Developing a patient decision aid for the treatment of women with early stage breast cancer: the struggle between simplicity and complexity

Development and alpha testing of a patient shared decision aid for prosthesis design for new lower limb prosthesis users

BACKGROUND

After lower limb amputation, several prosthesis design options exist. However, prosthesis design decisions do not always reflect a prosthesis user's needs, values, and preferences.

OBJECTIVE

To develop a patient decision aid (PDA) prototype for prosthetists and new prosthesis users facing prosthesis design decisions after lower limb amputation, and to assess its usability, accuracy, and comprehensibility.

STUDY DESIGN

Exploratory mixed methods.

METHODS

PDA development was informed by a qualitative needs assessment and guided by the International Patient Decision Aid Standards. The PDA was evaluated by steering groups of experienced prosthesis users and prosthetic professionals (prosthetists and researchers) to test usability, accuracy, and comprehensibility through focus groups, individual interviews, and rating on a Likert scale ranging from 1 to 10.

RESULTS

The resulting PDA included 6 sections: (1) Amputation and Early Recovery, (2) Communication, (3) Values, (4) Prosthesis Design, (5) Preferences, and (6) Prosthetic Journey. Usability, accuracy, and comprehensibility were rated as 9.2, 9.6, and 9.6, respectively, by prosthetic professionals, and 9.4, 9.6, and 9.6, respectively, by prosthesis users.

DISCUSSION

The PDA incorporated guidance by relevant stakeholders and was rated favorably, emphasizing a need for shared decision-making support in prosthesis design. One challenge was determining the amount of information in the PDA, highlighting the diversity in end users' informational needs. Future iterations of the PDA should undergo beta testing in clinical settings.

CONCLUSIONS

A standardized, iterative method was used to develop a PDA for new lower limb prosthesis users and prosthetists when considering prosthesis design decisions. The PDA was considered useable, accurate, and comprehensible.

Implementing shared decision-making interventions in breast cancer clinical practice: a scoping review

BACKGROUND

Shared decision-making (SDM) is a collaborative process whereby patients and clinicians jointly deliberate on the best treatment option that takes into account patients' preferences and values. In breast cancer care, different treatment options have become available to patients in the last decade. Various interventions, including patient decision aids (PtDAs), have been designed to promote SDM in this disease area. This study aimed at investigating the factors that influence the successful adoption and implementation of SDM interventions in real-world healthcare delivery settings.

METHODS

A scoping review of scientific and grey literature was conducted for the period 2006-2021 to analyse the support for SDM interventions and their adoption in breast cancer clinical practice. The interpretation of findings was based on the Practical, Robust Implementation and Sustainability Model (PRISM) for integrating research findings into practice.

RESULTS

Overall, 19 studies were included for data synthesis, with more than 70% published since 2017. The availability of SDM tools does not automatically translate into their actual use in clinical settings. Factors related to users' co-creation, the clinical team's attitude and knowledge, organisational support and regulatory provisions facilitate the adoption of SDM interventions. However, overlooking aspects such as the re-organisation of care pathways, patient characteristics, and assigning of resources (human, financial, and facilities) can hinder implementation efforts.

CONCLUSIONS

Compared to the mounting evidence on the efficacy of SDM interventions, knowledge to support their sustained implementation in daily care is still limited, albeit results show an increasing interest in strategies that facilitate their uptake in breast cancer care over time. These findings highlight different strategies that can be used to embed SDM interventions in clinical practice. Future work should investigate which approaches are more effective in light of organisational conditions and external factors, including an evaluation of costs and healthcare system settings.

Experiences of Using Patient Decision Aids for Decisions About Cancer Treatment: A Meta-Aggregation of Qualitative Studies

BACKGROUND

Inconsistent results have been found regarding the effects of patient decision aids (PtDAs) in supporting patients' decision-making for cancer treatment.

OBJECTIVE

This qualitative meta-aggregation presents the experiences of using PtDAs, as perceived by adult patients with cancer, and highlights the components they perceived as important.

METHODS

We used the 3-phase process for meta-aggregation suggested by Joanna Briggs Institute to identify published studies with qualitative evidence from CINAHL, Ovid-MEDLINE, APA PsycINFO, and EMBASE databases. The selected studies involved adults with various cancer diagnoses. The phenomenon of interest and the context for this review were people's experiences of using PtDAs for decisions about first-line cancer treatment.

RESULTS

A total of 16 studies were included. The authors achieved consensus on 5 synthesized findings about PtDAs: (1) improved understanding of treatment options and patient values and preferences; (2) served as platforms for expressing concerns, obtaining support, and having meaningful conversations with healthcare providers; (3) facilitated active personal and family engagement in decision-making; (4) enabled recall of information and evaluation of satisfaction with decisions; and (5) presented potential structural barriers.

CONCLUSIONS

This study used qualitative evidence to demonstrate the usefulness of PtDAs and identify aspects patients with cancer find particularly beneficial.

IMPLICATIONS FOR PRACTICE

Nurses play a crucial role in supporting patients and family caregivers throughout the decision-making process for cancer treatment. Patient decision aids that balance complex treatment information with simple language and illustrations or graphs can enhance patients' comprehension. The integration of values clarification exercises into care can further improve patients' decisional outcomes.

Development of the Tool to Empower Parental Telling and Talking (TELL Tool): A digital decision aid intervention about children's origins from donated gametes or embryos

Objective

This study aimed to create and develop a well-designed, theoretically driven, evidence-based, digital, decision Tool to Empower Parental Telling and Talking (TELL Tool) prototype.

Methods

This developmental study used an inclusive, systematic, and iterative process to formulate a prototype TELL Tool: the first digital decision aid for parents who have children 1 to 16 years of age and used donated gametes or embryos to establish their families. Recommendations from the International Patient Decision Aids Standards Collaboration and from experts in decision aid development, digital health interventions, design thinking, and instructional design guided the process.

Results

The extensive developmental process incorporated researchers, clinicians, parents, children, and other stakeholders, including donor-conceived adults. We determined the scope and target audience of the decision aid and formed a steering group. During design work, we used the decision-making process model as the guiding framework for selecting content. Parents' views and decisional needs were incorporated into the prototype through empirical research and review, appraisal, and synthesis of the literature. Clinicians' perspectives and insights were also incorporated. We used the experiential learning theory to guide the delivery of the content through a digital distribution plan. Following creation of initial content, including storyboards and scripts, an early prototype was redrafted and redesigned based on feedback from the steering group. A final TELL Tool prototype was then developed for alpha testing.

Conclusions

Detailing our early developmental processes provides transparency that can benefit the donor-conceived community as well as clinicians and researchers, especially those designing digital decision aids. Future research to evaluate the efficacy of the TELL Tool is planned.

Patient Perceptions of a Decision Support Tool for Men with Localized Prostate Cancer

Purpose. To evaluate patient perceptions of a Web-based decision aid for the treatment of localized prostate cancer. Methods. We assessed patient perceptions of a multicomponent, Web-based decision aid with a preference elicitation/values clarification exercise using adaptive conjoint analysis, the generation of a summary report, and provision of information about localized prostate cancer treatment options. Using a think-aloud approach, we conducted 21 cognitive interviews with prostate cancer patients presented with the decision aid prior to seeing their urologist. Thematic content analysis was used to examine patient perceptions of the tool's components and content prior to engaging in shared decision making with their clinician. Results. Five themes were identified: 1) patients had some negative emotional reactions to the tool, pointing out what they perceived to be unnecessarily negative framing and language used; 2) patients were forced to stop and think about preferences while going through the tool and found this deliberation to be useful; 3) patients were confused by the tool; 4) patients tried to discern the intent of the conjoint analysis questions; and 5) there was a disconnect between patients' negative reactions while using the tool and a contrasting general satisfaction with the final "values profile" created by the tool. Conclusions. Studies are needed to explore the disconnect between patients' expressing negative reactions while going through some components of decision aids but satisfaction with the final output. In particular, we hypothesize that this effect might be explained by cognitive biases such as choice-supportive bias, hindsight bias, and the "IKEA effect." This is one of the first projects to elicit patient reactions while they were completing a decision aid, and we recommend further similar, qualitative postprocess evaluation studies.

Highlights

We explored perceptions of a decision aid with education about localized prostate cancer treatment and preference elicitation using adaptive conjoint analysis.Patients found the tool useful but were also confused by it, tried to discern the intent of the questions, and expressed negative emotional reactions.In particular, there was a disconnect between patients' negative reactions while using the tool and general satisfaction with the final values profile generated by the tool, which is an area for future research.

Endocrine therapy initiation and overall survival outcomes with omission of radiation therapy in older Medicare patients with early‐stage hormone‐receptor‐positive breast cancer

BACKGROUND

Guidelines allow for the omission of radiotherapy in older women with early-stage, hormone-receptor-positive breast cancer, given that the patients receive adequate endocrine therapy (ET). However, the initiation of ET and survival outcomes after forgoing radiation therapy among these patients have not been well-studied.

METHODS

We identified patients aged 70 to 90 years old newly diagnosed in 2010-2015 with early-stage, hormone receptor positive, and human epidermal growth factor receptor 2 (HER2) negative (HR+/Her2-) breast cancer who received lumpectomy and omitted radiation therapy using the SEER-Medicare database. We examined the initiation of ET and the utilization patterns of ET using a multivariable logistic regression. We further examined the overall survival outcomes using Kaplan-Meier estimation and Cox proportional hazard model with inverse probability weighting.

RESULTS

Of the 2618 patients, 808 (30.9%) received no ET. The multivariable logistic regression showed that more recent years had better ET initiation (2013-2015 vs. 2010-2012: OR = 1.39, 95% CI:[1.16, 1.66]), while older patients (81-90 vs. 70-80: OR = 0.45, 95% CI:[0.38, 0.54]) were less likely to receive ET. Both the Kaplan-Meier estimation (log-rank p-value<0.0001) and the Cox proportional hazard model with inverse probability weighting (HR = 0.76, 95% CI:[0.58, 0.99]) showed that receiving ET was associated with better overall survival.

CONCLUSION

This population-based study suggests that a sizable proportion of patients who omitted radiation did not receive endocrine therapy and receiving endocrine therapy was beneficial among these patients. Although ET initiation has improved in more recent years, certain patient groups were still especially susceptible to no endocrine therapy.

Alpha Test of the Donor Conception Tool to Empower Parental Telling and Talking

OBJECTIVE

To conduct an alpha test of the prototype of a digital decision aid to help parents disclose donor conception to their children, the Donor Conception Tool to Empower Parental Telling and Talking (TELL Tool).

DESIGN

Convergent mixed-methods design.

SETTING

Virtual interviews in places convenient to the participants.

PARTICIPANTS

A purposeful sample (N = 16) of nine gamete-donor and embryo-recipient parents and eight clinicians, as one parent was also a clinician.

METHODS

We conducted cognitive interviews to explore participants' perceptions about the TELL Tool prototype and observe patterns of use. The International Patient Decision Aid Standards (i.e., usability, comprehensibility, and acceptability) guided the development of the qualitative interview guide and directed the qualitative analysis. We also collected data about participants' perceptions and ratings of the helpfulness of each of the prototype's webpages regarding parents' decision making about disclosure. Descriptive statistics were used to analyze the helpfulness ratings before we merged the two data sets to optimize understanding.

RESULTS

Participants reported that the TELL Tool was a helpful digital decision aid to help parents tell their children how they were conceived. Most (93.7%) webpage rating scores indicated that the content was very helpful or helpful. The participants identified content and technical areas that needed refinement and provided specific recommendations such as adding concise instructions (usability), tailoring adolescent language (comprehensibility), and softening verbiage (acceptability).

CONCLUSION

Alpha testing guided by the International Patient Decision Aid standards was an essential step in refining and improving the TELL Tool prototype before beta testing.

Development of a patient decision aid for patients with breast cancer who consider immediate breast reconstruction after mastectomy

Purpose

The aim of this study was to develop a patient decision aid (pDA) that could support patients with breast cancer (BC) in making an informed decision about breast reconstruction (BR) after mastectomy.

Methods

The development included four stages: (i) Establishment of a multidisciplinary team; (ii) Needs assessment consisting of semi‐structured interviews in patients and a survey among healthcare professionals (HCPs); (iii) Creation of content, design and technical system; and (iv) Acceptability and usability testing using a think‐aloud approach in patients and interviews among HCPs and representatives of the Dutch Breast Cancer Patient Organization.

Results

From the needs assessment, three themes were identified: Challenging period to make a decision, Diverse motivations for a personal decision and Information needed to make a decision about BR. HCPs valued the development of a pDA, especially to prepare patients for consultation. The pDA that was developed contained three parts: first, a consultation sheet for oncological breast surgeons to introduce the choice; second, an online tool including an overview of reconstructive options, the pros and cons of each option, information on the consequences of each option for daily life, exercises to clarify personal values and patient stories; and third, a summary sheet with patients’ values, preferences and questions to help inform and guide the discussion between the patient and her plastic surgeon. The pDA was perceived to be informative, helpful and easy to use by patients and HCPs.

Conclusion

Consistent with information needs, a pDA was developed to support patients with BC who consider immediate BR in making an informed decision together with their plastic surgeon.

Patient or Public Contribution

Patients participated in the needs assessment and in acceptability and usability testing.

Encounter decision aids to facilitate shared decision-making with women experiencing heavy menstrual bleeding or symptomatic uterine fibroids: A before-after study

OBJECTIVE

Is the level of shared decision-making (SDM) higher after introduction of a SDM package (including encounter decision aids on treatment options for heavy menstrual bleeding and training for clinicians) than before?.

METHODS

This before-after study, performed in OB-GYN practice, compared consultations before and after introduction of a SDM package. The target sample size was 25 patients per group. Women seeking treatment for heavy menstrual bleeding were eligible. After their appointments, patients filled out a three-item patient-reported SDM measure. Treatment discussions were audio-recorded and rated for SDM using Observer OPTION⁵. Consultation transcripts in the 'after' group were checked for adherence to the steps required for intended use of decision aids.

RESULTS

16 gynaecologists participated. 25 patients participated before introduction of the decision aids and 28 after. The proportion of women reporting optimal SDM was higher after introduction (75 %) than before (50 %;p < 0.001). The mean observer-rated level of SDM was also significantly higher after than before (MD = 12.50,95 % CI 5.53-19.47).

CONCLUSION

The level of SDM was higher after the introduction of the package than before.

PRACTICE IMPLICATIONS

This study was conducted in a real-life setting in three clinics, both large academic and small rural, offering opportunities for implementation in different type of organizations.

Systematic Development of Patient Decision Aids: An Update from the IPDAS Collaboration

BACKGROUND

The 2013 update of the evidence informing the quality dimensions behind the International Patient Decision Aid Standards (IPDAS) offered a model process for developers of patient decision aids.

OBJECTIVE

To summarize and update the evidence used to inform the systematic development of patient decision aids from the IPDAS Collaboration.

METHODS

To provide further details about design and development methods, we summarized findings from a subgroup (n = 283 patient decision aid projects) in a recent systematic review of user involvement by Vaisson et al. Using a new measure of user-centeredness (UCD-11), we then rated the degree of user-centeredness reported in 66 articles describing patient decision aid development and citing the 2013 IPDAS update on systematic development. We contacted the 66 articles' authors to request their self-reports of UCD-11 items.

RESULTS

The 283 development processes varied substantially from minimal iteration cycles to more complex processes, with multiple iterations, needs assessments, and extensive involvement of end users. We summarized minimal, medium, and maximal processes from the data. Authors of 54 of 66 articles (82%) provided self-reported UCD-11 ratings. Self-reported scores were significantly higher than reviewer ratings (reviewers: mean [SD] = 6.45 [3.10]; authors: mean [SD] = 9.62 [1.16], P < 0.001).

CONCLUSIONS

Decision aid developers have embraced principles of user-centered design in the development of patient decision aids while also underreporting aspects of user involvement in publications about their tools. Templates may reduce the need for extensive development, and new approaches for rapid development of aids have been proposed when a more detailed approach is not feasible. We provide empirically derived benchmark processes and a reporting checklist to support developers in more fully describing their development processes.[Box: see text].

The Next Step Toward Patient-Centeredness in Multidisciplinary Cancer Team Meetings: An Interview Study with Professionals

Background

Patient-centeredness is essential in complex oncological multidisciplinary team decision-making. Improvement seems to be needed, while there is a lack of knowledge about health care providers’ needs for improvement.

Objective

To explore multidisciplinary team members’ perspectives on the need to improve patient-centeredness in complex decision-making, and subsequently the strategies to enhance it.

Methods

This was a qualitative descriptive interview study. The participants were twenty-four professionals who attended multidisciplinary cancer team meetings weekly. The setting was five multidisciplinary teams (gastrointestinal, gynecological, urological, head and neck, and hematological cancer) in a Dutch academic hospital. Data were collected by semi-structured interviews and were analyzed with a combination of inductive and deductive content analysis.

Results

The participants voiced the need for additional information (patient-centered information, patients’s needs and preferences, individualized medical information) during the multidisciplinary team meeting, to be more patient-centered in the decision-making conversation with the patient following the meeting, and for more information following the meeting to support patient-centeredness. The strategies, which mostly originated from the needs, were categorized as organization, decision-making, and communication. The most prominent strategies were those aimed at collecting and using patient-centered information, and to facilitate the decision-making conversation with the patient following the multidisciplinary team meeting.

Conclusion

Our findings highlighted the need to improve patient-centeredness in oncological multidisciplinary teams and provided a comprehensive overview of strategies for improvement, supported by multidisciplinary team members. These strategies emphasize involvement of patients throughout the continuous process of decision-making for patients with cancer. These strategies may be implemented in other oncological multidisciplinary teams, taking in mind the local needs. Future research may help to prioritize the strategies and to determine and evaluate the effect on endpoints, like patient or professional satisfaction, shared decision-making, and on the decision that was made.

Research progress in decision-making aids for breast cancer patients

Decision-making aid for cancer patients is of great significance in the diagnosis and treatment for diseases. Breast cancer is one of the most common malignant tumors in women all over the world, and breast cancer patients have become the main target population for decision-aided research. Application of decision-making assistance for patients in Western countries has developed to a certain extent, while relevant research in China is still at the early stage. There are kinds of intervention forms for patients' decision aids, including traditional brochures and videos, decision aids systems, decision coaching, multidisciplinary breast cancer teams, etc. The tools for decision-making quality evaluation include the patients' awareness for decision-making, participation, decision-making conflict, decision-making satisfaction, decision-making regret, which can provide important guidance for the application of decision-making aid treatment in breast cancer patients in the future.

Implementing a breast cancer patient decision aid: Process evaluation using medical files and the patients' perspective

Objective

Although patient decision aids (PtDAs) have been shown to improve shared decision‐making, integration into clinical care pathways remains limited. This study investigated, among other outcomes, the uptake of the PtDA by professionals and the uptake as perceived by patients.

Methods

We performed a process evaluation among four breast cancer care teams that had been exposed to a multifaceted implementation strategy. Data were gathered by auditing patient files using a standardised data extraction sheet and conducting telephone interviews with patients using a structured interview guide. We analysed the data by using descriptive statistics.

Results

We found that the implementation strategies, including advice on how and when to present the PtDA to the patient, were followed for 14% of the included patients (N = 84); 92% of the patients reported to have received a login code for the web‐based PtDA, while 67% logged in and used the PtDA at home. An important factor influencing the use was the clinician promoting it when delivering the PtDA (OR 9.95 95% CI 3.03–37.72).

Discussion

The implementation strategies were followed in 14% of the patients, and a high delivery of the PtDA was achieved. Redesigning the care pathway and providing personal instruction on using PtDAs seem crucial.

Elicitation of preferences in the second half of the shared decision making process needs attention; a qualitative study

BACKGROUND

It is known that the use of a Patient Decision Aid (PtDA), combined with advice for professionals on how and when to use it, can enhance the involvement of patients in the treatment decision. However, we need more knowledge with respect to the intention-behaviour gap. This study aims to analyse patients' experiences with the Shared Decision Making (SDM) process to find clues to close this gap.

METHODS

This qualitative study was part of a pilot study aiming to implement SDM in early adopter breast cancer teams. Patients were given access to a personalised PtDA. Breast cancer teams were instructed on how and when to deliver the PtDA. We interviewed 20 patients about their experience with the PtDA and SDM in general.

RESULTS

Most patients experienced SDM, though to a certain extent. Choice talk and option talk were commonly experienced, however the elicitation of preferences and decision talk was rare. The PtDA was used by the majority of patients (N = 13), all indicating that it was useful, especially to recall all the information given. Patients appreciated the contribution of breast cancer nurses in the SDM process. They considered them as true case managers, easy to approach and supportive.

CONCLUSION

Although patients felt well-informed and satisfied about risk-communication, the elicitation of preferences appeared very limited to non-existent. We recommend that breast cancer teams divide tasks in the SDM process and reallocate the elicitation of preferences to the nurses in a well-defined clinical pathway.

What matters to me - a web-based preference elicitation tool for clients in long-term care: a user-centred design

Background

During the process of decision-making for long-term care, clients are often dependent on informal support and available information about quality ratings of care services. However, clients do not take ratings into account when considering preferred care, and need assistance to understand their preferences. A tool to elicit preferences for long-term care could be beneficial. Therefore, the aim of this qualitative descriptive study is to understand the user requirements and develop a web-based preference elicitation tool for clients in need of long-term care.

Methods

We applied a user-centred design in which end-users influence the development of the tool. The included end-users were clients, relatives, and healthcare professionals. Data collection took place between November 2017 and March 2018 by means of meetings with the development team consisting of four users, walkthrough interviews with 21 individual users, video-audio recordings, field notes, and observations during the use of the tool. Data were collected during three phases of iteration: Look and feel, Navigation, and Content. A deductive and inductive content analysis approach was used for data analysis.

Results

The layout was considered accessible and easy during the Look and feel phase, and users asked for neutral images. Users found navigation easy, and expressed the need for concise and shorter text blocks. Users reached consensus about the categories of preferences, wished to adjust the content with propositions about well-being, and discussed linguistic difficulties.

Conclusion

By incorporating the requirements of end-users, the user-centred design proved to be useful in progressing from the prototype to the finalized tool ‘What matters to me’. This tool may assist the elicitation of client’s preferences in their search for long-term care.

The Dutch chaos case: A scoping review of knowledge and decision support tools available to clinicians in the Netherlands

BACKGROUND

To keep clinicians up-to-date with the latest evidence, clinical practice and patient preferences, more and more knowledge tools - aiming to synthesise knowledge and support (shared) decision-making - are being developed. Unfortunately, it seems that in the Netherlands, and possibly elsewhere, the amount of different knowledge tool types makes it difficult to see the forest through the trees.

METHODS

A scoping review, exploring types of knowledge tools available to Dutch clinicians (and patients) and how these tools are described. The search terms were collected from thesauri and textbooks, and used to search the websites and documents of selected national tool developing organisations.

RESULTS

The review yielded 126 tool types. We included 67 different tool types, such as guidelines, protocols, standards and clinical pathways. Half of those tool types were aimed at clinicians, 14 at patients and 18 at both. In general, descriptions of the tool types were hard to find or incomplete.

CONCLUSIONS

There exists a myriad of knowledge tool types and their descriptions are mostly unclear. The information overload experienced by clinicians is not addressed effectively by developing numerous unclearly defined knowledge tools. We recommend limiting the number of tool types and making a greater effort in clearly defining them. This abundance of poorly defined tools does not seem to be restricted to the Netherlands.

Development and pilot-testing of a colorectal cancer screening decision aid for individuals with varying health literacy levels

OBJECTIVE

Making an informed decision about colorectal cancer screening requires health literacy. Our aim was to develop and pilot-test a computer-based decision aid to support informed decision making about whether or not to participate in colorectal cancer screening for individuals with varying health literacy levels in the Netherlands.

METHODS

First, we designed and adapted the decision aid prototype among 25 individuals with low (n = 15) and adequate (n = 10) health literacy. Second, we used a before/after study to assess changes in knowledge, attitude, intention, decisional conflict, deliberation, anxiety and risk perception in an online survey among 81 individuals eligible for colorectal cancer screening with low (n = 35) and adequate (n = 46) health literacy.

RESULTS

The decision aid was acceptable, comprehensible, reduced decisional conflict, increased deliberation and improved knowledge about colorectal cancer screening, but not about colorectal cancer, among individuals with adequate and low health literacy. Usability was slightly higher for participants with adequate health literacy compared to those with low health literacy.

CONCLUSION

The decision aid is promising in supporting informed decision making about colorectal cancer screening, also among individuals with lower health literacy.

PRACTICE IMPLICATIONS

Further refinement of interactive features, such as videos, animations and the values clarification exercise, is needed to increase the usability of the decision aid.

Future Directions for Geriatric Anesthesiology

"With a rapidly aging world population, it is critical for physicians of every specialty to adapt the ways they provide medical and perioperative care to patients. Older adults represent the largest population of health care users, and they have very different needs and preferences compared with their younger counterparts. In this article, the authors discuss some of the current gaps in geriatric anesthesia and perioperative care, as they elaborate on what can be expected in the near future at different levels of the health care system: the patient, the environment, and the anesthesia specialty."

Reducing complexity of patient decision aids for community-based older adults with dementia and their caregivers: multiple case study of Decision Boxes

OBJECTIVES

To identify patient decision aids' features to limit their complexity for older adults with dementia and their family caregivers.

DESIGN

Mixed method, multiple case study within a user-centred design (UCD) approach.

SETTING

Community-based healthcare in the province of Quebec in Canada.

PARTICIPANTS

23 older persons (aged 65+ years) with dementia and their 27 family caregivers.

RESULTS

During three UCD evaluation-modification rounds, participants identified strengths and weaknesses of the patient decision aids' content and visual design that influenced their complexity. Weaknesses of content included a lack of understanding of the decision aids' purpose and target audience, missing information, irrelevant content and issues with terminology and sentence structure. Weaknesses of visual design included critics about the decision aids' general layout (density, length, navigation) and their lack of pictures. In response, the design team implemented a series of practical features and design strategies, comprising: a clear expression of the patient decision aids' purpose through simple text, picture and personal stories; systematic and frequent use of pictograms illustrating key points and helping structure patient decision aids' general layout; a glossary; removal of scientific references from the main document; personal stories to clarify more difficult concepts; a contact section to facilitate implementation of the selected option; GRADE ratings to convey the quality of the evidence; a values clarification exercise formatted as a checklist and presented at the beginning of the document to streamline navigation; involvement of a panel of patient/caregiver partners to guide expression of patient priorities; editing of the text to a sixth grade reading level; UCD process to optimise comprehensiveness and relevance of content and training of patients/caregivers in shared decision-making.

CONCLUSIONS

The revised template for patient decision aids is designed to meet the needs of adults living with dementia and their caregivers better, which may translate into fewer evaluation-modification rounds.

An evaluation of oncofertility decision support resources among breast cancer patients and health care providers

BACKGROUND

Cancer patients of reproductive age are at risk of infertility as a result of their treatment. Oncofertility decision support resources can assist patients with fertility decision-making before treatment yet available oncofertility resources contain varying levels of detail and different fertility options. The key information/sections needed in oncofertility resources remain unclear. To explore the information needs for oncofertility decision-making before cancer treatment, we aimed to evaluate existing oncofertility decision support resources with breast cancer patients and providers.

METHODS

We conducted 30 to 90-min interviews that included a survey questionnaire and open-ended questions with patients and providers between March and June 2016. Interviews were transcribed verbatim. Analysis involved descriptive statistics for survey responses and thematic analysis of qualitative data.

RESULTS

A total of 16 participants completed interviews. Key information perceived by most participants as necessary for fertility decision-making included tailored post-treatment pregnancy rates, cost ranges and financial assistance for the fertility options based on patients' situation. However, patient and provider participants expressed differing opinions on the inclusion of all before and after treatment fertility options and the amount of fertility information required at diagnosis.

CONCLUSION

The evaluation identified fertility information needs among patients in addition to providers' views on patient needs. While existing oncofertility resources contain information perceived as necessary for decision-making there is an opportunity to use these findings to create or enhance resources to better meet the needs of patients. Additionally, patients and providers differing views on information needs highlight the opportunity for provider training to ensure better communication using resources in clinic to understand specific patient needs.

Feasibility and Efficacy of Decision Aids to Improve Decision Making for Postmastectomy Breast Reconstruction: A Systematic Review and Meta-analysis

Background. The decision-making process for women considering breast reconstruction following mastectomy is complex. Research suggests that fewer than half of women undergoing mastectomy have adequate knowledge and make treatment decisions that are concordant with their underlying values. This systematic review assesses the feasibility and efficacy of preoperative decision aids (DAs) to improve the patient decision-making process for breast reconstruction. Methods. A systematic review was performed using PubMed, Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Databases published prior to January 4, 2018. Studies that assessed the impact of a DA on patient decision making for breast reconstruction were identified. The effect of preoperative DAs on decisional conflict in randomized controlled trials (RCTs) was measured with inverse variance-weighted mean differences (mean difference [MD] ± 95% confidence interval [CI]). Results. Among 1299 unique articles identified, 1197 were excluded after reviewing titles and abstracts against selection criteria. Among the 17 studies included in this review, 11 assessed the efficacy of DAs for breast reconstruction and 6 additional studies described the development and usability of these DAs. Studies suggest that DAs reduce patient-reported decisional conflict (MD, –4.55 [95% CI, –8.65 to –0.45], P = 0.03 in the fixed-effects model and MD, –4.70 [95% CI, –10.75 to 1.34], P = 0.13 in the random-effects model). Preoperative DAs also improved patient satisfaction with information and perceived involvement in the decision-making process. Conclusions. The existing literature suggests that DAs reduce decisional conflict, improve self-reported satisfaction with information, and improve perceived involvement in the decision-making process for women considering breast reconstruction.