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PubMed2006

Who uses decision aids? Subgroup analyses from a randomized controlled effectiveness trial of two prostate cancer screening decision support interventions.

OBJECTIVE: To examine who reported using unsolicited prostate cancer screening decision aids distributed as part of a randomized controlled trial, whether reported use varied by type of aid (video or pamphlet), and what affect reported use had on study outcomes. METHODS: A total of 1,152 men aged 50 and older from four medical facilities in the United States were randomly assigned to pamphlet, video or usual care (control). Materials were mailed 2 weeks prior to clinic appointments in general internal medicine. Outcomes were assessed by phone survey 1 week after appointments. Analyses examined the reported use of materials by study group, the association between patient characteristics and reported use, and the impact of reported use (adjusting for patient characteristics) on a 10-item knowledge index. RESULTS: Fifty-six percent of those randomized to receive the video and 50% of those randomized to receive the pamphlet reported using the materials. Reported use of the video was higher for patients who had greater than a high school education (OR 1.73), were married (OR 2.20), and reported no prior abnormal prostate cancer screening test results (OR 3.39). Reported use of the pamphlet did not vary by patient characteristics. In intent-to-treat analyses (ignoring reported use), individuals randomized to the video and pamphlet groups had significantly higher knowledge scores relative to the control group (7.44, 7.26 and 6.90 respectively). Adjusting for reported use modestly increased the estimated differences across treatment groups but did not substantially change conclusions about the relative effects of these aids on knowledge. CONCLUSIONS: Only half of men receiving unsolicited prostate cancer screening decision aids before a visit reported using the aids, and who reported using them varied by type of aid. Efforts to broadly implement decision aids may need to offer a variety of approaches, and incorporate creative strategies to enhance reaching all population subgroups.

Aged↗
PubMed2006

Development and pilot-testing of a decision aid for women with a breech-presenting baby.

OBJECTIVE: To develop a decision aid for pregnant women with a breech presentation at term, and to assess its acceptability. METHODS: The external cephalic version (ECV) decision aid was developed using the Ottawa Decision Support Framework and a systematic review of the evidence to provide probabilistic information about the benefits and risks of options. It incorporates a workbook supplemented by a CD and worksheet, and these were evaluated in a pilot study using self-administered questionnaires. PARTICIPANTS: 19 women with a breech presentation attending antenatal clinics at a local obstetric hospital and 11 recently pregnant women. FINDINGS: Of 30 women surveyed, nearly all found the decision aid clear and easy to understand, and thought that enough information was provided for them to make a decision. Women experienced increased knowledge, reduced decisional conflict, increased satisfaction and participation in decision making without increased anxiety. Participants also found the tool helpful and would recommend it to others. KEY CONCLUSIONS: The ECV decision aid was well accepted and helpful for pregnant women with a breech presenting baby. We are currently evaluating the decision aid in a randomised trial to assess cognitive, affective and health outcomes.

Adult↗
PubMed2006

Exploring the black box of a decision aid: what information do patients select from an interactive Cd-Rom on treatment options in breast cancer?

OBJECTIVE: It is thought that patients fare better when they participate in treatment decision-making, and when they have more control over the amount and type of information they receive. To facilitate informed decision-making, interactive decision aids have been introduced in health care. This article describes how much, and which information patients select from an interactive decision aid on breast cancer. To explore whether the interactive system facilitates that different patients receive different information, associations between patients' characteristics and information selection are inspected. METHODS: The interactive decision aid was provided to 106 patients after an initial discussion with their surgeon about their diagnosis and treatment options. Information regarding patients' age, completed education, treatment preference, psychological functioning, decision uncertainty and decision style was collected with a written, structured questionnaire. The questionnaire was completed before patients used the interactive decision aid. To create categories, a median-split procedure was employed on the scores of the continuous background variables. The information patients selected from the interactive decision aid were registered into logfiles. Associations between patients' background variables and information selection were investigated by means of univariate statistics. RESULTS: Patients (n=97; 92%) used the interactive decision aid intensively. On average, patients spent almost 70min searching for information and selected 21 information topics. Overall, treatment related information was clearly more selected than other types of information. Age, education, and decision style factors were associated with information selection. CONCLUSION: The interactive breast cancer decision aid was utilized intensively. The interactive system was found to facilitate that different patients received different amounts and types of information. PRACTICE IMPLICATIONS: Interactive decision aids may improve information giving to patients, and as a result, the quality of care. To safeguard informed-choice, decision aids should be used in conjunction with other communication strategies. Decision aids should be available continuously and throughout the patients' disease journey. The Internet may help to achieve broad dissemination and enduring access.

Adaptation, Psychological↗
PubMed2001

Randomised controlled trial of an interactive multimedia decision aid on benign prostatic hypertrophy in primary care.

OBJECTIVE: To determine whether a decision aid on benign prostatic hypertrophy influences decision making, health outcomes, and resource use. DESIGN: Randomised controlled trial. SETTING: 33 general practices in the United Kingdom. PARTICIPANTS: 112 men with benign prostatic hypertrophy. INTERVENTION: Patients' decision aid consisting of an interactive multimedia programme with booklet and printed summary. OUTCOME MEASURES: Patients' and general practitioners' perceptions of who made the decision, decisional conflict scores, treatment choice and prostatectomy rate, American Urological Association symptom scale, costs, anxiety, utility, and general health status. RESULTS: Both patients and general practitioners found the decision aid acceptable. A higher proportion of patients (32% v 4%; mean difference 28%, 95% confidence interval 14% to 41%) and their general practitioners (46% v 25%; 21%, 3% to 40%) perceived that treatment decisions had been made mainly or only by patients in the intervention group compared with the control group. Patients in the intervention group had significantly lower decisional conflict scores than those in the control group at three months (2.3 v 2.6; -0.3, -0.5 to -0.1, P<0.01) and this was maintained at nine months. No differences were found between the groups for anxiety, general health status, prostatic symptoms, utility, or costs (excluding costs associated with the video disc equipment). CONCLUSIONS: The decision aid reduced decisional conflict in men with benign prostatic hypertrophy, and the patients played a more active part in decision making. Such programmes could be delivered cheaply by the internet, and there are good arguments for coordinated investment in them, particularly for conditions in which patient utilities are important.

Aged↗
PubMed2001

Randomised controlled trial of an interactive multimedia decision aid on hormone replacement therapy in primary care.

OBJECTIVE: To determine whether a decision aid on hormone replacement therapy influences decision making and health outcomes. DESIGN: Randomised controlled trial. SETTING: 26 general practices in the United Kingdom. PARTICIPANTS: 205 women considering hormone replacement therapy. INTERVENTION: Patients' decision aid consisting of an interactive multimedia programme with booklet and printed summary. OUTCOME MEASURES: Patients' and general practitioners' perceptions of who made the decision, decisional conflict, treatment choice, menopausal symptoms, costs, anxiety, and general health status. RESULTS: Both patients and general practitioners found the decision aid acceptable. At three months, mean scores for decisional conflict were significantly lower in the intervention group than in the control group (2.5 v 2.8; mean difference -0.3, 95% confidence interval -0.5 to -0.2); this difference was maintained during follow up. A higher proportion of general practitioners perceived that treatment decisions had been made "mainly or only" by the patient in the intervention group than in the control group (55% v 31%; 24%, 8% to 40%). At three months a lower proportion of women in the intervention group than in the control group were undecided about treatment (14% v 26%; -12%, -23% to -0.4%), and a higher proportion had decided against hormone replacement therapy (46% v 32%; 14%, 1% to 28%); these differences were no longer apparent by nine months. No differences were found between the groups for anxiety, use of health service resources, general health status, or utility. The higher costs of the intervention were largely due to the video disc technology used. CONCLUSIONS: An interactive multimedia decision aid in the NHS would be popular with patients, reduce decisional conflict, and let patients play a more active part in decision making without increasing anxiety. The use of web based technology would reduce the cost of the intervention.

Decision Making, Computer-Assisted↗
PubMedDate not supplied

Randomized controlled trial of a patient decision aid for colorectal cancer screening.

PURPOSE: To conduct a pilot test of a decision aid designed to help patients choose among currently recommended colorectal cancer screening programs. METHODS: Randomized controlled trial comparing a patient decision aid based on multicriteria decision-making theory with a simple educational intervention. PATIENT POPULATION: 96 patients at average risk for colorectal cancer seen in an Internal Medicine practice in Rochester, New York. OUTCOME MEASURES: The two primary outcome measures were patient decision process and the decision outcome. Patient decision process was assessed using the decisional conflict scale. Decision outcome was defined as the proportion of colorectal cancer screening plans carried out. RESULTS: After controlling for the effects of the physicians in a factorial analysis of variance, patients who used the decision aid had lower decisional conflict regarding colorectal cancer screening decisions (F ratio 6.47, P = 0.01) due to increased knowledge, better clarity of values, and higher ratings of the quality of the decisions they made. There was no difference between the groups in decision outcomes: 52% of patients in the control group and 49% in the experimental group completed planned screening tests (P = 1.0). CONCLUSIONS: In a pilot study, a multicriteria-based patient decision aid for colorectal cancer screening improved patients' decision-making processes but had no effect on the implementation of screening plans.

Aged↗
PubMed2003

Development and evaluation of a breast cancer prevention decision aid for higher-risk women.

OBJECTIVE: To develop and evaluate the effectiveness of a breast cancer prevention decision aid for women aged 50 and older at higher risk of breast cancer. DESIGN: Pre-test-post-test study using decision aid alone and in combination with counselling. SETTING: Breast Cancer Risk Assessment Clinic. PARTICIPANTS: Twenty-seven women aged 50-69 with 1.66% or higher 5-year risk of breast cancer. INTERVENTION: Self-administered breast cancer prevention decision aid. MAIN OUTCOME MEASURES: Acceptability; decisional conflict; knowledge; realistic expectations; choice predisposition; intention to improve life-style practices; psychological distress; and satisfaction with preparation for consultation. RESULTS: The decision aid alone, or in combination with counselling, decreased some dimensions of decisional conflict, increased knowledge (P < 0.01), and created more realistic expectations (P < 0.01). The aid in combination with counselling, significantly reduced decisional conflict (P < 0.01) and psychological distress (P < 0.02), helped the uncertain become certain (P < 0.02), and increased intentions to adopt healthier life-style practices (P < 0.03). Women rated the aid as acceptable, and both women and practitioners were satisfied with the effect it had on the counselling session. CONCLUSION: The decision aid shows promise as a useful decision support tool. Further research should compare the effect of the decision aid in combination with counselling to counselling alone.

Aged↗
PubMed2005

Treatment decision aids: conceptual issues and future directions.

BACKGROUND: In the last 10 years, there has been a major growth in the development of treatment decision aids. Multiple goals have been identified for these tools. However, the rationale for and meaning of these goals at the conceptual level, the mechanisms through which decision aids are intended to achieve these goals, and value assumptions underlying the design of aids and associated values clarification exercises have often not been made explicit. OBJECTIVE: In this paper, we present ideas to help inform the future development and evaluation of decision aids. RESULTS: We suggest, (i) that the appropriateness of using any decision aid be assessed within the context of the wider decision-making encounter within which it is embedded; (ii) that goal setting activities drive measurement activities and not the other way round; (iii) that the rationale for and meaning of goals at the conceptual level, and mechanisms through which they are intended to have an impact be clearly thought through and made explicit; (iv) that value assumptions underlying both decision aids and associated values clarification exercises be communicated to patients; (v) that taxonomies developed and used to classify various types of decision aids include a section on value assumptions underlying each tool; (vi) that further debate and discussion take place on the role of explicit values clarification exercises as a component of or adjunct to treatment decision aids and the feasibility of implementing valid measures. CONCLUSION: Further debate and discussion is needed on the above issues.

Canada↗
PubMedDate not supplied

Decision aids for benign prostatic hyperplasia: applicability across race and education.

BACKGROUND/METHOD: Decision aids have not been widely tested in diverse audiences. The authors conducted interviews in a 2 x 2 race by education design with participants who were 50 years old (n = 188). The decision aid was a benign prostatic hyperplasia videotape. RESULTS: There was an increase in knowledge equal in all groups, with baseline knowledge higher in whites. The decision stage increased in all groups and was equivalent in the marginal-illiterate subgroup (n = 0.15). CONCLUSION: Contrary to expectations, results show no difference by race or college education in knowledge gain or increase in reported readiness to decide. The video appeared to produce change across race and education. The end decision stage was high, especially in less educated men. Results suggest that decision aids may be effective without tailoring, as suggested previously to enhance health communication in diverse audiences. Research should test findings in representative samples and in clinical encounters and identify types of knowledge absorbed from decision aids and whether the shift to decision reflects data/knowledge or shared decision-making message.

Aged↗
PubMed2006

A randomised controlled trial of a decision-aid leaflet to facilitate women's choice between pregnancy termination methods.

OBJECTIVE: To evaluate the effectiveness of a decision aid to help women choose between surgical and medical methods of pregnancy termination. DESIGN: A randomised controlled trial comparing a decision-aid leaflet about termination methods with a control leaflet about contraception. SETTING: An NHS regional centre for pregnancy termination. SAMPLE: All women less than 9 weeks of gestation referred for termination of pregnancy over 7 months in 2002. METHODS: Participants were given an envelope containing either the decision-aid or the control leaflet prior to choosing between medical and surgical termination methods and completed two questionnaires, one immediately after this consultation and another after the termination procedure. MAIN OUTCOME MEASURES: Choice of termination method; measures of effective decision making including risk perception, attitudes and knowledge of both the medical and surgical methods; decisional conflict; anxiety and usefulness of the leaflet. RESULTS: Three hundred and twenty-eight women participated. There was no difference in the method chosen between the groups (60/162 women in the decision-aided group chose a medical method versus 54/164 women in the control group (OR 1.2; 95% CI 0.76-1.9). Women in the decision-aided group had higher knowledge and lower risk-perception scores about both methods, more positive attitudes about the medical method, lower decisional conflict, more stable evaluations of the decision information over time and higher perceived usefulness of information ratings. Anxiety was high but unrelated to leaflet type. CONCLUSIONS: Women made more informed decisions when provided with an evidence-based decision-aid leaflet preceding a routine consultation about choices of termination method.

Abortion, Induced↗
PubMed2002

Development and pilot testing of a decision aid for postmenopausal women with osteoporosis.

This study's aim was to develop and pilot test an evidence-based decision aid for postmenopausal women with osteoporosis who are considering options to prevent fractures. The aid was based on the Ottawa Decision Support Framework, and integrated evidence from our Cochrane systematic reviews. Following development by a panel of experts in osteoporosis and decision making, a user review panel of practitioners and women who had already made their decision about osteoporosis therapy reviewed the decision aid for acceptability. Then the decision aid was pilot tested using a before-after design in women at the point of decision making. Compared to baseline, there were statistically significant improvements in knowledge, realistic expectations and decreased decisional conflict. Our decision aid shows promise in preparing women for counseling about osteoporosis therapies. Long-term adherence to chosen therapy and quality of life will be evaluated in a randomized controlled trial.

Aged↗
PubMed2005

Effects of a web based decision aid on parental attitudes to MMR vaccination: a before and after study.

OBJECTIVE: To determine whether an evidence based decision aid on the measles, mumps, and rubella (MMR) vaccine changed parents' attitudes towards vaccination. DESIGN: Before and after study. SETTING: Website promoted through search engines and online parenting and health websites. PARTICIPANTS: 158 people completing online questions out of 1277 who accessed the website. INTERVENTION: Evidence based decision aid with text and graphical representation of the possible outcomes of measles, mumps, and rubella diseases compared with MMR vaccination. MAIN OUTCOME MEASURES: Attitudes towards MMR vaccination. RESULTS: Significantly more participants indicated they were "leaning towards" vaccination after using the decision aid (39% before v 55% after, P < 0.001). Compared with those who were undecided or "leaning away from" vaccination after using the decision aid, participants "leaning towards" it were more likely to strongly value its potential to protect their children from the serious side effects of disease (98% v 84%) and other children who could not be vaccinated for medical reasons (68% v 25%). Participants with an unfavourable attitude to vaccination were more likely to be very concerned about the rare side effects of vaccination (78% v 57%), have residual concerns about autism and bowel disease (78% v 27%), and anticipate guilt should their child have an adverse reaction (77% v 50%). Those with a positive attitude to vaccination after using the decision aid were also more likely to feel well informed (83% v 48%). CONCLUSIONS: A web based decision aid significantly improved parental attitudes to MMR vaccination. Residual concerns about autism and bowel disease and the rare chance of serious complications remained as attitudinal barriers to some parents.

Adult↗
PubMed2005

Development and initial testing of a computer-based patient decision aid to promote colorectal cancer screening for primary care practice.

BACKGROUND: Although colorectal cancer screening is recommended by major policy-making organizations, rates of screening remain low. Our aim was to develop a patient-directed, computer-based decision aid about colorectal cancer screening and investigate whether it could increase patient interest in screening. METHODS: We used content from evidence-based literature reviews and our previous decision aid research to develop a prototype. We performed two rounds of usability testing with representative patients to revise the content and format. The final decision aid consisted of an introductory segment, four test-specific segments, and information to allow comparison of the tests across several key parameters. We then conducted a before-after uncontrolled trial of 80 patients 50-75 years old recruited from an academic internal medicine practice. RESULTS: Mean viewing time was 19 minutes. The decision aid improved patients' intent to ask providers for screening from a mean score of 2.8 (1 = not at all likely to ask, 4 = very likely to ask) before viewing the decision aid to 3.2 afterwards (difference, 0.4; p < 0.0001, paired t-test). Most found the aid useful and reported that it improved their knowledge about screening. Sixty percent said they were ready to be tested, 18% needed more information, and 22% were not ready to be screened. Within 6 months of viewing, 43% of patients had completed screening tests. CONCLUSION: We conclude that a computer-based decision aid can increase patient intent to be screened and increase interest in screening. PRACTICE IMPLICATIONS: This decision aid can be viewed by patients prior to provider appointments to increase motivation to be screened and to help them decide about which modality to use for screening. Further work is required to integrate the decision aid with other practice change strategies to raise screening rates to target levels.

Academic Medical Centers↗
PubMed1999

A patient decision aid regarding antithrombotic therapy for stroke prevention in atrial fibrillation: a randomized controlled trial.

CONTEXT: Decision aids are tools designed to help patients participate in the clinical decision-making process. OBJECTIVE: To determine whether use of an audiobooklet (AB) decision aid explaining the results of a clinical trial affected the decision-making process of study participants. DESIGN: Randomized controlled trial conducted from May 1997 to April 1998. SETTING: Fourteen centers that participated in the Stroke Prevention in Atrial Fibrillation (SPAF) III trial. PARTICIPANTS: A total of 287 patients from the SPAF III aspirin cohort study, in which patients with atrial fibrillation and a relatively low risk of stroke received 325 mg/d of aspirin and were followed up for a mean of 2 years. INTERVENTION: At the end of SPAF III, participants were randomized to be informed of the study results with usual care plus use of an AB (AB group) vs usual care alone (control group). The AB included pertinent information to help patients decide whether to continue taking aspirin or switch to warfarin. MAIN OUTCOME MEASURES: Patients' ability to make choices regarding antithrombotic therapy, and 6-month adherence to these decisions. Their knowledge, expectations, decisional conflict (the amount of uncertainty about the course of action to take), and satisfaction with the decision-making process were also measured. RESULTS: More patients in the AB group made a choice about antithrombotic therapy than in the control group (99% vs 94%; P = .02). Patients in the AB group were more knowledgeable and had more realistic expectations about the risk of stroke and hemorrhage (in the AB group, 53%-80% correctly estimated different risks; in the control group, 16%-28% gave correct estimates). Decisional conflict and satisfaction were similar for the 2 groups. After 6 months, a similar percentage of patients were still taking their initial choice of antithrombotic therapy (95% vs 93%; P = .44). CONCLUSIONS: For patients with atrial fibrillation who had participated in a major clinical trial, the use of an AB decision aid improved their understanding of the benefits and risks associated with different treatment options and helped them make definitive choices about which therapy to take. Further studies are necessary to evaluate the acceptability and impact of decision aids in other clinical settings.

Aged↗
PubMedDate not supplied

Physician evaluation after medical errors: does having a computer decision aid help or hurt in hindsight?

OBJECTIVE: The authors examined whether physicians' use of computerized decision aids affects patient satisfaction and/or blame for medical outcomes. METHOD: Experiment 1: Fifty-nine undergraduates read about a doctor who made either a correct or incorrect diagnosis and either used a decision aid or did not. All rated the quality of the doctor's decision and the likelihood of recommending the doctor. Those receiving a negative outcome also rated negligence and likelihood of suing. Experiment 2: One hundred sixty-six medical students and 154 undergraduates read negative-outcome scenarios in which a doctor either agreed with the aid, heeded the aid against his own opinion, defied the aid in favor of his own opinion, or did not use a decision aid. Subjects rated doctor fault and competence and the appropriateness of using decision aids in medicine. Medical students made judgments for themselves and for a layperson. RESULTS: Experiment 1: Using a decision aid caused a positive outcome to be rated less positively and a negative outcome to be rated less negatively. Experiment 2: Agreeing with or heeding the aid was associated with reduced fault, whereas defying the aid was associated with roughly the same fault as not using one at all. Medical students were less harsh than undergraduates but accurately predicted undergraduate's responses. CONCLUSION: Agreeing with or heeding a decision aid, but not defying it, may reduce liability after an error. However, using an aid may reduce favorability after a positive outcome.

Attitude to Computers↗
PubMed1999

Decision aids for patients considering options affecting cancer outcomes: evidence of efficacy and policy implications.

Some cancer screening and treatment decisions are not clear cut because outcomes are uncertain or options have different benefit/risk profiles. "Decision aids" have been developed as adjuncts to counseling so that patients can learn about benefits and risks, can consider their personal values, and can participate with their practitioner in decision making. The purpose of this paper is to review published evidence about the efficacy of decision aids focused on cancer outcomes and to outline research and dissemination issues. Studies evaluating cancer-related decision aids demonstrate that they are acceptable to patients and help those who are uncertain at baseline to make choices. They also increase the likelihood that choices are based on better knowledge, realistic expectations of outcomes, and personal values. Decision aids reduce some dimensions of decisional conflict, and their effect on decisions is variable. Few studies examine the downstream effects of decision aids on long-term persistence with choices, regret, and quality of life. The differences between simpler and more intensive methods of decision support appear to be negligible in terms of knowledge and satisfaction as well as variable in terms of decisions and decisional conflict. However, more intensive methods are superior in terms of user acceptability and of the extent to which choices are based on realistic expectations and personal values. The clinical importance of these differences and the cost-effectiveness remain to be established. On the basis of this review, several recommendations for research are made, and dissemination issues are identified.

Decision Making↗
PubMedDate not supplied

Evaluating black-boxes as medical decision aids: issues arising from a study of neural networks.

The rigorous evaluation of medical decision aids will be critical to promoting their development, establishing their clinical value and legalizing their use. Many decision aids are transparent in the sense that their internal structure and function can be examined and verified. Some decision aids, however, use complex models of associations in training data to construct 'black-box' systems whose workings are largely impenetrable and inexplicable. The issues surrounding the evaluation of such systems, as exemplified by connectionist (neural network) models, are discussed. For such systems the two major aspects that can be evaluated are the training data from which the system is derived, and its performance on test data. A number of questions about the use of black-box systems as medical decision aids are posed which require consideration by the medical informatics community.

Diagnosis, Computer-Assisted↗