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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: 0] [Impact Index Per Article: 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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Yu L, Yang S, Zhang C, Guo P, Zhang X, Xu M, Tian Q, Cui X, Zhang W. Decision aids for prenatal testing: A systematic review and meta-analysis. J Adv Nurs 2021; 77:3964-3979. [PMID: 33942356 DOI: 10.1111/jan.14875] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 04/09/2021] [Indexed: 02/01/2023]
Abstract
AIMS To analyse the effect of decision aids (DAs) used by pregnant women on prenatal testing decisions. DESIGN Systematic review and meta-analysis. DATA RESOURCES We searched Embase, PubMed, Web of Science and the Cochrane Central Library ending October 2020. REVIEW METHODS Papers were selected for analysis in accordance with the PRISMA guidelines. The meta-analysis was carried out using Review Manager 5.3 software. The quality of the studies was assessed using the risk of bias tool recommended by the Cochrane Handbook. The result is knowledge, decision conflict, anxiety and other secondary outcomes. RESULTS A total of 18 studies were included in the systematic review and meta-analysis. Comprehensive analysis showed that DAs could significantly improve knowledge and decision-making satisfaction, reduce decision conflict, increase the proportion of women who make informed choice and had no influence on anxiety and decision regret. CONCLUSIONS This article systematically reviewed the positive effect of DAs on the decision-making of pregnant women facing prenatal testing. In the future, nurses should be encouraged to develop DAs in accordance with strict standards and apply them to pregnant women of different backgrounds. IMPACT There is a growing consensus that health care should be patient-centred, and the values and preferences of pregnant women who undergo prenatal testing need to be incorporated into the clinical decision-making process. This review reports that the use of DAs can increase pregnant women's chances of participating in prenatal testing decisions and may improve the quality of their decision-making. It also provides information on the role and practice of nurses in promoting evidence-based prenatal testing for DAs.
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Affiliation(s)
- Lin Yu
- School of Nursing, Jilin University, Changchun, Jilin Province, China
| | - Shu Yang
- School of Nursing, Jilin University, Changchun, Jilin Province, China
| | - Chunmiao Zhang
- The Second Hospital of Jilin University, Changchun, Jilin Province, China
| | - Pingping Guo
- School of Nursing, Jilin University, Changchun, Jilin Province, China
| | - Xuehui Zhang
- School of Nursing, Jilin University, Changchun, Jilin Province, China
| | - Mengmeng Xu
- School of Nursing, Jilin University, Changchun, Jilin Province, China
| | - Qi Tian
- School of Nursing, Jilin University, Changchun, Jilin Province, China
| | - Xuan Cui
- School of Nursing, Jilin University, Changchun, Jilin Province, China
| | - Wei Zhang
- School of Nursing, Jilin University, Changchun, Jilin Province, China
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Paz Y Miño F, Martinez-Portilla RJ, Pauta M, Borrell A. A Randomized Controlled Trial on the Influence of Prenatal Counseling on the Attitudes and Preferences Toward Invasive Prenatal Testing Among Women in Their First Trimester of Pregnancy (INVASIVE). Front Genet 2020; 11:561283. [PMID: 33240315 PMCID: PMC7682740 DOI: 10.3389/fgene.2020.561283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 10/05/2020] [Indexed: 12/18/2022] Open
Abstract
Objective To assess the impact of prenatal genetic counseling on the attitudes and preferences toward invasive testing in first-trimester pregnant women. Methods This is a randomized open-label study, of pregnant women undergoing first trimester combined screening for aneuploidies. Women were divided into the experimental or control groups in a 1:1 design. The intervention consisted of 15-min extra counseling about prenatal screening and diagnosis. The main outcome was the desire to choose an invasive testing as their first prenatal testing option which was measured as absolute risk. Results After excluding those with incomplete data, 75 women remained in the experimental group and 75 as controls. Women receiving counseling were 32% more likely to choose an invasive prenatal testing as their first-line option after extra 15-min extensive counseling, reducing the first-trimester combined screening by 20% and the cell-free DNA by 12%. If given the opportunity, 59% of the women would like to be able to choose the prenatal test that suits their needs. Conclusion Women given an extensive prenatal counseling are more likely to choose an invasive testing as their first-line test in spite of the concerning risks. Clinical Trial Registration www.ClinicalTrials.gov, identifier NCT04119349.
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Affiliation(s)
- Fernanda Paz Y Miño
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Barcelona, Spain.,Prenatal Diagnosis Unit, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Raigam Jafet Martinez-Portilla
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Barcelona, Spain.,Prenatal Diagnosis Unit, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain.,Clinical Research Department, National Institute of Perinatology, Mexico City, Mexico
| | - Montse Pauta
- Prenatal Diagnosis Unit, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Antoni Borrell
- Prenatal Diagnosis Unit, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
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Dekens C, Fontaine C, Carpentier E, Barcat L, Gondry J, Tourneux P. [Maternal anxiety related to how the pediatrician provided prenatal information about preterm birth]. Arch Pediatr 2017; 24:1076-1082. [PMID: 28988636 DOI: 10.1016/j.arcped.2017.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 06/24/2017] [Accepted: 08/14/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Women hospitalized for preterm labor require clear information about prematurity. This study assessed whether or not specific written information about prematurity delivered at admission to the unit combined with an oral explanation from a pediatrician would decrease women's anxiety compared to an oral explanation alone. MATERIAL AND METHODS This was a prospective, single-center observational study. Women were included in the high-risk pregnancies department and distributed into two groups: receiving "only oral" information for a prenatal clinical consultation with a senior pediatrician or receiving "combined" oral information+a booklet about prematurity given to the women at admission. The primary endpoint was the change in anxiety-state (before and after the information procedure) evaluated by the State Trait Anxiety Inventory-Y (STAI-Y). RESULTS The anxiety score before receiving information did not differ between the two groups (STAI-Y-A "combined" group: 46.7±3.0 vs. "only oral" group: 42.7±2.74; P=0.55). After consultation with a pediatrician, the acute anxiety-state score STAI-Y-A decreased significantly in the "combined" group (-6.7±1.9) compared to the "only oral" group (-2.5±4.6; P<0.05). DISCUSSION A booklet about prematurity combined with oral information from a pediatrician reduced patients' anxiety more than oral information alone. Given that the psychology of the mother interacts with the pregnancy, it is necessary to provide clear and adapted information. Giving a booklet appears to be one of the modalities to improve information. Other modalities such as video documents have to be studied.
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Affiliation(s)
- C Dekens
- Service de médecine néonatale, pôle femme-couple-enfant, CHU d'Amiens-Picardie, 80054 Amiens cedex 1, France; Service de néonatologie, centre hospitalier Beauvais, avenue Léon-Blum, 60021 Beauvais cedex, France
| | - C Fontaine
- Service de médecine néonatale, pôle femme-couple-enfant, CHU d'Amiens-Picardie, 80054 Amiens cedex 1, France
| | - E Carpentier
- Service de médecine néonatale, pôle femme-couple-enfant, CHU d'Amiens-Picardie, 80054 Amiens cedex 1, France; Service de réanimation néonatale, pôle femme-couple-enfant, CHU d'Amiens-Picardie, 80054 Amiens cedex 1, France
| | - L Barcat
- Service de réanimation néonatale, pôle femme-couple-enfant, CHU d'Amiens-Picardie, 80054 Amiens cedex 1, France
| | - J Gondry
- Service de gynécologie-obstétrique, pôle femme-couple-enfant, CHU d'Amiens-Picardie, 80054 Amiens cedex 1, France
| | - P Tourneux
- Service de réanimation néonatale, pôle femme-couple-enfant, CHU d'Amiens-Picardie, 80054 Amiens cedex 1, France; PériTox (UMR-I 01), faculté de médecine, université de Picardie-Jules-Verne, Amiens, France.
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5
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Chaillet N, Bujold E, Masse B, Grobman WA, Rozenberg P, Pasquier JC, Shorten A, Johri M, Beaudoin F, Abenhaim H, Demers S, Fraser W, Dugas M, Blouin S, Dubé E, Gauthier R. A cluster-randomized trial to reduce major perinatal morbidity among women with one prior cesarean delivery in Québec (PRISMA trial): study protocol for a randomized controlled trial. Trials 2017; 18:434. [PMID: 28931404 PMCID: PMC5608183 DOI: 10.1186/s13063-017-2150-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 08/15/2017] [Indexed: 11/10/2022] Open
Abstract
Background Rates of cesarean delivery are continuously increasing in industrialized countries, with repeated cesarean accounting for about a third of all cesareans. Women who have undergone a first cesarean are facing a difficult choice for their next pregnancy, i.e.: (1) to plan for a second cesarean delivery, associated with higher risk of maternal complications than vaginal delivery; or (b) to have a trial of labor (TOL) with the aim to achieve a vaginal birth after cesarean (VBAC) and to accept a significant, but rare, risk of uterine rupture and its related maternal and neonatal complications. The objective of this trial is to assess whether a multifaceted intervention would reduce the rate of major perinatal morbidity among women with one prior cesarean. Methods/design The study is a stratified, non-blinded, cluster-randomized, parallel-group trial of a multifaceted intervention. Hospitals in Quebec are the units of randomization and women are the units of analysis. As depicted in Figure 1, the study includes a 1-year pre-intervention period (baseline), a 5-month implementation period, and a 2-year intervention period. At the end of the baseline period, 20 hospitals will be allocated to the intervention group and 20 to the control group, using a randomization stratified by level of care. Medical records will be used to collect data before and during the intervention period. Primary outcome is the rate of a composite of major perinatal morbidities measured during the intervention period. Secondary outcomes include major and minor maternal morbidity; minor perinatal morbidity; and TOL and VBAC rate. The effect of the intervention will be assessed using the multivariable generalized-estimating-equations extension of logistic regression. The evaluation will include subgroup analyses for preterm and term birth, and a cost-effectiveness analysis. Discussion The intervention is designed to facilitate: (1) women’s decision-making process, using a decision analysis tool (DAT), (2) an estimate of uterine rupture risk during TOL using ultrasound evaluation of low-uterine segment thickness, (3) an estimate of chance of TOL success, using a validated prediction tool, and (4) the implementation of best practices for intrapartum management. Trial registration Current Controlled Trials, ID: ISRCTN15346559. Registered on 20 August 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2150-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- N Chaillet
- Department of Obstetrics and Gynaecology, Laval University, Quebec, QC, Canada. .,Faculté de Médecine, Département d'Obstétrique & Gynécologie, Université Laval, Centre de recherche du CHUQ, 2705, Boul. Laurier, local T-R-92, Quebec, QC, G1V 4G2, Canada.
| | - E Bujold
- Department of Obstetrics and Gynaecology, Laval University, Quebec, QC, Canada
| | - B Masse
- Department of Epidemiology and Biostatistics, University of Montréal, Montréal, QC, Canada
| | - W A Grobman
- Department of Obstetrics and Gynaecology, Northwestern University, Chicago, IL, USA
| | - P Rozenberg
- Service de gynécologie obstétrique et médecine de la reproduction, Centre hospitalier intercommunal de Poissy/Saint-Germain-en-Laye, 10, rue du Champ-Gaillard, 78303, Poissy, France
| | - J C Pasquier
- Department of Obstetrics and Gynecology, Sherbrooke University, Quebec, QC, Canada
| | - A Shorten
- UAB School of Nursing, University of Alabama, Birmingham, AL, USA
| | - M Johri
- University of Montreal, Hospital Research Center (CRCHUM), Montreal, QC, Canada
| | - F Beaudoin
- Department of Obstetrics and Gynecology, University of Montreal, Montreal, QC, Canada
| | - H Abenhaim
- Department of Obstetrics and Gynecology, McGill University, Jewish Hospital, Montreal, QC, Canada
| | - S Demers
- Department of Obstetrics and Gynaecology, Laval University, Quebec, QC, Canada
| | - W Fraser
- Department of Obstetrics and Gynecology, Sherbrooke University, Quebec, QC, Canada
| | - M Dugas
- Population Health and Optimal Health Practices Research Unit, CHU de Québec Research Centre, Quebec, QC, Canada
| | - S Blouin
- Department of Obstetrics and Gynaecology, Laval University, Quebec, QC, Canada
| | - E Dubé
- Department of Obstetrics and Gynaecology, Laval University, Quebec, QC, Canada
| | - R Gauthier
- Department of Obstetrics and Gynecology, University of Montreal, Montreal, QC, Canada
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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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Griffith JM, Sorenson JR, Bowling JM, Jennings-Grant T. Assessment of an Interactive Computer-Based Patient Prenatal Genetic Screening and Testing Education Tool. HEALTH EDUCATION & BEHAVIOR 2016; 32:613-26. [PMID: 16148208 DOI: 10.1177/1090198105278747] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Enhancing Patient Prenatal Education study tested the feasibility and educational impact of an interactive program for patient prenatal genetic screening and testing education. Patients at two private practices and one public health clinic participated ( N = 207). The program collected knowledge and measures of anxiety before and after use of the tool. Time in various prenatal visit activities was collected prior to and after the introduction of the education tool. Providers completed an assessment of their experiences with patients who had used the program. Results indicate that patient knowledge significantly increased from pre to post ( p = .0001) with no increase in anxiety ( p = .31). Time in clinic activities, including overall visit time, increased. A majority of providers indicated that the program disrupted clinic flow. This assessment suggests that the program increases patient knowledge and does not increase patient anxiety. However, challenges remain to using this program in a clinic setting.
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Affiliation(s)
- Jennifer M Griffith
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, NC 27599-7590, USA.
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Abstract
Maternal serum levels of alpha fetoprotein (AFP), human chorionic gonadotropin (hCG), and unconjugated estriol (uE3) can be used to screen pregnancies for neural tube defects, Down syndrome, Trisomy 18, and pregnancy complications. This article summarizes the most recent information regarding maternal serum screening, including genetic counseling issues.
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Affiliation(s)
- K E Ormond
- Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vermont
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Drake ER, Engler-Todd L, O'Connor AM, Surh LC, Hunter A. Development and Evaluation of a Decision Aid About Prenatal Testing for Women of Advanced Maternal Age. J Genet Couns 2015; 8:217-33. [PMID: 26142262 DOI: 10.1023/a:1022998415890] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To develop and evaluate a decision aid designed to prepare patients of advanced maternal age for counseling about prenatal diagnostic testing. SETTING A regional genetics center. DESIGN A before/after study. INTERVENTIONS Participants used an audioguided workbook to learn about options and outcomes and to clarify personal risks, values, questions, and predispositions. SUBJECTS 21 women of advanced maternal age and 17 spouses. MAIN OUTCOME MEASURES Knowledge of prenatal testing alternatives, decisional conflict, level of anxiety, and acceptability of the decision aid. RESULTS After using the decision aid, participants had significantly reduced decisional conflict (uncertainty) and a significant increase in knowledge. There was no effect on state or trait anxiety. More than three-quarters of participants were satisfied with the length, clarity, balance, and acceptability of the decision aid. CONCLUSIONS The decision aid shows promise as a useful aid for preparing couples for counseling.
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Affiliation(s)
- E R Drake
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
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10
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Shared decision-making and decision support: their role in obstetrics and gynecology. Curr Opin Obstet Gynecol 2015; 26:523-30. [PMID: 25319001 DOI: 10.1097/gco.0000000000000120] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To discuss the role for shared decision-making in obstetrics/gynecology and to review evidence on the impact of decision aids on reproductive health decision-making. RECENT FINDINGS Among the 155 studies included in a 2014 Cochrane review of decision aids, 31 (29%) addressed reproductive health decisions. Although the majority did not show evidence of an effect on treatment choice, there was a greater uptake of mammography in selected groups of women exposed to decision aids compared with usual care; and a statistically significant reduction in the uptake of hormone replacement therapy among detailed decision aid users compared with simple decision aid users. Studies also found an effect on patient-centered outcomes of care, such as medication adherence, quality-of-life measures, and anxiety scores. In maternity care, only decision analysis tools affected final treatment choice, and patient-directed aids yielded no difference in planned mode of birth after cesarean. SUMMARY There is untapped potential for obstetricians/gynecologists to optimize decision support for reproductive health decisions. Given the limited evidence-base guiding practice, the preference-sensitive nature of reproductive health decisions, and the increase in policy efforts and financial incentives to optimize patients' satisfaction, it is increasingly important for obstetricians/gynecologists to appreciate the role of shared decision-making and decision support in providing patient-centered reproductive healthcare.
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Ames AG, Metcalfe SA, Archibald AD, Duncan RE, Emery J. Measuring informed choice in population-based reproductive genetic screening: a systematic review. Eur J Hum Genet 2015; 23:8-21. [PMID: 24848746 PMCID: PMC4266751 DOI: 10.1038/ejhg.2014.89] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 03/11/2014] [Accepted: 04/10/2014] [Indexed: 11/09/2022] Open
Abstract
Genetic screening and health-care guidelines recommend that programmes should facilitate informed choice. It is therefore important that accurate measures of informed choice are available to evaluate such programmes. This review synthesises and appraises measures used to evaluate informed choice in population-based genetic screening programmes for reproductive risk. Databases were searched for studies offering genetic screening for the purpose of establishing reproductive risk to an adult population sample, in which aspects of informed choice were measured. Studies were included if, at a minimum, measures of uptake of screening and knowledge were used. Searches identified 1462 citations and 76 studies were reviewed in full text; 34 studies met the inclusion criteria. Over 20 different measures of informed choice were used. Many measures lacked adequate validity and reliability data. This systematic review will inform future evaluation of informed choice in population genetic screening programmes.
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Affiliation(s)
- Alice Grace Ames
- Genetics Education and Health Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sylvia Ann Metcalfe
- Genetics Education and Health Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Alison Dalton Archibald
- Genetics Education and Health Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Victorian Clinical Genetics Services, Melbourne, Victoria, Australia
| | - Rony Emily Duncan
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
- Centre for Adolescent Health, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
- Health Services Delivery for Adolescents, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Jon Emery
- General Practice and Primary Care Academic Centre, University of Melbourne, Parkville, Victoria, Australia
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Skjøth MM, Draborg E, Pedersen CD, Hansen HP, Lamont RF, Jørgensen JS. Providing information about prenatal screening for Down syndrome: a systematic review. Acta Obstet Gynecol Scand 2014; 94:125-32. [DOI: 10.1111/aogs.12543] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 11/06/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Mette M. Skjøth
- Research Unit of Gynecology and Obstetrics; Department of Gynecology and Obstetrics; Institute of Clinical Research; University of Southern Denmark; Odense University Hospital; Odense Denmark
| | - Eva Draborg
- Institute of Public Health; University of Southern Denmark; Odense Denmark
| | - Claus D. Pedersen
- Centre for Innovative Medical Technology; Odense University Hospital; Odense Denmark
| | - Helle P. Hansen
- Institute of Public Health; University of Southern Denmark; Odense Denmark
| | - Ronald F. Lamont
- Research Unit of Gynecology and Obstetrics; Department of Gynecology and Obstetrics; Institute of Clinical Research; University of Southern Denmark; Odense University Hospital; Odense Denmark
- Division of Surgery; Northwick Park Institute for Medical Research; University College London; London UK
| | - Jan S. Jørgensen
- Research Unit of Gynecology and Obstetrics; Department of Gynecology and Obstetrics; Institute of Clinical Research; University of Southern Denmark; Odense University Hospital; Odense Denmark
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Goldbeck L, Fidika A, Herle M, Quittner AL. Psychological interventions for individuals with cystic fibrosis and their families. Cochrane Database Syst Rev 2014; 2014:CD003148. [PMID: 24941199 PMCID: PMC7388585 DOI: 10.1002/14651858.cd003148.pub3] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND With increasing survival estimates for individuals with cystic fibrosis, long-term management has become an important focus. Psychological interventions are largely concerned with adherence to treatment, emotional and social adaptation and health-related quality of life. We are unaware of any relevant systematic reviews. OBJECTIVES To determine whether psychological interventions for people with cystic fibrosis provide significant psychosocial and physical benefits in addition to standard medical care. SEARCH METHODS Studies were identified from two Cochrane trials registers (Cystic Fibrosis and Genetic Disorders Group; Depression, Anxiety and Neurosis Group), Ovid MEDLINE and PsychINFO; unpublished trials were located through professional networks and Listserves. Most recent search of the Cystic Fibrosis and Genetic Disorders Group's register: 19 December 2013.Most recent search of the Depression, Anxiety and Neurosis Group's register: 12 November 2013. SELECTION CRITERIA Randomised controlled studies of a broad range of psychological interventions evaluating subjective and objective health outcomes, such as quality of life or pulmonary function, in individuals of all ages with cystic fibrosis and their immediate family. We were interested in psychological interventions, including psychological methods within the scope of psychotherapeutic or psychosomatic mechanism of action (e.g. cognitive behavioural, cognitive, family systems or systemic, psycho-dynamic, or other, e.g. supportive, relaxation, or biofeedback), which were aimed at improving psychological and psychosocial outcomes (e.g. quality of life, levels of stress or distress, psychopathology, etc.), adaptation to disease management and physiological outcomes. DATA COLLECTION AND ANALYSIS Three authors were involved in selecting the eligible studies and two of these authors assessed their risk of bias. MAIN RESULTS The review includes 16 studies (eight new studies included in this update) representing data from 556 participants. Studies are diverse in their design and their methods. They cover interventions with generic approaches, as well as interventions developed specifically to target disease-specific symptoms and problems in people with cystic fibrosis. These include cognitive behavioural interventions to improve adherence to nutrition or psychosocial adjustment, cognitive interventions to improve adherence or those associated with decision making in lung transplantation, a community-based support intervention and other interventions, such as self-hypnosis, respiratory muscle biofeedback, music therapy, dance and movement therapy, and a tele-medicine intervention to support patients awaiting transplantation.A substantial proportion of outcomes relate to adherence, changes in physical status or other specific treatment concerns during the chronic phase of the disease.There is some evidence that behavioural interventions targeting nutrition and growth in children (4 to 12 years) with cystic fibrosis are effective in the short term. Evidence was found that providing a structured decision-making tool for patients considering lung transplantation improves patients' knowledge of and expectations about the transplant, and reduces decisional conflict in the short term. One study about training in biofeedback-assisted breathing demonstrated some evidence that it improved some lung function measurements. Currently there is insufficient evidence for interventions aimed at other aspects of the disease process. AUTHORS' CONCLUSIONS Currently, insufficient evidence exists on psychological interventions or approaches to support people with cystic fibrosis and their caregivers, although some of the studies were promising. Due to the heterogeneity between studies, more of each type of intervention are needed to support preliminary evidence. Multicentre studies, with consequent funding implications, are needed to increase the sample size of these studies and enhance the statistical power and precision to detect important findings. In addition, multicentre studies could improve the generalisation of results by minimizing centre or therapist effects. Psychological interventions should be targeted to illness-specific symptoms or behaviours to demonstrate efficacy.
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Affiliation(s)
- Lutz Goldbeck
- Dptm. Child and Adolescent Psychiatry/Psychotherapy, University Clinic Ulm, Steinhoevelstr. 5, Ulm, Baden-Württemberg, Germany, D-89075
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14
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Snaith VJ, Hewison J, Steen IN, Robson SC. Antenatal telephone support intervention with and without uterine artery Doppler screening for low risk nulliparous women: a randomised controlled trial. BMC Pregnancy Childbirth 2014; 14:121. [PMID: 24685072 PMCID: PMC4021157 DOI: 10.1186/1471-2393-14-121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 03/19/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The number of routine antenatal visits provided to low risk nulliparous women has been reduced in the UK, acknowledging this change in care may result in women being less satisfied with their care and having poorer psychosocial outcomes. The primary aim of the study was to investigate whether the provision of proactive telephone support intervention (TSI) with and without uterine artery Doppler screening (UADS) would reduce the total number of antenatal visits required. A secondary aim was to investigate whether the interventions affected psychological outcomes. METHODS A three-arm randomised controlled trial involving 840 low risk nulliparous women was conducted at a large maternity unit in North East England. All women received antenatal care in line with current UK guidance. Women in the TSI group (T) received calls from a midwife at 28, 33 and 36 weeks and women in the telephone and Doppler group (T + D) received the TSI and additional UADS at 20 weeks' gestation. The main outcome measure was the total number of scheduled and unscheduled antenatal visits received after 20 weeks' gestation. RESULTS The median number of unscheduled (n = 2.0), scheduled visits (n = 7.0) and mean number of total visits (n = 8.8) were similar in the three groups. The majority (67%) of additional antenatal visits were made to a Maternity Assessment Unit because of commonly occurring pregnancy complications. Additional TSI+/-UADS was not associated with differences in clinical outcomes, levels of anxiety, social support or satisfaction with care. There were challenges to the successful delivery of the telephone support intervention; 59% of women were contacted at 29 and 33 weeks gestation reducing to 52% of women at 37 weeks. CONCLUSIONS Provision of additional telephone support (with or without UADS) in low risk nulliparous women did not reduce the number of unscheduled antenatal visits or reduce anxiety. This study provides a useful insight into the reasons why this client group attend for unscheduled visits. TRIAL REGISTRATION ISRCTN62354584.
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Affiliation(s)
- Vikki J Snaith
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jenny Hewison
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ian N Steen
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen C Robson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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15
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Stacey D, Légaré F, Col NF, Bennett CL, Barry MJ, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Thomson R, Trevena L, Wu JHC. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014:CD001431. [PMID: 24470076 DOI: 10.1002/14651858.cd001431.pub4] [Citation(s) in RCA: 836] [Impact Index Per Article: 83.6] [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 intended to help people participate in decisions that involve weighing the benefits and harms of treatment options often with scientific uncertainty. OBJECTIVES To assess the effects of decision aids for people facing treatment or screening decisions. SEARCH METHODS For this update, we searched from 2009 to June 2012 in MEDLINE; CENTRAL; EMBASE; PsycINFO; and grey literature. Cumulatively, we have searched each database since its start date including CINAHL (to September 2008). SELECTION CRITERIA We included published randomized controlled trials of decision aids, which are interventions designed to support patients' decision making by making explicit the decision, providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies of participants making hypothetical decisions. DATA COLLECTION AND ANALYSIS Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were:A) 'choice made' attributes;B) 'decision-making process' attributes.Secondary outcomes were behavioral, health, and health-system effects. We pooled results using mean differences (MD) and relative risks (RR), applying a random-effects model. MAIN RESULTS This update includes 33 new studies for a total of 115 studies involving 34,444 participants. For risk of bias, selective outcome reporting and blinding of participants and personnel were mostly rated as unclear due to inadequate reporting. Based on 7 items, 8 of 115 studies had high risk of bias for 1 or 2 items each.Of 115 included studies, 88 (76.5%) used at least one of the IPDAS effectiveness criteria: A) 'choice made' attributes criteria: knowledge scores (76 studies); accurate risk perceptions (25 studies); and informed value-based choice (20 studies); and B) 'decision-making process' attributes criteria: feeling informed (34 studies) and feeling clear about values (29 studies).A) Criteria involving 'choice made' attributes:Compared to usual care, decision aids increased knowledge (MD 13.34 out of 100; 95% confidence interval (CI) 11.17 to 15.51; n = 42). When more detailed decision aids were compared to simple decision aids, the relative improvement in knowledge was significant (MD 5.52 out of 100; 95% CI 3.90 to 7.15; n = 19). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.82; 95% CI 1.52 to 2.16; n = 19). Exposure to a decision aid with explicit values clarification resulted in a higher proportion of patients choosing an option congruent with their values (RR 1.51; 95% CI 1.17 to 1.96; n = 13).B) Criteria involving 'decision-making process' attributes:Decision aids compared to usual care interventions resulted in:a) lower decisional conflict related to feeling uninformed (MD -7.26 of 100; 95% CI -9.73 to -4.78; n = 22) and feeling unclear about personal values (MD -6.09; 95% CI -8.50 to -3.67; n = 18);b) reduced proportions of people who were passive in decision making (RR 0.66; 95% CI 0.53 to 0.81; n = 14); andc) reduced proportions of people who remained undecided post-intervention (RR 0.59; 95% CI 0.47 to 0.72; n = 18).Decision aids appeared to have a positive effect on patient-practitioner communication in all nine studies that measured this outcome. For satisfaction with the decision (n = 20), decision-making process (n = 17), and/or preparation for decision making (n = 3), those exposed to a decision aid were either more satisfied, or there was no difference between the decision aid versus comparison interventions. No studies evaluated decision-making process attributes for helping patients to recognize that a decision needs to be made, or understanding that values affect the choice.C) Secondary outcomes Exposure to decision aids compared to usual care reduced the number of people of choosing major elective invasive surgery in favour of more conservative options (RR 0.79; 95% CI 0.68 to 0.93; n = 15). Exposure to decision aids compared to usual care reduced the number of people choosing to have prostate-specific antigen screening (RR 0.87; 95% CI 0.77 to 0.98; n = 9). When detailed compared to simple decision aids were used, fewer people chose menopausal hormone therapy (RR 0.73; 95% CI 0.55 to 0.98; n = 3). For other decisions, the effect on choices was variable.The effect of decision aids on length of consultation varied from 8 minutes shorter to 23 minutes longer (median 2.55 minutes longer) with 2 studies indicating statistically-significantly longer, 1 study shorter, and 6 studies reporting no difference in consultation length. Groups of patients receiving decision aids do not appear to differ from comparison groups in terms of anxiety (n = 30), general health outcomes (n = 11), and condition-specific health outcomes (n = 11). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive. AUTHORS' CONCLUSIONS There is high-quality evidence that decision aids compared to usual care improve people's knowledge regarding options, and reduce their decisional conflict related to feeling uninformed and unclear about their personal values. There is moderate-quality evidence that decision aids compared to usual care stimulate people to take a more active role in decision making, and improve accurate risk perceptions when probabilities are included in decision aids, compared to not being included. There is low-quality evidence that decision aids improve congruence between the chosen option and the patient's values.New for this updated review is further evidence indicating more informed, values-based choices, and improved patient-practitioner communication. There is a variable effect of decision aids on length of consultation. Consistent with findings from the previous review, decision aids have a variable effect on choices. They reduce the number of people choosing discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, cost-effectiveness, use with lower literacy populations, and level of detail needed in decision aids need further evaluation. Little is known about the degree of detail that decision aids need in order to have a positive effect on attributes of the choice made, or the decision-making process.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada
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Rashidian H, Nedjat S, Majdzadeh R, Gholami J, Haghjou L, Abdollahi BS, Davatchi F, Rashidian A. The perspectives of Iranian physicians and patients towards patient decision aids: a qualitative study. BMC Res Notes 2013; 6:379. [PMID: 24066792 PMCID: PMC3849268 DOI: 10.1186/1756-0500-6-379] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 09/24/2013] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Patient preference is one of the main components of clinical decision making, therefore leading to the development of patient decision aids. The goal of this study was to describe physicians' and patients' viewpoints on the barriers and limitations of using patient decision aids in Iran, their proposed solutions, and, the benefits of using these tools. METHODS This qualitative study was conducted in 2011 in Iran by holding in-depth interviews with 14 physicians and 8 arthritis patient. Interviewees were selected through purposeful and maximum variation sampling. As an example, a patient decision aid on the treatment of knee arthritis was developed upon literature reviews and gathering expert opinion, and was presented at the time of interview. Thematic analysis was conducted to analyze the data by using the OpenCode software. RESULTS The results were summarized into three categories and ten codes. The extracted categories were the perceived benefits of using the tools, as well as the patient-related and physician-related barriers in using decision aids. The following barriers in using patient decision aids were identified in this study: lack of patients and physicians' trainings in shared decision making, lack of specialist per capita, low treatment tariffs and lack of an exact evaluation system for patient participation in decision making. CONCLUSIONS No doubt these barriers demand the health authorities' special attention. Hence, despite patients and physicians' inclination toward using patient decision aids, these problems have hindered the practical usage of these tools in Iran--as a developing country.
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Affiliation(s)
- Hamideh Rashidian
- Department of Epidemiology and Biostatistics, School of Public Health, Kerman University of Medical Sciences, Kerman, Iran
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Saharnaz Nedjat
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
- Knowledge Utilization Research Center (KURC), Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Majdzadeh
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
- Knowledge Utilization Research Center (KURC), Tehran University of Medical Sciences, Tehran, Iran
| | - Jaleh Gholami
- Knowledge Utilization Research Center (KURC), Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Haghjou
- Knowledge Utilization Research Center (KURC), Tehran University of Medical Sciences, Tehran, Iran
| | - Bahar Sadeghi Abdollahi
- Rheumatology Research Center, Tehran University of Medical Sciences, Shariati Hospital, Tehran, Iran
| | - Fereydoun Davatchi
- Rheumatology Research Center, Tehran University of Medical Sciences, Shariati Hospital, Tehran, Iran
| | - Arash Rashidian
- Knowledge Utilization Research Center (KURC), Tehran University of Medical Sciences, Tehran, Iran
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Dugas M, Shorten A, Dubé E, Wassef M, Bujold E, Chaillet N. Decision aid tools to support women's decision making in pregnancy and birth: a systematic review and meta-analysis. Soc Sci Med 2012; 74:1968-78. [PMID: 22475401 DOI: 10.1016/j.socscimed.2012.01.041] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Revised: 12/21/2011] [Accepted: 01/30/2012] [Indexed: 11/15/2022]
Abstract
Support for a model of shared medical decision making, where women and their care providers discuss risks and benefits of their different options, reveal their preferences, and jointly make a decision, is a growing expectation in obstetric care. The objective of this study was to conduct a systematic review and meta-analysis of randomized controlled trials evaluating the efficacy of different decision aid tools compared to regular care for women facing several options in the specific field of obstetric care. We included published studies about interventions designed to aid mothers' decision making and provide information about obstetrical treatment or screening options. Following a search of electronic databases for articles published in English and French from 1994 to 2010, we found ten studies that met the inclusion criteria. In this systematic review and meta-analysis we found that all decision aid tools, except for Decision Trees, facilitated significant increases in knowledge. The Computer-based Information Tool, the Decision Analysis Tools, Individual Counseling and Group Counseling intervention presented significant results in reducing anxiety levels. The Decision Analysis Tools and the Computer-based Information tool were associated with a reduction in levels of decisional conflict. The Decision Analysis Tool was the only tool that presented evidence of an impact on the final choice and final outcome. Decision aid tools can assist health professionals to provide information and counseling about choices during pregnancy and support women in shared decision making. The choice of a specific tool should depend on resources available to support their use as well as the specific decisions being faced by women, their health care setting and providers.
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Affiliation(s)
- Marylène Dugas
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Montreal, 3175 chemin de la Côte Ste-Catherine, Montreal, QC, Canada.
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Abstract
This paper examines the history of population screening through an analysis of contemporary medical journals. The term was first used in the modern sense in the inter-war years to describe the school health examination which sought to identify the early signs of disease and abnormality, a strategy which was extended to new recruits during the Second World War. After the war, screening began to target those illnesses in the civilian population which had a clear temporal trajectory, especially 'chronic' illnesses. Since the 1980s, enthusiasm for population screening has declined within the medical community: opportunistic screening has seemed more appropriate for diseases with multifactorial aetiology, and those programmes which have survived have been increasingly challenged through an expanding analysis of their potential harms. In identifying the early precursors of clinical disease in apparently normal populations, however, screening heralded the emergence of a new form of clinical practice concerned with the surveillance of 'healthy' patients within the context of new temporal spaces of illness.
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Affiliation(s)
- David Armstrong
- Department of Primary Care and Public Health Sciences, King's College London, London SE1 3QD, UK.
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Stacey D, Bennett CL, Barry MJ, Col NF, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Légaré F, Thomson R. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2011:CD001431. [PMID: 21975733 DOI: 10.1002/14651858.cd001431.pub3] [Citation(s) in RCA: 550] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Decision aids prepare people to participate in decisions that involve weighing benefits, harms, and scientific uncertainty. OBJECTIVES To evaluate the effectiveness of decision aids for people facing treatment or screening decisions. SEARCH STRATEGY For this update, we searched from January 2006 to December 2009 in MEDLINE (Ovid); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, issue 4 2009); CINAHL (Ovid) (to September 2008 only); EMBASE (Ovid); PsycINFO (Ovid); and grey literature. Cumulatively, we have searched each database since its start date. SELECTION CRITERIA We included published randomised controlled trials (RCTs) of decision aids, which are interventions designed to support patients' decision making by providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies in which participants were not making an active treatment or screening decision. DATA COLLECTION AND ANALYSIS Two review authors independently screened abstracts for inclusion, extracted data, and assessed potential risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards, were:A) decision attributes;B) decision making process attributes.Secondary outcomes were behavioral, health, and health system effects. We pooled results of RCTs using mean differences (MD) and relative risks (RR), applying a random effects model. MAIN RESULTS Of 34,316 unique citations, 86 studies involving 20,209 participants met the eligibility criteria and were included. Thirty-one of these studies are new in this update. Twenty-nine trials are ongoing. There was variability in potential risk of bias across studies. The two criteria that were most problematic were lack of blinding and the potential for selective outcome reporting, given that most of the earlier trials were not registered.Of 86 included studies, 63 (73%) used at least one measure that mapped onto an IPDAS effectiveness criterion: A) criteria involving decision attributes: knowledge scores (51 studies); accurate risk perceptions (16 studies); and informed value-based choice (12 studies); and B) criteria involving decision process attributes: feeling informed (30 studies) and feeling clear about values (18 studies).A) Criteria involving decision attributes:Decision aids performed better than usual care interventions by increasing knowledge (MD 13.77 out of 100; 95% confidence interval (CI) 11.40 to 16.15; n = 26). When more detailed decision aids were compared to simpler decision aids, the relative improvement in knowledge was significant (MD 4.97 out of 100; 95% CI 3.22 to 6.72; n = 15). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.74; 95% CI 1.46 to 2.08; n = 14). The effect was stronger when probabilities were expressed in numbers (RR 1.93; 95% CI 1.58 to 2.37; n = 11) rather than words (RR 1.27; 95% CI 1.09 to 1.48; n = 3). Exposure to a decision aid with explicit values clarification compared to those without explicit values clarification resulted in a higher proportion of patients achieving decisions that were informed and consistent with their values (RR 1.25; 95% CI 1.03 to 1.52; n = 8).B) Criteria involving decision process attributes:Decision aids compared to usual care interventions resulted in: a) lower decisional conflict related to feeling uninformed (MD -6.43 of 100; 95% CI -9.16 to -3.70; n = 17); b) lower decisional conflict related to feeling unclear about personal values (MD -4.81; 95% CI -7.23 to -2.40; n = 14); c) reduced the proportions of people who were passive in decision making (RR 0.61; 95% CI 0.49 to 0.77; n = 11); and d) reduced proportions of people who remained undecided post-intervention (RR 0.57; 95% CI 0.44 to 0.74; n = 9). Decision aids appear to have a positive effect on patient-practitioner communication in the four studies that measured this outcome. For satisfaction with the decision (n = 12) and/or the decision making process (n = 12), those exposed to a decision aid were either more satisfied or there was no difference between the decision aid versus comparison interventions. There were no studies evaluating the decision process attributes relating to helping patients to recognize that a decision needs to be made or understand that values affect the choice.C) Secondary outcomesExposure to decision aids compared to usual care continued to demonstrate reduced choice of: major elective invasive surgery in favour of conservative options (RR 0.80; 95% CI 0.64 to 1.00; n = 11). Exposure to decision aids compared to usual care also resulted in reduced choice of PSA screening (RR 0.85; 95% CI 0.74 to 0.98; n = 7). When detailed compared to simple decision aids were used, there was reduced choice of menopausal hormones (RR 0.73; 95% CI 0.55 to 0.98; n = 3). For other decisions, the effect on choices was variable. The effect of decision aids on length of consultation varied from -8 minutes to +23 minutes (median 2.5 minutes). Decision aids do not appear to be different from comparisons in terms of anxiety (n = 20), and general health outcomes (n = 7), and condition specific health outcomes (n = 9). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive. AUTHORS' CONCLUSIONS New for this updated review is evidence that: decision aids with explicit values clarification exercises improve informed values-based choices; decision aids appear to have a positive effect on patient-practitioner communication; and decision aids have a variable effect on length of consultation.Consistent with findings from the previous review, which had included studies up to 2006: decision aids increase people's involvement, and improve knowledge and realistic perception of outcomes; however, the size of the effect varies across studies. Decision aids have a variable effect on choices. They reduce the choice of discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, patient-practitioner communication, cost-effectiveness, and use with developing and/or lower literacy populations need further evaluation. Little is known about the degree of detail that decision aids need in order to have positive effects on attributes of the decision or decision-making process.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada
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Say R, Robson S, Thomson R. Helping pregnant women make better decisions: a systematic review of the benefits of patient decision aids in obstetrics. BMJ Open 2011; 1:e000261. [PMID: 22189349 PMCID: PMC3334824 DOI: 10.1136/bmjopen-2011-000261] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
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.
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Affiliation(s)
- Rebecca Say
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Stephen Robson
- Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Richard Thomson
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
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Modra LJ, Massie RJ, Delatycki MB. Ethical considerations in choosing a model for population-based cystic fibrosis carrier screening. Med J Aust 2010; 193:157-60. [PMID: 20678044 DOI: 10.5694/j.1326-5377.2010.tb03836.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Accepted: 12/22/2009] [Indexed: 11/17/2022]
Abstract
Cystic fibrosis (CF) carrier testing can be used to inform reproductive decision making, allowing carriers to avoid having a child with CF. A government-funded, population-based CF carrier screening program would allow greater equity of access to this test. The setting in which CF carrier screening is offered significantly affects the extent to which participants make well informed, voluntary decisions to accept or decline testing. Screening offered before pregnancy and in non-clinical environments better promotes participant autonomy than screening offered in the prenatal consultation.
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Hwa HL, Huang LH, Hsieh FJ, Chow SN. Informed consent for antenatal serum screening for Down syndrome. Taiwan J Obstet Gynecol 2010; 49:50-6. [PMID: 20466293 DOI: 10.1016/s1028-4559(10)60009-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2008] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Respect for patients' autonomy is a principle issue in medical ethics. Patients' understanding of antenatal serum screening for Down syndrome upon informed consent has barely been assessed. Our objective was to evaluate pregnant women's perceived level of understanding of this serum screening. MATERIALS AND METHODS Pregnant women between the 15(th) and 21(st) gestational week were randomized into control and experimental groups, and were asked to complete a questionnaire before and after genetic counselling provided by researchers. The primary endpoints were the perceived level of understanding of serum screening for Down syndrome and the autonomy of the decision making for this serum screening. The secondary endpoints were the anxiety and depression levels of these women. RESULTS Participants in the experimental group (n = 96) had a significantly higher perceived level of understanding of antenatal serum screening for Down syndrome than participants in the control group (n = 97). There were significantly more respondents in the experimental group making the decision themselves to undergo serum screening than women in the control group. Anxiety and depression levels were not significantly different between the women in the two groups. CONCLUSION Pregnant women should be offered more information to allow them to make an informed decision before they undergo antenatal serum screening for Down syndrome. Comprehensive genetic counseling improved pregnant women's autonomy in deciding whether to participate in serum screening. Health service providers should make effort to fulfill the ethical requirements of informed consent.
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Affiliation(s)
- Hsiao-Lin Hwa
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and College of Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Gidiri M, Holding S, Lindow SW. Reduction in Down's Syndrome Screening Acceptance is Predominantly Observed in Women Aged 25–35 Years. WOMENS HEALTH 2010; 6:525-9. [DOI: 10.2217/whe.10.29] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background: The risk of having a child with Down's syndrome increases with maternal age. However, uptake of screening has never been analyzed according to age. Different studies have shown different screening uptake rates, some low and some high, but it is not clear which age categories are responsible for these trends. Aims: To demonstrate if any age cohorts are responsible for the noted decline in uptake of serum screening. Setting: A large teaching hospital in Hull and East Yorkshire, which has offered second trimester serum screening for Down's syndrome for over 16 years using the same test (triple test). Main outcome measures: Uptake of serum screening for Down's syndrome in each 5-year age cohort per year, over 4 years. A secondary outcome measure was the uptake according to parity. Methods: We accessed our hospital records covering a 5-year period for all women booking and delivering in a large North of England teaching hospital. The women were categorized into 5-year age cohorts for analysis of the data. Results: Down's syndrome screening uptake rates indicate a decline from 63.2 and 65.1% in 2003 to 38.6 and 39% in 2006, respectively, in the age groups 25–29.9 and 30–34.9 years who constitute at least 50% of all pregnant women. There was no evidence of the effect of parity on serum screening. Conclusion: It is apparent that the noted overall decline in the trends of serum screening uptake are due to the reduced uptake by the 25–35 years age group.
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Affiliation(s)
- Muchabayiwa Gidiri
- Academic Department of Obstetrics & Gynaecology, Hull Royal Infirmary, Hull, UK
| | - Stephen Holding
- Department of Clinical Biochemistry, Hull Royal Infirmary, Hull, UK
| | - Stephen W Lindow
- Academic Department of Obstetrics & Gynaecology, Hull Royal Infirmary, Hull, UK
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Gunning M, Denison F, Stockley C, Ho S, Sandhu H, Reynolds R. Assessing maternal anxiety in pregnancy with the State‐Trait Anxiety Inventory (STAI): issues of validity, location and participation. J Reprod Infant Psychol 2010. [DOI: 10.1080/02646830903487300] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Wagner D, Pargas C, Donnenfeld AE. Moderately Increased Risks of Down's Syndrome (1/51–1/270) Identified on First Trimester Sequential Screening: What do Patients do with this Information? J Med Screen 2010; 17:4-7. [DOI: 10.1258/jms.2009.009086] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objective To document patient decisions after being informed of a first trimester sequential screen Down's syndrome risk between 1/51 and 1/270. Setting A database analysis of sequential screen results for patients seen in the Philadelphia, PA (USA) area between January 2006 and March 2008 was examined. Methods All patients with first trimester sequential screen Down's syndrome risks in the 1/51–1/270 range were identified. Patient decisions regarding invasive testing (prior to completing the second trimester stage of the sequential screen), completion of the second trimester blood draw or no additional testing were tabulated. Results A total of 10,850 patients underwent first trimester sequential screening during this interval. Five hundred and fifty-seven patients (5.1%) met the study inclusion criteria and had risks between 1/51 and 1/270. Ninety-three percent of these patients completed the sequential screening process before making any decisions regarding invasive testing. Four percent did not elect an invasive prenatal diagnosis procedure, but also did not complete the second trimester sequential screening blood draw and only 3.2% elected an invasive procedure based on their first trimester risk without completing the second trimester blood draw. Five women (0.9%) with low risks after the second stage screen chose to have an amniocentesis. Conclusion The vast majority (97%) of patients in the moderately increased Down's syndrome risk range (1/51–1/270) following first trimester sequential screening did not pursue an invasive procedure based on their first trimester sequential screen risk. Using a ≥ 1/50 risk cut-off in the first trimester is an effective screening policy for sequential screening.
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Affiliation(s)
| | | | - Alan E Donnenfeld
- Obstetrics and Gynecology, Genzyme Genetics and Main Line Perinatology, 353 Lankenau Medical Building East, Wynnewood, PA 19096, USA
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Gale T, Pasalodos-Sanchez S, Kerzin-Storrar L, Hall G, MacLeod R. Explaining Mendelian inheritance in genetic consultations: an IPR study of counselor and counselee experiences. J Genet Couns 2010; 19:55-67. [PMID: 20049518 DOI: 10.1007/s10897-009-9263-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Accepted: 09/25/2009] [Indexed: 10/20/2022]
Abstract
The explanation of Mendelian inheritance is a key component of most genetic counselling consultations, yet no evidence base exists for this area of practice. This qualitative study used Interpersonal Process Recall (IPR) to explore how information about X-linked inheritance is provided and received in genetic counseling. Twelve consultations involving two senior genetic counselors and 21 counselees were videotaped. Section(s) of videotape featuring the explanation were subsequently played back separately to both counselees and counselors and their responses and reflections recorded. All interviews were fully transcribed and analysed using the constant comparison method. A personalized diagram, drawn "live" by the counselor during the consultation was recalled by counselees as being central to their understanding of the "bottom line". This helped bridge the gap between scientific information and their family experience and did not appear to require a baseline understanding of genetic concepts such as genes or chromosomes. Counselors reflected on the diagram's positive impact on the way they sequenced, paced and tailored the explanation. A positive counselor-counselee relationship was vital even during this educative exchange: for counselees to feel at ease discussing complex genetic information and to help gauge counselee understanding.
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Affiliation(s)
- Theodora Gale
- Genetic Medicine, Manchester Academic Health Science Centre, Central Manchester University Hospitals NHS Foundation Trust and University of Manchester, Manchester, M13 9WL, UK.
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O'Connor AM, Bennett CL, Stacey D, Barry M, Col NF, Eden KB, Entwistle VA, Fiset V, Holmes-Rovner M, Khangura S, Llewellyn-Thomas H, Rovner D. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2009:CD001431. [PMID: 19588325 DOI: 10.1002/14651858.cd001431.pub2] [Citation(s) in RCA: 409] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Decision aids prepare people to participate in 'close call' decisions that involve weighing benefits, harms, and scientific uncertainty. OBJECTIVES To conduct a systematic review of randomised controlled trials (RCTs) evaluating the efficacy of decision aids for people facing difficult treatment or screening decisions. SEARCH STRATEGY We searched MEDLINE (Ovid) (1966 to July 2006); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library; 2006, Issue 2); CINAHL (Ovid) (1982 to July 2006); EMBASE (Ovid) (1980 to July 2006); and PsycINFO (Ovid) (1806 to July 2006). We contacted researchers active in the field up to December 2006. There were no language restrictions. SELECTION CRITERIA We included published RCTs of interventions designed to aid patients' decision making by providing information about treatment or screening options and their associated outcomes, compared to no intervention, usual care, and alternate interventions. We excluded studies in which participants were not making an active treatment or screening decision, or if the study's intervention was not available to determine that it met the minimum criteria to qualify as a patient decision aid. DATA COLLECTION AND ANALYSIS Two review authors independently screened abstracts for inclusion, and extracted data from included studies using standardized forms. The primary outcomes focused on the effectiveness criteria of the International Patient Decision Aid Standards (IPDAS) Collaboration: attributes of the decision and attributes of the decision process. We considered other behavioural, health, and health system effects as secondary outcomes. We pooled results of RCTs using mean differences (MD) and relative risks (RR) using a random effects model. MAIN RESULTS This update added 25 new RCTs, bringing the total to 55. Thirty-eight (69%) used at least one measure that mapped onto an IPDAS effectiveness criterion: decision attributes: knowledge scores (27 trials); accurate risk perceptions (11 trials); and value congruence with chosen option (4 trials); and decision process attributes: feeling informed (15 trials) and feeling clear about values (13 trials).This review confirmed the following findings from the previous (2003) review. Decision aids performed better than usual care interventions in terms of: a) greater knowledge (MD 15.2 out of 100; 95% CI 11.7 to 18.7); b) lower decisional conflict related to feeling uninformed (MD -8.3 of 100; 95% CI -11.9 to -4.8); c) lower decisional conflict related to feeling unclear about personal values (MD -6.4; 95% CI -10.0 to -2.7); d) reduced the proportion of people who were passive in decision making (RR 0.6; 95% CI 0.5 to 0.8); and e) reduced proportion of people who remained undecided post-intervention (RR 0.5; 95% CI 0.3 to 0.8). When simpler decision aids were compared to more detailed decision aids, the relative improvement was significant in knowledge (MD 4.6 out of 100; 95% CI 3.0 to 6.2) and there was some evidence of greater agreement between values and choice.In this review, we were able to explore the use of probabilities in decision aids. Exposure to a decision aid with probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.6; 95% CI 1.4 to 1.9). The effect was stronger when probabilities were measured quantitatively (RR 1.8; 95% CI 1.4 to 2.3) versus qualitatively (RR 1.3; 95% CI 1.1 to 1.5).As in the previous review, exposure to decision aids continued to demonstrate reduced rates of: elective invasive surgery in favour of conservative options, decision aid versus usual care (RR 0.8; 95% CI 0.6 to 0.9); and use of menopausal hormones, detailed versus simple aid (RR 0.7; 95% CI 0.6 to 1.0). There is now evidence that exposure to decision aids results in reduced PSA screening, decision aid versus usual care (RR 0.8; 95% CI 0.7 to 1.0) . For other decisions, the effect on decisions remains variable.As in the previous review, decision aids are no better than comparisons in affecting satisfaction with decision making, anxiety, and health outcomes. The effects of decision aids on other outcomes (patient-practitioner communication, consultation length, continuance, resource use) were inconclusive.There were no trials evaluating the IPDAS decision process criteria relating to helping patients to recognize a decision needs to be made, understand that values affect the decision, or discuss values with the practitioner. AUTHORS' CONCLUSIONS Patient decision aids increase people's involvement and are more likely to lead to informed values-based decisions; however, the size of the effect varies across studies. Decision aids have a variable effect on decisions. They reduce the use of discretionary surgery without apparent adverse effects on health outcomes or satisfaction. The degree of detail patient decision aids require for positive effects on decision quality should be explored. The effects on continuance with chosen option, patient-practitioner communication, consultation length, and cost-effectiveness need further evaluation.
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Affiliation(s)
- Annette M O'Connor
- Professor, School of Nursing, Department of Epidemiology, University of Ottawa, Senior Scientist, Clinical Epidemiology Program, Ottawa Health Research Institute, 1053 Carling Avenue, (ASB 2-008), Ottawa, Ontario, Canada, K1Y 4E9
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Marcus SF, Ward PA, Wood PL. Maternal serum screening for Down syndrome in women aged 40 years and over. J OBSTET GYNAECOL 2009; 19:604-8. [PMID: 15512411 DOI: 10.1080/01443619963824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Two hundred and thirty-nine women aged 40 years were booked for delivery at Kettering General Hospital from 1992 to 1997. Six women were not eligible for the triple test (TT) as they booked too late. Eighty-eight women declined TT. The reasons were; fear and anxiety about the risk of miscarriage associated with amniocentesis if the test result were a high risk (70.5%), worries about the false negative result associated with the TT (20.5%) and reluctance to terminate the pregnancies if the fetus were abnormal (9%). One hundred and forty-five women (62.2%) elected for TT of whom 91 (62.8%) had received a high risk results. Of the women who received a high-risk result 61/91 (67%) had an amniocentesis. The study provides an accurate probability of receiving a high risk TT screening in women aged 40 years and highlights the need for a more sensitive screening test or a less invasive diagnostic test for the detection of Down syndrome.
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Affiliation(s)
- S F Marcus
- Kettering General Hospital NHS Trust, UK
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Nagle C, Hodges R, Wolfe R, Wallace EM. Reporting Down syndrome screening results: women's understanding of risk. Prenat Diagn 2009; 29:234-9. [DOI: 10.1002/pd.2210] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Kryworuchko J, Stacey D, Bennett C, Graham ID. Appraisal of primary outcome measures used in trials of patient decision support. PATIENT EDUCATION AND COUNSELING 2008; 73:497-503. [PMID: 18701235 DOI: 10.1016/j.pec.2008.07.011] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2008] [Revised: 06/05/2008] [Accepted: 07/04/2008] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To appraise instruments used as primary outcome measures in trials measuring the effectiveness of patient decision support interventions. METHODS Primary outcome measures were identified in trials of patient decision aids included in the 2003 Cochrane Review. Instruments were appraised for: use in calculating sample size, appropriateness, reliability, validity, responsiveness, precision, interpretability, acceptability, and feasibility. RESULTS Of the 35 trials, there were 35 unique primary outcome measures and 8 instruments were appraised. Actual or preferred choice was the primary outcome measure in 18 trials. Two instruments met at least 6 of 8 appraisal criteria: Control Preference Scale (n=2 trials) and Decisional Conflict Scale (n=5 trials). The Decision Conflict Scale was used to calculate sample size in 4 trials. CONCLUSION Decision was the most consistent outcome measure. Most publications provided inadequate detail for appraising the instruments. Four instruments (Decisional Conflict, Control Preferences, Genetic Testing Knowledge Questionnaire, and McBride's Satisfaction with Decision) measured one or more International Patient Decision Aid Standards criteria for evaluating effectiveness. PRACTICE IMPLICATIONS Selecting relevant and high quality outcome measures remains challenging and is an important area for further research in the field of shared decision making.
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Abstract
BACKGROUND With increasing survival estimates for cystic fibrosis (CF) long-term management has become an important focus. Psychological interventions are largely concerned with adherence to treatment, emotional and social adjustments and quality of life. We are unaware of any relevant systematic reviews. OBJECTIVES Assess whether psychological interventions for CF provide significant psychosocial and physical benefits in addition to standard care. SEARCH STRATEGY Trials were identified from two Cochrane trial registers (CF and Genetic Disorders Group; Depression, Anxiety and Neurosis Group), Ovid MEDLINE and PsychINFO; unpublished trials were located through professional networks and Listserves. Most recent search: September 2007. SELECTION CRITERIA Randomised controlled trials of a broad range of psychological interventions in children and adults with CF and their immediate family. DATA COLLECTION AND ANALYSIS Two authors independently selected relevant trials and assessed their methodological quality. MAIN RESULTS The review includes 13 studies (five new at this update) representing data from 529 participants. Studies mainly assessed behavioural and educational interventions:1. gene pre-test education counselling for relatives of those with CF;2. biofeedback, massage and music therapy to assist physiotherapy;3. behavioural and educational interventions to improve dietary intake and airway clearance;4. self-administration of medication and education to promote independence, knowledge and quality of life; and5. systemic interventions promoting psychosocial functioning.A substantial proportion of outcomes were educational or behavioural relating to issues of adherence, change in physical status or other specific treatment concerns during the chronic phase of the disease. Some evidence was found for relative's acceptance of a genetic test for carrier status when using home-based rather than clinic-based information leaflets and testing. There is some evidence that behavioural interventions improve emotional outcomes in people with CF and their carers, and that psychoeducational interventions improve knowledge in the short term. There was no consistent effect on lung function, although one small study showed that biofeedback-assisted breathing re-training helped improve some lung function measurements. Some studies point to educational and behavioural interventions aiding nutrition and growth in people with CF. Currently there is insufficient evidence for interventions aimed at other aspects of the disease process. AUTHORS' CONCLUSIONS Currently no clear evidence exists on the best psychological interventions to help people with CF and their carers manage the disease. Trials of interventions to improve adherence to treatment are needed. Multicentre approaches, with consequent funding implications, will increase the sample size of trials and enhance the power and precision of their findings.
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Affiliation(s)
- Claire A Glasscoe
- Academic Child Mental Health Unit, Royal Liverpool Children's Hospital, Eaton Road, Liverpool, UK, L12 2AP.
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Measuring the benefits of health promotion programmes: application of the contingent valuation method. Health Policy 2008; 87:235-48. [PMID: 18295926 DOI: 10.1016/j.healthpol.2008.01.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2007] [Revised: 01/08/2008] [Accepted: 01/08/2008] [Indexed: 11/22/2022]
Abstract
Economic evaluation of health promotion programmes presents well documented challenges. These programmes often generate significant non-health benefits which are typically ignored within economic evaluation. This study explored the use of the contingent valuation (CV) method to value the broader benefits of a women's group programme to improve maternal and newborn health in Nepal. Interviews were conducted with 93 women's group members, 70 women non-members and 33 men. Respondents were asked to give reasons for their willingness-to-pay (WTP) in terms of health and/or non-health benefits. WTP was regressed against socio-economic and demographic variables using ordinary least squares. Seventy eight percent of respondents were willing-to-pay for the women's groups. There was no significant difference between the WTP of women's group members compared to female non-members. Men were willing-to-pay significantly more than women. WTP reflected non-health benefits in over 80% of cases. At least 11% of women attending meetings and 38% of those not attending were WTP for altruistic motives. Future research should address the relative value of non-health compared to health benefits; and motivations behind non-user values and their consistency across settings.
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Favre R, Moutel G, Duchange N, Vayssière C, Kohler M, Bouffet N, Hunsinger MC, Kohler A, Mager C, Neumann M, Vayssière C, Viville B, Hervé C, Nisand I. What about informed consent in first-trimester ultrasound screening for Down syndrome? Fetal Diagn Ther 2008; 23:173-84. [PMID: 18417975 DOI: 10.1159/000116738] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2006] [Accepted: 12/01/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We evaluate the level of information and informed consent given for the screening of Down syndrome (DS) before the first-trimester ultrasound scan. We evaluate the nature of the medical information given and the patient's understanding. This makes it possible to analyze the existence of the necessary elements (level of information and consent) for the patients to exercise their autonomy as to their decision making during the first-trimester ultrasound scan. METHODS A total of 350 patients were recruited prospectively in 2 hospitals. Patients were divided into 3 groups according to the results of maternal serum screening for DS. Group 1: Patients at high risk of having a child with DS with the second-trimester maternal serum screening (MSS) (risk >1/250). Group 2: Patients having a low risk (risk <1/250). Group 3: Patients who did not undergo maternal serum screening test. A questionnaire was completed before the medical consultation, to assess the quality of the medical consultation before the ultrasound, the level of prior knowledge and the maternal consent. RESULTS We excluded 45 of the 350 questionnaires from the analysis because they were incomplete (13.1%). We therefore analyzed a total of 305 questionnaires. The three groups analysed were: Group 1: 89 patients (29.2%) identified as at high risk after MSS. Group 2: 137 patients (44.9%) identified as at low risk accordingly to MSS. Group 3: 79 women (25.9%) who did not undergo maternal serum screening test for diverse reasons. The frequency of genuine informed consent was significantly (p < 0.001) higher in group 3 (56.9%) than in group 1 (52.8%) or group 2 (32.1%). Finally, the number of completely uninformed patients was significantly higher in group 2 (18%) than in the other two groups (7.8% for group 1 and 6.3% for group 3, p < 0.001). With multiple regression analysis, we found that maternal consent depended on 4 independent components: (1) Educational level (<baccalaureate, baccalaureate or at least 2 years of higher education after baccalaureate) (p < 0.03). (2) The location of consultations (hospital or private doctor's practice) (p < 0.01). (3) History of medical termination (p < 0.001). (4) The score attributed to the doctor for information about early ultrasound scans (p < 0.001). The rate of consent increased with increasing educational level and was higher for women consulting at a hospital, for women with a history medical termination and for women whose doctors had a high score. Other criteria such as belonging to group 1, 2 or 3, age of the patient, first language, number of children, history of miscarriage, sex and age group of the professionals were not found significant. CONCLUSIONS The response to the question 'Is the level of medical information provided to patients concerning early screening by first-trimester ultrasound scans appropriate?' is 'no'. There is no difference in our result according to social-economic level. However, educational level (66% consent for patients with 2 years of higher education after the baccalaureate), a history of medical termination (85% consent), being followed at a hospital (77% consent) and the score of the doctor (71% consent) were all significantly associated with the level of consent to prenatal screening. It is difficult for patients to exercise their autonomy as concerns first-trimester ultrasound scans. Too many patients (82%) consider such scans to be compulsory. Overall, the level of knowledge of the patients was moderate, with 227 of the 305 patients (74%) having a satisfactory knowledge score (> or =10). The negative responses to the various questions calls into question the legitimacy of consent for first-trimester ultrasound scans, particularly as concerns the measurement of nucal translucency.
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Affiliation(s)
- Romain Favre
- Department of Ultrasound and Fetal Medicine, Strasbourg, France
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O'Connor AM, Bennett C, Stacey D, Barry MJ, Col NF, Eden KB, Entwistle V, Fiset V, Holmes-Rovner M, Khangura S, Llewellyn-Thomas H, Rovner DR. Do Patient Decision Aids Meet Effectiveness Criteria of the International Patient Decision Aid Standards Collaboration? A Systematic Review and Meta-analysis. Med Decis Making 2007; 27:554-74. [PMID: 17873255 DOI: 10.1177/0272989x07307319] [Citation(s) in RCA: 195] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective. To describe the extent to which patient decision aids (PtDAs) meet effectiveness standards of the International Patient Decision Aids Collaboration (IPDAS). Data sources. Five electronic databases (to July 2006) and personal contacts (to December 2006). Results. Among 55 randomized controlled trials, 38 (69%) used at least 1 measure that mapped onto an IPDAS effectiveness criterion. Measures of decision quality were knowledge scores (27 trials), accurate risk perceptions (12 trials), and value congruence with the chosen option (3 trials). PtDAs improved knowledge scores relative to usual care (weighted mean difference [WMD] = 15.2%, 95% confidence interval [CI] = 11.7 to 18.7); detailed PtDAs were somewhat more effective than simpler PtDAs (WMD = 4.6%, 95% CI = 3.0 to 6.2). PtDAs with probabilities improved accurate risk perceptions relative to those without probabilities (relative risk = 1.6, 95% CI = 1.4 to 1.9). Relative to simpler PtDAs, detailed PtDAs improved value congruence with the chosen option. Only 2 of 6 IPDAS decision process criteria were measured: feeling informed (15 trials) and feeling clear about values (13 trials). PtDAs improved these process measures relative to usual care (feeling uninformed WMD = —8.4, 95% CI = —11.9 to —4.8; unclear values WMD = —6.3, 95% CI = —10.0 to —2.7). There was no difference in process measures when detailed and simple PtDAs were compared. Conclusions. PtDAs improve decision quality and the decision process's measures of feeling informed and clear about values; however, the size of the effect varies across studies. Several IPDAS decision process measures have not been used. Future trials need to use a minimum data set of IPDAS evaluation measures. The degree of detail PtDAs require for positive effects on IPDAS criteria should be explored.
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Feldman-Stewart D, Brennenstuhl S, McIssac K, Austoker J, Charvet A, Hewitson P, Sepucha KR, Whelan T. A systematic review of information in decision aids. Health Expect 2007; 10:46-61. [PMID: 17324194 PMCID: PMC5060377 DOI: 10.1111/j.1369-7625.2006.00420.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE We completed a systematic review of information reported as included in decision aids (DAs) for adult patients, to determine if it is complete, balanced and accurate. SEARCH STRATEGY DAs were identified using the Cochrane Database of DAs and searches of four electronic databases using the terms: 'decision aid'; shared decision making' and 'patients'; 'multimedia or leaflets or pamphlets or videos and patients and decision making'. Additionally, publications reporting DA development and actual DAs that were reported as publicly available on the Internet were consulted. Publications were included up to May 2006. DATA EXTRACTION Data were extracted on the following variables: external groups consulted in development of the DA, type of study used, categories of information, inclusion of probabilities, use of citation lists and inclusion of patient experiences. MAIN RESULTS 68 treatment DAs and 30 screening DAs were identified. 17% of treatment DAs and 47% of screening DAs did not report any external consultation and, of those that did, DA producers tended to rely more heavily on medical experts than on patients' guidance. Content evaluations showed that (i) treatment DAs frequently omit describing the procedure(s) involved in treatment options and (ii) screening DAs frequently focus on false positives but not false negatives. About 1/2 treatment DAs reported probabilities with a greater emphasis on potential benefits than harms. Similarly, screening DAs were more likely to provide false-positive than false-negative rates. CONCLUSIONS The review led us to be concerned about completeness, balance and accuracy of information included in DAs.
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Affiliation(s)
- Deb Feldman-Stewart
- Division of Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, Canada.
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Chiappa E. The impact of prenatal diagnosis of congenital heart disease on pediatric cardiology and cardiac surgery. J Cardiovasc Med (Hagerstown) 2007; 8:12-6. [PMID: 17255810 DOI: 10.2459/01.jcm.0000247429.28957.80] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Since the early 1980s prenatal diagnosis of congenital heart disease (CHD) has progressively impacted on the practice of pediatric cardiology and cardiac surgery. Fetal cardiology today raises special needs in screening programs, training of the involved staff, and allocations of services. Due to the increased detection rate and to the substantial number of terminations, the reduced incidence of CHD at birth can affect the workload of centers of pediatric cardiology and surgery. In utero transportation and competition among centers may change the area of referral in favor of the best centers. Echocardiography is a powerful means to diagnose and to guide lifesaving medical treatment of sustained tachyarrhythmias in the fetus. Prenatal diagnosis not only improves the preoperative conditions in most cases but also postoperative morbidity and mortality in selected types of CHD. Intrauterine transcatheter valvuloplasty in severe outflow obstructive lesions has been disappointing so far and this technique remains investigational, until its benefits are determined by controlled trials. Prenatal diagnosis allows counselling of families which are better prepared for the foreseeable management and outcome of the fetus. These benefits can reduce the risks of litigation for missed ultrasound diagnosis. As increased costs can be expected in institutions dealing with a large number of fetal CHD, the administrators of these institutions should receive protected funds, proportional to their needs.
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Affiliation(s)
- Enrico Chiappa
- Fetal and Maternal Cardiology Unit, Division of Pediatric Cardiology, Azienda Ospedaliera O.I.R.M.-S. Anna, Turin, Italy.
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Hinshaw K, El-Bishry G, Davison S, Hildreth AJ, Cooper A. Randomised controlled trial comparing three methods of presenting risk of Down's syndrome. Eur J Obstet Gynecol Reprod Biol 2006; 133:40-6. [PMID: 16949722 DOI: 10.1016/j.ejogrb.2006.07.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2006] [Revised: 06/05/2006] [Accepted: 07/14/2006] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare three simple methods of presenting information to patients about the risk of Down's syndrome. STUDY DESIGN Randomised controlled trial of 150 " low risk" women booking for antenatal care before 19 weeks gestation at Sunderland Royal Hospital. After informing the women about the purpose of the study and reassuring them that they were "low risk", each patient was given a questionnaire, which used one of three different methods (graphic, written and interactive) to present information about the risk of Down's syndrome. A visual analogue scale allowed us to assess their level of understanding and anxiety before and after the information about risk was given to them. RESULTS All three methods significantly altered patients' perception and anxiety about the risk of Down's syndrome. The interactive method was found to be the most effective of the three. CONCLUSION This pilot study suggests that discussing the patients' worries about fetal anomalies with medical staff can markedly reduce their degree of anxiety. The interactive method was most effective at putting information across to the patient. It significantly reduced their level of anxiety as well as their overall worry about pregnancy.
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Affiliation(s)
- Kim Hinshaw
- Obstetrics & Gynaecology Department, Sunderland Royal Hospital, Kayll Road, Sunderland SR4 7TP, United Kingdom
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Gregory KD, Johnson CT, Johnson TRB, Entman SS. The content of prenatal care. Womens Health Issues 2006; 16:198-215. [PMID: 16920524 DOI: 10.1016/j.whi.2006.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Accepted: 05/22/2006] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The Content of Prenatal Care report of the US Preventative Health Service (USPHS) Expert Panel established an important benchmark when published in 1989, but has not been significantly updated since that time. METHODS The literature since 1989 is reviewed to assess which recommendations have been validated and/or implemented. Additionally, new findings that support the recommendations put forth or expand the scope of prenatal care outlined in the 1989 report are examined and discussed. RESULTS The USPHS recommendation of a reduced prenatal visit schedule has support, and new content for the preconception visit has been identified, although this preconception visit has not been validated or widely implemented. CONCLUSIONS We identified new opportunities and initiatives for the content of prenatal care, particularly improvement in the electronic medical record, attention to multidisciplinary approaches to patient education and improved patient literacy, and an extended maternal life span approach, including postgestation visits.
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Affiliation(s)
- Kimberly D Gregory
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, California, USA
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Lilford R, Girling A, Stevens A, Almasri A, Mohammed MA, Braunholtz D. Adjusting for treatment refusal in rationing decisions. BMJ 2006; 332:542-4. [PMID: 16513714 PMCID: PMC1388139 DOI: 10.1136/bmj.332.7540.542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Assessments of cost effectiveness are increasingly used to get the most value from limited health resources. Could adjusting for people who wouldn't want the treatment improve the process?
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Affiliation(s)
- Richard Lilford
- Department of Public Health and Epidemiology, University of Birmingham, Birmingham B15 2TT.
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41
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West H, Bramwell R. Do maternal screening tests provide psychologically meaningful results? Cognitive psychology in an applied setting. J Reprod Infant Psychol 2006. [DOI: 10.1080/02646830500475278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Carrigan N, Gardner PH, Conner M, Maule J. The impact of structuring information in a patient decision aid. Psychol Health 2004. [DOI: 10.1080/08870440310001652641] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Baker H, Uus K, Bamford J, Marteau TM. Increasing knowledge about a screening test: preliminary evaluation of a structured, chart-based, screener presentation. PATIENT EDUCATION AND COUNSELING 2004; 52:55-59. [PMID: 14729291 DOI: 10.1016/s0738-3991(02)00249-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The provision and understanding of good quality information is one of the key characteristics of an informed choice. However, written materials alone often fail to achieve good understanding of screening tests. The present study describes the preliminary evaluation of a structured, chart-directed presentation, aimed at increasing knowledge of a screening test. Forty mothers of babies undergoing a newborn hearing test received either a standard, or a standard plus structured, presentation of the screening test. Standard presentation was a leaflet and short verbal explanation of the test. Structured presentation comprised an illustrated chart explaining the process and possible outcomes of screening, followed by screeners checking mothers understanding of key points and, if necessary, giving further explanation. After screening, maternal knowledge of the test was assessed using seven multiple choice items. Overall knowledge was high. For women with lower levels of education, the structured presentation resulted in significantly higher levels of knowledge than the standard presentation only.
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Affiliation(s)
- Holly Baker
- Psychology and Genetics Research Group, King's College London, Thomas Guy House, Guy's Campus, London SE1 9RT, UK
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Abstract
OBJECTIVE Attempts to synthesize the evidence on the effects of decision aids have been hampered by the lack of consensus regarding how such effectiveness should be measured. This paper seeks to describe and critically assess the range of measures of effectiveness used in randomized controlled trials of decision aids. SEARCH STRATEGY The published systematic reviews of the field were used to identify primary studies evaluating the effects of decision aids. INCLUSION CRITERIA Non-randomized trials were excluded from this review. As were abstracts and theses of subsequently published studies, methodological papers and reports of subgroups of a study's main publication. MAIN RESULTS A wide range of measures were used to evaluate the effectiveness of decision aids. The most commonly used measures sought to assess treatment decisions, patient's knowledge and the decision-making process. This pattern was repeated when primary measures of effectiveness were examined. No study attempted to measure the extent to which decisions made were consistent with patient's values. CONCLUSIONS Within the current literature there is little consensus on what the aims of decision aids should be. If we can agree that the aim of a decision aid is to help patients make specific personal treatment choices, then evaluations of decision aids should measure the primary effectiveness of their interventions in terms of the extent to which they enable patient's to undergo treatments that agree with their values.
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Affiliation(s)
- Andrew D M Kennedy
- Health Economics Research Group, Brunel University, Uxbridge, Middlesex, UK.
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Bekker HL, Legare F, Stacey D, O'Connor A, Lemyre L. Is anxiety a suitable measure of decision aid effectiveness: a systematic review? PATIENT EDUCATION AND COUNSELING 2003; 50:255-262. [PMID: 12900095 DOI: 10.1016/s0738-3991(03)00045-4] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Several trials have employed anxiety measures to assess decision aid effectiveness. This study employed a systematic review method to integrate their findings. The affective impact of decision aids and the appropriateness of anxiety as a measure of decision aid effectiveness are explored. From 11,361 citations generated from searching electronic databases and journals, 26 randomised controlled trials evaluated patient decision aids; 10 included anxiety measures (HADS; STAI). The data were too heterogeneous to integrate statistically. No studies showed an increase in anxiety from exposure to decision aids versus usual care. Some patterns emerged between level of anxiety and characteristics of the decision. As raised levels of anxiety are associated with both more effective decision strategies and stressful health interventions, anxiety is an inappropriate measure to employ when evaluating decision aids. Future research needs to investigate the relationship between affect, cognition and decision aids in order to facilitate effective patient decision making.
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Affiliation(s)
- Hilary L Bekker
- Academic Unit of Psychiatry and Behavioural Science, School of Medicine, University of Leeds, UK.
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Abstract
OBJECTIVE To assess the level of knowledge about Down syndrome screening among a sample of health professionals providing antenatal care. DESIGN A structured questionnaire-based survey. SETTING Health professionals allied to a tertiary level maternity hospital in metropolitan Melbourne. METHODS A self-administered questionnaire was given or posted to 166 health care providers to assess their knowledge of prenatal Down syndrome screening. RESULTS A total of 140 completed surveys were returned (83% response rate), including 70 from general practitioners, 34 from midwives, 33 from obstetricians and three from geneticists. Of these, 130 confirmed that they regularly counsel women about prenatal screening for Down syndrome. Sixteen per cent of those indicated that they only offered testing to selected 'high risk' women rather than all women. Overall, there was a high level of awareness regarding the gestations at which the commonly used screening tests are offered but a poor appreciation of the relative performances of those tests. Seventy-eight (60%) of those counselling indicated that they discussed detection and screen positive rates specific for the age of the woman. However, less than 10% were able to provide those rates. CONCLUSION Knowledge of Down syndrome screening was variable among those who regularly counsel women about these tests. The results of the present survey highlight the need for professional education about prenatal screening.
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Affiliation(s)
- Katrina Tyzack
- Centre for Women's Health Research, Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
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Ultrasound screening in pregnancy: advancing technology, soft markers for fetal chromosomal aberrations, and unacknowledged ethical dilemmas. Soc Sci Med 2003; 56:2045-57. [PMID: 12697196 DOI: 10.1016/s0277-9536(02)00200-9] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Fetal ultrasound screening has become routine practice in many western countries. During the last decade, such screening has led to frequent situations characterised by clinical uncertainty due to the disclosure of soft markers in the unborn child. Soft markers are minor anatomical variations indicating a somewhat increased likelihood that the fetus has a chromosomal aberration, most frequently trisomy 21 (Down syndrome). This paper presents the results of a comprehensive literature search of the National Library of Medicine with emphasis on the chronological development of scientific knowledge in relation to soft markers and the link between advancing imaging technology and clinical counselling dilemmas. An analysis of the literature makes evident that many ultrasound examiners have counselled individual pregnant women on the basis of insufficient data. Moral dilemmas have thus emerged as a direct result of advancing medical technology, and healthy fetal lives prove to have been lost due to invasive diagnostic testing aimed at resolving clinical uncertainty. Ultrasound examiners have warned against a policy of disclosing all findings of soft markers to expectant parents, but no exploration of experiential aspects linked to the disclosure of fetal soft markers has yet been published in the medical literature. The emotional reactions of mothers are important to consider given their potential impact on the biological development of the fetus. In conclusion, this paper stresses the need for paying close attention to the crucial distinction between technology development and technology implementation in relation to prenatal testing. Furthermore, it provides strong arguments for scrutinising the interface between prenatal testing and human experience.
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O'Connor AM, Stacey D, Entwistle V, Llewellyn-Thomas H, Rovner D, Holmes-Rovner M, Tait V, Tetroe J, Fiset V, Barry M, Jones J. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2003:CD001431. [PMID: 12804407 DOI: 10.1002/14651858.cd001431] [Citation(s) in RCA: 392] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Decision aids prepare people to participate in preference-sensitive decisions. OBJECTIVES 1. Create a comprehensive inventory of patient decision aids focused on healthcare options. 2. Review randomized controlled trials (RCT) of decision aids, for people facing healthcare decisions. SEARCH STRATEGY Studies were identified through databases and contact with researchers active in the field. SELECTION CRITERIA Two independent reviewers screened abstracts for interventions designed to aid patients' decision making by providing information about treatment or screening options and their associated outcomes. Information about the decision aids was compiled in an inventory; those that had been evaluated in a RCT were reviewed in detail. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data using standardized forms. Results of RCTs were pooled using weighted mean differences (WMD) and relative risks (RR) using a random effects model. MAIN RESULTS Over 200 decision aids were identified. Of the 131 available decision aids, most are intended for use before counselling. Using the CREDIBLE criteria to evaluate the quality of the decision aids: a) most included potential harms and benefits, credentials of the developers, description of their development process, update policy, and were free of perceived conflict of interest; b) many included reference to relevant literature; c) few included a description of the level of uncertainty regarding the evidence; and d) few were evaluated. Thirty of these decision aids were evaluated in 34 RCTs and another trial evaluated a suite of eight decision aids. An additional 30 trials are yet to be published. Among the trials comparing decision aids to usual care, decision aids performed better in terms of: a) greater knowledge (WMD 19 out of 100, 95% CI: 13 to 24; b) more realistic expectations (RR 1.4, 95%CI: 1.1 to 1.9); c) lower decisional conflict related to feeling informed (WMD -9.1 of 100, 95%CI: -12 to -6); d) increased proportion of people active in decision making (RR 1.4, 95% CI: 1.0 to 2.3); and e) reduced proportion of people who remained undecided post intervention (RR 0.43, 95% CI: 0.3 to 0.7). When simpler were compared to more detailed decision aids, the relative improvement was significant in: a) knowledge (WMD 4 out of 100, 95% CI: 3 to 6); b) more realistic expectations (RR 1.5, 95% CI: 1.3 to 1.7); and c) greater agreement between values and choice. Decision aids appeared to do no better than comparisons in affecting satisfaction with decision making, anxiety, and health outcomes. Decision aids had a variable effect on which healthcare options were selected. REVIEWER'S CONCLUSIONS The availability of decision aids is expanding with many on the Internet; however few have been evaluated. Trials indicate that decision aids improve knowledge and realistic expectations; enhance active participation in decision making; lower decisional conflict; decrease the proportion of people remaining undecided, and improve agreement between values and choice. The effects on persistence with chosen therapies and cost-effectiveness require further evaluation. Finally, optimal strategies for dissemination need to be explored.
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Affiliation(s)
- A M O'Connor
- School of Nursing and Faculty of Medicine, University of Ottawa, C4 Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario, Canada, K1Y 4E9.
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Abstract
BACKGROUND As survival estimates for cystic fibrosis (CF) steadily increase long-term management has become an important focus for intervention. Psychological interventions are largely concerned with emotional and social adjustments, adherence to treatment and quality of life, however no systematic review of such interventions has been undertaken for this disease. OBJECTIVES To describe the extent and quality of effectiveness studies utilising psychological interventions for CF and whether these interventions provide significant psychosocial and physical benefits in addition to standard care. SEARCH STRATEGY Relevant trials were identified from searches of Ovid MEDLINE, the Cochrane trial registers for CF and Depression, Anxiety and Neurosis Groups and PsychINFO; unpublished trials were located through professional networks and Listserves. Most recent search: April 2003. SELECTION CRITERIA This review included RCTs and quasi-randomised trials. Study participants were children and adults diagnosed with CF, and their immediate family members. Psychological interventions were from a broad range of modalities and outcomes were primarily psychosocial, although physical outcomes and cost effectiveness were also considered. DATA COLLECTION AND ANALYSIS Two reviewers independently selected relevant trials and assessed their methodological quality. For binary and continuous outcomes a pooled estimate of treatment effect was calculated for each outcome. MAIN RESULTS This review is based on the findings of eight studies, representing data from a total of 358 participants. Studies fell into four conceptually similar groups: (1) gene pre-test education counselling for relatives of those with CF (one study); (2) biofeedback, massage and music therapy to assist physiotherapy (three studies); (3) behavioural intervention to improve dietary intake in children up to 12 years (three studies); and (4) self-administration of treatments to improve quality of life in adults (one study). Interventions were largely educational or behavioural, targeted at specific treatment concerns during the chronic phase. No completed studies concentrating on complex treatment approaches were found. There is some evidence that behavioural interventions can improve emotional outcomes in people with CF and their carers. There was no consistent effect on lung function although one small study showed that biofeedback assisted breathing re-training was associated with improvement in some measures of spirometric lung function. Insufficient evidence is available at this point for interventions aimed at other aspects of the disease process. REVIEWER'S CONCLUSIONS Multicentre approaches are required to increase the sample sizes of studies in the psychosocial field and to enhance the power and precision of the findings. This has consequent implications for funding.
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Affiliation(s)
- C A Glasscoe
- University Child Mental Health, Royal Liverpool Children's NHS Trust, 1st Floor, Mulberry House, Alder Hey Children's Hospital, Eaton Road, Liverpool, Merseyside, UK, L12 2AP
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Garcia J, Bricker L, Henderson J, Martin MA, Mugford M, Nielson J, Roberts T. Women's views of pregnancy ultrasound: a systematic review. Birth 2002; 29:225-50. [PMID: 12431263 DOI: 10.1046/j.1523-536x.2002.00198.x] [Citation(s) in RCA: 181] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Ultrasound has become a routine part of care for pregnant women in most countries with developed health services. It is one of a range of techniques used in screening and diagnosis, but it differs from most others because of the direct access that it gives parents to images of the fetus. A review of women's views of ultrasound was commissioned as part of a larger study of the clinical and economic aspects of routine antenatal ultrasound use. METHODS Studies of women's views about antenatal screening and diagnosis were searched for on electronic databases. Studies about pregnancy ultrasound were then identified from this material. Further studies were found by contacting researchers, hand searches, and following up references. The searches were not intentionally limited by date or language. Studies that reported direct data from women about pregnancy ultrasound were then included in a structured review. Studies were not excluded on the basis of methodological quality unless they were impossible to understand. They were read by one author and tabulated. The review then addressed a series of questions in a nonquantitative way. RESULTS The structured review included 74 primary studies represented by 98 reports. Studies from 18 countries were included, and they employed methods ranging from qualitative interviewing to psychometric testing. The review included studies from the very early period of ultrasound use up to reports of research on contemporary practice. Ultrasound is very attractive to women and families. Women's early concerns about the safety of ultrasound were rarely reported in more recent research. Women often lack information about the purposes for which an ultrasound scan is being done and the technical limitations of the procedure. The strong appeal of diagnostic ultrasound use may contribute to the fact that pregnant women are often unprepared for adverse findings. CONCLUSIONS Despite the highly varied study designs and contexts for the research included, this review provided useful information about women's views of pregnancy ultrasound. One key finding for clinicians was the need for all staff, women, and partners to be well informed about the specific purposes of ultrasound scans and what they can and cannot achieve.
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Affiliation(s)
- Jo Garcia
- National Perinatal Epidemiology Unit, Institute of Health Sciences, Oxford University, Headington, Oxford, United Kingdom
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