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Stacey D, Lewis KB, Smith M, Carley M, Volk R, Douglas EE, Pacheco-Brousseau L, Finderup J, Gunderson J, Barry MJ, Bennett CL, Bravo P, Steffensen K, Gogovor A, Graham ID, Kelly SE, Légaré F, Sondergaard H, Thomson R, Trenaman L, Trevena L. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2024; 1:CD001431. [PMID: 38284415 PMCID: PMC10823577 DOI: 10.1002/14651858.cd001431.pub6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
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.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, Canada
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | | | - Meg Carley
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robert Volk
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elisa E Douglas
- Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Michael J Barry
- Informed Medical Decisions Program, Massachusetts General Hospital, Boston, MA, USA
| | - Carol L Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Paulina Bravo
- Education and Cancer Prevention, Fundación Arturo López Pérez, Santiago, Chile
| | - Karina Steffensen
- Center for Shared Decision Making, IRS - Lillebælt Hospital, Vejle, Denmark
| | - Amédé Gogovor
- VITAM - Centre de recherche en santé durable, Université Laval, Quebec, Canada
| | - Ian D Graham
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, Canada
| | - Shannon E Kelly
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - France Légaré
- Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Université Laval, Quebec, Canada
| | | | - Richard Thomson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Logan Trenaman
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
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Lemos M, Restrepo J, Espina C, Feliu A, Ferreccio C, Garcés-Palacio IC, Jurberg C, de Albuquerque Melo F, Cornejo-Ovalle M, Arrossi S, Murillo R, Acosta Pérez E, Venegas G, Finck C. Latin America and the Caribbean Code Against Cancer 1st edition: Formative research on the comprehension and persuasiveness of the recommendations by the general population. Cancer Epidemiol 2023; 86 Suppl 1:102456. [PMID: 37852727 DOI: 10.1016/j.canep.2023.102456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 09/13/2023] [Accepted: 09/20/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Cancer prevention is the most efficient and cost-effective strategy in cancer control. One prevention strategy is giving credible, clear, and evidence-based recommendations to the individual; however, it is key that these messages are accepted and understood properly by the public. This study aimed to pilot the draft recommendations developed as part of the Latin America and the Caribbean (LAC) Code Against Cancer 1st edition, in terms of comprehension and persuasion of each message. METHODS A mixed method two-wave study, in which two versions of the messages were presented to the general population in five LAC countries. We used an ad-hoc questionnaire and interviews that followed the cognitive-pretesting methodology. RESULTS Findings suggest that the messages were generally well understood, especially in Spanish speaking countries, and that the messages were generally more understandable than persuasive. We adapted and revised the recommendations based on the findings of the first Wave and held a second iteration in the Spanish speaking countries. We observed a better understanding of most messages in Wave 2. CONCLUSION The LAC Code Against Cancer is a valuable tool of well understood messages for the public, with concrete actions everyone can take to prevent cancer. Further research should assess particularities of the region for further efficient dissemination of these important health messages, identify key messages for certain population groups and future interventions that strengthen health literacy in rural and less educated populations to increase behavior change.
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Affiliation(s)
- Mariantonia Lemos
- Escuela de Artes y Humanidades, Universidad EAFIT, Medellín, Colombia
| | - Julia Restrepo
- Escuela de Artes y Humanidades, Universidad EAFIT, Medellín, Colombia
| | - Carolina Espina
- International Agency for Research on Cancer (IARC/WHO), Environment and Lifestyle Epidemiology Branch, 25 avenue Tony Garnier CS 90627, 69366 CEDEX 07 Lyon, France
| | - Ariadna Feliu
- International Agency for Research on Cancer (IARC/WHO), Environment and Lifestyle Epidemiology Branch, 25 avenue Tony Garnier CS 90627, 69366 CEDEX 07 Lyon, France
| | - Catterina Ferreccio
- Facultad de Medicina, Departamento de Salud Pública, Pontificia Universidad Católica de Chile, Santiago, Chile. Advanced Center for Chronic Diseases (ACCDiS), Santiago, Chile
| | | | - Claudia Jurberg
- Oswaldo Cruz Institute, Oswaldo Cruz Foundation and Carlos Chagas Filho Foundation for Research Support of Rio de Janeiro State (FAPERJ), Rio de Janeiro, Brazil
| | | | | | - Silvina Arrossi
- Centre for the Study of State and Society, National Council for Scientific and Technical Research, Buenos Aires, Argentina
| | - Raúl Murillo
- Centro Javeriano de Oncología - Hospital Universitario San Ignacio - Facultad de Medicina - Pontificia Universidad Javeriana, Bogotá, Colombia
| | | | - Gino Venegas
- Clínica Angloamericana Lima-Peru - Facultad de medicina, Universidad de Piura, Lima, Peru
| | - Carolyn Finck
- Departamento de Psicología Universidad de los Andes, Bogotá, Colombia.
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Hsu SH, Tang KP, Lin CH, Chen PC, Wang LH. Applying the theory of planned behavior to investigate type 2 diabetes patients' intention to receive injection therapy. Front Public Health 2023; 11:1066633. [PMID: 36875423 PMCID: PMC9978190 DOI: 10.3389/fpubh.2023.1066633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 02/01/2023] [Indexed: 02/18/2023] Open
Abstract
Objectives This study applied the theory of planned behavior (TPB) in shared decision making (SDM) to understand behavioral intention in patients with type 2 diabetes with regard to injection therapy for blood sugar control. Methods A cross sectional study was conducted. Two hundred and fifty-four patients with type 2 diabetes participated this study and were interviewed by pharmacists in different clinics. A patient decision aid (PDA) entitled "Should I receive injection therapy regarding my type 2 diabetes condition?" was developed for this study and served as interview agenda which comprised 18 items to inquire their willingness to use injection therapy and related considerations during the SDM process. Results The questionnaires were revised using item analysis, exploratory factor analysis, and a criteria of Cronbach's α > 0.7. This resulted in three constructs for all questionnaires that fit the TPB model. Attitude (β = 0.432; P < 0.001) and PBC (β = 0.258; P < 0.001) were directly correlated with intention. TPB explained 35.2% of the variance in intention toward the use of injection therapy. Conclusions Attitude and PBC toward injection therapy positively and significantly influence the patients' intention to use injection therapy. Practical implications These findings identify a key association for understanding behavioral intention in patients with type 2 diabetes with regard to blood sugar control during SDM.
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Affiliation(s)
- Su-Han Hsu
- Department of Pharmacy, Taipei City Hospital Yangming Branch, Taipei, Taiwan.,School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan.,Department of Pharmacy and Master Program, Tajen University, Pingtung City, Taiwan
| | - Kung-Pei Tang
- Department of Education and Humanities in Medicine, School of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Early Childhood and Family Education, College of Education, National Taipei University of Education, Taipei, Taiwan
| | - Chia-Hui Lin
- Department of Pharmacy, Taipei City Hospital Yangming Branch, Taipei, Taiwan.,Department of Pharmacy and Master Program, Tajen University, Pingtung City, Taiwan
| | - Pei-Chun Chen
- Department of Pharmacy, Taipei City Hospital Yangming Branch, Taipei, Taiwan
| | - Li-Hsuan Wang
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan.,Department of Pharmacy, Taipei Medical University Hospital, Taipei, Taiwan
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Hahlweg P, Bieber C, Levke Brütt A, Dierks ML, Dirmaier J, Donner-Banzhoff N, Eich W, Geiger F, Klemperer D, Koch K, Körner M, Müller H, Scholl I, Härter M. Moving towards patient-centered care and shared decision-making in Germany. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2022; 171:49-57. [PMID: 35595668 DOI: 10.1016/j.zefq.2022.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 06/15/2023]
Abstract
The main focus of this paper is to describe the development and current state of policy, research and implementation of patient-centered care (PCC) and shared decision-making (SDM) in Germany. What is the current state in health policy? Since 2013, the Law on Patients' Rights has standardized all rights and responsibilities regarding medical care for patients in Germany. This comprises the right to informed decisions, comprehensive and comprehensible information, and decisions based on a clinician-patient partnership. In addition, reports and action plans such as the German Ethics Council's report on patient well-being, the National Health Literacy Action Plan, or the National Cancer Plan emphasize and foster PCC and SDM on a policy level. There are a number of public organizations in Germany that support PCC and SDM. How are patients and the public involved in health policy and research? Publishers and funding agencies increasingly demand patient and public involvement. Numerous initiatives and organizations are involved in publicizing ways to engage patients and the public. Also, an increasing number of public and research institutions have established patient advisory boards. How is PCC and SDM taught? Great progress has been made in introducing SDM into the curricula of medical schools and other health care providers' (HCPs) schools (e.g., nursing, physical therapy). What is the German research agenda? The German government and other public institutions have constantly funded research programs in which PCC and SDM are important topics. This yielded several large-scale funding initiatives and helped to develop SDM training programs for HCPs in different fields of health care and information materials. Recently, two implementation studies on SDM have been conducted. What is the current uptake of PCC and SDM in routine care, and what implementation efforts are underway? Compared to the last country report from 2017, PCC and SDM efforts in policy, research and education have been intensified. However, many steps are still needed to reliably implement SDM in routine care in Germany. Specifically, the further development and uptake of decision tools and countrywide SDM trainings for HCPs require further efforts. Nevertheless, an increasing number of decision support tools - primarily with support from health insurance funds and other public agencies - are to be implemented in routine care. Also, recent implementation efforts are promising. For example, reimbursement by health insurance companies of hospital-wide SDM implementation is being piloted. A necessary next step is to nationally coordinate the gathering and provision of the many PCC and SDM resources available.
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Affiliation(s)
- Pola Hahlweg
- University Medical Center Hamburg-Eppendorf, Department of Medical Psychology, Hamburg, Germany; University Medical Center Hamburg-Eppendorf, Center for Healthcare Research, Hamburg, Germany
| | - Christiane Bieber
- Heidelberg University Hospital, Department of General Internal Medicine and Psychosomatics, Heidelberg, Germany
| | - Anna Levke Brütt
- Carl von Ossietzky University of Oldenburg, Department of Health Services Research, Oldenburg, Germany
| | - Marie-Luise Dierks
- Hannover Medical School, Institute for Epidemiology, Social Medicine and Health Systems Research, Hanover, Germany
| | - Jörg Dirmaier
- University Medical Center Hamburg-Eppendorf, Department of Medical Psychology, Hamburg, Germany; University Medical Center Hamburg-Eppendorf, Center for Healthcare Research, Hamburg, Germany
| | | | - Wolfgang Eich
- Heidelberg University Hospital, Department of General Internal Medicine and Psychosomatics, Heidelberg, Germany
| | - Friedemann Geiger
- University Hospital Schleswig-Holstein, National Competency Center for Shared Decision Making, Kiel, Germany
| | - David Klemperer
- Ostbayerische Technische Hochschule Regensburg, Faculty of Social and Health Sciences, Regensburg, Germany
| | - Klaus Koch
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany
| | - Mirjam Körner
- University of Freiburg, Department of Medical Psychology and Medical Sociology, Freiburg, Germany
| | - Hardy Müller
- Health Insurance Fund Techniker Krankenkasse (TK), Health Care Management, Hamburg, Germany
| | - Isabelle Scholl
- University Medical Center Hamburg-Eppendorf, Department of Medical Psychology, Hamburg, Germany; University Medical Center Hamburg-Eppendorf, Center for Healthcare Research, Hamburg, Germany
| | - Martin Härter
- University Medical Center Hamburg-Eppendorf, Department of Medical Psychology, Hamburg, Germany; University Medical Center Hamburg-Eppendorf, Center for Healthcare Research, Hamburg, Germany; Agency for Quality in Medicine (ÄZQ), Berlin, Germany.
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Hsieh PJ. Determinants of Knowledge-Sharing Intentions for Shared Decision-Making Platforms. JOURNAL OF COMPUTER INFORMATION SYSTEMS 2021. [DOI: 10.1080/08874417.2021.1980747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Pi-Jung Hsieh
- Chia Nan University of Pharmacy & Science, Tainan, Taiwan (R.O.C.)
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Lindson N, Pritchard G, Hong B, Fanshawe TR, Pipe A, Papadakis S. Strategies to improve smoking cessation rates in primary care. Cochrane Database Syst Rev 2021; 9:CD011556. [PMID: 34693994 PMCID: PMC8543670 DOI: 10.1002/14651858.cd011556.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Primary care is an important setting in which to treat tobacco addiction. However, the rates at which providers address smoking cessation and the success of that support vary. Strategies can be implemented to improve and increase the delivery of smoking cessation support (e.g. through provider training), and to increase the amount and breadth of support given to people who smoke (e.g. through additional counseling or tailored printed materials). OBJECTIVES To assess the effectiveness of strategies intended to increase the success of smoking cessation interventions in primary care settings. To assess whether any effect that these interventions have on smoking cessation may be due to increased implementation by healthcare providers. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries to 10 September 2020. SELECTION CRITERIA We included randomized controlled trials (RCTs) and cluster-RCTs (cRCTs) carried out in primary care, including non-pregnant adults. Studies investigated a strategy or strategies to improve the implementation or success of smoking cessation treatment in primary care. These strategies could include interventions designed to increase or enhance the quality of existing support, or smoking cessation interventions offered in addition to standard care (adjunctive interventions). Intervention strategies had to be tested in addition to and in comparison with standard care, or in addition to other active intervention strategies if the effect of an individual strategy could be isolated. Standard care typically incorporates physician-delivered brief behavioral support, and an offer of smoking cessation medication, but differs across studies. Studies had to measure smoking abstinence at six months' follow-up or longer. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods. Our primary outcome - smoking abstinence - was measured using the most rigorous intention-to-treat definition available. We also extracted outcome data for quit attempts, and the following markers of healthcare provider performance: asking about smoking status; advising on cessation; assessment of participant readiness to quit; assisting with cessation; arranging follow-up for smoking participants. Where more than one study investigated the same strategy or set of strategies, and measured the same outcome, we conducted meta-analyses using Mantel-Haenszel random-effects methods to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs). MAIN RESULTS We included 81 RCTs and cRCTs, involving 112,159 participants. Fourteen were rated at low risk of bias, 44 at high risk, and the remainder at unclear risk. We identified moderate-certainty evidence, limited by inconsistency, that the provision of adjunctive counseling by a health professional other than the physician (RR 1.31, 95% CI 1.10 to 1.55; I2 = 44%; 22 studies, 18,150 participants), and provision of cost-free medications (RR 1.36, 95% CI 1.05 to 1.76; I2 = 63%; 10 studies,7560 participants) increased smoking quit rates in primary care. There was also moderate-certainty evidence, limited by risk of bias, that the addition of tailored print materials to standard smoking cessation treatment increased the number of people who had successfully stopped smoking at six months' follow-up or more (RR 1.29, 95% CI 1.04 to 1.59; I2 = 37%; 6 studies, 15,978 participants). There was no clear evidence that providing participants who smoked with biomedical risk feedback increased their likelihood of quitting (RR 1.07, 95% CI 0.81 to 1.41; I2 = 40%; 7 studies, 3491 participants), or that provider smoking cessation training (RR 1.10, 95% CI 0.85 to 1.41; I2 = 66%; 7 studies, 13,685 participants) or provider incentives (RR 1.14, 95% CI 0.97 to 1.34; I2 = 0%; 2 studies, 2454 participants) increased smoking abstinence rates. However, in assessing the former two strategies we judged the evidence to be of low certainty and in assessing the latter strategies it was of very low certainty. We downgraded the evidence due to imprecision, inconsistency and risk of bias across these comparisons. There was some indication that provider training increased the delivery of smoking cessation support, along with the provision of adjunctive counseling and cost-free medications. However, our secondary outcomes were not measured consistently, and in many cases analyses were subject to substantial statistical heterogeneity, imprecision, or both, making it difficult to draw conclusions. Thirty-four studies investigated multicomponent interventions to improve smoking cessation rates. There was substantial variation in the combinations of strategies tested, and the resulting individual study effect estimates, precluding meta-analyses in most cases. Meta-analyses provided some evidence that adjunctive counseling combined with either cost-free medications or provider training enhanced quit rates when compared with standard care alone. However, analyses were limited by small numbers of events, high statistical heterogeneity, and studies at high risk of bias. Analyses looking at the effects of combining provider training with flow sheets to aid physician decision-making, and with outreach facilitation, found no clear evidence that these combinations increased quit rates; however, analyses were limited by imprecision, and there was some indication that these approaches did improve some forms of provider implementation. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that providing adjunctive counseling by an allied health professional, cost-free smoking cessation medications, and tailored printed materials as part of smoking cessation support in primary care can increase the number of people who achieve smoking cessation. There is no clear evidence that providing participants with biomedical risk feedback, or primary care providers with training or incentives to provide smoking cessation support enhance quit rates. However, we rated this evidence as of low or very low certainty, and so conclusions are likely to change as further evidence becomes available. Most of the studies in this review evaluated smoking cessation interventions that had already been extensively tested in the general population. Further studies should assess strategies designed to optimize the delivery of those interventions already known to be effective within the primary care setting. Such studies should be cluster-randomized to account for the implications of implementation in this particular setting. Due to substantial variation between studies in this review, identifying optimal characteristics of multicomponent interventions to improve the delivery of smoking cessation treatment was challenging. Future research could use component network meta-analysis to investigate this further.
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Affiliation(s)
- Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Gillian Pritchard
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
- Canadian Public Health Association, Ottawa, Canada
| | - Bosun Hong
- Oral Surgery Department, Birmingham Dental Hospital, Birmingham, UK
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Andrew Pipe
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
| | - Sophia Papadakis
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
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Gültzow T, Zijlstra DN, Bolman C, de Vries H, Dirksen CD, Muris JWM, Smit ES, Hoving C. Decision aids to facilitate decision making around behavior change in the field of health promotion: A scoping review. PATIENT EDUCATION AND COUNSELING 2021; 104:1266-1285. [PMID: 33531158 DOI: 10.1016/j.pec.2021.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To broadly synthesize literature regarding decision aids (DAs) supporting decision making about diet, physical activity, sleeping and substance use a scoping review was performed. METHODS Multiple sources were used: (1) Scientific literature searches, (2) excluded references from a Cochrane review regarding DAs for treatments and screenings, and (3) results from additional searches. Interventions had to (1) support informed decision making and (2) provide information and help to choose between at least two options. Two researchers screened titles and abstracts. Relevant information was extracted descriptively. RESULTS Thirty-five scientific articles and four DAs (grey literature) were included. Results were heterogeneous. Twenty-nine (94%) studies described substance use DAs. All DAs offered information and value and/or preference clarification. Many other elements were included (e.g., goal-setting). DA's effects were mixed. Few studies used standardized measures, e.g., decisional conflict (n = 4, 13%). Some positive behavioral effects were reported: e.g., smoking abstinence (n = 1). CONCLUSIONS This research shows only some positive behavioral effects of DAs. However, studies reported heterogeneous results/outcomes, impeding knowledge synthesis. Areas of improvement were identified, e.g., establishing which intervention elements are effective regarding health behavior decision making. PRACTICE IMPLICATIONS DAs can potentially be beneficial in supporting people to change health behaviors - especially regarding smoking.
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Affiliation(s)
- Thomas Gültzow
- CAPHRI Care and Public Health Research Institute, Department of Health Promotion, Maastricht University, Maastricht, the Netherlands.
| | - Daniëlle N Zijlstra
- CAPHRI Care and Public Health Research Institute, Department of Health Promotion, Maastricht University, Maastricht, the Netherlands
| | - Catherine Bolman
- Faculty of Psychology, Open University of the Netherlands, the Netherlands
| | - Hein de Vries
- CAPHRI Care and Public Health Research Institute, Department of Health Promotion, Maastricht University, Maastricht, the Netherlands
| | - Carmen D Dirksen
- CAPHRI Care and Public Health Research Institute, Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Jean W M Muris
- CAPHRI Care and Public Health Research Institute, Department of General Practice, Maastricht University, Maastricht, the Netherlands
| | - Eline S Smit
- University of Amsterdam, Amsterdam School of Communication Research/ASCoR, Department of Communication Science, Amsterdam, the Netherlands
| | - Ciska Hoving
- CAPHRI Care and Public Health Research Institute, Department of Health Promotion, Maastricht University, Maastricht, the Netherlands
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Sato M, Oshitani H, Tamaki R, Oyamada N, Sato K, Nadra AR, Landicho J, Alday PP, Lupisan SP, Tallo VL. Factors affecting mothers' intentions to visit healthcare facilities before hospitalisation of children with pneumonia in Biliran province, Philippines: a qualitative study. BMJ Open 2020; 10:e036261. [PMID: 32847907 PMCID: PMC7451295 DOI: 10.1136/bmjopen-2019-036261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite a substantial reduction in the mortality rate of children under 5 years in the past 25 years, pneumonia remains the single-largest infectious cause of child deaths worldwide. This study explored the chronological order of visited healthcare facilities and practitioners, and the factors affecting mothers' intention to seek care before the hospitalisation of children with pneumonia. METHODS AND ANALYSIS A qualitative research design was employed using theory of planned behaviour as a framework for the analysis. Using purposive sampling technique, 11 mothers, whose children under 5 years old were hospitalised with severe pneumonia, were recruited for individual semi-structured interviews. Their socio-demographic information was analysed using descriptive statistics. RESULTS Mothers brought their sick children to multiple facilities, and 1 to 19 days had passed before hospitalisation. We identified four major factors determining mothers' intentions: (1) doing something useful for the sick child, (2) expecting the child to receive the necessary assessment and treatment, (3) accepting advice to visit a healthcare facility and be referred to a hospital and (4) considering issues and benefits associated with hospitalisation. Mothers noticed their children's unusual symptoms and monitored them while applying home remedies. They also took their children to traditional healers despite knowing that the treatments were not necessarily effective. Mothers expected children to be checked by health professionals and listened to advice from family members regarding the facilities to visit, and from healthcare staff to be referred to a hospital. Financial issues and the double burden of housework and caring for the hospitalised child were mothers' major concerns about hospitalisation. CONCLUSION Children were hospitalised after several days because they visited multiple healthcare facilities, including traditional healers. Improving care quality at healthcare facilities and reducing financial and mothers' burden may reduce the hospitalisation delay for children with pneumonia.
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Affiliation(s)
- Mari Sato
- Department of Virology, Tohoku University, Sendai, Miyagi, Japan
| | - Hitoshi Oshitani
- Department of Virology, Tohoku University, Sendai, Miyagi, Japan
| | - Raita Tamaki
- Japan International Cooperation Agency, Nairobi, Kenya
| | - Nobuko Oyamada
- Department of Maternal Nursing, Tohoku University, Sendai, Miyagi, Japan
| | - Kineko Sato
- Department of Maternal Nursing, Tohoku University, Sendai, Miyagi, Japan
| | | | - Jhoys Landicho
- Epidemiology and Biostatics, Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - Portia P Alday
- Epidemiology and Biostatics, Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - Socorro P Lupisan
- Epidemiology and Biostatics, Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - Veronica L Tallo
- Epidemiology and Biostatics, Research Institute for Tropical Medicine, Muntinlupa City, Philippines
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Wieringa TH, Rodriguez-Gutierrez R, Spencer-Bonilla G, de Wit M, Ponce OJ, Sanchez-Herrera MF, Espinoza NR, Zisman-Ilani Y, Kunneman M, Schoonmade LJ, Montori VM, Snoek FJ. Decision aids that facilitate elements of shared decision making in chronic illnesses: a systematic review. Syst Rev 2019; 8:121. [PMID: 31109357 PMCID: PMC6528254 DOI: 10.1186/s13643-019-1034-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 04/29/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Shared decision making (SDM) is a patient-centered approach in which clinicians and patients work together to find and choose the best course of action for each patient's particular situation. Six SDM key elements can be identified: situation diagnosis, choice awareness, option clarification, discussion of harms and benefits, deliberation of patient preferences, and making the decision. The International Patient Decision Aid Standards (IPDAS) require that a decision aid (DA) support these key elements. Yet, the extent to which DAs support these six key SDM elements and how this relates to their impact remain unknown. METHODS We searched bibliographic databases (from inception until November 2017), reference lists of included studies, trial registries, and experts for randomized controlled trials of DAs in patients with cardiovascular, or chronic respiratory conditions or diabetes. Reviewers worked in duplicate and independently selected studies for inclusion, extracted trial, and DA characteristics, and evaluated the quality of each trial. RESULTS DAs most commonly clarified options (20 of 20; 100%) and discussed their harms and benefits (18 of 20; 90%; unclear in two DAs); all six elements were clearly supported in 4 DAs (20%). We found no association between the presence of these elements and SDM outcomes. CONCLUSIONS DAs for selected chronic conditions are mostly designed to transfer information about options and their harms and benefits. The extent to which their support of SDM key elements relates to their impact on SDM outcomes could not be ascertained. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number: CRD42016050320 .
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Affiliation(s)
- Thomas H Wieringa
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands.
| | - Rene Rodriguez-Gutierrez
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.,Division of Endocrinology, Department of Internal Medicine, "Dr. Jose E. González" University Hospital, Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico.,Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic, KER Unit México, "Dr. Jose E. González" University Hospital, Autonomous University of Nuevo Leon, Monterrey, Nuevo Leon, Mexico
| | - Gabriela Spencer-Bonilla
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.,Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Maartje de Wit
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Oscar J Ponce
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | | | - Nataly R Espinoza
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | | | - Marleen Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.,Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Frank J Snoek
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
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10
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Adarkwah CC, Jegan N, Heinzel-Gutenbrunner M, Kühne F, Siebert U, Popert U, Donner-Banzhoff N, Kürwitz S. The Optimizing-Risk-Communication (OptRisk) randomized trial - impact of decision-aid-based consultation on adherence and perception of cardiovascular risk. Patient Prefer Adherence 2019; 13:441-452. [PMID: 30988601 PMCID: PMC6441552 DOI: 10.2147/ppa.s197545] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Shared decision-making is a well-established approach to increasing patient participation in medical decisions. Increasingly, using lifetime-risk or time-to-event (TTE) formats has been suggested, as these might have advantages in comparison with a 10-year risk prognosis, particularly for younger patients, whose lifetime risk for some events may be considerably greater than their 10-year risk. In this study, a randomized trial, the most popular 10-year risk illustration in the decision-aid software Arriba (emoticons), is compared with a newly developed TTE illustration, which is based on a Markov model. The study compares the effect of these two methods of presenting cardiovascular risk to patients on their subsequent adherence to intervention. METHODS A total of 294 patients were interviewed 3 months after they had had a consultation with their GP on cardiovascular risk prevention. Adherence to behavioral change or medication intervention was measured as the primary outcome. The latter was expressed as a generated score. Furthermore, different secondary outcomes were measured, ie, patient perception of risk and self-rated importance of avoiding a cardiovascular event, as well as patient numeracy, which was used as a proxy for patient health literacy. RESULTS Overall, no significant difference in patient adherence was found depending on risk representation. In the emoticon group, the number of interventions had a significant impact on the adherence score (P=0.025). Perception of risk was significantly higher in patients counseled with the TTE risk display, whereas the importance of avoiding a cardiovascular event was rated equally highly in both groups and actually increased over time. CONCLUSION The TTE format is an appropriate means for counseling patients. Adherence is a very complex construct, which cannot be fully explained by our findings. The study results support our call for considering TTE illustrations as a valuable alternative to current decision-support tools covering cardiovascular prevention. Nevertheless, further research is needed to shed light on patient motivation and adherence with regard to cardiovascular risk prevention. TRIAL REGISTRATION The study was registered at the German Clinical Trials Register and at the WHO International Clinical Trials Register Platform (ICTRP, ID DRKS00004933); registered February 2, 2016 (retrospectively registered).
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Affiliation(s)
- Charles Christian Adarkwah
- Department of General Practice and Family Medicine, University of Marburg, Marburg, Germany,
- Department of Health Services Research and General Practice, Faculty of Life Sciences, University of Siegen, Siegen, Germany,
- Department of Health Services Research, Maastricht University, Maastricht, The Netherlands,
| | - Nikita Jegan
- Department of General Practice and Family Medicine, University of Marburg, Marburg, Germany,
| | | | - Felicitas Kühne
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
- Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria
- Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria
- Center for Health Decision Science, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
| | - Uwe Popert
- Department of General Practice, University of Göttingen, Göttingen, Germany
| | - Norbert Donner-Banzhoff
- Department of General Practice and Family Medicine, University of Marburg, Marburg, Germany,
| | - Sarah Kürwitz
- Department of General Practice and Family Medicine, University of Marburg, Marburg, Germany,
- Department of Public Health, University of Bielefeld, Germany
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11
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Jegan NRA, Kürwitz SA, Kramer LK, Heinzel-Gutenbrunner M, Adarkwah CC, Popert U, Donner-Banzhoff N. The effect of a new lifetime-cardiovascular-risk display on patients' motivation to participate in shared decision-making. BMC FAMILY PRACTICE 2018; 19:84. [PMID: 29885661 PMCID: PMC5994251 DOI: 10.1186/s12875-018-0766-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 05/18/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND This study investigated the effects of three different risk displays used in a cardiovascular risk calculator on patients' motivation for shared decision-making (SDM). We compared a newly developed time-to-event (TTE) display with two established absolute risk displays (i.e. emoticons and bar charts). The accessibility, that is, how understandable, helpful, and trustworthy patients found each display, was also investigated. METHODS We analysed a sample of 353 patients recruited in general practices. After giving consent, patients were introduced to one of three fictional vignettes with low, medium or high cardiovascular risk. All three risk displays were shown in a randomized order. Patients were asked to rate each display with regard to motivation for SDM and accessibility. Two-factorial repeated measures analyses of variance were conducted to compare the displays and investigate possible interactions with age. RESULTS Regarding motivation for SDM, the TTE elicited the highest motivation, followed by the emoticons and bar chart (p < .001). The displays had no differential influence on the age groups (p = .445). While the TTE was generally rated more accessible than the emoticons and bar chart (p < .001), the emoticons were only superior to the bar chart in the younger subsample. However, this was only to a small effect (interaction between display and age, p < .01, η 2 = 0.018). CONCLUSIONS Using fictional case vignettes, the novel TTE display was superior regarding motivation for SDM and accessibility when compared to established displays using emoticons and a bar chart. If future research can replicate these results in real-life consultations, the TTE display will be a valuable addition to current risk calculators and decision aids by improving patients' participation.
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Affiliation(s)
- Nikita Roman A Jegan
- Department of General Practice and Family Medicine, Philipps-University Marburg, Karl-von-Frisch-Str. 4, 35032, Marburg, Germany.
| | - Sarah Anna Kürwitz
- Department of General Practice and Family Medicine, Philipps-University Marburg, Karl-von-Frisch-Str. 4, 35032, Marburg, Germany
| | - Lena Kathrin Kramer
- Department of General Practice and Family Medicine, Philipps-University Marburg, Karl-von-Frisch-Str. 4, 35032, Marburg, Germany
| | | | - Charles Christian Adarkwah
- Department of General Practice and Family Medicine, Philipps-University Marburg, Karl-von-Frisch-Str. 4, 35032, Marburg, Germany
- Department of Health Services Research, Maastricht University, Maastricht, the Netherlands
| | - Uwe Popert
- Department of General Practice and Family Medicine, Philipps-University Marburg, Karl-von-Frisch-Str. 4, 35032, Marburg, Germany
- Department of General Practice, Georg-August-University, Göttingen, Germany
| | - Norbert Donner-Banzhoff
- Department of General Practice and Family Medicine, Philipps-University Marburg, Karl-von-Frisch-Str. 4, 35032, Marburg, Germany
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12
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Muth C, Uhlmann L, Haefeli WE, Rochon J, van den Akker M, Perera R, Güthlin C, Beyer M, Oswald F, Valderas JM, Knottnerus JA, Gerlach FM, Harder S. Effectiveness of a complex intervention on Prioritising Multimedication in Multimorbidity (PRIMUM) in primary care: results of a pragmatic cluster randomised controlled trial. BMJ Open 2018; 8:e017740. [PMID: 29478012 PMCID: PMC5855483 DOI: 10.1136/bmjopen-2017-017740] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Investigate the effectiveness of a complex intervention aimed at improving the appropriateness of medication in older patients with multimorbidity in general practice. DESIGN Pragmatic, cluster randomised controlled trial with general practice as unit of randomisation. SETTING 72 general practices in Hesse, Germany. PARTICIPANTS 505 randomly sampled, cognitively intact patients (≥60 years, ≥3 chronic conditions under pharmacological treatment, ≥5 long-term drug prescriptions with systemic effects); 465 patients and 71 practices completed the study. INTERVENTIONS Intervention group (IG): The healthcare assistant conducted a checklist-based interview with patients on medication-related problems and reconciled their medications. Assisted by a computerised decision support system, the general practitioner optimised medication, discussed it with patients and adjusted it accordingly. The control group (CG) continued with usual care. OUTCOME MEASURES The primary outcome was a modified Medication Appropriateness Index (MAI, excluding item 10 on cost-effectiveness), assessed in blinded medication reviews and calculated as the difference between baseline and after 6 months; secondary outcomes after 6 and 9 months' follow-up: quality of life, functioning, medication adherence, and so on. RESULTS At baseline, a high proportion of patients had appropriate to mildly inappropriate prescriptions (MAI 0-5 points: n=350 patients). Randomisation revealed balanced groups (IG: 36 practices/252 patients; CG: 36/253). Intervention had no significant effect on primary outcome: mean MAI sum scores decreased by 0.3 points in IG and 0.8 points in CG, resulting in a non-significant adjusted mean difference of 0.7 (95% CI -0.2 to 1.6) points in favour of CG. Secondary outcomes showed non-significant changes (quality of life slightly improved in IG but continued to decline in CG) or remained stable (functioning, medication adherence). CONCLUSIONS The intervention had no significant effects. Many patients already received appropriate prescriptions and enjoyed good quality of life and functional status. We can therefore conclude that in our study, there was not enough scope for improvement. TRIAL REGISTRATION NUMBER ISRCTN99526053. NCT01171339; Results.
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Affiliation(s)
- Christiane Muth
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Lorenz Uhlmann
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Justine Rochon
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Marjan van den Akker
- Department of Family Medicine, School CAPHRI, Maastricht University, Maastricht, The Netherlands
- Department of Public Health and Primary Care, Academic Center for General Practice, KU Leuven, Leuven, Belgium
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Corina Güthlin
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Martin Beyer
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Frank Oswald
- Interdisciplinary Ageing Research (IAW), Faculty of Educational Sciences, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Jose Maria Valderas
- APEx Collaboration for Academic Primary Care, University of Exeter Medical School, Exeter, UK
| | - J André Knottnerus
- Department of Family Medicine, School CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Ferdinand M Gerlach
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Sebastian Harder
- Institute for Clinical Pharmacology, Johann Wolfgang Goethe University Hospital, Frankfurt / Main, Germany
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13
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Hersch J, McGeechan K, Barratt A, Jansen J, Irwig L, Jacklyn G, Houssami N, Dhillon H, McCaffery K. How information about overdetection changes breast cancer screening decisions: a mediation analysis within a randomised controlled trial. BMJ Open 2017; 7:e016246. [PMID: 28988168 PMCID: PMC5640026 DOI: 10.1136/bmjopen-2017-016246] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 08/14/2017] [Accepted: 08/17/2017] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES In a randomised controlled trial, we found that informing women about overdetection changed their breast screening decisions. We now present a mediation analysis exploring the psychological pathways through which study participants who received the intervention processed information about overdetection and how this influenced their decision-making. We examined a series of potential mediators in the causal chain between exposure to overdetection information and women's subsequently reported breast screening intentions. DESIGN Serial multiple mediation analysis within a randomised controlled trial. SETTING New South Wales, Australia. PARTICIPANTS 811 women aged 48-50 years with no personal history of breast cancer. INTERVENTIONS Two versions of a decision aid giving women information about breast cancer deaths averted and false positives from mammography screening, either with (intervention) or without (control) information on overdetection. MAIN OUTCOME Intentions to undergo breast cancer screening in the next 2-3 years. MEDIATORS Knowledge about overdetection, worry about breast cancer, attitudes towards breast screening and anticipated regret. RESULTS The effect of information about overdetection on women's breast screening intentions was mediated through multiple cognitive and affective processes. In particular, the information led to substantial improvements in women's understanding of overdetection, and it influenced-both directly and indirectly via its effect on knowledge-their attitudes towards having screening. Mediation analysis showed that the mechanisms involving knowledge and attitudes were particularly important in determining women's intentions about screening participation. CONCLUSIONS Even in this emotive context, new information influenced women's decision-making by changing their understanding of possible consequences of screening and their attitudes towards undergoing it. These findings emphasise the need to provide good-quality information on screening outcomes and to communicate this information effectively, so that women can make well-informed decisions. TRIAL REGISTRATION NUMBER This study was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12613001035718) on 17 September 2013.
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Affiliation(s)
- Jolyn Hersch
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
| | - Kevin McGeechan
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
| | - Alexandra Barratt
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
| | - Jesse Jansen
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
| | - Les Irwig
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia
| | - Gemma Jacklyn
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia
| | - Nehmat Houssami
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia
| | - Haryana Dhillon
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
- Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia
- Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, New South Wales, Australia
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14
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Härter M, Dirmaier J, Scholl I, Donner-Banzhoff N, Dierks ML, Eich W, Müller H, Klemperer D, Koch K, Bieber C. The long way of implementing patient-centered care and shared decision making in Germany. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2017; 123-124:46-51. [PMID: 28546055 DOI: 10.1016/j.zefq.2017.05.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The main focus of the paper is on the description of the development and current state of research and implementation of patient-centered care (PCC) and shared decision making (SDM) after fifteen years of substantial advances in health policy and health services research. What is the current state of SDM in health policy? The "Patients' Rights Act" from 2013 standardizes all rights and responsibilities within the framework of medical treatment for German citizens and legal residents. This comprises the right to informed decisions, comprehensive and comprehensible information for patients, and decisions based on a clinician-patient-partnership. What is the current state of SDM interventions and patient decision support tools? SDM training programs for healthcare professionals have been developed. Their implementation in medical schools has been successful. Several decision support tools - primarily with support from health insurance funds and other public agencies - are to be implemented in routine care, specifically for national cancer screening programs. What is the current state of research and routine implementation? The German government and other public institutions are constantly funding research programs in which patient-centered care and shared decision-making are important topics. The development and implementation of decision tools for patients and professionals as well as the implementation of CME trainings for healthcare professionals require future efforts. What does the future look like? With the support of health policy and scientific evidence, transfer of PCC and SDM to practice is regarded as meaningful. Research can help to assess barriers, facilitators, and needs, and subsequently to develop and evaluate corresponding strategies to successfully implement PCC and SDM in routine care, which remains challenging.
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Affiliation(s)
- Martin Härter
- University Medical Center Hamburg-Eppendorf, Department of Medical Psychology, Hamburg, Germany; Agency for Quality in Medicine (ÄZQ), Berlin, Germany.
| | - Jörg Dirmaier
- University Medical Center Hamburg-Eppendorf, Department of Medical Psychology, Hamburg, Germany
| | - Isabelle Scholl
- University Medical Center Hamburg-Eppendorf, Department of Medical Psychology, Hamburg, Germany; Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH, USA
| | | | - Marie-Luise Dierks
- University Medical Center Hannover, Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover, Germany
| | - Wolfgang Eich
- University Medical Center Heidelberg, Department of General Internal Medicine and Psychosomatics, Heidelberg, Germany
| | - Hardy Müller
- Scientific Institute for Benefit and Efficiency in Health Care, Techniker Krankenkasse (TK), Hamburg, Germany
| | - David Klemperer
- Ostbayerische Technische Hochschule Regensburg, Faculty of Social and Health Sciences, Regensburg, Germany
| | - Klaus Koch
- Institute for Quality and Efficiency (IQWiG) in Health Care, Cologne, Germany
| | - Christiane Bieber
- University Medical Center Heidelberg, Department of General Internal Medicine and Psychosomatics, Heidelberg, Germany
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15
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Stacey D, Légaré F, Lewis K, Barry MJ, Bennett CL, Eden KB, Holmes‐Rovner M, Llewellyn‐Thomas H, Lyddiatt A, Thomson R, Trevena L. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2017; 4:CD001431. [PMID: 28402085 PMCID: PMC6478132 DOI: 10.1002/14651858.cd001431.pub5] [Citation(s) in RCA: 1212] [Impact Index Per Article: 173.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Dawn Stacey
- University of OttawaSchool of Nursing451 Smyth RoadOttawaONCanada
- Ottawa Hospital Research InstituteCentre for Practice Changing Research501 Smyth RdOttawaONCanadaK1H 8L6
| | - France Légaré
- CHU de Québec Research Center, Université LavalPopulation Health and Optimal Health Practices Research Axis10 Rue de l'Espinay, D6‐727Québec CityQCCanadaG1L 3L5
| | - Krystina Lewis
- University of OttawaSchool of Nursing451 Smyth RoadOttawaONCanada
| | | | - Carol L Bennett
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramAdministrative Services Building, Room 2‐0131053 Carling AvenueOttawaONCanadaK1Y 4E9
| | - Karen B Eden
- Oregon Health Sciences UniversityDepartment of Medical Informatics and Clinical EpidemiologyBICC 5353181 S.W. Sam Jackson Park RoadPortlandOregonUSA97239‐3098
| | - Margaret Holmes‐Rovner
- Michigan State University College of Human MedicineCenter for Ethics and Humanities in the Life SciencesEast Fee Road956 Fee Road Rm C203East LansingMichiganUSA48824‐1316
| | - Hilary Llewellyn‐Thomas
- Dartmouth CollegeThe Dartmouth Center for Health Policy & Clinical Practice, The Geisel School of Medicine at DartmouthHanoverNew HampshireUSA03755
| | - Anne Lyddiatt
- No affiliation28 Greenwood RoadIngersollONCanadaN5C 3N1
| | - Richard Thomson
- Newcastle UniversityInstitute of Health and SocietyBaddiley‐Clark BuildingRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Lyndal Trevena
- The University of SydneyRoom 322Edward Ford Building (A27)SydneyNSWAustralia2006
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Adarkwah CC, Jegan N, Heinzel-Gutenbrunner M, Kühne F, Siebert U, Popert U, Donner-Banzhoff N, Kürwitz S. Time-to-event versus ten-year-absolute-risk in cardiovascular risk prevention - does it make a difference? Results from the Optimizing-Risk-Communication (OptRisk) randomized-controlled trial. BMC Med Inform Decis Mak 2016; 16:152. [PMID: 27899103 PMCID: PMC5129612 DOI: 10.1186/s12911-016-0393-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 11/22/2016] [Indexed: 12/02/2022] Open
Abstract
Background The concept of shared-decision-making is a well-established approach to increase the participation of patients in medical decisions. Using lifetime risk or time-to-event (TTE) formats has been increasingly suggested as they might have advantages, e.g. in younger patients, to better show consequences of unhealthy behaviour. In this study, the most-popular ten-year risk illustration in the decision-aid-software arribaTM (emoticons), is compared within a randomised trial to a new-developed TTE illustration, which is based on a Markov model. Methods Thirty-two General Practitioners (GPs) took part in the study. A total of 304 patients were recruited and counseled by their GPs with arribaTM, and randomized to either the emoticons or the TTE illustration, followed by a patient questionnaire to figure out the degree of shared-decision-making (PEF-FB9, German questionnaire to measure the participation in the shared decision-making process, primary outcome), as well as the decisional conflict, perceived risk, accessibility and the degree of information, which are all secondary outcomes. Results Regarding our primary outcome PEF-FB9 the new TTE illustration is not inferior compared to the well-established emoticons taking the whole study population into account. Furthermore, the non-inferiority of the innovative TTE could be confirmed for all secondary outcome variables. The explorative analysis indicates even advantages in younger patients (below 46 years of age). Conclusion The TTE format seems to be as useful as the well-established emoticons. For certain patient populations, especially younger patients, the TTE may be even superior to demonstrate a cardiovascular risk at early stages. Our results suggest that time-to-event illustrations should be considered for current decision support tools covering cardiovascular prevention. Trial registration The study was registered at the German Clinical Trials Register and at the WHO International Clinical Trials Register Platform (ICTRP, ID DRKS00004933); registered 2 February 2016 (retrospectively registered). Electronic supplementary material The online version of this article (doi:10.1186/s12911-016-0393-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Charles Christian Adarkwah
- Department of General Practice and Family Medicine, Philipps-University, Marburg, Germany. .,CAPHRI School for Public Health and Primary Care, Department of Health Services Research, Maastricht University, Maastricht, The Netherlands.
| | - Nikita Jegan
- Department of General Practice and Family Medicine, Philipps-University, Marburg, Germany
| | | | - Felicitas Kühne
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria.,Division of Public Health Decision Modelling, Health Technology Assessment and Health Economics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria.,Center for Health Decision Science, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
| | - Uwe Popert
- Department of General Practice, Georg-August-University, Göttingen, Germany
| | | | - Sarah Kürwitz
- Department of General Practice and Family Medicine, Philipps-University, Marburg, Germany.,Department of Public Health, University of Bielefeld, Bielefeld, Germany
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Stacey D, Légaré F, Col NF, Bennett CL, Barry MJ, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Thomson R, Trevena L, Wu JHC. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014:CD001431. [PMID: 24470076 DOI: 10.1002/14651858.cd001431.pub4] [Citation(s) in RCA: 838] [Impact Index Per Article: 83.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada
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Heesen C, Köpke S, Solari A, Geiger F, Kasper J. Patient autonomy in multiple sclerosis--possible goals and assessment strategies. J Neurol Sci 2013; 331:2-9. [PMID: 23711752 DOI: 10.1016/j.jns.2013.02.018] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 02/20/2013] [Indexed: 11/24/2022]
Abstract
Patient autonomy has been increasingly acknowledged as prerequisite for successful medical decision making in Western countries. In medical decisions with a need to involve a health professional, patient autonomy becomes apparent in the extent of patients' participation in the communication as described in the concept of shared decision making. Patient autonomy can be derived from different perspectives or goals and the focus of evaluation approaches may vary accordingly. Multiple sclerosis (MS) is a paradigmatic disease to study patient autonomy mainly because MS patients are highly disease competent and due to ambiguous evidence on many aspects of disease-related medical decision making. This review gives an overview on measurement issues in studying decision making in MS, categorized according to prerequisites, process measures and outcomes of patient autonomy. As relevant prerequisites role preferences, risk attribution, risk tolerance, and risk knowledge are discussed. Regarding processes, we distinguish intra-psychic and interpersonal aspects. Intra-psychic processes are elucidated using the theory of planned behavior, which guided development of a 30-item scale to capture decisions about immunotherapy. Moreover, a theory of uncertainty management has been created resulting in the development of a corresponding measurement concept. Interpersonal processes evolving between physician and patient can be thoroughly analyzed from different perspectives by use of the newly developed comprehensive MAPPIN'SDM inventory. Concerning outcomes, besides health related outcomes, we discuss match of preferred roles during the decision encounters (preference match), decisional conflict as well as an application of the multidimensional measure of informed choice to decisions of MS patients. These approaches provide an overview on patient-inherent and interpersonal factors and processes modulating medical decision making and health behavior in MS and beyond.
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Affiliation(s)
- C Heesen
- Institute of Neuroimmunology and Clinical MS Research, University Medical Center Hamburg, Hamburg, Germany.
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Austvoll-Dahlgren A, Falk RS, Helseth S. Cognitive factors predicting intentions to search for health information: an application of the theory of planned behaviour. Health Info Libr J 2012; 29:296-308. [DOI: 10.1111/hir.12006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 08/07/2012] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Sølvi Helseth
- Oslo and Akershus University College of Applied Sciences; Oslo; Norway
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Kasper J, Köpke S, Fischer K, Schäffler N, Backhus I, Solari A, Heesen C. Applying the theory of planned behaviour to multiple sclerosis patients' decisions on disease modifying therapy--questionnaire concept and validation. BMC Med Inform Decis Mak 2012; 12:60. [PMID: 22747904 PMCID: PMC3416666 DOI: 10.1186/1472-6947-12-60] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 06/11/2012] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Patients making important medical decisions need to evaluate complex information in the light of their own beliefs, attitudes and priorities. The process can be considered in terms of the theory of planned behaviour. Decision support technologies aim at helping patients making informed treatment choices. Instruments assessing informed choices need to include risk knowledge, attitude (towards therapy) and actual uptake. However, mechanisms by which decision support achieves its goals are poorly understood.Our aim was therefore to develop and validate an instrument modeling the process of multiple sclerosis (MS) patients' decision making about whether to undergo disease modifying (immuno-)therapies (DMT). METHODS We constructed a 30-item patient administered questionnaire to access the elaboration of decisions about DMT in MS according to the theory of planned behaviour. MS-patients' belief composites regarding immunotherapy were classified according to the domains "attitude", "subjective social norm" and "control beliefs" and within each domain to either "expectations" or "values" yielding 6 sub-domains. A randomized controlled trial (n = 192) evaluating an evidence based educational intervention tested the instrument's predictive power regarding intention to use immunotherapy and its sensitivity to the intervention. RESULTS The psychometric properties of the questionnaire were satisfactory (mean item difficulty 62, mean SD 0.9, range 0-3). Responses explain up to 68% of the variability in the intention to use DMT was explained by up to 68% in the total sample. Four weeks after an educational intervention, predictive power was higher in the intervention (IG) compared to the control group (CG) (intention estimate: CG 56% / IG 69%, p = .179; three domains CG 56% / IG 74%, p = .047; six sub-domains CG 64% / IG 78%, p = .073). The IG held more critical beliefs towards immunotherapy (p = .002) and were less willing to comply with social norm (p = .012). CONCLUSIONS The questionnaire seems to provide a valid way of explaining patients' inherent decision processes and to be sensitive towards varying levels of elaboration. Similar tools based on the theory of planned behaviour could be applied to other decision making scenarios.
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Affiliation(s)
- Jürgen Kasper
- Institute of Neuroimmunology and Clinical MS-Research-inims and Department of Neurology, University Medical Center, Hamburg, Germany.
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Lenz M, Buhse S, Kasper J, Kupfer R, Richter T, Mühlhauser I. Decision aids for patients. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:401-8. [PMID: 22778792 PMCID: PMC3389744 DOI: 10.3238/arztebl.2012.0401] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 01/16/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients want to be more involved in medical decision-making. To this end, some decision aids are now available. METHODS We present an overview of this subject, in which we explain the terms "shared decision-making", "decision aid", and "evidence-based patient information" and survey information on the available decision aids in German and other languages on the basis of a literature search in MEDLINE, EMBASE and PsycInfo and a current Cochrane Review. We also searched the Internet for providers of decision aids in Germany. RESULTS Decision aids exist in the form of brochures, decision tables, videos, and computer programs; they address various topics in the prevention, diagnosis, and treatment of disease. They typically contain information on the advantages and disadvantages of the available options, as well as guidance for personal decision-making. They can be used alone or as a part of structured counseling or patient education. Minimal quality standards include an adequate evidence base, completeness, absence of bias, and intelligibility. Our search revealed 12 randomized controlled trials (RCTs) of decision aids in German and 106 RCTs of decision aids in other languages. These trials studied the outcome of the use of decision aids not just with respect to clinical developments, but also with respect to patient knowledge, adherence to treatment regimens, satisfaction, involvement in decision-making, autonomy preference, and decisional conflicts. CONCLUSION Only a small fraction of the available decision aids were systematically developed and have been subjected to systematic evaluation. Patients are still not receiving the help in decision-making to which medical ethics entitles them. Structures need to be put in place for the sustainable development, evaluation and implementation of high-quality decision aids.
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Affiliation(s)
- Matthias Lenz
- Hamburg University, School of Mathematics, Informatics and Natural Sciences, Hamburg, Germany.
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Kramer L, Rabanizada N, Haasenritter J, Bösner S, Baum E, Donner-Banzhoff N. Do guidelines on first impression make sense? Implementation of a chest pain guideline in primary care: a systematic evaluation of acceptance and feasibility. BMC FAMILY PRACTICE 2011; 12:128. [PMID: 22103603 PMCID: PMC3267789 DOI: 10.1186/1471-2296-12-128] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 11/21/2011] [Indexed: 12/05/2022]
Abstract
BACKGROUND Most guidelines concentrate on investigations, treatment, and monitoring instead of patient history and clinical examination. We developed a guideline that dealt with the different aetiologies of chest pain by emphasizing the patient's history and physical signs. The objective of this study was to evaluate the guideline's acceptance and feasibility in the context of a practice test. METHODS The evaluation study was nested in a diagnostic cross-sectional study with 56 General Practitioners (GPs) and 862 consecutively recruited patients with chest pain. The evaluation of the guideline was conducted in a mixed method design on a sub-sample of 17 GPs and 282 patients. Physicians' evaluation of the guideline was assessed via standardized questionnaires and case record forms. Additionally, practice nursing staff and selected patients were asked for their evaluation of specific guideline modules. Quantitative data was analyzed descriptively for frequencies, means, and standard deviations. In addition, two focus groups with a total of 10 GPs were held to gain further insights in the guideline implementation process. The data analysis and interpretation followed the standards of the qualitative content analysis. RESULTS The overall evaluation of the GPs participating in the evaluation study regarding the recommendations made in the chest pain guideline was positive. A total of 14 GPs were convinced that there was a need for this kind of guideline and perceived the guideline recommendations as useful. While the long version was partially criticized for a perceived lack of clarity, the short version of the chest pain guideline and the heart score were especially appreciated by the GPs. However, change of clinical behaviour as consequence of the guideline was inconsistent. While on a concrete patient related level, GPs indicated to have behaved as the guideline recommended, the feedback on a more general level was heterogeneous. Several suggestions to improve guideline implementation were made by participating physicians. Due to the small number of practice nursing staff evaluating the flowchart and patients remembering the patient leaflet, no valid results regarding the flowchart and patient leaflet modules could be reported. CONCLUSIONS Overall, the participating GPs perceived the guideline recommendations as useful to increase awareness and to reflect on diagnostic issues. Although behaviour change in consequence of the guideline was not reported on a general level, guidelines on history taking and the clinical examination may serve an important conservative and practical function in a technology driven environment. Further research to increase the implementation success of the guideline should be undertaken.
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Affiliation(s)
- Lena Kramer
- Department of General Practice, Philipps University of Marburg, Germany
| | - Nagela Rabanizada
- Department of General Practice, Philipps University of Marburg, Germany
| | - Jörg Haasenritter
- Department of General Practice, Philipps University of Marburg, Germany
| | - Stefan Bösner
- Department of General Practice, Philipps University of Marburg, Germany
| | - Erika Baum
- Department of General Practice, Philipps University of Marburg, Germany
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Stacey D, Bennett CL, Barry MJ, Col NF, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Légaré F, Thomson R. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2011:CD001431. [PMID: 21975733 DOI: 10.1002/14651858.cd001431.pub3] [Citation(s) in RCA: 550] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Decision aids prepare people to participate in decisions that involve weighing benefits, harms, and scientific uncertainty. OBJECTIVES To evaluate the effectiveness of decision aids for people facing treatment or screening decisions. SEARCH STRATEGY For this update, we searched from January 2006 to December 2009 in MEDLINE (Ovid); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, issue 4 2009); CINAHL (Ovid) (to September 2008 only); EMBASE (Ovid); PsycINFO (Ovid); and grey literature. Cumulatively, we have searched each database since its start date. SELECTION CRITERIA We included published randomised controlled trials (RCTs) of decision aids, which are interventions designed to support patients' decision making by providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies in which participants were not making an active treatment or screening decision. DATA COLLECTION AND ANALYSIS Two review authors independently screened abstracts for inclusion, extracted data, and assessed potential risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards, were:A) decision attributes;B) decision making process attributes.Secondary outcomes were behavioral, health, and health system effects. We pooled results of RCTs using mean differences (MD) and relative risks (RR), applying a random effects model. MAIN RESULTS Of 34,316 unique citations, 86 studies involving 20,209 participants met the eligibility criteria and were included. Thirty-one of these studies are new in this update. Twenty-nine trials are ongoing. There was variability in potential risk of bias across studies. The two criteria that were most problematic were lack of blinding and the potential for selective outcome reporting, given that most of the earlier trials were not registered.Of 86 included studies, 63 (73%) used at least one measure that mapped onto an IPDAS effectiveness criterion: A) criteria involving decision attributes: knowledge scores (51 studies); accurate risk perceptions (16 studies); and informed value-based choice (12 studies); and B) criteria involving decision process attributes: feeling informed (30 studies) and feeling clear about values (18 studies).A) Criteria involving decision attributes:Decision aids performed better than usual care interventions by increasing knowledge (MD 13.77 out of 100; 95% confidence interval (CI) 11.40 to 16.15; n = 26). When more detailed decision aids were compared to simpler decision aids, the relative improvement in knowledge was significant (MD 4.97 out of 100; 95% CI 3.22 to 6.72; n = 15). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.74; 95% CI 1.46 to 2.08; n = 14). The effect was stronger when probabilities were expressed in numbers (RR 1.93; 95% CI 1.58 to 2.37; n = 11) rather than words (RR 1.27; 95% CI 1.09 to 1.48; n = 3). Exposure to a decision aid with explicit values clarification compared to those without explicit values clarification resulted in a higher proportion of patients achieving decisions that were informed and consistent with their values (RR 1.25; 95% CI 1.03 to 1.52; n = 8).B) Criteria involving decision process attributes:Decision aids compared to usual care interventions resulted in: a) lower decisional conflict related to feeling uninformed (MD -6.43 of 100; 95% CI -9.16 to -3.70; n = 17); b) lower decisional conflict related to feeling unclear about personal values (MD -4.81; 95% CI -7.23 to -2.40; n = 14); c) reduced the proportions of people who were passive in decision making (RR 0.61; 95% CI 0.49 to 0.77; n = 11); and d) reduced proportions of people who remained undecided post-intervention (RR 0.57; 95% CI 0.44 to 0.74; n = 9). Decision aids appear to have a positive effect on patient-practitioner communication in the four studies that measured this outcome. For satisfaction with the decision (n = 12) and/or the decision making process (n = 12), those exposed to a decision aid were either more satisfied or there was no difference between the decision aid versus comparison interventions. There were no studies evaluating the decision process attributes relating to helping patients to recognize that a decision needs to be made or understand that values affect the choice.C) Secondary outcomesExposure to decision aids compared to usual care continued to demonstrate reduced choice of: major elective invasive surgery in favour of conservative options (RR 0.80; 95% CI 0.64 to 1.00; n = 11). Exposure to decision aids compared to usual care also resulted in reduced choice of PSA screening (RR 0.85; 95% CI 0.74 to 0.98; n = 7). When detailed compared to simple decision aids were used, there was reduced choice of menopausal hormones (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 to +23 minutes (median 2.5 minutes). Decision aids do not appear to be different from comparisons in terms of anxiety (n = 20), and general health outcomes (n = 7), and condition specific health outcomes (n = 9). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive. AUTHORS' CONCLUSIONS New for this updated review is evidence that: decision aids with explicit values clarification exercises improve informed values-based choices; decision aids appear to have a positive effect on patient-practitioner communication; and decision aids have a variable effect on length of consultation.Consistent with findings from the previous review, which had included studies up to 2006: decision aids increase people's involvement, and improve knowledge and realistic perception of outcomes; however, the size of the effect varies across studies. Decision aids have a variable effect on choices. They reduce the choice of discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, patient-practitioner communication, cost-effectiveness, and use with developing and/or lower literacy populations need further evaluation. Little is known about the degree of detail that decision aids need in order to have positive effects on attributes of the decision or decision-making process.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada
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Härter M, Müller H, Dirmaier J, Donner-Banzhoff N, Bieber C, Eich W. Patient participation and shared decision making in Germany - history, agents and current transfer to practice. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2011; 105:263-70. [PMID: 21620319 DOI: 10.1016/j.zefq.2011.04.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The main focus of the present paper is to describe 1) the healthcare system specific influences on patient participation in medical decision making and 2) the current state of research and implementation of shared decision making (SDM) after ten years of substantial advances in health policy and research in this field. WHAT ABOUT POLICY REGARDING SDM? The "Medical Patients Rights Act" is to standardise all the rights and responsibilities within the scope of medical treatment. This also comprises the right to informed decisions, comprehensive and comprehensible information for patients, and decisions based on the partnership of clinicians and patients. WHAT ABOUT TOOLS - DECISION SUPPORT FOR PATIENTS? SDM training programmes for healthcare professionals have been developed and partly implemented. Several decision support interventions - primarily with support from health insurance funds - have been developed and evaluated. WHAT ABOUT PROFESSIONAL INTEREST AND IMPLEMENTATION? Against the background of the German health policy's endorsement of patient participation, the German government and other public institutions are currently funding different research programmes in which shared decision making is playing a substantial role. The development and implementation of decision support tools for patients and professionals as well as the implementation of trainings for healthcare professionals require stronger efforts. WHAT DOES THE FUTURE LOOK LIKE? With the support of health policy and with the utilisation of scientific evidence, the transfer of shared decision making into practice is considered to be meaningful in the German healthcare system. The translation into routine care will remain an important task for the future.
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Affiliation(s)
- Martin Härter
- University Medical Center Hamburg-Eppendorf, Department of Medical Psychology.
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Légaré F, St-Jacques S, Gagnon S, Njoya M, Brisson M, Frémont P, Rousseau F. Prenatal screening for Down syndrome: a survey of willingness in women and family physicians to engage in shared decision-making. Prenat Diagn 2011; 31:319-26. [PMID: 21268046 DOI: 10.1002/pd.2624] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Revised: 07/22/2010] [Accepted: 08/15/2010] [Indexed: 11/08/2022]
Affiliation(s)
- France Légaré
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Québec City, Canada.
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Scholl I, Loon MKV, Sepucha K, Elwyn G, Légaré F, Härter M, Dirmaier J. Measurement of shared decision making – a review of instruments. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2011; 105:313-24. [DOI: 10.1016/j.zefq.2011.04.012] [Citation(s) in RCA: 212] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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