Development and pilot testing of a decision aid for postmenopausal women with osteoporosis

Cost-effectiveness of a multicomponent-adherence intervention in fracture liaison services

BACKGROUND

This study aims to assess the lifetime cost-effectiveness of a multi-component adherence intervention (MCAI), including a patient decision aid and motivational interviewing, compared to usual care in patients with a recent fracture attending fracture liaison services (FLS) and eligible for anti-osteoporosis medication (AOM).

RESEARCH DESIGN AND METHODS

Data on AOM initiation and one-year persistence were collected from a quasi-experimental study conducted between 2019 and 2023 in two Dutch FLS centers. An individual level, state-transition Markov model was used to simulate lifetime costs and quality-adjusted life years (QALYs) with a societal perspective of MCAI vs usual care. One-way and probabilistic sensitivity analyses were conducted including variation in additional FLS and MCAI costs (no MCAI cost in baseline).

RESULTS

MCAI was associated with gain in QALYs (0.0012) and reduction in costs (-€16) and is therefore dominant. At the Dutch willingness-to-pay threshold of €50,000/QALY, MCAI remained cost-effective when increasing costs of the FLS visit or the yearly maintenance cost for MCAI up to +€60. Probabilistic sensitivity analysis demonstrated MCAI to be dominant in 54% of the simulations and cost-effective in 87% with a threshold of €50,000/QALY.

CONCLUSIONS

A MCAI implemented in FLS centers may lead to cost-effective allocation of resources in FLS care, depending on extra costs.

Development and evaluation of shared decision-making tools in rheumatology: A scoping review

INTRODUCTION

Shared decision-making (SDM) tools are facilitators of decision-making through a collaborative process between patients/caregivers and clinicians. These tools help clinicians understand patient's perspectives and help patients in making informed decisions based on their preferences. Despite their usefulness for both patients and clinicians, SDM tools are not widely implemented in everyday practice. One barrier is the lack of clarity on the development and evaluation processes of these tools. Such processes have not been previously described in the field of rheumatology.

OBJECTIVE

To describe the development and evaluation processes of shared decision-making (SDM) tools used in rheumatology.

METHODS

Bibliographic databases (e.g., EMBASE and CINAHL) were searched for relevant articles. Guidelines for the PRISMA extension for scoping reviews were followed. Studies included were: addressing SDM among adults in rheumatology, focusing on development and/or evaluation of SDM tool, full texts, empirical research, and in the English language.

RESULTS

Of the 2030 records screened, forty-six reports addressing 36 SDM tools were included. Development basis and evaluation measures varied across the studies. The most commonly reported development basis was the International Patient Decision Aids Standards (IPDAS) criteria (19/36, 53 %). Other developmental foundations reported were: The Ottawa Decision Support Framework (ODSF) (6/36, 16 %), Informed Medical Decision Foundation elements (3/36, 8 %), edutainment principles (2/36, 5.5 %), and others (e.g. DISCERN and MARKOV Model) (9/31,29 %). The most commonly used evaluation measures were the Decisional Conflict Scale (18/46, 39 %), acceptability and knowledge (7/46, 15 %), and the preparation for decision-making scale (5/46,11 %).

CONCLUSION

For better quality and wider implementation of such tools, there is a need for detailed, transparent, systematic, and consistent reporting of development methods and evaluation measures. Using established checklists for reporting development and evaluation is encouraged.

OMERACT Core outcome measurement set for shared decision making in rheumatic and musculoskeletal conditions: a scoping review to identify candidate instruments

OBJECTIVES

Shared decision making (SDM) is a central tenet in rheumatic and musculoskeletal care. The lack of standardization regarding SDM instruments and outcomes in clinical trials threatens the comparative effectiveness of interventions. The Outcome Measures in Rheumatology (OMERACT) SDM Working Group is developing a Core Outcome Set for trials of SDM interventions in rheumatology and musculoskeletal health. The working group reached consensus on a Core Outcome Domain Set in 2020. The next step is to develop a Core Outcome Measurement Set through the OMERACT Filter 2.2.

METHODS

We conducted a scoping review (PRISMA-ScR) to identify candidate instruments for the OMERACT Filter 2.2 We systematically reviewed five databases (Ovid MEDLINE®, Embase, Cochrane Library, CINAHL and Web of Science). An information specialist designed search strategies to identify all measurement instruments used in SDM studies in adults or children living with rheumatic or musculoskeletal diseases or their important others. Paired reviewers independently screened titles, abstracts, and full text articles. We extracted characteristics of all candidate instruments (e.g., measured construct, measurement properties). We classified candidate instruments and summarized evidence gaps with an adapted version of the Summary of Measurement Properties (SOMP) table.

RESULTS

We found 14,464 citations, read 239 full text articles, and included 99 eligible studies. We identified 220 potential candidate instruments. The five most used measurement instruments were the Decisional Conflict Scale (traditional and low literacy versions) (n=38), the Hip/Knee-Decision Quality Instrument (n=20), the Decision Regret Scale (n=9), the Preparation for Decision Making Scale (n=8), and the CollaboRATE (n=8). Only 44 candidate instruments (20%) had any measurement properties reported by the included studies. Of these instruments, only 57% matched with at least one of the 7-criteria adapted SOMP table.

CONCLUSION

We identified 220 candidate instruments used in the SDM literature amongst people with rheumatic and musculoskeletal diseases. Our classification of instruments showed evidence gaps and inconsistent reporting of measurement properties. The next steps for the OMERACT SDM Working Group are to match candidate instruments with Core Domains, assess feasibility and review validation studies of measurement instruments in rheumatic diseases or other conditions. Development and validation of new instruments may be required for some Core Domains.

Evaluating the Acceptability and Feasibility of a Sexual Health-Focused Contraceptive Decision Aid for Diverse Young Adults: User-Centered Usability Study

BACKGROUND

Young adults with low sexual health literacy levels may find it difficult to make informed decisions about contraceptive methods. We developed and pilot-tested a web-based decision aid-Healthy Sex Choices-designed to support diverse young adults with their contraceptive decision-making.

OBJECTIVE

This pilot study aimed to evaluate whether the Healthy Sex Choices decision aid is acceptable and feasible to patients and clinicians.

METHODS

We used the Ottawa Decision Support Framework and the International Patient Decision Aid Standards to develop and pilot the decision tool. We first conducted a needs assessment with our advisory panel (5 clinicians and 2 patients) that informed decision aid development. All panelists participated in semistructured interviews about their experience with contraceptive counseling. Clinicians also completed a focus group session centered around the development of sex education content for the tool. Before commencing the pilot study, 5 participants from ResearchMatch (Vanderbilt University Medical Center) assessed the tool and suggested improvements.

RESULTS

Participants were satisfied with the tool, rating the acceptability as "good." Interviewees revealed that the tool made contraceptive decision-making easier and would recommend the tool to a family member or friend. Participants had a nonsignificant change in knowledge scores (53% before vs 45% after; P=.99). Overall, decisional conflict scores significantly decreased (16.1 before vs 2.8 after; P<.001) with the informed subscale (patients feeling more informed) having the greatest decline (23.1 vs 4.7; mean difference 19.0, SD 27.1). Subanalyses of contraceptive knowledge and decisional conflict illustrated that participants of color had lower knowledge scores (48% vs 55%) and higher decisional conflict (20.0 vs 14.5) at baseline than their white counterparts.

CONCLUSIONS

Participants found Healthy Sex Choices to be acceptable and reported reduced decisional conflict after using the tool. The development and pilot phases of this study provided a foundation for creating reproductive health decision aids that acknowledge and provide guidance for diverse patient populations.

Long Non-Coding RNA Metastasis Associated Lung Adenocarcinoma Transcript 1 (LncRNA MALAT1) Shuttling Through Exosome from Bone Marrow Mesenchymal Stem Cell (BMSC) Regulates the Differentiation of Osteoblast in Osteoporosis Rats

This study assesses the effect of LncRNA MALAT1 on osteoblast differentiation in OP rats. The BMSC were transfected with LncRNA MALAT1. The OP rats’ model was established and then assigned into NC set, OP set, BMSC set, BMSCs/LncRNA-NC set and BMSCs/LncRNA MALAT1 set followed by analysis of LncRNA MALAT1, microRNA-34 and cSATB2 expression by RT-PCR, and Bax, Caspase-3 and ALP level in exosome by Western Blot assy. The protein expression of Bax and Caspase-3 in OP set was significantly increased compared with NC set but reduced in BMSCs/LncRNA MALAT1 set without significant differences between BMSC set and BMSC/NC set. There was orderly array of collagenous fiber in lamellar bone of NC set. The quantity of bone lacuna was moderate with orderly array of bone trabecula. There was disorderly array of collagenous fiber in lamellar bone of model set. There were a large number of distribution of osteoblast in the breakdown area with the dissolution of periosteum. The protein level of Bax and Caspase-3 was reduced by LncRNA MALAT1 from BMSC and the level of ALP, microRNA-34 and cSATB2 in the differentiation of osteoblast was increased, thereby promoting the differentiation of osteoblast.

Information Provision, Decision Self-efficacy, and Decisional Conflict in Adopting Health Behaviors Among Patients Treated for Colorectal Cancer: A Cross-sectional Study

BACKGROUND

Health promotion is necessary to mitigate the negative consequences of colorectal cancer and its treatment. Rates of behavior modification are low in populations of cancer patients. Studies are needed to determine the factors, such as decisional conflict, which influence adoption of healthy behaviors following a cancer diagnosis.

OBJECTIVE

To examine the effects of information provision, decision self-efficacy, and decisional conflict on the adoption of healthy behaviors among patients with colorectal cancer.

METHODS

This cross-sectional study focused on 251 patients with colorectal cancer in South Korea. Information provision, decision self-efficacy, and decisional conflict were measured using validated instruments. Patients rated their decisional conflict related to the adoption of behaviors that include regular exercise and a balanced diet.

RESULTS

Most participants (73%) reported low satisfaction with the amount of information received. Of the participants, 64% had low decision self-efficacy, and 80% experienced decisional conflict. The perception of a higher level of information provision was associated with greater decision self-efficacy (odds ratio, 4.63; 95% confidence interval, 1.61-13.35). Higher decision self-efficacy was associated with lower decisional conflict (odds ratio, 5.19; 95% confidence interval, 2.33-11.59).

CONCLUSION

Receiving adequate information is important for promoting patients' confidence in making decisions about their health and reducing decisional conflict in the adoption of healthy lifestyle changes following a cancer diagnosis.

IMPLICATION FOR PRACTICE

Oncology nurses should assess patient information needs and promote decision self-efficacy, thus empowering patients diagnosed with colorectal cancer to make lifestyle decisions that improve their health and quality of life.

The impact of a patient decision aid on intention to undergo surgery for subacromial pain syndrome: An online randomised controlled trial

OBJECTIVE

To evaluate the effects of a patient decision aid for people considering shoulder surgery.

METHODS

Participants with shoulder pain considering shoulder surgery (n = 425) were recruited online and randomised to (i) a decision aid outlining the benefits and harms of shoulder surgery and non-surgical options (then randomised to a side-by-side vs. top-and-bottom display of options); and (ii) general information about shoulder pain from the NHS. Outcomes included treatment intention (primary), knowledge, attitudes, informed choice, and decisional conflict. Linear and logistic regression models were used to evaluate between-groups differences in outcomes.

RESULTS

409 participants (96%) had post-intervention data. Mean age was 41.3 years, 44.2% were female. There was no between-group difference in post-intervention treatment intention (MD -0.2, 95% CI: -3.3 to 2.8) and likelihood of intending to have shoulder surgery (OR 0.7, 95% CI: 0.3-1.5). The decision aid slightly improved knowledge (MD 4.4, 95% CI: 0.2-8.6), but not any other secondary outcomes. The display of options did not influence any outcome.

CONCLUSIONS

In this online trial, a co-designed patient decision aid had no effect on treatment intention, attitudes, informed choice, and decisional conflict, but a small effect on improving knowledge.

PRACTICE IMPLICATIONS

Research is needed to understand reasons for the lack of anticipated effects.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry (ACTRN12621000992808).

Safety Evaluation of Natural Drugs in Chronic Skeletal Disorders: A Literature Review of Clinical Trials in the Past 20 years

Chronic skeletal disorders (CSDs), including degenerative diseases such as osteoporosis (OP) and autoimmune disorders, have become a leading cause of disability in an ageing society, with natural drugs being indispensable therapeutic options. The clinical safety evaluation (CSE) of natural drugs in CSDs has been given priority and has been intensively studied. To provide fundamental evidence for the clinical application of natural drugs in the elderly population, clinical studies of natural drugs in CSDs included in this review were selected from CNKI, Web of Science, PubMed, Science Direct and Google Scholar since 2001. Seventeen randomized controlled trials (RCTs) met our inclusion criteria: four articles were on OP, seven on osteoarthritis (OA), four on rheumatoid arthritis (RA) and two on gout. Common natural drugs used for the treatment of OP include Epimedium brevicornu Maxim [Berberidaceae], Dipsacus asper Wall ex DC [Caprifoliaceae] root, and Phalaenopsis cornu-cervi (Breda) Blume & Rchb. f[ Orchidaceae], which have been linked to several mild adverse reactions, such as skin rash, gastric dysfunction, abnormal urine, constipation and irritability. The safety of Hedera helix L [Araliaceae] extract, Boswellia serrata Roxb [Burseraceae] extract and extract from perna canaliculus was evaluated in OA and upper abdominal pain, and unstable movements were obsrerved as major side effects. Adverse events, including pneumonia, vomiting, diarrhoea and upper respiratory tract infection, were reported when RA was treated with Tripterygium wilfordii, Hook. F [Celastraceae][TwHF] polyglycosides and quercetin (Capsella bursa-pastoris (L.) Medik [Brassicaceae]). The present review aimed to summarize the CSE results of natural drugs in CSDs and could provide evidence-based information for clinicians.

Development and Pilot Usefulness Testing of an Interactive Computerized Patient Decision Aid for Intraocular Lens Selection Before Cataract Surgery

PURPOSE

Modern cataract surgeries aim to treat impaired vision and also improve quality of life. An appropriate pre-operative selection of the intraocular lens is important to post-operative quality of life. Patients often have difficulty in choosing the best fit for individual needs. Patient decision aids (PDAs) are useful tools to assist patients in such decision-making process. However, most PDAs are paper-based and lack user interaction. This study is aimed to develop and evaluate an interactive computerized patient decision aid (cPDA) to help patients in the selection of an appropriate intraocular lens model before cataract surgery.

MATERIALS AND METHODS

Patients and their families who were making the decision regarding intraocular lens selection before cataract surgeries were eligible to participate in this study. A cPDA was built on an interactive robot, to help the patients in the decision-making process. The usefulness of the cPDA was measured with the Decision Self-Efficacy (DSE) scale and Preparation for Decision Making (PrepDM) scale.

RESULTS

A total of 50 participants (18 men and 32 women) were enrolled in the pilot test. The mean pre-cPDA DSE score was 46.5 ± 13.6, and the post-cPDA DSE score was 72.6 ±12.8. The average gain score on DSE was 26.1, and the standard deviation was 8.0. The gain score on DSE was statistically significant, and the effect size was bigger than 3. The patients with junior or senior high degrees had the highest gain score on DSE, and the ones with college or above degrees had the lowest. The patients with college or above degrees had the highest PrepDM score, and the ones with elementary school or below had the lowest. Age and sex were not significant correlates of PrepDM. The patients with college or above degrees had the highest preparedness, but the lowest gain on DSE.

CONCLUSION

Education levels are associated with the usefulness of cPDA, both for the preparedness and decision efficacy of patients. The results provide insight into the feasibility of cPDA for the decision-making of pre-operative intraocular lens selection.

Assessment of Parental Choice Predisposition for Tonsillectomy in Children

Importance

The decision to proceed with tonsillectomy to treat pediatric obstructive sleep-disordered breathing (OSDB) often falls on individual families. Despite emphasis on shared decision-making between parents and surgeons about tonsillectomy for OSDB, the extent to which parents have already decided about surgery prior to the child's consultation is not known.

Objective

To identify predictors of parent choice predisposition for surgical treatment of OSDB with tonsillectomy and describe its association with parent-clinician communication.

Design, Setting, and Participants

Observational cohort study conducted at 3 outpatient clinical sites (urban-based outpatient center, suburban off-site outpatient center, and community-based medical center) associated with a large academic center. A total of 149 parents of children undergoing their initial otolaryngology consultation for OSDB were identified through clinic scheduling records and deemed eligible for participation in this study. Of the 149 parents, a volunteer sample of 64 parents (42.9%) agreed to participate and have their consultation audiorecorded. Of these 64 participants, 12 parents were excluded because their child had previously been evaluated for OSDB by a specialist.

Main Outcomes and Measures

The primary outcomes and measures were treatment choice predisposition scale (a measure of the strength of a patient's treatment decision prior to entering a medical consultation), parent communication behaviors coded in consultation audiorecordings (substantive questions asked, introduced medical jargon, expression of treatment preference, and scores on the OSDB and Adenotonsillectomy Knowledge Scale for parents).

Results

A total of 52 parent participants were included in the final analysis. Most parent participants were female (n = 48; 92%); 50% (n = 26) of parents were non-Hispanic White, 37% (n = 19) were Black, 10% (n = 5) were Hispanic/Latino, and 4% (n = 2) self-reported race/ethnicity as "Other." Mean (range) choice predisposition was 6.84 (2-10), with 22 parents (42%) more predisposed to choose tonsillectomy. Parents more predisposed to choose tonsillectomy used more medical jargon during the consultation (odds ratio [OR], 3.95; 95% CI, 1.16-15.15) and were less likely to ask questions (OR, 0.22; 95% CI, 0.05-0.87). Parental predictors of greater predisposition toward choosing surgery were White race (OR, 7.31; 95% CI, 1.77-39.33) and prior evaluation by a pediatrician for OSDB (OR, 6.10; 95% CI, 1.44-33.34).

Conclusions and Relevance

In this cohort study of parents of children with OSDB, many parents were predisposed to choose treatment with tonsillectomy prior to initial surgical consultation, which may lessen engagement and influence 2-way communication. In this cohort, greater predisposition for tonsillectomy was observed in non-Hispanic White parents and parents of patients who had been previously evaluated by a pediatrician for OSDB. Understanding parent choice predisposition for surgery may promote improved communication and parental engagement during surgical consultations. It may also help direct education about sleep and tonsillectomy to nonsurgical forums.

Preferences, satisfaction and decision-making processes in osteoporosis treatment: a systematic review of the literature

Aim: To synthesize information available in the literature on patients' preferences and satisfaction with osteoporosis treatment and their unmet needs on the treatment decision-making process. Materials & methods: Systematic literature review consulting international database and grey literature of articles published between January 1, 2009 and January 1, 2019. Results: Nineteen publications were reviewed, 79% of them focused on evaluating the importance that patients attached to the mode and frequency of administration, adverse events and treatment efficacy. 21% of them provided information about treatment satisfaction and 26% regarding unmet needs on treatment-decision making process. Conclusion: Aligning treatment with patients' preferences, promoting physician-patient communication and identifying patients' concerns with treatment may contribute to improve treatment satisfaction and adherence and ultimately achieve the treatment goal.

The Effect of a Complementary Therapy Education Seminar on Support Persons of Individuals with Cancer

Objectives: Complementary therapy (CT) use is prevalent among individuals living with cancer, who often consult family and friends (i.e., support persons) in making decisions about CT. This study examines the effect of an education seminar for adult cancer patients and support persons on the support persons' use, knowledge, and decision-making processes related to CT. Design: A patient education seminar that included support persons was developed and evaluated as part of a CT decision support research program. Survey data were collected before and after the education seminar to examine its impact on support persons' knowledge and use of CT, as well as their engagement in the CT decision-making process. Setting: The study was conducted in Western Canada. Subjects: 62 adult support persons. Interventions: Participants attended a 4-h CT education seminar at one in four provincial cancer centers. The seminar provided recommendations regarding how to make informed decisions about CT, where to find credible information, and key issues to consider to avoid potential risks of CT use. The evidence related to popular CT was also reviewed. Outcome Measures: The primary outcome was support persons' CT knowledge. Secondary outcomes included CT use, information-seeking behavior, decision self-efficacy, decision conflict, and distress. Results: A significant increase in support persons' CT knowledge was observed, as well as improved confidence in CT decision making. There was no significant difference in participants' CT use following the education seminar. Most indicated they would continue to locate information about CT using the Internet. A significant decrease in support persons' decisional conflict was reported; however, there were no significant change in distress related to CT decision making. Conclusions: This study demonstrates the importance of including support persons in patient education related to CT and the positive impact on their knowledge and treatment decision-making processes. No significant change in CT use, information seeking behavior and distress related to CT decisions, however, was observed in the study.

Needs assessment for a decision support tool in oral cancer requiring major resection and reconstruction: a mixed-methods study protocol

INTRODUCTION

Advanced oral cancer and its ensuing treatment engenders significant morbidity and mortality. Patients are often elderly with significant comorbidities. Toxicities associated with surgical resection can be devastating and they are often highlighted by patients as impactful. Given the potential for suboptimal oncological and functional outcomes in this vulnerable patient population, promotion and performance of shared decision making (SDM) is crucial.Decision aids (DAs) are useful instruments for facilitating the SDM process by presenting patients with up-to-date evidence regarding risks, benefits and the possible postoperative course. Importantly, DAs also help elicit and clarify patient values and preferences. The use of DAs in cancer treatment has been shown to reduce decisional conflict and increase SDM. No DAs for oral cavity cancer have yet been developed.This study endeavours to answer the question: Is there a patient or surgeon driven need for development and implementation of a DA for adult patients considering major surgery for oral cancer?

METHODS AND ANALYSIS

This study is the first step in a multiphase investigation of SDM during major head and neck surgery. It is a multi-institutional convergent parallel mixed-methods needs assessment study. Patients and surgeon dyads will be recruited to complete questionnaires related to their perception of the SDM process (nine-item Shared Decision-Making Questionnaire, SDM-Q-9 and SDM-Q-Doc) and to take part in semistructured interviews. Patients will also complete questionnaires examining decisional self-efficacy (Ottawa Decision Self-Efficacy Scale) and decisional conflict (Decisional Conflict Scale). Questionnaires will be completed at time of recruitment and will be used to assess the current level of SDM, self-efficacy and conflict in this setting. Thematic analysis will be used to analyse transcripts of interviews. Quantitative and qualitative components of the study will be integrated through triangulation, with matrix developed to promote visualisation of the data.

ETHICS AND DISSEMINATION

This study has been approved by the research ethics boards of the Nova Scotia Health Authority (Halifax, Nova Scotia) and the University Health Network (Toronto, Ontario). Dissemination to clinicians will be through traditional approaches and creation of a head and neck cancer SDM website. Dissemination to patients will include a section within the website, patient advocacy groups and postings within clinical environments.

Quality and effectiveness of osteoporosis treatment decision aids: a systematic review and environmental scan

Decision aids (DAs) are evidence-based tools that support shared decision-making (SDM) implementation in practice; this study aimed to identify existing osteoporosis DAs and assess their quality and efficacy; and to gain feedback from a patient advisory group on findings and implications for further research. We searched multiple bibliographic databases to identify research studies from 2000 to 2019 and undertook an environmental scan (search conducted February 2019, repeated in March 2020). A pair of reviewers, working independently selected studies for inclusion, extracted data, evaluated each trial's risk of bias, and conducted DA quality assessment using the International Patient Decision Aid Standards (IPDAS). Public contributors (patients and caregivers with experience of osteoporosis and fragility fractures) participated in discussion groups to review a sample of DAs, express preferences for a new DA, and discuss plans for development of a new DA. We identified 6 studies, with high or unclear risk of bias. Across included studies, use of an osteoporosis DA was reported to result in reduced decisional conflict compared with baseline, increased SDM, and increased accuracy of patients' perceived fracture risk compared with controls. Eleven DAs were identified, of which none met the full set of IPDAS criteria for certification for minimization of bias. Public contributors expressed preferences for encounter DAs that are individualized to patients' own needs and risk. Using a systematic review and environmental scan, we identified 11 decision aids to inform patient decisions about osteoporosis treatment and 6 studies evaluating their effectiveness. Use of decision aids increased accuracy of risk perception and shared decision-making but the decision aids themselves fail to comprehensively meet international quality standards and patient needs, underpinning the need for new DA development.

User testing of a hypospadias decision aid prototype at a pediatric medical conference

INTRODUCTION

Based on our previous qualitative work, we created a web-based decision aid (DA) prototype to facilitate shared decision-making regarding hypospadias.

OBJECTIVE

The objective of this study was to obtain rapid feedback on the prototype as part of an iterative, human-centered design process.

METHODS

We conducted this study at a statewide, pediatric educational conference in May 2019, recruiting attendees by verbal/written announcements. The DA consisted of: hypospadias overview and surgery "storyboard," frequently asked questions, parent testimonials, and a values clarification exercise. Participants viewed the DA on a tablet as they participated in semi-structured, qualitative interviews covering website acceptability, usability, and preference for surgical photographs versus illustrations. Three coders used qualitative content analysis to identify themes and resolved disagreements by consensus.

RESULTS

Of 295 conference attendees, all 50 who approached us agreed to participate. Responses from 49 participants were available for analysis: 67% female, ages 20-69, 65% Caucasian, 55% MDs. 96% of participants thought the website design matched its purpose; 59.1% preferred surgical illustrations, 8.2% preferred photos, 30.6% preferred both and 2.0% did not like either. Participants recommended improvements in: a) usability/accessibility (e.g. site navigation, visual layout, page length), b) content coverage (e.g. epidemiology, consequences of no/delayed surgery, lifelong risks), c) parent-centeredness (e.g. reading level/writing style) and d) implementation (provider tools, printable handouts). The Extended Summary Figure shows a revised image of the first step of a hypospadias repair based on feedback about participants' preferences for illustrations rather than photographs.

DISCUSSION

The main strength of our study was the valuable feedback we obtained to inform critical revisions of the DA prototype. We also demonstrated the feasibility and efficacy of a conducting a usability evaluation of a web-based DA in a medical conference setting. One limitation of this study is that the relatively small population sampled limits generalizability and our findings may not reflect the views of all providers who care for hypospadias patients.

CONCLUSIONS

The vast majority of providers thought that the design of the Hypospadias Homepage matched its purpose and most preferred surgical illustrations rather than photos to demonstrate the steps of hypospadias surgery. Based on their feedback, we plan to focus our efforts in the following areas: 1) improvement of navigation/menus, 2) reduction in the amount of text per page, 3) expansion of specific content coverage and 4) inclusion of "parent-friendly" visuals such as infographics to represent quantitative data and colorful illustrations to depict hypospadias and its surgical repair.

Exploration of Decisional Control Preferences in Adolescents and Young Adults with Cancer and Other Complex Medical Conditions

Purpose: Adolescent and young adults (AYA) with cancer encounter many medical treatment decisions but may have variable desires for involvement in decision-making. This study describes the degree of decisional control AYA patients preferred in complex medical decisions. Methods: A cross-sectional descriptive correlational design evaluated experienced AYA patients' decision-making role preferences using the Control Preference Scale and explored relationships in a proposed model of decision control. Results: Overall, most patients preferred an "active collaborative" role (39%), where the patient prefers to make the final decision with input from the provider, or a "shared decision-making" role (34%), wherein the decision is jointly made between patient and provider. Oncology AYA patients tended to prefer a more passive role than nononcology AYA patients. Time since diagnosis also positively correlated with control preference, with patients preferring a more active level of decisional control as the number of days from diagnosis increased. While no other statistically significant relationships were found between factors put forth in the exploratory model and decision control, there were strong associations between the factors themselves that warrant future study. Conclusion: The findings advance the knowledge of AYA preferences for decision-making involvement, enhancing our ability to identify patients at risk for low health care engagement and explore the consequences of limited or impaired decisional capacity. Future research might examine interventions to promote self-management skills and patient decisional role preferences, fulfilling the need to respect both the desire for decision-making involvement of some patients and the preference to defer to the expertise of providers for others.

Comparison of multimedia and printed patient education tools for patients with osteoporosis: a 6-month randomized controlled trial

We conducted a randomized controlled trial to compare the efficacy of adding a video tool to a printed booklet on osteoporosis. Both strategies were effective in increasing knowledge and decreasing decisional conflict. There was no difference in the measured outcomes between the intervention and control groups. Patient preferences and learning styles are key factors in deciding a presentation format when educating patients with osteoporosis.

INTRODUCTION

Innovative approaches to patient education about self-management in osteoporosis may improve outcomes.

METHODS

We conducted a randomized controlled trial to compare the efficacy of adding a multimedia patient education tool involving video modeling to a printed educational booklet on osteoporosis. Participants were post-menopausal women with osteoporosis. We assessed osteoporosis knowledge, decisional conflict, self-efficacy, and effectiveness in disease management at baseline, immediately post-intervention, and at 3 and 6 months. Linear regression models were used to explore changes in outcomes at 6 months with respect to baseline characteristics.

RESULTS

Two hundred and twenty-five women were randomized, 111 to receive the multimedia tool in addition to the booklet and 114 to receive the booklet alone. Knowledge and decisional conflict scores significantly improved in both groups at all post-intervention assessment points, but with no significant differences in score changes between the groups. Self-efficacy and disease management effectiveness showed no significant changes from baseline. In the entire cohort, younger age was associated with better effectiveness in disease management and Hispanic women had greater gains in knowledge at 6 months compared to White women. Women with limited health literacy who had received the multimedia tool in addition to the printed materials had higher decisional conflict than those who received printed materials alone.

CONCLUSION

Both multimedia and printed tools increased knowledge and decreased decisional conflict to the same extent, neither of the educational materials proved to be better than the other. For women with limited health literacy, receiving the booklet alone was more effective in reducing decisional conflict after 6 months, than adding the multimedia tool.

"Get Ready and Empowered About Treatment" (GREAT) Study: a Pragmatic Randomized Controlled Trial of Activation in Persons Living with HIV

BACKGROUND

Little is known about strategies to improve patient activation, particularly among persons living with HIV (PLWH).

OBJECTIVE

To assess the impact of a group intervention and individual coaching on patient activation for PLWH.

DESIGN

Pragmatic randomized controlled trial.

SITES

Eight practices in New York and two in New Jersey serving PLWH.

PARTICIPANTS

Three hundred sixty PLWH who received care at participating practices and had at least limited English proficiency and basic literacy.

INTERVENTION

Six 90-min group training sessions covering use of an ePersonal Health Record loaded onto a handheld mobile device and a single 20-30 min individual pre-visit coaching session.

MAIN MEASURES

The primary outcome was change in Patient Activation Measure (PAM). Secondary outcomes were changes in eHealth literacy (eHEALS), Decision Self-efficacy (DSES), Perceived Involvement in Care Scale (PICS), health (SF-12), receipt of HIV-related care, and change in HIV viral load (VL).

KEY RESULTS

The intervention group showed significantly greater improvement than the control group in the primary outcome, the PAM (difference 2.82: 95% confidence interval [CI] 0.32-5.32). Effects were largest among participants with lowest quartile PAM at baseline (p < 0.05). The intervention doubled the odds of improving one level on the PAM (odds ratio 1.96; 95% CI 1.16-3.31). The intervention group also had significantly greater improvement in eHEALS (difference 2.67: 95% CI 1.38-3.9) and PICS (1.27: 95% CI 0.41-2.13) than the control group. Intervention effects were similar by race/ethnicity and low education with the exception of eHealth literacy where effects were stronger for minority participants. No statistically significant effects were observed for decision self-efficacy, health status, adherence, receipt of HIV relevant care, or HIV viral load.

CONCLUSIONS

The patient activation intervention modestly improved several domains related to patient empowerment; effects on patient activation were largest among those with the lowest levels of baseline patient activation.

TRIAL REGISTRATION

This study is registered at Clinical Trials.Gov (NCT02165735).

Effects of a Patient Activation Tool on Decision Making Between Surgery and Nonoperative Management for Pediatric Appendicitis: A Randomized Clinical Trial

Importance

Strategies to activate and engage patients and caregivers in shared decision making in the acute care setting may result in improved outcomes.

Objective

To determine whether a patient activation tool (PAT) can improve decision-making and patient-centered outcomes among pediatric patients and their caregivers who choose between surgery and nonoperative management for their child's appendicitis.

Design, Setting, and Participants

This single-blind, randomized clinical trial collected data from a single tertiary children's hospital from March 1, 2014, through April 30, 2016, with 1-year follow-up completed on May 1, 2017. Two hundred of 236 eligible children and adolescents aged 7 to 17 years with uncomplicated appendicitis enrolled with their caregivers. After receiving the randomized clinical intervention, caregivers chose surgery or nonoperative management. Data were analyzed from March 1, 2014, through May 1, 2017.

Interventions

Randomization to a scripted standardized surgical consultation that emphasized patient choice or a scripted standardized surgical consultation plus the PAT (a tablet-based tool that presents each treatment, encourages participation in medical decision making, and aims at alleviating decisional uncertainty).

Main Outcomes and Measures

Decisional self-efficacy immediately after treatment decision, health care satisfaction at discharge, and disability days for the child at 1-year follow-up.

Results

Among 200 participants (median age, 12 years [interquartile range (IQR), 9-15 years]; 120 [60.0%] male), 98 were randomized to the PAT and 102 to the standardized consultation groups. The percentages choosing nonoperative management were similar (standardized consultation group, 42 of 102 [41.2%]; PAT group, 31 of 98 [31.6%]; P = .19). Immediate decisional self-efficacy was similar in the standardized consultation and PAT groups (median score, 100 [IQR, 97.7-100] vs 100 [IQR, 95.5-100]; P = .03), which was not significant at the planned significance level of P = .02. Total scores on health care satisfaction at discharge were similar (median, 99 [IQR, 94.7-100] vs 98 [IQR, 91.7-100]; P = .27). Disability days at 1-year follow-up were also similar (median, 6 [IQR, 2-11] vs 5 [IQR, 2-15]; P = .67). No difference in the failure rate of nonoperative management at 1 year (13 of 38 [34.2%] vs 11 of 30 [36.7%]; P > .99) or in the rate of complicated appendicitis 30 days after discharge (7 of 68 [10.3%] vs 9 of 71 [12.7%]; P = .79) occurred.

Conclusions and Relevance

In this study, a technology-based PAT did not improve measures of decision making for pediatric patients and caregivers needing to make an urgent treatment decision between surgery and nonoperative management for appendicitis. However, the overall high scores in both groups suggest that pediatric patients and caregivers can process information in the acute care setting and effectively participate in an informed shared decision-making process around the need for surgery.

Trial Registration

ClinicalTrials.gov identifier: NCT02110485.

Understanding Patients' Preferences: A Systematic Review of Psychological Instruments Used in Patients' Preference and Decision Studies

BACKGROUND

Research has been mainly focused on how to elicit patient preferences, with less attention on why patients form certain preferences.

OBJECTIVES

To assess which psychological instruments are currently used and which psychological constructs are known to have an impact on patients' preferences and health-related decisions including the formation of preferences and preference heterogeneity.

METHODS

A systematic database search was undertaken to identify relevant studies. From the selected studies, the following information was extracted: study objectives, study population, design, psychological dimensions investigated, and instruments used to measure psychological variables.

RESULTS

Thirty-three studies were identified that described the association between a psychological construct, measured using a validated instrument, and patients' preferences or health-related decisions. We identified 33 psychological instruments and 18 constructs, and categorized the instruments into 5 groups, namely, motivational factors, cognitive factors, individual differences, emotion and mood, and health beliefs.

CONCLUSIONS

This review provides an overview of the psychological factors and related instruments in the context of patients' preferences and decisions in healthcare settings. Our results indicate that measures of health literacy, numeracy, and locus of control have an impact on health-related preferences and decisions. Within the category of constructs that could explain preference and decision heterogeneity, health locus of control is a strong predictor of decisions in several healthcare contexts and is useful to consider when designing a patient preference study. Future research should continue to explore the association of psychological constructs with preference formation and heterogeneity to build on these initial recommendations.

Efficacy of a Preference-Based Decision Tool on Treatment Decisions for a First-Time Anterior Shoulder Dislocation: A Randomized Controlled Trial of At-Risk Patients

BACKGROUND

First-time anterior shoulder dislocations (FTASD) provide an opportunity to examine the value of integrating stated-preference data with decision modeling to differentiate between patients whose preferred management strategy involves operative or nonoperative treatment. The objective of this study was to evaluate the efficacy of a FTASD decision tool intervention with individual preference measurement compared with a text-based control in a randomized controlled trial.

METHODS

Two hundred respondents between 18 and 35 years of age at risk for experiencing an FTASD were enrolled from the orthopedic clinics and randomized to receive either an interactive decision tool intervention capable of eliciting patient preferences for treatment of an FTASD or a text-based control on shoulder dislocations and treatments. The primary outcome was preference for operative or nonoperative treatment choice. Secondary outcomes included the decisional conflict scale (DCS), stage of decision making, patient activation and engagement, awareness of preference sensitive decisions, knowledge retention, and instrument acceptability.

RESULTS

One hundred respondents were randomized to the intervention and 100 to the control. A total of 154 men and 46 women with an average age of 23.6 years completed the survey. Participants in the intervention group made treatment decisions that aligned more closely with evidence-based recommendations than those in the control group ( P = 0.016). Secondary outcomes showed no difference between intervention and control, excluding several DCS subscales.

DISCUSSION

An interactive, preference-based decision tool for treatment of FTASD affects patient decision making by guiding respondents toward treatment decisions that align more closely with evidence-based recommendations in the absence of a consultation with an orthopedic provider compared with a standard-of-care control tool. Additional study is needed to evaluate the long-term effects of this tool on treatment outcomes, patient adherence, and satisfaction.

LEVEL OF EVIDENCE

2.

Supporting breast cancer screening decisions for caregivers of older women with dementia: study protocol for a randomized controlled trial

BACKGROUND

Alzheimer's disease and related dementias (ADRD) impact a woman's life expectancy and her ability to participate in medical decision-making about breast cancer screening, necessitating the involvement of family caregivers. Making decisions about mammography screening for women with ADRD is stressful. There are no data that suggest that breast cancer screening helps women with ADRD live longer or better. Decision aids may improve the quality of decision-making about mammography for ADRD patients and may inform family caregivers about the risks, benefits, and need for decision-making around mammography screening.

METHODS/DESIGN

The Decisions about Cancer Screening in Alzheimer's Disease (DECAD) trial, a randomized controlled clinical trial, will enroll 426 dyads of older women with ADRD (≥75 years) and a family caregiver from clinics and primary-care practices in Indiana to test a novel, evidence-based decision aid. This decision aid includes information about the impact of ADRD on life expectancy, the benefit of mammograms, and the impact on the quality of life for older women with ADRD. Dyads will be randomized to receive the decision aid or active control information about home safety. This trial will examine the effect on the caregiver's decisional conflict (primary outcome) and the caregiver's decision-making self-efficacy (secondary outcome). A second follow-up at 15 months will include a brief, semi-structured interview with the caregiver regarding the patient's experience with mammograms and decision-making about mammograms. At the same time, a review of the patient's electronic medical record (EMR) will look at discussions about mammography with their primary-care physician and mammogram orders, receipt, results, and burden (e.g., additional diagnostic procedures due to false-positive results, identification of an abnormality on the screening exam but further work-up declined, and identification of a clinically unimportant cancer). A third follow-up at 24 months will extract EMR data on mammogram orders, occurrences, results, and the burden of mammograms.

DISCUSSION

We hypothesize that caregivers who receive the decision aid will have lower levels of decisional conflict and higher levels of decision-making self-efficacy compared to the control group. We also hypothesize that the DECAD decision aid will reduce mammography use among older women with ADRD.

TRIAL REGISTRATION

Clinical Trials Register, NCT03282097 . Registered on 13 September 2017.

Evaluation of the CPR video decision aid with patients with end stage renal disease

BACKGROUND

People with end stage renal disease (ESRD) face important health-related decisions concerning end-of-life care and the use of life-support technologies. While people often want to be involved in making decisions about their health, there are many challenges. People with advanced illness may have limited or wavering ability to participate fully in decision-making conversations - or lack decisional capacity for making decisions. Additionally, they may have a limited understanding of CPR and tend to receive inconsistent information on the process and outcome of CPR. Unfortunately, these discussions are often avoided. Shared decision-making approaches are an approach to overcoming these challenges. The objectives of this research was to design, test, and analyze a novel CPR video decision aid (VDA) with nephrology patients and their families in a clinical setting.

METHODS

The Interprofessional Shared Decision-making Model was used as a framework to guide the research. A prospective quasi-experimental design included pre/posttest measures of knowledge and confidence in decision-making, and posttest only measure of uncertainty about the decision.

RESULTS

Participant knowledge about CPR increased from a mean score of 4.8/9 (standard deviation [SD] = 1.65) before viewing the video to 7.5/9 (SD = 1.40) (p = 0.000) after viewing the video. Decisional self-efficacy improved slightly from 84% pre intervention (SD 17.04, range 20-100) to 86% after the intervention (SD 14.13, range 39-100) (p = 0.005) for patient participants. Before the intervention, most patients (43/49; 86%) had an order to have CPR in the physician orders and very few (7/49; 14%) had an order not to have CPR. Immediately after viewing the CPR-VDA and completing the values clarification worksheet, fewer 28/49 (57%) chose to have CPR, 13 (27%) chose not to have CPR and 8 (16%) were unsure.

CONCLUSIONS

The CPR-VDA was feasible and acceptable to patients with ESRD, their families and the healthcare team. The CPR-VDA positively affected decision-making: improving patient and family knowledge about CPR, clarity of values, patients' decisional self-efficacy, the congruence between documented physician's orders and patient choice, quality of communication about CPR, while reducing decisional conflict (uncertainty) amongst patients, families, and physicians.

The Impact of Multifaceted Osteoporosis Group Education on Patients' Decision-Making regarding Treatment Options and Lifestyle Changes

INTRODUCTION

Patients with chronic diseases like osteoporosis constantly have to make decisions related to their disease. Multifaceted osteoporosis group education (GE) may support patients' decision-making. This study investigated multifaceted osteoporosis GE focusing on the impact of GE on patients' decision-making related to treatment options and lifestyle.

MATERIAL AND METHODS

An interpretive description design using ethnographic methods was utilized with 14 women and three men diagnosed with osteoporosis who attended multifaceted GE. Data consisted of participant observation during GE and individual interviews.

RESULTS

Attending GE had an impact on the patients' decision-making in all educational themes. Patients decided on new ways to manage osteoporosis and made decisions regarding bone health and how to implement a lifestyle ensuring bone health. During GE, teachers and patients shared evidence-based knowledge and personal experiences and preferences, respectively, leading to a two-way exchange of information and deliberation about recommendations. Though teachers and patients explored the implications of the decisions and shared their preferences, teachers stressed that the patients ultimately had to make the decision. Teachers therefore refrained from participating in the final step of the decision-making process.

CONCLUSION

Attending GE has an impact on the patients' decision-making as it can initiate patient reflection and support decision-making.

Development and Pilot Testing of Multimedia Patient Education Tools for Patients With Knee Osteoarthritis, Osteoporosis, and Rheumatoid Arthritis

OBJECTIVE

We developed and tested multimedia patient education tools (video tools) for patients with knee osteoarthritis (OA), osteoporosis (OP), and rheumatoid arthritis (RA).

METHODS

We followed an "edutainment" model, incorporating educational patient story lines. The goals were designed to make the programs both didactic and entertaining, with navigation and graphic user interfaces as simple as possible. We created both English and Spanish language versions. Once the video tool was finalized, 60 patients, 20 per disease, were shown the tool and interviewed. Disease knowledge was our primary outcome, and decision conflict, disease management, and acceptability were secondary outcomes.

RESULTS

We observed statistically significant differences in pre- to postintervention knowledge questionnaire scores (before and after viewing the video tool) (OA: P = 0.03, OP: P = 0.01, and RA: P < 0.0001). Most participants felt they gained "clarity" on disease duration, symptoms, and the time medication takes to start acting; were "encouraged to see their doctor regularly"; and were more aware about taking their medications. In terms of acceptability, most patients in all disease groups found the length and amount of information presented in the video tools to be "just right," and the presentation to be "balanced." In terms of comprehension, all participants provided a favorable evaluation of the video tool; all found the video easy to use, the vocabulary easy to understand, and the materials to be well organized.

CONCLUSION

Multimedia tools that incorporate videos may help patients better understand and manage their disease. Patient involvement in the development process is essential to ensure relevant content and usability.

Facilitating decision-making in women undergoing genetic testing for hereditary breast cancer: BRECONDA randomized controlled trial results

BACKGROUND

Decision-making concerning risk-reducing mastectomy for women at hereditary risk of breast cancer entails complex personal choices. Deciding whether and how to restore breast shape after risk-reducing mastectomy is a key part of this process. We developed a web-based decision aid, BRECONDA (Breast Reconstruction Decision Aid), to assist women in decision-making regarding breast reconstruction.

METHOD

This study assessed the efficacy of BRECONDA to assist women at increased risk of breast cancer in making decisions regarding risk-reducing mastectomy in terms of decisional conflict, knowledge, and satisfaction with information. Women at hereditary risk of breast cancer (N = 64) were recruited into this randomized controlled trial from four Australian hereditary cancer clinics. Participants initially provided online consent and completed baseline questionnaires assessing decisional conflict, knowledge, and satisfaction with information. They were then randomly assigned to either: 1) Intervention - unlimited access to BRECONDA, with usual care; or, 2) Control - usual care. At 2-months follow-up (N = 60) the outcomes were re-assessed. Intervention participants also completed user acceptability ratings for the intervention overall and specific key modules.

RESULTS

MANCOVA analyses indicated that Intervention participants reported lower decisional conflict (P = 0.027), and greater knowledge (P = 0.019) and satisfaction with information (P < 0.0005) at 2-months follow-up compared with Controls. Intervention participants reported high user acceptability and satisfaction with the intervention.

CONCLUSION

BRECONDA benefits women considering risk-reducing mastectomy by reducing decisional conflict, and improving knowledge and satisfaction with information. These benefits, coupled with high user acceptability, demonstrate the feasibility of implementing BRECONDA in the hereditary cancer risk context.

Patient reported outcomes following video assisted thoracoscopic (VATS) resection or stereotactic ablative body radiotherapy (SABR) for treatment of non-small cell lung cancer: protocol for an observational pilot study (LiLAC)

BACKGROUND

Lung cancer is increasingly a disease of the elderly and frail population with a median age of 70 years at diagnosis. Therefore, consideration of the impact of interventions on health-related quality of life (HRQOL) and not only absolute survival is especially important. For non-small cell lung cancer (NSCLC), video-assisted thoracoscopic surgery (VATS) has been gaining popularity over the last few decades, replacing traditional open lobectomies. For high-risk patients who are not deemed suitable for surgery, stereotactic ablative body radiotherapy (SABR) provides a potentially curative alternative. However, little is known about how VATS and SABR affect HRQOL measured using patient reported outcome measures (PROMs). The LiLAC study (Life after Lung Cancer) aims to explore HRQOL following intervention with VATS or SABR using validated PROMs and to pilot the use of an online questionnaire system (QTool) in this setting. We hope the results will aid both patients and clinicians in decision making and improve the management of post-intervention problems.

METHODS

In total, 300 patients (150 VATS and 150 SABR) patients will be recruited over the study period. Patients will be approached prior to intervention and asked to complete baseline HRQOL questionnaires. They will be given access to the QTool online system and then in the 12 months following intervention will be asked to complete questionnaires (paper or online) at 4-time points. Answers will available for patients and clinicians to view throughout the study period. Clinical information (age, gender, co-morbidity, current medications and smoking status along with treatment-specific information) will also be collected. Primary outcome will be to detect changes of PROs (HRQOL and patient satisfaction) after VATS lung resections or SABR in early stage lung cancer patients. Secondary outcomes include correlation of patient's clinical data with HRQOL results to identify predictors of poor outcomes and exploration of patient and clinician views on the usefulness of QOL measurements.

DISCUSSION

(I) This first study will primarily compare multiple patients reported outcomes for 12 months after VATS lobectomy and SABR in early stages NSCLC patients. We will explore the acceptability of an online assessment of the HRQOL in NSCLC patients. (II) The study is also focused on the patients' opinion during the shared decision-making process, which has rarely been investigated in surgical lung cancer patients. (III) This is not a randomised trial. As a consequence, inherent cohort selection bias and unknown or unaccounted confounders correlated with the outcome of interest may influence the results of the comparison between the treatment groups. (IV) LILAC is not looking at a direct comparison, but to depict the trajectory of recovery post-treatments and preservation or improvement of the HRQOL. This study has received ethical approval from NRES Yorkshire and the Humber- Leeds East Research Ethics Committee (REC Ref: 16/YH/0407). Results of this study will be shared with participating hospitals and made available to the academic community through submission for publication in international peer-reviewed journals and presentation at relevant national and international conferences.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02882750.

Reducing Decisional Conflict and Enhancing Satisfaction with Information among Women Considering Breast Reconstruction following Mastectomy: Results from the BRECONDA Randomized Controlled Trial

BACKGROUND

Deciding whether or not to have breast reconstruction following breast cancer diagnosis is a complex decision process. This randomized controlled trial assessed the impact of an online decision aid [Breast RECONstruction Decision Aid (BRECONDA)] on breast reconstruction decision-making.

METHODS

Women (n = 222) diagnosed with breast cancer or ductal carcinoma in situ, and eligible for reconstruction following mastectomy, completed an online baseline questionnaire. They were then assigned randomly to receive either standard online information about breast reconstruction (control) or standard information plus access to BRECONDA (intervention). Participants then completed questionnaires at 1 and 6 months after randomization. The primary outcome was participants' decisional conflict 1 month after exposure to the intervention. Secondary outcomes included decisional conflict at 6 months, satisfaction with information at 1 and 6 months, and 6-month decisional regret.

RESULTS

Linear mixed-model analyses revealed that 1-month decisional conflict was significantly lower in the intervention group (27.18) compared with the control group (35.5). This difference was also sustained at the 6-month follow-up. Intervention participants reported greater satisfaction with information at 1- and 6-month follow-up, and there was a nonsignificant trend for lower decisional regret in the intervention group at 6-month follow-up. Intervention participants' ratings for BRECONDA demonstrated high user acceptability and overall satisfaction.

CONCLUSIONS

Women who accessed BRECONDA benefited by experiencing significantly less decisional conflict and being more satisfied with information regarding the reconstruction decisional process than women receiving standard care alone. These findings support the efficacy of BRECONDA in helping women to arrive at their breast reconstruction decision.

Children's Decision-Making Involvement About Research Participation: Associations With Perceived Fairness and Self-Efficacy

The primary objective of this study was to examine the associations of children's involvement in decisions about research participation with their perceptions of the decision-making process and self-efficacy. Participants were children (ages 8-17) who enrolled in research studies in the prior 2 months. Children completed a questionnaire that yielded three decision-making involvement subscales: Researcher Engages Child, Researcher Supports Autonomy, and Child Participates. Children reported on fairness of the decision-making process and health-related decision self-efficacy. After adjusting for age, higher scores on Researcher Engages Child were associated with greater self-efficacy, and higher scores on Researcher Supports Autonomy were associated with greater perceived fairness. These data underscore the potential importance of researcher-child interactions about research participation when assent is sought, including proactively involving children in the decision by asking for their opinions and communicating their central role in the decision, which are likely to be more meaningful to children than receiving information or signing a form.

Evaluation of a Decision Aid for Women with Epilepsy Who Are Considering Pregnancy: A Randomized Controlled Trial

BACKGROUND

For many women with epilepsy (WWE), decision making about pregnancy is complicated by considerations such as the potential teratogenicity of antiepileptic drugs, offspring risk of epilepsy, seizure occurrence during pregnancy, and the challenges of parenting amidst poorly controlled seizures.

OBJECTIVE

This proof-of-concept, randomized controlled trial aimed to evaluate a decision aid (DA) developed to help WWE decide if they should start or enlarge their families.

METHODS

Seventy-nine WWE of childbearing age were recruited from Epilepsy Action Australia between October and November 2013 and randomized to receive the intervention (the DA) or not, and to complete a set of questionnaires pre- and post- intervention. The DA, delivered as a PDF booklet, provided balanced evidence-based information about options, risks and benefits, including probabilities; as well as steps for clarifying values and considering options within one's personal situation.

RESULTS

Compared with the control group, the DA group had statistically significant improvements in knowledge about pregnancy and epilepsy (Cohen's d = 1.24; 95%CI = 0.77 to 1.83) and reduced decisional conflict (Cohen's d = 0.59; 95%CI = 0.21 to 0.99). Changes in decision self-efficacy, certainty of choice, patient-practitioner communication abilities and value congruence with choice were comparable between the DA and control group. Importantly, women's decisions about motherhood were not biased towards either direction, and there were no adverse effects on depression or anxiety. All women who received the DA indicated they would recommend it to other WWE.

CONCLUSIONS

The DA has the potential to serve as a useful support tool for WWE who are considering motherhood. Future research is needed to test the DA in clinical settings with guidance from a health professional. The trial was registered with the Australian New Zealand Clinical Trials Registry (ID ACTRN12613001082796).

Show Me My Health Plans: a study protocol of a randomized trial testing a decision support tool for the federal health insurance marketplace in Missouri

BACKGROUND

The implementation of the ACA has improved access to quality health insurance, a necessary first step to improving health outcomes. However, access must be supplemented by education to help individuals make informed choices for plans that meet their individual financial and health needs.

METHODS/DESIGN

Drawing on a model of information processing and on prior research, we developed a health insurance decision support tool called Show Me My Health Plans. Developed with extensive stakeholder input, the current tool (1) simplifies information through plain language and graphics in an educational component; (2) assesses and reviews knowledge interactively to ensure comprehension of key material; (3) incorporates individual and/or family health status to personalize out-of-pocket cost estimates; (4) assesses preferences for plan features; and (5) helps individuals weigh information appropriate to their interests and needs through a summary page with "good fit" plans generated from a tailored algorithm. The current study will evaluate whether the online decision support tool improves health insurance decisions compared to a usual care condition (the healthcare.gov marketplace website). The trial will include 362 individuals (181 in each group) from rural, suburban, and urban settings within a 90 mile radius around St. Louis. Eligibility criteria includes English-speaking individuals 18-64 years old who are eligible for the ACA marketplace plans. They will be computer randomized to view the intervention or usual care condition.

DISCUSSION

Presenting individuals with options that they can understand tailored to their needs and preferences could help improve decision quality. By helping individuals narrow down the complexity of health insurance plan options, decision support tools such as this one could prepare individuals to better navigate enrollment in a plan that meets their individual needs. The randomized trial was registered in clinicaltrials.gov (NCT02522624) on August 6, 2015.

Activation of persons living with HIV for treatment, the great study

Background

Patient empowerment represents a potent tool for addressing racial, ethnic and socioeconomic disparities in health care, particularly for chronic conditions such as HIV infection that require active patient engagement. This multimodal intervention, developed in concert with HIV patients and clinicians, aims to provide HIV patients with the knowledge, skills, attitudes and tools to become more activated patients.

Methods/Design

Randomized controlled trial of a multimodal intervention designed to activate persons living with HIV. The intervention includes four components: 1) use of a web-enabled hand-held device (Apple iPod Touch) loaded with a Personal Health Record (ePHR) customized for HIV patients; 2) six 90-minute group-based training sessions in use of the device, internet and the ePHR; 3) a pre-visit coaching session; and 4) clinician education regarding how they can support activated patients. Outcome measures include pre- post changes in patient activation measure score (primary outcome), eHealth literacy, patient involvement in decision-making and care, medication adherence, preventive care, and HIV Viral Load.

Discussion

We hypothesize that participants receiving the intervention will show greater improvement in empowerment and the intervention will reduce disparities in study outcomes. Disparities in these measures will be smaller than those in the usual care group. Findings have implications for activating persons living with HIV and for other marginalized groups living with chronic illness.

Trial registration

ClinicalTrials.gov Identifier: NCT02165735, 6/13/2014.

Older Adults' Use of Online and Offline Sources of Health Information and Constructs of Reliance and Self-Efficacy for Medical Decision Making

We know little about older adults' use of online and offline health information sources for medical decision making despite increasing numbers of older adults who report using the Internet for health information to aid in patient-provider communication and medical decision making. Therefore we investigated older adult users and nonusers of online and offline sources of health information and factors related to medical decision making. Survey research was conducted using random digit dialing of Florida residents' landline telephones. The Decision Self-Efficacy Scale and the Reliance Scale were used to measure relationships between users and nonusers of online health information. Study respondents were 225 older adults (age range = 50-92 years, M = 68.9, SD = 10.4), which included users (n = 105) and nonusers (n = 119) of online health information. Users and nonusers differed in frequency and types of health sources sought. Users of online health information preferred a self-reliant approach and nonusers of online health information preferred a physician-reliant approach to involvement in medical decisions on the Reliance Scale. This study found significant differences between older adult users and nonusers of online and offline sources of health information and examined factors related to online health information engagement for medical decision making.

Coaching patients in the use of decision and communication aids: RE-AIM evaluation of a patient support program

Background

Decision aids educate patients about treatment options and outcomes. Communication aids include question lists, consultation summaries, and audio-recordings. In efficacy studies, decision aids increased patient knowledge, while communication aids increased patient question-asking and information recall. Starting in 2004, we trained successive cohorts of post-baccalaureate, pre-medical interns to coach patients in the use of decision and communication aids at our university-based breast cancer clinic.

Methods

From July 2005 through June 2012, we used the RE-AIM framework to measure Reach, Effectiveness, Adoption, Implementation and Maintenance of our interventions.

Results

Reach: Over the study period, our program sent a total of 5,153 decision aids and directly administered 2,004 communication aids. In the most recent program year (2012), out of 1,524 eligible patient appointments, we successfully contacted 1,212 (80 %); coached 1,110 (73 %) in the self-administered use of decision and communication aids; sent 958 (63 %) decision aids; and directly administered communication aids for 419 (27 %) patients. In a 2010 survey, coached patients reported self-administering one or more communication aids in 81 % of visits

Effectiveness: In our pre-post comparisons, decision aids were associated with increased patient knowledge and decreased decisional conflict. Communication aids were associated with increased self-efficacy and number of questions; and with high ratings of patient preparedness and satisfaction

Adoption: Among visitors sent decision aids, 82 % of survey respondents reviewed some or all; among those administered communication aids, 86 % reviewed one or more after the visit

Implementation: Through continuous quality adaptations, we increased the proportion of available staff time used for patient support (i.e. exploitation of workforce capacity) from 29 % in 2005 to 84 % in 2012

Maintenance: The main barrier to sustainability was the cost of paid intern labor. We addressed this by testing a service learning model in which student interns work as program coaches in exchange for academic credit rather than salary. The feasibility test succeeded, and we are now expanding the use of unpaid interns.

Conclusion

We have sustained a clinic-wide implementation of decision and communication aids through a novel staffing model that uses paid and unpaid student interns as coaches.

Encounter Decision Aid vs. Clinical Decision Support or Usual Care to Support Patient-Centered Treatment Decisions in Osteoporosis: The Osteoporosis Choice Randomized Trial II

PURPOSE

Osteoporosis Choice, an encounter decision aid, can engage patients and clinicians in shared decision making about osteoporosis treatment. Its effectiveness compared to the routine provision to clinicians of the patient's estimated risk of fracture using the FRAX calculator is unknown.

METHODS

Patient-level, randomized, three-arm trial enrolling women over 50 with osteopenia or osteoporosis eligible for treatment with bisphosphonates, where the use of Osteoporosis Choice was compared to FRAX only and to usual care to determine impact on patient knowledge, decisional conflict, involvement in the decision-making process, decision to start and adherence to bisphosphonates.

RESULTS

We enrolled 79 women in the three arms. Because FRAX estimation alone and usual care produced similar results, we grouped them for analysis. Compared to these, use of Osteoporosis Choice increased patient knowledge (median score 6 vs. 4, p = .01), improved understanding of fracture risk and risk reduction with bisphosphonates (p = .01 and p<.0001, respectively), had no effect on decision conflict, and increased patient engagement in the decision making process (OPTION scores 57% vs. 43%, p = .001). Encounters with the decision aid were 0.8 minutes longer (range: 33 minutes shorter to 3.0 minutes longer). There were twice as many patients receiving and filling prescriptions in the decision aid arm (83% vs. 40%, p = .07); medication adherence at 6 months was no different across arms.

CONCLUSION

Supporting both patients and clinicians during the clinical encounter with the Osteoporosis Choice decision aid efficiently improves treatment decision making when compared to usual care with or without clinical decision support with FRAX results.

TRIAL REGISTRATION

clinical trials.gov NCT00949611.

Middle-aged women's decisions about body weight management: needs assessment and testing of a knowledge translation tool

OBJECTIVE

This study aims to assess middle-aged women's needs when making body weight management decisions and to evaluate a knowledge translation tool for addressing their needs.

METHODS

A mixed-methods study used an interview-guided theory-based survey of professional women aged 40 to 65 years. The tool summarized evidence to address their needs and enabled women to monitor actions taken. Acceptability and usability were reported descriptively.

RESULTS

Sixty female participants had a mean body mass index of 28.0 kg/m(2) (range, 17.0-44.9 kg/m(2)), and half were premenopausal. Common options for losing (82%) or maintaining (18%) weight included increasing physical activity (60%), eating healthier (57%), and getting support (40%). Decision-making involved getting information on options (52%), soliciting others' decisions/advice (20%), and being self-motivated (20%). Preferred information sources included written information (97%), counseling (90%), and social networking websites (43%). Five professionals (dietitian, personal trainer, occupational therapist, and two physicians) had similar responses. Of 53 women sent the tool, 27 provided acceptability feedback. They rated it as good to excellent for information on menopause (96%), body weight changes (85%), and managing body weight (85%). Most would tell others about it (81%). After 4 weeks of use, 25 women reported that the wording made sense (96%) and that the tool had clear instructions (92%) and was easy to use across time (88%). The amount of information was rated as just right (64%), but the tool had limited space for responding (72%).

CONCLUSIONS

When making decisions about body weight management, women's needs were "getting information" and "getting support." The knowledge translation tool was acceptable and usable, but further evaluation is required.

Minimum standards for the certification of patient decision support interventions: feasibility and application

OBJECTIVE

Patient decision support interventions are not currently subject to standardized quality control. The current study aims to assess the feasibility of applying a proposed set of minimum standards (previously developed as part of a possible certification process) to a selection of existing patient decision support interventions.

METHODS

A convenience sample of interventions selected from those included in the 2009 Cochrane systematic review of patient decision aids was scored by trained raters using the International Patient Decision Aids Standards (IPDAS) instrument. Scores were then evaluated against the published proposed minimum standards.

RESULTS

Twenty-five out of thirty included interventions met all qualifying criteria while only three met the proposed certification criteria. The changes required for an intervention to meet the proposed certification standards were relatively minor. There was considerable variation between raters' mean scores.

CONCLUSIONS

Most interventions did not meet the certification criteria due to lack of information on modifiable items such as update policy and funding source.

PRACTICE IMPLICATIONS

Specifying minimum standards for patient decision support interventions is a feasible development. However, it remains unclear whether the minimum standards can be applied to interventions designed for use within clinical encounters and to those that target screening and diagnostic tests.

The digital health divide: evaluating online health information access and use among older adults

OBJECTIVE

Innovations in health information technology (HIT) provide opportunities to reduce health care spending, improve quality of care, and improve health outcomes for older adults. However, concerns relating to older adults' limited access and use of HIT, including use of the Internet for health information, fuel the digital health divide debate. This study evaluated the potential digital health divide in relation to characteristic and belief differences between older adult users and nonusers of online health information sources.

METHODS

A cross-sectional survey design was conducted using a random sample of older adults. A total of 225 older adults (age range = 50-92 years, M = 68.9 years, SD = 10.4) participated in the study.

RESULTS

Seventy-six percent of all respondents had Internet access. Users and nonusers of online health information differed significantly on age (M = 66.29 vs. M = 71.13), education, and previous experience with the health care system. Users and nonusers of online health information also differed significantly on Internet and technology access, however, a large percentage of nonusers had Internet access (56.3%), desktop computers (55.9%), and laptop computers or netbooks (43.2%). Users of online health information had higher mean scores on the Computer Self-Efficacy Measure than nonusers, t(159) = -7.29, p < .0001.

CONCLUSION

This study found significant differences between older adult users and nonusers of online health information. Findings suggest strategies for reducing this divide and implications for health education programs to promote HIT use among older adults.

The development and evaluation of a five-language multi-perspective standardised measure: clinical decision-making involvement and satisfaction (CDIS)

BACKGROUND

The aim of this study was to develop and evaluate a brief quantitative five-language measure of involvement and satisfaction in clinical decision-making (CDIS) - with versions for patients (CDIS-P) and staff (CDIS-S) - for use in mental health services.

METHODS

An English CDIS was developed by reviewing existing measures, focus groups, semistructured interviews and piloting. Translations into Danish, German, Hungarian and Italian followed the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Task Force principles of good practice for translation and cultural adaptation. Psychometricevaluation involved testing the measure in secondary mental health services in Aalborg, Debrecen, London, Naples, Ulm and Zurich.

RESULTS

After appraising 14 measures, the Control Preference Scale and Satisfaction With Decision-making English-language scales were modified and evaluated in interviews (n = 9), focus groups (n = 22) and piloting (n = 16). Translations were validated through focus groups (n = 38) and piloting (n = 61). A total of 443 service users and 403 paired staff completed CDIS. The Satisfaction sub-scale had internal consistency of 0.89 (0.86-0.89 after item-level deletion) for staff and 0.90 (0.87-0.90) for service users, both continuous and categorical (utility) versions were associated with symptomatology and both staff-rated and service userrated therapeutic alliance (showing convergent validity), and not with social disability (showing divergent validity), and satisfaction predicted staff-rated (OR 2.43, 95%CI 1.54- 3.83 continuous, OR 5.77, 95%CI 1.90-17.53 utility) and service user-rated (OR 2.21, 95%CI 1.51-3.23 continuous, OR 3.13, 95%CI 1.10-8.94 utility) decision implementation two months later. The Involvement sub-scale had appropriate distribution and no floor or ceiling effects, was associated with stage of recovery, functioning and quality of life (staff only) (showing convergent validity), and not with symptomatology or social disability (showing divergent validity), and staff-rated passive involvement by the service user predicted implementation (OR 3.55, 95%CI 1.53-8.24). Relationships remained after adjusting for clustering by staff.

CONCLUSIONS

CDIS demonstrates adequate internal consistency, no evidence of item redundancy, appropriate distribution, and face, content, convergent, divergent and predictive validity. It can be recommended for research and clinical use. CDIS-P and CDIS-S in all 3 five languages can be downloaded at http://www.cedar-net.eu/instruments.

TRIAL REGISTRATION

ISRCTN75841675.

Improving urban African Americans' blood pressure control through multi-level interventions in the Achieving Blood Pressure Control Together (ACT) study: a randomized clinical trial

BACKGROUND

Given their high rates of uncontrolled blood pressure, urban African Americans comprise a particularly vulnerable subgroup of persons with hypertension. Substantial evidence has demonstrated the important role of family and community support in improving patients' management of a variety of chronic illnesses. However, studies of multi-level interventions designed specifically to improve urban African American patients' blood pressure self-management by simultaneously leveraging patient, family, and community strengths are lacking.

METHODS/DESIGN

We report the protocol of the Achieving Blood Pressure Control Together (ACT) study, a randomized controlled trial designed to study the effectiveness of interventions that engage patient, family, and community-level resources to facilitate urban African American hypertensive patients' improved hypertension self-management and subsequent hypertension control. African American patients with uncontrolled hypertension receiving health care in an urban primary care clinic will be randomly assigned to receive 1) an educational intervention led by a community health worker alone, 2) the community health worker intervention plus a patient and family communication activation intervention, or 3) the community health worker intervention plus a problem-solving intervention. All participants enrolled in the study will receive and be trained to use a digital home blood pressure machine. The primary outcome of the randomized controlled trial will be patients' blood pressure control at 12months.

DISCUSSION

Results from the ACT study will provide needed evidence on the effectiveness of comprehensive multi-level interventions to improve urban African American patients' hypertension control.

Development of a patient decision aid for people with refractory angina: protocol for a three-phase pilot study

Background

Refractory angina is a severe chronic disease, defined as angina which cannot be controlled by usual treatments for heart disease. This disease is frightening, debilitating, and difficult to manage. Many people suffering refractory have inadequate pain relief, continually revisit emergency departments for help, undergo repeated cardiac investigations, and struggle with obtaining appropriate care. There is no clear framework to help people understand the risks and benefits of available treatment options in Canada. Some treatments for refractory angina are invasive, while others are not covered by provincial health insurance plans. Effective care for refractory angina sufferers in Canada is critically underdeveloped; it is important that healthcare professionals and refractory angina sufferers alike understand the treatment options and their implications. This proposal builds on the recent Canadian practice guidelines for the management of refractory angina. We propose to develop a decision support tool in order to help people suffering from refractory angina make well-informed decisions about their healthcare and reduce their uncertainty about treatment options.

Methods

This project will be conducted in three phases: a) development of the support tool with input from clinical experts, the Canadian refractory angina guidelines, and people living with refractory angina, b) pilot testing of the usability of the tool, and c) formal preliminary evaluation of the effectiveness of the support tool to help people make informed decisions about treatment options.

Discussion

A decision support tool for refractory angina is needed and the available data suggest that by developing such a tool, we may be able to help refractory angina sufferers better understand their condition and the effectiveness of available treatment options (in their respective clinical settings) as well as their implications (e.g. risks vs. benefits). By virtue of this tool, we may also be able to facilitate identification and inclusion of patients’ values and preferences in the decision making process. This is particularly important as refractory angina is an intractable condition, necessitating that the selected course of treatment be lifelong. This study will yield a much needed patient decision aid for people living with refractory angina and pilot data to support a subsequent effectiveness study.

The evaluation of a rectal cancer decision aid and the factors influencing its implementation in clinical practice

BACKGROUND

Colorectal cancer is common in North America. Two surgical options exist for rectal cancer patients: low anterior resection with re-establishment of bowel continuity, and abdominoperineal resection with a permanent stoma. A rectal cancer decision aid was developed using the International Patient Decision Aid Standards to facilitate patients being more actively involved in making this decision with the surgeon. The overall aim of this study is to evaluate this decision aid and explore barriers and facilitators to implementing in clinical practice.

METHODS

First, a pre- and post- study will be guided by the Ottawa Decision Support Framework. Eligible patients from a colorectal cancer center include: 1) adult patients diagnosed with rectal cancer, 2) tumour at a maximum of 10 cm from anal verge, and 3) surgeon screened candidates eligible to consider both low anterior resection and abdominoperineal resection. Patients will be given a paper-version and online link to the decision aid to review at home. Using validated tools, the primary outcomes will be decisional conflict and knowledge of surgical options. Secondary outcomes will be patient's preference, values associated with options, readiness for decision-making, acceptability of the decision aid, and feasibility of its implementation in clinical practice. Proposed analysis includes paired t-test, Wilcoxon, and descriptive statistics. Second, a survey will be conducted to identify the barriers and facilitators of using the decision aid in clinical practice. Eligible participants include Canadian surgeons working with rectal cancer patients. Surgeons will be given a pre-notification, questionnaire, and three reminders. The survey package will include the patient decision aid and a facilitators and barriers survey previously validated among physicians and nurses. Principal component analysis will be performed to determine common themes, and logistic regression will be used to identify variables associated with the intention to use the decision aid.

DISCUSSION

This study will evaluate the impact of the rectal cancer decision aid on patients and help with planning strategies to overcome barriers and facilitate implementation of the decision aid in routine clinical practice. To our knowledge this is the first study designed to evaluate a decision aid in the field of colorectal surgery.

Knowledge, attitudes, and self-efficacy as predictors of preparedness for oncology clinical trials: a mediational model

OBJECTIVE

This study used the Ottawa Decision Support Framework to evaluate a model examining associations between clinical trial knowledge, attitudinal barriers to participating in clinical trials, clinical trial self-efficacy, and clinical trial preparedness among 1256 cancer patients seen for their first outpatient consultation at a cancer center. As an exploratory aim, moderator effects for gender, race/ethnicity, education, and metastatic status on associations in the model were evaluated.

METHODS

. Patients completed measures of cancer clinical trial knowledge, attitudinal barriers, self-efficacy, and preparedness. Structural equation modeling (SEM) was conducted to evaluate whether self-efficacy mediated the association between knowledge and barriers with preparedness.

RESULTS

. The SEM explained 26% of the variance in cancer clinical trial preparedness. Self-efficacy mediated the associations between attitudinal barriers and preparedness, but self-efficacy did not mediate the knowledge-preparedness relationship.

CONCLUSIONS

. Findings partially support the Ottawa Decision Support Framework and suggest that assessing patients' level of self-efficacy may be just as important as evaluating their knowledge and attitudes about cancer clinical trials.

Development and feasibility testing of decision support for patients who are candidates for a prophylactic implantable defibrillator: a study protocol for a pilot randomized controlled trial

BACKGROUND

Patients, identified to be at risk for but who have never experienced a potentially lethal cardiac arrhythmia, have the option of receiving an implantable cardioverter defibrillator (ICD) as prophylaxis against sudden cardiac death - a primary prevention indication. In Canada, there is no clear framework to support patients' decision-making for these devices. Decision support, using a decision aid, could moderate treatment-related uncertainty and prepare patients to make well-informed decisions. Patient decision aids provide information on treatment options, risks, and benefits, to help patients clarify their values for outcomes of treatment options. The objectives of this research are: 1) develop a decision aid, 2) evaluate the decision aid, and 3) determine the feasibility of conducting a trial.

METHODS/DESIGN

A development panel comprised of the core investigative team, health service researchers, decision science experts, cardiovascular healthcare practitioners, and ICD patient representatives will collaborate to provide input on the content and format of the aid. To generate probabilities to include in the aid, we will synthesize primary prevention ICD evidence. To obtain anonymous input about the facts and content, we will employ a modified Delphi process. To evaluate the draft decision aid will invite ICD patients and their families (n = 30) to rate its acceptability. After we evaluate the aid, to determine the feasibility, we will conduct a feasibility pilot randomized controlled trial (RCT) in new ICD candidates (n = 80). Participants will be randomized to receive a decision aid prior to specialist consultation versus usual care. Results from the pilot RCT will determine the feasibility of research processes; inform sample size calculation, measure decision quality (knowledge, values, decision conflict) and the influence of health related quality of life on decision-making.

DISCUSSION

Our study seeks to develop a decision aid, for patients offered their first ICD for prophylaxis against sudden cardiac death. This paper outlines the background and methods of a pilot randomized trial which will inform a larger multicenter trial. Ultimately, decision support prior to specialist consultation could enhance the decision-making process between patients, physicians, and families, associated with life-prolonging medical devices like the ICD.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01876173.

Attitudes and experience of youth and their parents with psychiatric medication and relationship to self-reported adherence

Few studies have directly examined the interrelationship of teen and parent attitudes toward psychiatric medication and how this relates to medication adherence. In the current study, survey data from 19 parent-child dyads were analyzed to investigate the relationship of parent and teen attitudes toward medication, decision self-efficacy, and current involvement in decisions about psychiatric medication with self-reported adherence. Structural equation modeling techniques were used to fit actor-partner interdependence models to examine bidirectional effects of the dyadic relationships. Teens and parents had similarly positive attitudes toward medication, high levels of self-efficacy and self-reported adherence. Current involvement in decisions about medications was significantly lower for teens compared to their parents. The actor-partner interdependence models revealed that parent levels of decision self-efficacy were related to youth self-reported adherence (partner effect). Youth attitudes toward medications were related to youth self-reported adherence (actor effect). Parent and teen actor effects of decisional self-efficacy were significantly associated with current involvement. Providers need to be aware of the importance of engaging both teens and parents in decisions about psychiatric medication and recognize the need to explicitly elicit questions and concerns from young patients.

Awareness of osteoporosis, risk and protective factors and own diagnostic status: a cross-sectional study

We conducted a cross-sectional study of the understanding on osteoporosis amongst community-dwelling geriatric patients. Patient understanding on the pathology, risk factors and its complications was suboptimal, but better amongst women and persons with diagnosed osteoporosis. Improving patient osteoporosis education may lead to improved compliance with preventive and therapeutic measures.

PURPOSE

Osteoporosis is often preventable and treatable. Establishing levels of understanding in an Irish population will help inform future public and patient education.

METHODS

We conducted a cross-sectional survey of 126 randomly selected geriatric day hospital patients, interviewing next of kin where abbreviated mental test score was <6. Questions assessed awareness of (1) basic pathology, (2) predisposing and protective factors, (3) complications and (4) personal osteoporosis status and treatment.

RESULTS

Participants included 103 patients and 23 carers; 78.6 % were female; patients' mean age was 81.6 years. Of the patients surveyed, 87.3 % had heard of osteoporosis; 56.1 % knew affected bone; and 30.2 % were cognisant of architectural change. About 65.9 % reported that a doctor had never discussed the condition; 92.9 % correctly identified whether diagnosed with osteoporosis, and >96 % correctly identified their treatment status. Rates of risk factor identification were as follows: 88.9 % for ageing, 83.8 % female gender, 65.1 % smoking, 62.4 % low BMI and 51.6 % alcohol excess; <10 % identified other risk factors. Awareness of complications ranged from 91.3 % for fractures to 44.4 % for height loss. Awareness of protective factors (calcium/vitamin D-rich food, medication and exercise) was >85 % for each. More women had heard of osteoporosis (p = 0.02), knew affected bone (p = 0.005) and recognised gender as a risk factor (p = 0.015) and pain (p = 0.05) or kyphosis (p = 0.014) as complications. Osteoporotic patients (N = 38) were more likely to know it as affected bone (p = 0.006). Amongst patients surveyed [abbreviated mental test score (AMTS) 6-10], AMTS score did not predict understanding. Age did not predict understanding, nor were next of kin more likely to understand osteoporosis than patients.

CONCLUSION

There is scope for enhancing patient osteoporosis education, which may improve compliance with preventive and therapeutic measures.

Cancer patient and survivor research from the cancer information service research consortium: a preview of three large randomized trials and initial lessons learned

The authors describe 3 large randomized trials from the Cancer Information Service Research Consortium. Three web-based multimedia programs are being tested to help newly diagnosed prostate (Project 1) and breast cancer patients (Project 2) make informed treatment decisions and breast cancer patients prepare for life after treatment (Project 3). Project 3 also tests a telephone callback intervention delivered by a cancer information specialist. All participants receive standard print material specific to each project. Preliminary results from the 2-month follow-up interviews are reported for the initial wave of enrolled participants, most of whom were recruited from the Cancer Information Service (1-800-4-CANCER) telephone information program (Project 1: n =208; Project 2: n =340; Project 3: n =792). Self-reported use of the multimedia program was 51%, 52%, and 67% for Projects 1, 2, and 3, respectively. Self-reported use of the print materials (read all, most, or some) was 90%, 85%, and 83% for Projects 1, 2, and 3, respectively. The callback intervention was completed by 92% of Project 3 participants. Among those using the Cancer Information Service Research Consortium interventions, perceived usefulness and benefit was high, and more than 90% reported that they would recommend them to other cancer patients. The authors present 5 initial lessons learned that may help inform future cancer communications research.

Evaluation of nurses' perceptions on providing patient decision support with cardiopulmonary resuscitation

The decision whether to receive cardiopulmonary resuscitation (CPR) is a decision in which the personal values of the patient must be considered along with information about the risks and benefits of the treatment. A decision aid can be used to provide patient decision support to a patient who is seriously ill and needs to consider CPR options. The goal of this project was to identify the barriers and facilitators to using a CPR decision aid, through evaluating nursing perceptions on providing patient decision support. Using a needs assessment, it was determined that implementing a patient decision aid for CPR status in the Acute Monitor Area (AMA) of The Ottawa Hospital would be an excellent quality improvement project. The nurses who chose to participate were given an education session regarding patient decision support. Questionnaires were distributed to evaluate their views of patient decision support and decision aids before and after the education session and implementation of the CPR decision aid. Questionnaire results did not indicate a significant change between before or after education session and decision aid implementation. Qualitative reports did indicate that nurses generally have positive attitudes toward patient decision support and decision aids. The nurses identified specific barriers and facilitators in their commentaries. This clinically relevant data supports the idea that patient decision support should be integrated into daily nursing practice.

Culturally tailoring patient education and communication skills training to empower African-Americans with diabetes

New translational strategies are needed to improve diabetes outcomes among low-income African-Americans. Our goal was to develop/pilot test a patient intervention combining culturally tailored diabetes education with shared decision-making training. This was an observational cohort study. Surveys and clinical data were collected at baseline, program completion, and 3 and 6 months. There were 21 participants; the mean age was 61 years. Eighty-six percent of participants attended >70 % of classes. There were improvements in diabetes self-efficacy, self-care behaviors (i.e., following a "healthful eating plan" (mean score at baseline 3.4 vs. 5.2 at program's end; p = 0.002), self glucose monitoring (mean score at baseline 4.3 vs. 6.2 at program's end; p = 0.04), and foot care (mean score at baseline 4.1 vs. 6.0 at program's end; p = 0.001)), hemoglobin A1c (8.24 at baseline vs. 7.33 at 3-month follow-up, p = 0.02), and HDL cholesterol (51.2 at baseline vs. 61.8 at 6-month follow-up, p = 0.01). Combining tailored education with shared decision-making may be a promising strategy for empowering low-income African-Americans and improving health outcomes.