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Meulenkamp B, Brillinger J, Fergusson D, Stacey D, Graham ID. Development and field testing of a patient decision aid for management of acute Achilles tendon rupture: a study protocol. BMC Med Inform Decis Mak 2021; 21:225. [PMID: 34303358 PMCID: PMC8310595 DOI: 10.1186/s12911-021-01589-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/18/2021] [Indexed: 11/10/2022] Open
Abstract
Background Achilles tendon ruptures are common injuries in an otherwise healthy, active population. Several treatment options exist, with both surgical and non-surgical options. Each treatment option has a unique set of risks and harms, which may present patients with decisional conflict. The aim of the proposed study is to develop, alpha test and field test a patient decision aid for patients presenting with acute Achilles tendon ruptures. Methods This is a three-stage study protocol. First, we will assemble a multi-disciplinary steering group including patients, clinicians, educators, and researchers to develop the patient decision aid prototype using the Ottawa Decision Support Framework. Second, we will perform a mixed-methods alpha test of the decision aid prototype with patients and clinicians experienced in acute Achilles tendon ruptures. Outcomes measured will include acceptability and usability of the patient decision aid measured using validated outcome scales and semi-structured interviews. A minimum of three rounds of feedback will be obtained. Results will be analyzed using descriptive statistics, reviewed by the steering group, to guide revisions to decision aid prototype at each round. The third stage will be field testing the revised decision aid prototype in usual clinical care. A pre-/post-study will be performed with patients with acute Achilles tendon ruptures. Patients will be recruited from the emergency department and complete the pre-consultation decision aid prior to a one-week follow up with their surgeon. The primary outcome of field testing will be feasibility of implementing the decision aid in the clinical setting and will be measured with recruitment and completion metrics. Secondary outcomes include acceptability of the decision aid, knowledge, preparedness for decision making, and decisional conflict, measured using validated outcome measures. Statistical analysis will be performed using descriptive analysis for primary outcomes and a student t-test and Wilcoxon Rank-Sum test for secondary outcomes. Discussion This comprehensive study protocol outlines the development, alpha testing, and field testing of a patient decision aid for patients with acute Achilles tendon rupture. Systematic and transparent development and testing of patient decision aids is critical to improve decision aid quality. Trial registration Not Applicable. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-021-01589-5.
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Affiliation(s)
- Brad Meulenkamp
- Department of Medicine, University of Ottawa, Ottawa, Canada. .,Orthopaedic Trauma, Foot and Ankle Surgery, The Ottawa Hospital, Ottawa, Canada.
| | | | - Dean Fergusson
- Department of Medicine, University of Ottawa, Ottawa, Canada.,Ottawa Hospital Research Institute, Ottawa, Canada.,Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Dawn Stacey
- Centre for Practice-Changing Research, Ottawa Hospital Research Institute, Ottawa, Canada.,Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Ian D Graham
- Centre for Practice-Changing Research, Ottawa Hospital Research Institute, Ottawa, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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Durand MA, Yen RW, O'Malley AJ, Schubbe D, Politi MC, Saunders CH, Dhage S, Rosenkranz K, Margenthaler J, Tosteson ANA, Crayton E, Jackson S, Bradley A, Walling L, Marx CM, Volk RJ, Sepucha K, Ozanne E, Percac-Lima S, Bergin E, Goodwin C, Miller C, Harris C, Barth RJ, Aft R, Feldman S, Cyr AE, Angeles CV, Jiang S, Elwyn G. What matters most: Randomized controlled trial of breast cancer surgery conversation aids across socioeconomic strata. Cancer 2020; 127:422-436. [PMID: 33170506 PMCID: PMC7983934 DOI: 10.1002/cncr.33248] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/02/2020] [Accepted: 08/18/2020] [Indexed: 01/17/2023]
Abstract
Background Women of lower socioeconomic status (SES) with early‐stage breast cancer are more likely to report poorer physician‐patient communication, lower satisfaction with surgery, lower involvement in decision making, and higher decision regret compared to women of higher SES. The objective of this study was to understand how to support women across socioeconomic strata in making breast cancer surgery choices. Methods We conducted a 3‐arm (Option Grid, Picture Option Grid, and usual care), multisite, randomized controlled superiority trial with surgeon‐level randomization. The Option Grid (text only) and Picture Option Grid (pictures plus text) conversation aids were evidence‐based summaries of available breast cancer surgery options on paper. Decision quality (primary outcome), treatment choice, treatment intention, shared decision making (SDM), anxiety, quality of life, decision regret, and coordination of care were measured from T0 (pre‐consultation) to T5 (1‐year after surgery. Results Sixteen surgeons saw 571 of 622 consented patients. Patients in the Picture Option Grid arm (n = 248) had higher knowledge (immediately after the visit [T2] and 1 week after surgery or within 2 weeks of the first postoperative visit [T3]), an improved decision process (T2 and T3), lower decision regret (T3), and more SDM (observed and self‐reported) compared to usual care (n = 257). Patients in the Option Grid arm (n = 66) had higher decision process scores (T2 and T3), better coordination of care (12 weeks after surgery or within 2 weeks of the second postoperative visit [T4]), and more observed SDM (during the surgical visit [T1]) compared to usual care arm. Subgroup analyses suggested that the Picture Option Grid had more impact among women of lower SES and health literacy. Neither intervention affected concordance, treatment choice, or anxiety. Conclusions Paper‐based conversation aids improved key outcomes over usual care. The Picture Option Grid had more impact among disadvantaged patients. Lay Summary The objective of this study was to understand how to help women with lower incomes or less formal education to make breast cancer surgery choices. Compared with usual care, a conversation aid with pictures and text led to higher knowledge. It improved the decision process and shared decision making (SDM) and lowered decision regret. A text‐only conversation aid led to an improved decision process, more coordinated care, and higher SDM compared to usual care. The conversation aid with pictures was more helpful for women with lower income or less formal education. Conversation aids with pictures and text helped women make better breast cancer surgery choices.
A paper‐based pictorial conversation aid (pictures plus text) is beneficial to all patients with early‐stage breast cancer and particularly to disadvantaged patients. Between‐surgeon variation suggests that the maximal impact of such interventions requires standardized physician training combined with these interventions.
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Affiliation(s)
- Marie-Anne Durand
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire.,UMR 1027 Team EQUITY, Paul Sabatier University, Toulouse, France
| | - Renata W Yen
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire
| | - A James O'Malley
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire.,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Danielle Schubbe
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire
| | - Mary C Politi
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Catherine H Saunders
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire.,Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Shubhada Dhage
- Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, New York, New York
| | | | - Julie Margenthaler
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Anna N A Tosteson
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire.,Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Eloise Crayton
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Sherrill Jackson
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ann Bradley
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire
| | - Linda Walling
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire
| | - Christine M Marx
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Robert J Volk
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Karen Sepucha
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Elissa Ozanne
- Department of Population Health Sciences, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Sanja Percac-Lima
- Massachusetts General Hospital Chelsea HealthCare Center, Chelsea, Massachusetts
| | | | - Courtney Goodwin
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | - Camille Harris
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire
| | | | - Rebecca Aft
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | - Amy E Cyr
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | - Shuai Jiang
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Glyn Elwyn
- Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire
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3
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Politi MC, Yen RW, Elwyn G, Kurien N, Czerwinski SG, Schubbe D, Saunders CH, Durand MA. Encounter Decision Aids Can Prompt Breast Cancer Surgery Cost Discussions: Analysis of Recorded Consultations. Med Decis Making 2019; 40:62-71. [PMID: 31829111 DOI: 10.1177/0272989x19893308] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background. Patients frequently worry about care costs, but clinicians seldom address the topic. Cost information is not typically included in patient decision aids (DAs). We examined whether including cost information in an encounter DA, with clinician training, influenced cost conversations. Method. As part of a larger trial, 14 surgeons from 4 cancer centers were randomized to 1 of 3 interventions: (1) Picture Option Grid DA that included a prompt to discuss relative treatment costs, hereafter called "cost prompt group"; (2) a text-only Option Grid DA that did not include cost information; (3) usual care. Groups 2 and 3 hereafter are referred to as "non-cost prompt groups." Adult (18+) female patients, with stages I-IIIA breast cancer, eligible for both breast-conserving surgery and mastectomy were included. We gave surgeons feedback about adherence to the study protocol at 3, 6, and 12-months. We adapted a checklist to code the content of the audio-recorded clinical encounters. Results. 424/622 (68%) patients consented; 311 (73%) were eligible and successfully recorded (143 in the cost prompt group, 168 in the non-cost prompt groups). Costs were discussed in 132/311 (42.4%) encounters, and occurred more often in the cost prompt versus non-cost prompt groups (66.7% versus 33.3%; p<.001). Surgeons initiated the cost discussion in 86.4% of encounters in the cost prompt group vs. 34.1% in the non-cost prompt groups (p<0.001). In the non-cost prompt groups, insurance or employment questions led patients to ask about costs. Cost discussions lasted about 34 seconds when present and had sparse comparative details. Conclusions. Encounter DAs containing cost information trigger cost discussions. Additional support should help clinicians improve the quality of cost discussions and address financial distress.
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Affiliation(s)
- Mary C Politi
- Division of Public Health Sciences, Department of Surgery, School of Medicine, Washington University, St. Louis, MO, USA
| | - Renata W Yen
- Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, NH, USA
| | - Glyn Elwyn
- Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, NH, USA
| | - Natasha Kurien
- Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, NH, USA.,Catalyst, Center for the Advancement of Team Science, Analytics, and Systems Thinking, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Sophie G Czerwinski
- Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, NH, USA
| | - Danielle Schubbe
- Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, NH, USA
| | - Catherine H Saunders
- Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, NH, USA
| | - Marie-Anne Durand
- Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, NH, USA
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What matters most: protocol for a randomized controlled trial of breast cancer surgery encounter decision aids across socioeconomic strata. BMC Public Health 2018; 18:241. [PMID: 29439691 PMCID: PMC5812033 DOI: 10.1186/s12889-018-5109-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 01/22/2018] [Indexed: 01/25/2023] Open
Abstract
Background Breast cancer is the most commonly diagnosed malignancy in women. Mastectomy and breast-conserving surgery (BCS) have equivalent survival for early stage breast cancer. However, each surgery has different benefits and harms that women may value differently. Women of lower socioeconomic status (SES) diagnosed with early stage breast cancer are more likely to experience poorer doctor-patient communication, lower satisfaction with surgery and decision-making, and higher decision regret compared to women of higher SES. They often play a more passive role in decision-making and are less likely to undergo BCS. Our aim is to understand how best to support women of lower SES in making decisions about early stage breast cancer treatments and to reduce disparities in decision quality across socioeconomic strata. Methods We will conduct a three-arm, multi-site randomized controlled superiority trial with stratification by SES and clinician-level randomization. At four large cancer centers in the United States, 1100 patients (half higher SES and half lower SES) will be randomized to: (1) Option Grid, (2) Picture Option Grid, or (3) usual care. Interviews, field-notes, and observations will be used to explore strategies that promote the interventions’ sustained use and dissemination. Community-Based Participatory Research will be used throughout. We will include women aged at least 18 years of age with a confirmed diagnosis of early stage breast cancer (I to IIIA) from both higher and lower SES, provided they speak English, Spanish, or Mandarin Chinese. Our primary outcome measure is the 16-item validated Decision Quality Instrument. We will use a regression framework, mediation analyses, and multiple informants analysis. Heterogeneity of treatment effects analyses for SES, age, ethnicity, race, literacy, language, and study site will be performed. Discussion Currently, women of lower SES are more likely to make treatment decisions based on incomplete or uninformed preferences, potentially leading to poorer decision quality, quality of life, and decision regret. This study hopes to identify solutions that effectively improve patient-centered care across socioeconomic strata and reduce disparities in decision and care quality. Trial registration NCT03136367 at ClinicalTrials.gov Protocol version: Manuscript based on study protocol version 2.2, 7 November 2017. Electronic supplementary material The online version of this article (10.1186/s12889-018-5109-2) contains supplementary material, which is available to authorized users.
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Savelberg W, van der Weijden T, Boersma L, Smidt M, Willekens C, Moser A. Developing a patient decision aid for the treatment of women with early stage breast cancer: the struggle between simplicity and complexity. BMC Med Inform Decis Mak 2017; 17:112. [PMID: 28764688 PMCID: PMC5540178 DOI: 10.1186/s12911-017-0505-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 07/10/2017] [Indexed: 11/29/2022] Open
Abstract
Background A patient decision aid (PtDA) can support shared decision making (SDM) in preference-sensitive care, with more than one clinically applicable treatment option. The development of a PtDA is a complex process, involving several steps, such as designing, developing and testing the draft with all the stakeholders, known as alpha testing. This is followed by testing in ‘real life’ situations, known as beta testing, and then finalising the definite version. Our aim was developing and alpha testing a PtDA for primary treatment of early stage breast cancer, ensuring that the tool is considered relevant, valid and feasible by patients and professionals. Methods Our qualitative descriptive study applied various methods including face-to-face think-aloud interviews, a focus group and semi-structured telephone interviews. The study population consisted of breast cancer patients facing the choice between breast-conserving therapy with or without preceding neo-adjuvant chemotherapy and mastectomy, and professionals involved in breast cancer care in dedicated multidisciplinary breast cancer teams. Results A PtDA was developed in four iterative test rounds, taking nearly 2 years, involving 26 patients and 26 professionals. While the research group initially opted for simplicity for the sake of implementation, the clinicians objected that the complexity of the decision could not be ignored. Other topics of concern were the conflicting views of professionals and patients regarding side effects, the amount of information and how to present it. Conclusion The development was an extensive process, because the professionals rejected the simplifications proposed by the research group. This resulted in the development of a completely new draft PtDA, which took double the expected time and resources. The final version of the PtDA appeared to be well-appreciated by professionals and patients, although its acceptability will only be proven in actual practice (beta testing). Trial registration NTR TC 5721. Electronic supplementary material The online version of this article (doi:10.1186/s12911-017-0505-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- W Savelberg
- Oncology Centre, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
| | - T van der Weijden
- School for Public Health and Primary Care (CAPHRI) Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands.,Department of Family Medicine, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, The Netherlands
| | - L Boersma
- Department of Radiotherapy, Maastricht University Medical Center, (MAASTRO clinic) Dr. Tanslaan 12, 6229 ET, Maastricht, The Netherlands
| | - M Smidt
- Oncology Centre, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - C Willekens
- SBOH (Foundation for vocational training in family medicine), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - A Moser
- Zuyd University of Applied Sciences, Nieuw Eyckholt 300, 6419 DJ, Heerlen, The Netherlands
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Nota I, Drossaert CHC, Melissant HC, Taal E, Vonkeman HE, Haagsma CJ, van de Laar MAFJ. Development of a web-based patient decision aid for initiating disease modifying anti-rheumatic drugs using user-centred design methods. BMC Med Inform Decis Mak 2017; 17:51. [PMID: 28441950 PMCID: PMC5405550 DOI: 10.1186/s12911-017-0433-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 03/29/2017] [Indexed: 04/05/2023] Open
Abstract
Background A main element of patient-centred care, Patient Decision Aids (PtDAs) facilitate shared decision-making (SDM). A recent update of the International Patient Decision Aids Standards (IPDAS) emphasised patient involvement during PtDA development, but omitted a methodology for doing so. This article reports on the value of user-centred design (UCD) methods for the development of a PtDA that aims to support inflammatory arthritis patients in their choice between disease modifying anti-rheumatic drugs (DMARDs). Methods The IPDAS development process model in combination with UCD methods were applied. The process was overseen by an eight-member multidisciplinary steering group. Patients and health professionals were iteratively consulted. Qualitative in-depth interviews combined with rapid prototyping were conducted with patients to assess their needs for specific functionality, content and design of the PtDA. Group meetings with health professionals were organized to assess patients’ needs and to determine how the PtDA should be integrated into patient pathways. The current literature was reviewed to determine the clinical evidence to include in the PtDA. To evaluate usability among patients, they were observed using the PtDA while thinking aloud and then interviewed. Results The combination of patient interviews with rapid prototyping revealed that patients wanted to compare multiple DMARDs both for their clinical aspects and implications for daily life. Health professionals mainly wanted to refer patients to a reliable, easily adjustable source of information about DMARDs. A web-based PtDA was constructed consisting of four parts: 1) general information about SDM, inflammatory arthritis and DMARDs; 2) an application to compare particular DMARDs; 3) value clarification exercises; and 4) a printed summary of patients’ notes, preferences, worries and questions that they could bring to discuss with their rheumatologist. Conclusions The study demonstrated that UCD methods can be of great value for the development of PtDAs. The early, iterative involvement of patients and health professionals was helpful in developing a novel user-friendly PtDA that allowed patients to choose between DMARDs. The PtDA fits the values of all stakeholders and easily integrates with the patient pathway and daily workflow of health professionals. This collaborative designed PtDA may improve SDM and patient participation in arthritis care. Electronic supplementary material The online version of this article (doi:10.1186/s12911-017-0433-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ingrid Nota
- Department of Psychology, Health and Technology, University of Twente, PO Box 217, 7500AE, Enschede, The Netherlands.
| | - Constance H C Drossaert
- Department of Psychology, Health and Technology, University of Twente, PO Box 217, 7500AE, Enschede, The Netherlands
| | - Heleen C Melissant
- Department of Clinical Psychology, VU University Amsterdam, Van der Boechorststraat 1, 1081 BT, Amsterdam, The Netherlands
| | - Erik Taal
- Department of Psychology, Health and Technology, University of Twente, PO Box 217, 7500AE, Enschede, The Netherlands
| | - Harald E Vonkeman
- Department of Rheumatology and Clinical Immunology, Medisch Spectrum Twente, PO Box 50 000, 7500 KA, Enschede, The Netherlands
| | - Cees J Haagsma
- Department of Rheumatology, Ziekenhuisgroep Twente, PO Box 7600, 7600 SZ, Almelo, The Netherlands
| | - Mart A F J van de Laar
- Department of Rheumatology and Clinical Immunology, Medisch Spectrum Twente, PO Box 50 000, 7500 KA, Enschede, The Netherlands
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Alam S, Elwyn G, Percac-Lima S, Grande S, Durand MA. Assessing the acceptability and feasibility of encounter decision aids for early stage breast cancer targeted at underserved patients. BMC Med Inform Decis Mak 2016; 16:147. [PMID: 27871271 PMCID: PMC5117693 DOI: 10.1186/s12911-016-0384-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 11/07/2016] [Indexed: 01/08/2023] Open
Abstract
Background Women of low socioeconomic status (SES) diagnosed with early stage breast cancer are less likely to be involved in treatment decisions. They tend to report higher decisional regret and poorer communication. Evidence suggests that well-designed encounter decision aids (DAs) could improve outcomes and potentially reduce healthcare disparities. Our goal was to evaluate the acceptability and feasibility of encounter decision aids (Option Grid, Comic Option Grid, and Picture Option Grid) adapted for a low-SES and low-literacy population. Methods We used a multi-phase, mixed-methods approach. In phase 1, we conducted a focus group with rural community stakeholders. In phase 2, we developed and administered a web-based questionnaire with patients of low and high SES. In phase 3, we interviewed patients of low SES and relevant healthcare professionals. Results Data from phase 1 (n = 5) highlighted the importance of addressing treatment costs for patients. Data from phase 2 (n = 268) and phase 3 (n = 15) indicated that using both visual displays and numbers are helpful for understanding statistical information. Data from all three phases suggested that using plain language and simple images (Picture Option Grid) was most acceptable and feasible. The Comic Option Grid was deemed least acceptable. Conclusion Option Grid and Picture Option Grid appeared acceptable and feasible in facilitating patient involvement and improving perceived understanding among patients of high and low SES. Picture Option Grid was considered most acceptable, accessible and feasible in the clinic visit. However, given the small sample sizes used, those findings need to be interpreted with caution. Further research is needed to determine the impact of pictorial and text-based encounter decision aids in underserved patients and across socioeconomic strata.
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Affiliation(s)
- Shama Alam
- The Dartmouth Institute for Health Policy and Clinical Practice, Level 5, Williamson Translational Research Building, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Level 5, Williamson Translational Research Building, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Sanja Percac-Lima
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Stuart Grande
- The Dartmouth Institute for Health Policy and Clinical Practice, Level 5, Williamson Translational Research Building, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Marie-Anne Durand
- The Dartmouth Institute for Health Policy and Clinical Practice, Level 5, Williamson Translational Research Building, One Medical Center Drive, Lebanon, NH 03756, USA.
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Syrowatka A, Krömker D, Meguerditchian AN, Tamblyn R. Features of Computer-Based Decision Aids: Systematic Review, Thematic Synthesis, and Meta-Analyses. J Med Internet Res 2016; 18:e20. [PMID: 26813512 PMCID: PMC4748141 DOI: 10.2196/jmir.4982] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 11/01/2015] [Accepted: 12/21/2015] [Indexed: 11/13/2022] Open
Abstract
Background Patient information and education, such as decision aids, are gradually moving toward online, computer-based environments. Considerable research has been conducted to guide content and presentation of decision aids. However, given the relatively new shift to computer-based support, little attention has been given to how multimedia and interactivity can improve upon paper-based decision aids. Objective The first objective of this review was to summarize published literature into a proposed classification of features that have been integrated into computer-based decision aids. Building on this classification, the second objective was to assess whether integration of specific features was associated with higher-quality decision making. Methods Relevant studies were located by searching MEDLINE, Embase, CINAHL, and CENTRAL databases. The review identified studies that evaluated computer-based decision aids for adults faced with preference-sensitive medical decisions and reported quality of decision-making outcomes. A thematic synthesis was conducted to develop the classification of features. Subsequently, meta-analyses were conducted based on standardized mean differences (SMD) from randomized controlled trials (RCTs) that reported knowledge or decisional conflict. Further subgroup analyses compared pooled SMDs for decision aids that incorporated a specific feature to other computer-based decision aids that did not incorporate the feature, to assess whether specific features improved quality of decision making. Results Of 3541 unique publications, 58 studies met the target criteria and were included in the thematic synthesis. The synthesis identified six features: content control, tailoring, patient narratives, explicit values clarification, feedback, and social support. A subset of 26 RCTs from the thematic synthesis was used to conduct the meta-analyses. As expected, computer-based decision aids performed better than usual care or alternative aids; however, some features performed better than others. Integration of content control improved quality of decision making (SMD 0.59 vs 0.23 for knowledge; SMD 0.39 vs 0.29 for decisional conflict). In contrast, tailoring reduced quality of decision making (SMD 0.40 vs 0.71 for knowledge; SMD 0.25 vs 0.52 for decisional conflict). Similarly, patient narratives also reduced quality of decision making (SMD 0.43 vs 0.65 for knowledge; SMD 0.17 vs 0.46 for decisional conflict). Results were varied for different types of explicit values clarification, feedback, and social support. Conclusions Integration of media rich or interactive features into computer-based decision aids can improve quality of preference-sensitive decision making. However, this is an emerging field with limited evidence to guide use. The systematic review and thematic synthesis identified features that have been integrated into available computer-based decision aids, in an effort to facilitate reporting of these features and to promote integration of such features into decision aids. The meta-analyses and associated subgroup analyses provide preliminary evidence to support integration of specific features into future decision aids. Further research can focus on clarifying independent contributions of specific features through experimental designs and refining the designs of features to improve effectiveness.
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Affiliation(s)
- Ania Syrowatka
- Clinical and Health Informatics Research Group, McGill University, Montreal, QC, Canada.
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9
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Berry DL, Halpenny B, Bosco JLF, Bruyere J, Sanda MG. Usability evaluation and adaptation of the e-health Personal Patient Profile-Prostate decision aid for Spanish-speaking Latino men. BMC Med Inform Decis Mak 2015. [PMID: 26204920 PMCID: PMC4513952 DOI: 10.1186/s12911-015-0180-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The Personal Patient Profile-Prostate (P3P), a web-based decision aid, was demonstrated to reduce decisional conflict in English-speaking men with localized prostate cancer early after initial diagnosis. The purpose of this study was to explore and enhance usability and cultural appropriateness of a Spanish P3P by Latino men with a diagnosis of prostate cancer. METHODS P3P was translated to Spanish and back-translated by three native Spanish-speaking translators working independently. Spanish-speaking Latino men with a diagnosis of localized prostate cancer, who had made treatment decisions in the past 24 months, were recruited from two urban clinical care sites. Individual cognitive interviews were conducted by two bilingual research assistants as each participant used the Spanish P3P. Notes of user behavior, feedback, and answers to direct questions about comprehension, usability and perceived usefulness were analyzed and categorized. RESULTS Seven participants with a range of education levels identified 25 unique usability issues in navigation, content comprehension and completeness, sociocultural appropriateness, and methodology. Revisions were prioritized to refine the usability and cultural and linguistic appropriateness of the decision aid. CONCLUSIONS Usability issues were discovered that are potential barriers to effective decision support. Successful use of decision aids requires adaptation and testing beyond translation. Our findings led to revisions further refining the usability and linguistic and cultural appropriateness of Spanish P3P.
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Affiliation(s)
- Donna L Berry
- Biobehavioral Nursing and Health Systems, University of Washington, Seattle, WA, USA. .,The Phyllis F. Cantor Center, Dana-Farber Cancer Institute, Boston, MA, USA.
| | - Barbara Halpenny
- The Phyllis F. Cantor Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jaclyn L F Bosco
- The Phyllis F. Cantor Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | - John Bruyere
- Joan C. Edwards School of Medicine- Marshall University, Huntington, WV, USA
| | - Martin G Sanda
- Department of Urology, Emory University School of Medicine, Atlanta, USA
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Sherman KA, Harcourt DM, Lam TC, Shaw LK, Boyages J. BRECONDA: Development and acceptability of an interactive decisional support tool for women considering breast reconstruction. Psychooncology 2014; 23:835-8. [PMID: 24991748 DOI: 10.1002/pon.3498] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 01/12/2014] [Accepted: 01/15/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Kerry A. Sherman
- Centre for Emotional Health, Department of Psychology; Macquarie University; Sydney Australia
- Westmead Breast Cancer Institute, Westmead Hospital; University of Sydney; Sydney Australia
| | - Diana M. Harcourt
- Centre for Appearance Research; University of the West of England; Bristol UK
| | - Thomas C. Lam
- Westmead Breast Cancer Institute, Westmead Hospital; University of Sydney; Sydney Australia
| | - Laura-Kate Shaw
- Centre for Emotional Health, Department of Psychology; Macquarie University; Sydney Australia
| | - John Boyages
- Westmead Breast Cancer Institute, Westmead Hospital; University of Sydney; Sydney Australia
- Macquarie University Cancer Institute; Sydney Australia
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Exploring inequalities in access to care and the provision of choice to women seeking breast reconstruction surgery: a qualitative study. Br J Cancer 2013; 109:1181-91. [PMID: 23928662 PMCID: PMC3778305 DOI: 10.1038/bjc.2013.461] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 07/16/2013] [Accepted: 07/21/2013] [Indexed: 12/03/2022] Open
Abstract
Background: Breast reconstruction (BR) may improve psychosocial and cosmetic outcomes after mastectomy for breast cancer but currently, few women opt for surgery. Reasons for this are unclear. The aim of this qualitative study was to explore access to care and the provision of procedure choice to women seeking reconstructive surgery. Methods: Semi-structured interviews with a purposive sample of patients who had undergone BR and professionals providing specialist care explored participants' experiences of information provision before BR. Interviews were transcribed verbatim and analysed using the constant comparative technique of grounded theory. Sampling, data collection and analysis were performed concurrently and iteratively until data saturation was achieved. Results: Both patients and professionals expressed concerns about the provision of adequate procedure choice and access to care. Lack of information and/or time, involvement in decision making and issues relating to the evolution and organisation of reconstructive services, emerged as potential explanations for the inequalities seen. Interventions to improve cross-speciality collaboration were proposed to address these issues. Conclusion: Inequalities in the provision of choice in BR exist, which may be explained by a lack of integration between surgical specialities. Pathway restructuring, service reorganisation and standardisation of training may enhance cross-speciality collaboration and improve the patient experience.
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Flynn D, Ford GA, Stobbart L, Rodgers H, Murtagh MJ, Thomson RG. A review of decision support, risk communication and patient information tools for thrombolytic treatment in acute stroke: lessons for tool developers. BMC Health Serv Res 2013; 13:225. [PMID: 23777368 PMCID: PMC3734197 DOI: 10.1186/1472-6963-13-225] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 06/06/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tools to support clinical or patient decision-making in the treatment/management of a health condition are used in a range of clinical settings for numerous preference-sensitive healthcare decisions. Their impact in clinical practice is largely dependent on their quality across a range of domains. We critically analysed currently available tools to support decision making or patient understanding in the treatment of acute ischaemic stroke with intravenous thrombolysis, as an exemplar to provide clinicians/researchers with practical guidance on development, evaluation and implementation of such tools for other preference-sensitive treatment options/decisions in different clinical contexts. METHODS Tools were identified from bibliographic databases, Internet searches and a survey of UK and North American stroke networks. Two reviewers critically analysed tools to establish: information on benefits/risks of thrombolysis included in tools, and the methods used to convey probabilistic information (verbal descriptors, numerical and graphical); adherence to guidance on presenting outcome probabilities (IPDASi probabilities items) and information content (Picker Institute Checklist); readability (Fog Index); and the extent that tools had comprehensive development processes. RESULTS Nine tools of 26 identified included information on a full range of benefits/risks of thrombolysis. Verbal descriptors, frequencies and percentages were used to convey probabilistic information in 20, 19 and 18 tools respectively, whilst nine used graphical methods. Shortcomings in presentation of outcome probabilities (e.g. omitting outcomes without treatment) were identified. Patient information tools had an aggregate median Fog index score of 10. None of the tools had comprehensive development processes. CONCLUSIONS Tools to support decision making or patient understanding in the treatment of acute stroke with thrombolysis have been sub-optimally developed. Development of tools should utilise mixed methods and strategies to meaningfully involve clinicians, patients and their relatives in an iterative design process; include evidence-based methods to augment interpretability of textual and probabilistic information (e.g. graphical displays showing natural frequencies) on the full range of outcome states associated with available options; and address patients with different levels of health literacy. Implementation of tools will be enhanced when mechanisms are in place to periodically assess the relevance of tools and where necessary, update the mode of delivery, form and information content.
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Affiliation(s)
- Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Gary A Ford
- Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle Upon Tyne, UK
| | - Lynne Stobbart
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Helen Rodgers
- Institute for Ageing and Health (Stroke Research Group), Newcastle University, Newcastle Upon Tyne, UK
| | | | - Richard G Thomson
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
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Elwyn G, Lloyd A, Joseph-Williams N, Cording E, Thomson R, Durand MA, Edwards A. Option Grids: shared decision making made easier. PATIENT EDUCATION AND COUNSELING 2013; 90:207-212. [PMID: 22854227 DOI: 10.1016/j.pec.2012.06.036] [Citation(s) in RCA: 205] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 05/29/2012] [Accepted: 06/26/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To describe the exploratory use of short decision support tools for patients, called Option Grids. Option Grids are summary tables, using one side of paper to enable rapid comparisons of options, using questions that patients frequently ask (FAQs) and designed for face-to-face clinical encounters. To date, most evidence about 'patient decision aids' has been based on tools with high content levels, designed for patients to use independently, either before or after visits. METHODS We studied the use of Option Grids in a quality improvement project, collecting field notes and conducting interviews with clinical teams. RESULTS In the 'Making Good Decisions in Collaboration' (MAGIC) program, clinicians found that using Option Grids made it easier to explain the existence of options and reported a 'handover' effect, where patient involvement in decision making was enhanced. CONCLUSION Option Grids made options more visible and clinicians found it easier to undertake shared decision making when these tools were available. Used in a collaborative way, they enhance patients' confidence and voice, increasing their involvement in collaborative dialogs. PRACTICE IMPLICATIONS Further work to confirm these preliminary findings is required, to measure processes and to assess whether these tools have similar impact in other clinical settings.
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Affiliation(s)
- Glyn Elwyn
- Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Heath Park, UK.
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