Standards for UNiversal reporting of patient Decision Aid Evaluation studies: the development of SUNDAE Checklist

BACKGROUND

Patient decision aids (PDAs) are evidence-based tools designed to help patients make specific and deliberated choices among healthcare options. The International Patient Decision Aid Standards (IPDAS) Collaboration review papers and Cochrane systematic review of PDAs have found significant gaps in the reporting of evaluations of PDAs, including poor or limited reporting of PDA content, development methods and delivery. This study sought to develop and reach consensus on reporting guidelines to improve the quality of publications evaluating PDAs.

METHODS

An international workgroup, consisting of members from IPDAS Collaboration, followed established methods to develop reporting guidelines for PDA evaluation studies. This paper describes the results from three completed phases: (1) planning, (2) drafting and (3) consensus, which included a modified, two-stage, online international Delphi process. The work was conducted over 2 years with bimonthly conference calls and three in-person meetings. The workgroup used input from these phases to produce a final set of recommended items in the form of a checklist.

RESULTS

The SUNDAE Checklist (Standards for UNiversal reporting of patient Decision Aid Evaluations) includes 26 items recommended for studies reporting evaluations of PDAs. In the two-stage Delphi process, 117/143 (82%) experts from 14 countries completed round 1 and 96/117 (82%) completed round 2. Respondents reached a high level of consensus on the importance of the items and indicated strong willingness to use the items when reporting PDA studies.

CONCLUSION

The SUNDAE Checklist will help ensure that reports of PDA evaluation studies are understandable, transparent and of high quality. A separate Explanation and Elaboration publication provides additional details to support use of the checklist.

Twelve Lessons Learned for Effective Research Partnerships Between Patients, Caregivers, Clinicians, Academic Researchers, and Other Stakeholders

Research increasingly means that patients, caregivers, health professionals, other stakeholders, and academic investigators work in partnership. This requires effective collaboration rooted in mutual respect, involvement of all participants, and good communication. Having conducted such partnered research over multiple projects, and having recently completed a project together funded by the Patient-Centered Outcomes Research Institute, we collaboratively developed a list of 12 lessons we have learned about how to ensure effective research partnerships. To foster a culture of mutual respect, hold early in-person meetings, with introductions focused on motivation, offer appropriate orientation for everyone, and maintain awareness of individual and project goals. To actively involve all team members, it is important to ensure sufficient funding for everyone's participation, to ask for and recognize diverse contributions, and to seek the input of quiet members. To facilitate good communication, teams should carefully consider labels, avoid jargon and acronyms, judiciously use homogeneous and heterogeneous subgroups, and keep progress visible. In offering pragmatic, actionable lessons we have learned through our separate and shared experiences, we hope to help foster more patient-centered research via productive and enjoyable research collaborations.

Involving members of vulnerable populations in the development of patient decision aids: a mixed methods sequential explanatory study

Background

Patient decision aids aim to present evidence relevant to a health decision in understandable ways to support patients through the process of making evidence-informed, values-congruent health decisions. It is recommended that, when developing these tools, teams involve people who may ultimately use them. However, there is little empirical evidence about how best to undertake this involvement, particularly for specific populations of users such as vulnerable populations.

Methods

To describe and compare the development practices of research teams that did and did not specifically involve members of vulnerable populations in the development of patient decision aids, we conducted a secondary analysis of data from a systematic review about the development processes of patient decision aids. Then, to further explain our quantitative results, we conducted semi-structured telephone interviews with 10 teams: 6 that had specifically involved members of vulnerable populations and 4 that had not. Two independent analysts thematically coded transcribed interviews.

Results

Out of a total of 187 decision aid development projects, 30 (16%) specifically involved members of vulnerable populations. The specific involvement of members of vulnerable populations in the development process was associated with conducting informal needs assessment activities (73% vs. 40%, OR 2.96, 95% CI 1.18–7.99, P = .02) and recruiting participants through community-based organizations (40% vs. 11%, OR 3.48, 95% CI 1.23–9.83, P = .02). In interviews, all developers highlighted the importance, value and challenges of involving potential users. Interviews with developers whose projects had involved members of vulnerable populations suggested that informal needs assessment activities served to center the decision aid around users’ needs, to better avoid stigma, and to ensure that the topic truly matters to the community. Partnering with community-based organizations may facilitate relationships of trust and may also provide a non-threatening and accessible location for research activities.

Conclusions

There are a small number of key differences in the development processes for patient decision aids in which members of vulnerable populations were or were not specifically involved. Some of these practices may require additional time or resources. To address health inequities, researchers, communities and funders may need to increase awareness of these approaches and plan accordingly.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0399-8) contains supplementary material, which is available to authorized users.

Knowledge and values for cancer screening decisions: Results from a national survey

BACKGROUND

Guidelines recommend shared decision making (SDM) for cancer screening decisions. SDM requires providers to ensure that patients are informed about screening issues and to support decisions that are concordant with patient values. We evaluated decision-quality factors for breast, colorectal, and prostate cancer screening decisions.

METHODS

We conducted a national, population-based Internet survey of adults aged 40+ to characterize perceptions about about cancer screening, the importance of information sources, cancer screening knowledge, values and preferences for screening, and the most influential drivers of decisions.

RESULTS

Among 1452 participants who completed the survey, the mean age was 60, and 94% were insured. Most participants reported feeling well informed about cancer screening, though only 21% reported feeling extremely well informed. Most participants correctly answered about 50% of the knowledge questions, with the majority markedly overestimating lifetime risk of cancer diagnoses and mortality. Participants rated health care providers as the most important source of information.

CONCLUSION

Although respondents considered themselves well informed about cancer they performed poorly on knowledge questions. This discordance suggests the potential for poor-quality decision making.

PRACTICE IMPLICATIONS

To improve the quality of decision making, providers need training to utilize decision support tools and time to carry out SDM.

Decisions about medication use and cancer screening across age groups in the United States

OBJECTIVE

To describe decision process and quality for common cancer screening and medication decisions by age group.

METHODS

We included 2941 respondents to a national Internet survey who made at least one decision about colorectal, breast, and prostate cancer screening, blood pressure or cholesterol medications. Respondents were queried about decision processes.

RESULTS

Across the five decisions considered, decision process scores were similar (and generally low) across age groups for medication and cancer screening, indicating that all groups had poor involvement in medical decision making. Overall knowledge scores were low across age groups, with elderly (75+) having slightly higher knowledge about medications vs. younger respondents. Elderly respondents reported similar goals and concerns when making decisions, though placed greater importance of having peace of mind from a normal result for cancer screening vs. younger respondents.

CONCLUSION

Across age groups, respondents reported poor decision processes about common medications and cancer screening, despite little evidence of benefit for some interventions (cancer screening, cholesterol lowering medicines in low risk elderly) and possibility of harm in the elderly.

PRACTICE IMPLICATIONS

Particular care should be taken to help patients understand both benefit and risk of screening tests and routine medications.

Development and evaluation of a new survey instrument to measure the quality of colorectal cancer screening decisions

Background

Guidelines for colorectal cancer screening recommend that patients be informed about options and be able to select preferred method of screening; however, there are no existing measures available to assess whether this happens.

Methods

Colorectal Cancer Screening Decision Quality Instrument (CRC-DQI) includes knowledge items and patients' goals and concerns. Items were generated through literature review and qualitative work with patients and providers. Hypotheses relating to the acceptability, feasibility, discriminant validity and retest reliability of the survey were examined using data from three studies: (1) 2X2 randomized study of participants recruited online, (2) cross-sectional sample of patients recruited in community health clinics, and (3) cross-sectional sample of providers recruited from American Medical Association Master file.

Results

338 participants were recruited online, 94 participants were recruited from community health centers, and 115 physicians were recruited. The CRC-DQI was feasible and acceptable with low missing data and high response rates for both online and paper-based administrations. The knowledge score was able to discriminate between those who had seen a decision aid or not (84% vs. 64%, p < 0.001) and between providers, online patients and clinic patients (89% vs. 74% vs. 41%, p < 0.001 for all comparisons). The knowledge score and most of the goals had adequate retest reliability. About half of the participants received a test that matched their goals (47% and 51% in online and clinic samples respectively). Many respondents who had never been screened had goals that indicated a preference for colonoscopy. A minority of respondents in the online (21%) and in clinic (2%) samples were both well informed and received a test that matched their goals.

Conclusions

The CRC-DQI demonstrated good psychometric properties in diverse samples, and across different modes of administration. Few respondents made high quality decisions about colon cancer screening.

Clarifying values: an updated review

BACKGROUND

Consensus guidelines have recommended that decision aids include a process for helping patients clarify their values. We sought to examine the theoretical and empirical evidence related to the use of values clarification methods in patient decision aids.

METHODS

Building on the International Patient Decision Aid Standards (IPDAS) Collaboration's 2005 review of values clarification methods in decision aids, we convened a multi-disciplinary expert group to examine key definitions, decision-making process theories, and empirical evidence about the effects of values clarification methods in decision aids. To summarize the current state of theory and evidence about the role of values clarification methods in decision aids, we undertook a process of evidence review and summary.

RESULTS

Values clarification methods (VCMs) are best defined as methods to help patients think about the desirability of options or attributes of options within a specific decision context, in order to identify which option he/she prefers. Several decision making process theories were identified that can inform the design of values clarification methods, but no single "best" practice for how such methods should be constructed was determined. Our evidence review found that existing VCMs were used for a variety of different decisions, rarely referenced underlying theory for their design, but generally were well described in regard to their development process. Listing the pros and cons of a decision was the most common method used. The 13 trials that compared decision support with or without VCMs reached mixed results: some found that VCMs improved some decision-making processes, while others found no effect.

CONCLUSIONS

Values clarification methods may improve decision-making processes and potentially more distal outcomes. However, the small number of evaluations of VCMs and, where evaluations exist, the heterogeneity in outcome measures makes it difficult to determine their overall effectiveness or the specific characteristics that increase effectiveness.

Measuring decision quality: psychometric evaluation of a new instrument for breast cancer surgery

BACKGROUND

The purpose of this paper is to examine the acceptability, feasibility, reliability and validity of a new decision quality instrument that assesses the extent to which patients are informed and receive treatments that match their goals.

METHODS

Cross-sectional mail survey of recent breast cancer survivors, providers and healthy controls and a retest survey of survivors. The decision quality instrument includes knowledge questions and a set of goals, and results in two scores: a breast cancer surgery knowledge score and a concordance score, which reflects the percentage of patients who received treatments that match their goals. Hypotheses related to acceptability, feasibility, discriminant validity, content validity, predictive validity and retest reliability of the survey instrument were examined.

RESULTS

We had responses from 440 eligible patients, 88 providers and 35 healthy controls. The decision quality instrument was feasible to implement in this study, with low missing data. The knowledge score had good retest reliability (intraclass correlation coefficient=0.70) and discriminated between providers and patients (mean difference 35%, p<0.001). The majority of providers felt that the knowledge items covered content that was essential for the decision. Five of the 6 treatment goals met targets for content validity. The five goals had moderate to strong retest reliability (0.64 to 0.87). The concordance score was 89%, indicating that a majority had treatments concordant with that predicted by their goals. Patients who had concordant treatment had similar levels of confidence and regret as those who did not.

CONCLUSIONS

The decision quality instrument met the criteria of feasibility, reliability, discriminant and content validity in this sample. Additional research to examine performance of the instrument in prospective studies and more diverse populations is needed.

The role of perceived benefits and costs in patients' medical decisions

BACKGROUND

Many decisions can be understood in terms of actors' valuations of benefits and costs. The article investigates whether this is also true of patient medical decision making. It aims to investigate (i) the importance patients attach to various reasons for and against nine medical decisions; (ii) how well the importance attached to benefits and costs predicts action or inaction; and (iii) how such valuations are related to decision confidence.

METHODS

In a national random digit dial telephone survey of U.S. adults, patients rated the importance of various reasons for and against medical decisions they had made or talked to a health-care provider about during the past 2 years. Participants were 2575 English-speaking adults age 40 and older. Data were analysed by means of logistic regressions predicting action/inaction and linear regressions predicting confidence.

RESULTS

Aggregating individual reasons into those that may be regarded as benefits and those that may be regarded as costs, and weighting them by their importance to the patient, shows the expected relationship to action. Perceived benefits and costs are also significantly related to the confidence patients report about their decision.

CONCLUSION

The factors patients say are important in their medical decisions reflect a subjective weighing of benefits and costs and predict action/inaction although they do not necessarily indicate that patients are well informed. The greater the difference between the importance attached to benefits and costs, the greater patients' confidence in their decision.

Informing and involving patients to improve the quality of medical decisions

Good-quality care requires that procedures, treatments, and tests be not only medically appropriate, but also desired by informed patients. Current evidence shows that most medical decisions are made by physicians with little input from patients. This article describes issues surrounding informed patient decision making and the steps necessary to improve the way decisions are made. Creating incentives for providers and health care organizations to inform patients and incorporate patients' goals into decisions is critical. Patient surveys are needed to monitor the quality of decision making. Health information technology can help by collecting information from patients about their symptoms, how well they understand their options, and what is important to them, and sharing that information with providers. We review public and private developments that could facilitate the development of tools and methods to improve patient-centered care.

Decision quality instrument for treatment of hip and knee osteoarthritis: a psychometric evaluation

BACKGROUND

A high quality decision requires that patients who meet clinical criteria for surgery are informed about the options (including non-surgical alternatives) and receive treatments that match their goals. The aim of this study was to evaluate the psychometric properties and clinical sensibility of a patient self report instrument, to measure the quality of decisions about total joint replacement for knee or hip osteoarthritis.

METHODS

The performance of the Hip/Knee Osteoarthritis Decision Quality Instrument (HK-DQI) was evaluated in two samples: (1) a cross-sectional mail survey with 489 patients and 77 providers (study 1); and (2) a randomized controlled trial of a patient decision aid with 138 osteoarthritis patients considering total joint replacement (study 2). The HK-DQI results in two scores. Knowledge items are summed to create a total knowledge score, and a set of goals and concerns are used in a logistic regression model to develop a concordance score. The concordance score measures the proportion of patients whose treatment matched their goals. Hypotheses related to acceptability, feasibility, reliability and validity of the knowledge and concordance scores were examined.

RESULTS

In study 1, the HK-DQI was completed by 382 patients (79%) and 45 providers (58%), and in study 2 by 127 patients (92%), with low rates of missing data. The DQI-knowledge score was reproducible (ICC = 0.81) and demonstrated discriminant validity (68% decision aid vs. 54% control, and 78% providers vs. 61% patients) and content validity. The concordance score demonstrated predictive validity, as patients whose treatments were concordant with their goals had more confidence and less regret with their decision compared to those who did not.

CONCLUSIONS

The HK-DQI is feasible and acceptable to patients. It can be used to assess whether patients with osteoarthritis are making informed decisions about surgery that are concordant with their goals.

Informing and involving patients to improve the quality of medical decisions

Good-quality care requires that procedures, treatments, and tests be not only medically appropriate, but also desired by informed patients. Current evidence shows that most medical decisions are made by physicians with little input from patients. This article describes issues surrounding informed patient decision making and the steps necessary to improve the way decisions are made. Creating incentives for providers and health care organizations to inform patients and incorporate patients' goals into decisions is critical. Patient surveys are needed to monitor the quality of decision making. Health information technology can help by collecting information from patients about their symptoms, how well they understand their options, and what is important to them, and sharing that information with providers. We review public and private developments that could facilitate the development of tools and methods to improve patient-centered care.

Use of the Internet and ratings of information sources for medical decisions: results from the DECISIONS survey

BACKGROUND

The rise in Internet use for seeking health information raises questions about the role the Internet may play in how patients make medical decisions.

OBJECTIVE

To examine Internet use and perceived importance of different sources of information by patients making 9 specific medical decisions covering prescription medication initiation, cancer screening, and elective surgery.

SETTING

National sample of US adults identified by random-digit dialing.

DESIGN

Cross-sectional survey conducted between November 2006 and May 2007.

PARTICIPANTS

The final sample comprised 2575 English-speaking US adults aged 40 y and older who had either undergone 1 of 9 medical procedures or tests or talked with a health care provider about doing so during the previous 2 y.

MEASUREMENTS

Participants indicated if they or other family members used the Internet to seek information related to each of the specific medical decisions and rated how important the health care provider, the Internet (if used), family and friends, and the media (newspapers, magazines, and television) were in providing information to help make the medical decision.

RESULTS

Use of the Internet for information related to specific decisions among adults 40 y and older was generally low (28%) but varied across decisions, from 17% for breast cancer screening to 48% for hip/knee replacement. Internet use was higher at younger ages, rising from 14% among those aged 70 y and older to 38% for those aged 40 to 49 y. Internet users consistently rated health care providers as the most influential source of information for medical decisions, followed by the Internet, family and friends, and media.

LIMITATIONS

Telephone surveys are limited by coverage and nonresponse. The authors excluded health-related Internet use not associated with the 9 target decisions.

CONCLUSIONS

A minority of patients reported using the Internet to make specific common medical decisions, but use varied widely by type of decision. Perhaps reflecting perceived risk and uncertainty, use was lowest for screening decisions and highest for surgical decisions.

Patients' knowledge about 9 common health conditions: the DECISIONS survey

BACKGROUND

To make informed decisions, patients must have adequate knowledge of key decision-relevant facts.

OBJECTIVE

To determine adults' knowledge about information relevant to common types of medication, screening, or surgery decisions they recently made.

SETTING

National sample of US adults identified by random-digit dialing.

DESIGN

Cross-sectional survey conducted between November 2006 and May 2007.

PARTICIPANTS

A total of 2575 English-speaking adults aged 40 y or older who reported having discussed the following medical decisions with a health care provider within the previous 2 y: prescription medications for hypertension, hypercholesterolemia, or depression; screening tests for colorectal, breast, or prostate cancer; or surgeries for knee/hip replacement, cataracts, or lower back pain.

MEASUREMENTS

Participants answered knowledge questions and rated the importance of their health care provider, family/friends, and the media as sources of information.

RESULTS

Accuracy rates varied widely across questions and decision contexts. For example, patients considering cataract surgery were more likely to correctly estimate recovery time than those patients considering lower back pain or knee/hip replacement (78% v. 29% and 39%, P < 0.001). Similarly, participants were more knowledgeable of facts about colorectal cancer screening than those who were asked about breast or prostate cancer. Finally, respondents were consistently more knowledgeable on comparable questions about blood pressure medication than cholesterol medication or antidepressants. The impact of demographic characteristics and sources of information also varied substantially. For example, blacks had lower knowledge than whites about cancer screening decisions (odds ratio [OR] = 0.57; 95% confidence interval [CI] = 0.43, 0.75; P = 0.001) and medication (OR = 0.77; 95% CI = 0.60, 0.97; P = 0.03) even after we controlled for other demographic factors. The same was not true for surgical decisions.

LIMITATIONS

The questions did not measure all knowledge relevant to informed decision making, were subject to recall biases, and may have assessed numeracy more than knowledge.

CONCLUSIONS

Patient knowledge of key facts relevant to recently made medical decisions is often poor and varies systematically by decision type and patient characteristics. Improving patient knowledge about risks, benefits, and characteristics of medical procedures is essential to support informed decision making.

How does feeling informed relate to being informed? The DECISIONS survey

BACKGROUND

An important part of delivering high-quality, patient-centered care is making sure patients are informed about decisions regarding their health care. The objective was to examine whether patients' perceptions about how informed they were about common medical decisions are related to their ability to answer various knowledge questions.

METHODS

A cross-sectional survey was conducted November 2006 to May 2007 of a national sample of US adults identified by random-digit dialing. Participants were 2575 English-speaking US adults aged 40 and older who had made 1 of 9 medication, cancer screening, or elective surgery decisions within the previous 2 years. Participants rated how informed they felt on a scale of 0 (not at all informed) to 10 (extremely well-informed), answered decision-specific knowledge questions, and completed standard demographic questions.

RESULTS

Overall, 36% felt extremely well informed (10), 30% felt well informed (8-9), and 33% felt not at all to somewhat informed (0-7). Multivariate logistic regression analyses showed no overall relationship between knowledge scores and perceptions of being extremely well informed (odds ratio [OR] = 0.94, 95% confidence interval [CI] 0.63-1.42, P = 0.78). Three patterns emerged for decision types: a negative relationship for cancer screening decisions (OR = 0.58, CI 0.33-1.02, P = 0.06), no relationship for medication decisions (OR = 0.99, CI 0.54-1.83, P = 0.98), and a positive relationship for surgery decisions (OR = 3.07, 95% CI 0.90-10.54, P = 0.07). Trust in the doctor was associated with feeling extremely well-informed for all 3 types of decisions. Lower education and lower income were also associated with feeling extremely well informed for medication and screening decisions. Retrospective survey data are subject to recall bias, and participants may have had different perspectives or more factual knowledge closer to the time of the decision.

CONCLUSIONS

Patients facing common medical decisions are not able to accurately assess how well informed they are. Clinicians need to be proactive in providing adequate information to patients and testing patients' understanding to ensure informed decisions.

Deficits and Variations in Patients’ Experience with Making 9 Common Medical Decisions: The DECISIONS Survey

Background

Although many researchers have examined patient involvement and patient-provider interactions within specific clinical environments, no nationally representative data exist to characterize patient perceptions of decision making and patient-provider communications across multiple common medical decisions.

Objective

To identify deficits and variations in the patient experience of making common medical decisions about initiation of prescription medications for hypertension, hypercholesterolemia, or depression; screening tests for colorectal, breast, or prostate cancer; and surgeries for knee or hip replacement, cataracts, or lower back pain, as well as to identify factors associated with patient confidence in the decisions.

Setting

National sample of US adults identified by random-digit dialing.

Design

Cross-sectional survey conducted from November 2006 to May 2007.

Participants

Included 2473 English-speaking adults age 40 and older who reported undertaking 1 or more of the above 9 medical actions or discussing doing so with a health care provider within the past 2 years.

Measurements

Patients reported who initiated discussions and made the final decisions, how much discussion of pros and cons occurred, whether they were asked about their preferences, and their confidence that the decision “was the right one.”

Results

The proportion of patient-driven decisions varied significantly across decisions (range: blood pressure: 16% to knee/hip replacement: 48%). Most patients (78%–85%) reported that providers made a recommendation, and such recommendations generally favored taking medical action. Fewer patients reported that providers asked them about their preferences (range: colon cancer screening: 34% to knee/hip replacement: 80%) or discussed reasons not to take action (range: breast cancer screening: 20% to lower back surgery: 80%). Decision confidence was higher among patients who reported primarily making the decision themselves (odds ratio [OR] = 14.6, P < 0.001) or having been asked for their preference (OR = 1.32, P < 0.01) and was lower among patients whose patient provider discussions included cons (OR = 0.74, P = 0.008).

Limitations

Recall biases may affect patients’ memories of their decision-making processes.

Conclusions

Decisions participants reported wide variations in the proportion of discussions that included a conversation about reasons not to take action or a conversation about patients’ preferences about what they would like to do. These factors appear directly related to patients’ confidence that the decision was “right.”

Decision-making processes for breast, colorectal, and prostate cancer screening: the DECISIONS survey

BACKGROUND

Patients should understand the risks and benefits of cancer screening in order to make informed screening decisions.

OBJECTIVES

To evaluate the extent of informed decision making in patient-provider discussions for colorectal (CRC), breast (BrCa), and prostate (PCa) cancer screening.

SETTING

National sample of US adults identified by random-digit dialing.

DESIGN

Cross-sectional survey conducted between November 2006 and May 2007.

PARTICIPANTS

English-speaking US adults aged 50 y and older who had discussed cancer screening with a health care provider within the previous 2 y.

MEASUREMENTS

Cancer screening survey modules that asked about demographic characteristics, cancer knowledge, the importance of various sources of information, and self-reported cancer screening decision-making processes.

RESULTS

Overall, 1082 participants completed 1 or more of the 3 cancer modules. Although participants generally considered themselves well informed about screening tests, half or more could not correctly answer even 1 open-ended knowledge question for any given module. Participants consistently overestimated risks for being diagnosed with and dying from each cancer and overestimated the positive predictive values of prostate-specific antigen tests and mammography. Providers were the most highly rated information source, usually initiated screening discussions (64%-84%), and often recommended screening (73%-90%). However, participants reported that providers elicited their screening preferences in only 31% (CRC women) to 57% (PCa) of discussions. Although more than 90% of the discussions addressed the pros of screening, only 19% (BrCa) to 30% (PCa) addressed the cons of screening.

LIMITATIONS

Recall bias is possible because screening process reports were not independently validated.

CONCLUSIONS

Cancer screening decisions reported by patients who discussed screening with their health care providers consistently failed to meet criteria for being informed. Given the high ratings for provider information and frequent recommendations for screening, providers have important opportunities to ensure that informed decision making occurs for cancer screening decisions.

Plans to stop cancer screening tests among adults who recently considered screening

OBJECTIVE

We sought to estimate what proportion of adults plan to stop cancer screening tests among adults who recently considered screening and to explore factors associated with these screening plans.

DESIGN

Telephone Survey

PARTICIPANTS

A total of 1,237 participants aged 50 and older who reported having made one or more cancer screening decisions in the past 2 years completed 1,454 cancer screening modules for breast, prostate and colorectal screening.

MAIN RESULTS

Of all module respondents, 9.8% reported plans to stop screening, 12.6% for breast, 6.0 % for prostate and 9.5% for colon cancer. We found no statistically significant differences in plans to stop for those ages >or=70 (8.2%) compared to those ages 50 to 69 (10.2%) (p = 0.14.) Black respondents were less likely to report plans to stop than white respondents (OR = 0.32, 95% CI 0.12, 0.87). Participation in the decision-making process was associated with plans to stop screening; those who reported they made the final decision about screening (OR 5.9, 95% CI 1.4, 24.7) or made the decision with the health care provider (OR 4.1, 95% CI 1.0, 16.8) were more likely to have plans to stop screening compared to respondents who reported that their health care provider made the final decision.

CONCLUSIONS

Plans to stop screening were uncommon among participants who had recently faced a screening decision. Given the recent US Preventive Services Task Force recommendations limiting routine cancer screening for older adults, additional efforts to educate adults about the potential risks and benefits of screening may be warranted.

Development of instruments to measure the quality of breast cancer treatment decisions

BACKGROUND

Women with early-stage breast cancer face a multitude of decisions. The quality of a decision can be measured by the extent to which the treatment reflects what is most important to an informed patient. Reliable and valid measures of patients' knowledge and their goals and concerns related to breast cancer treatments are needed to assess the decision quality.

OBJECTIVE

To identify a set of key facts and goals relevant to each of three breast cancer treatment decisions (surgery, reconstruction and adjuvant chemotherapy and hormone therapy) and to evaluate the validity of the methods used to identify them.

METHODS

Candidate facts and goals were chosen based on evidence review and qualitative studies with breast cancer patients and providers. Cross-sectional surveys of patients and providers were conducted for each decision. The accuracy, importance and completeness of the items were examined.

RESULTS

Thirty-eight facts (11-14 per decision) and 27 goals (8-10 per decision) were identified. An average of 17 patients and 21 providers responded to each survey. The sets of facts were accurate and complete for all three decisions. The sets of goals and concerns were important for surgery and reconstruction, but not chemotherapy/hormone therapy. Patients and providers disagreed about the relative importance of several key facts and goals.

CONCLUSIONS

Overall, breast cancer patients and providers found the sets of facts and goals accurate, important and complete for three treatment decisions. Because patients' and providers' perspectives are different, it is vital that instrument development should include items reflecting both views.

The DECISIONS Study: A Nationwide Survey of United States Adults Regarding 9 Common Medical Decisions

Background

Patient involvement is required before patients’ preferences can be reflected in the medical care they receive. Furthermore, patients are a vital link between physicians’ assessments of patients’ needs and actual implementation of appropriate care. Yet no study has specifically examined how and when a representative sample of patients considered, discussed, and made medical decisions.

Objective

To identify decision prevalence and decision-making processes regarding 1) initiation of prescription medications for hypertension, hypercholesterolemia, or depression; 2) screening tests for colorectal, breast, or prostate cancer; and 3) surgeries for knee or hip replacement, cataracts, or lower back pain.

Design

Computer-assisted telephone interview survey.

Setting

Nationally representative sample of US adults in households with telephones.

Participants

3010 English-speaking adults age 40 and older identified using a stratified random sample of telephone numbers.

Measurements

Estimated prevalence of medical decisions, defined as the patient having initiated medications, been screened, or had surgery within the past 2 years or having discussed these actions with a health care provider during the same interval, as well as decision-specific data regarding patient knowledge, attitudes and patient-provider interactions.

Results

82.2% of the target population reported making at least 1 medical decision in the preceding 2 years. The proportion of decisions resulting in patient action varied dramatically both across decision type (medications [61 %] v. screening [83%] v. surgery [44%]; P < 0.001), and within each category (e.g., blood pressure medications [76%] v. cholesterol medications [55%] vs. depression medications [48%]; P < 0.001). Respondents reported making more decisions if they had a primary care provider or poorer health status and fewer decisions if they had lower education, were male, or were under age 50.

Limitations

Retrospective self-reports may incorporate recall biases.

Conclusions

Medical decisions with significant life-saving, quality of life, and cost implications are a pervasive part of life for most US adults. The DECISIONS dataset provides a rich research environment for exploring factors influencing when and how patients make common medical decisions.

Prostate cancer screening decisions: results from the National Survey of Medical Decisions (DECISIONS study)

BACKGROUND

Guidelines recommend informing patients about the risks and benefits of prostate cancer screening. We evaluated the medical decision-making process for prostate-specific antigen (PSA) testing.

METHODS

We conducted a telephone survey of a randomly selected national sample of 3010 English-speaking US adults 40 years and older. Included in the survey were 375 men who had either undergone or discussed (with health care providers [HCPs]) PSA testing in the previous 2 years. We asked subjects about sociodemographic characteristics, prostate cancer screening discussion features, prostate cancer knowledge, and the importance of various decision factors and sources of information.

RESULTS

Overall, 69.9% of subjects discussed screening before making a testing decision, including 14.4% who were not tested. Health care providers most often (64.6%) raised the idea of screening, and 73.4% recommended PSA testing. Health care providers emphasized the pros of testing in 71.4% of discussions but infrequently addressed the cons (32.0%). Although 58.0% of subjects felt well-informed about PSA testing, 47.8% failed to correctly answer any of the 3 knowledge questions. Only 54.8% of subjects reported being asked for their screening preferences. An HCP recommendation (odds ratio, 2.67; 95% confidence interval, 1.08-6.58) was the only discussion characteristic associated with testing. Valuing HCP information was also associated with testing (odds ratio, 1.26; 95% confidence interval, 1.04-1.54).

CONCLUSIONS

Recommendations and information from HCPs strongly influenced testing decisions. However, most prostate cancer screening decisions did not meet criteria for shared decision making because subjects did not receive balanced discussions of decision consequences, had limited knowledge, and were not routinely asked for their preferences.

Developing instruments to measure the quality of decisions: early results for a set of symptom-driven decisions

OBJECTIVE

To identify a set of critical facts and key goals and concerns for five common medical conditions, benign prostate disease, hip and knee osteoarthritis, herniated disc and spinal stenosis and examine the validity of the method for identifying these items.

METHODS

Investigators identified facts and goals through literature reviews and qualitative work with patients and providers. A cross-sectional survey of patients and providers was conducted to examine the accuracy, importance and completeness of the identified items.

RESULTS

42 facts (6-16 per condition) and 31 goals and concerns (4-13 per condition) were identified. 182 responses were obtained from patients (76.5% response rate) and 113 responses from providers (78% response rate). Overall, the facts were accurate, important and complete across all conditions. For one condition (hip osteoarthritis), the goals did not meet the criteria for completeness. There was more disagreement between patients and providers around the ranking of goals than of facts.

CONCLUSIONS

Overall, respondents found the identified facts and goals accurate, important and complete. Significant differences between patients' and providers' rankings highlight the importance of including both perspectives.

PRACTICE IMPLICATIONS

Instruments to measure whether or not patients are informed and the extent to which treatments reflect patients' goals must balance patients' and providers' perspectives when selecting items to include.

Prevalence and treatment of diagnosed depression among elderly nursing home residents in Ohio

OBJECTIVES

To examine the prevalence and treatment of diagnosed depression among elderly nursing home residents and determine the resident and facility characteristics associated with diagnosis and treatment.

DESIGN, SETTING, AND PARTICIPANTS

Documented depression, pharmacotherapy, psychotherapy, sociodemographics, and medical characteristics were obtained from Ohio's Minimum Data Set for 76 735 residents in 921 nursing homes. The data were merged with Online Survey Certification and Reporting System data to study the impact of facility characteristics. Chi-squared statistics were used to test group differences in depression diagnosis and treatment. Multiple logistic regressions were used to examine the prevalence of diagnosed depression, and among those diagnosed, of receiving any treatment.

RESULTS

There were 48% of residents who had an active depression diagnosis; among those diagnosed, 23% received no treatment; 74% received antidepressants; 0.5% received psychotherapy; and 2% received both. African Americans, the severely cognitively impaired, and those in government facilities were less likely to be diagnosed. Residents aged 85 and older, African Americans, individuals with severe mental illness, those with severe ADL or cognitive impairment, and individuals living in a facility with 4 or more deficiencies were less likely to receive treatment.

CONCLUSION

Significant disparities exist both in diagnosis and treatment of depression among elderly residents. Disadvantaged groups such as African Americans and residents with physical and cognitive impairments are less likely to be diagnosed and treated. Our results indicate that work needs to be done in the nursing home environment to improve the quality of depression care for all residents.

The Relationship Between Organizational Factors and Resident Satisfaction with Nursing Home Care and Life

We examined the relationships between nursing home (NH) resident satisfaction and NH organizational characteristics, while controlling for the effect of resident characteristics within facilities. We used a stratified, random sample of NHs (N = 72) from two states and a prescreened and randomized sample of 1496 residents. Data sources included resident interviews, an administrator survey, the Minimum Data Set (MDS), and the Online Survey, Certification and Reporting System (OSCAR). Using Hierarchical Linear Modeling (HLM) techniques, we found that non-chain affiliation, certified nursing assistant staffing, and provision of a family council had significant positive effects on total resident satisfaction. The presence of a special care unit was associated with lower levels of satisfaction.

Resident and Family Perspectives on Assisted Living

This research describes and compares the relative importance residents and family members place on attributes of the environment, the programs, and the policies of assisted living; describes their satisfaction with these features; and identifies factors associated with congruence between residents' and family members' ratings of importance and satisfaction. Both residents and their family members had high importance and satisfaction ratings. Family members gave the assisted living setting lower satisfaction ratings on all features than did residents. Congruence ranged from 34% to 71% for importance items and from 29% to 63% for satisfaction. Female residents, affectionate family relationships, and residing in an AL owned by a chain were positively associated with congruence on importance items, while resident and family education, resident income, and family involvement were negatively associated with congruence on importance items. For congruence on satisfaction items, having an affectionate relationship was positively associated and higher ADL dependency, more family involvement at the facility, and family members who viewed the facility as a safe place were negatively associated with congruence. This study makes a major stride forward because cognitively intact residents' perspectives are compared and contrasted with their own family members' perspectives, thus showing that residents and family members are two distinct groups, each with a unique set of preferences.

The independence of size perception and distance perception

Research on distance perception has focused on environmental sources of information, which have been well documented; in contrast, size perception research has focused on familiarity or has relied on distance information. An analysis of these two parallel bodies of work reveals their lack of equivalence. Furthermore, definitions of familiarity need environmental grounding, specifically concerning the amount of size variation among different tokens of an object. To demonstrate the independence of size and distance perception, subjects in two experiments were asked to estimate the sizes of common objects from memory and then to estimate both the sizes and the distances of a subset of such objects displayed in front of them. The experiments found that token variation was a critical variable in the accuracy of size estimations, whether from memory or with vision, and that distance had no impact at all on size perception. Furthermore, when distance information was good, size had no effect on distance estimation; in contrast, at far distances, the distances to token variable or unknown objects were estimated with less accuracy. The results suggest that size perception has been misconceptualized, so that the relevant research to understand its properties has not been undertaken. The size-distance invariance hypothesis was shown to be inadequate for both areas of research.

Visual angle as a determinant of perceived interobject distance

Two new experiments and a reanalysis of Toye's (1986) data are used to examine the relationship between true distance and perceived distance in natural scenes. In the first experiment, 8 subjects estimated 78 interobject distances, formed by all pairs of 13 objects, while viewing the objects from a fixed position. The results showed that estimated distance is a linear function of the visual angle between objects as well as of the true distance. This relationship results in distances perpendicular to the line of sight being overestimated in relation to true distances and to distances parallel to the line of sight. These findings were confirmed by reanalysis of a comparable data set from Toye. Since changes in the visual angle can come about through changes in alignment with the line of sight, viewing distance, or interobject distance, Experiment 2 was designed to determine whether the visual angle effect was due to one of these, or whether it was an independent effect. In Experiment 2, 8 subjects estimated six interobject distances from 12 viewing positions. The results showed that visual angle predicted estimated distance independently of how the change in visual angle came about, suggesting that the greater the visual angle between objects, the more their separation is overestimated.

Properties of spatial representations: data from sighted and blind subjects

Five questions concerning the properties of spatial representations are explored. (1) How accurately does a spatial representation correspond to the true scene? (2) If inaccurate, how does it differ? (3) Are representations of a familiar scene more accurate than those of an unfamiliar one? (4) Do representations of a scene currently in view differ from those retained in memory? (5) Do the representations of the blind have properties comparable to those of the sighted? Seven sighted and 7 highly mobile blind subjects, all familiar with a room, and 6 sighted subjects unfamiliar with it, were asked to estimate the absolute distances between 10 salient objects in the room. The 14 familiar subjects made their estimates twice: while they were in the room, and while they were remote from it. Regression analyses showed that the estimates of all subjects had strong metric properties, being linearly related to true distance, with a true zero point; and multidimensional scaling showed that all subjects produced distance estimates that could be scaled in two dimensions to closely match the actual locations of the objects. Familiarity had no effect. The effect of location of testing was the same for both the sighted and the blind: all subjects displayed better spatial knowledge when tested in the room; and all subjects underestimated true distance substantially when tested out of the room. The results showed no qualitative differences as a function of blindness, at least for these highly skilled blind travelers.