An exploratory mixed-methods crossover study comparing DVD- vs. Web-based patient decision support in three conditions: The importance of patient perspectives

Mixed-Method Systematic Review and Meta-Analysis of Shared Decision-Making Tools for Cancer Screening

This review aimed to synthesize evidence on the effectiveness of shared decision-making (SDM) tools for cancer screening and explored the preferences of vulnerable people and clinicians regarding the specific characteristics of the SDM tools. A mixed-method convergent segregated approach was employed, which involved an independent synthesis of quantitative and qualitative data. Articles were systematically selected and screened, resulting in the inclusion and critical appraisal of 55 studies. Results from the meta-analysis revealed that SDM tools were more effective for improving knowledge, reducing decisional conflict, and increasing screening intentions among vulnerable populations compared to non-vulnerable populations. Subgroup analyses showed minimal heterogeneity for decisional conflict outcomes measured over a six-month period. Insights from the qualitative findings revealed the complexities of clinicians' and vulnerable populations' preferences for an SDM tool in cancer screening. Vulnerable populations highly preferred SDM tools with relevant information, culturally tailored content, and appropriate communication strategies. Clinicians, on the other hand, highly preferred tools that can be easily integrated into their medical systems for efficient use and can effectively guide their practice for cancer screening while considering patients' values. Considering the complexities of patients' and clinicians' preferences in SDM tool characteristics, fostering collaboration between patients and clinicians during the creation of an SDM tool for cancer screening is essential. This collaboration may ensure effective communication about the specific tool characteristics that best support the needs and preferences of both parties.

Effectiveness of a decision aid for colorectal cancer screening on components of informed choice according to educational attainment: A randomised controlled trial

BACKGROUND

The decision to take up colorectal cancer screening has to be made on informed grounds balancing benefits and harms. Self-administered decision aids can support citizens in making an informed choice. A self-administered web-based decision aid targeting citizens with lower educational attainment has been evaluated within the target population. However, the effectiveness in the general screening population remains unexplored. The aim of this study was to evaluate the effectiveness of a web-based decision aid for colorectal cancer screening on components of informed choice among previous non-participants in colorectal cancer screening.

METHODS AND FINDINGS

The study was designed as a parallel randomised controlled trial among non-participants in colorectal cancer screening in Central Denmark Region (men and women aged 53-74 years). Respondents to baseline and follow-up questionnaires comprised the study population (n = 1,723). The intervention group received the decision aid electronically along with the second reminder. The control group received only the second reminder. The main outcomes (knowledge, attitudes, uptake and decisional conflict) were obtained through questionnaires data and from the Danish Colorectal Cancer Screening Database. The decision aid increased the uptake rate by 8 percentage points (95% CI: 3.4;12.6) but had no effect on either knowledge (scale score differences: 0.09; 95% CI: -0.05;0.24) or attitudes (0.45; 95% CI: -0.00;0.91). Decisional conflict decreased by 1.69 scale points (95% CI: -3.18;-0.20). The effect was similar across educational attainment levels.

CONCLUSIONS

The web-based decision aid offers a feasible way to provide individualised screening information in a "one size fits all" approach that may hold the potential to increase informed CRC screening uptake.

TRIAL REGISTRATION

ClinicalTrials.gov registration number: NCT03253888.

The LEAD trial-The effectiveness of a decision aid on decision making among citizens with lower educational attainment who have not participated in FIT-based colorectal cancer screening in Denmark: A randomised controlled trial

OBJECTIVES

This trial tested the effectiveness of a self-administered web-based decision aid, targeted at citizens with lower educational attainment, on informed choice about colorectal cancer screening participation as assessed by group levels of knowledge, attitudes and uptake.

METHODS

The randomised controlled trial was conducted among 2702 screening-naïve Danish citizens, 53-74 years old, with lower educational attainment. Baseline questionnaire respondents (62%) were allocated to intervention and control groups. Intervention group citizens received the decision aid. Outcomes were informed choice, worries and decisional conflict.

RESULTS

Analyses were conducted among 339 eligible citizens. The mean difference in knowledge score change between intervention and control group was 0.00 (95% confidence interval (CI): -0.38;0.38). Trends towards more positive screening attitudes (mean difference in score change: 0.72, 95% CI: -0.38;1.81) and higher screening uptake (7.6%, 95% CI:-2.2;17.4%) were observed. Worries (-0.33, 95% CI: -0.97;0.32) and decisional conflict (mean difference: -3.5, 95%CI: -7.0;-0.1) were slightly reduced.

CONCLUSIONS

The decision aid did not affect informed choice or knowledge. However, there were trends towards increased screening uptake and more positive screening attitudes.

PRACTICE IMPLICATIONS

Being a simple intervention and easily administered, the decision aid could represent a cost-effective way of enhancing screening uptake, and some elements of informed decision-making.

Comparative Effectiveness of Two Interventions to Increase Colorectal Cancer Screening for Those at Increased Risk Based on Family History: Results of a Randomized Trial

BACKGROUND

First-degree relatives (FDR) of patients with colorectal cancer are at risk for colorectal cancer, but may not be up to date with colorectal cancer screening. We sought to determine whether a one-time recommendation about needing colorectal cancer screening using patient navigation (PN) was better than just receiving the recommendation only.

METHODS

Participants were FDRs of patients with Lynch syndrome-negative colorectal cancer from participating Ohio hospitals. FDRs from 259 families were randomized to a website intervention (528 individuals), which included a survey and personal colorectal cancer screening recommendation, while those from 254 families were randomized to the website plus telephonic PN intervention (515 individuals). Primary outcome was adherence to the personal screening recommendation (to get screened or not to get screened) received from the website. Secondary outcomes examined who benefited from adding PN.

RESULTS

At the end of the 14-month follow-up, 78.6% of participants were adherent to their recommendation for colorectal cancer screening with adherence similar between arms (P = 0.14). Among those who received a recommendation to have a colonoscopy immediately, the website plus PN intervention significantly increased the odds of receiving screening, compared with the website intervention (OR: 2.98; 95% confidence interval, 1.68-5.28).

CONCLUSIONS

Addition of PN to a website intervention did not improve adherence to a colorectal cancer screening recommendation overall; however, the addition of PN was more effective in increasing adherence among FDRs who needed screening immediately.

IMPACT

These findings provide important information as to when the additional costs of PN are needed to assure colorectal cancer screening among those at high risk for colorectal cancer.

Knowledge, attitudes, and worries among different health literacy groups before receiving first invitation to colorectal cancer screening: Cross-sectional study

Background

Colorectal cancer screening uptake is associated with knowledge, attitudes and worries about screening. People with higher levels of health literacy usually have higher screening-related knowledge, but its association with attitudes and worries is sparsely described.The aim of this study was to describe knowledge, attitudes, and worries about colorectal cancer screening among unscreened citizens, and to estimate the association between these and health literacy.

Methods

In a cross-sectional study 10,030 53-74 year-old Central Denmark Region citizens received a questionnaire assessing knowledge, attitudes, worry and health literacy. Socioeconomic and -demographic data were linked from Statistics Denmark after data collection.

Results

In total, 7142 (71.2%) questionnaires were completed. A good general level of knowledge was observed (4.91 and 5.13 out of 7 for men and women, respectively). Citizens tended to be positive towards screening (21.4 and 21.3 on a 4-28 range scale for men and women respectively), and showed low levels of worries (8.8 and 9.09 on a 3-15 range scale for men and women respectively). Knowledge decreased and worries increased with lower levels of health literacy. Further, attitudes tended to be more positive with higher levels of health literacy.

Conclusions

In general, citizens tend to have good knowledge, positive attitudes and few worries about colorectal cancer screening. People with lower health literacy could benefit from targeted interventions that address knowledge and worries about screening to support informed decision making.

Assessing Preference Shift and Effects on Patient Knowledge and Decisional Conflict: Cross-Sectional Study of an Interactive Prostate-Specific Antigen Test Patient Decision Aid

Background

Randomized trials of Web-based decision aids for prostate-specific antigen (PSA) testing indicate that these interventions improve knowledge and reduce decisional conflict. However, we do not know about these tools’ impact on people who spontaneously use a PSA testing patient decision aid on the internet.

Objective

The objectives of this study were to (1) determine the impact of the Web-based PSA Option Grid patient decision aid on preference shift, knowledge, and decisional conflict; (2) identify which frequently asked questions (FAQs) are associated with preference shift; and (3) explore the possible relationships between these outcomes.

Methods

Data were collected between January 1, 2016, and December 30, 2017. Users who accessed the Web-based, interactive PSA Option Grid were provided with 3 options: have a PSA test, no PSA test, or unsure. Users first declared their initial preference and then completed 5 knowledge questions and a 4-item (yes or no) validated decisional conflict scale (Sure of myself, Understand information, Risk-benefit ratio, Encouragement; SURE). Next, users were presented with 10 FAQs and asked to identify their preference for each question based on the information provided. At the end, users declared their final preference and completed the same knowledge and decisional conflict questions. Paired sample t tests were employed to compare before and after knowledge and decisional conflict scores. A multinomial regression analysis was performed to determine which FAQs were associated with a shift in screening preference.

Results

Of all the people who accessed the PSA Option Grid, 39.8% (186/467) completed the interactive journey and associated surveys. After excluding 22 female users, we analyzed 164 responses. At completion, users shifted their preference to “not having the PSA test” (43/164, 26.2%, vs 117/164, 71.3%; P<.001), had higher levels of knowledge (112/164, 68.3%, vs 146/164, 89.0%; P<.001), and lower decisional conflict (94/164, 57.3%, vs 18/164, 11.0%; P<.001). There were 3 FAQs associated with preference shift: “What does the test involve?” “If my PSA level is high, what are the chances that I have prostate cancer?” and “What are the risks?” We did not find any relationship between knowledge, decisional conflict, and preference shift.

Conclusions

Unprompted use of the interactive PSA Option Grid leads to preference shift, increased knowledge, and reduced decisional conflict, which confirms the ability of these tools to influence decision making, even when used outside clinical encounters.

A review of paper-based advance care planning aids

Background

Advance care planning (ACP) aids can help prepare patients, family members, and physicians for in-the-moment medical decision-making. We wished to describe the content and approach of paper-based ACP aids in order to characterize existing aids and inform the development of a new ACP aid.

Methods

Paper-based ACP aids were identified through an environmental scan and screened for eligibility. ACP conceptual frameworks and data were gathered via stakeholder engagement and used to inform the coding framework that two investigators used to independently code each aid. A directed content analysis was conducted on these eligible aids. Aids were categorized through a deliberative process with an investigator abstracting general information for each aid.

Results

Fifteen aids met the eligibility criteria. They ranged in length from 6 to 78 pages with the average aid written at an eighth-grade reading level. The content analysis revealed that many aids encouraged choosing a surrogate decision maker and informed users about legal medical documents. Fewer than half of the aids facilitated patient clarification of values regarding quality of life issues. The authors identified and termed the following three categories of aids: informative; semi-action oriented; and action-oriented. It was often unclear whether patients contributed to the development or testing of the ACP aids reviewed.

Conclusions

Most existing paper-based ACP aids address legal matters such as completing an advance directive. Only a minority elicited patient values and it was unclear whether any were developed in partnership with patients. Future development of ACP aids should account for patient preferences with a goal of supporting in-the-moment medical decision-making.

Internet or dvd for distance learning to isolated rural health professionals, what is the best approach?

BACKGROUND

Distance Learning (DL) is a means to overcome the barriers that prevent health workers access to medical education and training sessions to update their knowledge. The main objective of this study is to compare the knowledge acquisition among practitioners Heads of Health Based Center (HBC) for the management of hypertension in two training modalities, one interactive, via internet (by Visio conferencing and video Conferencing), and other non-interactive, via DVD in the three regions (Miarinarivo, Moramanga and Manjakandriana) of Madagascar.

METHODS

This is a quasi-experimental study comparing two distance learning methodologies, one via internet (VS or VD) and the other via DVD before and after training. Ninety-two (92) Heads of HBC participated in the training, including 56 via the Internet (24 doctors and 32 paramedics) and 36 via DVD (24 doctors and 12 paramedics).

RESULTS

According to the training mode: the mean score of knowledge of the participants was 7 (+ -2) for two terms before training. It is 14 (+ -2.5) in the internet group (VS or VD) and 15 (+ -2.7) in the DVD group after training. The difference between the two groups was not significant p = 0.076. For doctors, the score was 7 (+ -3.1) via internet and 8 (+ -2.3) via DVD in pre test and 14 (+ - 2.4) via internet and 16 (+ -. 2.7) via DVD in post test, the difference between the two training methods was significant (p = 0.008). Among the paramedics, the results are the same for both conditions, 7 (+ - 2.4 to + -3.2) in pre test and 14 (+ - 2.2 to + -2.7) in post test.

CONCLUSION

Both training methods have improved participants' knowledge and the DVD mode is the first choice for Heads HBC of Madagascar with the majority located in remote areas.