The potential benefits of decision aids in clinical medicine

Left Atrial Appendage Occlusion, Shared Decision-Making, and Comprehensive Atrial Fibrillation Management

The epidemic of atrial fibrillation (AF) requires a comprehensive management strategy that uses the full force of available data and technology, including anticoagulation, ablative therapy, and left atrial appendage occlusion. Patient-centered care with an emphasis on shared decision-making is particularly relevant to the authors' understanding of the complexity of AF and has helped them tailor therapy in this ever-growing patient population.

Preference-Based Antithrombotic Therapy in Atrial Fibrillation: Implications for Clinical Decision Making

Background. Patient preferences and expert-generated clinical practice guidelines regarding treatment decisions may not be identical. The authors compared the thresholds for antithrombotic treatment from studies that determined or modeled the treatment preferences of patients with atrial fibrillation with recommendations from clinical practice guidelines. Methods. Methods included MEDLINE identification, systematic review, and pooling with some reanalysis of primary data from relevant studies. Results. Eight pertinent studies, including 890 patients, were identified. These studies used 3 methods (decision analysis, probability tradeoff, and decision aids) to determine or model patient preferences. All methods highlighted that the threshold above which warfarin was preferred over aspirin was highly variable. In 6 of 8 studies, patient preferences indicated that fewer patients would take warfarin compared to the recommendations of the guidelines. In general, at a stroke rate of 1% with aspirin, half of the participants would prefer warfarin, and at a rate of 2% with aspirin, two thirds would prefer warfarin. In 3 studies, warfarin must provide at least a 0.9% to 3.0% per year absolute reduction in stroke risk for patients to be willing to take it, corresponding to a stroke rate of 2% to 6% on aspirin. Conclusions. For patients with atrial fibrillation, treatment recommendations from clinical practice guidelines often differ from patient preferences, with substantial heterogeneity in their individual preferences. Since patient preferences can have a substantial impact on the clinical decision-making process, acknowledgment of their importance should be incorporated into clinical practice guidelines. Practicing physicians need to balance the patient preferences with the treatment recommendations from clinical practice guidelines.

A Randomized Controlled Trial of a Decision Aid for Women at Increased Risk of Ovarian Cancer

Purpose. To carry out a randomized controlled trial of a decision aid for women at increased risk of developing ovarian cancer to facilitate decision making regarding risk management options. Methods. This randomized trial, conducted through 6 familial cancer centers, compared the efficacy of tailored decision aid to that of a general educational pamphlet in preparing women for decision making. Participants. 131 women with a family history of breast and/or ovarian cancer or of hereditary nonpolyposis colorectal cancer. Outcome measures. Decisional conflict, knowledge about ovarian cancer risk management options, and psychological adjustment were reassessed at 3 time points. Results. Compared to those who received the pamphlet (control), women who received the decision aid (intervention) were significantly more likely to report a high degree of acceptability of the educational material at both follow-up assessment time points. Findings indicate neither group experienced significant increases in psychological distress at either follow-up assessment time points relative to baseline. Two weeks postintervention, the intervention group demonstrated a significant decrease in decisional conflict compared to the control group (t = 2.4, P < 0.025) and a trend for a greater increase in knowledge about risk management options (t = 2.1, P = 0.037). No significant differences were found 6 months postintervention. Conclusion. This form of educational material is successful in increasing knowledge about risk management options and in reducing decisional conflict in the shorter term. The decision aid is an effective and acceptable strategy for patient education to facilitate an inclusive and informed decision-making process about managing ovarian cancer risk.

Development of a personalized decision aid for breast cancer risk reduction and management

BACKGROUND

Breast cancer risk reduction has the potential to decrease the incidence of the disease, yet remains underused. We report on the development a web-based tool that provides automated risk assessment and personalized decision support designed for collaborative use between patients and clinicians.

METHODS

Under Institutional Review Board approval, we evaluated the decision tool through a patient focus group, usability testing, and provider interviews (including breast specialists, primary care physicians, genetic counselors). This included demonstrations and data collection at two scientific conferences (2009 International Shared Decision Making Conference, 2009 San Antonio Breast Cancer Symposium).

RESULTS

Overall, the evaluations were favorable. The patient focus group evaluations and usability testing (N = 34) provided qualitative feedback about format and design; 88% of these participants found the tool useful and 94% found it easy to use. 91% of the providers (N = 23) indicated that they would use the tool in their clinical setting.

CONCLUSION

BreastHealthDecisions.org represents a new approach to breast cancer prevention care and a framework for high quality preventive healthcare. The ability to integrate risk assessment and decision support in real time will allow for informed, value-driven, and patient-centered breast cancer prevention decisions. The tool is being further evaluated in the clinical setting.

What is lacking in current decision aids on cancer screening?

Recent guidelines on cancer screening have provided not only more screening options but also conflicting recommendations. Thus, patients, with their clinicians' support, must decide whether to get screened, which modality to use, and how often to undergo screening. Decision aids could potentially lead to better shared decision-making regarding screening between the patient and the clinician. A total of 73 decision aids concerning screening for breast, cervical, colorectal, and prostate cancers were reviewed. The goal of this review was to assess the effectiveness of such decision aids, examine areas in need of more research, and determine how the decision aids can be currently applied in the real-world setting. Most studies used sound study designs. Significant variation existed in the setting, theoretical framework, and measured outcomes. Just over one-third of the decision aids included an explicit values clarification. Other than knowledge, little consistency was noted with regard to which patient attributes were measured as outcomes. Few studies actually measured shared decision-making. Little information was available regarding the feasibility and outcomes of integrating decision aids into practice. In this review, the implications for future research, as well as what clinicians can do now to incorporate decision aids into their practice, are discussed.

Critical pathways for post-emergency outpatient diagnosis and treatment: tools to improve the value of emergency care

The decision to admit a patient to the hospital after an emergency department (ED) visit is expensive, frequently not evidence-based, and variable. Outpatient critical pathways are a promising approach to reduce hospital admission after emergency care. Critical pathways exist to risk stratify patients for potentially serious diagnoses (e.g., acute myocardial infarction [AMI]) or evaluate response to therapy (e.g., community-acquired pneumonia) within a short time period (i.e., less than 36 hours), to determine if further hospital-based acute care is needed. Yet, such pathways are variably used while many patients are admitted for conditions for which they could be treated as outpatients. In this article, the authors propose a model of post-ED critical pathways, describe their role in emergency care, list common diagnoses that are amenable to critical pathways in the outpatient setting, and propose a research agenda to address barriers and solutions to increase the use of outpatient critical pathways. If emergency providers are to routinely conduct rapid evaluations in outpatient or observation settings, they must have several conditions at their disposal: 1) evidence-based tools to accurately risk stratify patients for protocolized care, 2) systems of care that reliably facilitate workup in the outpatient setting, and 3) a medical environment conducive to noninpatient pathways, with aligned risks and incentives among patients, providers, and payers. Increased use of critical pathways after emergency care is a potential way to improve the value of emergency care.

Preferences related to attention-deficit/hyperactivity disorder and its treatment

OBJECTIVES

A growing body of literature has highlighted the importance of considering patient preferences as part of the medical decision-making process. The purpose of the current review was to identify and summarize published research on preferences related to attention-deficit/hyperactivity disorder (ADHD) and its treatment, while suggesting directions for future research.

METHODS

A literature search identified 15 articles that included a choice-based assessment of preferences related to ADHD.

RESULTS

The 15 studies were grouped into four categories based on preference content: preference for a treatment directly experienced by the respondent or the respondent's child; preference for general treatment approaches; preference for a specific treatment attribute or outcome; and preference for aspects of ADHD-related treatment. Preference assessment methods ranged from global single items to detailed choice-based procedures, with few studies using rigorously developed assessment methods. Respondents included patients with ADHD, clinicians, parents, teachers, and survey respondents from the general population. Factors influencing preference include treatment characteristics, effectiveness for specific symptoms, side effects, and respondent demographics. Minimal research has examined treatment preferences of adults with ADHD.

DISCUSSION

Because there is no dominant treatment known to be the first choice for all patients, ADHD is a condition for which individual preferences can play an important role when making treatment decisions for individual patients. Given the potential role of preferences in clinical decision-making, more research is needed to better understand the preferences of patients with ADHD and other individuals who are directly affected by the disorder, such as parents and teachers.

Systematic review of implementation strategies for risk tables in the prevention of cardiovascular diseases

Background

Cardiovascular disease prevention is guided by so-called risk tables for calculating individual’s risk numbers. However, they are not widely used in routine practice and it is important to understand the conditions for their use.

Objectives

Systematic review of the literature on professionals’ performance regarding cardiovascular risk tables, in order to develop effective implementation strategies.

Selection criteria

Studies were eligible for inclusion if they reported quantitative empirical data on the effect of professional, financial, organizational or regulatory strategies on the implementation of cardiovascular risk tables. Participants were physicians or nurses.

Outcome measure

Primary: professionals’ self-reported performance related to actual use of cardiovascular risk tables. Secondary: patients’ cardiovascular risk reduction.

Data collection and analysis

An extensive strategy was used to search MEDLINE, EMBASE, CINAHL, and PSYCHINFO from database inception to February 2007.

Main results

The review included 9 studies, covering 3 types of implementation strategies (or combinations). Reported effects were moderate, sometimes conflicting and contradictory. Although no clear relation was observed between a particular type of strategy and success or failure of the implementation, promising strategies for patient selection and risk assessment seem to be teamwork, nurse led-clinics and integrated IT support.

Conclusions

Implementation strategies for cardiovascular risk tables have been sparsely studied. Future research on implementation of cardiovascular risk tables needs better embedding in the systematic and problem-based approaches developed in implementation science.

Ambivalence related to potential lifestyle changes following preventive cardiovascular consultations in general practice: a qualitative study

BACKGROUND

Motivational interviewing approaches are currently recommended in primary prevention and treatment of cardiovascular disease (CVD) in general practice in Denmark, based on an empirical and multidisciplinary body of scientific knowledge about the importance of motivation for successful lifestyle change among patients at risk of lifestyle related diseases. This study aimed to explore and describe motivational aspects related to potential lifestyle changes among patients at increased risk of CVD following preventive consultations in general practice.

METHODS

Individual interviews with 12 patients at increased risk of CVD within 2 weeks after the consultation. Grounded theory was used in the analysis.

RESULTS

Ambivalence related to potential lifestyle changes was the core motivational aspect in the interviews, even though the patients rarely verbalised this experience during the consultations. The patients experienced ambivalence in the form of conflicting feelings about lifestyle change. Analysis showed that these feelings interacted with their reflections in a concurrent process. Analysis generated a typology of five different ambivalence sub-types: perception, demand, information, priority and treatment ambivalence.

CONCLUSION

Ambivalence was a common experience in relation to motivation among patients at increased risk of CVD. Five different ambivalence sub-types were found, which clinicians may use to explore and resolve ambivalence in trying to aid patients to adopt lifestyle changes. Future research is needed to explore whether motivational interviewing and other cognitive approaches can be enhanced by exploring ambivalence in more depth, to ensure that lifestyle changes are made and sustained. Further studies with a wider range of patient characteristics are required to investigate the generalisability of the results.

Rethinking the objectives of decision aids: a call for conceptual clarity

Health decision aids are a potentially valuable adjunct to patient-physician communication and decision making. Although the overarching goal of decision aids--to help patients make informed, preference-sensitive choices--is widely accepted, experts do not agree on the means to achieve this end. In this article, the authors critically examine the theoretical basis and appropriateness of 2 widely accepted criteria used to evaluate decision aids: values clarification and reduction of decisional conflict. First, they argue that although clarifying values is central to decision making under uncertainty, it is not clear that decision aids--as they have been conceived and operationalized so far--can and should be used to achieve this goal. The pursuit of clarifying values, particularly values clarification exercises, raises a number of ethical, methodological, and conceptual issues, and the authors suggest research questions that should be addressed before values clarification is routinely endorsed. Second, the authors argue that the goal of reducing decisional conflict is conceptually untenable and propose that it be eliminated as an objective of decision aids.

Pilot Trial of a Computerized Decision Aid for Breast Cancer Prevention

This study sought to evaluate a shared decision-making aid for breast cancer prevention care designed to help women make appropriate prevention decisions by presenting information about risk in context. The decision aid was implemented in a high-risk breast cancer prevention program and pilot-tested in a randomized clinical trial comparing standard consultations to use of the decision aid. Physicians completed training with the decision aid prior to enrollment. Thirty participants enrolled (15 per group) and completed measures of clinical feasibility and effectiveness prior to, immediately after, and at 9 months after their consultations. The decision aid was feasible to use during the consultations as measured by consultation duration, user satisfaction, patient knowledge, and decisional conflict. The mean consultation duration was not significantly different between groups (24 minutes for intervention group versus 21 minutes for control group, p = 0.42). The majority found the decision aid acceptable and useful and would recommend it to others. Both groups showed an improvement in breast cancer prevention knowledge postvisit, which was significant in the intervention group (p = 0.01) but not the control group (p = 0.13). However, the knowledge scores returned to baseline at follow-up in both groups. Decision preference for patients who chose chemoprevention post consultations remained constant at follow-up for the intervention group, but not for the control group. The decision framework provides access to key information during consultations and facilitates the integration of emerging biomarkers in this setting. Initial results suggest that the decision aid is feasible for use in the consultation room. The tendency for the decision choices and knowledge scores to return to baseline at follow-up suggests the need for initial and ongoing prevention decision support.

Decision aids for familial breast cancer: exploring women's views using focus groups

BACKGROUND

There is increasing need for accessible information about familial breast cancer for those facing complex decisions around genetic testing, screening and treatment. Information currently includes leaflets and computerized decision aids, offering interactive interfaces to clarify complex choices.

OBJECTIVE

Exploration of users' views and reactions to three decision aids for genetic testing for breast cancer using focus groups.

SETTING

A regional cancer genetics service in the UK.

PARTICIPANTS

Women over 18 years of age who had been referred to Cancer Genetics Service for Wales (CGSW) and had received a risk assessment for familial breast cancer.

METHODS

Qualitative study involving one pilot and six extended focus groups with 39 women at high, moderate and population risk. Two CD-ROMs and one paper-based aid evaluated for: clarity of presentation, ease of handling, emotive response, increased knowledge and greater informed choice.

RESULTS

Women reported variable preferences for different types of decision aids and mixed emotions, indicating the sensitivity of raising issues in decision support tools, lack of consensus over the most appropriate aid and no systematic differences between risk groups. Women remarked that aids increased their knowledge, particularly about breast cancer genes and risk and wanted a decision aid designed within the context of the NHS, in both paper-based and CD-ROM formats from an authoritative source. Mixed views about presentation styles suggest decision aids would be most effective with a user-selected range of formats.

CONCLUSIONS

Decision aid development should be informed by users and should meet the needs of those concerned about their risk of breast cancer in the UK. Without such aids, patients will continue to search for information from a variety of sources of varying quality.

Dispositional optimism as a predictor of men's decision-related distress after localized prostate cancer

This study investigated prospectively the relationship between optimism, threat appraisal, seeking support and information, cognitive avoidance, physical treatment side effects, and decision-related distress in 111 men with localized prostate cancer. Men were assessed at diagnosis and 2 and 12 months after treatment. Baseline decision-related distress predicted distress 2 and 12 months after treatment. Optimism was a significant prospective and concurrent predictor of decision-related distress, with the effect mediated by proximal cancer threat appraisal. Seeking support and information and cognitive avoidance were not associated with decision-related distress at any time point. For physical treatment side effects, concurrent urinary symptoms were predictive of decision-related distress 2 months after treatment. Results suggest that decision-related distress is generated by similar processes to that of the psychological distress that follows a cancer diagnosis. Screening for men with high decision-related distress for referral to in-depth decision support is suggested. Outcome expectations may present as a therapy target to increase the effectiveness of decisional support that is utility based.

An integrative model of shared decision making in medical encounters

OBJECTIVE

Given the fluidity with which the term shared decision making (SDM) is used in teaching, assessment and research, we conducted a focused and systematic review of articles that specifically address SDM to determine the range of conceptual definitions.

METHODS

In April 2005, we ran a Pubmed (Medline) search to identify articles published through 31 December 2003 with the words shared decision making in the title or abstract. The search yielded 681 citations, 342 of which were about SDM in the context of physician-patient encounters and published in English. We read and reviewed the full text of all 342 articles, and got any non-redundant references to SDM, which yielded an additional 76 articles.

RESULTS

Of the 418 articles examined, 161 (38.5%) had a conceptual definition of SDM. We identified 31 separate concepts used to explicate SDM, but only "patient values/preferences" (67.1%) and "options" (50.9%) appeared in more than half the 161 definitions. Relatively few articles explicitly recognized and integrated previous work.

CONCLUSION

Our review reveals that there is no shared definition of SDM. We propose a definition that integrates the extant literature base and outlines essential elements that must be present for patients and providers to engage in the process of SDM.

PRACTICE IMPLICATIONS

The integrative definition of SDM is intended to provide a useful foundation for describing and operationalizing SDM in further research.

Breast Cancer Risk Assessment and Prevention: A Framework for Shared Decision-Making Consultations

Options for breast cancer prevention, used in combination with screening and surveillance, include lifestyle modifications, chemoprevention with tamoxifen, and prophylactic surgery. Preventive health decisions are often preference driven: patients typically must choose whether to initiate effective treatments that hold the possibility of side effects that can negatively impact quality of life. This situation demands that patients be well informed and have a full understanding of the risks associated with each option. Investigators have developed a comprehensive decision-making framework designed to support breast cancer prevention consultations within a shared decision-making setting. The framework integrates predictive information from current risk models within the context of a woman's general health to appropriately frame breast cancer risk management consultations and outlines the application of available treatments and emerging biomarker information to individual patient decisions. Using an evidence-based approach, specialized risk-benefit projections can be provided in the clinical setting. A more comprehensive individualized risk profile allows for tailored medical management plans and can better prepare patients to make informed decisions. The framework is intended to encourage a shared decision-making approach to prevention consultations, a method for researchers to increase accrual to trials, and to more quickly incorporate new findings into the routine of practice.

Decision Making in Pediatric Oncology: Who Should Take the Lead? The Decisional Priority in Pediatric Oncology Model

Decision making in pediatric oncology can look different to the ethicist and the clinician. Popular ethical theories argue that clinicians should not make decisions for patients, but rather provide information so that patients can make their own decisions. However, this theory does not always reflect clinical reality. We present a new model of decision making that reconciles this apparent discrepancy. We first distinguish decisional priority from decisional authority. The person (parent, child, or clinician) who first identifies a preferred choice exercises decisional priority. In contrast, decisional authority is a nondelegable parental right and duty, in which a mature child may join. This distinction enables us to analyze decisional priority without diminishing parental authority. This model analyzes decisions according to two continuous underlying characteristics. One dominant characteristic is the likelihood of cure. Because cure, when possible, is the ultimate goal, the clinician is in a better position to assume decisional priority when a child probably can be cured. The second characteristic is whether there is more than one reasonable treatment option. The interaction of these two complex continual results in distinctive types of decisional situations. This model explains why clinicians sometimes justifiably assume decisional priority when there is one best medical choice. It also suggests that clinicians should particularly encourage parents (and children, when appropriate) to assume decisional priority when there are two or more clinically reasonable choices. In this circumstance, the family, with its deeper understanding of the child's nature and preferences, is better positioned to take the lead.

The DiAMOND trial protocol: a randomised controlled trial of two decision aids for mode of delivery among women with a previous caesarean section [ISRCTN84367722]

Background

Caesarean section (CS) has become an increasingly common method of delivery worldwide, rising in the UK from 9% of deliveries in 1980 to over 21% 2001. This increase, and the question of whether CS should be available to women on request, has been the subject of considerable debate, and national reports and guidelines have specifically highlighted the importance of patient choice in the decision making process. For women who have already experienced CS, the UK National Institute of Clinical Excellence recommends that the decision should consider maternal preferences and priorities in addition to general discussion of the overall risks and benefits of CS. Decision aids for many different medical treatment and screening decisions have been developed and evaluated, but there is relatively little evidence for the use of decision aids for choice of mode of delivery among women with a previous CS. The aim of the study is to evaluate two interventions to assist decision making about mode of delivery among pregnant women with one previous CS.

Methods/design

Women with one previous CS are recruited to the trial during their booking visit at approximately 12–20 weeks' gestation in participating maternity units in Bristol, Weston and Dundee. Using central randomisation, women are allocated to one of three arms: information programme and website; decision analysis; usual care. Both interventions are computer-based, and are designed to provide women with detailed information about the potential outcomes for both mother and baby of planned vaginal delivery, planned CS and emergency CS. The decision analysis intervention additionally provides a recommended 'preferred option' based on maximised expected utility. There are two primary outcomes (decisional conflict and actual mode of delivery), and five secondary outcomes (anxiety, knowledge, perceptions of shared decision making; satisfaction with decision making process, proportion of women attempting vaginal delivery). Primary follow up for the questionnaire measures is at 36–37 weeks' gestation, and a total of 660 women will be recruited to the study. The primary intention-to-treat analyses will comprise three pair-wise comparisons between decision analysis, information and usual care groups, for each of the two primary outcomes. A qualitative study will investigate women's experiences of the decision making in more depth, and an economic evaluation from the perspective of the NHS will be conducted.

Discussion

Provision of information to women facing this decision appears variable. The DiAMOND study aims to inform best practice in this area by evaluating the effectiveness of two interventions designed to aid decision making.

Patients' ideas, fears and expectations of their coronary risk: barriers for primary prevention

The application of cardiovascular guidelines and risk tables may be impeded by many barriers. In the present paper, we explored the role of patients in the feasibility of cardiovascular preventive care in general practice. Patient-related barriers were examined by means of a qualitative study. Fifteen GPs audio-taped one or two consultations on primary cardiovascular preventive care. The tapes were used to guide the subsequent semi-structured in-depth interviews with patients. Twenty-two patients were interviewed. Patients' understanding of prevention of cardiovascular disease (CVD) was often insufficient. The risk table and the multi-factorial approach were difficult to understand. Risk perception was often unrealistic and dichotomous, and mainly based on personal experiences. There was a demand for more information and cholesterol tests. At the patient level, many barriers impede effective prevention of cardiovascular diseases. In particular, the highly individualized high-risk approach needs to be explained to patients. Educational patient materials, intended to support both the GP and the patient, should take into account the ideas, fears and expectations of patients.

Assessment of a Decision Aid to Assist Genetic Testing Research Participants in the Informed Consent Process

Limited attention has been given to applying decision-making theories from psychology to the content and process of informed consent in genetic testing research. Data are presented from a study that developed and assessed a psychological theory-based decision aid as part of the informed consent process. This innovative approach assisted at-risk women in assessing the consequences of participating in a research project that offered them free hemophilia A genetic carrier testing. Results suggest: (1) the decision aid can be incorporated into the consent process with few problems; (2) women of varying educational backgrounds can complete the decision aid; (3) while women consider many consequences of genetic testing, their primary focus is on the implications for their family; and (4) this is in marked contrast to the typical benefit-harm statements prepared by researchers for genetic testing.

Managing health risks: junior doctors' views of risk and decision making

Managing risk and making decisions presents an increasing challenge to doctors as they are encouraged to adopt a partnership approach with patients to dealing with risk, within a "risk society" constructed around individuality, uncertainty, blame and responsibility. In-depth interviews, stimulated by clinical vignettes, were used to explore the key position of doctors within this risk society. Analysis, sensitised through contemporary texts, revealed unexpected findings that portrayed doctors as reflexive jugglers of risk. Discourses in this study revealed indecision and uncertainty, balanced against needs to preserve professional roles and engage patients in addressing risk, whilst preventing widespread harm and conflict. In concluding, the alternative approaches to risk with older people will suggest a more trusting and positive process that presents a real opportunity for truly sharing risk and decisions that benefit both doctor and patient.

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.

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.

Manufactured but not imported: new directions for research in shared decision making support and skills

Significant conceptual work on shared decision making has taken place but there are still significant challenges in achieving it in routine clinical practice. This paper outlines what research has identified to date that may promote shared decision making, and the further research that is required to enable continuing progress. Greater understanding of the models of decision making and instruments to identify them in practice are still required. Specifying consumer competences, developing instruments to assess these and interventions to enhance them may also be important. Clarifying all these aspects may enable those charged with training professionals to improve the content of professional development programmes. This may be particularly important in the field of cancer treatments where the stakes are high-patients usually desire much information but their desire for involvement in decision making is more variable. The consequences of getting this balance right or wrong are significant with much to be gained or lost. Continued development and evaluation of decision aids and decision explorers that use interactive technology will also be important in identifying how to progress with consumer involvement. If we can learn these lessons, then wider implementation of shared decision making or consumer involvement may become a nearer prospect.

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.

Physicians' adoption of information technology: a consumer behavior approach

Studies report physician resistance to information technology in a time when the practice of medicine could benefit from technological support. Anecdotally, it is suspected that lack of training, discomfort with technological innovations, a perceived shift in the doctor/patient relationship, or medical/legal issues may account for this circumstance. Empirical studies attribute this lag to age, personality factors, behavioral issues, and occupational influences. This paper integrates the information technology and consumer behavior literatures to discuss physicians' acceptance, adoption, and application of IT.

Making decisions about treatment for localized prostate cancer

OBJECTIVE

To describe the decision-making processes used by men diagnosed with localized prostate cancer who were considering treatment.

PATIENTS AND METHODS

Men newly diagnosed with localized prostate cancer from outpatient urology clinics and urologists' private practices were approached before treatment. Their decision-making processes and information-seeking behaviour was assessed; demographic information was also obtained.

RESULTS

Of 119 men approached, 108 (90%) were interviewed; 91% reported non-systematic decision processes, with deferral to the doctor, positive and negative recollections of others' cancer experiences, and the pre-existing belief that surgery is a better cancer treatment being most common. For systematic information processing the mean (sd, range) number of items considered was 4.19 (2.28, 0-11), with 57% of men considering four or fewer treatment/medical aspects of prostate cancer. Men most commonly considered cancer stage (59%), urinary incontinence (55%) and impotence (51%) after surgery, and low overall mortality (45%). Uncertainty about probabilities for cure was reported by 43% of men and fear of cancer spread by 37%. Men also described uncertainty about the probabilities of side-effects (27%), decisional uncertainty (25%) and anticipated decisional regret (18%). Overall, 73% of men sought information about prostate cancer from external sources, most commonly the Internet, followed by family and friends.

CONCLUSIONS

In general, men did not use information about medical treatments comprehensively or systematically when making treatment decisions, and their processing of medical information was biased by their previous beliefs about cancer and health. These findings have implications for the provision of informational and decisional support to men considering prostate cancer treatment.

Promoting informed decision making about prostate cancer screening

Because prostate cancer screening with prostate specific antigen is controversial, informed consent is recommended. Physicians are encouraged to discuss facts about prostate specific antigen with patients and to supplement such discussions with informational brochures or videotapes.

Consumers' views of quality in the consultation and their relevance to 'shared decision-making' approaches

BACKGROUND

There is a recognized need to assess the effects of shared decision-making and other communication interventions. However, the outcomes usually assessed for evidence of 'effectiveness' are determined by researchers and have not been based on consumers' views.

AIM

This study aimed to identify the important outcomes of consultations for consumers, and to compare with those reported in the current literature.

SETTING AND PARTICIPANTS

Forty-seven participants attending six focus group interviews. Most interviews took place in and all were orientated towards the UK primary care setting.

METHODS

Focus group study.

RESULTS

Many affective outcomes were identified, consistent with the current literature trends. However, many cognitive and behavioural outcomes that are assessed in the current literature were not noted by participants as important. Furthermore, a broader range of outcomes than is evident in the current literature was viewed as important to these participants.

CONCLUSIONS

There is a need to revisit the outcomes which are assessed in decision-making and communication research. The outcomes of greatest importance to consumers must be identified and confirmed by new research which is based directly on the views of consumers themselves.

"I can't afford that!": dilemmas in the care of the uninsured and underinsured

When patients lack sufficient health care insurance, financial matters become integrally intertwined with biomedical considerations in the process of clinical decision making. With a growing medically indigent population, clinicians may be compelled to bend billing or reimbursement rules, lower standards, or turn patients away when they cannot afford the costs of care. This article focuses on 3 types of dilemmas that clinicians face when patients cannot pay for needed medical services: (1) whether to refer the individual to a safety net provider, such as a public clinic; (2) whether to forgo indicated tests and therapies because of cost; and (3) whether to reduce fees by fee waivers or other adjustments in billing. Clinicians' responses to these dilemmas impact on quality of care, continuity, safety net providers, and the liability risk of committing billing violations or offering nonstandard care. Caring for the underinsured in the current health care climate requires an understanding of billing regulations, a commitment to informed consent, and a beneficent approach to finding individualized solutions to each patient care/financial dilemma. To effect change, however, physicians must address issues of social justice outside of the office through political and social activism.

Effects of patients' preferences on the treatment of atrial fibrillation: observational study of patient-based decision analysis

OBJECTIVE

To investigate the effect of patients' preferences in the treatment of atrial fibrillation by using individualized decision analysis in which probability and utility assessments are combined into a decision tree.

DESIGN

Observational study based on interviews with patients.

SETTING

8 general practices in Avon, England.

PARTICIPANTS

260 randomly selected patients aged 70 to 85 years with atrial fibrillation.

MAIN OUTCOME MEASURES

Patients' treatment preferences regarding anticoagulation treatment (warfarin sodium) after individualized decision analysis; comparison of these preferences with treatment guidelines on the basis of comorbidity and absolute risk and compared with current prescription.

RESULTS

Of 195 eligible patients, 97 participated in decision making using decision analysis. Among these 97, the decision analysis indicated that 59 (61%; 95% confidence interval, 50%-71%) would prefer anticoagulation treatment, considerably fewer than those who would be recommended treatment according to guidelines. There was marked disagreement between the decision analysis and guideline recommendations (kappa> or =0.25). Of 38 patients whose decision analysis indicated a preference for anticoagulation, 17 (45%) were being prescribed warfarin; on the other hand, 28 (47%) of 59 patients were not being prescribed warfarin, although the results of their decision analysis suggested they wanted to be.

CONCLUSIONS

In the context of shared decision making, individualized decision analysis is valuable in a sizable proportion of elderly patients with atrial fibrillation. Taking account of patients' preferences would lead to fewer prescriptions for warfarin than under published recommendations. Decision analysis as a shared decision-making tool should be evaluated in a randomized controlled trial.

Randomised controlled trial of three day versus 10 day intravenous antibiotics in acute pyelonephritis: effect on renal scarring

BACKGROUND

Acute pyelonephritis often leaves children with permanent renal scarring.

AIMS

To compare the prevalence of scarring following initial treatment with antibiotics administered intravenously for 10 or three days.

METHODS

In a prospective two centre trial, 220 patients aged 3 months to 16 years with positive urine culture and acute renal lesions on initial DMSA scintigraphy, were randomly assigned to receive intravenous ceftriaxone (50 mg/kg once daily) for 10 or three days, followed by oral cefixime (4 mg/kg twice daily) to complete a 15 day course. After three months, scintigraphy was repeated in order to diagnose renal scars.

RESULTS

Renal scarring developed in 33% of the 110 children in the 10 day intravenous group and 36% of the 110 children in the three day group. Children older than 1 year had more renal scarring than infants (42% (54/129) and 24% (22/91), respectively). After adjustment for age, sex, duration of fever before treatment, degree of inflammation, presence of vesicoureteric reflux, and the patients' recruitment centres, there was no significant difference between the two treatments on renal scarring. During follow up, 15 children had recurrence of urinary infection with no significant difference between the two treatment groups.

CONCLUSION

In children with acute pyelonephritis, initial intravenous treatment for 10 days, compared with three days, does not significantly reduce the development of renal scarring.

The impact of patients' preferences on the treatment of atrial fibrillation: observational study of patient based decision analysis

OBJECTIVE

To investigate the impact of patients' preferences for the treatment of atrial fibrillation, by using individualised decision analysis combining probability and utility assessments into a decision tree.

DESIGN

Observational study based on interviews with patients.

SETTING

Eight general practices in Avon.

PARTICIPANTS

260 randomly selected patients aged 70-85 years with atrial fibrillation.

MAIN OUTCOME MEASURES

Patients' treatment preferences regarding anticoagulation treatment (warfarin) after individualised decision analysis; comparison of these preferences with treatment guidelines on the basis of comorbidity and absolute risk and compared with current prescription.

RESULTS

Of 195 eligible patients, 97 participated in decision making using decision analysis. Among these 97, the decision analysis indicated that 59 (61%; 95% confidence interval 50% to 71%) would prefer anticoagulation treatment-considerably fewer than those who would be recommended treatment according to guidelines. There was marked disagreement between the decision analysis and guideline recommendations (kappa=0.25 or less). Of 38 patients whose decision analysis indicated a preference for anticoagulation, 17 (45%) were being prescribed warfarin; on the other hand, 28 (47%) of 59 patients were not being prescribed warfarin although the results of their decision analysis suggested they wanted to be.

CONCLUSIONS

In the context of shared decision making, individualised decision analysis is valuable in a sizeable proportion of elderly patients with atrial fibrillation. Taking account of patients' preferences would lead to fewer prescriptions for warfarin than under published guideline recommendations. Decision analysis as a shared decision making tool should be evaluated in a randomised controlled trial.