survivors.

Decision making preferences in the medical encounter--a factorial survey design

BACKGROUND

Up to now it has not been systematically investigated in which kind of clinical situations a consultation style based on shared decision making (SDM) is preferred by patients and physicians. We suggest the factorial survey design to address this problem.This method, which so far has hardly been used in health service research, allows to vary relevant factors describing clinical situations as variables systematically in an experimental random design and to investigate their importance in large samples.

METHODS/DESIGN

To identify situational factors for the survey we first performed a literature search which was followed by a qualitative interview study with patients, physicians and health care experts. As a result, 7 factors (e.g. "Reason for consultation" and "Number of therapeutic options") with 2 to 3 levels (e.g. "One therapeutic option" and "More than one therapeutic option") will be included in the study. For the survey the factor levels will be randomly combined to short stories describing different treatment situations.A randomized sample of all possible short stories will be given to at least 300 subjects (100 GPs, 100 patients and 100 members of self-help groups) who will be asked to rate how the decision should be made. Main outcome measure is the preference for participation in the decision making process in the given clinical situation.Data analysis will estimate the effects of the factors on the rating and also examine differences between groups.

DISCUSSION

The results will reveal the effects of situational variations on participation preferences. Thus, our findings will contribute to the understanding of normative values in the medical decision making process and will improve future implementation of SDM and decision aids.

Exploring informed choice in the context of prenatal testing: findings from a qualitative study

PURPOSE

This study explored whether and how a sample of women made informed choices about prenatal testing for foetal anomalies; its aim was to provide insights for future health policy and service provision.

METHODS

We conducted semi-structured interviews with 38 mothers in Ottawa, Ontario, all of whom had been offered prenatal tests in at least one pregnancy. Using the Multi-dimensional Measure of Informed Choice as a general guide to analysis, we explored themes relevant to informed choice, including values and knowledge, and interactions with health professionals.

RESULTS

Many, but not all, participants seemed to have made informed decisions about prenatal testing. Values and knowledge were interrelated and important components of informed choice, but the way they were discussed differed from the way they have been presented in scientific literature. In particular, 'values' related to expressions of women's moral views or ideas about 'how life should be lived' and 'knowledge' related to the ways in which women prioritized and interpreted factual information, through their own and others' experiences and in 'thinking through' the personal implications of testing. While some women described non-directive discussions with health professionals, others perceived testing as routine or felt pressured to accept it.

CONCLUSIONS

Our findings suggest a need for maternity care providers to be vigilant in promoting active decision making about prenatal testing, particularly around the consideration of personal implications. Further development of measures of informed choice may be necessary to fully evaluate decision support tools and to determine whether prenatal testing programmes are meeting their objectives.

A generic tool for development of decision aids based on clinical practice guidelines

OBJECTIVE

Patient involvement in medical decision making has been suggested to contribute to patients' satisfaction and better patient outcomes. Decision aids are particularly useful for preference-sensitive decisions. Ideally, these should be based on up-to-date evidence-based guidelines. The objective of this project was to develop a generic format for development and maintenance of decision aids based on evidence-based guidelines.

METHODS

Decision aids, evidence-based guidelines and IPDAS standards were used for development of a generic format for decision aids. Patient focus groups were used to assess patients' information needs, expectations, personal values and preferences for presentation of information.

RESULTS

We developed a generic format for decision aids and six specific decision aids derived from evidence-based guidelines. The decision aids were published on the Dutch national health care portal. Furthermore, we reached formal agreement on ownership and maintenance of the decision aids with all stakeholders. We achieved these results within 12 months.

CONCLUSION

Our generic format facilitated the efficient production of specific decision aids based on evidence-based guidelines.

PRACTICE IMPLICATIONS

If guidelines and decision aids are developed in parallel, high-quality patient information can be produced within a short time frame. The process of development should include adequate patient involvement and a strategy for maintenance.

Shared decision-making--transferring research into practice: the Analytic Hierarchy Process (AHP)

OBJECTIVE

To illustrate how the Analytic Hierarchy Process (AHP) can be used to promote shared decision-making and enhance clinician-patient communication.

METHODS

Tutorial review.

RESULTS

The AHP promotes shared decision-making by creating a framework that is used to define the decision, summarize the information available, prioritize information needs, elicit preferences and values, and foster meaningful communication among decision stakeholders.

CONCLUSIONS

The AHP and related multi-criteria methods have the potential for improving the quality of clinical decisions and overcoming current barriers to implementing shared decision-making in busy clinical settings. Further research is needed to determine the best way to implement these tools and to determine their effectiveness.

PRACTICE IMPLICATIONS

Many clinical decisions involve preference-based trade-offs between competing risks and benefits. The AHP is a well-developed method that provides a practical approach for improving patient-provider communication, clinical decision-making, and the quality of patient care in these situations.

Can people find patient decision aids on the Internet?

OBJECTIVE

To determine if people could find patient decision aids (PtDAs) on the Internet using the most popular general search engines.

METHODS

We chose five medical conditions for which English language PtDAs were available from at least three different developers. The search engines used were: Google (www.google.com), Yahoo! (www.yahoo.com), and MSN (www.msn.com). For each condition and search engine we ran six searches using a combination of search terms. We coded all non-sponsored Web pages that were linked from the first page of the search results.

RESULTS

Most first page results linked to informational Web pages about the condition, only 16% linked to PtDAs. PtDAs were more readily found for the breast cancer surgery decision (our searches found seven of the nine developers). The searches using Yahoo and Google search engines were more likely to find PtDAs. The following combination of search terms: condition, treatment, decision (e.g. breast cancer surgery decision) was most successful across all search engines (29%).

CONCLUSION

While some terms and search engines were more successful, few resulted in direct links to PtDAs.

PRACTICE IMPLICATIONS

Finding PtDAs would be improved with use of standardized labelling, providing patients with specific Web site addresses or access to an independent PtDA clearinghouse.

Clinical decision support tools for osteoporosis disease management: a systematic review of randomized controlled trials

BACKGROUND

Studies indicate a gap between evidence and clinical practice in osteoporosis management. Tools that facilitate clinical decision making at the point of care are promising strategies for closing these practice gaps.

OBJECTIVE

To systematically review the literature to identify and describe the effectiveness of tools that support clinical decision making in osteoporosis disease management.

DATA SOURCES

Medline, EMBASE, CINAHL, and EBM Reviews (CDSR, DARE, CCTR, and ACP J Club), and contact with experts in the field.

REVIEW METHODS

Randomized controlled trials (RCTs) in any language from 1966 to July 2006 investigating disease management interventions in patients at risk for osteoporosis. Outcomes included fractures and bone mineral density (BMD) testing. Two investigators independently assessed articles for relevance and study quality, and extracted data using standardized forms.

RESULTS

Of 1,246 citations that were screened for relevance, 13 RCTs met the inclusion criteria. Reported study quality was generally poor. Meta-analysis was not done because of methodological and clinical heterogeneity; 77% of studies included a reminder or education as a component of their intervention. Three studies of reminders plus education targeted to physicians and patients showed increased BMD testing (RR range 1.43 to 8.67) and osteoporosis medication use (RR range 1.60 to 8.67). A physician reminder plus a patient risk assessment strategy found reduced fractures [RR 0.58, 95% confidence interval (CI) 0.37 to 0.90] and increased osteoporosis therapy (RR 2.44, CI 1.43 to 4.17).

CONCLUSION

Multi-component tools that are targeted to physicians and patients may be effective for supporting clinical decision making in osteoporosis disease management.

The design of a decision aid about diabetes medications for use during the consultation with patients with type 2 diabetes

OBJECTIVE

To describe the process used to develop a medication choice decision aid (DA) for patients with type 2 diabetes.

METHODS

We developed the DA through active collaboration with patients, clinicians, and designers, direct observations of clinical encounters, literature review, and collaborative development of design criteria. Insights from these processes informed the iterative creation of prototypes that were reviewed and field tested in actual consultations.

RESULTS

The goal of the DA was to facilitate a conversation between the clinician and the patient about diabetes medication options. Four iterations of the DA were developed and field-tested before arriving at issue cards that organized the data for five medications around glucose control, hypoglycemia, weight changes, daily routine, self-monitoring and side effects. These cards successfully generated conversations during consultations. An ongoing clinical trial will determine if this DA affects patient adherence and outcomes.

CONCLUSIONS

A collaboratively developed DA designed to create a conversation about diabetes medications may lead to more patient-centered treatment choices.

PRACTICE IMPLICATIONS

If effective, this DA could replace disease-centered treatment algorithms for patient-centered conversations that enhance the management of patients with type 2 diabetes.

Appraisal of primary outcome measures used in trials of patient decision support

OBJECTIVE

To appraise instruments used as primary outcome measures in trials measuring the effectiveness of patient decision support interventions.

METHODS

Primary outcome measures were identified in trials of patient decision aids included in the 2003 Cochrane Review. Instruments were appraised for: use in calculating sample size, appropriateness, reliability, validity, responsiveness, precision, interpretability, acceptability, and feasibility.

RESULTS

Of the 35 trials, there were 35 unique primary outcome measures and 8 instruments were appraised. Actual or preferred choice was the primary outcome measure in 18 trials. Two instruments met at least 6 of 8 appraisal criteria: Control Preference Scale (n=2 trials) and Decisional Conflict Scale (n=5 trials). The Decision Conflict Scale was used to calculate sample size in 4 trials.

CONCLUSION

Decision was the most consistent outcome measure. Most publications provided inadequate detail for appraising the instruments. Four instruments (Decisional Conflict, Control Preferences, Genetic Testing Knowledge Questionnaire, and McBride's Satisfaction with Decision) measured one or more International Patient Decision Aid Standards criteria for evaluating effectiveness.

PRACTICE IMPLICATIONS

Selecting relevant and high quality outcome measures remains challenging and is an important area for further research in the field of shared decision making.

Genetic counselling and testing for inherited gene mutations in newly diagnosed patients with breast cancer: a review of the existing literature and a proposed research agenda

Many women newly diagnosed with breast cancer and with a strong family history of breast cancer are referred to a family cancer service for genetic counselling and for consideration of genetic testing for germline mutations in cancer predisposition genes following completion of their cancer treatment. However, there is growing evidence that mutation status may influence treatment recommendations, and that there may be benefits in having 'treatment-focused genetic counselling and testing' available shortly after cancer diagnosis. This article reviews the literature that could inform the development of treatment-focused genetic counselling and testing, including: the rationale for genetic testing to aid with treatment decisions; the potential benefits of using mutation or risk status to tailor management; the criteria that may be used to identify patients most likely to carry germline mutations; and the evidence regarding women's decision-making regarding treatment-focused genetic counselling and testing and the associated psychological impact.

How should the impact of different presentations of treatment effects on patient choice be evaluated? A pilot randomized trial

Background

Different presentations of treatment effects can affect decisions. However, previous studies have not evaluated which presentations best help people make decisions that are consistent with their own values. We undertook a pilot study to compare different methods for doing this.

Methods and Findings

We conducted an Internet-based randomized trial comparing summary statistics for communicating the effects of statins on the risk of coronary heart disease (CHD). Participants rated the relative importance of treatment consequences using visual analogue scales (VAS) and category rating scales (CRS) with five response options. We randomized participants to either VAS or CRS first and to one of six summary statistics: relative risk reduction (RRR) and five absolute measures of effect: absolute risk reduction, number needed to treat, event rates, tablets needed to take, and natural frequencies (whole numbers). We used logistic regression to determine the association between participants' elicited values and treatment choices. 770 participants age 18 or over and literate in English completed the study. In all, 13% in the VAS-first group failed to complete their VAS rating, while 9% of the CRS-first group failed to complete their scoring (p = 0.03). Different ways of weighting the elicited values had little impact on the analyses comparing the different presentations. Most (51%) preferred the RRR compared to the other five summary statistics (1% to 25%, p = 0.074). However, decisions in the group presented the RRR deviated substantially from those made in the other five groups. The odds of participants in the RRR group deciding to take statins were 3.1 to 5.8 times that of those in the other groups across a wide range of values (p = 0.0007). Participants with a scientific background, who were more numerate or had more years of education were more likely to decide not to take statins.

Conclusions

Internet-based trials comparing different presentations of treatment effects are feasible, but recruiting participants is a major challenge. Despite a slightly higher response rate for CRS, VAS is preferable to avoid approximation of a continuous variable. Although most participants preferred the RRR, participants shown the RRR were more likely to decide to take statins regardless of their values compared with participants who were shown any of the five other summary statistics.

Trial Registration

Controlled-Trials.com ISRCTN85194921

A systematic review of decision support needs of parents making child health decisions

OBJECTIVE

To identify the decision support needs of parents attempting to make an informed health decision on behalf of a child.

CONTEXT

The first step towards implementing patient decision support is to assess patients' information and decision-making needs.

SEARCH STRATEGY

A systematic search of key bibliographic databases for decision support studies was performed in 2005. Reference lists of relevant review articles and key authors were searched. Three relevant journals were hand searched.

INCLUSION CRITERIA

Non-intervention studies containing data on decision support needs of parents making child health decisions.

DATA EXTRACTION AND SYNTHESIS

Data were extracted on study characteristics, decision focus and decision support needs. Studies were quality assessed using a pre-defined set of criteria. Data synthesis used the UK Evidence for Policy and Practice Information and Co-ordinating Centre approach.

MAIN RESULTS

One-hundred and forty nine studies were included across various child health decisions, settings and study designs. Thematic analysis of decision support needs indicated three key issues: (i) information (including suggestions about the content, delivery, source, timing); (ii) talking to others (including concerns about pressure from others); and (iii) feeling a sense of control over the process that could be influenced by emotionally charged decisions, the consultation process, and structural or service barriers. These were consistent across decision type, study design and whether or not the study focused on informed decision making.

Does narrative information bias individual's decision making? A systematic review

Including narratives in health-care interventions is increasingly popular. However, narrative information may bias individual's decision making, resulting in patients making poorer decisions. This systematic review synthesises the evidence about the persuasiveness of narrative information on individuals' decision making. Seventeen studies met the review criteria; 41% of studies employed first person narration, 59% third person. Narrative information influenced decision making more than the provision of no additional information and/or statistically based information in approximately a third of the studies (5/17); studies employing first person narratives were twice as likely to find an effect. There was some evidence that narrative information encouraged the use of heuristic rather than systematic processing. However, there was little consistency in the methods employed and the narratives' content to provide evidence on why narratives affect the decision process and outcome, whether narratives facilitate or bias decision making, and/or whether narratives affect the quality of the decision being made. Until evidence is provided on why and how narratives influence decision making, the use of narratives in interventions to facilitate medical decision making should be treated cautiously.

SSRIs and depression in children and adolescents: the imperative for shared decision-making

OBJECTIVE

In the context of controversy and uncertainty about the role of selective serotonin reuptake inhibitors (SSRIs) for the treatment of depressive disorders in children and adolescents, we consider the evidence of the benefits and risks of this class of medication and the possible role of shared decision-making as a practical way to guide clinicians, young people and their families through treatment decisions.

CONCLUSION

We suggest that there is an imperative for clinicians to engage young people in a process of shared decision-making, given the uncertainties about SSRI medication in this age group. Shared decision-making provides a way for clinicians to engage young people and ensure they receive the treatment required for this disorder, the potential outcomes of which are severe.

A randomized trial comparing web-based decision aids on prostate cancer knowledge for African-American men

OBJECTIVES

Few decision aids are tailored for African-American men. We sought to determine if web-based decision aids increased knowledge of prostate cancer screening among African men.

METHODS

This postintervention, quasiexperimental research measured knowledge of prostate cancer screening among African-American men following receipt of 1 of 2 web-based decision aids: enhanced or usual care. Men ages 40-65 were recruited at the annual convention of the Prince Hall Masons in the summer of 2007, which was attended by 1170 masons. The primary outcome was knowledge of prostate cancer screening.

RESULTS

There were 87 participants in the sample with a mean age of 52 years (standard deviation = 6.9). Forty-six masons were randomized to the enhanced decision aid, and 41 masons were randomized to the usual care decision aid. Knowledge scores were statistically significantly higher among the men receiving the enhanced decision aid compared to the usual care decision aid after simultaneously adjusting for age, educational level, marital status, family history, previous prostate specific antigen test and digital rectal exam (p = 0.01).

CONCLUSION

We found evidence that the enhanced web decision aid was significantly more effective than the usual care decision aid in promoting knowledge of the benefits, limitations and risks of prostate cancer screening. Web-based sites may be effective in facilitating discussions about screening between patients and health care providers.

Information needs and preferences of low and high literacy consumers for decisions about colorectal cancer screening: utilizing a linguistic model

CONTEXT

The use of written decision aids (DAs) in clinical practice has proliferated. However, few DAs have been developed for low literacy users, despite this group having low knowledge about healthcare and lacking involvement in health decisions.

OBJECTIVE

To explore the information needs and understanding of adults with varying literacy in relation to colorectal cancer screening, and to consider their responses to two versions of a decision aid. Participants Thirty-three men and women aged 45-74 years were recruited from Adult Basic Education classes (n = 17) and University Continuing Education programs (n = 16).

METHODS

We used qualitative methods (in-depth, semi-structured interviews) to compare and contrast the views of adults with lower and higher literacy levels, to gain a better understanding of how people with lower literacy value and interpret specific DA content and components; and determine whether needs and preferences are specific to lower literacy groups or generic across the broad literacy spectrum.

RESULTS

Regardless of literacy perspective, participants' interpretations of the DA were shaped by their prior knowledge and expectations, as well as their values and preferences. This influenced perceptions of the DAs role in supporting informed decision making. A linguistic theoretical model was applied to interpret the findings. This facilitated considerations beyond the traditional focus on the readability of materials.

CONCLUSION

Decision aids developers may find it useful to apply alternative approaches (linguistic) when creating DAs for consumers of varying literacy.

Views of older persons with multiple morbidities on competing outcomes and clinical decision-making

OBJECTIVES

To examine the ways in which older persons with multiple conditions think about potentially competing outcomes in order to gain insight into how processes to elicit values regarding these outcomes can be grounded in the patient's perspective.

DESIGN

Qualitative study consisting of purposefully sampled focus groups.

SETTING

Community.

PARTICIPANTS

Persons aged 65 and older taking five or more medications.

MEASUREMENTS

Participants were asked their perceptions about whether their illnesses or treatment interacted with each other, goals of their treatment, and decisions to change or stop treatment.

RESULTS

Although participants were largely unaware that treatment of one condition could worsen another, many had experience with adverse medication effects as a competing outcome. Participants initially discussed their conditions in terms of disease-specific outcomes, such as achieving a target blood pressure or lipid level. In the context of decision-making, participants shifted their discussion from disease-specific to global, cross-disease health outcomes, such as survival, preservation of physical function, and relief of symptoms. Despite having some misconceptions regarding the likelihood of these outcomes, they weighed the outcomes against one another to consider what was most important to them. Their preference was for the treatment that would achieve the most desired outcome.

CONCLUSION

Because of their experience with adverse medication effects, older persons with multiple morbidities can understand the concept of competing outcomes. The task of prioritizing global, cross-disease outcomes can help to clarify what is most important to seniors who are faced with complex healthcare decisions.

"Surgery is certainly one good option": quality and time-efficiency of informed decision-making in surgery

BACKGROUND

Informed decision-making has been widely promoted in several medical settings, but little is known about the actual practice in orthopaedic surgery and there are no clear guidelines on how to improve the process in this setting. This study was designed to explore the quality of informed decision-making in orthopaedic practice and to identify excellent time-efficient examples with older patients.

METHODS

We recruited orthopaedic surgeons, and patients sixty years of age or older, in a Midwestern metropolitan area for a descriptive study performed through the analysis of audiotaped physician-patient interviews. We used a valid and reliable measure to assess the elements of informed decision-making. These included discussions of the nature of the decision, the patient's role, alternatives, pros and cons, and uncertainties; assessment of the patient's understanding and his or her desire to receive input from others; and exploration of the patient's preferences and the impact on the patient's daily life. The audiotapes were scored with regard to whether there was a complete discussion of each informed-decision-making element (an IDM-18 score of 2) or a partial discussion of each element (an IDM-18 score of 1) as well as with a more pragmatic metric (the IDM-Min score), reflecting whether there was any discussion of the patient's role or preference and of the nature of the decision. The visit duration was studied in relation to the extent of the informed decision-making, and excellent time-efficient examples were sought.

RESULTS

There were 141 informed-decision-making discussions about surgery, including knee and hip replacement as well as wrist/hand, shoulder, and arthroscopic surgery. Surgeons frequently discussed the nature of the decision (92% of the time), alternatives (62%), and risks and benefits (59%); they rarely discussed the patient's role (14%) or assessed the patient's understanding (12%). The IDM-18 scores of the 141 discussions averaged 5.9 (range, 0 to 15; 95% confidence interval, 5.4 to 6.5). Fifty-seven percent of the discussions met the IDM-Min criteria. The median duration of the visits was sixteen minutes; the extent of informed decision-making had only a modest relationship with the visit duration. Time-efficient strategies that were identified included use of scenarios to illustrate distinct choices, encouraging patient input, and addressing primary concerns rather than lengthy recitations of pros and cons.

CONCLUSIONS

In this study, which we believe is the first to focus on informed decision-making in orthopaedic surgical practice, we found opportunities for improvement but we also found that excellent informed decision-making is feasible and can be accomplished in a time-efficient manner.

Does outpatient telephone coaching add to hospital quality improvement following hospitalization for acute coronary syndrome?

BACKGROUND

Telephone counseling in chronic disease self-management is increasing, but has not been tested in studies that control for quality of medical care.

OBJECTIVE

To test the effectiveness of a six-session outpatient telephone-based counseling intervention to improve secondary prevention (behaviors, medication) in patients with acute coronary syndrome (ACS) following discharge from hospital, and impact on physical functioning and quality of life at 8 months post-discharge.

DESIGN

Patient-level randomized trial of hospital quality improvement (QI-only) versus quality improvement plus brief telephone coaching in three months post-hospitalization (QI-plus).

DATA

medical record, state vital records, patient surveys (baseline, three and eight months post-hospitalization).

ANALYSIS

pooled-time series generalized estimating equations to analyze repeated measures; intention-to-treat analysis.

PARTICIPANTS

Seven hundred and nineteen patients admitted to one of five hospitals in two contiguous mid-Michigan communities enrolled; 525 completed baseline surveys.

MEASUREMENTS

We measured secondary prevention behaviors, physical functioning, and quality of life.

RESULTS

QI-plus patients showed higher self-reported physical activity (OR = 1.53; p = .01) during the first three months, with decline after active intervention was withdrawn. Smoking cessation and medication use were not different at 3 or 8 months; functional status and quality of life were not different at 8 months.

CONCLUSIONS

Telephone coaching post-hospitalization for ACS was modestly effective in accomplishing short-term, but not long-term life-style behavior change. Previous positive results shown in primary care did not transfer to free-standing telephone counseling as an adjunct to care following hospitalization.