Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease

Decision aids for people facing health treatment or screening decisions

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The use of e-consent in surgery and application to neurosurgery: a systematic review and meta-analysis

INTRODUCTION

The integration of novel electronic informed consent platforms in healthcare has undergone significant growth over the last decade. Adoption of uniform, accessible, and robust electronic online consenting applications is likely to enhance the informed consent process and improve the patient experience and has the potential to reduce medico-legal ramifications of inadequate consent. A systematic review and meta-analysis was conducted to evaluate the utility of novel electronic means of informed consent in surgical patients and discuss its application to neurosurgical cohorts.

METHODS

A review of randomised controlled trials, non-randomised studies of health interventions, and single group pre-post design studies in accordance with the PRISMA statement. Random effects modelling was used to estimate pooled proportions of study outcomes. Patient satisfaction with the informed consent process and patients' gain in knowledge were compared for electronic technologies versus non-electronic instruments. A sub-group analysis was conducted to compare the utility of electronic technologies in neurosurgical cohorts relative to other surgical patients in the context of patient satisfaction and knowledge gain.

RESULTS

Of 1042 screened abstracts, 63 studies were included: 44 randomised controlled trials (n = 4985), 4 non-randomised studies of health interventions (n = 387), and 15 single group pre-post design studies (n = 872). Meta-analysis showed that electronic technologies significantly enhanced patient satisfaction with the informed consent process (P < 0.00001) and patients' gain in knowledge (P < 0.00001) compared to standard non-electronic practices. Sub-group analysis demonstrated that neurosurgical patient knowledge was significantly enhanced with electronic technologies when compared to other surgical patients (P = 0.009), but there was no difference in patient satisfaction between neurosurgical cohorts and other surgical patients with respect to electronic technologies (P = 0.78).

CONCLUSIONS

Novel electronic technologies can enhance patient satisfaction and increase patients' gain in knowledge of their surgical procedures. Electronic patient education tools can significantly enhance patient knowledge for neurosurgical patients. If used appropriately, these modalities can shorten and/or improve the consent discussion, streamlining the surgical process and improving satisfaction for neurosurgical patients.

Interventions to Facilitate Shared Decision-Making Using Decision Aids with Coronary Heart Disease Patients: Systematic Review and Meta-Analysis

Background

Coronary heart disease (CHD) is the leading cause of death in the world. There are some decision-making conflicts in the management of chest pain, treatment methods, stent selection, and other aspects due to the unstable condition of CHD in the treatment stage. Although using decision aids to facilitate shared decision-making (SDM) contributes to high-quality decision-making, it has not been evaluated in the field of CHD. This review systematically assessed the effects of SDM in patients with CHD.

Methods

We conducted a systematic review and meta-analysis of randomized controlled trials of SDM interventions in patients with CHD from database inception to 1 June 2022 (PROSPERO [Unique identifier: CRD42022338938]). We searched for relevant studies in the PubMed, Embase, Cochrane Library, Web of Science, CNKI, and Wan Fang databases. The primary outcomes were knowledge and decision conflict. The secondary outcomes were satisfaction, patient participation, trust, acceptance, quality of life, and psychological condition.

Results

A total of 8244 studies were retrieved. After screening, ten studies were included in the analysis. Compared with the control group, SDM intervention with patient decision aids obviously improved patients' knowledge, decision satisfaction, participation, and medical outcomes and reduced decision-making conflict. There was no significant effect of SDM on trust.

Conclusions

This study showed that SDM intervention in the form of decision aids was beneficial to decision-making quality and treatment outcomes among patients with CHD. The results of SDM interventions need to be evaluated in different environments.

Shared decision making in cardiology: a systematic review and meta-analysis

OBJECTIVES

To evaluate the effectiveness of interventions to improve shared decision making (SDM) in cardiology with particular focus on patient-centred outcomes such as decisional conflict.

METHODS

We searched Embase (OVID), the Cochrane library, PubMed and Web of Science electronic databases from inception to January 2021 for randomised controlled trials that investigated the effects of interventions to increase SDM in cardiology. The primary outcomes were decisional conflict, decisional anxiety, decisional satisfaction or decisional regret; a secondary outcome was knowledge gained by the patients.

RESULTS

Eighteen studies which reported on at least one outcome measure were identified, including a total of 4419 patients. Interventions to increase SDM had a significant effect on reducing decisional conflict (standardised mean difference (SMD) -0.211, 95% CI -0.316 to -0.107) and increasing patient knowledge (SMD 0.476, 95% CI 0.351 to 0.600) compared with standard care.

CONCLUSIONS

Interventions to increase SDM are effective in reducing decisional conflict and increasing patient knowledge in the field of cardiology. Such interventions are helpful in supporting patient-centred healthcare and should be implemented in wider cardiology practice.

Application of patient decision aids in treatment selection of cardiac surgery patients: a scoping review

BACKGROUND

The choice of treatment is an unavoidable challenge faced in the day to day medical decision making pertaining to patients with organic heart disease. As a professional discipline, cardiac surgery focuses on creating and using the most advanced evidence-based patient decision aids (PtDAs) to achieve high-quality decision-making.

OBJECTIVES

To describe the basic situation, influencing factors, and the outcome of indicators of PtDAs among cardiac surgery patients.

METHODS

Seven electronic databases were systematically searched for relevant reviews on the application of PtDAs among cardiac surgery patients. The methodological framework proposed by Arskey and O'Malley was used to guide the scoping review. The extracted data was analyzed qualitatively and quantitatively.

RESULTS

After dual, blinded screening of titles and abstracts, 12 articles were included in the review. 10 were quantitative studies, 1 was a mixed study, 1 was a qualitative study.

CONCLUSIONS

Compared with the burden of heart disease and the huge evidence base, the application of PtDAs in cardiac surgery is obviously insufficient. The published literature mainly provide information about the factors to be solved from the perspective of researchers, and also summarize obstacle factors. This is the basis for the application and construction of PtDAs in cardiac surgery patients.

Patient Preferences for Neoadjuvant Therapy in Pancreatic Ductal Adenocarcinoma

OBJECTIVES

Physicians are increasingly recommending neoadjuvant therapy (NT) before surgery for pancreatic ductal adenocarcinoma (PDAC). However, patient preferences for and opinions regarding NT are poorly understood.

METHODS

Survivors and caregivers from a national PDAC patient advocacy organization completed an online survey assessing preferences for NT versus surgery first (SF) and factors influencing their decision making.

RESULTS

Among 54 participants, 74.1% had a personal history of PDAC. While most patients preferred SF for resectable disease, NT was the preferred treatment approach for borderline resectable, locally advanced, and resectable cancers with high carbohydrate antigen 19-9. The most important factor influencing patient decision making regarding NT was its impact on overall survival while the least important was published national guidelines. The most preferred rationale for NT was ability to downstage to surgical resection and early treatment of micrometastatic disease.

CONCLUSIONS

Among a national cohort of PDAC survivors and caregivers, the majority preferred SF for resectable PDAC, whereas NT was preferred when the resectability of a tumor was in question. The impact of NT on quantity and quality of life, as well as the likelihood of achieving surgical resection, was most highly valued by participants.

The use of video for patient information and education: A scoping review of the variability and effectiveness of interventions

OBJECTIVE

To provide an overview of video interventions used for patient information and education, and of the tools used to evaluate their effectiveness, in order to consider the feasibility of developing generic guidelines and appraisal tools for the use of video in patient care.

METHODS

A scoping review was carried out to describe and synthesise emerging knowledge, using thematic analysis of data. Studies focussed upon videos for health professional education were excluded, as were those which consider the impact of videos available via social media.

RESULTS

A narrative overview of 65 identified papers provides insight into the range and scope of studies. Common themes emerge, notably the aim of reducing anxiety and the variety of instruments designed to measure this. The use of self-report questionnaires was common, but their design is variable.

CONCLUSION

Targeted video-based intervention can improve patient experience and outcomes. High utility guidelines and appraisal tools, transferable between contexts, are needed to facilitate deployments at scale for sustainable outcomes.

PRACTICE IMPLICATIONS

Video production guidelines and appraisal tools will be of value to those engaged in video development and deployment. Guidance should be based upon emerging evidence of effectiveness and incorporate an emphasis on reusability.

Is greater patient involvement associated with higher satisfaction? Experimental evidence from a vignette survey

BACKGROUND

Patient-centredness is an essential quality parameter of modern healthcare. Accordingly, involving patients in decisions about care is required by international laws and an increasing number of medical codes and standards. These directives are based on ethical principles of autonomy. Still, there is limited empirical knowledge about the influence of patient involvement on satisfaction with care.

OBJECTIVE

In a large national vignette survey, we aimed to empirically test healthcare users' satisfaction with healthcare given different degrees of patient involvement, choices made and outcomes.

METHODS

A web-based cross-sectional survey distributed to a randomised sample of men in Denmark aged 45-70 years. Case vignettes used prostate-specific antigen (PSA) screening for early detection of prostate cancer as a clinical model. Using a 5-point Likert scale, we measured respondents' satisfaction with care in scenarios which differed in the amount of patient involvement (ranging from no involvement, through involvement with neutral or nudged information, to shared decision-making), the decision made (PSA test or no PSA test) and clinical outcomes (no cancer detected, detection of treatable cancer and detection of non-treatable cancer).

RESULTS

Participating healthcare users tended to be more satisfied with healthcare in scenarios illustrating greater levels of patient involvement. Participants were positive towards nudging in favour of the intervention but patient involvement through shared decision-making obtained the highest satisfaction ratings (Likert rating 3.81 without any involvement vs 4.07 for shared decision-making, p<0.001). Greater involvement also had an ameliorating effect on satisfaction if a non-treatable cancer was later diagnosed.

CONCLUSION

Our study provides empirical support for the hypothesis that greater patient involvement in healthcare decision-making improves satisfaction with care irrespective of decisions made and clinical outcomes. Overall satisfaction with the care illustrated was highest when decisions were reached through shared decision-making.

Is Better Patient Knowledge Associated with Different Treatment Preferences? A Survey of Patients with Stable Coronary Artery Disease

BACKGROUND

In stable coronary artery disease (CAD), shared decision-making (SDM) is encouraged when deciding whether to pursue percutaneous coronary intervention (PCI) given similar cardiovascular outcomes between PCI and medical therapy. However, it remains unclear whether improving patient-provider communication and patient knowledge, the main tenets of SDM, changes patient preferences or the treatment chosen. We explored the relationships between patient-provider communication, patient knowledge, patient preferences, and the treatment received.

METHODS

We surveyed stable CAD patients referred for elective cardiac catheterization at seven hospitals from 6/2016 to 9/2018. Surveys assessed patient-provider communication, medical knowledge, and preferences for treatment and decision-making. We verified treatments received by chart review. We used linear and logistic regression to examine relationships between patient-provider communication and knowledge, knowledge and preference, and preference and treatment received.

RESULTS

Eighty-seven patients completed the survey. More discussion of the benefits and risks of both medical therapy and PCI associated with higher patient knowledge scores (β=0.28, p<0.01). Patient knowledge level was not associated with preference for PCI (OR=0.78, 95% CI 0.57-1.03, p=0.09). Black patients had more than four times the odds of preferring medical therapy to PCI (OR=4.49, 1.22-18.45, p=0.03). Patients preferring medical therapy were not significantly less likely to receive PCI (OR=0.67, 0.16-2.52, p=0.57).

CONCLUSIONS

While communicating the risks of PCI may improve patient knowledge, this knowledge may not affect patient treatment preferences. Rather, other factors such as race may be significantly more influential on a patient's treatment preferences. Furthermore, patient preferences are still not well reflected in the treatment received. Improving shared decision-making in stable CAD therefore may require not only increasing patient education but also better understanding and including a patient's background and pre-existing beliefs.

Strategies for implementing shared decision making in elective surgery by health care practitioners: A systematic review

RATIONALE, AIMS AND OBJECTIVES

To summarize relevant international scientific evidence on strategies aimed at facilitating or improving health care practitioners' adoption of shared decision making in elective surgery. The review evaluated the effectiveness of these strategies and described the characteristics of identified strategies.

METHOD

A systematic search of the literature was conducted up to March 2019. The review included interventions that targeted patients, health care practitioners, or health systems/organizations. Main outcomes were measures of decision process and decision outcomes. Two independent reviewers conducted study selection, assessed methodological quality and extracted data.

RESULTS

Fifteen randomized controlled trials, one pseudo-randomized controlled trial, and four quasi-experimental studies were included in this review. The heterogeneity of interventions and the variability of outcomes used to measure the impact of these interventions precluded meta-analysis. All of the interventions included an educational component regarding the medical condition of interest and available treatment options and a supportive component to encourage patients to ask questions and involve themselves in the decision making. Published evidence on shared decision-making interventions in elective surgery is most prevalent in the breast cancer/endocrine and urology specialties, with most studies targeting their shared decision-making interventions at the patient population. The use of multiple media components within an intervention including interactive video appeared to improve patient satisfaction with the shared decision-making process.

CONCLUSIONS

The use of well-developed educational information provided through interactive multimedia, computer or DVD based, may enhance the decision-making process. The evidence suggests that such multimedia can be used prior to the surgical consultation, presenting medical and surgical information relevant to the upcoming consultation. A decision and communication aid also appears to be an effective method to support the surgeon in patient participation and involvement in the decision-making process.

Decision aids that facilitate elements of shared decision making in chronic illnesses: a systematic review

BACKGROUND

Shared decision making (SDM) is a patient-centered approach in which clinicians and patients work together to find and choose the best course of action for each patient's particular situation. Six SDM key elements can be identified: situation diagnosis, choice awareness, option clarification, discussion of harms and benefits, deliberation of patient preferences, and making the decision. The International Patient Decision Aid Standards (IPDAS) require that a decision aid (DA) support these key elements. Yet, the extent to which DAs support these six key SDM elements and how this relates to their impact remain unknown.

METHODS

We searched bibliographic databases (from inception until November 2017), reference lists of included studies, trial registries, and experts for randomized controlled trials of DAs in patients with cardiovascular, or chronic respiratory conditions or diabetes. Reviewers worked in duplicate and independently selected studies for inclusion, extracted trial, and DA characteristics, and evaluated the quality of each trial.

RESULTS

DAs most commonly clarified options (20 of 20; 100%) and discussed their harms and benefits (18 of 20; 90%; unclear in two DAs); all six elements were clearly supported in 4 DAs (20%). We found no association between the presence of these elements and SDM outcomes.

CONCLUSIONS

DAs for selected chronic conditions are mostly designed to transfer information about options and their harms and benefits. The extent to which their support of SDM key elements relates to their impact on SDM outcomes could not be ascertained.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42016050320 .

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

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

Patients Should Define Value in Health Care: A Conceptual Framework

The main tenet of value-based health care is delivering high-quality care that is centered on the patient, improving health, and minimizing cost. Collaborative decision-making frameworks have been developed to help facilitate delivering care based on patient preferences (patient-centered care). The current value-based health care model, however, focuses on improving population health and overlooks the individuality of patients and their preferences for care. We highlight the importance of eliciting patient preferences in collaborative decision making and describe a conceptual framework that incorporates individual patients' preferences when defining value.

Discharge communication practices and healthcare provider and patient preferences, satisfaction and comprehension: A systematic review

Purpose

To systematically review the available evidence about hospital discharge communication practices and identify which practices were preferred by patients and healthcare providers, improved patient and provider satisfaction, and increased patients' understanding of their medical condition.

Data sources

OVID Medline, Web of Science, ProQuest, PubMed and CINAHL plus.

Study selection

Databases were searched for peer-reviewed, English-language papers, published to August 2016, of empirical research using quantitative or qualitative methods. Reference lists in the papers meeting inclusion criteria were searched to identify further papers.

Data extraction

Of the 3489 articles identified, 30 met inclusion criteria and were reviewed.

Results of data synthesis

Much research to date has focused on the use of printed material and person-based discharge communication methods including verbal instructions (either in person or via telephone calls). Several studies have examined the use of information technology (IT) such as computer-generated and video-based discharge communication practices. Utilizing technology to deliver discharge information is preferred by healthcare providers and patients, and improves patients' understanding of their medical condition and discharge instructions.

Conclusion

Well-designed IT solutions may improve communication, coordination and retention of information, and lead to improved outcomes for patients, their families, caregivers and primary healthcare providers as well as expediting the task for hospital staff.

The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

Video-based patient decision aids: A scoping review

OBJECTIVE

This study reviews the published literature on the use of video-based decision aids (DA) for patients. The authors describe the areas of medicine in which video-based patient DA have been evaluated, the medical decisions targeted, their reported impact, in which countries studies are being conducted, and publication trends.

METHOD

The literature review was conducted systematically using Medline, Embase, CINAHL, PsychInfo, and Pubmed databases from inception to 2016. References of identified studies were reviewed, and hand-searches of relevant journals were conducted.

RESULTS

488 studies were included and organized based on predefined study characteristics. The most common decisions addressed were cancer screening, risk reduction, advance care planning, and adherence to provider recommendations. Most studies had sample sizes of fewer than 300, and most were performed in the United States. Outcomes were generally reported as positive. This field of study was relatively unknown before 1990s but the number of studies published annually continues to increase.

CONCLUSION

Videos are largely positive interventions but there are significant remaining knowledge gaps including generalizability across populations.

PRACTICE IMPLICATIONS

Clinicians should consider incorporating video-based DA in their patient interactions. Future research should focus on less studied areas and the mechanisms underlying effective patient decision aids.

Development of a Shared Decision Making Model in a Community Mental Health Center

Shared Decision Making (SDM) is an essential component of recovery oriented treatment for clients with severe and persistent mental illnesses. SDM has been found to be effective in improving outcome of treatment of non-psychiatric ailments, and studies of SDM in community mental health settings are limited. We designed and implemented a low tech SDM program in a non-academic community mental health center and evaluated the outcome on decisional certainty and satisfaction with services. The results suggest that SDM can be effectively integrated with evidence based psychiatric rehabilitation practices utilizing already existing resources.

Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial

BACKGROUND

Patient decision aids (PtDA) support quality decision-making. The aim of this research was to evaluate the feasibility of conducting a randomized controlled trial delivering an implantable cardioverter defibrillator (ICD)-specific PtDA to new ICD candidates and examining preliminary estimates of differences in outcomes.

METHODS

Prior to recruitment, ICD candidacy was determined. Consented patients were randomized to (1) usual care or (2) PtDA intervention. Feasibility outcomes included referral and recruitment rates, successful PtDA delivery, and completion of measures. The PtDA intervention was administered prior to specialist consultation and baseline demographics, and measures of decision quality including decisional conflict (DCS), SURE test (Sure of myself, Understand information, Risk-benefit ratio, Encouragement), patient's ICD specific values, ICD knowledge, and health-related quality of life were recorded. Post-consultation, participant's DCS was repeated and decisions to proceed, decline, or defer ICD implantation were collected. Feasibility data was determined using descriptive statistics (continuous and categorical). Preliminary estimates of differences in outcomes were assessed using mean differences. Concordance between values and decision choice was assessed using logistic regression of the intervention group.

RESULTS

We identified 135 eligible patients. Eighty-two consented to the trial randomizing patients to usual care (n = 41) or PtDA intervention (n = 41). Feasibility outcome results were (1) referral rate at approximately 20/month, (2) recruitment rate 61%, and (3) successful delivery of PtDA and study management. Pre-consultation, PtDA patients scored lower on the DCS scale (mean, standard deviation [SD] 27.3 (18.4) compared to usual care, 49.4 (18.6); the between-group difference in means [95% confidence interval (CI)] was - 22.1[- 30.23, - 13.97]. A difference remained post-implantation 21.2 (11.7), PtDA intervention 29.9 (13.3), and usual care - 8.7 [- 14.61, - 2.86]. SURE test results supported DCS differences. The PtDA group scored higher on the ICD-related knowledge questions, with 47.50% scoring greater than 3/5 of the knowledge questions correct, compared to 23.09% receiving usual care. The mean [SD] number of correct knowledge responses out of 5 was 3.33(1.19) in the PtDA group and 2.62 (1.16) in usual care pre-implant. Concordance between values and decision choice found a strong association between predicted and actual ICD implant status in the intervention group.

CONCLUSION

Our results suggest that a future definitive trial is feasible. The ICD-specific PtDA shows promise with respect to preliminary estimates of differences in outcomes.

TRIAL REGISTRATION

NCT01876173.

[Left-heart catheterization followed by other invasive procedures: Regional comparisons reveal peculiar differences]

BACKGROUND AND AIMS

Diagnostic left heart catheterization (LHC) is recommended if the therapeutic consequences of a bypass operation or percutaneous coronary intervention (PCI) are being considered. The present study examines regional differences in healthcare provision and therapeutic consequences of LHC, differentiated by counties and hospitals of the German federal state of Saxony-Anhalt. In addition, it looks at which patient-related factors influence the proportion of follow-up interventions. The relation between the rates of LHC, interventions and hospital discharge due to myocardial infarction is examined.

METHODS

The data of 9,791 individuals having statutory health insurance coverage by the AOK Saxony-Anhalt with 10,906 anonymized inpatient cases of LHCs in 2011 were followed until 12/31/2012, and it was examined whether they subsequently received a coronary bypass or PCI. The data was used to compare both the counties of Saxony-Anhalt (according to residence, adjusted for age and sex) and their hospitals. Regression analysis was run to identify determinants of receiving a LHC without consequences.

RESULTS

Overall, 54.2 % of the patients with LHC had no invasive follow-up intervention. Regression analysis showed an approximately linear relationship for the counties: the number of LHCs provided correlates with the number of LHCs requiring no PCI or bypass within a period of at least 12 months. Regional LHC rates are not correlated with hospitalizations due to acute myocardial infarction. No bypass or PCI in the follow-up period was reported for 37 to 85 % of the cases, depending on the hospital providing the LHC. Women and younger patients have a higher risk to undergo LHC without therapeutic impact.

DISCUSSION

The analysis indicates that there are specific regions in Saxony-Anhalt and diagnoses where the indications for LHC should be more conservative. However, more detailed analyses are needed to verify the identified potentials for improving healthcare provision.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

PCI Choice Decision Aid for Stable Coronary Artery Disease

Background—

Percutaneous coronary intervention (PCI) for stable coronary artery disease does not reduce the risk of death and myocardial infarction compared with optimal medical therapy (OMT), but many patients think otherwise. PCI Choice, a decision aid (DA), was designed for use during the clinical visit and includes information on quality of life and mortality outcomes for PCI with OMT versus OMT alone for stable coronary artery disease.

Methods and Results—

We conducted a randomized trial to assess the impact of the PCI Choice DA compared with usual care when there is a choice between PCI and optimal medical therapy. Primary outcomes were patient knowledge and decisional conflict, and the secondary outcome was an objective measure of shared decision making. A total of 124 patients were eligible for final analysis. Knowledge was higher among patients receiving the DA compared with usual care (60% DA; 40% usual care; P =0.034), and patients felt more informed ( P =0.043). Other measures of decisional quality were not improved, and engagement of the patient by the clinician in shared decision making did not change with use of the DA. There was evidence that clinicians used the DA as an educational tool.

Conclusions—

The PCI Choice DA improved patient knowledge but did not significantly impact decisional quality. Further work is needed to effectively address clinician knowledge gaps in shared decision-making skills, even in the context of carefully designed DAs.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov/ . Unique identifier: NCT01771536.

Explaining Variation in Physician Practice Patterns and Their Propensities to Recommend Services

Variations in physician practice patterns have important implications for quality and cost. The purpose of this article is to explain variation in physicians' practice patterns in terms of physician personal characteristics, practice setting, patient population, and managed care involvement. Data on 2,455 primary care physicians were derived from the Community Tracking Study Physician Survey (1996-1997). Factor scores were determined based on responses to three clinical scenarios that represent discretionary medical decisions. These scenarios include a specialist referral for benign prostatic hyperplasia, prescription drugs for elevated cholesterol, and an office visit for vaginal discharge. Physician age, being a foreign medical school graduate, being a solo practitioner, and having a larger proportion of Medicaid patients were all associated with higher factor scores, a greater likelihood of ordering a service. Being board certified was associated with lower factor scores. Managed care involvement was not a significant predictor of factor scores.

Decision Aids for Benign Prostatic Hyperplasia: Applicability across Race and Education

Background/Method. Decision aids have not been widely tested in diverse audiences. The authors conducted interviews in a 2 2 race by education design with participants who were 50 years old (n = 188). The decision aid was a benign prostatic hyperplasia videotape. Results. There was an increase in knowledge equal in all groups, with baseline knowledge higher in whites. The decision stage increased in all groups and was equivalent in the marginal-illiterate subgroup (n = 0.15). Conclusion. Contrary to expectations, results show no difference by race or college education in knowledge gain or increase in reported readiness to decide. The video appeared to produce change across race and education. The end decision stage was high, especially in less educated men. Results suggest that decision aids may be effective without tailoring, as suggested previously to enhance health communication in diverse audiences. Research should test findings in representative samples and in clinical encounters and identify types of knowledge absorbed from decision aids and whether the shift to decision reflects data/ knowledge or shared decision-making message.

Web Resources for Transplant Candidates, Recipients, and Donors

Many valuable Web-based resources for transplant candidates, donors, and recipients exist; however, high-quality Web sites that are appropriate for patient use can be difficult to find. This article describes how patients can benefit from the use of transplant-specific Web sites and highlights Web resources that medical professionals can recommend to Internet-literate patients and their families. General guidelines for finding accurate and unbiased transplant-related information on the Internet are provided and 6 Web sites that offer features such as comprehensive educational information and opportunities for patient-to-patient interaction are detailed.

Features of Computer-Based Decision Aids: Systematic Review, Thematic Synthesis, and Meta-Analyses

Background

Patient information and education, such as decision aids, are gradually moving toward online, computer-based environments. Considerable research has been conducted to guide content and presentation of decision aids. However, given the relatively new shift to computer-based support, little attention has been given to how multimedia and interactivity can improve upon paper-based decision aids.

Objective

The first objective of this review was to summarize published literature into a proposed classification of features that have been integrated into computer-based decision aids. Building on this classification, the second objective was to assess whether integration of specific features was associated with higher-quality decision making.

Methods

Relevant studies were located by searching MEDLINE, Embase, CINAHL, and CENTRAL databases. The review identified studies that evaluated computer-based decision aids for adults faced with preference-sensitive medical decisions and reported quality of decision-making outcomes. A thematic synthesis was conducted to develop the classification of features. Subsequently, meta-analyses were conducted based on standardized mean differences (SMD) from randomized controlled trials (RCTs) that reported knowledge or decisional conflict. Further subgroup analyses compared pooled SMDs for decision aids that incorporated a specific feature to other computer-based decision aids that did not incorporate the feature, to assess whether specific features improved quality of decision making.

Results

Of 3541 unique publications, 58 studies met the target criteria and were included in the thematic synthesis. The synthesis identified six features: content control, tailoring, patient narratives, explicit values clarification, feedback, and social support. A subset of 26 RCTs from the thematic synthesis was used to conduct the meta-analyses. As expected, computer-based decision aids performed better than usual care or alternative aids; however, some features performed better than others. Integration of content control improved quality of decision making (SMD 0.59 vs 0.23 for knowledge; SMD 0.39 vs 0.29 for decisional conflict). In contrast, tailoring reduced quality of decision making (SMD 0.40 vs 0.71 for knowledge; SMD 0.25 vs 0.52 for decisional conflict). Similarly, patient narratives also reduced quality of decision making (SMD 0.43 vs 0.65 for knowledge; SMD 0.17 vs 0.46 for decisional conflict). Results were varied for different types of explicit values clarification, feedback, and social support.

Conclusions

Integration of media rich or interactive features into computer-based decision aids can improve quality of preference-sensitive decision making. However, this is an emerging field with limited evidence to guide use. The systematic review and thematic synthesis identified features that have been integrated into available computer-based decision aids, in an effort to facilitate reporting of these features and to promote integration of such features into decision aids. The meta-analyses and associated subgroup analyses provide preliminary evidence to support integration of specific features into future decision aids. Further research can focus on clarifying independent contributions of specific features through experimental designs and refining the designs of features to improve effectiveness.

Patient Decision Control and the Use of Cardiac Catheterization

Background:

Shared decision-making is a key determinant of patient-centered care. A lack of patient involvement in treatment decisions may explain persistent racial disparities in rates of cardiac catheterization (CCATH). To date, limited evidence exists to demonstrate whether patients who engage in shared decision-makingare more or less likely to undergo non-emergency CCATH.

Objective:

To assess the relationship between participation in the decision to undergo a CCATH and the use of CCATH. We also examined whether preference for or actual engagement in decision-making varied by patient race.

Methods:

We analyzed data from 826 male Veterans Administration patients for whom CCATH was indicated and who participated in the Cardiac Decision Making Study.

Results:

After controlling for confounders, patients reporting any degree of decision control were more likely to receive CCATH compared with those reporting no control (doctor made decision without patient input) (54% vs 39%, P<.0001). Across racial groups, patients were equally likely to report a preference for control over decision-making (P=.53) as well as to experience discordance between their preference for control and their perception of the actual decision-making process (P=.59). Therefore, these factors did not mediate racial disparities in rates of CCATH use.

Conclusion:

Shared decision-making is an essential feature of whole-person care. While participation in decision-making may not explain disparities in CCATH rates, further work is required to identify strategies to improve congruence between patients' desire for and actual control over decision-making to actualize patient-centered care.

Patients or Volunteers? The Impact of Motivation for Trial Participation on the Efficacy of Patient Decision Aids: A Secondary Analysis of a Cochrane Systematic Review

Background. Efficacy of patient decision aids (PtDAs) may be influenced by trial participants’ identity either as patients seeking to benefit personally from involvement or as volunteers supporting the research effort. Aim. To determine if study characteristics indicative of participants’ trial identity might influence PtDA efficacy. Methods. We undertook exploratory subgroup meta-analysis of the 2011 Cochrane review of PtDAs, including trials that compared PtDA with usual care for treatment decisions. We extracted data on whether participants initiated the care pathway, setting, practitioner interactions, and 6 outcome variables (knowledge, risk perception, decisional conflict, feeling informed, feeling clear about values, and participation). The main subgroup analysis categorized trials as “volunteerism” or “patienthood” on the basis of whether participants initiated the care pathway. A supplementary subgroup analysis categorized trials on the basis of whether any volunteerism factors were present (participants had not initiated the care pathway, had attended a research setting, or had a face-to-face interaction with a researcher). Results. Twenty-nine trials were included. Compared with volunteerism trials, pooled effect sizes were higher in patienthood trials (where participants initiated the care pathway) for knowledge, decisional conflict, feeling informed, feeling clear, and participation. The subgroup difference was statistically significant for knowledge only ( P = 0.03). When trials were compared on the basis of whether volunteerism factors were present, knowledge was significantly greater in patienthood trials ( P < 0.001), but there was otherwise no consistent pattern of differences in effects across outcomes. Conclusions. There is a tendency toward greater PtDA efficacy in trials in which participants initiate the pathway of care. Knowledge acquisition appears to be greater in trials where participants are predominantly patients rather than volunteers.

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.

Patients' online access to their electronic health records and linked online services: a systematic review in primary care

BACKGROUND

Online access to medical records by patients can potentially enhance provision of patient-centred care and improve satisfaction. However, online access and services may also prove to be an additional burden for the healthcare provider.

AIM

To assess the impact of providing patients with access to their general practice electronic health records (EHR) and other EHR-linked online services on the provision, quality, and safety of health care.

DESIGN AND SETTING

A systematic review was conducted that focused on all studies about online record access and transactional services in primary care.

METHOD

Data sources included MEDLINE, Embase, CINAHL, Cochrane Library, EPOC, DARE, King's Fund, Nuffield Health, PsycINFO, OpenGrey (1999-2012). The literature was independently screened against detailed inclusion and exclusion criteria; independent dual data extraction was conducted, the risk of bias (RoB) assessed, and a narrative synthesis of the evidence conducted.

RESULTS

A total of 176 studies were identified, 17 of which were randomised controlled trials, cohort, or cluster studies. Patients reported improved satisfaction with online access and services compared with standard provision, improved self-care, and better communication and engagement with clinicians. Safety improvements were patient-led through identifying medication errors and facilitating more use of preventive services. Provision of online record access and services resulted in a moderate increase of e-mail, no change on telephone contact, but there were variable effects on face-to-face contact. However, other tasks were necessary to sustain these services, which impacted on clinician time. There were no reports of harm or breaches in privacy.

CONCLUSION

While the RoB scores suggest many of the studies were of low quality, patients using online services reported increased convenience and satisfaction. These services positively impacted on patient safety, although there were variations of record access and use by specific ethnic and socioeconomic groups. Professional concerns about privacy were unrealised and those about workload were only partly so.

The cost-effectiveness of patient decision aids: A systematic review

The Affordable Care Act includes provisions to encourage patient-centered care through the use of shared decision making (SDM) and patient decision aids (PtDA). PtDAs are tools that can help encourage SDM by providing information about competing treatment options and elucidating patients׳ values and preferences. Implementing PtDAs into routine practice may incur additional costs through training or increases in physician time. Prominent commentaries have proposed that these costs might be offset if patients choose less expensive options than their providers. However, the cost-effectiveness of PtDAs to date is unclear. The aim of this study was to review the economic evidence from PtDA trials. Our search identified 5347 articles, with 29 included following full-text review. Only one economic evaluation of a PtDA has been completed, which found a PtDA to be cost-saving in women with menorrhagia. Other studies included in the review indicated that PtDAs will likely increase up-front costs, but in some contexts may reduce short-term costs by reducing the uptake of invasive treatments, such as elective surgery. Few studies comprehensively captured long-term costs or measured benefits in a manner conducive to economic evaluation (QALYs or general health utilities). Our review suggests that policy makers currently have insufficient economic evidence to appropriately consider their investments in PtDAs.

How cardiologists present the benefits of percutaneous coronary interventions to patients with stable angina: a qualitative analysis

IMPORTANCE

Patients with stable coronary artery disease (CAD) attribute greater benefit to percutaneous coronary interventions (PCI) than indicated in clinical trials. Little is known about how cardiologists' presentation of the benefits and risks may influence patients' perceptions.

OBJECTIVES

To broadly describe the content of discussions between patients and cardiologists regarding angiogram and PCI for stable CAD, and to describe elements that may affect patients' understanding.

DESIGN, SETTING, AND PARTICIPANTS

Qualitative content analysis of encounters between cardiologists and patients with stable CAD who participated in the Verilogue Point-of-Practice Database between March 1, 2008, and August 31, 2012. Transcripts in which angiogram and PCI were discussed were retrieved from the database. Patients were aged 44 to 88 years (median, 64 years); 25% were women; 50% reported symptoms of angina; and 6% were taking more than 1 medication to treat angina.

MAIN OUTCOMES AND MEASURES

Results of conventional and directed qualitative content analysis.

RESULTS

Forty encounters were analyzed. Five major categories and subcategories of factors that may affect patients' understanding of benefit were identified: (1) rationale for recommending angiogram and PCI (eg, stress test results, symptoms, and cardiologist's preferences); (2) discussion of benefits (eg, accurate discussion of benefit [5%], explicitly overstated benefit [13%], and implicitly overstated benefit [35%]); (3) discussion of risks (eg, minimization of risk); (4) cardiologist's communication style (eg, humor, teach-back, message framing, and failure to respond to patient questions); and (5) patient and family member contributions to the discussion.

CONCLUSIONS AND RELEVANCE

Few cardiologists discussed the evidence-based benefits of angiogram and PCI for stable CAD, and some implicitly or explicitly overstated the benefits. The etiology of patient misunderstanding is likely multifactorial, but if future quantitative studies support the findings of this hypothesis-generating analysis, modifications to cardiologists' approach to describing the risks and benefits of the procedure may improve patient understanding.

The Impact of Mental Illness Stigma on Seeking and Participating in Mental Health Care

Treatments have been developed and tested to successfully reduce the symptoms and disabilities of many mental illnesses. Unfortunately, people distressed by these illnesses often do not seek out services or choose to fully engage in them. One factor that impedes care seeking and undermines the service system is mental illness stigma. In this article, we review the complex elements of stigma in order to understand its impact on participating in care. We then summarize public policy considerations in seeking to tackle stigma in order to improve treatment engagement. Stigma is a complex construct that includes public, self, and structural components. It directly affects people with mental illness, as well as their support system, provider network, and community resources. The effects of stigma are moderated by knowledge of mental illness and cultural relevance. Understanding stigma is central to reducing its negative impact on care seeking and treatment engagement. Separate strategies have evolved for counteracting the effects of public, self, and structural stigma. Programs for mental health providers may be especially fruitful for promoting care engagement. Mental health literacy, cultural competence, and family engagement campaigns also mitigate stigma's adverse impact on care seeking. Policy change is essential to overcome the structural stigma that undermines government agendas meant to promote mental health care. Implications for expanding the research program on the connection between stigma and care seeking are discussed.

Variation in patients' perceptions of elective percutaneous coronary intervention in stable coronary artery disease: cross sectional study

OBJECTIVES

To assess the perceptions of patients with stable coronary artery disease of the urgency and benefits of elective percutaneous coronary intervention and to examine how they vary across centers and by providers.

DESIGN

Cross sectional study.

SETTING

10 US academic and community hospitals performing percutaneous coronary interventions between 2009 and 2011.

PARTICIPANTS

991 patients with stable coronary artery disease undergoing elective percutaneous coronary intervention.

MAIN OUTCOME MEASURES

Patients' perceptions of the urgency and benefits of percutaneous coronary intervention, assessed by interview. Multilevel hierarchical logistic regression models examined the variation in patients' understanding across centers and operators after adjusting for patient characteristics, using median odds ratios.

RESULTS

The most common reported benefits from percutaneous coronary intervention were to extend life (90%, n=892; site range 80-97%) and to prevent future heart attacks (88%, n=872; site range 79-97%). Although nearly two thirds of patients (n=661) reported improvement of symptoms as a benefit of percutaneous coronary intervention (site range 52-87%), only 1% (n=9) identified this as the only benefit. Substantial variability was noted in the ways informed consent was obtained at each site. After adjusting for patient and operator characteristics, the median odds ratios showed significant variation in patients' perceptions of percutaneous coronary intervention across sites (range 1.4-3.1) but not across operators within a site.

CONCLUSION

Patients have a poor understanding of the benefits of elective percutaneous coronary intervention, with significant variation across sites. No sites had a high proportion of patients accurately understanding the benefits. Coupled with the wide variability in the ways in which hospitals obtain informed consent, these findings suggest that hospital level interventions into the structure and processes of obtaining informed consent for percutaneous coronary intervention might improve patient comprehension and understanding.

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.

Shared decision-making and comparative effectiveness research for patients with chronic conditions: an urgent synergy for better health

Chronic conditions are the most important cause of morbidity, mortality and health expense in the USA. Comparative effectiveness research (CER) seeks to provide evidence supporting the relative value of alternative courses of action. This research often concludes with estimates of the likelihood of desirable and undesirable outcomes associated with each option. Patients with chronic conditions should engage with their clinicians in deciding which of these options best fits their goals and context. In practicing shared decision-making (SDM), clinicians and patients should make use of CER to inform their deliberations. In these ways, SDM and CER are interrelated. SDM translates CER into patient-centered practice, while CER provides the backbone evidence about options and outcomes in SDM interventions. In this review, we explore the potential for a SDM-CER synergy in improving healthcare for patients with chronic conditions.

Strategies for reducing regional variation in the use of surgery: a systematic review

OBJECTIVE

To review the literature evaluating the effect of practice guidelines and decision aids on use of surgery and regional variation.

BACKGROUND

The use of surgical procedures varies widely across geographic regions. Although practice guidelines and decision aids have been promoted for reducing variation, their true effectiveness is uncertain.

METHODS

Studies evaluating the influence of clinical practice guidelines or consensus statements, shared decision making and decision aids, or provider feedback of comparative utilization, on rates of surgical procedures were identified through literature searches of Ovid MEDLINE, EMBASE, and Web of Science.

RESULTS

A total of 1946 studies were identified and 27 were included in the final review. Of the 12 studies evaluating implementation of guidelines, 6 reported a significant effect. Those examining overall population-based rates had mixed effects, but all studies evaluating procedure choice described at least a small increase in use of recommended therapy. Three of 5 studies examining the effect of guidelines on regional variation reported a significant reduction after dissemination. Of the 15 studies examining decision aids, 5 revealed significant effects. Many studies of decision aids reported decreases in population-based procedure rates. Nearly all studies evaluating the impact of decision aids on procedure choice reported increases in rates of less invasive procedures. Only one study of decision aids assessed changes in regional variation and found mixed results.

CONCLUSIONS

Both practice guidelines and decision aids have been proven effective in many clinical contexts. Expanding the clinical scope of these tools and eliminating barriers to implementation will be essential to further efforts directed toward reducing regional variation in the use of surgery.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Undetermined impact of patient decision support interventions on healthcare costs and savings: systematic review

OBJECTIVE

To perform a systematic review of studies that assessed the potential of patient decision support interventions (decision aids) to generate savings.

DESIGN

Systematic review.

DATA SOURCES

After registration with PROSPERO, we searched 12 databases, from inception to 15 March 2013, using relevant MeSH terms and text words. Included studies were assessed with Cochrane's risk of bias method and Drummond's quality checklist for economic studies. Per patient costs and projected savings associated with introducing patient decision support interventions were calculated, as well as absolute changes in treatment rates after implementation.

ELIGIBILITY CRITERIA

Studies were included if they contained quantitative economic data, including savings, spending, costs, cost effectiveness analysis, cost benefit analysis, or resource utilization. We excluded studies that lacked quantitative data on savings, costs, monetary value, and/or resource utilization.

RESULTS

After reviewing 1508 citations, we included seven studies with eight analyses. Of these seven studies, four analyses predicted system-wide savings, with two analyses from the same study. The predicted savings range from $8 (£5, €6) to $3068 (£1868, €2243) per patient. Larger savings accompanied reductions in treatment utilization rates. The impact on utilization rates was mixed. Authors used heterogeneous methods to allocate costs and calculate savings. Quality scores were low to moderate (median 4.5, range 0-8 out of 10), and risk of bias across the studies was moderate to high (3.5, range 3-6 out of 6), with studies predicting the most savings having the highest risk of bias. The range of issues identified in the studies included the relative absence of sensitivity analyses, the absence of incremental cost effectiveness ratios, and short time periods.

CONCLUSION

Although there is evidence to show that patients choose more conservative approaches when they become better informed, there is insufficient evidence, as yet, to be confident that the implementation of patient decision support interventions leads to system-wide savings. Further work-with sensitivity analyses, longer time horizons, and more contexts-is required to avoid premature or unrealistic expectations that could jeopardize implementation and lead to the loss of already proved benefits.

REGISTRATION

PROSPERO registration CRD42012003421.

Systematic review and meta-analysis of audio-visual information aids for informed consent for invasive healthcare procedures in clinical practice

OBJECTIVE

To systematically review audio-visual (AV) interventions for promoting informed consent (IC) in clinical practice and to consider the impact of reading age adjustment.

METHODS

Systematic review of randomized controlled trials (RCTs) comparing AV interventions to standard IC in clinical practice. Outcomes included recall (immediate <1 day; intermediate 1-14 days; late >14 days), satisfaction and anxiety. Data were synthesized using random effects meta-analyses. Comparisons were made between studies that did and did not adjust for participant reading age.

RESULTS

Of 11,813 abstracts screened, 29 RCTs were eligible (30 intervention arms). Interventions included videos (n=17), computer programs (n=5), electronic presentations (n=3), compact discs (n=3) and websites (n=2). Meta-analysis showed AV interventions improved immediate recall (standardized mean difference [SMD] 0.64, 95% confidence interval [CI] 0.45-0.85). Results for intermediate and late recall were too heterogeneous to synthesize. AV interventions did not consistently affect either satisfaction or anxiety. Adjusting the reading age of interventions improved immediate recall (reading age interventions: adjusted SMD 1.21, 95%CI 0.81-1.61; non-reading age adjusted SMD 0.51, 95%CI 0.36-0.66).

CONCLUSION

AV interventions, especially those adjusted for participant reading age, improve immediate information recall for IC. Practice implications Wider use of AV aids is justified when obtaining IC in clinical practice.

An effort to spread decision aids in five California primary care practices yielded low distribution, highlighting hurdles

Despite the proven efficacy of decision aids as interventions for increasing patient engagement and facilitating shared decision making, they are not used routinely in clinical care. Findings from a project designed to achieve such integration, conducted at five primary care practices in 2010-12, document low rates of distribution of decision aids to eligible patients due for colorectal cancer screening (9.3 percent) and experiencing back pain (10.7 percent). There were also no lasting increases in distribution rates in response to training sessions and other promotional activities for physicians and clinic staff. The results of focus groups, ethnographic field notes, and surveys suggest that major structural and cultural changes in health care practice and policy are necessary to achieve the levels of use of decision aids and shared decision making in routine practice envisioned in current policy. Among these changes are ongoing incentives for use, physician training, and a team-based practice model in which all care team members bear formal responsibility for the use of decision aids in routine primary care.