A decision aid for women considering hormone therapy after menopause: decision support framework and evaluation

Development and preliminary testing of a patient decision aid to assist pharmaceutical care in the prevention of cardiovascular disease

STUDY OBJECTIVE

To develop and test a decision aid for patients with hypertension and/or dyslipidemia because a decision aid may assist in pharmaceutical care by providing relevant evidence-based information.

DESIGN

Before and after use of a decision aid.

SETTING

Hypertension clinic of a university hospital and a specialized coronary heart disease-prevention clinic.

PATIENTS

A convenience sample of 16 patients receiving pharmacologic treatment for hypertension and/or dyslipidemia.

INTERVENTION

A face-to-face interview was conducted before using the decision aid. This was followed by a telephone interview after the patient used the decision aid to assess the acceptability of the decision aid to the patient, as well as the patient's knowledge, risk perception, and decisional conflict.

MEASUREMENTS AND MAIN RESULTS

The decision aid consists of a booklet containing general, evidence-based information and a personal worksheet. The worksheet provides information on patient risk factors, personal estimates of cardiovascular disease (CVD) risk, the benefits of treatment options, and values clarification exercise. It invites patients to specify an action plan and follow their own progress over time. Most patients (86-93%) rated the presentation of the information as excellent or very good, 80% judged the information about lifestyle changes and drug therapy to be balanced, 93% rated the amount of information "just right," and 100% found the decision aid useful. After using the decision aid, patients had higher knowledge scores for general risk factors (before, 91%; after, 100%, p=0.014), personal risk factors (73%, 92%, p=0.016), and treatment options (68%, 99%, p<0.001). More patients were able to estimate correctly their CVD risk category (50%, 93%, p=0.03) and their absolute 10-year CVD risk (0%, 93%, p<0.001), whereas the overall decisional conflict score decreased (p=0.007).

CONCLUSION

The decision aid was acceptable to patients and improved their knowledge, risk perception, and decisional conflict. Therefore, the feasibility and impact of using the decision aid in community pharmacies and medical clinics should be assessed.

A prospective study of the use of alternative therapies by men with localized prostate cancer

Although the use of alternative therapies is highly prevalent amongst men with prostate cancer, research about the predictors of such use is limited. The current study aimed to describe prospectively the use of alternative therapies by men diagnosed with localized prostate cancer and identify predictors of alternative therapy use. In all, 111 men newly diagnosed with localized prostate cancer (93% response) were recruited to the study prior to treatment. Men's use of alternative therapies and psychological variables including: psychological distress, orientation to health care, decisional conflict, and health locus of control, were assessed at three time points-(1) before treatment; (2) 2 months after completion of treatment; and (3) 12 months after completion of treatment. Demographic information was also obtained. The percentage of men using alternative therapies was 25, 17 and 14% before treatment, 2 and 12 months after treatment, respectively. In general, the most commonly used therapies were dietary changes, vitamins and herbal and nutrient remedies. Alternative therapy use was not related to final treatment choices. Before treatment, men who used alternative therapies were more uncertain about prostate cancer compared to men who were not using these therapies. Men who were using alternative therapies 12 months after treatment were less psychologically distressed that men who were not using these therapies. Health locus of control and orientation to health care were not found to be related to men's use of alternative therapies. In conclusion, men's use of alternative therapies after localized prostate cancer varied across time in terms of the incidence of use, the types of therapies used, and the psychological correlates of therapy use. Informational support that targets uncertainty about prostate cancer may assist men at diagnosis who are considering alternative therapy use. The potential for alternative therapies to have a supportive function in patient care requires further investigation.

To have or to take: discourse, positioning, and narrative identity in women's accounts of HRT

Using 'social cognitive' frameworks, attitudes to HRT have been examined as if they were stable entities located within individuals. However, qualitative studies have revealed variations and contradictions in women's 'attitudes'. We seek to explain these apparent contradictions by using a social constructionist approach to the analysis of qualitative data from 7 focus group discussions about HRT with 48 women in New Zealand. A discourse analysis of 'interpretative repertoires', subject positions and narrative identity was undertaken to explain the construction of HRT in situated practice, and the negotiation and accomplishment of a unitary orientation to HRT across situations. The results summarize the interpretative repertoires used by the women, and one example of a subject position negotiated at a moment of patently problematic intersecting interpretative repertoires, to highlight the construction of subject positions using discursive resources. The importance of the study of subjectivity in applied areas of psychology is discussed.

Eliciting women's preferences in health care: a review of the literature

OBJECTIVES

The increasing availability of information about health care suggests an expanding role for consumers to exercise their preferences in health-care decision-making. Numerous methods are available to assess consumer preferences in health care. We conducted a systematic review to characterize the study of women's preferences about health care.

METHODS

A MEDLINE search from 1965 to July 1999 was conducted as well as hand searches of the Medical Decision Making Journal (1981-1999) and references from retrieved articles. Only original articles on women's health issues were selected. Information on thirty-one variables related to study characteristics and preferences were extracted by two independent investigators. A third investigator resolved disagreements. Qualitative and quantitative analyses were conducted to synthesize the data.

RESULTS

Four hundred eighty-three studies were identified in the initial search. Seventy articles were selected for review based on title, abstract, and inclusion criteria. There was an increase in published articles and number of methods used to elicit preferences. White women were studied more than black women (p < .001). Preferences were mainly studied in outpatient settings (p < .005) and in the United States, United Kingdom, and Canada (83 percent). Preferences related to participation in decision-making were the most common (21 percent). Only 4 percent of the studies were performed to inform the debate for public policy questions. Willingness to pay was the method most used (11 percent), followed by category scaling (10 percent), rating scale (9 percent), standard-gamble (6 percent). Preferences for individual particular (opposed to sequential and health states) outcomes (68 percent), different treatments/tests (47 percent), and related to a treatment episode (31 percent) were addressed. Information regarding diseases, conditions, or procedures was given in 57 percent of studies. Information provided was mainly written (37 percent) and included positive and negative potential outcomes (67 percent). There is no relationship between the method or tool used for delivery information and the choice performed.

CONCLUSIONS

The literature on preferences in women's health care is limited to a fairly homogeneous population (white women from the United States, United Kingdom, and Canada). Additionally, use of utility-based measures to capture preferences has decreased over time while others methods (e.g., time trade-off [TTO], contingent valuation) have increased. Women's preferences are not necessarily uniform even when asked similar questions using similar tools. Little information on women's preferences exists to inform policy-makers about women's health care.

Improving patient safety through informatics tools for shared decision making and risk communication

This paper describes how informatics tools can support shared decision making and risk communication and thereby play an important role in enhancing patient safety. Using preference elicitation techniques and knowledge on risk communication, such tools can help patients understand their treatment options and associated short- and long-term benefits and risks, assist in the elicitation of patient preferences, and help patients and clinicians in making treatment choices with the highest likelihood of achieving desired patient outcomes. Important features of such tools are proposed, including: (1) Interactive tutorials to improve risk comprehension and prepare patients and clinicians for the decision making task; (2) choices between different presentation modes to meet patients' individual reading levels and presentation preferences; (3) risk calculations that account for individual risk profiles; (4) performance of necessary calculations to reach the actual decision; (5) automatic updates of evidence; and (6) the use of different preference-elicitation techniques.

Decision support: helping patients and families to find a balance at the end of life

Terminally ill patients and their families face many decisions at the end of life that can sometimes be overwhelming. Nurses play a key role in providing decision support so that patients and their families can make timely decisions about their health care that reflect their individual needs and circumstances. The Ottawa Decision Support Framework can help nurses to assess patients' decision-making needs, provide tailored decision support and evaluate the effect of their interventions. The theoretical underpinnings of the model and its implications for palliative care clinical practice are discussed.

Decision analysis for newly diagnosed hypertensive patients: a qualitative investigation

This study adopted a qualitative approach to explore patients' views on the usefulness of a decision analytic decision aid (DA). Semi-structured interviews were conducted with 15 newly diagnosed hypertensive patients who had been recruited for a factorial randomised controlled trial of two decision aids. Issues investigated included respondents' attitudes to information, their views on the nature of their relationship with their general practitioner (GP) (paternalistic, shared or consumerist), the ease of use and potential wider application of the computerised decision aid and its influence upon their decision-making about whether or not to begin anti-hypertensive treatment. Views on the decision aid were favourable. For the majority, the decision aid appeared to confirm and/or clarify their stated preferences towards medicine-taking. Occasionally it could provoke a major shift in a respondent's attitude to medicine-taking, while in a few it had no discernible effect. While views on the decision aid were favourable, it was difficult to determine whether this was due to the individualised cardiovascular risk information it provided or the decision analytic process itself.

Patient-centered advance care planning in special patient populations: a pilot study

The purpose of this study was to assess the feasibility of a patient-centered advance care planning (PC-ACP) approach to patients with chronic illnesses and their surrogates with respect to promotion of shared decision-making outcomes-congruence between patient and surrogate, patient's decisional conflict, and knowledge of advance care planning. An experimental design was used. The settings were the heart failure, renal dialysis, and cardiovascular surgery clinics at Gundersen Lutheran Medical Center in La Crosse, WI. Twenty-seven patient-surrogate pairs participated. A 1-hour PC-ACP interview was provided to the experimental group. Only usual care was delivered to participants in the control group. Comparison of the composite scores of a Statement of Treatment Preferences indicated that congruence in decision-making for future medical treatment in patient-surrogate pairs in the treatment group was significantly higher than in the control group. Greater satisfaction with the decision-making process and less decisional conflict were demonstrated in the treatment group. The PC-ACP interview can be effective in promoting shared decision-making between patients and their surrogates and in producing greater satisfaction with the process of decision-making and less decisional conflict.

Making choices for childbirth: development and testing of a decision-aid for women who have experienced previous caesarean

This paper presents the development and pilot testing of an evidence-based decision-aid for pregnant women who have experienced previous caesarean section and who are considering options for birth in a subsequent pregnancy. The Ottawa Decision Support Framework (DSF) has been utilised and modified in the development of a tailored booklet entitled "Birth Choices: What is best for you...vaginal or caesarean birth?" Development included a review by women who had experienced previous caesarean birth as well as obstetric, midwifery and educational experts. The booklet was also reviewed for acceptability by 21 pregnant women who were facing this birth decision. Pre- and post-booklet preferences for birth were elicited and compared to actual birth outcomes. This decision-aid shows promise in facilitating informed decision-making in pregnancy. It is currently undergoing an evaluation in a multi-centre randomised controlled trial.

Women's Decision Making About the Use of Hormonal and Nonhormonal Remedies for the Menopausal Transition

OBJECTIVE

To critically review qualitative research on women's decision making about the use of hormonal and nonhormonal remedies for the menopausal transition.

DATA SOURCES

Computerized searches in CINAHL, MEDLINE, Medscape, and PsychINFO databases, using the keywords decision making, hormone therapy, herbal remedies, attitude toward hormone therapy, and qualitative research; and ancestral bibliographies.

STUDY SELECTION

Articles from indexed journals from 1982 to 2001 in the English language relevant to the keywords were evaluated. Sixteen studies met inclusion criteria and were included in the analysis.

DATA EXTRACTION

Study findings were organized into several categories and compared and contrasted across publications and categories.

DATA SYNTHESIS

Half of the researchers described decision making as a weighing of benefits and risks. Women's considerations, beliefs, and values, as well as interaction with the environment, were primary influences on the process.

CONCLUSIONS

Major gaps in care for midlife women were identified. Women need information about the process of menopause and the range of available options for menopause management. Nurses can play a major role in providing information, counseling, and developing decision aids. Women's values and beliefs, cultures, life contexts, and desire for involvement in the decision should guide interventions.

Factors associated with the difference in score between women's and doctors' decisional conflict about hormone therapy: a multilevel regression analysis

OBJECTIVE

To explore factors associated with the difference in score between women's and doctors' decisional conflict about hormone therapy (HT).

DESIGN

Secondary analysis.

SETTING AND PARTICIPANTS

family doctors were randomized to prepare women for counselling about HT using either a decision aid or a pamphlet.

MAIN VARIABLES STUDIED

After each counselling session, decisional conflict was assessed in women and doctors using the Decisional Conflict Scale (DCS) and the Provider Decision Process Assessment Instrument (PDPAI), respectively. The difference in score between the DCS and PDPAI was computed and entered as the dependent variable in a multilevel regression analysis.

MAIN OUTCOME RESULTS

A total of 40 doctors and 167 women were included in the analysis. The intra-doctor correlation coefficient was 0.25. Factors associated with women experiencing higher decisional conflict than their doctor were: age of doctor >45 years, women who were undecided about the best choice after the counselling session, women with a university degree and women who said that their doctor usually does not give them control over treatment decision. Factors associated with doctors experiencing more decisional conflict than women were: doctors who were undecided about the quality of the decision, length of visit <30 min and women who thought that the decision was shared with their doctor.

CONCLUSION

In order to reduce the disparities between women's and doctors' decisional conflict about HT, interventions aimed at raising awareness of doctors about shared decision-making should be encouraged.

On what basis should the effectiveness of decision aids be judged?

OBJECTIVE

Attempts to synthesize the evidence on the effects of decision aids have been hampered by the lack of consensus regarding how such effectiveness should be measured. This paper seeks to describe and critically assess the range of measures of effectiveness used in randomized controlled trials of decision aids.

SEARCH STRATEGY

The published systematic reviews of the field were used to identify primary studies evaluating the effects of decision aids.

INCLUSION CRITERIA

Non-randomized trials were excluded from this review. As were abstracts and theses of subsequently published studies, methodological papers and reports of subgroups of a study's main publication.

MAIN RESULTS

A wide range of measures were used to evaluate the effectiveness of decision aids. The most commonly used measures sought to assess treatment decisions, patient's knowledge and the decision-making process. This pattern was repeated when primary measures of effectiveness were examined. No study attempted to measure the extent to which decisions made were consistent with patient's values.

CONCLUSIONS

Within the current literature there is little consensus on what the aims of decision aids should be. If we can agree that the aim of a decision aid is to help patients make specific personal treatment choices, then evaluations of decision aids should measure the primary effectiveness of their interventions in terms of the extent to which they enable patient's to undergo treatments that agree with their values.

Validation of a tool to assess health practitioners' decision support and communication skills

As patients become more involved in decisions affecting their health, it is important to monitor and improve the support clinicians provide to facilitate shared decision making. The Decision Support Analysis Tool (DSAT) was developed as a research tool to evaluate practitioners' use of decision support and related communication skills during a clinical encounter. The DSAT, consisting of six categories of decision support skills and four categories of communication skills, was tested with 34 actual transcripts of patient-physician dialogue. The patients were prepared for the clinical encounter with either a detailed decision aid plus worksheet (n=16) or a pamphlet (n=18). Pairs of raters, blinded to the intervention allocation, coded each transcript independently. The overall inter-rater agreement and kappa coefficients were, respectively 75% and 0.59 for the decision support skills and 76% and 0.68 for the communication skills categories. The frequency of DSAT skills coded: (a) were significantly correlated with three out of six patient and physician outcome measures (r>0.30, P<0.05); and (b) showed significant discrimination (P=0.05) or trends (P<0.15) in discrimination between the decision aid and pamphlet groups. The DSAT shows promise as a reliable and valid evaluation tool but requires further testing with larger samples.

Validation of a decision regret scale

BACKGROUND

As patients become more involved in health care decisions, there may be greater opportunity for decision regret. The authors could not find a validated, reliable tool for measuring regret after health care decisions.

METHODS

A 5-item scale was administered to 4 patient groups making different health care decisions. Convergent validity was determined by examining the scale's correlation with satisfaction measures, decisional conflict, and health outcome measures.

RESULTS

The scale showed good internal consistency (Cronbach's alpha = 0.81 to 0.92). It correlated strongly with decision satisfaction (r = -0.40 to -0.60), decisional conflict (r = 0.31 to 0.52), and overall rated quality of life (r = -0.25 to -0.27). Groups differing on feelings about a decision also differed on rated regret: F(2, 190) = 31.1, P < 0.001. Regret was greater among those who changed their decisions than those who did not, t(175) = 16.11, P < 0.001.

CONCLUSIONS

The scale is a useful indicator of health care decision regret at a given point in time.

A qualitative study of physicians' perceptions of three decision aids

The study objective was to investigate physicians' perceptions of three patient decision aids (DA). Semi-structured telephone interviews were conducted with 20 family physicians and 12 gynecologists about a DA for women considering long-term hormone replacement therapy; with 16 respirologists about a DA for the use of intubation and mechanical ventilation for patients with severe chronic obstructive pulmonary disease; and with 19 physicians (geriatricians, gastroenterologists, internists) about a DA for long-term placement of feeding tubes in the elderly. Participants were identified by a snowball sampling technique. The interviews were analyzed using standard qualitative methods. Most participants (81%) indicated some willingness to use the DAs. The characteristics of the DA viewed positively included it being: balanced, well organized, a useful tool, evidence-based, improves decision making process and multimedia. Some of the negative characteristics were stated as: too complex, the cost, the availability, only appropriate for certain groups of patients, and time consuming. The DAs were acceptable to most participants. Perceived positive and negative factors were similar for all DAs. Uptake of decision aids may be facilitated if physicians have an opportunity to examine and try them, and if they can have unfettered access to them for distribution purposes.

A survey of the decision-making needs of Canadians faced with complex health decisions

OBJECTIVE

To describe the decision-making needs of Canadians when faced with 'complex' health decisions characterized by balancing advantages against disadvantages. Although a national report emphasized that public confidence in the health-care system depends on support for personal knowledge and decision-making, there has been no systematic investigation of the Canadian population's decision-making needs.

DESIGN

Cross-sectional telephone survey using random digit dialling.

PARTICIPANTS

National sample of 635 adults over 18 years of age, living in Canada.

RESULTS

Forty-two percentage of eligible contacts participated. Sixty-five percent of contacts reported making 'complex' health decisions, commonly about medical or surgical treatments or birth control, and more commonly by women and by married/separated individuals. Most respondents took an active role in their decisions, often sharing the process with their partner or family. Being younger was associated with a more independent role. Physicians were more often involved in the decisions of respondents with less education. Fifty-nine percent of respondents experienced decisional conflict; more conflict was seen with those who were female and feeling uninformed about options, pressured to select one particular option, and unready or unskilled in decision-making. Less decisional conflict was seen in those who reported birth control decisions and in those who were 70 years and older. Participants used several strategies when deliberating about choices including: information gathering, clarifying their values, and seeking support and information from others. Personal counselling and printed information materials were commonly preferred methods of learning about options. 'Essential' criteria for judging satisfactory decision-making included: having sufficient knowledge about the options, outcomes, and probabilities; being clear about values; selecting and implementing a choice that agrees with personal values; and expressing satisfaction with the choice.

CONCLUSIONS

Canadians, particularly women, face difficult decisions and need support and information from credible sources.

The effect of decision aids on the agreement between women's and physicians' decisional conflict about hormone replacement therapy

The aim of this secondary analysis was to compare the effects of a tailored decision aid (DA) with those of a pamphlet on the agreement between women's and physicians' decisional conflict about hormone replacement therapy (HRT). A total of 40 physicians and 184 women provided data. The agreement between women's and physicians' decisional conflict scores was measured using the intraclass correlation coefficient (ICC). The ICC was higher for dyads in the DA group (ICC=0.44; 95% confidence interval (CI)=0.25-0.59) compared to the pamphlet group (ICC=0.28; 95% CI=0.06-0.47). When the average score of decisional conflict of women nested within a physician and of each physician were used, the ICC for the DA group and the pamphlet group was 0.41 (95% CI=-0.04 to 0.72) and 0.06 (95% CI=-0.41 to 0.49), respectively. Compared to pamphlets, DAs appear to improve the agreement between women's and physicians' decisional conflict about HRT.

What factors are associated with a woman's decision to take hormone replacement therapy? Evaluated in the context of a decision aid

OBJECTIVES

To understand the factors associated with a post-menopausal woman deciding to take hormone replacement therapy (HRT) after reviewing a decision aid (DA) and having a counselling visit with her physician as well as the factors associated with the act of taking HRT 2 months after the counselling interview.

DESIGN

A secondary analysis of data collected for a randomized controlled trial evaluating two DAs.

MAIN OUTCOME RESULTS

Although 28% of women were uncertain regarding their decision after the counselling interview, only 2.4% of women, at the assessment at 2 months, had not made a decision. The most significant factor associated with the decision to take HRT, after the physician visit, was the physician preference (OR: 62, 95% CI: 13.3, 289.7). Physician preference (OR: 78, 95% CI: 6.2, 975) remained the most significant factor for taking HRT 2 months after the counselling interview followed by low uncertainty about the decision (OR: 0.4, 95% CI: 0.2, 0.7).

CONCLUSION

Physician preference was the factor that was most associated with the woman's decision following counselling and 2 months later. Qualitative evaluation of the interview process involving the patient and physician would determine whether the patient and physician are reaching a shared decision or is the physician preference influencing the patient.

Beliefs and expectations of women under 50 years old regarding screening mammography: a qualitative study

OBJECTIVE

Because shared decision making has been recommended for screening mammography by women under age 50, we studied women's decision-making process regarding the procedure.

DESIGN

Qualitative research design using in-depth semi-structured interviews.

PATIENTS

Sixteen white and African-American women aged 38 to 45 receiving care at a large New England medical practice.

MEASUREMENTS AND MAIN RESULTS

We identified the following content areas in women's decision-making process: intentions for screening, motivating factors to undergo screening, attitudes toward screening mammography, attitudes toward breast cancer, and preferences for information and shared decision making. In our sample, all women had or intended to have a screening mammogram before age 50. They were motivated by the awareness of the recommendation to begin screening at age 40, knowing others with breast cancer, and a sense of personal responsibility for their health. Participants feared breast cancer and thought the benefits of screening mammography far outweighed its risks. Women's preferences for involvement in decision making varied from wanting full responsibility for screening decisions to deferring to their medical providers. All preferred the primary care provider to be the main source of information, yet the participants stated that their own providers played a limited role in educating them about the risks and benefits of screening and the mammography procedure itself. Most of their information was derived from the media.

CONCLUSIONS

The women in this study demonstrated little ambivalence in their desire for mammography screening prior to age 50. They reported minimal communication with their medical providers about the risks and benefits of screening. Better information flow regarding mammography screening is necessary. Given the lack of uncertainty among women's perceptions regarding screening mammography, shared decision making in this area may be difficult to achieve.

Development and evaluation of a breast cancer prevention decision aid for higher-risk women

OBJECTIVE

To develop and evaluate the effectiveness of a breast cancer prevention decision aid for women aged 50 and older at higher risk of breast cancer.

DESIGN

Pre-test-post-test study using decision aid alone and in combination with counselling.

SETTING

Breast Cancer Risk Assessment Clinic.

PARTICIPANTS

Twenty-seven women aged 50-69 with 1.66% or higher 5-year risk of breast cancer.

INTERVENTION

Self-administered breast cancer prevention decision aid.

MAIN OUTCOME MEASURES

Acceptability; decisional conflict; knowledge; realistic expectations; choice predisposition; intention to improve life-style practices; psychological distress; and satisfaction with preparation for consultation.

RESULTS

The decision aid alone, or in combination with counselling, decreased some dimensions of decisional conflict, increased knowledge (P < 0.01), and created more realistic expectations (P < 0.01). The aid in combination with counselling, significantly reduced decisional conflict (P < 0.01) and psychological distress (P < 0.02), helped the uncertain become certain (P < 0.02), and increased intentions to adopt healthier life-style practices (P < 0.03). Women rated the aid as acceptable, and both women and practitioners were satisfied with the effect it had on the counselling session.

CONCLUSION

The decision aid shows promise as a useful decision support tool. Further research should compare the effect of the decision aid in combination with counselling to counselling alone.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Decision aids prepare people to participate in preference-sensitive decisions.

OBJECTIVES

1. Create a comprehensive inventory of patient decision aids focused on healthcare options. 2. Review randomized controlled trials (RCT) of decision aids, for people facing healthcare decisions.

SEARCH STRATEGY

Studies were identified through databases and contact with researchers active in the field.

SELECTION CRITERIA

Two independent reviewers screened abstracts for interventions designed to aid patients' decision making by providing information about treatment or screening options and their associated outcomes. Information about the decision aids was compiled in an inventory; those that had been evaluated in a RCT were reviewed in detail.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data using standardized forms. Results of RCTs were pooled using weighted mean differences (WMD) and relative risks (RR) using a random effects model.

MAIN RESULTS

Over 200 decision aids were identified. Of the 131 available decision aids, most are intended for use before counselling. Using the CREDIBLE criteria to evaluate the quality of the decision aids: a) most included potential harms and benefits, credentials of the developers, description of their development process, update policy, and were free of perceived conflict of interest; b) many included reference to relevant literature; c) few included a description of the level of uncertainty regarding the evidence; and d) few were evaluated. Thirty of these decision aids were evaluated in 34 RCTs and another trial evaluated a suite of eight decision aids. An additional 30 trials are yet to be published. Among the trials comparing decision aids to usual care, decision aids performed better in terms of: a) greater knowledge (WMD 19 out of 100, 95% CI: 13 to 24; b) more realistic expectations (RR 1.4, 95%CI: 1.1 to 1.9); c) lower decisional conflict related to feeling informed (WMD -9.1 of 100, 95%CI: -12 to -6); d) increased proportion of people active in decision making (RR 1.4, 95% CI: 1.0 to 2.3); and e) reduced proportion of people who remained undecided post intervention (RR 0.43, 95% CI: 0.3 to 0.7). When simpler were compared to more detailed decision aids, the relative improvement was significant in: a) knowledge (WMD 4 out of 100, 95% CI: 3 to 6); b) more realistic expectations (RR 1.5, 95% CI: 1.3 to 1.7); and c) greater agreement between values and choice. Decision aids appeared to do no better than comparisons in affecting satisfaction with decision making, anxiety, and health outcomes. Decision aids had a variable effect on which healthcare options were selected.

REVIEWER'S CONCLUSIONS

The availability of decision aids is expanding with many on the Internet; however few have been evaluated. Trials indicate that decision aids improve knowledge and realistic expectations; enhance active participation in decision making; lower decisional conflict; decrease the proportion of people remaining undecided, and improve agreement between values and choice. The effects on persistence with chosen therapies and cost-effectiveness require further evaluation. Finally, optimal strategies for dissemination need to be explored.

A decision aid for women at increased risk for ovarian cancer

This paper reviews changes that have occurred within and without the medical profession that have fostered an increasing demand for decision aids as adjuncts to practitioners' counseling to prepare patients for decision making. In the absence of data on the efficacy of ovarian cancer screening and prophylactic strategies, decisions about optimal care are difficult for both women and their doctors. Because surveillance and preventive options are an area of great uncertainty, a decision aid has been developed specifically aimed at facilitating decisions involving ovarian cancer risk management options. This was achieved by reviewing and integrating the available literature on models of medical decision making, patient preferences for information and involvement in decision making, the utility of decision aids, and management options for ovarian cancer risk. Findings indicate that patients wish to be informed participants in the decision-making process and that decision aids are an acceptable and effective method of providing quality information in a format that facilitates an inclusive model of shared decision making. A decision aid designed for women at increased risk of ovarian cancer that facilitates informed decision making may be a valuable addition to patient support. A randomized controlled trial of this type of educational material will provide timely and much needed evidence on its acceptability and efficacy.

Women's decision-making about their health care: views over the life cycle

This paper describes a compilation and further analysis of three qualitative studies, conducted independently, on women's health care decisions. Key areas regarding women's health, which span the life cycle, were examined including prenatal genetic screening, hormone replacement therapy and the use of complementary/alternative medicine in the treatment of breast cancer. Common themes were evident across all the focus groups in each of the three studies including: women's information seeking behavior; reliance on trusted information sources; the desire for information sharing; active involvement in the decision-making process; and accepting the consequences of the final decision. The findings have important implications for health care professionals as they engage women in the decision-making process about health concerns.

Developing, implementing, and evaluating decision support systems for shared decision making in patient care: a conceptual model and case illustration

The importance of including patient preferences in decisions regarding their care has received increased emphasis over recent years. Medical informatics can play an important role in improving patient-centered care by developing decision support systems to support the inclusion of patient preferences in clinical decision making. However, development of such systems is a complex task that requires the integration of knowledge from four major research areas: (1) the clinical domain, for understanding of the decision problem, (2) decision science and research on shared decision making, to provide the theoretical underpinnings and techniques for eliciting patient preferences; (3) medical informatics, to provide the technology and algorithms for the collection, processing, structure, presentation and integration of patient preferences into patient care; and (4) organizational knowledge, to adapt the decision support system to the practices and work flows of clinicians and the organizational and professional context of the clinical practice settings. This paper describes a conceptual model comprising eight key components that are important to be considered in the development, implementation, and evaluation of decision support systems for shared decision making in patient care. The example of CHOICE, a decision support system to assist nurses in eliciting and integrating rehabilitation patients' preferences for functional performance in patient care is used to illustrate the eight components.

An evidence-based approach to managing women's decisional conflict

Women who face difficult health decisions are likely to experience decisional conflict. To date, women have been supported in their decision making through informal counseling and client education. The Ottawa Decision Support Framework guides practitioners in assessing decision-making needs in clinical practice, providing support for client decision making, and evaluating the effectiveness of their interventions. Several evidence-based decision support tools were derived from this framework, including practitioner-administered and client self-administered decision guides, condition-specific decision aids, and the Decisional Conflict Scale.

Addressing the support needs of women at high risk for breast cancer: evidence-based care by advanced practice nurses

PURPOSE/OBJECTIVES

To identify support needs of women at high risk for breast cancer and enhance an evidence-based service.

DESIGN

Descriptive study.

SETTING

A comprehensive, breast-health service for high-risk women.

SAMPLE

97 high-risk women with a 1.66% or greater five-year risk of breast cancer, atypical hyperplasia, lobular carcinoma in situ, or positive genetic screen.

METHODS

A self-assessment questionnaire completed previsit and a satisfaction survey completed postvisit.

MAIN RESEARCH VARIABLES

Women's perceived informational, emotional, and decisional support needs, current self-care practices, and satisfaction with the service provided.

FINDINGS

Women under age 50 (n = 54) wanted information on breast cancer screening, risk of breast cancer, lifestyle options to lower risk, and hormone replacement therapy; older women (n = 43) wanted information on risk of breast cancer, lifestyle options, breast cancer screening, and chemoprevention. More than 75% of all women wanted information to help them make decisions on breast cancer prevention options, benefits, and risks. The satisfaction survey (N = 61) revealed that most women's needs were met.

CONCLUSIONS

Support needs were consistent with the literature that focused primarily on younger women seeking genetic counseling. Proactive planning assisted with addressing the needs of these women.

IMPLICATIONS FOR NURSING

A previsit questionnaire facilitates individualized proactive planning before the visit. However, further assessment of self-care practices and emotional needs is required. Interventions should evaluate outcomes, such as accurate risk perception, lifestyle changes, screening follow-through, and decision quality. Advanced practice nurses require specialized skills, including evidence-based risk communication, behavior modification, and decision support.

Menopausal experiences and hormone replacement therapy use among women with physical impairments

This study describes the menopausal experiences of women with physical disabilities and their knowledge and use of hormone replacement therapy (HRT). 166 women completed a mailed survey of demographic and disability characteristics, health history, menopausal information, and HRT knowledge. The typical respondent was a 52-year-old, Anglo, college-educated woman with a neuromuscular disorder. Half of the menopausal women were taking HRT, and 47% had a hysterectomy. HRT use was significantly associated with hysterectomy status, amount of HRT information received from providers, and regular gynecologic examinations. Effective interventions are needed to assist these women in making key health decisions during menopause.

Development and pilot testing of a decision aid for postmenopausal women with osteoporosis

This study's aim was to develop and pilot test an evidence-based decision aid for postmenopausal women with osteoporosis who are considering options to prevent fractures. The aid was based on the Ottawa Decision Support Framework, and integrated evidence from our Cochrane systematic reviews. Following development by a panel of experts in osteoporosis and decision making, a user review panel of practitioners and women who had already made their decision about osteoporosis therapy reviewed the decision aid for acceptability. Then the decision aid was pilot tested using a before-after design in women at the point of decision making. Compared to baseline, there were statistically significant improvements in knowledge, realistic expectations and decreased decisional conflict. Our decision aid shows promise in preparing women for counseling about osteoporosis therapies. Long-term adherence to chosen therapy and quality of life will be evaluated in a randomized controlled trial.

Women's views of two interventions designed to assist in the prophylactic oophorectomy decision: a qualitative pilot evaluation

INTRODUCTION

A qualitative pilot evaluation of two different decision interventions for the prophylactic oophorectomy (PO) decision: a Decision Chart and a computerized clinical guidance programme (CGP) was undertaken. The Decision Chart, representing current practice in decision interventions, presents population-based information. The CGP elicits individual values to allow for quality-adjusted life years to be calculated and an explicit guidance statement is given. Prophylactic oophorectomy involves removal of the ovaries as an adjunct to hysterectomy to prevent ovarian cancer. The decision is complex because the operation can affect a number of long-term outcomes including breast cancer, coronary heart disease and osteoporosis.

METHODS

Both interventions were based on the evidence and were administered by a facilitator. The Decision Chart is a file, which progressively reveals information in the form of bar charts. The CGP is a decision-analysis based program integrating the results from a cluster of Markov cycle trees. The research evidence is incorporated with woman's individual risk factors, values and preferences. A purposive sample of 19 women awaiting hysterectomy used the decision interventions (10 CGP, nine Decision Chart). In-depth semi-structured interviews were undertaken. Interviews were transcribed and analysed to derive themes.

RESULTS

Reactions to the different decision interventions were mixed. Both were seen as clarifying the decision. Some women found some of the tasks difficult (e.g. rating health status). Some were surprised by the "individualized" guidance, which the CGP offered. The Decision Chart provided some with a sense of empowerment, although some found that it provided too much information.

CONCLUSIONS

Women were able to use both decision interventions. Both provided decision clarification. Problems were evident with both interventions, which give useful pointers for future development. These included the possibility for women to see how their individual risks of different outcomes are affected in the Decision Chart and enhanced explanation of the CGP tasks. Future design and evaluation of decision aids, will need to accommodate differences between patients in the desire for amount and type of information and level of involvement in the decision-making process.

Breast cancer risk reduction: strategies for women at increased risk

Breast cancer risk reduction now represents an achievable medical objective. Current interventions include selective estrogen receptor modulators (SERMs), prophylactic surgery, and lifestyle change. For SERMs, current evidence supports tamoxifen use for breast cancer risk reduction whereas raloxifene requires further study. Prophylactic mastectomy and prophylactic oophorectomy, effective in retrospective clinical experiences, should be considered only for women at substantial risk willing to accept the irreversible consequences of these procedures. Although dietary fat intake is under clinical trial evaluation, lifestyle change, including weight loss, dietary change, and increased physical activity, can be recommended based on other health considerations. Use of any intervention requires careful breast cancer risk assessment, risk-benefit calculations, and informed decision making with full patient participation. Future breast cancer risk assessment may incorporate additional biologic measures of estrogen exposure and/or analyses of collected breast cells. Under active evaluation are novel SERMs, aromatase inhibitors/inactivators, gonadotrophin-releasing hormone agonists, retinoids, statins, and tyrosine kinase and cyclooxygenase-2 inhibitors.

The decision to take hormone replacement therapy among women with disabilities

Whereas making decisions during menopause can be challenging for all women, those with physical impairments face special issues with respect to menopause in general and hormone replacement therapy (HRT) in particular. In this correlational study the authors explored the factors such women consider when making decisions about HRT One hundred sixty-seven women with physical impairments throughout the United States completed surveys concerning their attitudes and knowledge about HRT Approximately half the menopausal women were currently taking HRT The strongest predictor of HRT use was women's perceptions of their health care providers opinions about their taking HRT, combined with their motivation to comply with the provider's recommendation. Thisfinding points to the significant role that nurses and other health care providers play in assisting women to make informed health care choices during menopause.

What is this thing called hormone replacement therapy? Discursive construction of medication in situated practice

The use of hormone replacement therapy (HRT) involves complex decisions for mid-aged women owing to controversy about the meaning of menopause and uncertainty regarding risks and benefits. Qualitative studies show that women can hold apparently contradictory beliefs, for example, both resisting and relying on medicalization. Focus group data (48 participants) and discourse analysis theorizing were used to investigate the complex discursive field available to women to construct HRTand to explain apparent contradictions. Interpretative repertoires identified in this study (threatening change, natural, biomedical, and drug) support previous findings. It is not contradictory to use different repertoires to achieve different discursive acts. The application of these findings to the development of decision tools that help women to arrive at individually appropriate decisions is discussed.

The role of patients' meta-preferences in the design and evaluation of decision support systems

The arrival of new analysis-based decision technologies will necessitate a profound rethinking both of the nature of the patient-doctor relationship and of the way aids and support systems designed to improve decision-making within that relationship are designed and evaluated. One-dimensional typologies of the traditional 'paternalist/shared/informed' sort do not provide the complexity called for by the heterogeneity of patient's 'meta-preferences' regarding their relationship with a doctor on the one hand and regarding the analytical level of judgement and decision-making on the other. A multidimensional matrix embodying this distinction is proposed as a framework of the minimal complexity required for the design and evaluation of the full range of decision aids and decision modes. Essentially aids should be conceived of and evaluated cell-specifically and the search for universally satisfactory decision support systems abandoned. 'shared' and'informed' are best interpreted as attributes which may or not be in line with a patient's meta-preferences. Future research should focus on the higher level goal of better decision-making, a goal that will need to respect and reflect these meta-preferences.

Using disease risk estimates to guide risk factor interventions: field test of a patient workbook for self-assessing coronary risk

OBJECTIVE

To assess the feasibility and acceptability of a patient workbook for self-assessing coronary risk.

DESIGN

Pilot study, with post-study physician and patient interviews.

SETTING AND SUBJECTS

Twenty southern Ontario family doctors and 40 patients for whom they would have used the workbook under normal practice conditions.

INTERVENTIONS

The study involved convening two sequential groups of family physicians: the first (n=10) attended focus group meetings to help develop the workbook (using algorithms from the Framingham Heart Study); the second (n=20) used the workbook in practice with 40 patients. Follow-up interviews were by interviewer-administered questionnaire.

MAIN OUTCOMES MEASURES

Physicians' and patients' opinions of the workbook's format, content, helpfulness, feasibility, and potential for broad application, as well as patients' perceived 10-year risk of a coronary event measured before and after using the workbook.

RESULTS

It took an average of 18 minutes of physician time to use the workbook: roughly 7 minutes to introduce it to patients, and about 11 minutes to discuss the results. Assessments of the workbook were generally favourable. Most patients were able to complete it on their own (78%), felt they had learned something (80%) and were willing to recommend it to someone else (98%). Similarly, 19 of 20 physicians found it helpful and would use it in practice with an average of 18% of their patients (range: 1-80%). The workbook helped to correct misperceptions patients had about their personal risk of a coronary event over the next 10 years (pre-workbook (mean (SD) %): 35.2 (16.9) vs. post-workbook: 17.3 (13.5), P < 0.0001; estimate according to algorithm: 10.6 (7.6)).

CONCLUSIONS

Given a simple tool, patients can and will assess their own risk of CHD. Such tools could help inform otherwise healthy individuals that their risk is increased, allowing them to make more informed decisions about their behaviours and treatment.

A randomized trial of a computerized versus an audio-booklet decision aid for women considering post-menopausal hormone replacement therapy

Decision aids (DAs) are increasingly being developed to help patients make shared health care decisions with their practitioners. There are no formal comparisons of the efficacy of different delivery methods. Interactive computerized delivery methods have the advantage of allowing patients control over flow of information and to receive feedback on their comprehension. The purpose of this study was to compare the efficacy of an interactive computerized DA for women considering long-term hormone replacement therapy, to that of a validated audio-booklet version of the same intervention. Fifty-one peri-menopausal women were randomized to use either the computerized or the standard audio-booklet version of the DA. The computerized version presented identical information with the addition of feedback modules to reinforce the participant's understanding. The patients were interviewed with a pre- and post-intervention questionnaire. The computerized DA improved realistic expectations by 52.7% over baseline versus 27.6% with the audio-booklet (P=0.015). Knowledge (Kn) scores improved by 17.5 and 8.4% for the computer and standard DA groups, respectively (P=0.019). The results of this study have implications for future DA design, and other areas where patient Kn and understanding are important, such as in the setting of informed consent.

Women's knowledge of hormone therapy

The aim of this study was to assess women's knowledge of hormone therapy. Two hundred and seven women were interviewed by telephone. The median score to 24 questions concerning the benefits, risks and side effects of therapy was 54.2%. Almost three-quarters of women knew that hormone therapy may decrease the risk of osteoporosis, but half were unaware that it should be taken for at least 10 years for maximum protection against bone loss. While many women knew that hormone therapy may increase the risk of breast cancer, 13.5% believed that it would decrease their risk. Many women overestimated the potential reduction in lifetime risk of hip fracture and the potential increase in lifetime risk of breast cancer with hormone therapy. Women may have insufficient knowledge to make informed choices about hormone therapy. This has implications for physicians who wish to ensure that women are able to participate in informed decision-making.

Frequency or probability? A qualitative study of risk communication formats used in health care

BACKGROUND

The communication of probabilistic outcomes is an essential aspect of shared medical decision making.

METHODS

The authors conducted a qualitative study using focus groups to evaluate the response of women to various formats used in the communication of breast cancer risk.

FINDINGS

Graphic discrete frequency formats using highlighted human figures had greater salience than continuous probability formats using bar graphs. Potential biases in the estimation of risk magnitude were associated with the use of highlighted human figures versus bar graphs and the denominator size in graphics using highlighted human figures. The presentation of uncertainty associated with risk estimates caused some to loose trust in the information, whereas others were accepting of uncertainty in scientific data.

CONCLUSION

The qualitative studyidentified new constructs with regard to how patients process probabilistic information. Further research in the clinical setting is needed to provide a theoretical justification for the format used when presenting risk information to patients.

Women's responses to a mailed hormone replacement therapy workbook

OBJECTIVE

Effectively communicating information about the complex decisions that face women at midlife, including whether to use hormone replacement therapy (HRT), is an ongoing challenge. Although numerous decision-making tools exist, few have been evaluated. The objective of this study was to examine women's use of a workbook designed to promote informed HRT decision-making.

DESIGN

We developed a workbook to prepare women to discuss HRT, osteoporosis, heart disease, and breast cancer with their providers. To evaluate the workbook, women aged 45-65 years were randomly assigned to one of three groups: (1) workbook plus baseline and 6-month surveys, (2) workbook and 6-month survey, or (3) no workbook with both surveys. Results are based on the responses of 580 women in groups 1 and 2 (response rate, 84.2%).

RESULTS

At 6 months, 79% of women recalled receiving the workbook, of whom 51% read all or most of it, 35% skimmed or read part of it, and 14% did not read it. The percentages of women completing self-assessments were 55% osteoporosis; 56% heart disease; 58% breast cancer; 57% advantages and disadvantages of HRT; and 52% personal preferences about HRT. As a result of the workbook, 10% made an appointment with their providers, and 12% had a discussion about HRT with their providers. Use of the workbook was not associated with menopause symptoms, attitudes about or use of HRT, hysterectomy, or provider discussions about menopause and HRT.

CONCLUSION

This simple approach of using a mailed workbook holds promise as a successful mechanism to prepare women to discuss HRT and other related health issues with their providers.

Identifying patient preferences for communicating risk estimates: a descriptive pilot study

BACKGROUND

Patients increasingly seek more active involvement in health care decisions, but little is known about how to communicate complex risk information to patients. The objective of this study was to elicit patient preferences for the presentation and framing of complex risk information.

METHOD

To accomplish this, eight focus group discussions and 15 one-on-one interviews were conducted, where women were presented with risk data in a variety of different graphical formats, metrics, and time horizons. Risk data were based on a hypothetical woman's risk for coronary heart disease, hip fracture, and breast cancer, with and without hormone replacement therapy. Participants' preferences were assessed using likert scales, ranking, and abstractions of focus group discussions.

RESULTS

Forty peri- and postmenopausal women were recruited through hospital fliers (n = 25) and a community health fair (n = 15). Mean age was 51 years, 50% were non-Caucasian, and all had completed high school. Bar graphs were preferred by 83% of participants over line graphs, thermometer graphs, 100 representative faces, and survival curves. Lifetime risk estimates were preferred over 10 or 20-year horizons, and absolute risks were preferred over relative risks and number needed to treat.

CONCLUSION

Although there are many different formats for presenting and framing risk information, simple bar charts depicting absolute lifetime risk were rated and ranked highest overall for patient preferences for format.

Midlife women making hormone therapy decisions

This study focuses on midlife women aged 40-65 years who were in transition to menopause, were menopausal or had a hysterectomy, to examine and better understand hormone therapy (HT) choices women make. Among the nationally representative sample of women in the Commonwealth Fund 1998 Survey of Women's Health (n = 884), 39% of the menopausal women reported current HT use. The two primary reasons for initiating HT are following a doctor's recommendation and seeking relief of menopausal symptoms. Age, education, race, hysterectomy status, having health insurance, use of calcium supplements and comfort in communicating with a doctor are important factors associated with HT use. This study underscores the importance of physicians and other health professionals providing accurate HT information to assist women in making HT decisions.

Women at mid-life: symptoms, attitudes, and choices, an internet based survey

OBJECTIVES

This Internet-based survey questioned middle-aged women (age 35-69) regarding their current attitudes, beliefs, symptoms, and treatment choices surrounding the climacteric.

METHODS

448 respondents completed the 189 item, WEB-based survey that included measures of quality of life, lifestyle habits, anxiety symptoms, and questions regarding attitude toward and sources of information about menopause.

RESULTS

Three relationships were hypothesized and supported: frequency of self-reported menopause symptoms would be: (1) negatively associated with healthy behaviors; (2) positively associated with anxiety; (3) positively associated with stress. All measures were self-report. Fatigue, muscle and joint aches, and impatience were the most commonly reported symptoms. No particular symptom was strongly correlated (r > 0.4) to lifestyle behaviors. Questions regarding information exchange reveal that many women are not consulting with their healthcare providers about HRT or frequently discussing alternatives. Many receive health information from lay sources.

CONCLUSIONS

There is a need for improved information exchange on this subject. Our results are similar to those found using large randomized telephone survey methods, which supports the use of the Internet as a reliable and convenient venue for gathering data regarding health issues. It is important to consider healthy lifestyle behaviors toward the regulation of the climacteric syndrome.

A decision aid for long-term tube feeding in cognitively impaired older persons

OBJECTIVE

To describe the development and evaluation of a decision aid for long-term tube feeding in cognitively impaired older people.

DESIGN

Before-and-after study.

SETTING

Acute care hospitals in Ottawa, Canada.

PARTICIPANTS

Substitute decision makers for 15 cognitively impaired inpatients 65 years and older being considered for placement of a percutaneous endoscopic gastrostomy tube.

MEASUREMENTS

Questionnaires were used to compare the substitute decision makers' knowledge, decisional conflict, and predisposition regarding feeding tube placement before and after exposure to the decision aid. The acceptability of the decision aid was also assessed.

RESULTS

Substitute decision makers significantly increased their knowledge (P = .004) and decreased their decisional conflict (P = .004) regarding long-term tube feeding after using the decision aid. The impact of the decision aid on predisposition toward the intervention was greatest for those who were unsure of their preferences at baseline. All substitute decision makers found the decision aid helpful and acceptable despite very difficult and emotional circumstances.

CONCLUSIONS

A decision aid improves the decision-making process for long-term tube feeding in cognitively impaired older patients by decreasing decisional conflict and by promoting decisions that are informed and consistent with personal values. There are particular challenges for developing and evaluating these tools in the context of end-of-life decisions.

Determining the need for hip and knee arthroplasty: the role of clinical severity and patients' preferences

BACKGROUND

Area variation in the use of surgical interventions such as arthroplasty is viewed as concerning and inappropriate.

OBJECTIVES

To determine whether area arthroplasty rates reflect patient-related demand factors, we estimated the need for and the willingness to undergo arthroplasty in a high- and a low-use area of Ontario, Canada.

RESEARCH DESIGN

Population-based mail and telephone survey.

SUBJECTS

All adults aged > or =55 years in a high (n = 21,925) and low (n = 26,293) arthroplasty use area.

MEASURES

We determined arthritis severity and comorbidity with questionnaires, established the presence of arthritis with examination and radiographs, and evaluated willingness to have arthroplasty with interviews. Potential arthroplasty need was defined as severe arthritis, no absolute contraindication for surgery, and evidence of arthritis on examination and radiographs. Estimates of need were then adjusted for patients' willingness to undergo arthroplasty.

RESULTS

Response rates were 72.0% for questionnaires and interviews. The potential need for arthroplasty was 36.3/1,000 respondents in the high-rate area compared with 28.5/1,000 in the low-rate area (P <0.0001). Among individuals with potential need, only 14.9% in the high-rate area and 8.5% in the low-rate area were definitely willing to undergo arthroplasty (P = 0.03), yielding adjusted estimates of need of 5.4/1,000 and 2.4/1,000 in the high- and low-rate areas, respectively.

CONCLUSIONS

Demonstrable need and willingness were greater in the high-rate area, suggesting these factors explain in part the observed geographic rate variations for this procedure. Among those with severe arthritis, no more than 15% were definitely willing to undergo arthroplasty, emphasizing the importance of considering both patients' preferences and surgical indications when evaluating need and appropriateness of rates for surgery.

Are women being counseled about estrogen replacement therapy?

The U.S. Preventive Services Task Force and several medical professional associations have published guidelines recommending that all women be counseled around the time of menopause about the benefits and risks of estrogen replacement therapy (ERT) so that they may make an informed decision about its use. Despite the proliferation of ERT counseling guidelines, little is known about whether these guidelines are being followed. There were 1,500 female members (aged 40 to 69) of a Northeastern U.S. Independent Practice Association--model Health Maintenance Organization who were surveyed, and 51 percent reported that a health care provider had talked with them about the benefits and risks of ERT. In multivariate analyses, a woman's demographic characteristics (age, race, income), stage of menopause, severity of menopausal symptoms, and body weight were the major correlates of receipt of ERT counseling. Women at greater risk for osteoporosis or heart disease were no more likely to be counseled, although those with diagnosed osteoporosis were. What appear to be selective ERT counseling practices will need to be modified if the goal of providing universal ERT counseling to midlife women is to be attained.