Evidence-informed patient choice. Practical issues of involving patients in decisions about health care technologies

Patient engagement in the design of clinical research in Noonan syndrome spectrum disorders: a scoping review

Background

Noonan syndrome spectrum disorders are a group of disorders caused by mutations in several genes of the RAS/MAPK pathway. Because of a highly heterogeneity and variable phenotypical manifestations of the disorders, these children and adults have a variable number of symptoms. Inclusion of their perceived experience of their health and developmental problems in research (design) could contribute to increased relevance of the research process and outcomes. The aim of this study is to get insight in what way patients with a Noonan syndrome spectrum disorder have been involved in the research process in order to learn for future engagement practices.

Methods and results

To that end, the degree of engagement was measured by the eight levels of the participation ladder of Arnstein. Using a scoping review approach, 18 articles were selected in which patient engagement in the design of studies in patients with Noonan syndrome spectrum disorders was described over the past twenty years. Six of these articles reported engagement on the level of informing (level 3), 8 on the level of consultation (level 4), 2 on the level of placation (level 5)and 2 on the level of partnership (level 6).

Conclusions

The current results do show a positive albeit still modest development of patient engagement over the last few years. A promising way to stimulate engagement is aiming to yield insights in the most important patients’ needs by developing a patient guided research agenda. However, this is not automatically followed by patient engagement at higher levels of participation in subsequent research steps. For this reason, in the Netherlands for example, a Dutch Noonan syndrome spectrum disorders research agenda is being developed, in a collaboration between the Dutch Noonan Syndrome Foundation and national scientific and clinical professionals.

The contribution of French patient and consumer groups to health technology assessments over a 2-year period: an observational retrospective study

BACKGROUND

In 2017, The French National Authority for Health (HAS) created an open, online, systematic contribution process to enable patient and consumer groups (PCGs) to contribute to health technology assessment (HTA) carried out to aid public authorities in reimbursement and pricing decision making.

OBJECTIVES

This retrospective study analyzes how French PCGs contributed to the HTA process within the HAS for the first 2 years of this new mechanism.

METHODS

PCG contributions received between 01 January 2017 and 31 December 2018 and the recording of deliberations leading to reports of the corresponding HTAs were included. Analysis grids were designed by the investigators with 5 rounds of refinement tests on 10 random PCG contributions and the reports. Systematic data extraction was then performed separately by two investigators. PCG answers to the open-question templates and the related final HTA report published by the HAS were analyzed.

RESULTS

Seventy-nine contributions from 44 PCGs were received and analyzed by the HAS for 78 out of the 592 HTAs performed for drugs or medical devices during the 2-year period. Twenty-five percent of the HTAs performed for drugs received at least one contribution. The contributions covered quality-of-life aspects, access to care, and personal and family impact. Membership and budget of the contributing PCGs varied greatly.

CONCLUSIONS

The experience gained in the first 2 years demonstrates the feasibility of the process and the fact that PCG contribution actually provides relevant input on the patient perspective for HTAs used for reimbursement decisions. The challenges identified on the side of PCGs were time constraints and human resources.

How healthcare systems shape a purchaser's strategies and actions when managing chronic care

Healthcare purchasing organisations in both insurance-based and tax-based healthcare systems struggle to improve chronic care. A key challenge for purchasers is to deal with the chain of multiple providers involved in caring for patients with complex needs. To date, most research has focused on differences between healthcare systems in terms of regulation, tools and the freedom that healthcare purchasers have. However, this does not explain how such different healthcare system characteristics lead to different purchasing strategies and actions. A better understanding of this link between system characteristics and purchaser behaviour would assist policymakers seeking to improve healthcare purchasing. This multiple case study conducted in England, Sweden and the Netherlands examines the link between the different healthcare systems' characteristics and the purchasers' strategies and actions when managing chronic care chains. Purchasers' strategies and actions varied in terms of the purchaser's engagement, strategic lens and influencing style. Our findings suggest that differences in purchaser competition, purchaser governance and patient choice in healthcare systems are key factors in explaining a purchaser's strategies and actions when pursuing improvements in chronic care. This study contributes to knowledge on what shapes the purchaser's role, and shows how policymakers in both insurance- and tax-based regimes can improve healthcare purchasing.

Hospital Choice in Cancer Care: A Qualitative Study

AIMS

There is limited evidence about how patients respond to hospital choice policies, the factors that inform and influence patient choices or how relevant these policies are to cancer patients. This study sought to evaluate hospital choice policies from the perspective of men who received treatment for prostate cancer in the English National Health Service.

MATERIALS AND METHODS

Semi-structured interviews were undertaken with a purposive sample of 25 men across England. Fourteen men had chosen to receive treatment at a cancer centre other than their nearest. Interviews were recorded and analysed concurrently with data collection.

RESULTS

Men highlight that the geographical configuration of specialist services, the perceived urgency of the condition and the protocolisation of treatment pathways all limit their choice of a specialist treatment centre. Diseases such as cancer appear not to be well suited to the patient choice model, given the lack of hospital-level outcome data. Men instead use proxy measures of quality, leaving them vulnerable to influence by marketing and media reports. Men wishing to consider other treatment centres need to independently collect and appraise complex treatment-related information, which creates socioeconomic inequities in access to treatments. A positive impact of the choice agenda is that it enables patients to 'exit care' not meeting their expectations.

DISCUSSION

Policy makers have failed to consider the organisational, disease-specific and socio-cognitive factors that influence a patient's ability to choose their cancer treatment provider. Valid comparative hospital-level performance information is required to guide patients' choices, otherwise patients will continue to depend on informal sources, which will not necessarily improve their health care outcomes.

Detained – what's my choice? Part 1: Discussion

Choice, responsibility, recovery and social inclusion are concepts guiding the ‘modernisation’ and redesign of psychiatric services. Each has its advocates and detractors, and at the deep end of mental health/psychiatric practice they all interact. In the context of severe mental health problems choice and social inclusion are often deeply compromised; they are additionally difficult to access when someone is detained and significant aspects of personal responsibility have been temporarily taken over by others. One view is that you cannot recover while others are in control. We disagree and believe that it is possible to work in a recovery-oriented way in all service settings. This series of articles represents a collaborative dialogue between providers and consumers of compulsory psychiatric services and expert commentators. We worked together, reflecting on the literature and our own professional and personal experience to better understand how choice can be worked with as a support for personal recovery even in circumstances of psychiatric detention. We were particularly interested to consider whether and how detention and compulsion could be routes to personal recovery. We offer both the process of our co-working and our specific findings as part of a continuing dialogue on these difficult issues.

Shared decision-making, health choices and the menopause

Summary

The growing influence of the mass media on public understanding of health care matters has increased both information and misinformation in patients seeking help with menopausal symptoms. The use of shared decision-making strategies provides the opportunity to engage the patient in taking some responsibility for their own treatment. It also allows the identification and correction of any distortions in the perceived balance of evidence for and against any particular treatment. Shared decision-making balances the need to respect patients’ values and autonomy with the drive towards evidence-based medicine and clinical cost-effectiveness. Although ways of achieving such a balance are much discussed, the current need is for research which can identify effective strategies that allow the principles of “shared decision-making” and “evidence-based patient choice” to be validated and applied in clinical practice. Previous research focused on hormone replacement therapy indicates that the patient's decision is the outcome of the way they balance the pros and cons of taking (or not taking) it, and that their satisfaction with the decision is strongly associated with the perception that they have been given information about the full range of treatment available. It therefore seems likely that patients will respond more positively to consultations which include discussion of hormone replacement therapy alongside alternative strategies such as natural remedies and dietary/lifestyle changes. Psychological factors influencing treatment choice and the decision making process are discussed, and clinical and research implications for clinical practice in the menopause clinic examined.

Content and implementation of clinical decisions in the routine care of people with severe mental illness

BACKGROUND

Clinical decision making (CDM) in the treatment of people with severe mental illness relates to a wide range of life domains.

AIMS

To examine content of CDM in mental health care from the perspectives of service users and staff and to investigate variation in implementation of decisions for differing content.

METHOD

As part of the European multicenter study clinical decision making and outcome in routine care for people with severe mental illness (ISRCTN75841675), 588 service users and their clinicians were asked to identify the decisions made during their last meeting. Decisions were then coded into content categories. Two months later, both parties reported if these decisions had been implemented.

RESULTS

Agreement between patients and staff regarding decision making was moderate (k = 0.21–0.49; p < 0.001). Decisions relating to medication and social issues were most frequently identified. Overall reported level of implementation was 73.5% for patients and 74.7% for staff, and implementation varied by decision content.

CONCLUSIONS

A variety of relevant decision topics were shown for mental health care.Implementation rates varied in relation to topic and may need different consideration within the therapeutic dyad.

Positive distraction and the rehabilitation hospitals of joão filgueiras lima

OBJECTIVE

This article discusses the use of positive distraction, an evidence-based design approach, in rehabilitation hospitals in Brazil through the work of João Filgueiras Lima ("Lelé").

BACKGROUND

In many parts of the world architects may not formally incorporate theories of positive distraction and evidence-based design, but there are multiple international examples of health facility architects and designers that use nature, daylighting, art, and social interaction to enhance the healing experience. The work of the Brazilian architect João Filgueiras Lima is a particularly salient example. Lima has been a dominant figure in 20th and 21st century Brazilian architecture and the architect of several rehabilitation facilities.

METHODS

First positive distraction is defined as it relates to nature and art, and in the context of rehabilitation hospitals. Second, rehabilitation facilities are defined. The discussion then focuses on awareness of evidence-based design in Latin America. Next, Brazilian healthcare architecture is discussed along with the history of the Brazilian Sarah rehabilitation hospitals designed by Lelé and Lelé's role in the history of Brazilian architecture. Last we look at Lelé's use of positive distraction.

RESULTS

Despite Lelé's recognition in Brazil, his work has not gained much international exposure. Lelé played a critical role in the design of the Sarah facilities and served on the board of directors for the Technological Center of the Sarah Network (CTRS) in Brazil from 1992 to 2009. Based on our review of his work it was clear that Lelé used positive distraction as a tool for creating healing environments.

CONCLUSIONS

In spite of the lack of formal integration of evidence-based design in healthcare architecture in Latin America, many of its basic tenets have been incorporated in Brazilian rehabilitation hospitals. Lelé's projects are a clear example of this phenomenon and demonstrate an alignment between research and practitioner objectives. The presence of nature, art, and natural light in his rehabilitation hospitals serves as a model for evidence-based design in facilities throughout the world and presents an opportunity to measure the benefits of positive distraction on rehabilitation patient outcomes.

Competing patient and professional agendas in service development

PURPOSE

The purpose of this paper is to engage stakeholders in the development of a community based chronic pain-management service and identify their different agendas for service design and delivery.

DESIGN/METHODOLOGY/APPROACH

Data were collected using the Nominal Group Technique (NGT), a ten-step process that generates qualitative and quantitative data. Seven NGT groups were conducted in the south-west region of the UK, three with General Practitioners and nurses, three with chronic pain patients, and one with Healthcare Commissioners.

FINDINGS

The patient agenda for service development focused on process of care issues particularly the need for deep- empathy and emotional support from providers, while professionals prioritised cost-effectiveness. While there was some overlap between agendas they were largely discrete and often contradictory.

RESEARCH LIMITATIONS/IMPLICATIONS

- The findings imply service planners will need to make trade-offs between cost-containment and patient satisfaction. The methodology did not allow trade-offs to be put to participants in a structured form. However, such techniques are available, for example, Conjoint Analysis. There may also be value in bringing together patients and professionals in joint focus groups, to see if the gap between their different agendas can be bridged through discussion.

ORIGINALITY/VALUE

The findings provide a novel insight into the competing agendas of patients and professionals regarding service development and design which will be of value to service planners and managers as they strive to reconcile these differences.

Patient engagement in the inpatient setting: a systematic review

OBJECTIVE

To systematically review existing literature regarding patient engagement technologies used in the inpatient setting.

METHODS

PubMed, Association for Computing Machinery (ACM) Digital Library, Institute of Electrical and Electronics Engineers (IEEE) Xplore, and Cochrane databases were searched for studies that discussed patient engagement ('self-efficacy', 'patient empowerment', 'patient activation', or 'patient engagement'), (2) involved health information technology ('technology', 'games', 'electronic health record', 'electronic medical record', or 'personal health record'), and (3) took place in the inpatient setting ('inpatient' or 'hospital'). Only English language studies were reviewed.

RESULTS

17 articles were identified describing the topic of inpatient patient engagement. A few articles identified design requirements for inpatient engagement technology. The remainder described interventions, which we grouped into five categories: entertainment, generic health information delivery, patient-specific information delivery, advanced communication tools, and personalized decision support.

CONCLUSIONS

Examination of the current literature shows there are considerable gaps in knowledge regarding patient engagement in the hospital setting and inconsistent use of terminology regarding patient engagement overall. Research on inpatient engagement technologies has been limited, especially concerning the impact on health outcomes and cost-effectiveness.

The process of recovery in women who experienced psychosis following childbirth

BACKGROUND

Psychosis following childbirth affects 1-2 mothers per 1000 deliveries. Onset is rapid and functioning is severely affected. Although prognosis in terms of symptom remission is generally good, long-term disability can persist. The study's aim was to develop a theoretical understanding of recovery from psychosis following childbirth.

METHODS

Semi-structured interviews were conducted with 12 women with experience of psychosis following childbirth. Interview transcripts were analysed using grounded theory methodology.

RESULTS

A theory of four superordinate themes was developed from the data, including: (i) the process of recovery; (ii) evolving an understanding; (iii) strategies for recovery; and (iv) sociocultural context. The process of recovery and women's understanding of their experience were conceptualised as parallel processes, which informed one another. Women found that a diagnosis facilitated their use of particular strategies.

CONCLUSIONS

This study highlighted a complex and ongoing process of recovery from psychosis following childbirth. Sensitivity to a woman's position in the process of recovery has the potential to facilitate professionals in assessing readiness for different interventions which will be likely to result in women feeling more understood, accepted and supported.

Evidence-based health information from the users' perspective--a qualitative analysis

BACKGROUND

Evidence-based information is a precondition for informed decision-making and participation in health. There are several recommendations and definitions available on the generation and assessment of so called evidence-based health information for patients and consumers (EBHI). They stress the importance of objectively informing people about benefits and harms and any uncertainties in health-related procedures. There are also studies on the comprehensibility, relevance and user-friendliness of these informational materials. But to date there has been little research on the perceptions and cognitive reactions of users or lay people towards EBHI. The aim of our study is to define the spectrum of consumers' reaction patterns to written EBHI in order to gain a deeper understanding of their comprehension and assumptions, as well as their informational needs and expectations.

METHODS

This study is based on an external user evaluation of EBHI produced by the German Institute for Quality and Efficiency in Health Care (IQWiG), commissioned by the IQWiG. The EBHI were examined within guided group discussions, carried out with lay people. The test readers' first impressions and their appraisal of the informational content, presentation, structure, comprehensibility and effect were gathered. Then a qualitative text analysis of 25 discussion transcripts involving 94 test readers was performed.

RESULTS

Based on the qualitative text analysis a framework for reaction patterns was developed, comprising eight main categories: (i) interest, (ii) satisfaction, (iii) reassurance and trust, (iv) activation, (v) disinterest, (vi) dissatisfaction and disappointment, (vii) anxiety and worry, (viii) doubt.

CONCLUSIONS

Many lay people are unfamiliar with core characteristics of this special information type. Two particularly critical issues are the description of insufficient evidence and the attendant absence of clear-cut recommendations. Further research is needed to examine strategies to explain the specific character of EBHI so as to minimize unintended or adverse reaction patterns. The presented framework describes the spectrum of users' reaction patterns to EBHI. It may support existing best practice models for editing EBHI.

Pain intensity and patients' acceptance of surgical complication risks with lumbar fusion

STUDY DESIGN

Cross-sectional study with prospective recruitment.

OBJECTIVE

To determine the relationship of pain intensity (back and leg) on patients' acceptance of surgical complication risks when deciding whether or not to undergo lumbar spinal fusion.

SUMMARY OF BACKGROUND DATA

To formulate informed decisions regarding lumbar fusion surgery, preoperative discussions should include a review of the risk of complications balanced with the likelihood of symptom relief. Pain intensity has the potential to influence a patient's decision to consent to lumbar fusion. We hypothesized that pain intensity is associated with a patient's acceptance of surgical complication risks.

METHODS

Patients being seen for the first time by a spine surgeon for treatment of a nontraumatic or non-neoplastic spinal disorder completed a structured questionnaire. It posed 24 scenarios, each presenting a combination of risks of 3 complications (nerve damage, wound infection, and nonunion) and probabilities of symptom relief. For each scenario, the patient indicated whether he or she would or would not consent to a fusion for low back pain (LBP). The sum of the scenarios in which the patient responded that he or she would elect surgery was calculated to represent acceptance of surgical complication risks. A variety of other data were also recorded, including age, sex, education level, race, history of nonspinal surgery, duration of pain, and history of spinal injections. Data were analyzed using bivariate and multivariate regression analyses.

RESULTS

The mean number of scenarios accepted by 118 enrolled subjects was 10.2 (median, 8; SD, 8.5; range, 0-24, or 42.5% of scenarios). In general, subjects were more likely to accept scenarios with lower risks and higher efficacy. Spearman rank correlation estimates demonstrated a moderate association between the LBP intensity and acceptance of surgical complication risks (r = 0.37, P = 0.0001) whereas leg pain intensity had a weak but positive correlation (r = 0.19, P = 0.04). In bivariate analyses, a history of spinal injections was strongly associated with patients' acceptance of surgical complication risks and willingness to proceed with surgery (54.5% of scenarios accepted for those who had a history of spinal injections vs. 27.6% for those with no history of spinal injections, P = 0.0001). White patients were more willing to accept surgery (45.9% of scenarios) than non-white patients (28.4%, P = 0.03). With the available numbers, age, sex, history of nonspinal surgery, education, and the duration of pain demonstrated no clear association with acceptance of surgical complication risks. Although education overall was not an influential factor, more educated males had greater risk tolerance than less educated males whereas more educated females had less risk tolerance than less educated females (P = 0.023). In multivariate analysis, LBP intensity remained a highly statistically significant correlate (P = 0.001) of the proportion of scenarios accepted, as did a history of spinal injections (P = 0.001) and being white (0.03).

CONCLUSION

The current investigation indicates that the intensity of LBP is the most influential factor affecting a patient's decision to accept risk of complication and symptom persistence when considering lumbar fusion. This relationship has not been previously shown for any surgical procedure. These data could potentially change the manner in which patients are counseled to make informed choices about spinal surgery. With growing interest in adverse events and complications, these data could be important in establishing guidelines for patient-directed surgical decision making.

Risk Perception and Decision-making Processes in Candidates for Genetic Testing for Huntington's Disease: An Interpretative Phenomenological Analysis

This study is concerned with how candidates for pre-symptomatic genetic testing for Huntington's disease represent their risk status and how they describe the process involved in their deciding whether or not to take the test. Transcripts of semi-structured interviews with five women offered testing were analysed by interpretative phenomenological analysis (IPA). The women find it difficult to conceptualize their current risk, and express reasons for a perceived enhanced or diminished risk based on, for example, number of previous family members affected or pre-selection of a likely recipient of the genetic mutation. The article then illustrates the contextual factors, such as family discussion or a key triggering event, which can influence the decision process of whether or not to take the genetic test. The study has implications both for psychological models of decision making and for the practice of genetic counselling.

Can patients really make an informed choice? An evaluation of the availability of online information about consultant surgeons in the United Kingdom

OBJECTIVES

The National Health Service (NHS) 'Choose and Book' online scheme, which allows patients to select the location and time of hospital appointments, has now been extended to include the option for patients to select a specific consultant to carry out any necessary treatment. The aim of this study was to determine whether there is sufficient online information about consultants or consultant-led teams for patients to make an informed choice regarding a specific consultant.

DESIGN

A web-based analysis of the availability of information.

SETTING

North of England.

PARTICIPANTS

Two hundred websites of orthopaedic surgeons.

MAIN OUTCOME MEASURES

The websites were analysed using a bespoke template that took into account recommendations of the 2010 UK Government white paper. Each website was scored in relation to the availability of specific content relating to each surgeon.

RESULTS

The majority of websites detailed authorship information (73.2%), level of professional qualification (98.5%) and area of general (73.7%) and specialist (93.3%) interest. However, approximately 50% of websites provided no information in relation to update cycle, involvement in teaching or research and patient satisfaction. Only five (2.6%) of the websites presented death rates, and none indicated morbidity rates.

CONCLUSIONS

For patients to be able to make informed choices about their healthcare, surgeons need to ensure that sufficient information is available online, according to the identified limitations of the websites investigated in this study.

[Individualized medicine and what journalists can do to build a more realistic picture]

Journalistic reporting on medical topics is subject to the same basic quality requirements as "health information" in a stricter sense. The aim is to inform patients and the general public in an unbiased and understandable way. Using the example of reporting on individualized medicine, a concept is described of how statements on the benefit and harm of interventions can be distinguished and classified and their content assessed in journalistic research. The step-by-step analysis of statements on the benefit of (personalized) medicine and the comparison of these statements with scientific evidence will help to distinguish proven facts from uncertain predictions. Journalistic reporting is then required to ensure that the basic messages of the report comply with the quality of the scientific evidence and that uncertainties be presented adequately.

Understanding, comprehensibility and acceptance of an evidence-based consumer information brochure on fall prevention in old age: a focus group study

Background

Evidence-based patient and consumer information (EBPI) is an indispensable component of the patients' decision making process in health care. Prevention of accidental falls in the elderly has gained a lot of public interest during preceding years. Several consumer information brochures on fall prevention have been published; however, none fulfilled the criteria of an EBPI. Little is known about the reception of EBPI by seniors. Therefore we aimed to evaluate a recently developed EBPI brochure on fall prevention with regard to seniors' acceptance and comprehensibility in focus groups and to explore whether the participants' judgements differed depending on the educational background of the study participants.

Methods

Seven focus groups were conducted with 40 seniors, aged 60 years or older living independently in a community. Participants were recruited by two gatekeepers. A discussion guide was used and seniors were asked to judge the EBPI brochure on fall prevention using a Likert scale 1-6. The focus group discussions were tape recorded, transcribed verbatim, and analysed using content analysis.

Results

The participants generally accepted the EBPI brochure on fall prevention. Several participants expressed a need for more practical advice. The comprehensibility of the brochure was influenced positively by brief chapter summaries. Participants dismissed the statistical illustrations such as confidence intervals or a Fagan nomogram and only half of them agreed with the meta-information presented in the first chapter. The detailed information about fall prevalence was criticised by some seniors. The use of a case story was well tolerated by the majority of participants.

Conclusion

Our findings indicate that the recently developed EBPI brochure on fall prevention in old age was generally well accepted by seniors, but some statistical descriptions were difficult for them to understand. The brochure has to be updated. However, not all issues raised by the participants will be taken into account since some of them are contrary to the principles of EBPI.

Towards developing new partnerships in public services: users as consumers, citizens and/or co-producers in health and social care in England and Sweden

The causes and effects of marketization of public services have been analysed extensively in the literature, but there is relatively little research on how those policies impact on the development of new forms of governance, and the role of users in these new arrangements. This study reviews examples of competition, freedom of choice and personalized care in health and social services in England and Sweden, in order to examine the type of relationships emerging between the user/consumer vis-à-vis market driven providers and various agencies of the state under the marketized welfare. The article focuses on the possible roles users might assume in new hybrid arrangements between markets, collaborations and steering. A user typology: namely, that of a consumer, citizen, co-producer and responsibilized agent in various governance arrangements, is then suggested. The article concludes by arguing that pro-market policies instead of meeting the alleged needs of post-modern users for individualized public services are likely to promote a new type of highly volatile and fragile partnerships, and create a new subordinated user who has no choice but to ‘choose’ services they have little control over.

Patient choice and equity in the British National Health Service: towards developing an alternative framework

Choice and competition have been phased into many public health systems with the aim of achieving various and potentially exclusive goals such as improving efficiency, quality and responsiveness to users' needs. Yet their use to promote equity of access as evidenced recently in the British National Health Service (the NHS) is unprecedented. Giving users the power of exit over unresponsive providers is meant to address the failures of previous policies. This paper shows that there is a potential conflict between choice and equity, in terms of both the values and the outcomes each policy is likely to produce. Using a multidisciplinary and multidimensional framework, drawn from Bourdieusian sociology, feminist theory and economics, the study highlights the implications of the simplistic and one-sided conception of individual patient choice in relation to equity. It also uses the existing evidence on the impact of market competition and choice, in the UK and elsewhere, to emphasise the importance of socio-economic and psycho-social factors, which are left out of current policy considerations.

Presenting the results of Cochrane Systematic Reviews to a consumer audience: a qualitative study

OBJECTIVE

To develop and obtain feedback about a summary format for Cochrane reviews that is accessible to a consumer audience, without oversimplification or incorrect presentation.

METHODS

We developed 3 versions of a Plain Language Summary (PLS) format of a Cochrane Systematic Review. Using a semi-structured interview guide we tested these versions among 34 members of the public in Norway, Argentina, Canada, and Australia. The authors analyzed feedback, identified problems, and generated new solutions before retesting to produce a final version of a Plain Language Summary format.

RESULTS

Participants preferred results presented as words, supplemented by numbers in a table. There was a lack of understanding regarding the difference between a review and an individual study, that the effect is rarely an exact number, that evidence can be of low or high quality, and that level of quality is a separate issue from intervention effect. Participants also found it difficult to move between presentations of dichotomous and continuous outcomes. Rephrasing the introduction helped participants grasp the concept of a review. Confidence intervals were largely ignored or misunderstood. Our attempts to explain them were only partially successful. Text modifiers (''probably,'' ''may'') to convey different levels of quality were only partially understood, whereas symbols with explanations were more helpful. Participants often understood individual information elements about effect size and quality of these results, but did not always actively merge these elements.

CONCLUSION

Through testing and iteration the authors identified and addressed several problems, using explanations, rephrasing, and symbols to present scientific concepts. Other problems remain, including how best to present confidence intervals and continuous outcomes. Future research should also test information elements in combination rather than in isolation. The new Plain Language Summary format is being evaluated in a randomized controlled trial.

The effect of information on preferences stated in a choice-based conjoint analysis

OBJECTIVE

The objective of the study was to investigate the effect of a priori information on preferences for treatment elicited in a discrete choice experiment.

METHODS

A convenience sample of 100 subjects was randomly split into two groups. The groups received minimal or extensive information on the treatment of ankle and foot impairment in stroke. Then, they participated in a discrete choice experiment. Possible treatment was described using eight decision criteria with two to four levels each. Part-worth utility coefficients for the criteria levels, criteria importance and overall treatment preference were estimated. It was tested whether the amount of information that was received influenced the outcome of the discrete choice experiment.

RESULTS

In the extensively informed group fewer reversals in the expected order of part-worth utilities were found. Criteria importance for four of the eight criteria and criteria importance ranking between the minimally and extensively informed subject groups were significantly different. The difference in part-worth utility of the levels had a minor effect on the predicted utility of the available treatments.

CONCLUSION

The lower number of level rank reversals in the extensively informed subjects indicates a better understanding of outcome desirability and thus a better understanding of the decision task. The effect of more extensive information on predicted treatment preference was minimal.

PRACTICE IMPLICATIONS

While interpreting the results of a discrete choice experiment, the effect of prior knowledge on the decision problem has to be taken into account. Although information seems to increase the understanding of the decision task, outcomes valuation can also be directed by information and more extensive information increases the cognitive burden which is placed on the subjects. Future research should focus on the exact nature and size of the effects and the results of this study should be clinically validated.

How should the impact of different presentations of treatment effects on patient choice be evaluated? A pilot randomized trial

Background

Different presentations of treatment effects can affect decisions. However, previous studies have not evaluated which presentations best help people make decisions that are consistent with their own values. We undertook a pilot study to compare different methods for doing this.

Methods and Findings

We conducted an Internet-based randomized trial comparing summary statistics for communicating the effects of statins on the risk of coronary heart disease (CHD). Participants rated the relative importance of treatment consequences using visual analogue scales (VAS) and category rating scales (CRS) with five response options. We randomized participants to either VAS or CRS first and to one of six summary statistics: relative risk reduction (RRR) and five absolute measures of effect: absolute risk reduction, number needed to treat, event rates, tablets needed to take, and natural frequencies (whole numbers). We used logistic regression to determine the association between participants' elicited values and treatment choices. 770 participants age 18 or over and literate in English completed the study. In all, 13% in the VAS-first group failed to complete their VAS rating, while 9% of the CRS-first group failed to complete their scoring (p = 0.03). Different ways of weighting the elicited values had little impact on the analyses comparing the different presentations. Most (51%) preferred the RRR compared to the other five summary statistics (1% to 25%, p = 0.074). However, decisions in the group presented the RRR deviated substantially from those made in the other five groups. The odds of participants in the RRR group deciding to take statins were 3.1 to 5.8 times that of those in the other groups across a wide range of values (p = 0.0007). Participants with a scientific background, who were more numerate or had more years of education were more likely to decide not to take statins.

Conclusions

Internet-based trials comparing different presentations of treatment effects are feasible, but recruiting participants is a major challenge. Despite a slightly higher response rate for CRS, VAS is preferable to avoid approximation of a continuous variable. Although most participants preferred the RRR, participants shown the RRR were more likely to decide to take statins regardless of their values compared with participants who were shown any of the five other summary statistics.

Trial Registration

Controlled-Trials.com ISRCTN85194921

Eliminating cancer-related disparities: how nurses can respond to the challenge

OBJECTIVES

To review disparities in cancer incidence and mortality among several distinct population groups in the US and the challenges nurses face in eliminating these disparities.

DATA SOURCES

Journal articles, books, and government reports.

CONCLUSION

Despite the phenomenal progress in cancer detection and control, many populations in the US suffer needlessly and die from potentially curable cancers.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can address cancer care needs of population groups at increased risk for developing and/or dying from cancer.

Evaluation of an informed choice invitation for type 2 diabetes screening

OBJECTIVE

To evaluate an innovative invitation designed to facilitate informed choices for undergoing screening for type 2 diabetes.

METHODS

Four hundred and seventeen people aged 40-69 years (sex: F 53%/M 47%), without known diabetes, recruited from street locations. Participants were randomised to receive one of two hypothetical invitations for screening for type 2 diabetes; one based on General Medical Council guidelines and combined with a decisional balance sheet, the other a brief traditional invitation. Informed choice was assessed immediately after the invitation and 3 weeks later using measures of knowledge, attitudes and intentions.

RESULTS

Two weeks after receipt of the invitation, the proportion of informed choices was significantly higher among participants who received the informed choice invitation compared with those who received the traditional invitation (42.9% versus 11.2%; difference=31.7%, 95% CI: 22.5-40.5%; p<0.001). Mean knowledge scores were significantly higher after the receipt of the invitation designed to facilitate informed choices than after the traditional invitation (5.49 versus 3.90; t(405)=10.106, p<0.001). Intentions to participate in screening were unaffected by receipt of the informed choice invitation.

CONCLUSION

Compared with a traditional invitation, receipt of the invitation designed to facilitate informed choices increased the proportion of informed choices about type 2 diabetes screening attendance.

PRACTICE IMPLICATIONS

: Although the new invitation was associated with better knowledge of screening it had no differential effect on intention and its effect on attendance still requires evaluation.

What benefits will choice bring to patients? Literature review and assessment of implications

Objectives

To assess the demand for, and likely impact of, increasing patient choice in health care. The study examined whether patients would like to exercise choice of hospital, primary care provider and treatment, and investigated the likely impact of policies designed to increase choice on equity of access, and on the efficiency and quality of service delivery.

Method

Theory-based literature review including an analysis of the intended and unintended impact of choice-related policies in health care in the UK, European Union and USA. Selected papers focused not only on offering choice to individual patients but also evidence of the impact of choice by patients’ agents such as GPs, and on the impact of introducing choice in education and social services.

Results

Choosing between hospitals or primary care providers is not currently a high priority for the public, except where local services are poor, e.g. they have long waiting times and where individual patients’ circumstances do not limit their ability to travel. When patients become ill, they are increasingly likely to wish to rely on a trusted health practitioner to choose their treatment. Better educated populations make greater use of information and are more likely to exercise choice in health care. The increase in inequality which this could produce might be reduced by specific provision of information and help, enabling less advantaged populations to make choices about health care. There was little evidence in the literature that providing greater choice will in itself improve efficiency or quality of care.

Conclusion

Although patients may themselves make limited use of choices, the existence of choice may, in theory, stimulate providers to improve quality of care. Patients do, however, want to be more involved in individual decisions about their own treatment, and generally participate much less in these decisions than they would wish.

The Impact of Individualized Evidence-Based Decision Support on Aneurysm Patients' Decision Making, Ideals of Autonomy, and Quality of Life

Background . A major challenge in surgery is the integration of evidence-based medicine and patient autonomy. The authors present a randomized trial studying the effect of an individualized evidence-based brochure (IB) on patients' autonomous behavior, patients' ideals of autonomy, and quality of life. Method . Patients with an asymptomatic abdominal aneurysm and their surgeon were randomized to receive a general brochure (GB) or an IB presenting survival information and a ranking of the treatment strategies. Before and after receiving the brochure, patients filled out questionnaires on their behavior during the consultation, ideals of patient autonomy, and quality of life. Surgeons answered a short checklist evaluating the consultation. Results . One hundred patients participated, 49 in the intervention, 51 in the control group. The IB group had a better understanding of important issues in the treatment decision, had prepared more questions, and was less satisfied with the duration of the consultation. Their impression that the surgeon perceived them more as a medical problem than a patient with a problem increased. They agreed less with the surgeon's advice and lost some of their belief in ``the doctor knows best.'' Beforehand, the IB group had a stronger preference for patient-based decisions, but afterward they displayed more surgeon-based decisions. No effects were seen on patients' quality of life. Conclusions . Individualized evidence-based information stimulated patients' active involvement but in the context of our study led to less patient-based decisions. Patient-made decisions and patient autonomy should, however, not be equated.

Can language-concordant prevention care managers improve cancer screening rates?

OBJECTIVE

There is evidence that non-English speakers in the United States receive lower quality health care and preventive services than English speakers. We tested the hypothesis that Spanish-speaking women would respond differently to an intervention to increase up-to-date status for cancer screening.

STUDY DESIGN AND SETTING

A multisite randomized controlled trial showed that scripted telephone support, provided by a Prevention Care Manager (PCM), increased up-to-date rates for breast, cervical, and colorectal cancer screening. This subgroup analysis investigated the relative efficacy of the PCM among women who chose to communicate with the PCM in Spanish versus English.

RESULTS

Of 1,346 women in this analysis, 63% were Spanish speakers. Whereas the PCM intervention increased cancer screening rates generally, Spanish-speaking women seemed to benefit disproportionately more than English-speaking women for cervical cancer screening (unadjusted odds ratio, 1.77; 95% confidence interval, 1.03-3.05). In addition, in this exploratory analysis, there was a trend toward Spanish-speaking women receiving more benefit than English-speaking women from the intervention in increased breast and colorectal cancer screening rates.

CONCLUSION

Spanish-speaking women seemed to benefit more than did English-speaking women from a bilingual telephone support intervention aimed at increasing cancer screening rates.

Evidence-based (informed) macro practice: process and philosophy

Evidence-informed practice and policy at the macro level offers great potential for honoring ethical guidelines to integrate practice and research, to involve clients as informed participants, to respond ethically to problems of scarce resources, to enhance social and economic justice, and to empower clients. The process and philosophy of evidence-informed practice and care as described in original sources suggest a decision-making process designed to help social workers to integrate ethical, evidentiary, and application concerns. As with all innovations, objections will and should be raised. There are many challenges and obstacles to integrating evidentiary, ethical, and application concerns in practice.

Information acquisition for women facing surgical treatment for breast cancer: influencing factors and selected outcomes

OBJECTIVE

To examine, summarize, and critically assess the literature focusing on information use by early-stage breast cancer patients.

METHODS

Empirical articles reporting the information needs, sources used/preferred, and intervention-related outcomes experienced by patients in the context of making a treatment choice were chosen. Several healthcare databases were searched. Articles were limited to those published in English between January 1, 1986 and March 31, 2006.

RESULTS

A total of 25 articles met the inclusion criteria. Information needs were consistent, and highest rankings were for (in order): information about chances for a cure, stage of disease, and treatment options. Results were equivocal regarding the factors found to influence information need: age, time since diagnosis, and preferred role in decision-making. The highest ranked information sources accessed and preferred were physicians. Age, education, and type of treatment chosen influenced source choice. Patients using consumer decision aids (CDAs) had less decisional conflict, higher satisfaction with the decision made and the decision process, and higher knowledge levels.

CONCLUSION

Information needs and source use were influenced by several personal and contextual factors.

PRACTICE IMPLICATIONS

A better understanding of source use could provide more effective ways of disseminating information to patients.

Utilizing computerized entertainment education in the development of decision aids for lower literate and naïve computer users

Decision aids have been developed by using various delivery methods, including interactive computer programs. Such programs, however, still rely heavily on written information, health and digital literacy, and reading ease. We describe an approach to overcome these potential barriers for low-literate, underserved populations by making design considerations for poor readers and naïve computer users and by using concepts from entertainment education to engage the user and to contextualize the content for the user. The system design goals are to make the program both didactic and entertaining and the navigation and graphical user interface as simple as possible. One entertainment education strategy, the soap opera, is linked seamlessly to interactive learning modules to enhance the content of the soap opera episodes. The edutainment decision aid model (EDAM) guides developers through the design process. Although designing patient decision aids that are educational, entertaining, and targeted toward poor readers and those with limited computer skills is a complex task, it is a promising strategy for aiding this population. Entertainment education may be a highly effective approach to promoting informed decision making for patients with low health literacy.

Communication and decision making in cancer care: setting research priorities for decision support/patients' decision aids

The following is a summary report from a special symposium titled, "Translating Research into Practice: Setting a Research Agenda for Clinical Decision Tools in Cancer Prevention, Early Detection, and Treatment," that was held on 23 October 2005 in San Francisco at the Annual Meeting of the Society for Medical Decision Making (SMDM). The symposium was designed to answer the question: "What are the top 2 research priorities in the field of patients' cancer-related decision aids?" After introductory remarks by Dr. Barry, each of four panelists-Drs. Hilary Llewellyn-Thomas, Ellen Peters, Laura Siminoff, and Dale Collins-addressed the question and provided their rationale during prepared remarks. The moderator, Dr. Michael Barry, then facilitated a discussion between the panelists, with input from the audience, to further explore and add to the various proposed research questions. Finally, Dr. Amber Barnato conducted a simple vote count (see Table 1) to prioritize the panelists' and the audience's recommendations.

Shared decision making in the medical encounter: are we all talking about the same thing?

OBJECTIVE

This article aims to explore 1) whether after all the research done on shared decision making (SDM) in the medical encounter, a clear definition (or definitions) of SDM exists; 2) whether authors provide a definition of SDM when they use the term; 3) and whether authors are consistent, throughout a given paper, with respect to the research described and the definition they propose or cite.

METHODS

The authors searched different databases (Medline, HealthStar, Cinahl, Cancerlit, Sociological Abstracts, and Econlit) from 1997 to December 2004. The keywords used were informed decision making and shared decision making as these are the keywords more often encountered in the literature. The languages selected were English and French.

RESULTS

The 76 reported papers show that 1) several authors clearly define what they mean by SDM or by another closely related phrase, such as informed shared decision making. 2) About a third of the papers reviewed (25/76) cite these authors although 8 of them do not use the term in a manner consistent with the definition cited. 3) Certain authors use the term SDM inconsistently with the definition they propose, and some use the terms informed decision making and SDM as if they were synonymous. 4) Twenty-one papers do not provide or cite any definition, or their use of the term (i.e., SDM) is not consistent with the definition they provide.

CONCLUSION

Although several clear definitions of shared decision making have been proposed, they are cited by only about a third of the papers reviewed. In the other papers, authors refer to the term without specifying or citing a definition or use the term inconsistently with their definition. This is a problem because having a clear definition of the concept and following this definition are essential to guide and focus research. Authors should use the term consistently with the identified definition.

Measures used in studies of informed decision making about cancer screening: a systematic review

Interventions to promote informed decision making (IDM) for cancer screening are increasingly common. The resulting body of literature provides an opportunity for a systematic review of measures in use. We searched standard databases for intervention trials and other studies of screening decisions and decision aids, finding 2,110 unique citations (most with abstracts) that we reduced to 104 full-text articles; 36 studies met inclusion criteria (prostate = 20, colorectal = 9, breast = 6, cervical = 1). Two independent coders abstracted data on study characteristics, constructs, and measures. Our findings revealed that most studies measured screening (or intention) and knowledge; fewer measured recommended IDM-related constructs and none measured all outcomes proposed for evaluating IDM interventions. Validity and reliability of measures received inadequate attention in study reports, and conceptual overlap exists among measures. Few IDM measures have been developed/carefully adapted from treatment measures and tested for cancer screening or in diverse populations. We recommend that new and in-progress studies emphasize outcomes beyond knowledge-participation in decision making according to personal preference, satisfaction with the process, and consistency between decisions and values. Also needed is better use of theory to guide conceptualization and operationalization of measures, greater attention to reliability and validity (particularly in diverse populations), more thorough reporting of sources and operating characteristics of measures, and increased emphasis and resources focused on these issues by funders, researchers, and journal editors.

Patient involvement in treatment decision-making: the case for a broader conceptual framework

OBJECTIVE

To consider the conceptualisation of patient involvement in treatment decision-making.

METHOD

Conceptual review.

RESULTS

Current models and measures of patient involvement in treatment decision-making tend to focus on communication within consultations and/or on the patient's use of information to consider the selection of one treatment option from a well-defined set. These narrowly focused models and measures may obscure the relevance of patient involvement in decision-making for some health care contexts and limit investigations of the relationships between patient involvement in decision-making and health care outcomes. We outline a broader conceptual framework that reflects more of the complexity of the concept of involvement. It acknowledges that patients can be involved not only because of what they say and do to influence a decision, but also by virtue of what they think and feel about their roles, efforts and contributions to decision-making and their relationships with their clinicians. The framework encompasses the full range of activities associated with decision-making.

CONCLUSION

The proposed conceptual framework may broaden the relevance of patient involvement in decision-making and encourage a more comprehensive characterisation that may facilitate more sophisticated investigations of the relationships between patient involvement in decision-making and health care outcomes.

PRACTICE IMPLICATIONS

Clinicians who aspire to facilitate patient involvement in decision-making need to look beyond the way they discuss health care options with patients. They should also consider how they might enable patients to engage in the full range of decision-making activities and to develop a positive sense of involvement in these activities and with their clinicians.

Understanding of diabetes prevention studies: questionnaire survey of professionals in diabetes care

AIMS/HYPOTHESIS

Diabetes prevention studies have reported reductions of diabetes risk by up to 60%. Since the underlying metabolic changes are small, the clinical significance of this effect may be overestimated. The present survey explores the extent to which different formats of presenting study results may influence diabetes healthcare professionals' perceptions of the importance of intervention effects on diabetes risk.

SUBJECTS, MATERIALS AND METHODS

Participants of three European diabetes conferences (160 nurse educators, 112 physicians, 27 other professionals) were presented with a questionnaire that included nine items, in which results from three diabetes prevention studies were presented in different ways.

RESULTS

Participation rate was 96%. Effects were interpreted as important or very important by 92% (255/276) when results were presented as proportions of subjects with diabetes (14% intervention group, 29% control group), by 87% (248/285) when results were communicated as a risk reduction of 57%, by 39% (110/284) when the corresponding fasting plasma glucose values were presented (mean difference 0.3 mmol/l), and by 18% (52/283) when glycosylated haemoglobin values were used (6.0 vs 6.1%). Corresponding results of the three diabetes prevention studies were rated as being of identical importance by only 23, 13 and 16% of participants, respectively.

CONCLUSIONS AND INTERPRETATION

Healthcare professionals rate the benefit of preventive interventions substantially higher when changes in diabetes risk are communicated rather than related glycaemic parameters. Transformation of continuous metabolic data into diagnostic categories may impair understanding of study effects.

Evidence-based medicine and its role in ethical decision-making

The recent emergence of evidence-based medicine (EBM) presents medical ethics with the challenge of analyzing what is the current best medical evidence in ethical decision making. This article concludes that the use of the best available, most recently published research findings is a primary moral obligation. However, this does not automatically mean that the use of these research findings will lead to better ethical decision making. Research data can be distorted by methodological failings in the design and reporting of experiments, or by technical and commercial bias. Moreover, the introduction of norms, values, principles and ethical theories can lead to other choices than those proposed by empirical research findings. Ethical decision making must be informed and legitimated by the best available medical research. Nevertheless, ethical decision making is still primarily a choice based on values and norms.

Summaries of findings, descriptions of interventions, and information about adverse effects would make reviews more informative

BACKGROUND AND OBJECTIVE

To describe challenges when extracting and presenting relevant, consistent, and accessible information from systematic reviews.

MATERIALS AND METHODS

We systematically selected comparisons and outcomes from 18 Cochrane reviews, evaluated the quality of evidence for each outcome using the GRADE system, and developed standardized patient information. We evaluated the information using patient, review author, researcher, and clinician feedback.

RESULTS

Challenges included large numbers of comparisons and outcomes; missing information about treatments and adverse effects; and variations in how effect was measured and presented. By selecting comparisons and outcomes based on patient-relevance, quality, and nonredundancy, we halved the number of outcomes. We prepared information about treatments and adverse effects using other sources. We framed outcomes consistently and standardized the presentation of magnitude of effect.

CONCLUSIONS

The incorporation of summary of findings tables in reviews could address these challenges. Problems could also be reduced if review groups agreed upon standard outcomes; excluded less relevant outcomes; incorporated more information about interventions and adverse effects; and implemented clearer guidelines for the presentation of results.

An evaluation of patient preferences for osteoporosis medication attributes: results from the PREFER-US study

OBJECTIVE

To evaluate preferences for eight medication attributes that women may consider when evaluating prescription osteoporosis medications.

RESEARCH DESIGN AND METHODS

The eligible sample consisted of women aged 50 years or older who responded to the 2003 or 2004 Internet-based National Health and Wellness Survey as being diagnosed with osteoporosis, considering themselves at risk, or having a family history of osteoporosis. In this Internet survey (the PREFER survey), respondents were asked to: (1) force-rank order the eight attributes from one to eight according to their preferences and (2) separately rate the importance of each attribute on a Likert-type scale from 1 (extremely unimportant) to 7 (extremely important).

RESULTS

We collected 999 responses across 3 days from a sample of 3368 women and stopped compiling responses after achieving sample size targets. Drug effectiveness (e.g., ability to reduce the risk of fractures) was force ranked as the No. 1 preferred osteoporosis medication attribute by 37% of the sample. Side effects were force ranked as the No. 1 preferred medication attribute by 36% of the sample. Dosing frequency, dosing procedure, and formulation (i.e., how the drug is taken) were each force ranked as No. 1 by 2% or less of the sample. Drug effectiveness had the highest percentage of 'extremely important' responses (59%) followed by drug interactions (53%). Drug effectiveness was the highest-rated attribute (mean [S.D.] = 6.1 [1.6], median = 7), while dosing frequency was the lowest-rated attribute (mean [S.D.] = 4.7 [1.8], median = 5).

CONCLUSIONS

In our sample of women with a diagnosis of osteoporosis or at risk for osteoporosis, drug effectiveness was the most highly ranked and rated of eight osteoporosis medication attributes. Side effects and drug interactions were also highly ranked and rated. Healthcare providers should consider incorporating patient preferences for key medication attributes into their therapeutic decision-making processes.

Lay perceptions of evidence-based information--a qualitative evaluation of a website for back pain sufferers

Background

In an evidence-informed patient choice the patient has access to research-based information about the effectiveness of health care options and is encouraged to use this information in treatment decisions. This concept has seen growing popularity in recent years. However, we still know relatively little about users' attitudes to the use of research-based information, possibly because people have been unexposed to this type of information. After developing the BackInfo website where the results of Cochrane systematic reviews on the effects of low back pain were adapted and presented to lay users we evaluated how users responded to this information.

Methods

Focus group meetings were held with 18 chronic back pain sufferers, after they had been sent a link to the website before the meetings.

Results

The focus groups suggest that the most important challenges to the use of BackInfo's research-based information are not primarily tied to the comprehension or presentation of the information, but are mainly associated with participants' attitudes towards the credibility of research and researchers, and the applicability of research results to themselves as individuals. Possible explanations for participants' lack of trust in research and their apparent difficulties in applying this research to their own situations include aspects that may be typical for the general public including the media's presentation of research, and a lack of familiarity with and feelings of distance to research evidence. Other aspects may be typical for patient groups with chronic and unclear medical conditions, such as a lack of trust in the health care establishment in general.

Conclusion

In order to enhance the credibility and applicability of research evidence, providers of research-based information could explore a number of possibilities including the use of including personal stories to illustrate the research outcomes.

Shared decision-making and evidence-based practice

Shared decision-making refers to a process of health care delivery in which practitioners and clients seeking help for problems or disorders collaborate to access relevant information and to enable client-centered selection of health care resources. Though nearly all clients express a desire for more information, preferences for participation in health care decisions vary by individual and by illness. Two common strategies to promote shared decision-making are communication training for clients and clinicians, and decision aids to provide targeted information and values clarification. Research in several areas of medicine shows that active client participation results in a variety of benefits, from increased satisfaction to decreased symptom burden. Many current mental health interventions promote client-centered care, client choice, and self-directed care, but research on shared decision-making in mental health for clients with severe and persistent mental illness is just beginning.

Which surgical decisions should patients participate in and how? Reflections on women's recollections of discussions about variants of hysterectomy

Current guidance about informed consent suggests patients ought to know about the procedures involved in any treatments they agree to undergo, and have a right to be involved in decisions about their care. However, it is not clear how this guidance is and should be applied to decisions between variant surgical procedures such as abdominal or vaginal hysterectomy. We sent structured questionnaires about information provision and decision-making to 157 women who were scheduled for hysterectomy in north-east Scotland. A purposive sub-sample of 20 women was interviewed in depth post-operatively. 104 women (66%) responded to the questionnaires. 75% reported being told at outpatient clinics what kind of hysterectomy they would have, but fewer than half had been told about the advantages and disadvantages of different kinds. Between 26% and 65% of women thought they had been given too little information about various issues pertaining to different types of hysterectomy. The interview accounts suggested that gynaecologists offered women little opportunity to influence the selection of a surgical procedure. Women did not express a desire for a greater say in this selection, but appreciated being told, or would have liked to know, why particular procedures were recommended for them. There may be circumstances in which it is important for surgeons to tell patients about options they have ruled out in their particular cases. Decisions between alternative surgical procedures are often highly contingent on the dispositions and skills of individual surgeons. They raise practical and ethical issues that have been neglected in recent discussions about patient involvement in decision-making. As policy makers continue to emphasise the importance of choice and patients become increasingly aware of the existence of variant procedures, these issues need careful consideration.

Knowledge of cervical cancer and screening among women in east-central England

This study assesses the extent and accuracy of women's knowledge of cervical cancer, risk factors, and the efficacy of the national screening program. Data were obtained from a questionnaire survey of randomly selected women eligible for screening, drawn from a population in east-central England. The majority of women in the sample overestimated the current incidence of cervical cancer, both absolutely and relative to other cancers. Perceiving incidence to be high was associated with reporting worries about the disease. With respect to the screening process, 78.3% believe that the smear abnormality rate is higher than it actually is, and only 7.6% correctly appreciate that the abnormality rate is highest at younger ages. With respect to performance, 16.3% believed the smear test to be completely accurate, and more than half overestimated the likely number of cancer cases prevented by screening. While certain cervical cancer risk factors were correctly assigned by the majority of women, undue emphasis was placed on genetic influence, while the risks posed by human papillomavirus infection were unfamiliar to almost half of the sample. We conclude that women typically possess only a partial picture of risk factors and overestimate both the incidence of cervical cancer and the efficacy of screening.