The effect of physician's explanations on patients' treatment preferences: five-year survival data

Decision aids for people facing health treatment or screening decisions

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Decision aids for people facing health treatment or screening decisions

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Transforming Patient-Centered Care: Development of the Evidence Informed Decision Making through Engagement Model

BACKGROUND

In response to the passage of the Affordable Care Act in the United States, clinicians and researchers are critically evaluating methods to engage patients in implementing evidence-based care to improve health outcomes. However, most models on implementation only target clinicians or health systems as the adopters of evidence. Patients are largely ignored in these models. A new implementation model that captures the complex but important role of patients in the uptake of evidence may be a critical missing link.

DISCUSSION

Through a process of theory evaluation and development, we explore patient-centered concepts (patient activation and shared decision making) within an implementation model by mapping qualitative data from an elective induction of labor study to assess the model's ability to capture these key concepts. The process demonstrated that a new, patient-centered model for implementation is needed. In response, the Evidence Informed Decision Making through Engagement Model is presented. We conclude that, by fully integrating women into an implementation model, outcomes that are important to both the clinician and patient will improve.

CONCLUSIONS

In the interest of providing evidence-based care to women during pregnancy and childbirth, it is essential that care is patient centered. The inclusion of concepts discussed in this article has the potential to extend beyond maternity care and influence other clinical areas. Utilizing the newly developed Evidence Informed Decision Making through Engagement Model provides a framework for utilizing evidence and translating it into practice while acknowledging the important role that women have in the process.

The role of patients' expectation of appropriate initial manual therapy treatment in outcomes for patients with low back pain

OBJECTIVES

The purpose of this study was to compare the outcomes of patients with low back pain who had a matched, unmatched, or were indifferent with their pretreatment expectation/preference to the manual therapy thrust or nonthrust intervention. A secondary purpose was to explore baseline patient characteristics affiliated with a preference of manual therapy treatment type (thrust or nonthrust manipulation).

METHODS

The study is a secondary analysis of a prospective randomized controlled trial that enrolled 149 patients with low back pain, from 16 distinct outpatient physical therapy practices within the United States. Patient's pretreatment expectations were identified before randomization. The intervention included manual therapy (thrust or nonthrust manipulation) with a standardized exercise program, which was carried out for 2 treatment sessions. Six outcomes captured the constructs of (a) disability, (b) pain perception, (c) care intensity, (d) fear avoidance behaviors, and (e) perception of extent of recovery. Descriptive statistics, analysis of variance (and Tukey, a post hoc test), Fisher exact test, and a multivariate logistic regression analysis were used for analysis.

RESULTS

There were no statistical differences in any of the 6 dedicated outcomes measures between the matched, unmatched, and no preference groups. Therapist-determined patient "irritability" was associated with patient preference of nonthrust treatment, and higher body mass index was associated with patient preference of thrust treatment.

CONCLUSIONS

This study shows that patients demonstrated no statistical difference in disability or pain outcome measures when matched, unmatched, or indifferent to the intervention.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Methods for Performing Survival Curve Quality-of-Life Assessments

BACKGROUND

Many medical decisions involve an implied choice between alternative survival curves, typically with differing quality of life. Common preference assessment methods neglect this structure, creating some risk of distortions.

METHODS

Survival curve quality-of-life assessments (SQLA) were developed from Gompertz survival curves fitting the general population's survival. An algorithm was developed to generate relative discount rate-utility (DRU) functions from a standard survival curve and health state and an equally attractive alternative curve and state. A least means squared distance algorithm was developed to describe how nearly 3 or more DRU functions intersect. These techniques were implemented in a program called X-Trade and tested.

RESULTS

SQLA scenarios can portray realistic treatment choices. A side effect scenario portrays one prototypical choice, to extend life while experiencing some loss, such as an amputation. A risky treatment scenario portrays procedures with an initial mortality risk. A time trade scenario mimics conventional time tradeoffs. Each SQLA scenario yields DRU functions with distinctive shapes, such as sigmoid curves or vertical lines. One SQLA can imply a discount rate or utility if the other value is known and both values are temporally stable. Two SQLA exercises imply a unique discount rate and utility if the inferred DRU functions intersect. Three or more SQLA results can quantify uncertainty or inconsistency in discount rate and utility estimates. Pilot studies suggested that many subjects could learn to interpret survival curves and do SQLA.

LIMITATIONS

SQLA confuse some people. Compared with SQLA, standard gambles quantify very low utilities more easily, and time tradeoffs are simpler for high utilities. When discount rates approach zero, time tradeoffs are as informative and easier to do than SQLA.

CONCLUSIONS

SQLA may complement conventional utility assessment methods.

The average lifespan of patients discharged from hospital with heart failure

BACKGROUND

There are no life-tables quantifying the average life-spans of post-hospitalized heart failure populations across various strata of risk.

OBJECTIVE

To quantify the life-expectancies (i.e., average life-spans) of heart failure patients at the time of hospital discharge according to age, gender, predictive 30-day mortality heart failure risk index, and comorbidity burden.

DESIGN

Population-based retrospective cohort study.

SETTING

Ontario, Canada.

PATIENTS

7,865 heart failure patients discharged from Ontario hospitals between 1999 and 2000.

MEASUREMENTS

Data were obtained from the Enhanced Feedback for Effective Cardiac Treatment EFFECT provincial quality improvement initiative. All patients were linked to administrative data, and tracked longitudinally until March 31, 2010. Detailed clinical variables were obtained from medical chart abstraction, and death data were obtained from vital statistics. Average life-spans were calculated using Cox Proportion Hazards models in conjunction with the Declining Exponential Approximation of Life Expectancy (D.E.A.L.E) method to extrapolate life-expectancy, adjusting for age, gender, predicted 30-day mortality, left ventricular function and comorbidity, and was reported according to key prognostic risk-strata.

RESULTS

The average life-span of the cohort was 5.5 years (STD +/- 10.0) ranging from 19.5 years for low-risk women of less than 50 years old to 2.9 years for high-risk octogenarian males. Average life-spans were lower by 0.13 years among patients with impaired as compared with preserved left ventricular function, and by approximately one year among patients with three or more as compared with no concomitant comorbidities. In total, 17.4 % and 27 % of patients had died within 6 months and 1 year respectively, despite having predicted life-spans exceeding one-year.

LIMITATIONS

Data regarding changes in patient clinical status over time were unavailable.

CONCLUSIONS

The development of risk-adjusted life-tables for heart failure populations is feasible and mirrored those with advanced malignant diseases. Average life span varied widely across clinical risk strata, and may be less accurate among those at or near their end of life.

Simple and multistate survival curves: can people learn to use them?

OBJECTIVE AND SAMPLE: This investigation assessed the comprehension of survival curves in a community sample of 88 young and middle-aged adults when several aspects of good practice for graphical communication were implemented, and it compared comprehension for alternative presentation formats. DESIGN, METHOD, and

MEASUREMENTS

After reading worked examples of using survival curves that provided explanation and answers, participants answered questions on survival data for pairs of treatments. Study 1 compared presenting survival curves for both treatments on the same figure against presentation via 2 separate figures. Study 2 compared presenting data for 3 possible outcome states via a single "multistate" figure for each treatment against presenting each outcome on a separate figure (with both treatments on the same figure). Both studies compared alternative forms of questioning (e.g., "number alive" versus "number dead"). Numeracy levels (self-rated and objective measures) were also assessed.

RESULTS

Comprehension was generally good--exceeding 90% correct answers on half the questions--and was similar across alternative graphical formats. Lower accuracy was observed for questions requiring a calculation but was significantly lower only when the requirement for calculation was not explicit (13%-28% decrements in performance). In study 1, this effect was most acute for those with lower levels of numeracy. Subjective (self-rated) numeracy and objective (measured) numeracy were both moderate positive predictors of overall task accuracy (r ≈ 0.3).

CONCLUSIONS

A high degree of accuracy in extracting information from survival curves is possible, as long as any calculations that are required are made explicit (e.g., finding differences between 2 survival rates). Therefore, practitioners need not avoid using survival curves in discussions with patients, although clear and explicit explanations are important.

Decision aids for people facing health treatment or screening decisions

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.

Validation of a Predictive Model for Survival in Patients With Advanced Cancer: Secondary Analysis of RTOG 9714

Background

The objective of this study was to validate a simple predictive model for survival of patients with advanced cancer.

Methods

Previous studies with training and validation datasets developed a model predicting survival of patients referred for palliative radiotherapy using three readily available factors: primary cancer site, site of metastases and Karnofsky performance score (KPS). This predictive model was used in the current study, where each factor was assigned a value proportional to its prognostic weight and the sum of the weighted scores for each patient was survival prediction score (SPS). Patients were also classified according to their number of risk factors (NRF). Three risk groups were established. The Radiation Therapy and Oncology Group (RTOG) 9714 data was used to provide an additional external validation set comprised of patients treated among multiple institutions with appropriate statistical tests.

Results

The RTOG external validation set comprised of 908 patients treated at 66 different radiation facilities from 1998 to 2002. The SPS method classified all patients into the low-risk group. Based on the NRF, two distinct risk groups with significantly different survival estimates were identified. The ability to predict survival was similar to that of the training and previous validation datasets for both the SPS and NRF methods.

Conclusions

The three variable NRF model is preferred because of its relative simplicity.

What influences patients' decisions on artificial hydration at the end of life? A Q-methodology study

CONTEXT

Artificial hydration (AH) is used to palliate patients with reduced fluid intake at the end of life but is a controversial practice. Patients' involvement in decision making varies, and little is known about patients' understanding of the benefits and burdens of AH.

OBJECTIVES

To identify the factors that patients consider most important when making decisions regarding AH at the end of life.

METHODS

Interview study using Q-sort methodology conducted with 20 patients with advanced diseases recruited from inpatient and outpatient palliative care services.

RESULTS

Several domains appear to influence a decision about AH: the patient's understanding of AH, their philosophical position on end-of-life care, the process of discussion, and who makes the final decision. Patients generally based their decision on whether AH would improve quality of life, although prolonging life was important for some. Hydration was not considered a burden, and many would want a trial of AH in the event that they could no longer drink. Patients wanted to be guided by medical opinion, although some wanted to make the decision on their own. All patients welcomed the opportunity to discuss AH.

CONCLUSION

Patients view AH as an important issue and are keen to be involved in decision making. Health care professionals may withhold AH at the end of life because they perceive it as a burden on patients and on their interactions with family, although this view is not shared by patients. Some patients lack understanding regarding the likely benefits of AH. Research examining the impact of clinical information regarding AH on patients' decision making is now needed.

Using alternative statistical formats for presenting risks and risk reductions

BACKGROUND

The success of evidence-based practice depends on the clear and effective communication of statistical information.

OBJECTIVES

To evaluate the effects of using alternative statistical presentations of the same risks and risk reductions on understanding, perception, persuasiveness and behaviour of health professionals, policy makers, and consumers.

SEARCH STRATEGY

We searched Ovid MEDLINE (1966 to October 2007), EMBASE (1980 to October 2007), PsycLIT (1887 to October 2007), and the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2007, Issue 3). We reviewed the reference lists of relevant articles, and contacted experts in the field.

SELECTION CRITERIA

We included randomized and non-randomized controlled parallel and cross-over studies. We focused on four comparisons: a comparison of statistical presentations of a risk (eg frequencies versus probabilities) and three comparisons of statistical presentation of risk reduction: relative risk reduction (RRR) versus absolute risk reduction (ARR), RRR versus number needed to treat (NNT), and ARR versus NNT.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies for inclusion, extracted data, and assessed risk of bias. We contacted investigators to obtain missing information. We graded the quality of evidence for each outcome using the GRADE approach. We standardized the outcome effects using adjusted standardized mean difference (SMD).

MAIN RESULTS

We included 35 studies reporting 83 comparisons. None of the studies involved policy makers. Participants (health professionals and consumers) understood natural frequencies better than probabilities (SMD 0.69 (95% confidence interval (CI) 0.45 to 0.93)). Compared with ARR, RRR had little or no difference in understanding (SMD 0.02 (95% CI -0.39 to 0.43)) but was perceived to be larger (SMD 0.41 (95% CI 0.03 to 0.79)) and more persuasive (SMD 0.66 (95% CI 0.51 to 0.81)). Compared with NNT, RRR was better understood (SMD 0.73 (95% CI 0.43 to 1.04)), was perceived to be larger (SMD 1.15 (95% CI 0.80 to 1.50)) and was more persuasive (SMD 0.65 (95% CI 0.51 to 0.80)). Compared with NNT, ARR was better understood (SMD 0.42 (95% CI 0.12 to 0.71)), was perceived to be larger (SMD 0.79 (95% CI 0.43 to 1.15)).There was little or no difference for persuasiveness (SMD 0.05 (95% CI -0.04 to 0.15)). The sensitivity analyses including only high quality comparisons showed consistent results for persuasiveness for all three comparisons. Overall there were no differences between health professionals and consumers. The overall quality of evidence was rated down to moderate because of the use of surrogate outcomes and/or heterogeneity. None of the comparisons assessed behaviourbehaviour.

AUTHORS' CONCLUSIONS

Natural frequencies are probably better understood than probabilities. Relative risk reduction (RRR), compared with absolute risk reduction (ARR) and number needed to treat (NNT), may be perceived to be larger and is more likely to be persuasive. However, it is uncertain whether presenting RRR is likely to help people make decisions most consistent with their own values and, in fact, it could lead to misinterpretation. More research is needed to further explore this question.

Decision aids for people facing health treatment or screening decisions

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.

Discharge against medical advice: ethical considerations and professional obligations

Discharges against medical advice (AMA) account for approximately 1% of discharges for general medical patients. Patients discharged AMA have longer eventual hospital stays and worse health outcomes. These patients are also less likely to have an established relationship with a physician, tend to have poorer social supports, and are more likely to abuse alcohol and other substances. These discharges are also distressing for physicians and other health professionals. How should physicians manage their conflicted obligations to respect patients' choices and to prevent harms from befalling their patients? What are physicians' obligations to their patients who leave accepting only partial or inadequate treatment plans or no treatment at all? When should physicians question the decision-making capacity of patients who make dangerous judgments to leave the hospital? This article examines the ethical and professional implications of discharge AMA.

Discussing life expectancy with surgical patients: do patients want to know and how should this information be delivered?

BACKGROUND

Predicted patient life expectancy (LE) and survival probability (SP), based on a patient's medical history, are important components of surgical decision-making and informed consent. The objective of this study was to assess patients' interpretation of and desire to know information relating to LE, in addition to establishing the most effective format for discussion.

METHODS

A cross sectional survey of 120 patients (mean age = 68.7 years, range 50-90 years), recruited from general urological and surgical outpatient clinics in one District General and one Teaching hospital in Southwest England (UK) was conducted. Patients were included irrespective of their current diagnosis or associated comorbidity. Hypothetical patient case scenarios were used to assess patients' desire to know LE and SP, in addition to their preferred presentation format.

RESULTS

58% of patients expressed a desire to know their LE and SP, if it were possible to calculate, with 36% not wishing to know either. Patients preferred a combination of numerical and pictorial formats in discussing LE and SP, with numerical, verbal and pictorial formats alone least preferred. 71% patients ranked the survival curve as either their first or second most preferred graph, with 76% rating facial figures their least preferred. No statistically significant difference was noted between sexes or educational backgrounds.

CONCLUSION

A proportion of patients seem unwilling to discuss their LE and SP. This may relate to their current diagnosis, level of associated comorbidity or degree of understanding. However it is feasible that by providing this information in a range of presentation formats, greater engagement in the shared decision-making process can be encouraged.

Healthcare organizations, linguistic communities, and the emblematic model of palliative care

The linguistic-communicative paradigm offers some interesting perspectives in a context where the perception of patient needs is considered a critical step in high-quality care. This study describes healthcare organizations as linguistic communities based on the conceptual framework of Habermas' communicative action theory. Four communicative models are present in healthcare settings: objectifying-instrumental (hegemonic model), where elements of interaction are objectified for clinical purposes; dialogic model with strategic perspectives, in which conversations are used unilaterally as tools to access subjective states; non-dialogic-transmissional model, in which linguistic exchanges are replaced with artifacts to transmit information; and full communicative model (present in palliative care based in homecare and informal caregivers, emphasizing health team/family interactions). Based on these premises, we considered palliative care an emblematic communicative model based on multidisciplinary teams devoted to transdisciplinary collaboration. In these settings, linguistic interaction with patients and their families could provide a solid basis for organization of healthcare networks.

Numeric, verbal, and visual formats of conveying health risks: suggested best practices and future recommendations

Perception of health risk can affect medical decisions and health behavior change. Yet the concept of risk is a difficult one for the public to grasp. Whether perceptions of risk affect decisions and behaviors often relies on how messages of risk magnitudes (i.e., likelihood) are conveyed. Based on expert opinion, this article offers, when possible, best practices for conveying magnitude of health risks using numeric, verbal, and visual formats. This expert opinion is based on existing empirical evidence, review of papers and books, and consultations with experts in risk communication. This article also discusses formats to use pertaining to unique risk communication challenges (e.g., conveying small-probability events, interactions). Several recommendations are suggested for enhancing precision in perception of risk by presenting risk magnitudes numerically and visually. Overall, there are little data to suggest best practices for verbal communication of risk magnitudes. Across the 3 formats, few overall recommendations could be suggested because of 1) lack of consistency in testing formats using the same outcomes in the domain of interest, 2) lack of critical tests using randomized controlled studies pitting formats against one another, and 3) lack of theoretical progress detailing and testing mechanisms why one format should be more efficacious in a specific context to affect risk magnitudes than others. Areas of future research are provided that it is hoped will help illuminate future best practices.

Validation of the Subjective Numeracy Scale: effects of low numeracy on comprehension of risk communications and utility elicitations

BACKGROUND

In a companion article, the authors describe the Subjective Numeracy Scale (SNS), a self-assessment of numerical aptitude and preferences for numbers that correlates strongly with objective numeracy.

OBJECTIVE

The objective of this article is to validate the Subjective Numeracy Scale using measures of subjects' capacity to recall and comprehend complex risk statistics and to complete utility elicitations.

RESEARCH DESIGN

The study is composed of 3 general public surveys: 2 administered via the Web and 1 by paper and pencil. Subjects. Studies 1 and 3 surveyed 862 and 1234 people, respectively, recruited via a nationwide commercial Internet survey panel. Study 2 involved 245 people who completed paper-and-pencil surveys in a Veterans Administration hospital.

MEASURES

The authors tested whether one's score on the SNS predicted the likelihood of correct recall and interpretation of risk information (studies 1 and 2A) or the likelihood of effectively completing a time tradeoff or person-tradeoff utility elicitation (studies 2B and 3). In Studies 1 and 2, the authors also tested whether an objective test of quantitative ability would predict performance.

RESULTS

In all studies, survey participants with higher SNS scores performed significantly better than other respondents. The predictive ability of the SNS approached that observed for objective numeracy.

CONCLUSIONS

The SNS effectively predicts both risk comprehension and completion of utility elicitations without requiring survey participants to complete time-consuming and stress-inducing mathematics tests. The authors encourage the use of the SNS in a variety of health services research contexts.

Mortality versus survival graphs: improving temporal consistency in perceptions of treatment effectiveness

OBJECTIVE

Previous research has demonstrated that people perceive treatments as less effective when survival graphs show fewer years of data versus more data. We tested whether using mortality graphs would reduce this temporal inconsistency bias.

METHODS

A demographically diverse sample of 1461 Internet users read about a hypothetical disease and then were randomized to view either survival or mortality graphs that showed either 5 years of data or 15 years of treatment outcomes data. Participants identified the most effective treatment, provided ratings comparing the effectiveness of two treatments, and answered comprehension questions.

RESULTS

Treatment effectiveness ratings varied significantly between respondents seeing the 5 year and 15 year survival graphs even though the relative risk reduction was the same in both cases. This variation was significantly reduced in the mortality graph conditions. Responses on comprehension measures were mixed: viewers of mortality graphs were less able to identify which treatment was more effective but better able to correctly report individual data points.

CONCLUSIONS

Perceptions of treatment effectiveness appear more temporally consistent with mortality graphs than with survival graphs.

PRACTICE IMPLICATIONS

All line-based risk graphics (whether framed in survival or mortality terms) should highlight duration information to facilitate improved comprehension of treatment effectiveness.

Design features of graphs in health risk communication: a systematic review

This review describes recent experimental and focus group research on graphics as a method of communication about quantitative health risks. Some of the studies discussed in this review assessed effect of graphs on quantitative reasoning, others assessed effects on behavior or behavioral intentions, and still others assessed viewers' likes and dislikes. Graphical features that improve the accuracy of quantitative reasoning appear to differ from the features most likely to alter behavior or intentions. For example, graphs that make part-to-whole relationships available visually may help people attend to the relationship between the numerator (the number of people affected by a hazard) and the denominator (the entire population at risk), whereas graphs that show only the numerator appear to inflate the perceived risk and may induce risk-averse behavior. Viewers often preferred design features such as visual simplicity and familiarity that were not associated with accurate quantitative judgments. Communicators should not assume that all graphics are more intuitive than text; many of the studies found that patients' interpretations of the graphics were dependent upon expertise or instruction. Potentially useful directions for continuing research include interactions with educational level and numeracy and successful ways to communicate uncertainty about risk.

What's time got to do with it? Inattention to duration in interpretation of survival graphs

Reports of randomized clinical trials often use survival curves to summarize clinical outcomes over time and graphically demonstrate evidence of treatment effectiveness. Survival curves can also be used in patient communications to display how health risks accumulate over time. In a randomized survey experiment, administered online, we tested whether people viewing survival curves appropriately adjust their risk perceptions to account for the duration shown. Internet users (N= 864) were recruited from a demographically balanced U.S. panel. Participants read about a hypothetical disease and then viewed one of four survival graphs that displayed mortality risks with and without treatment. Survival graphs showed either a visually large or visually small difference between treatments and were labeled to represent either 5-year or 15-year risk statistics. Participants then provided ratings of disease seriousness, as well as treatment effectiveness for each possible treatment. Variations in ratings corresponded more with visual dissimilarity than with changes in the statistical risk exhibited, with participants perceiving somewhat greater disease seriousness and significant differences in treatment effectiveness in large visual difference graphs. We conclude that when people interpret survival curves, they often fail to sufficiently account for the timeframe represented and perceive more risk and larger differences when identical risks are displayed over longer periods of time. We recommend that all presentations of survival graphics, whether to patients, physicians, or scientists, emphasize duration information (e.g., in the title) and remind readers that attending to graph axis labels is the only way to pierce these visual illusions.

[Communication prostheses and behavioral alignment in hospital leaflets]

Review was made of publications that describe experience with printed material distributed to the lay public in hospital institutions. From the 146 leaflets examined, those aimed at professionals or disabled people, thus leaving 75 papers that illustrate the present pattern for the rationality behind the production, use and evaluation of this type of resource. In a general manner, such leaflets invest in the power of "ideal printed information" to align behavior with the hospital's biomedical agenda. The underlying rationality that permeates them perceives the "perfect information package" as one that efficiently describes its technical content for the purpose of unidirectional persuasion, is up-to-date in relation to readability scales and embellished by graphic design, and emphasizes the priorities defined by the professionals. Such "communication prostheses" should be capable of electronic validation by means of software suitable for proportioning the "doses" to the subject matter. Information as a drug, cognitivism, the lack of research on message reception and the need for communicative action for the deconstruction of systems of closed thinking within the hospital environment have been discussed.

Patients' autonomy in surgical care: a comparison of nurses' perceptions in five European countries

BACKGROUND

This report forms part of the results of an international comparative study funded by the European Commission (1998-2001).

AIM

To describe and compare the maintenance of patients' autonomy on surgical wards, from the point of view of nursing staff, in five European countries (Finland, Spain, Greece, Germany and Scotland). Autonomy is defined in terms of information received and decision making by patients.

METHOD

The data were collected using a questionnaire specifically designed for use in this study. Responses (response rate 66%) were obtained from 1280 nurses working on surgical wards. Data analysis was based on descriptive statistics, t-tests, analysis of variance (ANOVA) with posthoc Tukey's HSD test and logistic regression.

RESULTS

There were clear between-country differences in nurses' perceptions, especially on a north-south axis (Finland and Scotland vs. Greece and Spain), regarding the extent to which the autonomy of surgical patients is supported by nursing staff. Training and ethics education, in particular, were associated with nurses' perceptions of the maintenance of patient autonomy in Finland and Greece.

CONCLUSION

Further research is needed to establish whether the results obtained are caused by differences in cultures, nursing practices or roles of health-care personnel or patients in different European countries.

Patient and physician factors predict patients' comprehension of health information

While patients frequently do not comprehend health information, little is known about patient and physician factors that influence lack of comprehension. To assess effectiveness of health information exchange, 19 physicians and 145 patients were given post-encounter questionnaires to evaluate the preceding visit. We analyzed differences in beliefs between patients who comprehended health information and patients who did not, and whether physicians' attitudes and self-assessment of their educational abilities influenced this comprehension. Patients with insufficient comprehension were more likely to have schooling below college and cited language as a barrier. Physicians who believed health information delivery to be important had fewer patients with comprehension difficulties, while physicians who assessed themselves as very effective educators had significantly more patients with lack of comprehension, compared with physicians who did not feel as effective. Patients' comprehension of health information was associated not only with patient factors but also with physicians' attitude and self-assessment.

Decision aids for people facing health treatment or screening decisions

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.

Helping patients with localized prostate carcinoma manage uncertainty and treatment side effects: nurse-delivered psychoeducational intervention over the telephone

BACKGROUND

The objective of this study was to test the efficacy of an individualized uncertainty management intervention delivered by telephone to Caucasian and African-American men with localized prostate carcinoma and directed at managing the uncertainties of their disease and treatment.

METHODS

The authors delivered a psychoeducational intervention by phone to men with prostate carcinoma, with or without supplemented delivery to a close family member, that was directed at managing uncertainty and improving symptom control. One hundred thirty-four Caucasian men and 105 African-American men were assigned randomly to one of two approaches to delivering the intervention or to the control condition. Men entered the study immediately after surgical treatment or in the first 3 weeks of radiation therapy. Trained nurses delivered the intervention through weekly phone calls for 8 weeks.

RESULTS

The authors found that the majority of intervention effects were from baseline to 4 months postbaseline, when treatment side effects are most intense. Both Caucasian men and African-American men who received either one of the two approaches for delivering the intervention improved in the two uncertainty management methods of cognitive reframing and problem solving. Similarly, when the intervention groups were combined, men who received the intervention also improved significantly in control of incontinence by 4 months postbaseline. Decreases in the number of treatment side effects differed by time and treatment/ ethnic group interactions as did satisfaction with sexual functioning.

CONCLUSIONS

This is one of the first tests of a psychoeducational intervention among men with prostate carcinoma and was the first test that included a sufficient number of African-American men to test by ethnic group. Therefore, replication of these findings is advised.

Effect of framing as gain versus loss on understanding and hypothetical treatment choices: survival and mortality curves

BACKGROUND

Presentation of information using survival or mortality (i.e., incidence) curves offers a potentially powerful method of communication because such curves provide information about risk over time in a relatively simple graphic format. However, the effect of framing as survival versus mortality on understanding and treatment choice is not known.

METHODS

In this study, 451 individuals awaiting jury duty at the Philadelphia City Courthouse were randomized to receive 1 of 3 questionnaires: (1) survival curves, (2) mortality curves, or (3) both survival and mortality curves. Each questionnaire included a brief description of a hypothetical treatment decision, survival curve graphs and/or mortality curve graphs presenting the outcome of the treatment, and questions measuring understanding of the information contained in the graphs and preference for undergoing treatment. After completing a brief practice exercise, participants were asked to answer questions assessing their ability to interpret single points on a curve and the difference between curves, and then to decide whether they would choose to undergo preventive surgery for 3 different scenarios in which the benefit of surgery varied.

RESULTS

Participants who received only survival curves or who received both survival and mortality curves were significantly more accurate in answering questions about the information than participants who received only mortality curves (P < 0.05). For 2 of the 3 treatment presentations, participants who received only mortality curves were significantly less likely to prefer preventive surgery than participants who received survival curves only or both survival and mortality curves (P < 0.05). The effect of framing on understanding was greatest among participants with less than a college education and among non-Caucasian participants.

CONCLUSION

Framing graphic risk information as chance of death over time results in lower levels of understanding and less interest in preventive surgery than framing as chance of survival over time.

Understanding patient preferences for the treatment of lupus nephritis with adaptive conjoint analysis

BACKGROUND

Incorporation of patient preferences into treatment decisions is an essential component of medical care. Conjoint analysis is an established method of eliciting consumer preferences in market research and is being increasingly used to study patient preferences for health care.

OBJECTIVE

To examine the value of Adaptive Conjoint Analysis (ACA), a unique method of performing conjoint analysis, and to evaluate patient treatment preferences.

RESEARCH DESIGN

Interactive computer survey.

SUBJECTS

Consecutive women (n = 103) with lupus followed in three community rheumatology practices.

MEASURES

ACA was used to assess patients' relative preferences for specific cytotoxic medication characteristics, and to estimate the percentage of women preferring cyclophosphamide over azathioprine for different risk-benefit scenarios.

RESULTS

All participants were able to complete the conjoint task in 14 +/-5 minutes. Of the nine medication characteristics studied, efficacy and risk for infection had the greatest impact on preference (each accounting for 20% of the variation in preferences), suggesting that patients consider differences in the risk for infection equally as important as differences in the probability of renal survival. Premenopausal women wanting more children were less likely to choose cyclophosphamide compared with their counterparts (56% vs. 80%, P = 0.04). Modest changes in the probability of renal survival or risk for major toxicity lowered the percentage of women preferring cyclophosphamide by more than 20%, irrespective of their desire for more children.

CONCLUSIONS

ACA is a feasible method of assessing how patients consider specific medication characteristics and predicting treatment preferences under different risk-benefit scenarios. ACA may be a valuable tool to incorporate patient preferences into medical decision-making.

Patient decision-making behavior: an emerging paradigm for nursing science

BACKGROUND

As healthcare technology and medical therapies proliferate, healthcare providers have more options to offer and patients have more options from which to choose. Active patient participation in healthcare decision making is a relatively new phenomenon that has been born of sociocultural, ethical, and legal influences. Patients, however, often find healthcare decisions bewildering, stressful, and anxiety-provoking.

OBJECTIVES

The purpose of this review is to provide a framework for those interested in pursuing patient decision-making investigations and suggest ways in which current knowledge can be extended to develop a scientific platform upon which to build decision support interventions.

METHOD

Literature review.

DISCUSSION

This review (a) provides a context for understanding patient decision making; (b) explicates the state of the science of patient decision making; (c) identifies significant theoretical, methodological, and measurement issues; and, (d) identifies gaps in patient decision-making knowledge and propose areas for further investigation.

Using survival curve comparisons to inform patient decision making can a practice exercise improve understanding?

BACKGROUND

Patients often face medical decisions that involve outcomes that occur and change over time. Survival curves are a promising communication tool for patient decision support because they present information about the probability of an outcome over time in a simple graphic format. However, previous studies of survival curves did not measure comprehension, used face-to-face explanations, and focused on a VA population.

METHODS

In this study, 246 individuals awaiting jury duty at the Philadelphia County Courthouse were randomized to receive one of two questionnaires. The control group received a questionnaire describing two hypothetical treatments and a graph with two survival curves showing the outcomes of each treatment. The practice group received the same questionnaire preceded by a practice exercise asking questions about a graph containing a single curve. Subjects' ability to interpret survival from a curve and ability to calculate change in survival over time were measured.

RESULTS

Understanding of survival at a single point in time from a graph containing two survival curves was high overall, and was improved by the use of a single curve practice exercise. With a practice exercise, subjects were over 80% accurate in interpreting survival at a single point in time. Understanding of changes in survival over time was lower overall, and was not improved by the use of a practice exercise. With or without a practice exercise, subjects were only 55% accurate in calculating changes in survival.

CONCLUSION

The majority of the general public can interpret survival at a point in time from self-administered survival curves. This understanding is improved by a single curve practice exercise. However, a significant proportion of the general public cannot calculate change in survival over time. Further research is necessary to determine the effectiveness of survival curves in improving risk communication and patient decision making.

A physician's guide to talking about end-of-life care

A large majority of patients and close family members are interested in discussing end-of-life issues with their physician. Most expect their physician to initiate such dialogue. End-of-life discussions, however, must go beyond the narrow focus of resuscitation. Instead, such discussions should address the broad array of concerns shared by most dying patients and families: fears about dying, understanding prognosis, achieving important end-of-life goals, and attending to physical needs. Good communication can facilitate the development of a comprehensive treatment plan that is medically sound and concordant with the patient's wishes and values. This paper presents a practical 4-step approach to conducting end-of-life discussions with patients and their families: (1) Initiating Discussion, (2) Clarifying Prognosis, (3) Identifying End-of-Life Goals, and (4) Developing a Treatment Plan. By following these 4 steps, communication can be enhanced, fears allayed, pain and suffering minimized, and most end-of-life issues resolved comfortably, without conflict.

What influences a patient's desire to participate in the management of their hypertension?

There are potential benefits to giving the patient a more active role in the management of his or her care. This study explored the characteristics which influence a preference for participation and the extent to which hypertensive patients wish to participate in the management of their condition. A cross-sectional study with in-depth, face-to-face interviews was conducted with 49 hypertensive patients from one health centre. Interview themes were identified using content analysis. Characteristics predictive of participation desire were detected via quantitative analyses. Half of those interviewed were interested in participating in hypertension management. Those who had been hypertensive longer were less inclined to favour participation. Those with negative views of their 'disease' status and with higher blood pressure were more likely to want to participate. Patients needed further information and advice before decisions about future level of participation could be properly considered.

How should effectiveness of risk communication to aid patients' decisions be judged? A review of the literature

Risk-communication interventions are associated with benefits at both the individual and the public health level. However, the types of outcomes used to assess the effectiveness of risk-communication interventions vary greatly. This makes synthesis of the research in systematic review difficult, and limits both the implementation of advances in clinical practice and further research. This article reviews the outcomes used in risk-communication publications, particularly those addressing individual decisions about treatment. From the traditional cognitive and behavioral research outcomes of patient knowledge, risk perception, and compliance, the emphasis has shifted towards more affective outcomes, including satisfaction, assessment of the information provided and the decision-making process, and certainty about whether the best option has been chosen. These affective outcomes may be more specific and sensitive measures for risk-communication research. Further development and validation of measurement scales to address these issues is needed.

Evidence-informed patient choice. Practical issues of involving patients in decisions about health care technologies

Evidence-informed patient choice involves providing people with research-based information about the effectiveness of health care options and promoting their involvement in decisions about their treatment. Although the concept seems desirable, the processes and outcomes of evidence-informed patient choice are poorly understood, and it should be carefully evaluated.

Treatment decisions in palliative cancer care: patients' preferences for involvement and doctors' knowledge about it

The aim of this study was to evaluate the extent to which hospitalised patients with advanced cancer and a palliative treatment goal wanted to be involved in the process of making treatment decisions and how well their physicians actually knew their preferences for participation. 59 hospitalised patients with non-curable cancer, 86 hospitalised patients with chronic non-neoplastic disease, and 115 non-hospitalised persons were surveyed with a standardised questionnaire. In addition, the physicians of the hospitalised patients were asked to complete a similar questionnaire. The majority of patients with advanced cancer wanted to decide either by themselves/mainly by themselves (9%) or to collaborate and decide together with their physician (73%), compared with 17% and 49%, respectively, of patients with chronic non-neoplastic disease, and 40% and 56%, respectively, of the non-hospitalised persons (difference between groups: P = 0.001). Younger age, higher education, employment and higher Karnofsky index were significantly associated with active involvement. The agreement of patients' preference with their physicians' assessment did not exceed chance. In conclusion, most patients wanted to participate in a decision regarding their treatment, although physicians were unaware of their patients' preferences.

The doctor's role in discussing advance preferences for end-of-life care: perceptions of physicians practicing in the VA

OBJECTIVES

Although previous studies have shown physicians support advance directives, little is known about how they actually participate in decision-making. This study investigate (1) how much experience physicians have had discussing and following advance preferences and (2) how physicians perceive their role in the advance decision-making process.

DESIGN

Mail survey conducted in 1993.

SETTING

The Department of Veterans Affairs.

PARTICIPANTS

A national probability sample of 1050 VA internists, family physicians, and generalists.

MEASUREMENTS AND MAIN RESULTS

Questionnaires were returned by 67% of participants. In the last year, 79% stated they had discussed advance preference with at least one patient, and 19% had talked to more than 25. Seventy-three percent had used a written directive to make decisions for at least one incompetent patient. Younger age, board certification, spending less time in the outpatient setting, and personal experience with advance decision-making, were all associated independently with having advance preference discussions. Among physicians who had discussions, 59% said they often initiated the discussion, 55% said discussions often occurred in inpatient settings, and 31% said discussions often occurred in outpatient settings. Eighty-two percent of those responding thought physicians should be responsible for initiating discussions. Most would try to persuade a patient to change a decision that was not well informed (91%), not medically reasonable (88%), or not in the patient's best interest (88%); few would attempt to change decisions that conflicted with their own moral beliefs (14%).

CONCLUSIONS

Physicians report that they are actively involved with their patients in making decisions about end-of-life care. Most say they have had recent discussions with at least some of their patients and feel that as physicians they should play a large and important role in soliciting and shaping patient preferences.

Patients' prerogatives and perceptions of benefit

Patients today demand more information about their treatment. Doctors, however, seem reluctant to cast aside ingrained habits of paternalism, believing they can best interpret therapeutic choices for their patients. Whether doctors can be more objective and effective than patients in interpreting the "probabilities" of medical evidence is open to question. On the other hand, the exercise of choice by patients may itself have a bearing on the probabilities of outcome. Involving patients more in making therapeutic choices is justified if doctors can present options in an unbiased and effective manner and if the process improves the outcome of the care delivered.