Understanding and overcoming the barriers of implementing patient decision aids in clinical practice

Improving sustainability of a patient decision aid for systemic treatment of metastatic colorectal cancer: A qualitative study

Objective

To improve sustainability of a patient decision aid for systemic treatment of metastatic colorectal cancer, we evaluated real-world experiences and identified ways to optimize decision aid content and future implementation.

Methods

Semi-structured interviews with patients and medical oncologists addressed two main subjects: user experience and decision aid content. Content analysis was applied. Fifteen experts discussed the results and devised improvements based on experience and literature review.

Results

Thirteen users were interviewed. They confirmed the relevance of the decision aid for shared decision making. Areas for improvement of content concerned; 1) outdated and missing information, 2) an imbalance in presentation of treatment benefits and harms, and 3) medical oncologists' expressed preference for a more center-specific or patient individualized decision aid, presenting a selection of the guideline recommended treatment options. Key points for improvement of implementation were better alignment within the care pathway, and clear instruction to users.

Conclusion

We identified relevant opportunities for improvement of an existing decision aid and developed an updated version and accompanying implementation strategy accordingly.

Innovation

This paper outlines an approach for continued decision aid and implementation strategy development which will add to sustainability. Implementation success of the improved decision aid is currently being studied in a multi-center mixed-methods implementation study.

Exploring practice and perspectives on shared decision-making about osteoporosis medicines in Fracture Liaison Services: the iFraP development qualitative study

Interviews and focus groups with patients, FLS clinicians, and GPs identified challenges relating to clinical and shared decision-making about bone health and osteoporosis medicines. Findings will inform the development of the multicomponent iFraP intervention to address identified training needs and barriers to implementation to facilitate SDM about osteoporosis medicines.

PURPOSE

The iFraP (improving uptake of Fracture Prevention treatments) study aimed to develop a multicomponent intervention, including an osteoporosis decision support tool (DST), to support shared decision-making (SDM) about osteoporosis medicines. To inform iFraP intervention development, this qualitative study explored current practice in relation to communication about bone health and osteoporosis medicines, anticipated barriers to, and facilitators of, an osteoporosis DST, and perceived training needs.

METHODS

Patients attending an FLS consultation (n = 8), FLS clinicians (n = 9), and general practitioners (GPs; n = 7) were purposively sampled to participate in a focus group and/or telephone interview. Data were transcribed, inductively coded, and then mapped to the Theoretical Domains Framework (TDF) as a deductive framework to systematically identify possible barriers to, and facilitators of, implementing a DST.

RESULTS

Inductive codes were deductively mapped to 12 TDF domains. FLS clinicians were perceived to have specialist expertise (knowledge). However, clinicians described aspects of clinical decision-making and risk communication as difficult (cognitive skills). Patients reflected on decisional uncertainty about medicines (decision processes). Discussions about current practice and the proposed DST indicated opportunities to facilitate SDM, if identified training needs are met. Potential individual and system-level barriers to implementation were identified, such as differences in FLS configuration and a move to remote consulting (environmental context and resources).

CONCLUSIONS

Understanding of current practice revealed unmet training needs, indicating that using a DST in isolation would be unlikely to produce a sustained shift to SDM. Findings will shape iFraP intervention development to address unmet needs.

Current use of the National Surgical Quality Improvement Program surgical risk calculator in academic surgery: a mixed-methods study

Background

This study aims to quantitatively assess use of the NSQIP surgical risk calculator (NSRC) in contemporary surgical practice and to identify barriers to use and potential interventions that might increase use.

Materials and methods

We performed a cross-sectional study of surgeons at seven institutions. The primary outcomes were self-reported application of the calculator in general clinical practice and specific clinical scenarios as well as reported barriers to use.

Results

In our sample of 99 surgeons (49.7% response rate), 73.7% reported use of the NSRC in the past month. Approximately half (51.9%) of respondents reported infrequent NSRC use (<20% of preoperative discussions), while 14.3% used it in ≥40% of preoperative assessments. Reported use was higher in nonelective cases (30.2% vs 11.1%) and in patients who were ≥65 years old (37.1% vs 13.0%), functionally dependent (41.2% vs 6.6%), or with surrogate consent (39.9% vs 20.4%). NSRC use was not associated with training status or years in practice. Respondents identified a lack of influence on the decision to pursue surgery as well as concerns regarding the calculator's accuracy as barriers to use. Surgeons suggested improving integration to workflow and better education as strategies to increase NSRC use.

Conclusions

Many surgeons reported use of the NSRC, but few used it frequently. Surgeons reported more frequent use in nonelective cases and frail patients, suggesting the calculator is of greater utility for high-risk patients. Surgeons raised concerns about perceived accuracy and suggested additional education as well as integration of the calculator into the electronic health record.

What helps the successful implementation of digital decision aids supporting shared decision-making in cardiovascular diseases? A systematic review

Aims

Although digital decision aids (DAs) have been developed to improve shared decision-making (SDM), also in the cardiovascular realm, its implementation seems challenging. This study aims to systematically review the predictors of successful implementation of digital DAs for cardiovascular diseases.

Methods and results

Searches were conducted in MEDLINE, Embase, PsycInfo, CINAHL, and the Cochrane Library from inception to November 2021. Two reviewers independently assessed study eligibility and risk of bias. Data were extracted by using a predefined list of variables. Five good-quality studies were included, involving data of 215 patients and 235 clinicians. Studies focused on DAs for coronary artery disease, atrial fibrillation, and end-stage heart failure patients. Clinicians reported DA content, its effectivity, and a lack of knowledge on SDM and DA use as implementation barriers. Patients reported preference for another format, the way clinicians used the DA and anxiety for the upcoming intervention as barriers. In addition, barriers were related to the timing and Information and Communication Technology (ICT) integration of the DA, the limited duration of a consultation, a lack of communication among the team members, and maintaining the hospital's number of treatments. Clinicians' positive attitude towards preference elicitation and implementation of DAs in existing structures were reported as facilitators.

Conclusion

To improve digital DA use in cardiovascular diseases, the optimum timing of the DA, training healthcare professionals in SDM and DA usage, and integrating DAs into existing ICT structures need special effort. Current evidence, albeit limited, already offers advice on how to improve DA implementation in cardiovascular medicine.

Development of an adjective-selection measure evaluating clinicians' attitudes towards using patient decision aids: The ADOPT measure

BACKGROUND

The implementation of shared decision-making and patient decision aids (PDAs) is impeded by clinicians' attitudes.

OBJECTIVE

To develop a measure of clinician attitude towards PDAs.

METHODS

To develop the ADOPT measure, we used four stages, culminating in measure responses by medically qualified clinicians, 25 from each of the following specialties: emergency medicine, family medicine, oncology, obstetrics and gynaecology, orthopaedics, and psychiatry. To assess validity, we also posed three questions to assess the participants' attitudinal and behavioural endorsement of PDAs. Allocating a point per adjective, we calculated the sum as well as positive and negative scores. We used univariate logistic regression to determine associations between the scores and attitudinal or behavioural endorsements.

RESULTS

152 clinicians completed the measure. 'Time-saving' (39%) and 'easy' (34%) were the most frequently selected adjectives. 'Time-consuming' and 'unfamiliar' were the most frequently selected negative adjectives (both 19%). The sum scores were significantly associated with behavioural endorsement of PDAs.

DISCUSSION

Clinicians were able to respond to adjective-selection methods and the ADOPT measure could help assess clinician attitudes to PDAs. Validation will require further research.

PRACTICE IMPLICATIONS

The ADOPT measure could help identify the extent and source of attitudinal resistance.

Understanding the risk perception of visceral leishmaniasis exposure and the acceptability of sandfly protection measures among migrant workers in the lowlands of Northwest Ethiopia: a health belief model perspective

Background

Visceral leishmaniasis (VL) is the leading cause of health concerns among Ethiopian migrant workers. Understanding risk perception and health-protective behavior are significant challenges in the prevention and eradication of the disease. As a result, studies are required to assess these important epidemiological factors, which will provide guidance on how to assist migrant workers in taking preventive measures against VL.

Method

We conducted qualitative research among migrant workers on seasonal agricultural farms in Northwest Ethiopia between June and November 2019 to assess their perception of the risk of contracting VL and their willingness to use protective measures against the disease. Seventeen focus group discussions and 16 key informant interviews were conducted to study migrant workers’ risk perception in relation to sandfly bite exposure and use of sandfly control measures. For analysis, all interviews were recorded, transcribed, and translated. ATLASti was used to perform qualitative content analysis on the data.

Result

Migrant workers are fearful of VL because of previous exposure and the disease’s prevalence in the area. They believe, however, that VL is a minor illness that is easily treated. While Insecticide Treated Nets (ITNs) are widely accepted as a protective measure, there are still reservations about using them due to the seasonality of the transmission, difficulties in hanging them on farm areas, and a preference for alternative traditional practices. Regardless of perceived self-efficacy, the central cues were the message delivered by the health workers and an increase in sandfly bite irritation. Based on the findings, three levels of intervention modalities are suggested: 1) increasing pre-arrival awareness through outdoor media (posters, stickers, billboards), 2) encouraging proper use of protective measures upon arrival at farm camps, and 3) informing departing workers on disease recognition and best practices for health-seeking continuous use of protective measures at home.

Conclusion

This finding suggests that VL prevention interventions should focus on individuals’ perceptions in order to promote consistent use of protective measures. The findings are highly useful in planning effective interventions against VL.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13406-3.

Implementation and sustainability factors of two early-stage breast cancer conversation aids in diverse practices

BACKGROUND

Conversation aids can facilitate shared decision-making and improve patient-centered outcomes. However, few examples exist of sustained use of conversation aids in routine care due to numerous barriers at clinical and organizational levels. We explored factors that will promote the sustained use of two early-stage breast cancer conversation aids. We examined differences in opinions between the two conversation aids and across socioeconomic strata.

METHODS

We nested this study within a randomized controlled trial that demonstrated the effectiveness of two early-stage breast cancer surgery conversation aids, one text-based and one picture-based. These conversation aids facilitated more shared decision-making and improved the decision process, among other outcomes, across four health systems with socioeconomically diverse patient populations. We conducted semi-structured interviews with a purposive sample of patient participants across conversation aid assignment and socioeconomic status (SES) and collected observations and field notes. We interviewed trial surgeons and other stakeholders. Two independent coders conducted framework analysis using the NOrmalization MeAsure Development through Normalization Process Theory. We also conducted an inductive analysis. We conducted additional sub-analyses based on conversation aid assignment and patient SES.

RESULTS

We conducted 73 semi-structured interviews with 43 patients, 16 surgeons, and 14 stakeholders like nurses, cancer center directors, and electronic health record (EHR) experts. Patients and surgeons felt the conversation aids should be used in breast cancer care in the future and were open to various methods of giving and receiving the conversation aid (EHR, email, patient portal, before consultation). Patients of higher SES were more likely to note the conversation aids influenced their treatment discussion, while patients of lower SES noted more influence on their decision-making. Intervention surgeons reported using the conversation aids did not lengthen their typical consultation time. Most intervention surgeons felt using the conversation aids enhanced their usual care after using it a few times, and most patients felt it appeared part of their normal routine.

CONCLUSIONS

Key factors that will guide the future sustained implementation of the conversation aids include adapting to existing clinical workflows, flexibility of use, patient characteristics, and communication preferences.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03136367 , registered on May 2, 2017.

Does a Question Prompt List Improve Perceived Involvement in Care in Orthopaedic Surgery Compared with the AskShareKnow Questions? A Pragmatic Randomized Controlled Trial

BACKGROUND

Most conditions in orthopaedic surgery are preference-sensitive, where treatment choices are based on the patient's values and preferences. One set of tools increasingly used to help align treatment choices with patient preferences are question prompt lists (QPLs), which are comprehensive lists of potential questions that patients can ask their physicians during their encounters. Whether or not a comprehensive orthopaedic-specific question prompt list would increase patient-perceived involvement in care more effectively than might three generic questions (the AskShareKnow questions) remains unknown; learning the answer would be useful, since a three-question list is easier to use compared with the much lengthier QPLs.

QUESTION/PURPOSE

Does an orthopaedic-specific question prompt list increase patient-perceived involvement in care compared with the three generic AskShareKnow questions?

METHODS

We performed a pragmatic randomized controlled trial of all new patients visiting a multispecialty orthopaedic clinic. A pragmatic design was used to mimic normal clinical care that compared two clinically acceptable interventions. New patients with common orthopaedic conditions were enrolled between August 2019 and November 2019 and were randomized to receive either the intervention QPL handout (orthopaedic-specific QPL with 45 total questions, developed with similar content and length to prior QPLs used in hand surgery, oncology, and palliative care) or a control handout (the AskShareKnow model questions, which are: "What are my options? What are the benefits and harms of those options? How likely are each of those benefits and harms to happen to me?") before their visits. A total of 156 patients were enrolled, with 78 in each group. There were no demographic differences between the study and control groups in terms of key variables. After the visit, patients completed the Perceived Involvement in Care Scale (PICS), a validated instrument designed to evaluate patient-perceived involvement in their care, which served as the primary outcome measure. This instrument is scored from 0 to 13, with higher scores indicating higher perceived involvement.

RESULTS

There was no difference in mean PICS scores between the intervention and control groups (QPL 8.3 ± 2.3, control 8.5 ± 2.3, mean difference 0.2 [95% CI -0.53 to 0.93 ]; p = 0.71.

CONCLUSION

In patients undergoing orthopaedic surgery, a QPL does not increase patient-perceived involvement in care compared with providing patients the three AskShareKnow questions. Implementation of the three AskShareKnow questions can be a more efficient way to improve patient-perceived involvement in their care compared with a lengthy QPL.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Introducing Decision Aids into Routine Prostate Cancer Care in The Netherlands: Implementation and Patient Evaluations from the Multi-regional JIPPA Initiative

Uptake of decision aids (DAs) in daily routine is low, resulting in limited knowledge about successful DA implementation at a large scale. We assessed implementation rates after multi-regional implementation of three different prostate cancer (PCa) treatment DAs and patient-perceived barriers and facilitators to use a DA. Thirty-three hospitals implemented one out of the three DAs in routine care. Implementation rates for each DA were calculated per hospital. After deciding about PCa treatment, patients (n = 1033) completed a survey on pre-formulated barriers and facilitators to use a DA. Overall DA implementation was 40%. For each DA alike, implementation within hospitals varied from incidental (< 10% of eligible patients receiving a DA) to high rates of implementation (> 80%). All three DAs were evaluated positively by patients, although concise and paper DAs yielded higher satisfaction scores compared with an elaborate online DA. Patients were most satisfied when they received the DA within a week after diagnosis. Pre-formulated barriers to DA usage were experienced by less than 10% of the patients, and most patients confirmed the facilitators. Many patients received a DA during treatment counseling, although a wide variation in uptake across hospitals was observed for each DA. Most patients were satisfied with the DA they received. Sustained implementation of DAs in clinical routine requires further encouragement and attention.

Perceived facilitating and limiting factors for healthcare professionals to adopting a patient decision aid for breast cancer aftercare: A cross-sectional study

OBJECTIVE

Effective healthcare innovations are often not adopted and implemented. An implementation strategy based on facilitators and barriers for use as perceived by healthcare professionals could increase adoption rates. This study therefore aimed to identify the most relevant facilitators and barriers for use of an innovative breast cancer aftercare decision aid (PtDA) in healthcare practice.

METHODS

Facilitators and barriers (related to the PtDA, adopter and healthcare organisation) were assessed among breast cancer aftercare health professionals (n = 81), using the MIDI questionnaire. For each category, a backward regression analysis was performed (dependent = intention to adopt). All significant factors were then added to a final regression analysis to identify to most relevant determinants of PtDA adoption.

RESULTS

Expecting higher compatibility with daily practice and clinical guidelines, more positive outcomes of use, higher perceived relevance for the patient and increased self-efficacy were significantly associated with a higher intention to adopt. Self-efficacy and perceived patient relevance remained significant in the final model.

CONCLUSIONS

Low perceived self-efficacy and patient relevance are the most important barriers for health professions to adopt a breast cancer aftercare PtDA.

PRACTICE IMPLICATIONS

To target self-efficacy and perceived patient relevance, the implementation strategy could apply health professional peer champions.

Implementation of a decision aid for localized prostate cancer in routine care: A successful implementation strategy

For the treatment choice of localized prostate cancer, effective patient decision aids have been developed. The implementation of decision aids in routine care, however, lags behind. Main known barriers are lack of confidence in the tool, lack of training on its use, lack of resources and lack of time. A new implementation strategy addresses these barriers. Using this implementation strategy, the implementation rate of a decision aid was measured in eight hospitals and questionnaires were filled out by 24 care providers and 255 patients. The average implementation rate was 60 per cent (range 31%-100%). Hardly any barriers remained for care providers. Patients who did not use the decision aid appeared to be more unwilling than unable to use the decision aid. By addressing known barriers, that is, informing care providers on the effectiveness of the decision aid, providing instructions on its use, embedding it in the existing workflow and making it available free of charge, a successful implementation of a prostate cancer decision aid was reached.

Development and usability testing of a patient decision aid for newly diagnosed relapsing multiple sclerosis patients

BACKGROUND

Multiple sclerosis (MS) patients often struggle with treatment decisions, in part due to the increasing number of approved disease modifying therapies, each with different characteristics, and also since physicians can struggle to identify which of these characteristics matter most to each individual patient. Decision uncertainty can contribute to late treatment initiation and treatment non-adherence-causes of 'undertreatment' in MS. An interactive online patient decision aid that informs patients of their options, considers their individual preferences and goals, and facilitates conversations with their physicians, could improve how patients with relapsing forms of MS make evidence-based treatment decisions.

OBJECTIVE

To develop and evaluate a prototype patient decision aid (PtDA) for first-line disease modifying therapies for relapsing-remitting multiple sclerosis.

METHODS

Informed by previous studies and International Patient Decision Aid Standards guidelines, a prototype PtDA was developed for patients with relapsing multiple sclerosis considering first line treatment. Patients with relapsing multiple sclerosis were recruited from the University of British Columbia's Multiple Sclerosis Clinic to participate in either an online survey or a focus group. Online survey participants completed the PtDA, followed by measures of acceptability, usability, and preparedness for decision-making, and provided general feedback. Focus group participants assessed usability of the revised PtDA. The analysis of qualitative and quantitative data led to improvements of the PtDA prototype.

RESULTS

The prototype PtDA received high ratings for acceptability and usability, and after its use, participants reported high-levels of preparedness for decision-making. Analysis of all qualitative data identified three key themes: the need for credible information; the usefulness of the PtDA; and the importance of normalizing and sharing experiences. Nine content areas were identified for revision. Overall, participants found the PtDA to be a valuable tool for facilitating treatment decisions.

CONCLUSIONS

This mixed methods study has led to the development of a PtDA that can support patients with RRMS as they make treatment decisions. Future studies will assess the feasibility of implementation and the impact of the PtDA on both the timely treatment initiation and longer-term adherence.

Evaluation of Implementation Outcomes After Initiation of a Shared Decision-making Program for Men With Prostate Cancer

OBJECTIVE

To evaluate barriers to implementation of patient decision aids (PDAs) issued in an electronic medical record (EMR). We undertook an implementation outcomes analysis focused on what proportion of men eligible for the PDA received it (penetration), and of the men who received it, how many used it as intended (fidelity). We also evaluated various patient-centered outcomes related to decision-making.

MATERIALS AND METHODS

Men with incident localized prostate cancer were recruited from at UCLA from 2013 to 2017. PDA eligibility was determined via weekly EMR review. We also performed a retrospective chart review of all patients seen in clinic for one sample week to identify patients that were missed by the initial eligibility algorithm, and investigated the cause for miscategorization. We analyzed differences in patient-centered outcomes between those who did and did not receive the PDA.

RESULTS

About 314/374 men with incident prostate cancer completed the PDA conferring 84% fidelity. PDA penetration under initial identification prospective algorithm was assessed at 100% (n = 2/n = 2). However, penetration assessed by manual retrospective chart review was 20% (n = 2/n = 10). Improvements to the identification algorithm, including new EMR visit types, were identified. PDA completion was associated with less decisional conflict and higher perceived Shared decision-making (all P<.03).

CONCLUSION

No previous studies have investigated the challenges of implementing a PDA facilitated by the EMR. We identified modifiable system and EMR-related factors that limited program penetration. Our PDA showed decisional quality benefits.

Heading in a new direction? Recommendations for future research on patient decision aids

Decision aids can improve a number of patient outcomes, but they are not commonly used in clinical practice. This commentary paper provides suggestions for potential next steps of decision aid research, with the aim to facilitate their implementation. We suggest to further standardise clinically meaningful outcomes and outcome measures that should be used to examine the impact of decision aids. Second, using mediation analysis and active control groups could help tease out and explore variables that influence decision aids' effectiveness to help healthcare providers decide when and how to use them in clinical practice. Third, effectiveness trials should be clearly reported and replicated to investigate under what circumstances decision aids work best. Specific checklists for decision aid trials should be used to ensure that all relevant factors are reported in detail. Addressing the above issues will help identify what specific components of decision aids are effective and should be implemented. We can then move towards conducting implementation trials which help increase the use of decision aids in "real-world" healthcare.

Patient decision aid for contralateral prophylactic mastectomy for use in the consultation: a feasibility study

Background

Rates of contralateral prophylactic mastectomy (cpm) continue to rise internationally despite evidence-based guidance strongly discouraging its use in most women with unilateral breast cancer. The purpose of the present study was to develop and assess the feasibility of a knowledge translation tool [a patient decision aid (da)] designed to enhance evidence-informed shared decision-making about cpm.

Methods

A consultation da was developed using the Ottawa Patient Decision Aid Development eTraining in consultation with clinicians and knowledge translation experts. The final da was then assessed for feasibility with health care professionals and patients across Canada. The assessment involved a survey completed online (health care professionals) or by telephone (patients). Survey data were analyzed using descriptive statistics for closed-ended questions and qualitative content analysis for open-ended questions.

Results

The 51 participants who completed the survey included 39 health care professionals and 12 patients. The da was acceptable; 88% of participants viewed it as having the right amount of information or slightly more or less information than they would like. Almost all participants (98%) felt that the da would prepare patients to make better decisions. The aid was perceived to be usable, with 73% of participants stating that they would be willing to use or share the da.

Conclusions

The cpm patient da developed for the present study was viewed by health care professionals and patients across Canada to be acceptable and usable during the clinical consultation. It holds promise as a knowledge translation tool to be used by clinicians in consultation with women who have unilateral breast cancer to enhance evidence-informed and shared decision-making with respect to undergoing cpm.

National consensus recommendations on patient-centered care for ductal carcinoma in situ

PURPOSE

The purpose of this research was to generate recommendations on strategies to achieve patient-centered care (PCC) for ductal carcinoma in situ (DCIS).

METHODS

Thirty clinicians (surgeons, medical/radiation oncologists, radiologists, nurses, navigators) who manage DCIS and 32 DCIS survivors aged 18 or older were nominated. Forty-six recommendations to support PCC for DCIS were derived from primary research, and rated in a two-round Delphi process from March to June 2018.

RESULTS

A total of 29 clinicians and 27 women completed Round One, and 28 clinicians and 22 women completed Round Two. The 29 recommendations retained by both women and clinicians reflected the PCC domains of fostering patient-physician relationship (5), exchanging information (5), responding to emotions (1), managing uncertainty (4), making decisions (9), and enabling patient self-management (5). An additional 13 recommendations were retained by women only: fostering patient-physician relationship (1), exchanging information (3), responding to emotions (2), making decisions (3), and enabling patient self-management (4). Some recommendations refer to processes (i.e., ask questions about lifestyle or views about risks/outcomes to understand patient preferences); others to tools (i.e., communication aid). Panelists recommended a separate consensus process to refine the language that clinicians use when describing DCIS.

CONCLUSIONS

This is the first study to generate guidance on how to achieve PCC for DCIS. Organizations that deliver or oversee health care can use these recommendations on PCC for DCIS to plan, evaluate, or improve services. Ongoing research is needed to develop communication tools, and establish labels and language for DCIS that optimize communication.

Adopting patient-centred tools in cancer care: role of evidence and other factors

Background

Randomized controlled trials (rcts) provide limited evidence to support the use of survivorship care plans (scps), but they provide strong evidence for patient decision aids (ptdas). Despite that evidence, the uptake of ptdas has been limited, but scps are being endorsed and implemented in many cancer programs across Canada. The objective of the present study was to illuminate the decision-making processes involved in the adoption of scps and ptdas.

Methods

Informed by the principles of grounded theory, in-depth semi-structured interviews were conducted with clinicians, managers, and administrators who work in cancer care programs across Canada (n = 21). Data were collected and analyzed concurrently, using a constant comparative analysis approach. Data collection ended when theoretical saturation was reached.

Results

For these types of patient-centred tools, participants noted that high-quality research evidence is often unnecessary for adoption decisions. Six key factors contribute to adoption or non-adoption decisions for scps and ptdas:■ Alignment of research evidence with other evidence■ Perceived clinician benefit■ Endorsement by organizations and professional bodies■ Existence of local champions■ Adaptability to local contexts■ Ability to routinize and reach a large patient population.

Conclusions

High-level evidence is not always the main consideration when adopting new tools into practice. And yet, understanding how clinicians and health system decision-makers decide whether and how to adopt new tools is important to optimizing the use of new tools and practices that are supported by research evidence.

The Optimizing-Risk-Communication (OptRisk) randomized trial - impact of decision-aid-based consultation on adherence and perception of cardiovascular risk

BACKGROUND

Shared decision-making is a well-established approach to increasing patient participation in medical decisions. Increasingly, using lifetime-risk or time-to-event (TTE) formats has been suggested, as these might have advantages in comparison with a 10-year risk prognosis, particularly for younger patients, whose lifetime risk for some events may be considerably greater than their 10-year risk. In this study, a randomized trial, the most popular 10-year risk illustration in the decision-aid software Arriba (emoticons), is compared with a newly developed TTE illustration, which is based on a Markov model. The study compares the effect of these two methods of presenting cardiovascular risk to patients on their subsequent adherence to intervention.

METHODS

A total of 294 patients were interviewed 3 months after they had had a consultation with their GP on cardiovascular risk prevention. Adherence to behavioral change or medication intervention was measured as the primary outcome. The latter was expressed as a generated score. Furthermore, different secondary outcomes were measured, ie, patient perception of risk and self-rated importance of avoiding a cardiovascular event, as well as patient numeracy, which was used as a proxy for patient health literacy.

RESULTS

Overall, no significant difference in patient adherence was found depending on risk representation. In the emoticon group, the number of interventions had a significant impact on the adherence score (P=0.025). Perception of risk was significantly higher in patients counseled with the TTE risk display, whereas the importance of avoiding a cardiovascular event was rated equally highly in both groups and actually increased over time.

CONCLUSION

The TTE format is an appropriate means for counseling patients. Adherence is a very complex construct, which cannot be fully explained by our findings. The study results support our call for considering TTE illustrations as a valuable alternative to current decision-support tools covering cardiovascular prevention. Nevertheless, further research is needed to shed light on patient motivation and adherence with regard to cardiovascular risk prevention.

TRIAL REGISTRATION

The study was registered at the German Clinical Trials Register and at the WHO International Clinical Trials Register Platform (ICTRP, ID DRKS00004933); registered February 2, 2016 (retrospectively registered).

Using the Health Belief Model to explore why women decide for or against the removal of their ovaries to reduce their risk of developing cancer

BACKGROUND

Women at an increased risk of ovarian cancer often have to decide for or against the surgical removal of their healthy ovaries to reduce their cancer risk. This decision can be extremely difficult. Despite this, there is a lack of guidance on how to best support women in making this decision. Research that is guided by theoretical frameworks is needed to help inform clinical practice. We explored the decision-making process of women who are at an increased risk of developing ovarian cancer and had to decide for or against the removal of their ovaries.

METHODS

A qualitative study of 18 semi-structured interviews with women who have attended a cancer treatment centre or cancer counselling and information service in New South Wales, Australia. Data collection and analysis were informed by the Health Belief Model (HBM). Data was analysed using qualitative content analysis.

RESULTS

The paper describes women's decision making with the help of the four constructs of the HBM: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers. The more anxious and susceptible women felt about getting ovarian cancer, the more likely they were to have an oophorectomy. Women's anxiety was often fuelled by witnessing family members suffer or die from cancer. Women considered a number of barriers and potential benefits to having the surgery but based their decision on "gut feeling" and experiential factors, rather than statistical risk assessment. Age, menopausal status and family commitments seemed to influence but not determine women's decisions on oophorectomy. Women reported a lack of decision support and appreciated if their doctor explained their treatment choice, provided personalised information, involved their general practitioner in the decision-making process and offered a second consultation to follow-up on any questions women might have.

CONCLUSIONS

These findings suggest that deciding on whether to have an oophorectomy is a highly personal decision which can be described with the help of the HBM. The results also highlight the need for tailored decision support which could help improve doctor-patient-communication and patient-centred care related to risk reducing surgery in women at an increased risk of ovarian cancer.

End-user involvement in developing and field testing an online contraceptive decision aid

OBJECTIVES

Decision aids in the field of healthcare contribute to informed decision making. To increase the usefulness and effectiveness of decision aids, it is important to involve end-users in the development of these tools. This article reports on the development of an online contraceptive decision aid.

METHODS

An exploratory, qualitative study was conducted in the Netherlands between 2014 and 2016. The development process of the decision aid consisted of six steps and included a needs assessment and field test. Interviews were conducted with 17 female students.

RESULTS

The needs assessment provided information on the preferred content and structure of a contraceptive decision aid and guided the development of the online contraceptive decision aid prototype. Participants had an overall positive impression of the decision aid prototype during the field test. Minor revisions were made based on participants' feedback. Participants expected that the decision aid would positively contribute to decision making by increasing knowledge and awareness regarding the available contraceptive methods and their features and attributes, and by opening up to other options than the known methods.

CONCLUSION

The developed contraceptive decision aid can contribute to better informed decision making and consultation preparation. Involving end-users in development seems valuable to adapt decision aids to specific needs and to identify in what way a decision aid influences decision making.

Development and pilot testing of a Decision Aid (DA) for women with early-stage breast cancer considering contralateral prophylactic mastectomy

OBJECTIVE

Describe the development, acceptability and feasibility of a Decision Aid (DA) for women with early-stage breast cancer (BC) at average contralateral breast cancer (CBC) risk considering contralateral prophylactic mastectomy (CPM).

METHODS

The DA was developed using the International Patient Decision Aid Standards (IPDAS) and the Ottawa Decision Support Framework. It provides evidence-based information about CPM in a booklet format combining text, graphs and images of surgical options. Twenty-three women with a history of early-stage breast cancer were interviewed in person or over the phone using a 'think aloud approach'. Framework analysis was used to code and analyse data.

RESULTS

Twenty-three women participated in the study. Mean age of participants was 58.6 years and time since diagnosis ranged from 14 months to 21 years. Five women had CPM and eighteen had not. Women strongly endorsed the DA. Many felt validated by a section on appearance and found information on average risk of recurrence and metastases helpful, however, noted the importance of discussing personal risk with their surgeon. Many requested more information on surgery details (time taken, recovery) and costs of the different options.

CONCLUSION

The DA was acceptable to women, including the format, content and proposed implementation strategies. Practical and financial issues are important to women in considering treatment options.

PRACTICE IMPLICATIONS

Women appreciate information about CPM at diagnosis and emphasised the importance of discussing potential downsides of the procedure in addition to benefits. The DA was considered acceptable to facilitate such discussions.

Coaching to support men in making informed choices about prostate cancer screening: A qualitative study

OBJECTIVE

The objective of this study was to examine the perceptions of men, practice nurses (PNs) and general practitioners (GPs) on patient decision coaching for prostate cancer screening.

METHODS

Seven focus groups were conducted with 47 participants, representing three stakeholder groups - men, GPs and PNs. All focus group discussions were conducted by the same facilitator and guided by a semi-structured interview schedule. Transcriptions were analysed by thematic analysis.

RESULTS

Knowledge about the merits of prostate cancer screening was high amongst GPs, but limited with PNs and men. All groups saw the value in PN-led decision coaching for men considering screening for prostate cancer, but had reservations about its implementation in practice. Barriers to implementing a decision coaching system with PNs included staffing and cost of implementation.

CONCLUSION

GPs, PNs and men identified benefits for the use of a PN-led decision coaching support intervention to assist men with making an informed choice about screening for prostate cancer. Stakeholders had reservations about how a PN-led intervention would effectively work in clinical practice.

PRACTICE IMPLICATIONS

A feasibility study is required to examine barriers and enablers to implementing a PN-led decision coaching process for prostate cancer screening in the Australian primary healthcare setting.

Exploring women's experiences with a decision aid for neoadjuvant systemic therapy for operable breast cancer

BACKGROUND

Some women with operable breast cancer have a choice between receiving upfront surgery followed by chemotherapy or neoadjuvant systemic therapy (NAST) prior to receiving surgery. While survival outcomes are equivalent for both options, the decision about treatment sequence can be difficult due to its complexity and perceived urgency. A decision aid has been developed to help patients decide on whether to receive NAST.

AIMS

To explore, qualitatively, women's use and perceived benefit of a decision aid to help with their decision on NAST.

METHODS

A framework analysis process was conducted on a purposeful sample of 20, one-on-one, semistructured phone interviews with early-stage breast cancer patients eligible for NAST. Participants had recently decided on whether or not to have NAST.

RESULTS

Patients perceived the decision aid as useful to becoming more informed and involved in making a decision as to whether they receive NAST. They described the information provided in the decision aid as reliable, relevant, sufficient in terms of amount, and tailored to their needs. Reading and rereading the decision aid at home in-between the consultations with their surgeon and their medical oncologist allowed women to better understand their treatment options and easily integrate the decision aid into their care. The decision aid seemed to confirm but not change women's decisions on NAST.

CONCLUSION

The decision aid appears to help breast cancer patients support their decision about whether to receive NAST. Patients' ability to review the decision aid in-between two consultations seems to be an acceptable and feasible way of integrating the decision aid into patients' care.

A Randomized Controlled Trial Evaluating the Impact of Web-Based Information on Breast Cancer Patients' Knowledge of Surgical Treatment Options

BACKGROUND

Previous research suggests that providing information to women newly diagnosed with breast cancer, during the gap between cancer diagnosis and their first surgeon consultation, may support decision making. Our objective was to compare patients' knowledge after the pre-consultation delivery of standard websites vs a web-based decision aid (DA).

STUDY DESIGN

We randomized women with stage 0 to III breast cancer, within an academic and community breast clinic, to be emailed a link to selected standard websites (National Cancer Institute, American Cancer Society, Breastcancer.org,) vs the Health Dialog DA (Clinicaltrials.govNCT03116035). Patients seeking second opinions, diagnosed by excisional biopsy, or without an email address, were ineligible. Pre-consultation knowledge was assessed using the Breast Cancer Surgery Decision Quality Instrument. We compared differences in knowledge using t-test.

RESULTS

Median patient age was 59 years, 99% were white, and 65% had a college degree or higher, with no differences in demographics between study arms. Knowledge was higher in patients who received the DA (median 80% vs 66% correct, p = 0.01). Decision-aid patients were more likely to know that waiting a few weeks to make a treatment decision would not affect survival (72% vs 54%, p < 0.01). Patients in both arms found the information helpful (median score 8 of 10).

CONCLUSIONS

Although patients found receipt of any pre-consultation information helpful, the DA resulted in improved knowledge over standard websites and effectively conveyed that there is time to make a breast cancer surgery decision. Decreasing the urgency patients feel may improve the quality of patient-surgeon interactions and lead to more informed decision-making.

Development, Feasibility, and Small-Scale Implementation of a Web-Based Prognostic Tool-Surveillance, Epidemiology, and End Results Cancer Survival Calculator

BACKGROUND

Population datasets and the Internet are playing an ever-growing role in the way cancer information is made available to providers, patients, and their caregivers. The Surveillance, Epidemiology, and End Results Cancer Survival Calculator (SEER*CSC) is a Web-based cancer prognostic tool that uses SEER data, a large population dataset, to provide physicians with highly valid, evidence-based prognostic estimates for increasing shared decision-making and improving patient-provider communication of complex health information.

OBJECTIVE

The aim of this study was to develop, test, and implement SEER*CSC.

METHODS

An iterative approach was used to develop the SEER*CSC. Based on input from cancer patient advocacy groups and physicians, an initial version of the tool was developed. Next, providers from 4 health care delivery systems were recruited to do formal usability testing of SEER*CSC. A revised version of SEER*CSC was then implemented in two health care delivery sites using a real-world clinical implementation approach, and usage data were collected. Post-implementation follow-up interviews were conducted with site champions. Finally, patients from two cancer advocacy groups participated in usability testing.

RESULTS

Overall feedback of SEER*CSC from both providers and patients was positive, with providers noting that the tool was professional and reliable, and patients finding it to be informational and helpful to use when discussing their diagnosis with their provider. However, use during the small-scale implementation was low. Reasons for low usage included time to enter data, not having treatment options in the tool, and the tool not being incorporated into the electronic health record (EHR). Patients found the language in its current version to be too complex.

CONCLUSIONS

The implementation and usability results showed that participants were enthusiastic about the use and features of SEER*CSC, but sustained implementation in a real-world clinical setting faced significant challenges. As a result of these findings, SEER*CSC is being redesigned with more accessible language for a public facing release. Meta-tools, which put different tools in context of each other, are needed to assist in understanding the strengths and limitations of various tools and their place in the clinical decision-making pathway. The continued development and eventual release of prognostic tools should include feedback from multidisciplinary health care teams, various stakeholder groups, patients, and caregivers.

Impact of tailored blogs and content on usage of Web CIPHER - an online platform to help policymakers better engage with evidence from research

BACKGROUND

There is a need to develop innovations that can help bridge the gap between research and policy. Web CIPHER is an online tool designed to help policymakers better engage with research in order to increase its use in health policymaking. The aim of the present study was to test interventions in order to increase policymakers' usage of Web CIPHER. Namely, the impact of posting articles and blogs on topics relevant to the missions and scope of selected policy agencies in the Web CIPHER community.

METHODS

Five policy agencies were targeted for the intervention. Web CIPHER usage data was gathered over a 30-month period using Google Analytics. Time series analysis was used to evaluate whether publication of tailored articles and blogs led to significant changes in usage for all Web CIPHER members from policy agencies, including those from the five target agencies. We further evaluated whether these users showed greater increases in usage following publication of articles and blogs directly targeted at their agency, and if these effects were moderated by the blog author.

RESULTS

Web CIPHER usage gradually increased over time and was significantly predicted by the number of articles but not blogs that were posted throughout the study period. Publication of articles on sexual and reproductive health was followed by sustained increases in usage among all users, including users from the policy agency that targets this area. This effect of topic relevance did not occur for the four remaining target agencies. Finally, page views were higher for articles targeted at one's agency compared to other agencies. This effect also occurred for blogs, particularly when the author was internal to one's agency.

CONCLUSION

The findings suggest that Web CIPHER usage in general was motivated by general interest, engagement and appeal, as opposed to the agency specificity of content and work relevance. Blogs in and of themselves may not be effective at promoting usage. Thus, in order to increase policymakers' engagement with research through similar online platforms, a potentially effective approach would be to post abundant, frequently updated, engaging, interesting and widely appealing content irrespective of form.

Time-to-event versus ten-year-absolute-risk in cardiovascular risk prevention - does it make a difference? Results from the Optimizing-Risk-Communication (OptRisk) randomized-controlled trial

Background

The concept of shared-decision-making is a well-established approach to increase the participation of patients in medical decisions. Using lifetime risk or time-to-event (TTE) formats has been increasingly suggested as they might have advantages, e.g. in younger patients, to better show consequences of unhealthy behaviour. In this study, the most-popular ten-year risk illustration in the decision-aid-software arriba^TM (emoticons), is compared within a randomised trial to a new-developed TTE illustration, which is based on a Markov model.

Methods

Thirty-two General Practitioners (GPs) took part in the study. A total of 304 patients were recruited and counseled by their GPs with arriba^TM, and randomized to either the emoticons or the TTE illustration, followed by a patient questionnaire to figure out the degree of shared-decision-making (PEF-FB9, German questionnaire to measure the participation in the shared decision-making process, primary outcome), as well as the decisional conflict, perceived risk, accessibility and the degree of information, which are all secondary outcomes.

Results

Regarding our primary outcome PEF-FB9 the new TTE illustration is not inferior compared to the well-established emoticons taking the whole study population into account. Furthermore, the non-inferiority of the innovative TTE could be confirmed for all secondary outcome variables. The explorative analysis indicates even advantages in younger patients (below 46 years of age).

Conclusion

The TTE format seems to be as useful as the well-established emoticons. For certain patient populations, especially younger patients, the TTE may be even superior to demonstrate a cardiovascular risk at early stages. Our results suggest that time-to-event illustrations should be considered for current decision support tools covering cardiovascular prevention.

Trial registration

The study was registered at the German Clinical Trials Register and at the WHO International Clinical Trials Register Platform (ICTRP, ID DRKS00004933); registered 2 February 2016 (retrospectively registered).

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0393-1) contains supplementary material, which is available to authorized users.

An overview and discussion of the Patient-Centered Outcomes Research Institute's decision aid portfolio

Decision aids (DAs) help patients make informed healthcare decisions in a manner consistent with their values and preferences. Despite their promise, DAs developed with public research dollars are not being implemented and adopted in real-world patient care settings at a rate consistent with which they are being developed. To appraise the sum of the parts of the portfolio and create a strategic imperative surrounding future funding, the Patient-Centered Outcomes Research Institute (PCORI) tasked the Duke Evidence Synthesis Group with evaluating its DA portfolio. This paper describes PCORI's portfolio of DAs according to the Duke Evidence Synthesis Group's analysis in the context of PCORI's mission and the field of decision science. The results revealed a diversity within PCORI's portfolio of funded DA projects. Findings support the movement toward more rigorous DA development, assessment and maintenance. PCORI's funding priorities related to DAs are clarified and comparative questions of interest are posed.

Wilfully out of sight? A literature review on the effectiveness of cancer-related decision aids and implementation strategies

Background

There is evidence to suggest that decision aids improve a number of patient outcomes. However, little is known about the progression of research effort in this area over time. This literature review examined the volume of research published in 2000, 2007 and 2014 which tested the effectiveness of decision aids in improving cancer patient outcomes, coded by cancer site and decision type being targeted. These numbers were compared with the volume of research examining the effectiveness of strategies to increase the adoption of decision aids by healthcare providers.

Methods

A literature review of intervention studies was undertaken. Medline, Embase, PsychInfo and Cochrane Database of Systematic Reviews were searched. The search was limited to human studies published in English, French, or German. Abstracts were assessed against eligibility criteria by one reviewer and a random sample of 20 % checked by a second. Eligible intervention studies in the three time periods were categorised by: i) whether they tested the effectiveness of decision aids, coded by cancer site and decision type, and ii) whether they tested strategies to increase healthcare provider adoption of decision aids.

Results

Over the three time points assessed, increasing research effort has been directed towards testing the effectiveness of decision aids in improving patient outcomes (p < 0.0001). The number of studies on decision aids for cancer screening or prevention increased statistically significantly (p < 0.0001) whereas the number of studies on cancer treatment did not (p = 1.00). The majority of studies examined the effectiveness of decision aids for prostate (n = 10), breast (n = 9) or colon cancer (n = 7). Only two studies assessed the effectiveness of implementation strategies to increase healthcare provider adoption of decision aids.

Conclusions

While the number of studies testing the effectiveness of decision aids has increased, the majority of research has focused on screening and prevention decision aids for only a few cancer sites. This neglects a number of cancer populations, as well as other areas of cancer care such as treatment decisions. Also, given the apparent effectiveness of decision aids, more effort needs to be made to implement this evidence into meaningful benefits for patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0273-8) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

METHODS/DESIGN

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

DISCUSSION

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

Usage of an online tool to help policymakers better engage with research: Web CIPHER

BACKGROUND

There is a need to develop innovations that help policymakers better engage with research in order to increase its use in policymaking. As part of the Centre for Informing Policy in Health with Evidence from Research (CIPHER), we established Web CIPHER, an online tool with dynamic interactive elements such as hot topics, research summaries, blogs from trusted figures in health policy and research, a community bulletin board, multimedia section and research portal. The aim of this study was to examine policymakers' use of the website, and determine which sections were key drivers of use.

METHODS

Google Analytics (GA) was used to gather usage data during a 16-month period. Analysis was restricted to Web CIPHER members from policy agencies. We examined descriptive statistics including mean viewing times, number of page visits and bounce rates for each section and performed analyses of variance to compare usage between sections. Repeated measures analyses were undertaken to examine whether a weekly reminder email improved usage of Web CIPHER, particularly for research-related content.

RESULTS

During the measurement period, 223 policymakers from more than 32 organisations joined Web CIPHER. Users viewed eight posts on average per visit and stayed on the site for approximately 4 min. The bounce rate was less than 6%. The Blogs and Community sections received more unique views than all other sections. Blogs relating to improving policymakers' skills in applying research to policy were particularly popular. The email reminder had a positive effect on improving usage, particularly for research-related posts.

CONCLUSIONS

The data indicated a relatively small number of users. However, this sample may not be representative of policymakers since membership to the site and usage was completely voluntarily. Nonetheless, those who used the site appeared to engage well with it. The findings suggest that providing blog-type content written by trusted experts in health policy and research as well as regular email reminders may provide an effective means of disseminating the latest research to policymakers through an online web portal.

Screening strategies for colorectal cancer in asymptomatic adults

This article provides an update for the primary care community on the evidence and recommendations for colorectal cancer screening in the adult population without symptoms at average and increased risk, excluding patients with high-risk genetic syndromes. The current and possible new screening strategies are reviewed, along with clinical wisdom related to the implementation of each method.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

Provider perspectives on the utility of a colorectal cancer screening decision aid for facilitating shared decision making

BACKGROUND

Decision aids for colorectal cancer (CRC) screening have been shown to enable patients to identify a preferred screening option, but the extent to which such tools facilitate shared decision making (SDM) from the perspective of the provider is less well established.

OBJECTIVE

Our goal was to elicit provider feedback regarding the impact of a CRC screening decision aid on SDM in the primary care setting.

METHODS

Cross-sectional survey.

PARTICIPANTS

Primary care providers participating in a clinical trial evaluating the impact of a novel CRC screening decision aid on SDM and adherence.

MAIN OUTCOMES

Perceptions of the impact of the tool on decision-making and implementation issues.

RESULTS

Twenty-nine of 42 (71%) eligible providers responded, including 27 internists and two nurse practitioners. The majority (>60%) felt that use of the tool complimented their usual approach, increased patient knowledge, helped patients identify a preferred screening option, improved the quality of decision making, saved time and increased patients' desire to get screened. Respondents were more neutral is their assessment of whether the tool improved the overall quality of the patient visit or patient satisfaction. Fewer than 50% felt that the tool would be easy to implement into their practices or that it would be widely used by their colleagues.

CONCLUSION

Decision aids for CRC screening can improve the quality and efficiency of SDM from the provider perspective but future use is likely to depend on the extent to which barriers to implementation can be addressed.

Perceived barriers and facilitators of using a Web-based interactive decision aid for colorectal cancer screening in community practice settings: findings from focus groups with primary care clinicians and medical office staff

BACKGROUND

Information is lacking about the capacity of those working in community practice settings to utilize health information technology for colorectal cancer screening.

OBJECTIVE

To address this gap we asked those working in community practice settings to share their perspectives about how the implementation of a Web-based patient-led decision aid might affect patient-clinician conversations about colorectal cancer screening and the day-to-day clinical workflow.

METHODS

Five focus groups in five community practice settings were conducted with 8 physicians, 1 physician assistant, and 18 clinic staff. Focus groups were organized using a semistructured discussion guide designed to identify factors that mediate and impede the use of a Web-based decision aid intended to clarify patient preferences for colorectal cancer screening and to trigger shared decision making during the clinical encounter.

RESULTS

All physicians, the physician assistant, and 8 of the 18 clinic staff were active participants in the focus groups. Clinician and staff participants from each setting reported a belief that the Web-based patient-led decision aid could be an informative and educational tool; in all but one setting participants reported a readiness to recommend the tool to patients. The exception related to clinicians from one clinic who described a preference for patients having fewer screening choices, noting that a colonoscopy was the preferred screening modality for patients in their clinic. Perceived barriers to utilizing the Web-based decision aid included patients' lack of Internet access or low computer literacy, and potential impediments to the clinics' daily workflow. Expanding patients' use of an online decision aid that is both easy to access and understand and that is utilized by patients outside of the office visit was described as a potentially efficient means for soliciting patients' screening preferences. Participants described that a system to link the online decision aid to a computerized reminder system could promote a better understanding of patients' screening preferences, though some expressed concern that such a system could be difficult to keep up and running.

CONCLUSIONS

Community practice clinicians and staff perceived the Web-based decision aid technology as promising but raised questions as to how the technology and resultant information would be integrated into their daily practice workflow. Additional research investigating how to best implement online decision aids should be conducted prior to the widespread adoption of such technology so as to maximize the benefits of the technology while minimizing workflow disruptions.

Lessons learned from the conduct of a multisite cluster randomized practical trial of decision aids in rural and suburban primary care practices

Background

The decision aids for diabetes (DAD) trial explored the feasibility of testing the effectiveness of decision aids (DAs) about coronary prevention and diabetes medications in community-based primary care practices, including rural clinics that care for patients with type 2 diabetes.

Methods

As originally designed, we invited clinicians in eight practices to participate in the trial, reviewed the patient panel of clinicians who accepted our invitation for potentially eligible patients, and contacted these patients by phone, enrolling those who accepted our invitation. As enrollment failed to meet targets, we recruited four new practices. After discussing the study with the clinicians and receiving their support, we reviewed all clinic panels for potentially eligible patients. Clinicians were approached to confirm participation and patient eligibility, and patients were approached before their visit to provide written informed consent. This in-clinic approach required study coordinators to travel and stay longer at the clinics as well as to screen more patient records for eligibility. The in-clinic approach was associated with better recruitment rates, lower patient retention and outcome completion rates, and a better intervention effect.

Results

We drew four lessons: 1) difficulties identifying potentially eligible patients threaten the viability of practical trials of DAs; 2) to improve the recruitment yield, recruit clinicians and patients for the study at the clinic, just before their visit; 3) approaches that improve recruitment may be associated with reduced retention and survey response; and 4) procedures that involve working closely with the practice may improve recruitment and may also affect the quality of the implementation of the interventions.

Conclusion

Success in practice-based trials in usual primary care including rural clinics may require the smallest possible research footprint on the practice while implementing a streamlined protocol favoring in-clinic, in-person interactions with clinicians and patients.

Trial registration

ClinicalTrials.gov NCT01029288

Predictors of short-term postoperative survival after elective colectomy in colon cancer patients ≥ 80 years of age

BACKGROUND

Individuals ≥ 80 years of age represent an increasing proportion of colon cancer diagnoses. Selecting these patients for elective surgery is challenging because of diminished overall health, functional decline, and limited data to guide decisions. The objective was to identify overall health measures that are predictive of poor survival after elective surgery in these oldest-old colon cancer patients.

METHODS

Medicare beneficiaries ≥ 80 years who underwent elective colectomy for stage I-III colon cancer from 1992-2005 were identified from the Surveillance, Epidemiology and End Results(SEER)-Medicare database. Kaplan-Meier survival analysis determined 90-day and 1-year overall survival. Multivariable logistic regression assessed factors associated with short-term postoperative survival.

RESULTS

Overall survival for the 12,979 oldest-old patients undergoing elective colectomy for colon cancer was 93.4 and 85.7 %, at 90 days and 1 year. Older age, male gender, frailty, increased hospitalizations in prior year, and dementia were most strongly associated with decreased survival. In addition, AJCC stage III (vs stage I) disease and widowed (vs married) were highly associated with decreased survival at 1 year. Although only 4.4 % of patients were considered frail, this had the strongest association with mortality, with an odds ratio of 8.4 (95 % confidence interval, 6.4-11.1).

CONCLUSIONS

Although most oldest-old colon cancer patients do well after elective colectomy, a significant proportion (6.6 %) die by postoperative day 90 and frailty is the strongest predictor. The ability to identify frailty through billing claims is intriguing and suggests the potential to prospectively identify, through the electronic medical record, patients at highest risk of decreased survival.

The effect of a patient-oriented treatment decision aid for risk factor management in patients with diabetes (PORTDA-diab): study protocol for a randomised controlled trial

Background

To improve risk factor management in diabetes, we need to support effective interactions between patients and healthcare providers. Our aim is to develop and evaluate a treatment decision aid that offers personalised information on treatment options and outcomes, and is intended to empower patients in taking a proactive role in their disease management. Important features are: (1) involving patients in setting goals together with their provider; (2) encourage them to prioritise on treatments that maximise relevant outcomes; and (3) integration of the decision aid in the practice setting and workflow. As secondary aim, we want to evaluate the impact of different presentation formats, and learn more from the experiences of the healthcare providers and patients with the decision aid.

Methods and design

We will conduct a randomised trial comparing four formats of the decision aid in a 2×2 factorial design with a control group. Patients with type 2 diabetes managed in 18 to 20 primary care practices in The Netherlands will be recruited. Excluded are patients with a recent myocardial infarction, stroke, heart failure, angina pectoris, terminal illness, cognitive deficits, >65 years at diagnosis, or not able to read Dutch. The decision aid is offered to the patients immediately before their quarterly practice consultation. The same decision information will be available to the healthcare provider for use during consultation. In addition, the providers receive a set of treatment cards, which they can use to discuss the benefits and risks of different options. Patients in the control group will receive care as usual. We will measure the effect of the intervention on patient empowerment, satisfaction with care, beliefs about medication, negative emotions, health status, prescribed medication, and predicted cardiovascular risk. Data will be collected with questionnaires and automated extraction from medical records in 6 months before and after the intervention.

Discussion

This decision aid is innovative in supporting patients and their healthcare providers to make shared decisions about multiple treatments, using the patient’s data from electronic medical records. The results can contribute to the further development and implementation of electronic decision support tools for the management of chronic diseases.

Trial registration

Dutch Trial register NTR1942.

Arriba-lib: association of an evidence-based electronic library of decision aids with communication and decision-making in patients and primary care physicians

AIM

In shared decision-making, patients are empowered to actively ask questions and participate in decisions about their healthcare based on their preferences and values. Decision aids should help patients make informed choices among diagnostic or treatment options by delivering evidence-based information on options and outcomes; however, they have rarely been field tested, especially in the primary care context. We therefore evaluated associations between the use of an interactive, transactional and evidence-based library of decision aids (arriba-lib) and communication and decision-making in patients and physicians in the primary care context.

METHODS

Our electronic library of decision aids ('arriba-lib') includes evidence-based modules for cardiovascular prevention, diabetes, coronary heart disease, atrial fibrillation and depression. Twenty-nine primary care physicians recruited 192 patients. We used questionnaires to ask patients and physicians about their experiences with and attitudes towards the programme. Patients were interviewed via telephone 2 months after the consultation. Data were analysed by general estimation equations, cross tab analyses and by using effect sizes.

RESULTS

Only a minority (8.9%) of the consultations were felt to be too long because physicians said consultations were unacceptably extended by arriba-lib. We found a negative association between the detailedness of the discussion of the clinical problem's definition and the age of the patients. Physicians discuss therapeutic options in less detail with patients who have a formal education of less than 8 years. Patients who were counselled by a physician with no experience in using a decision aid more often reported that they do not remember being counselled with the help of a decision aid or do not wish to be counselled again with a decision aid.

CONCLUSIONS

Arriba-lib has positive associations to the decision-making process in patients and physicians. It can also be used with older age groups and patients with less formal education. Physicians seem to adapt their counselling strategy to different patient groups. Prior experience with the use of decision aids has an influence on the acceptance of arriba-lib in patients but not on their decision-making or decision implementation.

Arriba-lib: evaluation of an electronic library of decision aids in primary care physicians

Background

The successful implementation of decision aids in clinical practice initially depends on how clinicians perceive them. Relatively little is known about the acceptance of decision aids by physicians and factors influencing the implementation of decision aids from their point of view. Our electronic library of decision aids (arriba-lib) is to be used within the encounter and has a modular structure containing evidence-based decision aids for the following topics: cardiovascular prevention, atrial fibrillation, coronary heart disease, oral antidiabetics, conventional and intensified insulin therapy, and unipolar depression. The aim of our study was to evaluate the acceptance of arriba-lib in primary care physicians.

Methods

We conducted an evaluation study in which 29 primary care physicians included 192 patients. The physician questionnaire contained information on which module was used, how extensive steps of the shared decision making process were discussed, who made the decision, and a subjective appraisal of consultation length. We used generalised estimation equations to measure associations within patient variables and traditional crosstab analyses.

Results

Only a minority of consultations (8.9%) was considered to be unacceptably extended. In 90.6% of consultations, physicians said that a decision could be made. A shared decision was perceived by physicians in 57.1% of consultations. Physicians said that a decision was more likely to be made when therapeutic options were discussed “detailed”. Prior experience with decision aids was not a critical variable for implementation within our sample of primary care physicians.

Conclusions

Our study showed that it might be feasible to apply our electronic library of decision aids (arriba-lib) in the primary care context. Evidence-based decision aids offer support for physicians in the management of medical information. Future studies should monitor the long-term adoption of arriba-lib in primary care physicians.

Clinical effectiveness of a patient decision aid to improve decision quality and glycaemic control in people with diabetes making treatment choices: a cluster randomised controlled trial (PANDAs) in general practice

OBJECTIVE

To determine the effectiveness of a patient decision aid (PDA) to improve decision quality and glycaemic control in people with diabetes making treatment choices using a cluster randomised controlled trial (RCT).

DESIGN

A cluster RCT.

SETTING

49 general practices in UK randomised into intervention (n=25) and control (n=24).

PARTICIPANTS

General practices Inclusion criteria: >4 medical partners; list size >7000; and a diabetes register with >1% of practice population. 191 practices assessed for eligibility, and 49 practices randomised and completed the study. Patients People with type 2 diabetes mellitus (T2DM) taking at least two oral glucose-lowering drugs with maximum tolerated dose with a glycosolated haemoglobin (HbA1c) greater than 7.4% (IFCC HbA1c >57 mmol/mol) or advised in the preceeding 6 months to add or consider changing to insulin therapy.

EXCLUSION CRITERIA

currently using insulin therapy; difficulty reading or understanding English; difficulty in understanding the purpose of the study; visual or cognitive impairment or mentally ill. A total of 182 assessed for eligibility, 175 randomised to 95 intervention and 80 controls, and 167 completion and anlaysis.

INTERVENTION

Brief training of clinicians and use of PDA with patients in single consultation.

PRIMARY OUTCOMES

Decision quality (Decisional Conflict Scores, knowledge, realistic expectations and autonomy) and glycaemic control (glycosolated haemoglobin, HbA1c).

SECONDARY OUTCOMES

Knowledge and realistic expectations of the risks and benefits of insulin therapy and diabetic complications.

RESULTS

Intervention group: lower total Decisional Conflict Scores (17.4 vs 25.2, p<0.001); better knowledge (51.6% vs 28.8%, p<0.001); realistic expectations (risk of 'hypo', 'weight gain', 'complications'; 81.0% vs 5.2%, 70.5% vs 5.3%, 26.3% vs 5.0% respectively, p<0.001); and were more autonomous in decision-making (64.1% vs 42.9%, p=0.012). No significant difference in the glycaemic control between the two groups.

CONCLUSIONS

Use of the PANDAs decision aid reduces decisional conflict, improves knowledge, promotes realistic expectations and autonomy in people with diabetes making treatment choices in general practice. ISRCTN TRIALS REGISTER NUMBER: 14842077.

Acceptance of shared decision making with reference to an electronic library of decision aids (arriba-lib) and its association to decision making in patients: an evaluation study

Background

Decision aids based on the philosophy of shared decision making are designed to help patients make informed choices among diagnostic or treatment options by delivering evidence-based information on options and outcomes. A patient decision aid can be regarded as a complex intervention because it consists of several presumably relevant components. Decision aids have rarely been field tested to assess patients' and physicians' attitudes towards them. It is also unclear what effect decision aids have on the adherence to chosen options.

Methods

The electronic library of decision aids (arriba-lib) to be used within the clinical encounter has a modular structure and contains evidence-based decision aids for the following topics: cardiovascular prevention, atrial fibrillation, coronary heart disease, oral antidiabetics, conventional and intensified insulin therapy, and unipolar depression. We conducted an evaluation study in which 29 primary care physicians included 192 patients. After the consultation, patients filled in questionnaires and were interviewed via telephone two months later. We used generalised estimation equations to measure associations within patient variables and traditional crosstab analyses.

Results

Patients were highly satisfied with arriba-lib and the process of shared decision making. Two-thirds of patients reached in the telephone interview wanted to be counselled again with arriba-lib. There was a high congruence between preferred and perceived decision making. Of those patients reached in the telephone interview, 80.7% said that they implemented the decision, independent of gender and education. Elderly patients were more likely to say that they implemented the decision.

Conclusions

Shared decision making with our multi-modular electronic library of decision aids (arriba-lib) was accepted by a high number of patients. It has positive associations to general aspects of decision making in patients. It can be used for patient groups with a wide range of individual characteristics.

Helping pregnant women make better decisions: a systematic review of the benefits of patient decision aids in obstetrics

Objectives Patient decision aids can be used to support pregnant women engaging in shared decisions, but little is known about their effects in obstetrics. The authors aimed to evaluate the effects of patient decision aids designed for pregnant women on clinical and psychosocial outcomes. Design Systematic review. Data on all outcomes were extracted and summarised. All studies were critically appraised for potential sources of bias and, when possible to obtain, the reported decision aids were evaluated. Meta-analysis was not possible due to the heterogeneity of outcomes in primary studies and the small number of studies. Data sources Electronic searches were performed using Medline, Embase, the Cochrane Library and Medion databases from inception until December 2010. Reference lists of all included articles were also examined and key experts contacted. Eligibility criteria for selecting studies Eligibility criteria included randomised controlled trials, which reported on patient decision aids for women facing any treatment decision in pregnancy published in English. Studies evaluating health education material that did not address women's values and preferences were excluded. Results Patient decision aids have been developed for decisions about prenatal testing, vaginal birth after Caesarean section, external cephalic version and labour analgesia. Use of decision aids is associated with a number of positive effects including reduced anxiety, lower decisional conflict, improved knowledge, improved satisfaction and increased perception of having made an informed choice. Conclusions Patient decision aids have the potential to improve obstetric care. However, currently the evidence base is limited by the small number of studies, the quality of the studies and because they involved heterogeneous decision aids, patient groups and outcomes.

Understanding risk, patient and provider preferences, and obstetrical decision making: approach to delivery after cesarean

Decision making regarding approach to delivery after cesarean is complex and requires consideration of the probabilities of clinical outcomes and the preferences of pregnant women. Depending on the clinical situation, a range of management options may be appropriate, and understanding women's beliefs and values regarding the process and outcomes of obstetrical interventions, as well as providing them with clear information regarding risk, is a necessary part of providing evidence-based, patient-centered care. We conducted a review of the literature on risk communication, patient and provider preferences, and obstetrical decision-making and offer recommendations on how to incorporate patient preferences in the context of delivery after cesarean.