Evaluation of the effect of a patient decision aid about vasectomy on the decision-making process: a randomized trial. Contraception. 2010;82:556-562. [PMID: 21074020 DOI: 10.1016/j.contraception.2010.05.003]

Patient perspectives on vasectomy: findings from a TikTok® content analysis

Social media is increasingly used as a platform for patients to explore health care information. Our objective was to study the content on TikTok® in order to gain insight into the perspectives shared by the public on vasectomy. A search was performed using the hashtag ´#vasectomy´ on 12.20.2023 and the top 100 video posts from persons self-identifying as patients were included. Using an adaptation of a previously published system, a framework was created for organising and categorising the data related to vasectomy. Domains covered included reason for vasectomy, complications, vasectomy as a controversial topic in society and reference to the 2022 Dobbs v. Jackson ruling. Most content originated from the United States (85.0%) and the median number of views per video was 261 200 (interquartile range (IQR) 8416-1 800 000). In 12.0% of posts, the individual clearly stated that they were under 30 years of age. Two of the commonest topics to be addressed in the videos were recovery (41.0%) and pain (40.0%). 30.0% discussed the reason for undergoing vasectomy. Reasons included women's rights (12%), safety over tubal ligation (5.0%) and desire to be childless (4.0%). 9.0% referred to the Dobbs v. Jackson ruling. Complications were discussed in 19.0% including vasectomy failure (12.0%). 23.0% contained factually incorrect medical information. 31.0% of videos included the user voicing that vasectomy was considered to be a controversial subject. More than half of the videos (61.0%) were positive regarding the vasectomy process. Our findings reveal that vasectomy receives very high engagement on social media. This study confirms that patients do use it to share their experiences, both positive and negative. Misconceptions regarding this contraception method are common among the public and the urological community should work to address this.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017.

OBJECTIVES

To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach.

SEARCH METHODS

We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022.

SELECTION CRITERIA

We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence.

MAIN RESULTS

This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015.

AUTHORS' CONCLUSIONS

Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.

Male or female sterilization - the decision making process: Counselling and regret

OBJECTIVE(S)

To analyze the decision-making process of both male and female sterilization in order to improve counselling and prevent regret after sterilization in the future.

STUDY DESIGN

An online questionnaire regarding sterilization (counselling, sources of information and regret) was promoted on Facebook, Twitter and LinkedIn. A total of 1107 men and women who had undergone or considered sterilization in the Netherlands filled in the questionnaire.

RESULTS

A total of 88.9 % of the sterilized group and 67.4 % in the considered group responded that they felt well informed when they considered sterilization. However, less than half of the participants in both groups knew about all different sterilization methods. In both groups participants reported they consulted their partner the most when they considered sterilization. After sterilization 7.7 % reported having regret. Regret was reported more often when participants were sterilized ≤ 30 years. Most important reasons for regret reported by males were complications, pain, a new wish to conceive and divorce/remarriage. Most important reasons for regret reported by females were pain, complications, a new wish to conceive and menstrual symptoms. A total of 21.1 % in the sterilized and 38.0 % in the considered group responded they would have liked to use a decision aid when they considered sterilization.

CONCLUSIONS

Findings of this study provide insight in the decision-making process regarding sterilization. There is a lack of knowledge of different methods of sterilization and 7.7% regrets their sterilization afterwards. Furthermore, the results show an importance of developing a decision aid for couples considering sterilization.

Assessing Vasectomy-Related Information on YouTube: An Analysis of the Quality, Understandability, and Actionability of Information

This study aims to critically appraise the quality of vasectomy-related health information currently available on YouTube to better address patient information needs moving forward. A YouTube search was performed using the keyword “vasectomy.” The first 100 videos were assessed, with irrelevant and duplicate videos excluded. Two independent reviewers evaluated the remaining videos using the DISCERN instrument for evaluating the quality of information and the Patient Education Materials Assessment Tool for Audiovisual materials (PEMAT-A/V) for assessing the understandability and actionability of materials. Source characteristics and markers of bias and misinformation were also collected. Seventy-eight videos were included in the study, with a mean duration of 6.6 minutes and mean of 216,672 views. The median DISCERN score was poor at 28 (IQR 22–33) out of a possible 80 with mean PEMAT-AV Understandability and Actionability scores of 67.6% (±16.7%) and 33.8% (±36.2%), respectively. A medical doctor was present in 61 (78.2%) of the videos, of which 53 (86.9%) were urologists and 38 (62.2%) promoted their personal practice or institution. False statements regarding vasectomy were made in 14 (17.9%) videos. Notably, no significant difference was noted in quality, understandability, or actionability of videos created by those with personal promotion to those without. The quality of information regarding vasectomy on YouTube is poor and reaches a wide audience. Continued appraisal and creation of YouTube videos that contain quality, understandable and actionable information by urologists is necessary to ensure patients are well-informed.

Decisional conflict in breast cancer patients considering immediate breast reconstruction

Background

Breast cancer (BC) patients who are treated with mastectomy are frequently offered immediate breast reconstruction. This study aimed to assess decisional conflict in patients considering immediate breast reconstruction, and to identify factors associated with clinically significant decisional conflict (CSDC).

Methods

Baseline data of a multicenter randomized controlled trial evaluating the impact of an online decision aid for BC patients considering immediate breast reconstruction after mastectomy were analyzed. Participants completed questionnaires assessing sociodemographic and clinical characteristics, decisional conflict and other patient-reported outcomes related to decision-making such as breast reconstruction preference, knowledge, information resources used, preferred involvement in decision-making, information coping style, and anxiety. Multivariable logistic regression analysis was performed to identify factors associated with CSDC (score > 37.5 on decisional conflict).

Results

Of the 250 participants, 68% experienced CSDC. Patients with a slight preference for breast reconstruction (odds ratio (OR) = 6.19, p < .01), with no preference for or against breast reconstruction (OR = 11.84, p < .01), and with a strong preference for no breast reconstruction (OR = 5.20, p < .05) were more likely to experience CSDC than patients with a strong preference for breast reconstruction. Furthermore, patients with more anxiety were more likely to experience CSDC (OR = 1.03, p = .01).

Conclusion

A majority of BC patients who consider immediate breast reconstruction after mastectomy experience clinically significant decisional conflict. The findings emphasize the need for decision support, especially for patients who do not have a strong preference for breast reconstruction.

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A majority of patients considering immediate breast reconstruction experience decisional conflict.

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Patients without a strong preference for breast reconstruction are more likely to experience decisional conflict.

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Patients with more anxiety are more likely to experience decisional conflict.

High Users of Healthcare Services: Development and Alpha Testing of a Patient Decision Aid for Case Management

BACKGROUND

Some patients with complex healthcare needs become high users of healthcare services. Case management allows these patients and their interprofessional team to work together to evaluate their needs, priorities and available resources. High-user patients must make an informed decision when choosing whether to engage in case management and currently there is no tool to support them.

OBJECTIVE

The objective of this study was to develop and conduct a pilot alpha testing of a patient decision aid that supports high-user patients with complex needs and the teams who guide those patients in shared decision making when engaging in case management.

METHODS

We chose a user-centered design to co-develop a patient decision aid with stakeholders informed by the Ottawa Research Institute and International Patient Decision Aid Standards frameworks. Perceptions and preferences for the patient decision aid's content and format were assessed with patients and clinicians and were iteratively collected through interviews and focus groups. We developed a prototype and assessed its acceptability by using a think-aloud method and a questionnaire with three patient-partners, six clinicians and seven high-user patients with complex needs.

RESULTS

The three rounds of evaluation to assess the decision aid's acceptability highlighted comments related to simplicity, readability and visual aspect. A section presenting clinical vignettes including story telling was identified as the most helpful.

CONCLUSIONS

We created and evaluated a patient decision aid. Considering the positive comments, we believe that this aid has the potential to help high-user patients with complex care needs make better choices concerning case management.

Evaluation of a computerized contraceptive decision aid: A randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of a contraceptive decision aid in reducing decisional conflict among women seeking reversible contraception.

STUDY DESIGN

We conducted a randomized trial of a computer-based decision aid compared to a control group for women presenting for reversible contraception at two clinics affiliated with an academic medical center. The primary outcome was change in decisional conflict, measured before and after the healthcare visit using the validated Decisional Conflict Scale. We hypothesized the decision aid would reduce the decisional conflict score by 10 points on a 100-point scale (0 = no conflict, 100 = high conflict) compared to the control group. Secondary outcomes included contraceptive method chosen and satisfaction with the healthcare visit.

RESULTS

We enrolled and randomized 253 women, and 241 had complete data for our primary outcome. Overall, pre-visit decisional conflict scores were low, reflecting low levels of decisional conflict in our sample; median score 15 (range 0-80) in the decision aid and 10 (0-85) in the control group (p = 0.45). Both groups had a similar reduction in median decisional conflict after the healthcare visit: -10 (-80 to 25) and -10 (-60 to 5) in the decision aid and control groups respectively (p = 0.99). Choice of contraception (p = 0.23) and satisfaction with healthcare provider (p = 0.79) also did not differ by study group.

CONCLUSIONS

Decisional conflict around contraception was low in both groups at baseline. Use of a computerized contraceptive decision aid did not reduce decisional conflict, alter method choice, or impact satisfaction compared to the control group among women choosing reversible contraception.

IMPLICATIONS

Use of a computerized contraceptive decision aid did not reduce decisional conflict or alter method choice compared to the control group among women choosing reversible contraception. Future studies could focus on testing the decision aid in different clinical settings, especially where barriers to providing comprehensive contraceptive counseling exist.

Decision Quality Among Parents Who Are Offered Ventilation Tube Insertion for Their Children

Objective:

To develop a Decision Quality (DQ) tool to measure parents’ DQ concerning ventilation tube (VT) insertion in their children.

Method:

Parental survey during 2017 to 2018 in a tertiary care pediatric otolaryngology clinic comparing a validated Decisional Conflict (DC) scale with a DQ instrument including Shared Decision-Making (SDM) scale, parental treatment goals, and knowledge about VT.

Results:

Of 100 parent participants, 83% were mothers and 14% were fathers. 94% elected VT insertion, 6% elected monitoring or deferred the decision. 44% of the patients were <18 months, 42% were 19 months to 3 years, and the rest were older. The mean DC score was 8.26 out of 100 (95% CI 4.82-11.69), indicating low DC. Mean DQ score was 82.45 out of 100 (95% CI 80.18-84.72), including mean SDM of 87.71 (95% CI 83.53-91.88,), mean knowledge score of 87.5% (95% CI 84.56-91.59) and mean values score of 7.16 (95% CI 6.90-7.41). Comparisons between those who elected VT and those who did not showed that electors had lower DC scores (7.15 vs 24.74, P < .001), higher DQ scores (83.00 vs 72.61, P = .028) with higher SDM scores (88.70 vs 70.22, P = .044) and higher values score (7.20 vs 6.36, P = .034). Cronbach alpha for the DQ scale was 0.76. Spearman’s rho for DQ score versus DC score was −0.458, P < .001.

Conclusions:

DQ, as measured with this tool, was higher when parents chose to place tubes. Our DQ instrument has potential use for study of why parents may decline VT when their child meets criteria for them.

The impact of an online patient decision aid for women with breast cancer considering immediate breast reconstruction: study protocol of a multicenter randomized controlled trial

Background

Most breast cancer patients undergoing mastectomy are candidates for breast reconstruction. Deciding about breast reconstruction is complex and the preference-sensitive nature of this decision requires an approach of shared decision making between patient and doctor. Women considering breast reconstruction have expressed a need for decision support. We developed an online patient decision aid (pDA) to support decision making in women considering immediate breast reconstruction. The primary aim of this study is to assess the impact of the pDA in reducing decisional conflict, and more generally, on the decision-making process and the decision quality. Additionally, we will investigate the pDA’s impact on health outcomes, explore predictors, and assess its cost-effectiveness.

Methods

A multicenter, two-armed randomized controlled trial (1:1) will be conducted. Women with breast cancer or ductal carcinoma in situ who will undergo a mastectomy and are eligible for immediate breast reconstruction will be invited to participate. The intervention group will receive access to the online pDA, whereas the control group will receive a widely available free information leaflet on breast reconstruction. Participants will complete online questionnaires at: baseline (T0), 1 week after consultation with a plastic surgeon (T1), and 3 (T2) and 12 months (T3) after surgery. The primary outcome is decisional conflict. Secondary outcomes include other measures reflecting the decision-making process and decision quality (e.g., decision regret), patient-reported health outcomes (e.g., satisfaction with the breasts) and costs.

Discussion

This study will provide evidence about the impact of an online pDA for women who will undergo mastectomy and are deciding about breast reconstruction. It will contribute to the knowledge on how to optimally support women in making this difficult decision.

Trial registration

This study is retrospectively registered at ClinicalTrials.gov (NCT03791138).

A Review of Decision Aids for Patients Considering More Than One Type of Invasive Treatment

With continuous advances in medicine, patients are faced with several medical or surgical treatment options for their health conditions. Decision aids may be useful in helping patients navigate these options and choose based on their goals and values. We reviewed the literature to identify decision aids and better understand the effect on patient decision-making. We identified 107 decision aids designed to help patients make decisions between medical treatment or screening options; 39 decision aids were used to help patients choose between a medical and surgical treatment, and five were identified that aided patients in deciding between a major open surgical procedure and a less invasive option. Many of the decision aids were used to help patients decide between prostate, colorectal, and breast cancer screening or treatment options. Although most decision aids were not associated with a significant effect on the actual decision made, they were largely associated with increased patient knowledge, decreased decisional conflict, more accurate perception of risks, increased satisfaction with their decision, and no increase in anxiety surrounding their decision. These data identify a gap in use of decision aids in surgical decision-making and highlight the potential to help surgical patients make value-based, knowledgeable decisions regarding their treatment.

Explanation and elaboration of the Standards for UNiversal reporting of patient Decision Aid Evaluations (SUNDAE) guidelines: examples of reporting SUNDAE items from patient decision aid evaluation literature

This Explanation and Elaboration (E&E) article expands on the 26 items in the Standards for UNiversal reporting of Decision Aid Evaluations guidelines. The E&E provides a rationale for each item and includes examples for how each item has been reported in published papers evaluating patient decision aids. The E&E focuses on items key to reporting studies evaluating patient decision aids and is intended to be illustrative rather than restrictive. Authors and reviewers may wish to use the E&E broadly to inform structuring of patient decision aid evaluation reports, or use it as a reference to obtain details about how to report individual checklist items.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Decision aids are interventions that support patients by making their decisions explicit, providing information about options and associated benefits/harms, and helping clarify congruence between decisions and personal values.

OBJECTIVES

To assess the effects of decision aids in people facing treatment or screening decisions.

SEARCH METHODS

Updated search (2012 to April 2015) in CENTRAL; MEDLINE; Embase; PsycINFO; and grey literature; includes CINAHL to September 2008.

SELECTION CRITERIA

We included published randomized controlled trials comparing decision aids to usual care and/or alternative interventions. For this update, we excluded studies comparing detailed versus simple decision aids.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened citations for inclusion, extracted data, and assessed risk of bias. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made and the decision-making process.Secondary outcomes were behavioural, health, and health system effects.We pooled results using mean differences (MDs) and risk ratios (RRs), applying a random-effects model. We conducted a subgroup analysis of studies that used the patient decision aid to prepare for the consultation and of those that used it in the consultation. We used GRADE to assess the strength of the evidence.

MAIN RESULTS

We included 105 studies involving 31,043 participants. This update added 18 studies and removed 28 previously included studies comparing detailed versus simple decision aids. During the 'Risk of bias' assessment, we rated two items (selective reporting and blinding of participants/personnel) as mostly unclear due to inadequate reporting. Twelve of 105 studies were at high risk of bias.With regard to the attributes of the choice made, decision aids increased participants' knowledge (MD 13.27/100; 95% confidence interval (CI) 11.32 to 15.23; 52 studies; N = 13,316; high-quality evidence), accuracy of risk perceptions (RR 2.10; 95% CI 1.66 to 2.66; 17 studies; N = 5096; moderate-quality evidence), and congruency between informed values and care choices (RR 2.06; 95% CI 1.46 to 2.91; 10 studies; N = 4626; low-quality evidence) compared to usual care.Regarding attributes related to the decision-making process and compared to usual care, decision aids decreased decisional conflict related to feeling uninformed (MD -9.28/100; 95% CI -12.20 to -6.36; 27 studies; N = 5707; high-quality evidence), indecision about personal values (MD -8.81/100; 95% CI -11.99 to -5.63; 23 studies; N = 5068; high-quality evidence), and the proportion of people who were passive in decision making (RR 0.68; 95% CI 0.55 to 0.83; 16 studies; N = 3180; moderate-quality evidence).Decision aids reduced the proportion of undecided participants and appeared to have a positive effect on patient-clinician communication. Moreover, those exposed to a decision aid were either equally or more satisfied with their decision, the decision-making process, and/or the preparation for decision making compared to usual care.Decision aids also reduced the number of people choosing major elective invasive surgery in favour of more conservative options (RR 0.86; 95% CI 0.75 to 1.00; 18 studies; N = 3844), but this reduction reached statistical significance only after removing the study on prophylactic mastectomy for breast cancer gene carriers (RR 0.84; 95% CI 0.73 to 0.97; 17 studies; N = 3108). Compared to usual care, decision aids reduced the number of people choosing prostate-specific antigen screening (RR 0.88; 95% CI 0.80 to 0.98; 10 studies; N = 3996) and increased those choosing to start new medications for diabetes (RR 1.65; 95% CI 1.06 to 2.56; 4 studies; N = 447). For other testing and screening choices, mostly there were no differences between decision aids and usual care.The median effect of decision aids on length of consultation was 2.6 minutes longer (24 versus 21; 7.5% increase). The costs of the decision aid group were lower in two studies and similar to usual care in four studies. People receiving decision aids do not appear to differ from those receiving usual care in terms of anxiety, general health outcomes, and condition-specific health outcomes. Studies did not report adverse events associated with the use of decision aids.In subgroup analysis, we compared results for decision aids used in preparation for the consultation versus during the consultation, finding similar improvements in pooled analysis for knowledge and accurate risk perception. For other outcomes, we could not conduct formal subgroup analyses because there were too few studies in each subgroup.

AUTHORS' CONCLUSIONS

Compared to usual care across a wide variety of decision contexts, people exposed to decision aids feel more knowledgeable, better informed, and clearer about their values, and they probably have a more active role in decision making and more accurate risk perceptions. There is growing evidence that decision aids may improve values-congruent choices. There are no adverse effects on health outcomes or satisfaction. New for this updated is evidence indicating improved knowledge and accurate risk perceptions when decision aids are used either within or in preparation for the consultation. Further research is needed on the effects on adherence with the chosen option, cost-effectiveness, and use with lower literacy populations.

Patient perceptions of a decision support tool to assist with young women's contraceptive choice

OBJECTIVE

Contraceptive decision support tools (DSTs) have been suggested as a way to provide patient-centered contraceptive care, but little is known about the role they play in women's decision-making. The aim of this study is to understand patients' perceptions of the value of a contraceptive DST.

METHODS

We conducted 21 semi-structured interviews with unmarried women aged 18-29 from an integrated health care system who viewed the DST. Thematic analysis was conducted to identify common themes in the participants' experience.

RESULTS

Four themes were identified: Informative; Narrowing down options; Tool vs. doctor; and Preparation for a clinical visit. In general, participants felt the tool was valuable because it provided them relevant information and facilitated their decision-making process by narrowing down contraceptive options. Participants felt the tool could prepare them for a visit with their health care provider by helping them identify questions for their provider, but also saw distinctions between the DST and what their provider could offer.

CONCLUSION

Contraceptive DSTs are valuable to their users when they include information on contraceptive attributes women deem important and allow for user-driven tailoring.

PRACTICE IMPLICATIONS

Contraceptive DSTs may address patient informational needs and can serve as a complement to provider counseling.

Utah's 72-Hour Waiting Period for Abortion: Experiences Among a Clinic-Based Sample of Women

CONTEXT

In 2012, Utah became the first state to enact a 72-hour waiting period for abortion. Despite debate about the law's potential effects, research has not examined women's experiences with it.

METHODS

A cohort of 500 women recruited at four family planning facilities in Utah in 2013-2014 completed baseline surveys at the time of an abortion information visit and follow-up telephone interviews three weeks later. Logistic regression and coding of open-ended responses were used to examine which women had abortions and, for those who did not, their reasons.

RESULTS

Among the 309 women completing follow-up, 86% had had an abortion, 8% were no longer seeking abortion, 3% had miscarried or discovered they had not been pregnant, and 2% were still seeking abortion; one woman was still deciding, and the waiting period had pushed one woman beyond her facility's gestational limit for abortion. At the information visit, women reported little conflict about the abortion decision (mean score on a scale of 0-100 was 13.9 for those who eventually had an abortion and 28.5 for others). Low decisional conflict, but not socioeconomic status, was associated with having an abortion (odds ratio, 1.1). On average, eight days elapsed between the information visit and the abortion.

CONCLUSION

As most women in this cohort were not conflicted about their decision when they sought care, the 72-hour waiting requirement seems to have been unnecessary. Individualized patient counseling for the small minority who were conflicted when they presented for care may have been more appropriate.

More primary care patients regret health decisions if they experienced decisional conflict in the consultation: a secondary analysis of a multicenter descriptive study

Background

We sought to estimate the extent of decision regret among primary care patients and identify risk factors associated with regret.

Methods

Secondary analysis of an observational descriptive study conducted in two Canadian provinces. Unique patient-physician dyads were recruited from 17 primary care clinics and data on patient, physician and consultation characteristics were collected before, during and immediately after consultations, as well as two weeks post-consultation, when patients completed the Decision Regret Scale (DRS). We examined the DRS score distribution and performed ordinal logistic regression analysis to identify predictors of regret.

Results

Among 258 unique patient-physicians dyads, mean ± standard deviation of decision regret scores was 11.7 ± 15.1 out of 100. Overall, 43 % of patients reported no regret, 45 % reported mild regret and 12 % reported moderate to strong regret. In multivariate analyses, higher decision regret was strongly associated with increased decisional conflict and less significantly associated with patient age and education, as well with male (vs. female) physicians and residents (vs. teachers).

Conclusion

After consulting family physicians, most primary care patients experience little decision regret, but some experience more regret if there is decisional conflict. Strategies for reducing decisional conflict in primary care, such as shared decision-making with decision aids, seem warranted.

Effects of Design Features of Explicit Values Clarification Methods

Background. Diverse values clarification methods exist. It is important to understand which, if any, of their design features help people clarify values relevant to a health decision. Purpose. To explore the effects of design features of explicit values clarification methods on outcomes including decisional conflict, values congruence, and decisional regret. Data Sources. MEDLINE, all EBM Reviews, CINAHL, EMBASE, Google Scholar, manual search of reference lists, and expert contacts. Study Selection. Articles were included if they described the evaluation of 1 or more explicit values clarification methods. Data Extraction. We extracted details about the evaluation, whether it was conducted in the context of actual or hypothetical decisions, and the results of the evaluation. We combined these data with data from a previous review about each values clarification method’s design features. Data Synthesis. We identified 20 evaluations of values clarification methods within 19 articles. Reported outcomes were heterogeneous. Few studies reported values congruence or postdecision outcomes. The most promising design feature identified was explicitly showing people the implications of their values, for example, by displaying the extent to which each of their decision options aligns with what matters to them. Limitations. Because of the heterogeneity of outcomes, we were unable to perform a meta-analysis. Results should be interpreted with caution. Conclusions. Few values clarification methods have been evaluated experimentally. More research is needed to determine effects of different design features of values clarification methods and to establish best practices in values clarification. When feasible, evaluations should assess values congruence and postdecision measures of longer-term outcomes.

Design Features of Explicit Values Clarification Methods

Background. Values clarification is a recommended element of patient decision aids. Many different values clarification methods exist, but there is little evidence synthesis available to guide design decisions. Purpose. To describe practices in the field of explicit values clarification methods according to a taxonomy of design features. Data Sources. MEDLINE, all EBM Reviews, CINAHL, EMBASE, Google Scholar, manual search of reference lists, and expert contacts. Study Selection. Articles were included if they described 1 or more explicit values clarification methods. Data Extraction. We extracted data about decisions addressed; use of theories, frameworks, and guidelines; and 12 design features. Data Synthesis. We identified 110 articles describing 98 explicit values clarification methods. Most of these addressed decisions in cancer or reproductive health, and half addressed a decision between just 2 options. Most used neither theory nor guidelines to structure their design. “Pros and cons” was the most common type of values clarification method. Most methods did not allow users to add their own concerns. Few methods explicitly presented tradeoffs inherent in the decision, supported an iterative process of values exploration, or showed how different options aligned with users’ values. Limitations. Study selection criteria and choice of elements for the taxonomy may have excluded values clarification methods or design features. Conclusions. Explicit values clarification methods have diverse designs but can be systematically cataloged within the structure of a taxonomy. Developers of values clarification methods should carefully consider each of the design features in this taxonomy and publish adequate descriptions of their designs. More research is needed to study the effects of different design features.

Role of decision aids in orthopaedic surgery

Medical treatment of patients inherently entails the risk of undesired complication or side effects. It is essential to inform the patient about the expected outcomes, but also the possible undesired outcomes. The patients preference and values regarding the potential outcomes should be involved in the decision making process. Even though many orthopaedic surgeons are positive towards shared decision-making, it is minimally introduced in the orthopaedic daily practice and decision-making is still mostly physician based. Decision aids are designed to support the physician and patient in the shared- decision-making process. By using decision aids, patients can learn more about their condition and treatment options in advance to the decision-making. This will reduce decisional conflict and improve participation and satisfaction.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Decision aids are intended to help people participate in decisions that involve weighing the benefits and harms of treatment options often with scientific uncertainty.

OBJECTIVES

To assess the effects of decision aids for people facing treatment or screening decisions.

SEARCH METHODS

For this update, we searched from 2009 to June 2012 in MEDLINE; CENTRAL; EMBASE; PsycINFO; and grey literature. Cumulatively, we have searched each database since its start date including CINAHL (to September 2008).

SELECTION CRITERIA

We included published randomized controlled trials of decision aids, which are interventions designed to support patients' decision making by making explicit the decision, providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies of participants making hypothetical decisions.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were:A) 'choice made' attributes;B) 'decision-making process' attributes.Secondary outcomes were behavioral, health, and health-system effects. We pooled results using mean differences (MD) and relative risks (RR), applying a random-effects model.

MAIN RESULTS

This update includes 33 new studies for a total of 115 studies involving 34,444 participants. For risk of bias, selective outcome reporting and blinding of participants and personnel were mostly rated as unclear due to inadequate reporting. Based on 7 items, 8 of 115 studies had high risk of bias for 1 or 2 items each.Of 115 included studies, 88 (76.5%) used at least one of the IPDAS effectiveness criteria: A) 'choice made' attributes criteria: knowledge scores (76 studies); accurate risk perceptions (25 studies); and informed value-based choice (20 studies); and B) 'decision-making process' attributes criteria: feeling informed (34 studies) and feeling clear about values (29 studies).A) Criteria involving 'choice made' attributes:Compared to usual care, decision aids increased knowledge (MD 13.34 out of 100; 95% confidence interval (CI) 11.17 to 15.51; n = 42). When more detailed decision aids were compared to simple decision aids, the relative improvement in knowledge was significant (MD 5.52 out of 100; 95% CI 3.90 to 7.15; n = 19). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.82; 95% CI 1.52 to 2.16; n = 19). Exposure to a decision aid with explicit values clarification resulted in a higher proportion of patients choosing an option congruent with their values (RR 1.51; 95% CI 1.17 to 1.96; n = 13).B) Criteria involving 'decision-making process' attributes:Decision aids compared to usual care interventions resulted in:a) lower decisional conflict related to feeling uninformed (MD -7.26 of 100; 95% CI -9.73 to -4.78; n = 22) and feeling unclear about personal values (MD -6.09; 95% CI -8.50 to -3.67; n = 18);b) reduced proportions of people who were passive in decision making (RR 0.66; 95% CI 0.53 to 0.81; n = 14); andc) reduced proportions of people who remained undecided post-intervention (RR 0.59; 95% CI 0.47 to 0.72; n = 18).Decision aids appeared to have a positive effect on patient-practitioner communication in all nine studies that measured this outcome. For satisfaction with the decision (n = 20), decision-making process (n = 17), and/or preparation for decision making (n = 3), those exposed to a decision aid were either more satisfied, or there was no difference between the decision aid versus comparison interventions. No studies evaluated decision-making process attributes for helping patients to recognize that a decision needs to be made, or understanding that values affect the choice.C) Secondary outcomes Exposure to decision aids compared to usual care reduced the number of people of choosing major elective invasive surgery in favour of more conservative options (RR 0.79; 95% CI 0.68 to 0.93; n = 15). Exposure to decision aids compared to usual care reduced the number of people choosing to have prostate-specific antigen screening (RR 0.87; 95% CI 0.77 to 0.98; n = 9). When detailed compared to simple decision aids were used, fewer people chose menopausal hormone therapy (RR 0.73; 95% CI 0.55 to 0.98; n = 3). For other decisions, the effect on choices was variable.The effect of decision aids on length of consultation varied from 8 minutes shorter to 23 minutes longer (median 2.55 minutes longer) with 2 studies indicating statistically-significantly longer, 1 study shorter, and 6 studies reporting no difference in consultation length. Groups of patients receiving decision aids do not appear to differ from comparison groups in terms of anxiety (n = 30), general health outcomes (n = 11), and condition-specific health outcomes (n = 11). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive.

AUTHORS' CONCLUSIONS

There is high-quality evidence that decision aids compared to usual care improve people's knowledge regarding options, and reduce their decisional conflict related to feeling uninformed and unclear about their personal values. There is moderate-quality evidence that decision aids compared to usual care stimulate people to take a more active role in decision making, and improve accurate risk perceptions when probabilities are included in decision aids, compared to not being included. There is low-quality evidence that decision aids improve congruence between the chosen option and the patient's values.New for this updated review is further evidence indicating more informed, values-based choices, and improved patient-practitioner communication. There is a variable effect of decision aids on length of consultation. Consistent with findings from the previous review, decision aids have a variable effect on choices. They reduce the number of people choosing discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, cost-effectiveness, use with lower literacy populations, and level of detail needed in decision aids need further evaluation. Little is known about the degree of detail that decision aids need in order to have a positive effect on attributes of the choice made, or the decision-making process.

Providing information about options in patient decision aids

BACKGROUND

Legal, ethical, and psychological arguments indicate that patients need to receive information about their health situations before their care decisions are made. Patient decision aids (PtDAs) are designed to help patients make decisions; therefore, they should provide information that results in patients understanding their health situation. We reviewed studies that assessed the impact of PtDAs on patient knowledge and on their feeling of being uninformed.

METHODS

Our data sources were a published Cochrane Collaboration review that included randomized controlled trials (RCTs) published before 2010 and a systematic review we conducted of RCTs published in 2010. We included trials that compared 1) PtDAs to usual care, and 2) PtDAs with simple information to PtDAs with more detailed information. Outcomes included patients' knowledge and their feeling of being uninformed. Data were analyzed quantitatively and qualitatively. Meta-analyses of similar studies estimated the size of differences.

RESULTS

Thirty-nine RCTs compared a PtDA to usual care and all showed higher knowledge scores for patients in the PtDA groups; a meta-analysis estimated the advantage at 14 (of 100) points. Sixteen (of 39) studies used the Feeling Uninformed subscale; a meta-analysis estimated a reduction of 7 (of 100) points in the PtDA group over usual care. Twenty-one studies compared simple- to more-detailed information in PtDAs. There was a small overall advantage for more detailed information on knowledge scores; a meta-analysis estimated the advantage at 5 (of 100) points. Only one study found higher mean knowledge scores for simpler information. Nine (of 21) studies reported using the Feeling Uninformed subscale and a meta-analysis suggested a reduction of 3 (of 100) points for the more-detailed PtDAs over those with simpler information. Only one study found that simpler information resulted in patients feeling more informed.

CONCLUSIONS

It appears that PtDAs result in patients having higher knowledge scores and in reduced feelings of being uninformed over patients who receive usual care. It also appears that PtDAs with more detailed information generally result in slightly higher knowledge and lower "Feeling Uninformed" scores than those with simpler information, but the differences are small and can be reversed under some circumstances.

Validation of SURE, a four-item clinical checklist for detecting decisional conflict in patients

BACKGROUND

We sought to determine the psychometric properties of SURE, a 4-item checklist designed to screen for clinically significant decisional conflict in clinical practice.

METHODS

This study was a secondary analysis of a clustered randomized trial assessing the effect of DECISION+2, a 2-hour online tutorial followed by a 2-hour interactive workshop on shared decision making, on decisions to use antibiotics for acute respiratory infections. Patients completed SURE and also the Decisional Conflict Scale (DCS), as the gold standard, after consultation. We evaluated internal consistency of SURE using the Kuder-Richardson 20 coefficient (KR-20). We compared DCS and SURE scores using the Spearman correlation coefficient. We assessed sensitivity and specificity of SURE scores (cut-off score ≤3 out of 4) by identifying patients with and without clinically significant decisional conflict (DCS score >37.5 on a scale of 0-100).

RESULTS

Of the 712 patients recruited during the trial, 654 completed both tools. SURE scores showed adequate internal consistency (KR-20 coefficient of 0.7). There was a significant correlation between DCS and SURE scores (Spearman's ρ = -0.45, P < 0.0001). The prevalence of clinically significant decisional conflict as estimated by the DCS was 5.2% (95% CI 3.7-7.3). Sensitivity and specificity of SURE ≤3 were 94.1% (95% CI 78.9-99.0) and 89.8% (95% CI 87.1-92.0), respectively.

CONCLUSIONS

SURE shows adequate psychometric properties in a primary care population with a low prevalence of clinically significant decisional conflict. SURE has the potential to be a useful screening tool for practitioners, responding to the growing need for detecting clinically significant decisional conflict in patients.

Cryoconservation de spermatozoïdes avant vasectomie: utilité et paradoxes à travers l’activité des CECOS

Le recours à la vasectomie demeure largement moins utilisé en France que dans d’autres pays comme le montrent les données présentées dans cet article. Par ailleurs, environ 12 % des hommes qui ont recours à ce moyen de stérilisation volontaire vont dans le même temps procéder à une congélation de spermatozoïdes. Proposer de préserver la fertilité d’hommes qui n’envisagent pas ou plus de projet de paternité peut apparaître paradoxal. Nous reprenons dans cet article les éléments de réglementation, réflexion et évolution au cours du temps de la pratique de la vasectomie combinée à la congélation de spermatozoïdes. Les données montrent qu’environ 5 % des hommes qui ont préservé leur fertilité avant la chirurgie demanderont ultérieurement une utilisation de ces spermatozoïdes, le plus souvent lors d’une nouvelle union. L’analyse de l’évolution des pratiques montre également qu’actuellement, le recours aux inséminations artificielles a été largement supplanté par l’utilisation des techniques de fécondation in vitro avec des chances de grossesse nettement supérieures. Enfin, au regard de l’évolution de la réglementation et de l’évolution des pratiques, nous posons la question de l’utilité de continuer à proposer une préservation de fertilité préalablement à la vasectomie et présentons des pistes de réflexion sur ce point.

Federally funded sterilization: time to rethink policy?

In the 1970s, concern about coercive sterilization of low-income and minority women in the United States led the US Department of Health, Education, and Welfare to create strict regulations for federally funded sterilization procedures. Although these policies were instituted to secure informed consent and protect women from involuntary sterilization, there are significant data indicating that these policies may not, in fact, ensure that consent is truly informed and, further, may prevent many low-income women from getting a desired sterilization procedure. Given the alarmingly high rates of unintended pregnancy in the United States, especially among low-income populations, we feel that restrictive federal sterilization policies should be reexamined and modified to simultaneously ensure informed decision-making and honor women's reproductive choices.

Consequências da vasectomia: experiência de homens que se submeteram à cirurgia em Campinas (São Paulo), Brasil

OBJETIVO: Descrever a experiência de homens vasectomizados há pelo menos um ano em serviços públicos de saúde de Campinas, Estado de São Paulo. Procedimentos metodológicos: estudo descritivo com um componente qualitativo e outro quantitativo. Para a etapa qualitativa, realizaram-se 10 entrevistas semiestruturadas com homens selecionados de acordo com critérios propositais de escolaridade e número de filhos. Em seguida, foi aplicado um formulário estruturado a 202 homens, sorteados a partir da lista completa daqueles que haviam sido vasectomizados entre 1998 e 2004. Realizou-se análise temática do conteúdo das entrevistas semiestruturadas. Os dados quantitativos foram digitados e foi realizada análise descritiva. RESULTADOS: Observou-se que 97% dos homens estavam satisfeitos por terem feito a cirurgia e poucos referiram efeitos indesejados. Entre os poucos homens insatisfeitos, apenas um havia feito a reversão da cirurgia porque vivia com uma nova companheira e queria ter filhos; entre os demais a insatisfação devia-se à dor provocada pelo procedimento cirúrgico. A maioria dos entrevistados atribuiu à vasectomia mudanças para melhor sobre sua saúde, corpo, relacionamento em geral com a família e com a esposa, na vida sexual e na situação econômica. Prevaleceu a ideia de que a vasectomia só trouxera benefícios. A possibilidade de arrependimento foi mencionada pelos entrevistados como algo que não aconteceria com eles. CONCLUSÃO: Os resultados deste estudo permitiram verificar que os homens que optam pela vasectomia tendem a ver o método como fator de mudanças positivas, principalmente sobre a vida sexual e o relacionamento com a companheira e a família em geral.