Impact of an interactive video on decision making of patients with ischemic heart disease

Novel Way to Improve Satisfaction, Comprehension, and Anxiety in Caregivers: A Randomized Trial Exploring the Use of Comprehensive, Illustrated Children's Books for Pediatric Surgical Populations

BACKGROUND

Surgery generates anxiety and stress, which can negatively impact informed consent and postoperative outcomes. This study assessed whether educational, illustrated children's books improve comprehension, satisfaction, and anxiety of caregivers in pediatric surgical populations.

METHODS

A prospective randomized trial was initiated at a tertiary care children's hospital. All patients ≤ 18 years old with caregiver and diagnosis of 1) uncomplicated appendicitis (English or Spanish speaking); 2) ruptured appendicitis; 3) pyloric stenosis; 4) need for gastrostomy tube; or 5) umbilical hernia were eligible. Conventional consent was obtained followed by completion of 17 validated survey questions addressing apprehension, satisfaction, and comprehension. Randomization (2:1) occurred after consent and before operative intervention with the experimental group (EG) receiving an illustrated comprehensive children's book outlining anatomy, pathophysiology, hospital course, and postoperative care. A second identical survey was completed before discharge. Primary outcomes were caregiver apprehension, satisfaction, and comprehension.

RESULTS

Eighty caregivers were included (55: EG, 25: control group [CG]). There were no significant differences in patient or caregiver demographics between groups. The baseline survey demonstrated no difference in comprehension, satisfaction, or apprehension between groups (all p values NS). After intervention, EG had significant improvement in 14 of 17 questions compared with CG (all p < 0.05). When tabulated by content, there was significant improvement in comprehension (p = 0.0009), satisfaction (p < 0.0001), and apprehension (p < 0.0001).

CONCLUSION

The use of illustrated educational children's books to explain pathophysiology and surgical care is a novel method to improve comprehension, satisfaction, and anxiety of caregivers. This could benefit informed consent, understanding, and postoperative outcomes.

The Effect of Length of Hospital Stay and Patient Factors on Patient Satisfaction in an Academic Hospital

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a metric for patient satisfaction consisting of 19 questions divided into 10 domains. Scores affect hospital reimbursements and accreditation and may play a role in patient outcomes. It is unclear how length of stay and other factors affect each of the 10 domains. This retrospective review gathered data of 600 patients between December 2008 and January 2017 who completed the HCAHPS survey. The odds of complete satisfaction in each of the 10 domains was evaluated. The results suggest increased length of stay is associated with lower odds of patient satisfaction and decreased likelihood of recommending the hospital. The odds of being completely satisfied regarding communication with physicians, discharge information, and responsiveness of the hospital staff, as well as the odds of recommending the hospital to others, were lower if the care provider was younger than the patient. Obese patients were also more likely to be satisfied with responsiveness and care transition. Male patients were more satisfied with communication about medications (odds ratio [OR], 1.694), care transition (OR, 1.489), and cleanliness (OR, 2.120). Medicare and fewer consults were related to increased odds of patient satisfaction with care transition (OR, 1.748 and 0.573, respectively). Males, older patients, and White patients were more likely to recommend the hospital (OR, 1.476, 1.025, and 1.690, respectively). Length of stay affects patient satisfaction and likelihood of recommending the hospital to others. Other factors such as a younger provider age than the patient, lower body mass index, female sex, non-Medicare insurance, and higher number of consults are also associated with lower satisfaction in various domains. Hospital systems can bolster patient satisfaction by strategizing day-of-surgery and weekend staffing to reduce length of stay. [Orthopedics. 2020;43(6):373-379.].

Effectiveness of multimedia interventions in the provision of patient education on anticoagulation therapy: A review

OBJECTIVE

A literature review was conducted to identify available evidence on the use of multimedia patient educational interventions on anticoagulation therapy.

METHODS

A literature search was conducted on 9/4/2020 via six research databases. Publications that evaluated the effects of these interventions on anticoagulation therapy were included.

RESULTS

The review included ten original research studies (five randomized controlled trials, four observational studies and a pre- and post-interventional study), a systematic review and meta-analysis, three systematic reviews, a scoping review, and a literature review. Multimedia interventions significantly improved knowledge after education, but no significant differences found when compared to traditional methods. There was insufficient evidence to conclude whether knowledge retained over time. Patients were equally satisfied with both methods. Multimedia interventions significantly reduced healthcare professional's time required for education. Heterogeneity in intervention, methodology and results limited comparison and combination of findings across studies.

CONCLUSION

Multimedia patient educational interventions on anticoagulation therapy have similar outcomes to traditional methods in knowledge improvement and satisfaction, but they save health personnel time.

PRACTICE IMPLICATIONS

There is lack of evidence to support the effectiveness of multimedia interventions in educating patients on anticoagulation therapy. Larger randomized studies evaluating their benefits in health outcomes and clinical practice are warranted.

Differences of patients' perceptions for elective diagnostic coronary angiography and percutaneous coronary intervention in stable coronary artery disease between elderly and younger patients

Aims

There is limited evidence of the differences in expectations between elderly (≥80 years) and younger patients (<80 years) regarding treatment success of percutaneous coronary interventions (PCI). We conducted a survey in patients undergoing diagnostic coronary angiography (DA) and/or intervention (PCI) to identify differences in patient perceptions between elderly and younger patients.

Methods and results

This is an all-comers study of consecutive patients who underwent DA and/or PCI. Patients were asked to fill out a questionnaire prior to DA/PCI. This questionnaire consisted of ten questions with potential patient expectations based on an increasing scale of importance from 0 to 5 which were related to the procedure (eg, extend life, decrease symptoms etc.) and the value of "hard" cardiac endpoints like death, stroke, acute myocardial infarction and target lesion revascularization for the patient. Among 200 patients (mean age 76.6±9.3 years, 60.5% male, ejection fraction 63.7%±13.2%), 100 patients (50%) were ≥80 years. For these elderly patients the questions "to remain independent," "to maintain mobility, so that I can maintain my current life," and "to prevent myocardial infarction" were rated highest. Regarding "hard" cardiac endpoints "to avoid PCI in the future" was rated lowest in younger and in elderly patients. Significant differences were found between the age groups with the items "to avoid myocardial infarction," "avoid heart insufficiency," "to extend my life" and "to maintain mobility so that I can maintain my current life" (P<0.001).

Conclusions

In our survey we found significant differences in patient expectations between elderly and younger patients regarding the outcome of DA/PCI.

Video-based patient decision aids: A scoping review

OBJECTIVE

This study reviews the published literature on the use of video-based decision aids (DA) for patients. The authors describe the areas of medicine in which video-based patient DA have been evaluated, the medical decisions targeted, their reported impact, in which countries studies are being conducted, and publication trends.

METHOD

The literature review was conducted systematically using Medline, Embase, CINAHL, PsychInfo, and Pubmed databases from inception to 2016. References of identified studies were reviewed, and hand-searches of relevant journals were conducted.

RESULTS

488 studies were included and organized based on predefined study characteristics. The most common decisions addressed were cancer screening, risk reduction, advance care planning, and adherence to provider recommendations. Most studies had sample sizes of fewer than 300, and most were performed in the United States. Outcomes were generally reported as positive. This field of study was relatively unknown before 1990s but the number of studies published annually continues to increase.

CONCLUSION

Videos are largely positive interventions but there are significant remaining knowledge gaps including generalizability across populations.

PRACTICE IMPLICATIONS

Clinicians should consider incorporating video-based DA in their patient interactions. Future research should focus on less studied areas and the mechanisms underlying effective patient decision aids.

Shared Decision Making to Improve the Emergency Care of Older Adults: A Research Agenda

Older emergency department patients have high rates of serious illness and injury, are at high risk for side effects and adverse events from treatments and diagnostic tests, and in many cases, have nuanced goals of care in which pursuing the most aggressive approach is not desired. Although some forms of shared decision making (SDM) are commonly practiced by emergency physicians caring for older adults, broader use of SDM in this setting is limited by a lack of knowledge of the types of patients and conditions for which SDM is most helpful and the approaches and tools that can best facilitate this process. We describe a research agenda to generate new knowledge to optimize the use of SDM during the emergency care of older adults.

Educating Nurses and Patients to Manage Heart Failure

Patient education is an important component in the management of patients with heart failure and nurses are increasingly involved in this area. This paper reviews the literature on education to patients with heart failure and the education and training for heart failure nurses. Patients with heart failure need education in order to adapt to their chronic syndrome and perform self-care. The education process often starts during the hospital admission, but must continue in the outpatient setting. Nurses need to be skilled in assessing the requirements and level of the education given to the individual. Computer-based education has been found to be a preferred and effective compliment to the education provided by health care professionals. The effect of new materials and methods needs to be evaluated in order to improve the overall effectiveness of the education provided. The patient with heart failure should have an active role in this development and evaluation. The heart failure nurse needs to be experienced in cardiac care, have an ability to work independently in order to be delegated responsibilities such as drug titration and patient assessment. This requires optimal experience, training and education for advanced practice. In order to develop and evaluate the education of patients with heart failure and the overall effectiveness of heart failure nurses in this regard, national and international collaborations are needed.

Gender Differences in Patients with Heart Failure

Aim: The aim of this literature review was to review and discuss the differences between men and women with heart failure with regard to epidemiology, aetiology, diagnostics, prognosis, pharmacological and non-pharmacological treatment, and the impact of heart failure on psychosocial factors and healthcare utilisation. Method: Two primary health care resources, MEDLINE and CINAHL, were selected to review the current literature. In MEDLINE, 234 abstracts dealing with heart failure and gender/sex were found and in CINAHL, 20 abstracts. Conclusion: Men have a higher incidence of heart failure, but the overall prevalence rate is similar in both sexes, since women survive longer after the onset of heart failure. Women tend to be older when diagnosed with heart failure and more often have diastolic dysfunction than men. The extent of sex differences in treatment, hospital cost and quality of care can partly be explained by age differences. The life situations for men and women with heart failure are different. Physical and social restrictions affecting daily life activities are experienced as most bothersome for men, whereas restrictions affecting the possibility to support family and friends are most difficult to accept for women. Women with heart failure ascribe more positive meanings to their illness. Despite this, women seem to experience a lower overall quality of life than men. The known gender differences in patients with heart failure need to be highlighted in guidelines as well as implemented in standard care.

Decision Aids for Benign Prostatic Hyperplasia: Applicability across Race and Education

Background/Method. Decision aids have not been widely tested in diverse audiences. The authors conducted interviews in a 2 2 race by education design with participants who were 50 years old (n = 188). The decision aid was a benign prostatic hyperplasia videotape. Results. There was an increase in knowledge equal in all groups, with baseline knowledge higher in whites. The decision stage increased in all groups and was equivalent in the marginal-illiterate subgroup (n = 0.15). Conclusion. Contrary to expectations, results show no difference by race or college education in knowledge gain or increase in reported readiness to decide. The video appeared to produce change across race and education. The end decision stage was high, especially in less educated men. Results suggest that decision aids may be effective without tailoring, as suggested previously to enhance health communication in diverse audiences. Research should test findings in representative samples and in clinical encounters and identify types of knowledge absorbed from decision aids and whether the shift to decision reflects data/ knowledge or shared decision-making message.

Features of Computer-Based Decision Aids: Systematic Review, Thematic Synthesis, and Meta-Analyses

Background

Patient information and education, such as decision aids, are gradually moving toward online, computer-based environments. Considerable research has been conducted to guide content and presentation of decision aids. However, given the relatively new shift to computer-based support, little attention has been given to how multimedia and interactivity can improve upon paper-based decision aids.

Objective

The first objective of this review was to summarize published literature into a proposed classification of features that have been integrated into computer-based decision aids. Building on this classification, the second objective was to assess whether integration of specific features was associated with higher-quality decision making.

Methods

Relevant studies were located by searching MEDLINE, Embase, CINAHL, and CENTRAL databases. The review identified studies that evaluated computer-based decision aids for adults faced with preference-sensitive medical decisions and reported quality of decision-making outcomes. A thematic synthesis was conducted to develop the classification of features. Subsequently, meta-analyses were conducted based on standardized mean differences (SMD) from randomized controlled trials (RCTs) that reported knowledge or decisional conflict. Further subgroup analyses compared pooled SMDs for decision aids that incorporated a specific feature to other computer-based decision aids that did not incorporate the feature, to assess whether specific features improved quality of decision making.

Results

Of 3541 unique publications, 58 studies met the target criteria and were included in the thematic synthesis. The synthesis identified six features: content control, tailoring, patient narratives, explicit values clarification, feedback, and social support. A subset of 26 RCTs from the thematic synthesis was used to conduct the meta-analyses. As expected, computer-based decision aids performed better than usual care or alternative aids; however, some features performed better than others. Integration of content control improved quality of decision making (SMD 0.59 vs 0.23 for knowledge; SMD 0.39 vs 0.29 for decisional conflict). In contrast, tailoring reduced quality of decision making (SMD 0.40 vs 0.71 for knowledge; SMD 0.25 vs 0.52 for decisional conflict). Similarly, patient narratives also reduced quality of decision making (SMD 0.43 vs 0.65 for knowledge; SMD 0.17 vs 0.46 for decisional conflict). Results were varied for different types of explicit values clarification, feedback, and social support.

Conclusions

Integration of media rich or interactive features into computer-based decision aids can improve quality of preference-sensitive decision making. However, this is an emerging field with limited evidence to guide use. The systematic review and thematic synthesis identified features that have been integrated into available computer-based decision aids, in an effort to facilitate reporting of these features and to promote integration of such features into decision aids. The meta-analyses and associated subgroup analyses provide preliminary evidence to support integration of specific features into future decision aids. Further research can focus on clarifying independent contributions of specific features through experimental designs and refining the designs of features to improve effectiveness.

Variation in patients' perceptions of elective percutaneous coronary intervention in stable coronary artery disease: cross sectional study

OBJECTIVES

To assess the perceptions of patients with stable coronary artery disease of the urgency and benefits of elective percutaneous coronary intervention and to examine how they vary across centers and by providers.

DESIGN

Cross sectional study.

SETTING

10 US academic and community hospitals performing percutaneous coronary interventions between 2009 and 2011.

PARTICIPANTS

991 patients with stable coronary artery disease undergoing elective percutaneous coronary intervention.

MAIN OUTCOME MEASURES

Patients' perceptions of the urgency and benefits of percutaneous coronary intervention, assessed by interview. Multilevel hierarchical logistic regression models examined the variation in patients' understanding across centers and operators after adjusting for patient characteristics, using median odds ratios.

RESULTS

The most common reported benefits from percutaneous coronary intervention were to extend life (90%, n=892; site range 80-97%) and to prevent future heart attacks (88%, n=872; site range 79-97%). Although nearly two thirds of patients (n=661) reported improvement of symptoms as a benefit of percutaneous coronary intervention (site range 52-87%), only 1% (n=9) identified this as the only benefit. Substantial variability was noted in the ways informed consent was obtained at each site. After adjusting for patient and operator characteristics, the median odds ratios showed significant variation in patients' perceptions of percutaneous coronary intervention across sites (range 1.4-3.1) but not across operators within a site.

CONCLUSION

Patients have a poor understanding of the benefits of elective percutaneous coronary intervention, with significant variation across sites. No sites had a high proportion of patients accurately understanding the benefits. Coupled with the wide variability in the ways in which hospitals obtain informed consent, these findings suggest that hospital level interventions into the structure and processes of obtaining informed consent for percutaneous coronary intervention might improve patient comprehension and understanding.

Surgical inpatient satisfaction: what are the real drivers?

BACKGROUND

Inpatient satisfaction is a key element of hospital pay-for-performance programs. Communication and pain management are known to influence results, but additional factors may affect satisfaction scores. We tested the hypothesis that patient factors and outcome parameters not considered previously are clinically important drivers of inpatient satisfaction.

METHODS

Medical records were reviewed for 1,340 surgical patients who returned nationally standardized inpatient satisfaction questionnaires. These patients were managed by 41 surgeons in seven specialties at two academic medical centers. Thirty-two parameters based on the patient, surgeon, outcomes, and survey were measured. Univariate and multivariable analyses were performed.

RESULTS

Inpatients rated their overall experience favorably 75.7% of the time. Less-satisfied patients were more likely to be female, younger, less ill, taking outpatient narcotics, and admitted via the emergency department (all P < .02). Less-satisfied patients also were more likely to have unresected cancer (P < .001) or a postoperative complication (P < .001). The most relevant independent predictors of dissatisfaction in multivariable analyses were younger age, admission via the emergency department, preoperative narcotic use, lesser severity of illness, unresected cancer, and postoperative morbidity (all P < .01).

CONCLUSION

Several patient factors, expectations of patients with cancer, and postoperative complications are important and clinically relevant drivers of surgical inpatient satisfaction. Programs to manage expectations of cancer patient expectations and decrease postoperative morbidity should improve surgical inpatient satisfaction. Further efforts to risk-adjust patient satisfaction scores should be undertaken.

Refining a brief decision aid in stable CAD: cognitive interviews

Background

We describe the results of cognitive interviews to refine the “Making Choices©” Decision Aid (DA) for shared decision-making (SDM) about stress testing in patients with stable coronary artery disease (CAD).

Methods

We conducted a systematic development process to design a DA consistent with International Patient Decision Aid Standards (IPDAS) focused on Alpha testing criteria. Cognitive interviews were conducted with ten stable CAD patients using the “think aloud” interview technique to assess the clarity, usefulness, and design of each page of the DA.

Results

Participants identified three main messages: 1) patients have multiple options based on stress tests and they should be discussed with a physician, 2) take care of yourself, 3) the stress test is the gold standard for determining the severity of your heart disease. Revisions corrected the inaccurate assumption of item number three.

Conclusions

Cognitive interviews proved critical for engaging patients in the development process and highlighted the necessity of clear message development and use of design principles that make decision materials easy to read and easy to use. Cognitive interviews appear to contribute critical information from the patient perspective to the overall systematic development process for designing decision aids.

Educational videos to reduce racial disparities in ICD therapy via innovative designs (VIVID): a randomized clinical trial

BACKGROUND

Black individuals eligible for an implantable cardioverter/defibrillator (ICD) are considerably less likely than white individuals to receive one. This disparity may, in part, be explained by racial differences in patient preferences. We hypothesized that a targeted patient-centered educational video could improve knowledge of sudden cardiac arrest (SCA) and ICDs and reduce racial differences in ICD preferences. We conducted a pilot study to assess the feasibility of testing this hypothesis in a randomized trial.

METHODS

We created a video that included animation, physician commentary, and patient testimonials on SCA and ICDs. The primary outcome was the decision to have an ICD implanted as a function of race and intervention. Between January 1, 2011, and December 31, 2011, 59 patients (37 white and 22 black) were randomized to the video or health care provider counseling/usual care.

RESULTS

Relative to white patients, black patients were younger (median age, 55 vs 68 years) and more likely to have attended college or technical school. Baseline SCA and ICD knowledge was similar and improved significantly in both racial groups after the intervention. Black patients viewing the video were as likely as white patients to want an ICD (60.0% vs 79.2%, P = .20); and among those in the usual care arm, black patients were less likely than white patients to want an ICD (42.9% vs 84.6% P = .05).

CONCLUSION

Among individuals eligible for an ICD, a video decision aid increased patient knowledge and reduced racial differences in patient preference for an ICD.

Multimedia educational interventions for consumers about prescribed and over-the-counter medications

BACKGROUND

Health consumers increasingly want access to accurate, evidence-based information about their medications. Currently, education about medications (that is, information that is designed to achieve health or illness related learning) is provided predominantly via spoken communication between the health provider and consumer, sometimes supplemented with written materials. There is evidence, however, that current educational methods are not meeting consumer needs. Multimedia educational programs offer many potential advantages over traditional forms of education delivery.

OBJECTIVES

To assess the effects of multimedia patient education interventions about prescribed and over-the-counter medications in people of all ages, including children and carers.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2011, Issue 6), MEDLINE (1950 to June 2011), EMBASE (1974 to June 2011), CINAHL (1982 to June 2011), PsycINFO (1967 to June 2011), ERIC (1966 to June 2011), ProQuest Dissertation & Theses Database (to June 2011) and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of multimedia-based patient education about prescribed or over-the-counter medications in people of all ages, including children and carers, if the intervention had been targeted for their use.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of included studies. Where possible, we contacted study authors to obtain missing information.

MAIN RESULTS

We identified 24 studies that enrolled a total of 8112 participants. However, there was significant heterogeneity in the comparators used and the outcomes measured, which limited the ability to pool data. Many of the studies did not report sufficient information in their methods to allow judgment of their risk of bias. From the information that was reported, three of the studies had a high risk of selection bias and one was at high risk of bias due to lack of blinding of the outcome assessors. None of the included studies reported the minimum clinically important difference for the outcomes that were measured. We have therefore reported results from the studies but have been unable to interpret whether differences were of clinical importance.The main findings of the review are as follows.Knowledge: There is low quality evidence that multimedia education was more effective than usual care (non-standardised education provided as part of usual clinical care) or no education (standardised mean difference (SMD) 1.04, 95% confidence interval (CI) 0.49 to 1.58, six studies with 817 participants). There was considerable statistical heterogeneity (I(2) = 89%), however, all but one of the studies favoured the multimedia group. There is moderate quality evidence that multimedia education was not more effective at improving knowledge than control multimedia interventions (i.e. multimedia programs that do not provide information about the medication) (mean difference (MD) of knowledge scores 2.78%, 95% CI -1.48 to 7.0, two studies with 568 participants). There is moderate quality evidence that multimedia education was more effective when added to a co-intervention (written information or brief standardised instructions provided by a health professional) compared with the co-intervention alone (MD of knowledge scores 24.59%, 95% CI 22.34 to 26.83, two studies with 381 participants).Skill acquisition: There is moderate quality evidence that multimedia education was more effective than usual care or no education (MD of inhaler technique score 18.32%, 95% CI 11.92 to 24.73, two studies with 94 participants) and written education (risk ratio (RR) of improved inhaler technique 2.14, 95% CI 1.33 to 3.44, two studies with 164 participants). There is very low quality evidence that multimedia education was equally effective as education by a health professional (MD of inhaler technique score -1.01%, 95% CI -15.75 to 13.72, three studies with 130 participants).Compliance with medications: There is moderate quality evidence that there was no difference between multimedia education and usual care or no education (RR of complying 1.02, 95% CI 0.96 to 1.08, two studies with 4552 participants).We could not determine the effect of multimedia education on other outcomes, including patient satisfaction, self-efficacy and health outcomes, due to an inadequate number of studies from which to draw conclusions.

AUTHORS' CONCLUSIONS

This review provides evidence that multimedia education about medications is more effective than usual care (non-standardised education provided by health professionals as part of usual clinical care) or no education, in improving both knowledge and skill acquisition. It also suggests that multimedia education is at least equivalent to other forms of education, including written education and education provided by a health professional. However, this finding is based on often low quality evidence from a small number of trials. Multimedia education about medications could therefore be considered as an adjunct to usual care but there is inadequate evidence to recommend it as a replacement for written education or education by a health professional. Multimedia education may be considered as an alternative to education provided by a health professional, particularly in settings where provision of detailed education by a health professional is not feasible. More studies evaluating multimedia educational interventions are required in order to increase confidence in the estimate of effect of the intervention.Conclusions regarding the effect of multimedia education were limited by the lack of information provided by study authors about the educational interventions, and variability in their content and quality. Studies testing educational interventions should provide detailed information about the interventions and comparators. Research is required to establish a framework that is specific for the evaluation of the quality of multimedia educational programs. Conclusions were also limited by the heterogeneity in the outcomes reported and the instruments used to measure them. Research is required to identify a core set of outcomes which should be measured when evaluating patient educational interventions. Future research should use consistent, reliable and validated outcome measures so that comparisons can be made between studies.

Personalised risk communication for informed decision making about taking screening tests

BACKGROUND

There is a trend towards greater patient involvement in healthcare decisions. Although screening is usually perceived as good for the health of the population, there are risks associated with the tests involved. Achieving both adequate involvement of consumers and informed decision making are now seen as important goals for screening programmes. Personalised risk estimates have been shown to be effective methods of risk communication.

OBJECTIVES

To assess the effects of personalised risk communication on informed decision making by individuals taking screening tests. We also assess individual components that constitute informed decisions.

SEARCH METHODS

Two authors searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2012), MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL (EbscoHOST) and PsycINFO (OvidSP) without language restrictions. We searched from 2006 to March 2012. The date ranges for the previous searches were from 1989 to December 2005 for PsycINFO and from 1985 to December 2005 for other databases. For the original version of this review, we also searched CancerLit  and Science Citation Index (March 2001). We also reviewed the reference lists and conducted citation searches of included studies and other systematic reviews in the field, to identify any studies missed during the initial search.

SELECTION CRITERIA

Randomised controlled trials incorporating an intervention with a 'personalised risk communication element' for individuals undergoing screening procedures, and reporting measures of informed decisions and also cognitive, affective, or behavioural outcomes addressing the decision by such individuals, of whether or not to undergo screening.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each included trial for risk of bias, and extracted data. We extracted data about the nature and setting of interventions, and relevant outcome data. We used standard statistical methods to combine data using RevMan version 5, including analysis according to different levels of detail of personalised risk communication, different conditions for screening, and studies based only on high-risk participants rather than people at 'average' risk. 

MAIN RESULTS

We included 41 studies involving 28,700 people. Nineteen new studies were identified in this update, adding to the 22 studies included in the previous two iterations of the review. Three studies measured informed decision with regard to the uptake of screening following personalised risk communication as a part of their intervention. All of these three studies were at low risk of bias and there was strong evidence that the interventions enhanced informed decision making, although with heterogeneous results. Overall 45.2% (592/1309) of participants who received personalised risk information made informed choices, compared to 20.2% (229/1135) of participants who received generic risk information. The overall odds ratios (ORs) for informed decision were 4.48 (95% confidence interval (CI) 3.62 to 5.53 for fixed effect) and 3.65 (95% CI 2.13 to 6.23 for random effects). Nine studies measured increase in knowledge, using different scales. All of these studies showed an increase in knowledge with personalised risk communication. In three studies the interventions showed a trend towards more accurate risk perception, but the evidence was of poor quality. Four out of six studies reported non-significant changes in anxiety following personalised risk communication to the participants. Overall there was a small non-significant decrease in the anxiety scores. Most studies (32/41) measured the uptake of screening tests following interventions. Our results (OR 1.15 (95% CI 1.02 to 1.29)) constitute low quality evidence, consistent with a small effect, that personalised risk communication in which a risk score was provided (6 studies) or the participants were given their categorised risk (6 studies), increases uptake of screening tests. 

AUTHORS' CONCLUSIONS

There is strong evidence from three trials that personalised risk estimates incorporated within communication interventions for screening programmes enhance informed choices. However the evidence for increasing the uptake of such screening tests with similar interventions is weak, and it is not clear if this increase is associated with informed choices. Studies included a diverse range of screening programmes. Therefore, data from this review do not allow us to draw conclusions about the best interventions to deliver personalised risk communication for enhancing informed decisions. The results are dominated by findings from the topic area of mammography and colorectal cancer. Caution is therefore required in generalising from these results, and particularly for clinical topics other than mammography and colorectal cancer screening.

Learning to participate: effect of child age and parental education on participation in pediatric visits

Children's participation in health care improves outcomes, yet little is known about factors that affect participation. We examine how child age and parental education affect participation. Visit videotapes were coded to reflect key visit tasks: information giving, information gathering, and relationship building. Multivariable models were used to analyze how participation was associated with child age and parental education. For each year of child age, physicians did 3% more information gathering, incidence rate ratio (IRR) = 1.03, 95% confidence interval (95% CI) = 1.01-1.06, but reduced relationship building by 4%, IRR = 0.96, 95% CI = 0.94-0.97. Children of college-graduate parents spoke twice as much information-giving talk, IRR = 2.11, 95% CI = 1.07-4.17, and nearly 5 times as much relationship-building talk, IRR = 4.74, 95% CI = 1.45-15.52, as children with less educated parents. Results suggest physicians might attend to relationship building with older children and work to improve participation of children of less educated parents.

Improving informed consent to chemotherapy: a randomized controlled trial of written information versus an interactive multimedia CD-ROM

OBJECTIVE

This randomized controlled trial aimed to determine whether an interactive CD-ROM improved cancer patients' recall of chemotherapy treatment information over standard written information, and whether demographic, cognitive, and psychological factors better predicted recall than this format of delivery.

METHODS

One-hundred-and-one new patients about to commence chemotherapy were randomized to receive written information or a CD-ROM containing treatment information before giving informed consent. Patients' recall, concentration, short-term memory, reading comprehension, anxiety, depression, and coping styles were assessed with standardized measures pre-treatment. Seventy-seven patients completed tests for recall of treatment information before their second chemotherapy session.

RESULTS

Intention-to-treat analyses indicated no significant differences between the written information and CD-ROM groups across recall questions about number of drugs received (p=.43), treatment length (p=.23), and treatment goal (p=.69). Binary logistic regressions indicated that for groups combined different variables predicted each of the recall questions.

CONCLUSION

An interactive CD-ROM did not improve cancer patients' recall of treatment information enough to warrant changes in consent procedures.

PRACTICE IMPLICATIONS

Different variables predicted recall of different treatment aspects highlighting the complex nature of attempting to improve patient recall. Attending to the effect of depression on patient knowledge and understanding appears paramount.

Interactive digital education aid in breast reconstruction

BACKGROUND

An interactive digital education aid for breast reconstruction patients was developed because of a perceived need to provide patients with more education regarding the treatment so that they can make better informed treatment decisions. A prospective randomized study was conducted to assess its effectiveness.

METHODS

Breast cancer patients who were candidates for breast reconstruction were recruited and randomized into a control group and a study group. Both groups received routine assessment and education in the plastic surgery clinic, but the study group also watched the interactive digital education aid. Questionnaires assessing knowledge, anxiety, and satisfaction were administered (1) before the initial plastic surgery consultation, (2) immediately before surgery, and (3) 1 month after surgery.

RESULTS

A total of 133 women participated, 66 in the control group and 67 in the study group. Women in both groups showed decreased anxiety, increased knowledge, and enhanced satisfaction with their decision-making ability associated with preoperative instructions about reconstructive surgery. However, the study group was significantly more satisfied than the control group with the method of receiving information and showed a less steep learning curve regarding the different techniques of breast reconstruction. They also tended to have a reduced mean level of anxiety and increased satisfaction with the treatment choice compared with the control group.

CONCLUSIONS

An interactive digital education aid is a beneficial educational adjunct for patients contemplating breast reconstruction. Patients who use an interactive digital education aid demonstrate greater factual knowledge, reduced anxiety, and increased postoperative satisfaction compared with patients given preoperative instructions using standard methods alone. The benefit of an interactive digital education aid is expected to be higher in a broad-based practice setting outside of a comprehensive cancer center.

Nurse training of a patient-centered information procedure for CABG patients

OBJECTIVE

At the study hospital, all elective coronary artery bypass graft (CABG) surgery patients were given similar, standardized information by the nurses. The nurses reported problems in establishing contact and interacting with patients when using this approach. To help remedy communication problems between nurses and CABG patients, a programme training nurses in a patient-centred information procedure was developed and implemented. This article describes how challenging interactions were recorded and analysed for training nurses in the patient-centred approach.

METHOD

In group training for patient-centeredness, nurses presented audio-recordings of nurse-patient interactions they found problematic. These were used as a basis for discussions and training in the patient-centered approach. A set of cases was developed using a qualitative phenomenological approach, illustrating how the patient-centered approach could be applied to the difficult situations.

RESULTS

The nurses found the patient-centered approach particularly useful in situations when patients frequently asked questions, seemed to have difficulties expressing their worries, frequently complained, or when spouses expressed worries.

CONCLUSION

Nurses found the patient-centered approach and the training procedure used in this study useful in their clinical work with CABG patients.

PRACTICE IMPLICATIONS

This training which requires minimal resources and can be easily implemented, may guide the nurses in their interaction with patients. Providing a patient-centered approach to the CABG patients may enhance the nurse-patient contact and improve patients' hospital experience and subjective health.

Understanding of the benefits of coronary revascularization procedures among patients who are offered such procedures

BACKGROUND

To participate meaningfully in decisions regarding invasive procedure use, patients should understand the benefits and risks. Previous work has focused on risks; we assessed patient understanding of the benefits of coronary revascularization procedures.

METHODS

We interviewed 1650 patients and their treating physicians after elective coronary angiography performed at 3 Veterans Health Administration hospitals and 1 university hospital. We excluded patients for whom the decision to undergo revascularization was made before admission. This report focuses on 633 patients who had been offered coronary artery bypass surgery (CABG, n = 324) or percutaneous coronary interventions (PCIs) and responded to questions about expected benefits. Both patient and physician were asked to report the benefits they expected from revascularization. Forty-nine physicians reported on 490 patients.

RESULTS

Most patients were older (mean age 63.8 years), white (89.4%), and male (77.6%). Most patients expected improved symptoms (83%) and survival (83%). Physician-patient agreement regarding whether survival would improve was no better than chance (kappa = 0.02 for CABG, kappa = -0.01 for PCI, both P > .10). There was also poor agreement regarding whether symptoms were expected to improve, but this was better than chance (kappa = 0.09, P = .01 for CABG; kappa = 0.19, P = .02 for PCI). Physician-patient agreement was poor regardless of patient characteristics.

CONCLUSIONS

Patients have more optimistic expectations about benefits of coronary revascularization than the cardiologist offering the procedure. Further research should confirm this finding and clarify how physician-patient disagreement regarding the benefits of coronary revascularization affects patient participation in decision making.

Evaluating deliberation in pediatric primary care

OBJECTIVE

Patient participation during decision-making can improve health outcomes and satisfaction, even for routine pediatric concerns. The tasks that are involved in decision-making include both information exchange and deliberation about potential options, yet deliberation (ie, the process of expressing and evaluating potential options to reach a decision) is often assessed subjectively, if at all. We objectively assessed the amount of deliberation; the involvement of parents and children in deliberation; and how deliberation is associated with child, physician, parent, and visit characteristics.

METHODS

From videotapes of 101 children's acute care visits to 1 of 15 physicians, we coded the speaker, recipient, and timing of proposed plans (ie, options) and agreements or disagreements with the plans. Reliability of measures was assessed with Cohen's kappa or intraclass correlation coefficients; validity was assessed with Spearman correlations. Outcome measures included number of plans proposed, deliberation length, and parent/child involvement in deliberation as either active (child or parent proposed a plan or disagreed with a plan) or passive (physician alone proposed plans). Multivariable models that accounted for clustering by physician were used to relate child, physician, parent, and visit factors to deliberation measures.

RESULTS

The mean number of plans proposed was 4.1, and deliberation time averaged 2.9 minutes per visit. Passive involvement of parents/children occurred in 65% of visits. After adjustment, more plans were proposed in visits by girls, and shorter deliberations occurred with college-graduate parents. Longer visits were associated with more plans proposed, longer deliberation, and reduced odds for passive parent/child involvement.

CONCLUSIONS

Using a reliable and valid technique, deliberation was demonstrated to occupy a substantial portion of the visit and include multiple proposed plans, yet passive involvement of parents and children predominated. Results support the need to develop interventions to improve parent and child participation in deliberation.

A systematic review of information in decision aids

OBJECTIVE

We completed a systematic review of information reported as included in decision aids (DAs) for adult patients, to determine if it is complete, balanced and accurate.

SEARCH STRATEGY

DAs were identified using the Cochrane Database of DAs and searches of four electronic databases using the terms: 'decision aid'; shared decision making' and 'patients'; 'multimedia or leaflets or pamphlets or videos and patients and decision making'. Additionally, publications reporting DA development and actual DAs that were reported as publicly available on the Internet were consulted. Publications were included up to May 2006.

DATA EXTRACTION

Data were extracted on the following variables: external groups consulted in development of the DA, type of study used, categories of information, inclusion of probabilities, use of citation lists and inclusion of patient experiences.

MAIN RESULTS

68 treatment DAs and 30 screening DAs were identified. 17% of treatment DAs and 47% of screening DAs did not report any external consultation and, of those that did, DA producers tended to rely more heavily on medical experts than on patients' guidance. Content evaluations showed that (i) treatment DAs frequently omit describing the procedure(s) involved in treatment options and (ii) screening DAs frequently focus on false positives but not false negatives. About 1/2 treatment DAs reported probabilities with a greater emphasis on potential benefits than harms. Similarly, screening DAs were more likely to provide false-positive than false-negative rates.

CONCLUSIONS

The review led us to be concerned about completeness, balance and accuracy of information included in DAs.

Impact of an educational video on patient decision making in early breast cancer treatment

Previous research suggests that patient education programs promoting shared decision making (SDM) may improve patient satisfaction and outcomes, yet controlled clinical trials are lacking. The authors evaluate the impact of an early breast cancer treatment educational video on patients' decisional preferences and behavior. Newly diagnosed stage I/stage II breast cancer patients were assigned to SDM video program or control groups in alternating months. Surveys were administered prior to the provider visit and 1 week following the treatment decision. Variables assessed included autonomy preferences, perceived involvement in care, satisfaction, and treatment choice. There were no significant intervention effects on informational/decisional preferences, anxiety, knowledge, or satisfaction. Although 25% of SDM patients chose mastectomy compared to 14% of controls, this difference was not statistically significant. Eventhough enthusiasm for SDM programs remains high among some patients and providers, this study found only modest benefits.

Computer-based education for patients with chronic heart failure. A randomised, controlled, multicentre trial of the effects on knowledge, compliance and quality of life

OBJECTIVE

To evaluate the effects of a single-session, interactive computer-based educational program on knowledge, compliance and quality of life in heart failure patients with special emphasis on gender differences.

METHODS

One hundred and fifty-four patients, mean age 70 years, from five heart failure clinics were randomised to either receiving only standard education (n=72) or standard education and additional computer-based education (n=82).

RESULTS

Knowledge was increased in both groups after 1 month with a trend towards higher knowledge (P=0.07) in the computer-based group. The increase in knowledge was significantly higher in the computer-based group after 6 months (P=0.03). No differences were found between the groups with regard to compliance with treatment and self-care or quality of life. The women had significantly lower quality of life and did not improve after 6 months as the men did (P=0.0001).

CONCLUSION

Computer-based education gave increased knowledge about heart failure.

PRACTICE IMPLICATIONS

Computers can be a useful tool in heart failure education, but to improve compliance a single-session educational intervention is not sufficient. Gender differences in learning and quality of life should be further evaluated.

Personalised risk communication for informed decision making about taking screening tests

BACKGROUND

There is a trend towards greater patient involvement in healthcare decisions. Adequate discussion of the risks and benefits associated with different choices is often required if involvement is to be genuine and effective. Achieving both the adequate involvement of consumers and informed decision making are now seen as important goals for any screening programme. Personalised risk estimates have been shown to be effective methods of risk communication in general, but the effectiveness of different strategies has not previously been examined.

OBJECTIVES

To assess the effects of different types of personalised risk communication for consumers making decisions about taking screening tests.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2004), MEDLINE (1985 to December 2005), EMBASE (1985 to December 2005), CINAHL (1985 to December 2005), and PsycINFO (1989 to December 2005). Follow-up searches involved hand searching Preventive Medicine, citation searches on seven authors, and searching reference lists of articles. For the original version of this review (Edwards 2003c) we also searched CancerLit (1985 to 2001) and Science Citation Index Expanded (searched March 2002).

SELECTION CRITERIA

Randomised controlled trials addressing the decision by consumers of whether or not to undergo screening, incorporating an intervention with a 'personalised risk communication element' and reporting cognitive, affective, or behavioural outcomes. A 'personalised risk communication element' is based on the individual's own risk factors for a condition (such as age or family history). It may be calculated from an individual's risk factors using formulae derived from epidemiological data, and presented as an absolute or relative risk or as a risk score, or it may be categorised into, for example, high, medium or low risk groups. It may be less detailed still, involving a listing, for example, of a consumer's risk factors as a focus for discussion and intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each trial for quality and extracted data. We extracted data about the nature and setting of the intervention, and relevant outcome data, along with items relating to methodological quality. We then used standard statistical methods of the Consumers and Communication Review Group to combine data using MetaView, including analysis according to different levels of detail of personalised risk communication, different condition for screening, and studies based only on high risk participants rather than people at 'average' risk.

MAIN RESULTS

Twenty-two studies were included, nine of which were added in the 2006 update of this review. There was weak evidence, consistent with a small effect, that personalised risk communication (whether written, spoken or visually presented) increases uptake of screening tests (odds ratio (OR) 1.31 (random effects, 95% confidence interval (CI) 0.98 to 1.77). In three studies the interventions showed a trend towards more accurate risk perception (OR 1.65 (95% CI 0.96 to 2.81), and three other trials with heterogenous outcome measures showed improvements in knowledge with personalised risk interventions. There was little other evidence from these studies that the interventions promoted or achieved informed decision making by consumers about participation in screening. More detailed personalised risk communication may be associated with a smaller increase in uptake of tests. That is, for personalised risk communication which used and presented numerical calculations of risk, the OR for test uptake was 0.82 (95% CI 0.65 to 1.03). For risk estimates or calculations which were categorised into high, medium or low strata of risk, the OR was 1.42 (95% CI 1.07 to 1.89). For risk communication that simply listed personal risk factors the OR was 1.42 (95% CI 0.95 to 2.12). Over half of the included studies assessed interventions in the context of mammography. These studies showed similar effects to the overall dataset. The five studies examining risk communication in high risk individuals (individuals at higher risk due to, for example, a family history of breast cancer or other conditions) showed larger odds ratios for uptake of tests than the other studies (random effects OR 1.74; 95% CI 1.05 to 2.88). There were insufficient data from the included studies to report odds ratios on other key outcomes such as: intention to take tests, anxiety, satisfaction with decisions, decisional conflict, knowledge and resource use.

AUTHORS' CONCLUSIONS

Personalised risk communication (as currently implemented in the included studies) may have a small effect on increasing uptake of screening tests, and there is only limited evidence that the interventions have promoted or achieved informed decision making by consumers.

Shared decision making, preoperative expectations, and postoperative reality: differences in physician and patient predictions and ratings of knee surgery outcomes

PURPOSE

The present study was performed to determine the extent to which physicians and patients rate preoperative and postoperative knee pain and function differently, and to determine whether physicians or patients more accurately predict postoperative knee pain and function.

TYPE OF STUDY

Longitudinal, prospective study.

METHODS

Ninety-eight patients requiring either anterior cruciate ligament reconstruction surgery or meniscectomy and related surgery were interviewed 1 week before surgery, as well as 3 and 24 weeks postoperatively. Patients and their physicians completed ratings on knee pain and function at each time point. In addition, at their preoperative visit, patients and physicians completed ratings predicting their postoperative pain and functional status.

RESULTS

Physicians rated patients as having less pain and greater knee function preoperatively and at 24 weeks postoperatively. Patients had more significant differences between predicted and actual ratings.

CONCLUSIONS

Physicians tended to underestimate knee pain and overestimate knee function compared with patients. However, physicians better predicted postoperative knee pain and function ratings than did patients. These findings suggest that physician-patient discussions about preoperative expectations and postoperative reality might be an important part of clinical care.

LEVEL OF EVIDENCE

Level II, Prospective Longitudinal Study.

The phenomena of participation and non-participation in health care--experiences of patients attending a nurse-led clinic for chronic heart failure

BACKGROUND

Patient participation is stressed in the health care acts of many western countries yet a common definition of the concept is lacking. The understanding of experiences of patients with chronic heart failure (CHF) who attend nurse-led specialist clinics, a form of care suggested as beneficiary to this group, may promote a better understanding of participation.

AIM

To investigate the meanings of participation and non-participation as experienced by patients living with CHF.

METHODS

Narrative interviews analysed in the phenomenological hermeneutic tradition inspired by Ricoeur where the interpretation is made in the hermeneutic circle, explaining and understanding the experienced phenomena.

FINDINGS

Participation was experienced as to "be confident", "comprehend" and "seek and maintain a sense of control". Non-participation was experienced as to "not understand", "not be in control", "lack a relationship" and "not be accountable". The findings indicate that the experiences of participation and non-participation can change over time and phases of the disease and treatment.

CONCLUSION

The study suggests an extended view on the concept of participation. Patients' experiences of participation in health care can vary and should therefore be an issue for dialogue between nurses and patients with CHF in nurse-led specialist clinics.

The content and amount of information given by medical oncologists when telling patients with advanced cancer what their treatment options are. palliative chemotherapy and watchful-waiting

This study aimed to determine the content and the amount of information given by medical oncologists when proposing palliative chemotherapy and whether this information given is influenced by patient or physician background characteristics. In a prospective study, 95 patients with incurable cancer were interviewed before they consulted their medical oncologist. Their first consultation was audiotaped, and their eventual decision scored. A coding scheme comprised six categories of information given during the consultation. Medical oncologists mentioned or explained the disease course (53%), symptoms (35%) and prognosis (39%). Most patients were told about the absence of cure (84%). Watchful-waiting was mentioned to only half of the patients, either in one sentence (23%) or explained more extensively (27%). Multilevel analysis revealed that the patients' age, patient's marital status, and consulting in an academic hospital explained 38% of the amount of information given. Most of the physicians' attention is spent on the 'active' treatment option. Older patients, married patients and patients in academic hospitals receive more information.

Computers in patient education

Nurses in practice have an increasing need to become aware of the computer-based resources available and the evidence regarding their use in the process of patient education. This synthesis of the literature examines research related to computer-based patient education. A particular focus is placed on the nurse clinician's perspective and the role of the nurse as a patient educator in the digital age. Two primary healthcare database resources, MEDLINE and CINAHL, were selected for review of the current literature. A listing of articles related to the use of computer technology in patient education was obtained from both of these databases. The search strategy included exploding the subject heading terms "computer" and "patient education," and included articles from 1971 to 2001. Computer-based patient education is an effective strategy for improving healthcare knowledge and clinical outcomes. Computer-based learning can be tailored to the individual's age and specific learning needs. Furthermore, although access to computer-based resources continues to be a barrier for some, socioeconomic disparities have no reported impact on patients' abilities to use computer-based technologies effectively.

Personalised risk communication for informed decision making about entering screening programs

BACKGROUND

There is a trend towards greater patient involvement in health care decisions. Adequate discussion of the risks and benefits associated with different choices is often required if involvement is to be genuine and effective. Achieving adequate involvement of consumers and informed decision making are now seen as important goals for any screening programme. Individualised risk estimates have been shown to be effective methods of risk communication in general, but the effectiveness of different strategies has not previously been examined.

OBJECTIVES

To assess the effects of different types of individualised risk communication for consumers making decisions about participating in screening.

SEARCH STRATEGY

We searched the Cochrane Consumers and Communication Review Group specialised register (searched March 2001), MEDLINE (1985 to 2001), EMBASE (1985 to 2001), CancerLit (1985 to 2001), CINAHL (1985 to 2001), ClinPSYC (1989 to 2001), and the Science Citation Index Expanded (searched March 2002). Follow-up searches involved hand searching Preventive Medicine, citation searches on seven authors, and searching reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials addressing the decision by consumers of whether or not to undergo screening, incorporating an intervention with a 'personalised risk communication element' and reporting cognitive, affective, or behavioural outcomes. A 'personalised risk communication element' is based on the individual's own risk factors for a condition (such as age or family history). It may be calculated from an individual's risk factors using formulae derived from epidemiological data, and presented as an absolute risk or as a risk score, or it may be categorised into, for example, high, medium or low risk groups. It may be less detailed still, involving a listing, for example, of a consumer's risk factors as a focus for discussion and intervention.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Data about the nature and setting of the intervention, and the relevant outcome data were extracted, along with items relating to methodological quality.

MAIN RESULTS

Thirteen studies were included. Personalised risk communication (whether written, spoken or visually presented) was associated with increased uptake of screening tests (odds ratio (OR) 1.5 (95% confidence interval (CI) 1.11 to 2.03). There was no evidence from these studies that this increase in uptake of tests was related to informed decision making by consumers. More detailed personalised risk communication was associated with a smaller increase in uptake of tests. That is, for personalised risk communication which used and presented numerical calculations of risk, the OR for test uptake was 1.22 (95% CI 0.56 to 2.68). For risk estimates or calculations which were categorised into high, medium or low strata of risk, the OR was 1.42 (95% CI 1.07 to 1.88). For risk communication that simply listed risk personal risk factors the OR was 1.7 (95% CI 1.17 to 2.48). Most of the included studies addressed mammography programmes. These studies showed slightly smaller effects than the overall dataset, again with numerical calculated risk estimates being associated with lower ORs for uptake of tests (OR 1.13; 95% CI 0.98 to 1.29) than the other categories of (less detailed) personalised risk communication. The four studies examining risk communication in high risk individuals showed larger odds ratios for uptake of tests than the other studies. The OR for numerical calculated risk estimates was 1.48 (95% CI 1.06 to 2.07), compared to 4.66 (95% CI 2.24 to 9.69) for categorised risk estimates and 2.64 (95% CI 1.42 to 4.9) for listed personal risk factors. There were insufficient data from the included studies to report odds ratios on other key outcomes such as: intention to take tests, anxiety, satisfaction with decisions, decisional conflict, knowledge and risk perception.

REVIEWER'S CONCLUSIONS

Personalised risk communication (as currently implemented in the included studies) is associated with increased uptake of screening programmes, but this may not be interpretable as evidence of informed decision making by consumers.

Quality assurance processes for designing patient education web sites

In the future, more nurses and other healthcare professionals will be providing patient education on the Internet. Having knowledge of processes that lead to quality patient education Web site design is essential. These quality assurance processes include determining the site's purpose, selecting the user population, establishing the expected clinical and learning outcomes, providing an educational framework, incorporating specific design principles, and multiple and ongoing site evaluation. Therefore, Web site development processes designed to undergird quality patient education are presented, and an example Web site is used to illustrate them.

Formative evaluation of a multimedia program for patients about the side effects of cancer treatment

Formative evaluation of multimedia programs can prevent costly and time-consuming revisions and result in more effective programs. Yet systematic formative evaluation is seldom conducted. This paper reviews the basic principles of formative evaluation and describes how we applied those principles to the formative evaluation of a multimedia program for patients about the side effects of cancer treatment. It discusses the challenges of developing multimedia programs for patients and provides guidance to other health professionals interested in developing programs on other topics.

Development and preliminary evaluation of a clinical guidance programme for the decision about prophylactic oophorectomy in women undergoing a hysterectomy

OBJECTIVES

To develop a decision analysis based and computerised clinical guidance programme (CGP) that provides patient specific guidance on the decision whether or not to undergo a prophylactic oophorectomy to reduce the risk of subsequent ovarian cancer and to undertake a preliminary pilot and evaluation.

SUBJECTS

Women who had already agreed to have a hysterectomy who otherwise had no ovarian pathology.

SETTING

Oophorectomy decision consultation at the outpatient or pre-admission clinic.

METHODS

A CGP was developed with advice from gynaecologists and patient groups, incorporating a set of Markov models within a decision analytical framework to evaluate the benefits of undergoing a prophylactic oophorectomy or not on the basis of quality adjusted life expectancy, life expectancy, and for varying durations of hormone replacement therapy. Sensitivity analysis and preliminary testing of the CGP were undertaken to compare its overall performance with established guidelines and practice. A small convenience sample of women invited to use the CGP were interviewed, the interviews were taped and transcribed, and a thematic analysis was undertaken.

RESULTS

The run time of the programme was 20 minutes, depending on the use of opt outs to default values. The CGP functioned well in preliminary testing. Women were able to use the programme and expressed overall satisfaction with it. Some had reservations about the computerised formal and some were surprised at the specificity of the guidance given.

CONCLUSIONS

A CGP can be developed for a complex healthcare decision. It can give evidence-based health guidance which can be adjusted to account for individual risk factors and reflects a patient's own values and preferences concerning health outcomes. Future decision aids and support systems need to be developed and evaluated in a way which takes account of the variation in patients' preferences for inclusion in the decision making process.

Interactive education on CD-ROM-a new tool in the education of heart failure patients

The study aimed to develop and evaluate whether a computer-based program for patients with heart failure was user-friendly, could be operated by elderly patients and gave sufficient information about heart failure. The program was developed by a multidisciplinary group and designed with large, clear illustrations and buttons. A total of 42 patients aged 51-92 years tested the program and completed afterwards a questionnaire. Three heart failure nurses evaluated how the patients used the program and their attitudes towards the computer. All patients could use the program, despite the fact that only six had used a computer before. The patients were satisfied with the computer-based information and appreciated that the program was interactive, flexible and contained a self-test. They thought it was a better way of receiving information than reading a booklet or watching a video about heart failure. The nurses reported that the patients were positive towards the computer and seemed to understand the information and that the patient education was less time-consuming, when the patients could seek knowledge on their own.

Understanding risk and lessons for clinical risk communication about treatment preferences

This paper defines risk and its component elements and describes where clinical practice may be starting from in terms of what is reported in the literature about understanding risks and the information requirements of consumers. It notes briefly how theoretical models in the literature contribute to our understanding by providing a basis from which to summarise current evidence about the effects of healthcare interventions which address risks and risk behaviour. The situations or types of interventions in which risk related interventions are most effective are described, but a significant caveat is noted about the types of outcomes which have been reported in the literature and which are most appropriate to evaluate. The effects of "framing" variations in the information given to consumers and the ethical dilemmas these raise for a debate about "informed choice" in healthcare programmes are discussed. In response to both the practical and ethical dilemmas that arise from the current evidence, some of the areas where attention should be focused in the future are outlined so that both health gain and informed choice might be achieved. These include the use of decision aids, although their implementation is not widespread at present. Lessons from the current literature on how further progress can be made towards improved communication, discussion between professionals and consumers, and enhancing informed choice are discussed.

Modeling emotion and behavior in animated personas to facilitate human behavior change: the case of the HEART-SENSE game

The goal of this research is to determine whether a computer based training game (HEART-SENSE) can improve recognition of heart attack symptoms and shift behavioral issues so as to reduce pre-hospitalization delay in seeking treatment. Since treatment delay correlates with adverse outcomes, this research could reduce myocardial infarction mortality and morbidity. In Phase I we created and evaluated a prototype virtual village in which users encounter and help convince synthetic personas to deal appropriately with a variety of heart attack scenarios and delay issues. Innovations made here are: (1) a design for a generic simulator package for promoting health behavior shifts, and (2) algorithms for animated pedagogical agents to reason about how their emotional state ties to patient condition and user progress. Initial results show that users of the game exhibit a significant shift in intention to call 9-1-1 and avoid delay, that multi-media versions of the game foster vividness and memory retention as well as a better understanding of both symptoms and of the need to manage time during a heart attack event. Also, results provide insight into areas where emotive pedagogical agents help and hinder user performance. Finally, we conclude with next steps that will help improve the game and the field of pedagogical agents and tools for simulated worlds for healthcare education and promotion.

Should patients have control over their own health care?: empirical evidence and research issues

Available research indicates that purported patient insufficiencies in ability to process information and make rational and reliable decisions have likely been overestimated. Furthermore, data indicate that nonscientific factors often play a role in physician decision-making and that physicians may not value different health outcomes in the same way as patients. Though the data on patient cognitive functioning are limited because of heavy reliance on patient responses in hypothetical versus actual decision-making situations, these findings lend credence to arguments that patients should have increased control over their own health care. Research on the effects of interventions designed to enhance patient control indicates that: (a) patients generally respond positively to increased information, but few studies have evaluated the effects of information as a precursor to decision-making; (b) the few studies using simple behavioral control interventions have shown generally positive effects on a range of patient outcomes; and (c) studies of decisional control (with breast cancer patients) have had experimental confounds which prohibit conclusions regarding effectiveness. Areas in greatest need of research include: (a) further exploration of the utility of noninvasive behavioral control interventions in different settings; (b) measuring the impact of control manipulations on patient perception of control as well as patient control-related behaviors; (c) matching patient differences in desire for control to experimental conditions and to physician differences in receptiveness to patient control; and (d) clinical trials in which patients facing critical decisions in trade-off situations are actually given a choice.

Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease

OBJECTIVE

To determine the effect of the Ischemic Heart Disease Shared Decision-Making Program (IHD SDP) an interactive videodisc designed to assist patients in the decision-making process involving treatment choices for ischemic heart disease, on patient decision-making.

DESIGN

Randomized, controlled trial.

SETTING

The Toronto Hospital, University of Toronto, Toronto, Ontario, Canada.

PARTICIPANTS

Two hundred forty ambulatory patients with

MEASUREMENTS AND MAIN RESULTS

The primary outcome was patient satisfaction with the decision-making process. This was measured using the 12-item Decision-Making Process Questionnaire that was developed and validated in a randomized trial of the benign prostatic hyperplasia SDP. Secondary outcomes included patient knowledge (measured using 20 questions about knowledge deemed necessary for an informed treatment decision), treatment decision, patient-angiographer agreement on decision, and general health scores. Outcomes were measured at the time of treatment decision and/or at 6 months follow-up. Shared decision-making program scores were similar for the intervention and control group (71% and 70%, respectively; 95% confidence interval [CI] for 1% difference, -3% to 7%). The intervention group had higher knowledge scores (75% vs 62%; 95% CI for 13% difference, 8% to 18%). The intervention group chose to pursue revascularization less often (58% vs 75% for the controls; 95% CI for 17% difference, 4% to 31%). At 6 months, 52% of the intervention group and 66% of the controls had undergone revascularization (95% CI for 14% difference, 0% to 28%). General health and angina scores were not different between the groups at 6 months. Exposure to the IHD SDP resulted in more patient-angiographer disagreement about treatment decisions.

CONCLUSIONS

There was no significant difference in satisfaction with decision-making process scores between the IHD SDP and usual practice groups. The IHD SDP patients were more knowledgeable, underwent less revascularization (interventional therapies), and demonstrated increased patient decision-making autonomy without apparent impact on quality of life.

Decision aids for patients considering options affecting cancer outcomes: evidence of efficacy and policy implications

Some cancer screening and treatment decisions are not clear cut because outcomes are uncertain or options have different benefit/risk profiles. "Decision aids" have been developed as adjuncts to counseling so that patients can learn about benefits and risks, can consider their personal values, and can participate with their practitioner in decision making. The purpose of this paper is to review published evidence about the efficacy of decision aids focused on cancer outcomes and to outline research and dissemination issues. Studies evaluating cancer-related decision aids demonstrate that they are acceptable to patients and help those who are uncertain at baseline to make choices. They also increase the likelihood that choices are based on better knowledge, realistic expectations of outcomes, and personal values. Decision aids reduce some dimensions of decisional conflict, and their effect on decisions is variable. Few studies examine the downstream effects of decision aids on long-term persistence with choices, regret, and quality of life. The differences between simpler and more intensive methods of decision support appear to be negligible in terms of knowledge and satisfaction as well as variable in terms of decisions and decisional conflict. However, more intensive methods are superior in terms of user acceptability and of the extent to which choices are based on realistic expectations and personal values. The clinical importance of these differences and the cost-effectiveness remain to be established. On the basis of this review, several recommendations for research are made, and dissemination issues are identified.

Implementing shared decision-making in routine practice: barriers and opportunities

OBJECTIVE: Determine feasibility of shared decision-making programmes in fee-for-service hospital systems including physicians' offices and in-patient facilities. DESIGN: Survey and participant observation. Data obtained during Phase 1 of a patient outcome study. SETTINGS AND PARTICIPANTS: Three hospitals in Michigan: one 299-bed rural regional hospital, one 650-bed urban community hospital, one 459-bed urban and suburban teaching hospital. All nurses and physicians who agreed to use the programmes participated in the evaluation (n = 34). INTERVENTION: Two shared decision-making(R) (SDP) multimedia programmes: surgical treatment choice for breast cancer and ischaemic heart disease treatment choice. MAIN OUTCOME MEASURES: (1) clinicians' evaluations of programme quality; (2) challenges in hospital settings; and (3) patient referral rates. RESULTS: SDP programmes were judged to be clear, accurate and about the right length and amount of information. Programmes were judged to be informative and appropriate for patients to see before making a decision. Clinicians were neutral about patients' desire to participate in treatment decision-making. Referral volume to SDPs was lower than expected: 24 patients in 7 months across three hospitals. Implementation challenges centred on time pressures in patient care. CONCLUSIONS: Productivity and time pressure in US health care severely constrain shared decision-making programme implementation. Physician referral may not be a reliable mechanism for patient access. Possible innovations include: (1) incorporation into the informed consent process; (2) provider or payer negotiated requirement in the routine hospital procedure to use the SDP as a quality indicator; and (3) payer reimbursement to professional providers who make SDP programmes available to patients.

Perceptions of benefit and risk of patients undergoing first-time elective percutaneous coronary revascularization

OBJECTIVE

To assess reasons why patients undergo elective percutaneous coronary revascularization (PCR), patient expectations of the benefits of PCR, and their understanding of the risks associated with PCR. We hypothesized that patients overestimate the benefits and underestimate the risks associated with PCR.

DESIGN

A prospective, semistructured questionnaire.

PARTICIPANTS

Patients undergoing their first elective PCR.

MAIN RESULTS

Fifty-two consecutive patients with a mean age of 64.3 years (range 39-87) completed the interview. Although 30 (57%) patients cited relief of symptoms as at least 1 reason to have PCR, 32 (62%) patients cited either an abnormal diagnostic test result (i.e., exercise stress test or catheterization) or "pathophysiologic" problem (i.e., "I have a blockage"), with 17 patients (33%) citing these reasons alone as indications for PCR. Thirty-nine (75%) patients believed PCR would prevent a future myocardial infarction, and 37 (71%) patients felt PCR would prolong their life. Regarding the potential complications, only 24 patients (46%) could recall at least 1 possible complication. However, on a Deber questionnaire, the majority of patients (67%) stated that they should determine either mostly alone or equally with a physician how acceptable the risks of the procedure are for themselves.

CONCLUSIONS

The majority of patients had unrealistic expectations about the long-term benefits of elective PCR and was not aware of the potential risks, even though they expressed a strong interest in participating in the decision to have PCR. More work is needed to define the optimal strategy to educate patients about the benefits and risks of elective PCR, and whether such education will affect patient decision making.