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Stacey D, Lewis KB, Smith M, Carley M, Volk R, Douglas EE, Pacheco-Brousseau L, Finderup J, Gunderson J, Barry MJ, Bennett CL, Bravo P, Steffensen K, Gogovor A, Graham ID, Kelly SE, Légaré F, Sondergaard H, Thomson R, Trenaman L, Trevena L. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2024; 1:CD001431. [PMID: 38284415 PMCID: PMC10823577 DOI: 10.1002/14651858.cd001431.pub6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
BACKGROUND Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017. OBJECTIVES To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach. SEARCH METHODS We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022. SELECTION CRITERIA We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention. DATA COLLECTION AND ANALYSIS Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence. MAIN RESULTS This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015. AUTHORS' CONCLUSIONS Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, Canada
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | | | - Meg Carley
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robert Volk
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elisa E Douglas
- Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Michael J Barry
- Informed Medical Decisions Program, Massachusetts General Hospital, Boston, MA, USA
| | - Carol L Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Paulina Bravo
- Education and Cancer Prevention, Fundación Arturo López Pérez, Santiago, Chile
| | - Karina Steffensen
- Center for Shared Decision Making, IRS - Lillebælt Hospital, Vejle, Denmark
| | - Amédé Gogovor
- VITAM - Centre de recherche en santé durable, Université Laval, Quebec, Canada
| | - Ian D Graham
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, Canada
| | - Shannon E Kelly
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - France Légaré
- Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Université Laval, Quebec, Canada
| | | | - Richard Thomson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Logan Trenaman
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
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Scherf-Clavel O. Drug-Drug Interactions With Over-The-Counter Medicines: Mind the Unprescribed. Ther Drug Monit 2022; 44:253-274. [PMID: 34469416 DOI: 10.1097/ftd.0000000000000924] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/21/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND This review provides a summary of the currently available clinical data on drug-drug interactions (DDIs) involving over-the-counter (OTC) medicines. It aims to educate and increase awareness among health care providers and to support decisions in daily practice. METHODS An extensive literature search was performed using bibliographic databases available through PubMed.gov. An initial structured search was performed using the keywords "drug-drug-interaction AND (over-the-counter OR OTC)," without further restrictions except for the language. The initial results were screened for all described DDIs involving OTC drugs, and further information was gathered specifically on these drugs using dedicated database searches and references found in the bibliography from the initial hits. RESULTS From more than 1200 initial hits (1972-June 2021), 408 relevant publications were screened for DDIs involving OTC drugs, leading to 2 major findings: first, certain types of drug regimens are more prone to DDIs or have more serious DDI-related consequences, such as antiretroviral, anti-infective, and oral anticancer therapies. Second, although most DDIs involve OTC drugs as the perpetrators, some prescription drugs (statins or phosphodiesterase-5 inhibitors) that currently have OTC status can be identified as the victims in DDIs. The following groups were identified to be frequently involved in DDIs: nonsteroidal anti-inflammatory drugs, food supplements, antacids, proton-pump inhibitors, H2 antihistamines, laxatives, antidiarrheal drugs, and herbal drugs. CONCLUSIONS The most significant finding was the lack of high-quality evidence for commonly acknowledged interactions. High-quality interaction studies involving different phenotypes in drug metabolism (cytochrome P450) and distribution (transporters) are urgently needed. This should include modern and critical drugs, such as oral anticancer medications and direct oral anticoagulants.
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Affiliation(s)
- Oliver Scherf-Clavel
- Institute for Pharmacy and Food Chemistry, University of Würzburg, Würzburg, Germany
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Factors that influence how adults select oral over-the-counter analgesics: A systematic review. J Am Pharm Assoc (2003) 2022; 62:1113-1123.e8. [DOI: 10.1016/j.japh.2022.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/04/2022] [Accepted: 03/09/2022] [Indexed: 11/22/2022]
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Drug-induced liver injury and prospect of cytokine based therapy; A focus on IL-2 based therapies. Life Sci 2021; 278:119544. [PMID: 33945827 DOI: 10.1016/j.lfs.2021.119544] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/18/2021] [Accepted: 04/20/2021] [Indexed: 02/06/2023]
Abstract
Drug-induced liver injury (DILI) is one of the most frequent sources of liver failure and the leading cause of liver transplant. Common non-prescription medications such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and other prescription drugs when taken at more than the recommended doses may lead to DILI. The severity of DILI is affected by factors such as age, ethnicity, race, gender, nutritional status, on-going liver diseases, renal function, pregnancy, alcohol consumption, and drug-drug interactions. Characteristics of DILI-associated inflammation include apoptosis and necrosis of hepatocytes and hepatic infiltration of pro-inflammatory immune cells. If untreated or if the inflammation continues, DILI and associated hepatic inflammation may lead to development of hepatocarcinoma. The therapeutic approach for DILI-associated hepatic inflammation depends on whether the inflammation is acute or chronic. Discontinuing the causative medication, vaccination, and special dietary supplementation are some of the conventional approaches to treat DILI. In this review, we discuss a concise overview of DILI-associated liver complications, and current therapeutic options with special emphasis on biologics including the scope of cytokine therapy in hepatic repair and resolution of inflammation caused by over- the-counter (OTC) or prescription drugs.
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Giap TTT, Park M. Implementing Patient and Family Involvement Interventions for Promoting Patient Safety: A Systematic Review and Meta-Analysis. J Patient Saf 2021; 17:131-140. [PMID: 33208637 DOI: 10.1097/pts.0000000000000714] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aims of the study were to evaluate and to quantify the effects of patient and family involvement (PFI) interventions on patient safety by synthesizing the available global data. METHODS Four databases were searched to identify relevant studies that have assessed the impact of PFI on patient safety up to March 2019. Reference lists of potential selected articles were also used to identify additional relevant studies. Effect sizes (ESs) were calculated using random and fixed effects models. Statistical heterogeneity was measured using the I2 test. RESULTS Twenty-two studies met the review criteria. The meta-analysis showed that PFI were beneficial in significantly reducing adverse events (ES = -0.240, P < 0.001), decreasing the length of hospital stay (ES = -0.122, P < 0.001), increasing patient safety experiences (ES = 0.630, P = 0.007), and improving patient satisfaction (ES = 0.268, P = 0.004). However, the PFI interventions did not significantly enhance the perception of patient safety (ES = 0.205, P = 0.09) or the quality of life (ES = 0.057, P = 0.61). Moreover, moderate-to-high heterogeneity was found for all impacts except adverse events (I2 = 0%) and length of hospital stay (I2 = 35%). A funnel plot indicated a low degree of publication bias for the adverse event outcome. CONCLUSIONS The synthesized evidence in this review demonstrates the benefits of PFI for promoting patient safety. However, further studies should extend the research scope to fill the existing gaps for both the type of PFI interventions and the patient safety outcomes.
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Affiliation(s)
- Thi-Thanh-Tinh Giap
- From the College of Nursing, Chungnam National University, Daejeon, Republic of Korea
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Coronado-Vázquez V, Canet-Fajas C, Delgado-Marroquín MT, Magallón-Botaya R, Romero-Martín M, Gómez-Salgado J. Interventions to facilitate shared decision-making using decision aids with patients in Primary Health Care: A systematic review. Medicine (Baltimore) 2020; 99:e21389. [PMID: 32769870 PMCID: PMC7593011 DOI: 10.1097/md.0000000000021389] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Shared decision making (SDM) is a process within the physician-patient relationship applicable to any clinical action, whether diagnostic, therapeutic, or preventive in nature. It has been defined as a process of mutual respect and participation between the doctor and the patient. The aim of this study is to determine the effectiveness of decision aids (DA) in primary care based on changes in adherence to treatments, knowledge, and awareness of the disease, conflict with decisions, and patients' and health professionals' satisfaction with the intervention. METHODS A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted in Medline, CINAHL, Embase, the Cochrane Central Register of Controlled Trials, and the NHS Economic Evaluation Database. The inclusion criteria were randomized clinical trials as study design; use of SDM with DA as an intervention; primary care as clinical context; written in English, Spanish, and Portuguese; and published between January 2007 and January 2019. The risk of bias of the included studies in this review was assessed according to the Cochrane Collaboration's tool. RESULTS Twenty four studies were selected out of the 201 references initially identified. With the use of DA, the use of antibiotics was reduced in cases of acute respiratory infection and decisional conflict was decreased when dealing with the treatment choice for atrial fibrillation and osteoporosis. The rate of determination of prostate-specific antigen (PSA) in the prostate cancer screening decreased and colorectal cancer screening increased. Both professionals and patients increased their knowledge about depression, type 2 diabetes, and the perception of risk of acute myocardial infarction at 10 years without statins and with statins. The satisfaction was greater with the use of DA in choosing the treatment for depression, in cardiovascular risk management, in the treatment of low back pain, and in the use of statin therapy in diabetes. Blinding of outcomes assessment was the most common bias. CONCLUSIONS DA used in primary care are effective to reduce decisional conflict and improve knowledge on the disease and treatment options, awareness of risk, and satisfaction with the decisions made. More studies are needed to assess the impact of shared decision making in primary care.
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Affiliation(s)
- Valle Coronado-Vázquez
- Aragonese Primary Care Research Group B21-17R. Health Research Institute of Aragon (IIS). Department of Nursing. Faculty of Health Sciences. Catholic University of Ávila. Castilla La Mancha Health Service, Toledo
| | | | - Maria Teresa Delgado-Marroquín
- Bioethics Research Group. Health Research Institute of Aragon (IIS). Faculty of Medicine, University of Zaragoza. Delicias Norte Primary Care Health Center, Zaragoza
| | - Rosa Magallón-Botaya
- Aragonese Primary Care Research Group B21-17R. Health Research Institute of Aragon (IIS). Department of Medicine, University of Zaragoza. Arrabal Primary Care Health Center, Zaragoza
| | | | - Juan Gómez-Salgado
- Department of Sociology, Social Work and Public Health, Faculty of Labour Sciences, University of Huelva, Huelva, Spain
- Safety and Health Postgraduate Program, Espiritu Santo University, Guayaquil, Ecuador
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Park M, Giap TTT. Patient and family engagement as a potential approach for improving patient safety: A systematic review. J Adv Nurs 2019; 76:62-80. [PMID: 31588602 DOI: 10.1111/jan.14227] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 09/02/2019] [Accepted: 09/30/2019] [Indexed: 12/22/2022]
Abstract
AIMS To obtain a comprehensive insight of the impact of patient and family engagement on patient safety and identify issues in implementing this approach. BACKGROUND Patient and family engagement is increasingly emerging as a potential approach for improving patient safety. DESIGN Mixed method multilevel synthesis. DATA SOURCES PubMed, CINAHL, Embase, and Cochrance Library (January 2009-April 2018). REVIEW METHODS The review was conducted according to the principles recommended by the Cochrane Handbook for Systematic Review and in accordance with the PRISMA guidelines. RESULTS Forty-two relevant studies were identified. Common intervention groups included 'direct care' and 'organization' levels with 'consultation' and 'involvement' approaches, while the 'health system' level and 'partnership and shared leadership' approaches were rarely implemented. Findings revealed positive effects of the interventions on patient safety. Most study participants expressed their willingness to engage in or support patient and family engagement. However, existing gaps and barriers in implementing patient and family engagement were identified. CONCLUSION Future research should further focus on issuing consensus guidelines for implementing patient and family engagement in patient safety, extending the research scope for all aspects of patient and family engagement and patient safety and identifying priority areas for action that is suitable for each health facility. IMPACT Policymakers should issue guidelines for implementing patient and family engagement in healthcare systems which would enable healthcare providers to implement patient and family engagement and improve patient safety appropriately and effectively.
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Affiliation(s)
- Myonghwa Park
- College of Nursing, Chungnam National University, Daejeon, Republic of Korea
| | - Thi-Thanh-Tinh Giap
- College of Nursing, Chungnam National University, Daejeon, Republic of Korea
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Kim JM, Suarez-Cuervo C, Berger Z, Lee J, Gayleard J, Rosenberg C, Nagy N, Weeks K, Dy S. Evaluation of Patient and Family Engagement Strategies to Improve Medication Safety. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2018; 11:193-206. [PMID: 28795338 DOI: 10.1007/s40271-017-0270-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patient and family engagement (PFE) is critical for patient safety. We systematically reviewed types of PFE strategies implemented and their impact on medication safety. METHODS We searched MEDLINE, EMBASE, reference lists and websites to August 2016. Two investigators independently reviewed all abstracts and articles, and articles were additionally reviewed by two senior investigators for selection. One investigator abstracted data and two investigators reviewed the data for accuracy. Study quality was determined by consensus. Investigators developed a framework for defining the level of patient engagement: informing patients about medications (Level 1), informing about engagement with health care providers (Level 2), empowering patients with communication tools and skills (Level 3), partnering with patients in their care (Level 4), and integrating patients as full care team members (Level 5). RESULTS We included 19 studies that mostly targeted older adults taking multiple medications. The median level of engagement was 2, ranging from 2-4. We identified no level 5 studies. Key themes for patient engagement strategies impacting medication safety were patient education and medication reconciliation, with a subtheme of patient portals. Most studies (84%) reported implementation outcomes. The most commonly reported medication safety outcomes were medication errors, including near misses and discrepancies (47%), and medication safety knowledge (37%). Most studies (63%) were of medium to low quality, and risk of bias was generally moderate. Among the 11 studies with control groups, 55% (n = 6) reported statistically significant improvement on at least one medication safety outcome. Further synthesis of medication safety measures was limited due to intervention and outcome heterogeneity. CONCLUSIONS Key strategies for engaging patients in medication safety are education and medication reconciliation. Patient engagement levels were generally low, as defined by a novel framework for determining levels of patient engagement. As more patient engagement studies are conducted, this framework should be evaluated for associations with patient outcomes.
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Affiliation(s)
- Julia M Kim
- Johns Hopkins University, 200 N Wolfe St, Rubenstein Building, Room 2095, Baltimore, MD, 21287, USA.
| | - Catalina Suarez-Cuervo
- Johns Hopkins University, 200 N Wolfe St, Rubenstein Building, Room 2095, Baltimore, MD, 21287, USA
| | - Zackary Berger
- Johns Hopkins University, 200 N Wolfe St, Rubenstein Building, Room 2095, Baltimore, MD, 21287, USA
| | - Joy Lee
- Johns Hopkins University, 200 N Wolfe St, Rubenstein Building, Room 2095, Baltimore, MD, 21287, USA
| | - Jessica Gayleard
- Johns Hopkins University, 200 N Wolfe St, Rubenstein Building, Room 2095, Baltimore, MD, 21287, USA
| | - Carol Rosenberg
- Johns Hopkins University, 200 N Wolfe St, Rubenstein Building, Room 2095, Baltimore, MD, 21287, USA
| | - Natalia Nagy
- Johns Hopkins University, 200 N Wolfe St, Rubenstein Building, Room 2095, Baltimore, MD, 21287, USA
| | - Kristina Weeks
- Johns Hopkins University, 200 N Wolfe St, Rubenstein Building, Room 2095, Baltimore, MD, 21287, USA
| | - Sydney Dy
- Johns Hopkins University, 200 N Wolfe St, Rubenstein Building, Room 2095, Baltimore, MD, 21287, USA
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Stacey D, Légaré F, Lewis K, Barry MJ, Bennett CL, Eden KB, Holmes‐Rovner M, Llewellyn‐Thomas H, Lyddiatt A, Thomson R, Trevena L. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2017; 4:CD001431. [PMID: 28402085 PMCID: PMC6478132 DOI: 10.1002/14651858.cd001431.pub5] [Citation(s) in RCA: 1186] [Impact Index Per Article: 169.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Decision aids are interventions that support patients by making their decisions explicit, providing information about options and associated benefits/harms, and helping clarify congruence between decisions and personal values. OBJECTIVES To assess the effects of decision aids in people facing treatment or screening decisions. SEARCH METHODS Updated search (2012 to April 2015) in CENTRAL; MEDLINE; Embase; PsycINFO; and grey literature; includes CINAHL to September 2008. SELECTION CRITERIA We included published randomized controlled trials comparing decision aids to usual care and/or alternative interventions. For this update, we excluded studies comparing detailed versus simple decision aids. DATA COLLECTION AND ANALYSIS Two reviewers independently screened citations for inclusion, extracted data, and assessed risk of bias. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made and the decision-making process.Secondary outcomes were behavioural, health, and health system effects.We pooled results using mean differences (MDs) and risk ratios (RRs), applying a random-effects model. We conducted a subgroup analysis of studies that used the patient decision aid to prepare for the consultation and of those that used it in the consultation. We used GRADE to assess the strength of the evidence. MAIN RESULTS We included 105 studies involving 31,043 participants. This update added 18 studies and removed 28 previously included studies comparing detailed versus simple decision aids. During the 'Risk of bias' assessment, we rated two items (selective reporting and blinding of participants/personnel) as mostly unclear due to inadequate reporting. Twelve of 105 studies were at high risk of bias.With regard to the attributes of the choice made, decision aids increased participants' knowledge (MD 13.27/100; 95% confidence interval (CI) 11.32 to 15.23; 52 studies; N = 13,316; high-quality evidence), accuracy of risk perceptions (RR 2.10; 95% CI 1.66 to 2.66; 17 studies; N = 5096; moderate-quality evidence), and congruency between informed values and care choices (RR 2.06; 95% CI 1.46 to 2.91; 10 studies; N = 4626; low-quality evidence) compared to usual care.Regarding attributes related to the decision-making process and compared to usual care, decision aids decreased decisional conflict related to feeling uninformed (MD -9.28/100; 95% CI -12.20 to -6.36; 27 studies; N = 5707; high-quality evidence), indecision about personal values (MD -8.81/100; 95% CI -11.99 to -5.63; 23 studies; N = 5068; high-quality evidence), and the proportion of people who were passive in decision making (RR 0.68; 95% CI 0.55 to 0.83; 16 studies; N = 3180; moderate-quality evidence).Decision aids reduced the proportion of undecided participants and appeared to have a positive effect on patient-clinician communication. Moreover, those exposed to a decision aid were either equally or more satisfied with their decision, the decision-making process, and/or the preparation for decision making compared to usual care.Decision aids also reduced the number of people choosing major elective invasive surgery in favour of more conservative options (RR 0.86; 95% CI 0.75 to 1.00; 18 studies; N = 3844), but this reduction reached statistical significance only after removing the study on prophylactic mastectomy for breast cancer gene carriers (RR 0.84; 95% CI 0.73 to 0.97; 17 studies; N = 3108). Compared to usual care, decision aids reduced the number of people choosing prostate-specific antigen screening (RR 0.88; 95% CI 0.80 to 0.98; 10 studies; N = 3996) and increased those choosing to start new medications for diabetes (RR 1.65; 95% CI 1.06 to 2.56; 4 studies; N = 447). For other testing and screening choices, mostly there were no differences between decision aids and usual care.The median effect of decision aids on length of consultation was 2.6 minutes longer (24 versus 21; 7.5% increase). The costs of the decision aid group were lower in two studies and similar to usual care in four studies. People receiving decision aids do not appear to differ from those receiving usual care in terms of anxiety, general health outcomes, and condition-specific health outcomes. Studies did not report adverse events associated with the use of decision aids.In subgroup analysis, we compared results for decision aids used in preparation for the consultation versus during the consultation, finding similar improvements in pooled analysis for knowledge and accurate risk perception. For other outcomes, we could not conduct formal subgroup analyses because there were too few studies in each subgroup. AUTHORS' CONCLUSIONS Compared to usual care across a wide variety of decision contexts, people exposed to decision aids feel more knowledgeable, better informed, and clearer about their values, and they probably have a more active role in decision making and more accurate risk perceptions. There is growing evidence that decision aids may improve values-congruent choices. There are no adverse effects on health outcomes or satisfaction. New for this updated is evidence indicating improved knowledge and accurate risk perceptions when decision aids are used either within or in preparation for the consultation. Further research is needed on the effects on adherence with the chosen option, cost-effectiveness, and use with lower literacy populations.
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Affiliation(s)
- Dawn Stacey
- University of OttawaSchool of Nursing451 Smyth RoadOttawaONCanada
- Ottawa Hospital Research InstituteCentre for Practice Changing Research501 Smyth RdOttawaONCanadaK1H 8L6
| | - France Légaré
- CHU de Québec Research Center, Université LavalPopulation Health and Optimal Health Practices Research Axis10 Rue de l'Espinay, D6‐727Québec CityQCCanadaG1L 3L5
| | - Krystina Lewis
- University of OttawaSchool of Nursing451 Smyth RoadOttawaONCanada
| | | | - Carol L Bennett
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramAdministrative Services Building, Room 2‐0131053 Carling AvenueOttawaONCanadaK1Y 4E9
| | - Karen B Eden
- Oregon Health Sciences UniversityDepartment of Medical Informatics and Clinical EpidemiologyBICC 5353181 S.W. Sam Jackson Park RoadPortlandOregonUSA97239‐3098
| | - Margaret Holmes‐Rovner
- Michigan State University College of Human MedicineCenter for Ethics and Humanities in the Life SciencesEast Fee Road956 Fee Road Rm C203East LansingMichiganUSA48824‐1316
| | - Hilary Llewellyn‐Thomas
- Dartmouth CollegeThe Dartmouth Center for Health Policy & Clinical Practice, The Geisel School of Medicine at DartmouthHanoverNew HampshireUSA03755
| | - Anne Lyddiatt
- No affiliation28 Greenwood RoadIngersollONCanadaN5C 3N1
| | - Richard Thomson
- Newcastle UniversityInstitute of Health and SocietyBaddiley‐Clark BuildingRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Lyndal Trevena
- The University of SydneyRoom 322Edward Ford Building (A27)SydneyNSWAustralia2006
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