The decisional conflict scale: further validation in two samples of Dutch oncology patients

Effectiveness of a digital vs face-to-face preoperative assessment: A randomized, noninferiority clinical trial

STUDY OBJECTIVE

Digitalizing the preoperative assessment clinic can be a solution to keep up with the growing demand for surgery. It remains unclear if a digital preoperative assessment clinic is as safe, and effective in terms of patient health outcomes and experience compared to face-to-face consultations. This study aimed to compare quality of recovery and mental state in patients undergoing a digital preoperative assessment versus regular face-to-face consultations.

DESIGN

This was a single centre, randomized (1:1), parallel, open-label, noninferiority trial.

SETTING

The preoperative clinic and preoperative unit of an urban secondary care hospital.

PATIENTS

All adult, Dutch speaking, ASA I-IV patients with access to an online computer who required surgery.

INTERVENTIONS

Digital preoperative screening, consisting of an electronic screening questionnaire and web-based platform with personalized information and recommendations related to the procedure, or face-to-face screening, consisting of two 20-min in-hospital consultations.

MEASUREMENTS

The primary endpoint was quality of recovery, measured 48 h after surgery. The analysis followed a per-protocol principle, and only patients who underwent the intended screening were included in the analysis. The noninferiority margin was set at -6. The trial was registered at ClinicalTrials.gov, NCT05535205, during the study on 09/08/2022, before analysing results.

MAIN RESULTS

Between March 1, 2021 and 30 august 2021, 480 patients were assessed for eligibility. 400 patients were randomly assigned to the digital group (n = 200) or face-to-face group (n = 201), of which respectively 117 and 124 patients were eventually included in the primary analysis. The mean quality of recovery score of patients undergoing digital screening (158) was non-inferior to that of patients undergoing face-to-face screening (155), with a mean difference of 3·2 points and a 97.5% lower confidence limit of -2.1 points. There were no adverse events.

CONCLUSIONS

A digital preoperative screening is not inferior to face-to-face consultations in patients undergoing predominantly low to moderate risk surgery. Given its potential to reduce physician workload, reallocate healthcare resources, and lower healthcare costs, a digital preoperative screening may be a better choice for preoperative assessments.

Effectiveness of a patient decision aid for patients with superficial basal cell carcinoma: A pre- and post-implementation study

OBJECTIVE

This study evaluates whether using a patient decision aid (PDA) for patients with superficial basal-cell carcinoma (sBCC) results in a decreased decisional conflict level and increased knowledge.

METHODS

In a prospective multicentre study, patient groups were included before and after implementation of a PDA. Decisional conflict levels were compared directly after making the treatment decision, measured once as the mean score on the decisional conflict scale (DCS). Higher scores correspond with higher conflict levels (0-100). Secondary outcomes were knowledge on treatment options, recognizing a BCC, and risk factors for developing a BCC measured on an adapted version of a validated knowledge questionnaire for melanoma patients, and patient satisfaction with the PDA.

RESULTS

Data was available for 103 patients in the control-group and 109 in the PDA-group. The mean DCS score in the control-group was 22.78 (SD 14.76) compared to 22.34 (SD 14.54) in the PDA-group; the decrease was non-significant (p = 0.828). The average percentage correct answers on the knowledge questionnaire increased from 76.5% in the control-group to 80.5% in the PDA-group (p = 0.044). According to the majority of patients in the PDA-group (73.7%) the PDA had added value.

CONCLUSION

Using the PDA had no significant effect on decisional conflict levels, but increased overall knowledge on relevant issues concerning sBCC.

PRACTICE IMPLICATIONS

The PDA can be used as an informational tool by patients with sBCC.

Informed choice and routinization of the second-trimester anomaly scan: a national cohort study in the Netherlands

BACKGROUND

Since 2007 all pregnant women in the Netherlands are offered the second-trimester anomaly scan (SAS) in a nationwide prenatal screening program. This study aims to assess the level of informed choice of women opting for the SAS and to evaluate the presence of routinization 16 years after its implementation. It further explores decisional conflict and women's decision making.

METHODS

This prospective national survey study consisted of an online questionnaire which was completed after prenatal counseling and before undergoing the SAS. Informed choice was measured by the adapted multidimensional measure of informed choice (MMIC) and was defined in case women were classified as value-consistent, if their decision for the SAS was deliberated and made with sufficient knowledge.

RESULTS

A total of 894/1167 (76.6%) women completed the questionnaire. Overall, 54.8% made an informed choice, 89.6% had good knowledge, 59.8% had deliberated their choice and 92.7% held a positive attitude towards the SAS. Women with low educational attainment (p=0.004) or respondents of non-Western descent (p=0.038) were less likely to make an informed choice. Decisional conflict was low, with a significantly lower decisional conflict score in women that made an informed choice (p<0.001). Most respondents (97.9%) did not perceive pressure to undergo the SAS.

CONCLUSIONS

Our study showed a relatively low rate of informed choice for the SAS, due to absence of deliberation. Therefore, some routinization seem to be present in the Netherlands. However, most women had sufficient knowledge, did not perceive pressure and experienced low decisional conflict.

The effects of an online decision aid to support the reproductive decision-making process of genetically at risk couples-A pilot study

Couples at risk of transmitting a genetic disease to their offspring may experience doubts about their reproductive options. This study examines the effects of an online decision aid (DA) on the (joint) reproductive decision-making process of couples (not pregnant at time of inclusion) at risk of transmitting a genetic disease to their offspring. The primary outcome is decisional conflict, and secondary outcomes are knowledge, realistic expectations, deliberation, joint informed decision-making, and decisional self-efficacy. These outcomes were measured with a pretest-posttest design: before use (T0), after use (T1), and 2 weeks after use (T2) of the decision aid (DA). Usability of the DA was assessed at T1. Paired sample t-tests were used to compute differences between baseline and subsequent measurements. The comparisons of T0-T1 and T0-T2 indicate a significant reduction in mean decisional conflict scores with stronger effects for participants with high baseline decisional conflict scores. Furthermore, use of the DA led to increased knowledge, improved realistic expectations, and increased levels of deliberation, with higher increase in participants with low baseline scores. Decision self-efficacy only improved for participants with lower baseline scores. Participants indicated that the information in the DA was comprehensible and clearly organized. These first results indicate that this online DA is an appropriate tool to support couples at risk of transmitting a genetic disease and a desire to have (a) child(ren) in their reproductive decision-making process.

A web-based decision aid for shared decision making in pelvic organ prolapse: the SHADE-POP trial

INTRODUCTION AND HYPOTHESIS

Among women worldwide, pelvic organ prolapse (POP) is a common problem. There are three different treatment options for POP: pelvic floor muscle therapy, pessary treatment and prolapse surgery. As none of the three treatment options is clearly superior, shared decision making (SDM) is very important. A decision aid (DA) is known to facilitate patient participation and SDM. We hypothesise that the use of a web-based DA for POP increases patients' satisfaction with information and care and reduces decisional conflict.

METHODS

This two-arm, multicentre, cluster randomised controlled trial was performed in women with POP in five different Dutch hospitals. The control group received usual care (UC) and the intervention group received the DA in addition to UC. Primary outcome measures were satisfaction with treatment decision making and satisfaction with information. Analyses were performed using independent sample t tests, Chi-squared tests, and multilevel linear regression analyses.

RESULTS

Between the DA group (n=40) and the UC group (n=56) no differences were found concerning patients' satisfaction with information, with scores of 45.63 and 46.14 out of 50 respectively (p=0.67). Also, no differences were found concerning the perceived role in decision making, as patients scored 46.83 in the DA group and 46.41 in the UC group, out of a maximum of 54 (n=0.81).

CONCLUSIONS

No differences were found concerning patients' satisfaction with information and treatment decision making between the DA and UC. However, both groups scored high on the questionnaires, which suggests that the decision process is already of high quality.

Mainstream germline genetic testing in men with metastatic prostate cancer: design and protocol for a multicenter observational study

BACKGROUND

In international guidelines, germline genetic testing is recommended for patients with metastatic prostate cancer. Before undergoing germline genetic testing, these patients should receive pre-test counseling. In the standard genetic care pathway, pre-test counseling is provided by a healthcare professional of a genetics department. Because the number of patients with metastatic prostate cancer is large, the capacity in the genetics departments might be insufficient. Therefore, we aim to implement so-called mainstream genetic testing in the Netherlands for patients with metastatic prostate cancer. In a mainstream genetic testing pathway, non-genetic healthcare professionals discuss and order germline genetic testing. In our DISCOVER study, we will assess the experiences among patients and non-genetic healthcare professionals with this new pathway.

METHODS

A multicenter prospective observational cohort study will be conducted in 15 hospitals, in different regions of the Netherlands. We developed an online training module on genetics in prostate cancer and the counseling of patients. After completion of this module, non-genetic healthcare professionals will provide pre-test counseling and order germline genetic testing in metastatic prostate cancer patients. Both non-genetic healthcare professionals and patients receive three questionnaires. We will determine the experience with mainstream genetic testing, based on satisfaction and acceptability. Patients with a pathogenic germline variant will also be interviewed. We will determine the efficacy of the mainstreaming pathway, based on time investment for non-genetic healthcare professionals and the prevalence of pathogenic germline variants.

DISCUSSION

This study is intended to be one of the largest studies on mainstream genetic testing in prostate cancer. The results of this study can improve the mainstream genetic testing pathway in patients with prostate cancer.

TRIAL REGISTRATION

The study is registered in the WHO's International Clinical Trials Registry Platform (ICTRP) under number NL9617.

Individualised follow-up for head and neck cancer-design of a prospective cohort study to assess its feasibility

INTRODUCTION

It is a common practice for many cancer types to monitor patients after treatment to detect new disease manifestations early. For head and neck cancer (HNC), however, long-term routine follow-up is up for debate for several reasons. The benefits of prolonged routine follow-up on survival have not been proven. Also, cancer follow-up is putting increasing pressure on healthcare resources due to rising incidence and survival rates. Therefore, this study investigates a novel follow-up approach among HNC patients, giving them the opportunity to choose their own follow-up programme.

METHODS AND ANALYSIS

HNC patients are offered a decision-aided choice between standardised or individualised follow-up after 1.5 years of uncomplicated guideline-prescribed follow-up. Standardised follow-up entails continuing the 5-year guideline-prescribed schedule. Individualised follow-up means the patient only attends the outpatient clinic on their own initiative in case of physical symptoms or supportive care needs. Patients are educated on self-examination and when a control visit is necessary. The primary outcome measure is the feasibility of offering patients this choice. Secondary outcome measures are quality of life, costs, productivity loss and detection of new disease.

ETHICS AND DISSEMINATION

We believe that it is essential to let patients determine their follow-up programme based on their own values and preferences. If this choice is feasible, it can be implemented and investigated in other HNC care centres.

TRIAL REGISTRATION NUMBER

NCT05386225.

Mainstream genetic testing for women with ovarian cancer provides a solid basis for patients to make a well-informed decision about genetic testing

BACKGROUND

There is a growing need for genetic testing of women with epithelial ovarian cancer. Mainstream genetic testing provides an alternative care pathway in which non-genetic healthcare professionals offer pre-test counseling themselves. We aimed to explore the impact of mainstream genetic testing on patients' experiences, turnaround times and adherence of non-genetic healthcare professionals to the mainstream genetic testing protocol.

METHODS

Patients receiving pre-test counseling at the gynecology departments between April 2018 and April 2020 were eligible to participate in our intervention group. Patients receiving pre-test counseling at the genetics department between January 2017 and April 2020 were eligible to participate in our control group. We evaluated patients' experiences with questionnaires, consisting of questions regarding knowledge, satisfaction and psychosocial outcomes. Patients in the intervention group were sent two questionnaires: one after pre-test counseling and one after receiving their DNA test result. Patients in our control group were sent one questionnaire after receiving their test result. In addition, we collected data regarding turnaround times and adherence of non-genetic healthcare professionals to the mainstream genetic testing protocol.

RESULTS

Participation was 79% in our intervention group (105 out of 133 patients) and 60% in our control group (91 out of 152 patients). Knowledge regarding genetics, decisional conflict, depression, anxiety, and distress were comparable in the two groups. In the intervention group, the risk of breast cancer in patients carrying a pathogenic germline variant was discussed less often (49% versus 74% in control group, p ≤ 0.05), and the mean score of regret about the decision to have genetic testing was higher than in the control group (mean 12.9 in the intervention group versus 9.7 in the control group, p ≤ 0.05), although below the clinically relevant threshold of 25. A consent form for the DNA test and a checklist to assess family history were present for ≥ 95% of patients in the intervention group.

CONCLUSION

Mainstream genetic testing is an acceptable approach to meet the increase in genetic testing among women with epithelial ovarian cancer.

Patient and physician shared decision-making behaviors in oncology: Evidence on adequate measurement properties of the iSHARE questionnaires

OBJECTIVES

We have developed two Dutch questionnaires to assess the shared decision-making (SDM) process in oncology; the iSHAREpatient and iSHAREphysician. In this study, we aimed to determine: scores, construct validity, test-retest agreement (iSHAREpatient), and inter-rater (iSHAREpatient-iSHAREphysician) agreement.

METHODS

Physicians from seven Dutch hospitals recruited cancer patients, and completed the iSHAREphysician and SDM-Questionnaire-physician version. Their patients completed the: iSHAREpatient, nine-item SDM-Questionnaire, Decisional Conflict Scale, Combined Outcome Measure for Risk communication And treatment Decision-making Effectiveness, and five-item Perceived Efficacy in Patient-Physician Interactions. We formulated, respectively, one (iSHAREphysician) and 10 (iSHAREpatient) a priori hypotheses regarding correlations between the iSHARE questionnaires and questionnaires assessing related constructs. To assess test-retest agreement patients completed the iSHAREpatient again 1-2 weeks later.

RESULTS

In total, 151 treatment decision-making processes with unique patients were rated. Dimension and total iSHARE scores were high both in patients and physicians. The hypothesis on the iSHAREphysician and 9/10 hypotheses on the iSHAREpatient were confirmed. Test-retest and inter-rater agreement were>.60 for most items.

CONCLUSIONS

The iSHARE questionnaires show high scores, have good construct validity, substantial test-retest agreement, and moderate inter-rater agreement.

PRACTICE IMPLICATIONS

Results from the iSHARE questionnaires can inform both physician- and patient-directed efforts to improve SDM in clinical practice.

Disappointing evaluation of a shared decision-making intervention for residents and orthopaedic surgeons

OBJECTIVE

To evaluate a shared decision-making (SDM) intervention in orthopaedic hip and knee osteoarthritis care.

METHODS

Using a pre- post intervention design study, we tested an intervention, that included a decision aid for patients (ptDA) and a SDM training course for residents in training and orthopaedic surgeons. The theory of planned behaviour was used for intervention development. Primary outcomes included patient reported decisional conflict, SDM, and satisfaction. Secondary outcomes were physicians' attitude and knowledge, and uptake of the ptDA.

RESULTS

317 patients were included. The intervention improved physicians' knowledge about SDM but had no effect on the primary outcomes. 19 eligible patients used the ptDA (17%). SDM was higher for middle educated patients compared to lower educated (mean difference 9.91, p=0.004), patients who saw surgeons instead of residents (mean difference 5.46, p=0.044) and when surgery was chosen and desired by patients compared to situations where surgery was desired but not chosen (mean difference 15.39, p=0.036).

CONCLUSION

Our multifaceted intervention did not improve SDM and ptDA uptake was low.

PRACTICE IMPLICATIONS

In orthopaedic hip and knee osteoarthritic care other ways should be explored to successful implement SDM. Since residents received lower SDM scores, special focus should go to this group.

Decisional Conflict after Deciding on Potential Participation in Early Phase Clinical Cancer Trials: Dependent on Global Health Status, Satisfaction with Communication, and Timing

When standard treatment options are not available anymore, patients with advanced cancer may participate in early phase clinical trials. Improving this complex decision-making process may improve their quality of life. Therefore, this prospective multicenter study with questionnaires untangles several contributing factors to decisional conflict (which reflects the quality of decision-making) in patients with advanced cancer who recently decided upon early phase clinical trial participation (phase I or I/II). We hypothesized that health-related quality of life, health literacy, sense of hope, satisfaction with the consultation, timing of the decision, and the decision explain decisional conflict. Mean decisional conflict in 116 patients was 30.0 (SD = 16.9). Multivariate regression analysis showed that less decisional conflict was reported by patients with better global health status (β = −0.185, p = 0.018), higher satisfaction (β = −0.246, p = 0.002), and who made the decision before (β = −0.543, p < 0.001) or within a week after the consultation (β = −0.427, p < 0.001). These variables explained 37% of the variance in decisional conflict. Healthcare professionals should realize that patients with lower global health status and who need more time to decide may require additional support. Although altering such patient intrinsic characteristics is difficult, oncologists can impact the satisfaction with the consultation. Future research should verify whether effective patient-centered communication could prevent decisional conflict.

Psychometric Evaluation of the Chinese Version of Decisional Conflict Scale in Chinese Young Women Making HPV Vaccination Decisions

PURPOSE

The Decisional Conflict Scale (DCS) is a well-known scale for measuring personal decisional conflict, particularly when a person feels uninformed about the risks/benefits of choices, is unclear about personal values, and feels unsupported in making a choice. Higher scores of DCS indicate higher decisional conflict. In the present study, we aimed to assess the psychometric properties of the Chinese version of the DCS among Chinese young women making HPV vaccination decisions.

METHODS

A total of 107 HPV-unvaccinated Chinese women aged 18-26 completed the survey assessing decisional conflict, knowledge and decision of HPV vaccination. Factorial validity, construct validity, and reliability of the DCS were examined.

RESULTS

The mean score of the DCS-16 was 41.5 (SD=20.0). Principal component analysis extracted a 3-factor model of DCS containing 13 items (DCS-13), but both the original DCS-16 and extracted DCS-13 showed poor factorial validity. An alternative DCS-10 revealed a good fit to the data with Cronbach's alpha 0.86. Some subscales of the three versions of DCS showed inconsistent correlation.

CONCLUSION

The DCS-10 demonstrated good model fit to the data. By using the DCS-10 total score rather than sub-scores to measure Chinese young women's HPV vaccination decisional conflict a more valid assessment can be obtained.

Psychometric Assessment of the Mandarin Version of the Decisional Conflict Scale with Pregnant Women Making Prenatal Test Decisions

PURPOSE

Women with high-risk pregnancies are often required to make choices about further prenatal testing for Down syndrome, but the decisional conflict they face is poorly understood. This study aimed to test the validity and reliability of the Mandarin version of the decisional conflict scale (M-DCS) in Chinese women with high-risk pregnancies making choices about further prenatal testing for Down syndrome.

PATIENTS AND METHODS

A methodological study was conducted to determine the psychometric properties of the M-DCS, specially, reliability and content, construct, and concurrent validity. The convenience sample comprised 240 pregnant women with high risk for Down syndrome attending the out-patient clinic of the study hospital in Guangzhou, China.

RESULTS

The five-factor model of M-DCS was supported by confirmatory factor analysis with a satisfactory fit to the data (RMSEA <0.08, RMR <0.05, GFI, CFI, NFI, and IFI all >0.90, except AGFI=0.88 PNFI = 0.76). The internal consistency of the M-DCS was high, with Cronbach's α of 0.94.

CONCLUSION

The reliability and validity (content, construct, and concurrent) of the M-DCS were all demonstrated as good. This instrument is an important tool for researchers and health-care providers working with women with high-risk pregnancies who need to make choices about further prenatal testing for Down syndrome.

Adaptation and Validation of the Spanish Version of Decisional Conflict Scale in People with Migraine in Spain

PURPOSE

We aimed to validate the Spanish version of the Decisional Conflict Scale (DCS) and analyze its psychometric properties in people with migraine.

PATIENTS AND METHODS

The DCS validation comprised two phases. First, a translation and cross-cultural adaptation following the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Good Practices: 1-preparation, 2-independent forward translation, 3-reconciliation, 4-back-translation, 5-harmonization, 6-clinical review, and 7-content validation in a group of migraine patients. Second, the analysis of the psychometric properties. The reliability or internal consistency of the DCS scale and subscales was assessed using Cronbach's α value. The item-subscale correlation was also evaluated. A floor and ceiling effects for DCS score was considered when at least 15% of respondents obtained DCS >90 (ceiling) or <10 (floor). The construct validity was studied through the correlation between the DCS subscales and by the correlation between the DCS and other questionnaires (Decision Self-Efficacy Scale [DSES] and 9-item Shared Decision-Making [SDM-Q-9]). Spearman's coefficients were estimated for the correlations.

RESULTS

The cross-cultural adaptation was conducted on 17 patients who completed the questionnaire in a mean of 2.4 ±1.1 minutes. Generally, more than 75% of them considered that DCS items were adequate, easy to understand, and relevant. The psychometric properties were evaluated in a sample of n=128 patients. Accordingly, the internal consistency of DCS was high, with a Cronbach's α of 0.97 for the scale and between 0.87 to 0.96 for subscales. Also, a slight floor effect was observed, with 24.2% of patients having DCS scores <10. The correlation between subscales exceeded Spearman's coefficient of 0.7. Whereas the correlation between the DCS and the other questionnaires was generally moderate (Spearman's coefficient >0.4).

CONCLUSION

The Spanish version (Spain) of the DCS has very acceptable psychometric properties (reliability and construct validity) and good potential for assessing decisional conflicts among migraine patients.

A patient decision aid for breast cancer patients deciding on their radiation treatment, no change in decisional conflict but better informed choices

BACKGROUND AND PURPOSE

In selected breast cancer patients, radiation treatment (RT) lowers the recurrence risk, with minor or no improvement of survival. In these patients, the choice to undergo RT is considered a preference-sensitive decision. To facilitate shared decision-making (SDM) for this choice, a patient decision aid was made. We aimed to evaluate the effect of the PtDA on decisional conflict.

MATERIAL AND METHODS

We performed a multi-center pre- and post-intervention study (BRASA-trial). The first 214 patients made a choice without support of the PtDA; the subsequent 189 patients received a link to the PtDA. The primary endpoint was decisional conflict; secondary endpoints were perceived SDM and knowledge on treatment options. Patients filled out questionnaires immediately after, and three months after their decision. Data were analyzed with multi-level regression analysis.

RESULTS

After correcting for the difference in age and educational level, the mean (±SD) decisional conflict for the intervention group (27.3 ± 11.4) was similar to the control group (26.8 ± 11.4; difference = 0.86, 95 %CI 1.67,3.36) three months after their decision. This also applied to perceived SDM. Patients exposed to the PtDA pursued additional treatment less often (45% vs 56%, odds ratio 0.59, 95 %CI 0.37,0.95) and scored significantly higher on the knowledge test (7.4 ± 2.5 vs 6.1 ± 2.7, corrected difference = 1.0, 95 %CI 0.50,1.49). There was no significant increase in consultation time.

CONCLUSIONS

Handing out the PtDA was not associated with improved scores in decisional conflict or perceived SDM, but it was associated with a choice for less additional treatment and better knowledge about the treatment options.

The Evaluation of Health-Related Quality of Life Issues Experienced by Patients with Desmoid-Type Fibromatosis (The QUALIFIED Study)-A Protocol for an International Cohort Study

Sporadic desmoid-type fibromatosis (DTF) is a rare soft tissue tumour with an unpredictable clinical course. These tumours are incapable of metastasising, but their local aggressive tumour growth and tendency to recur locally can result in a substantial symptom burden. Measuring the impact of DTF on health-related quality of life (HRQoL) can be challenging due to the variable clinical presentation of the disease. Therefore, a HRQoL instrument assessing DTF-specific issues is needed. The QUALIFIED study aims to (1) pre-test a previously developed DTF-specific HRQoL tool (the DTF-QoL); (2) evaluate prevalence of HRQoL issues in adult DTF patients; and (3) identify subgroups at risk of impaired HRQoL. This study (NCT04289077) is an international, multicentre, cross-sectional, observational cohort study. Patients ≥ 18 years with sporadic DTF from the Netherlands and the United Kingdom will be invited to complete a set of questionnaires specifically composed for this patient group. Questionnaires will be completed using PROFILES (Patient Reported Outcomes Following Initial treatment and Long-term Evaluation of Survivorship). Analyses will include testing the psychometric properties of the DTF-QoL and evaluating the prevalence of HRQoL issues using the DTF-QoL, EORTC QOL-C30 and EQ-5D-5L, among other questionnaires. This study will provide insight into HRQoL issues experienced by patients with DTF. Awareness of these issues and the implementation of the DTF-QoL in research and clinical practice can help to improve overall HRQoL and to provide personalised care.

Couple-based expanded carrier screening provided by general practitioners to couples in the Dutch general population: psychological outcomes and reproductive intentions

Purpose

The aim of expanded preconception carrier screening (ECS) is to inform any couple wishing to conceive about their chances of having children with severe autosomal or X-linked recessive conditions. Responsible implementation of ECS as reproductive genetic screening in routine care requires assessment of benefits and harms. We examined the psychological outcomes of couple-based ECS for 50 autosomal recessive (AR) conditions provided by general practitioners (GPs) to couples from the Dutch general population.

Methods

Dutch GPs invited 4,295 women aged 18–40. We examined anxiety (State-Trait Anxiety Inventory, STAI-6), worry, decisional conflict (DCS) over time in participants declining GP counseling or attending GP counseling with/without testing.

Results

One hundred ninety couples participated; 130 attended counseling, of whom 117 proceeded with testing. No carrier couples were identified. Before counseling, worry (median 6.0) and anxiety (mean 30–34) were low and lower than the population reference (36.4), although some individuals reported increased anxiety or worry. At follow-up, test acceptors reported less anxiety than test decliners (mean 29 vs. 35); differences in anxiety after testing compared to before counseling were not meaningful. Most participants (90%) were satisfied with their decision (not) to undergo testing.

Conclusion

Some individuals reported temporarily clinically relevant distress. Overall, the psychological outcomes are acceptable and no barrier to population-wide implementation.

Decision Analysis in SHared decision making for Thromboprophylaxis during Pregnancy (DASH-TOP): a sequential explanatory mixed methods pilot study protocol

INTRODUCTION

Decision analysis is a quantitative approach to decision making that could bridge the gap between decisions based solely on evidence and the unique values and preferences of individual patients, a feature especially important when existing evidence cannot support clear recommendations and there is a close balance between harms and benefits for the treatments options under consideration. Low molecular weight heparin (LMWH) for the prevention of venous thromboembolism (VTE) during pregnancy represents one such situation. The objective of this paper is to describe the rationale and methodology of a pilot study that will explore the application of decision analysis to a shared decision-making process involving prophylactic LMWH for pregnant women or those considering pregnancy who have experienced a VTE.

METHODS AND ANALYSIS

We will conduct an international, mixed methods, explanatory, sequential study, including quantitative data collection and analysis followed by qualitative data collection and analysis. In step I, we will ask women who are pregnant or considering pregnancy and have experienced VTE to participate in a shared decision-making intervention for prophylactic LMWH. The intervention consists of three components: a direct choice exercise, a values elicitation exercise and a personalised decision analysis. After administration of the intervention, we will ask women to make a treatment decision and measure decisional conflict, self-efficacy and satisfaction. In step II, which follows the analysis of quantitative data, we will use the results to inform the qualitative interview. Step III will be a qualitative descriptive study that explores participants' experiences and perceptions of the intervention. In step IV, we will integrate findings from the qualitative and quantitative analyses to obtain meta-inferences.

ETHICS AND DISSEMINATION

Site-specific ethics boards have approved the study. All participants will provide informed consent. The research team will take an integrated approach to knowledge translation.

DIALysis or not: Outcomes in older kidney patients with GerIatriC Assessment (DIALOGICA): rationale and design

Background

The incidence and prevalence of older patients with kidney failure who are dependent on dialysis is increasing. However, observational studies showed limited or no benefit of dialysis on mortality in subgroups of these patients when compared to conservative care. As the focus is shifting towards health-related quality of life (HRQoL), current evidence of effects of conservative care or dialysis on HRQoL in older patients is both limited and biased. Dialysis comes with both high treatment burden for patients and high costs for society; better identification of patients who might not benefit from dialysis could result in significant cost savings. The aim of this prospective study is to compare HRQoL, clinical outcomes, and costs between conservative care and dialysis in older patients.

Methods

The DIALysis or not: Outcomes in older kidney patients with GerIatriC Assessment (DIALOGICA) study is a prospective, observational cohort study that started in February 2020. It aims to include 1500 patients from 25 Dutch and Belgian centres. Patients aged ≥70 years with an eGFR of 10–15 mL/min/1.73m² are enrolled in the first stage of the study. When dialysis is initiated or eGFR drops to 10 mL/min/1.73m² or lower, the second stage of the study commences. In both stages nephrogeriatric assessments will be performed annually, consisting of questionnaires and tests to assess most common geriatric domains, i.e. functional, psychological, somatic, and social status. The primary outcome is HRQoL, measured with the Twelve-item Short-Form Health Survey. Secondary outcomes are clinical outcomes (mortality, hospitalisation, functional status, cognitive functioning, frailty), cost-effectiveness, and decisional regret. All outcomes are (repeated) measures during the first year of the second stage. The total follow-up will be a maximum of 4 years with a minimum of 1 year in the second stage.

Discussion

By generating more insight in the effects of conservative care and dialysis on HRQoL, clinical outcomes, and costs, findings of this study will help patients and physicians make a shared decision on the best individual treatment option for kidney failure.

Trial registration

The study was registered in the Netherlands Trial Register (NL-8352) on 5 February 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02235-y.

The Effect of Providing Audiovisual Surgical Information on Decisional Conflict in Patients Undergoing Plate Fixation for Distal Radius Fractures

Backgroud

Patients experiencing acute trauma have limited time for their involvement in shared decision making, which may lead to decisional conflict. The purpose of this study was to evaluate whether providing audiovisual surgical information can reduce decisional conflict when deciding between surgical and nonsurgical treatment in patients with distal radius fractures (DRFs) and to evaluate factors that may affect decisional conflict.

Methods

We prospectively enrolled 50 consecutive patients who presented with acute DRFs and chose to undergo surgery, for which volar plate fixation was recommended. We randomized these patients into 2 groups. The test group was given a video clip of audiovisual surgical information in addition to regular information while the control group was only given regular information. The video clip consisted of the purpose, procedure, and effect of the surgery, precautions and complications after the operation, and other treatment options that could be performed if operation was not performed. At 2 weeks after the surgery, we evaluated patients' decisional conflict using a decisional conflict scale (DCS). In addition, we evaluated factors that might affect decisional conflict, such as age, dominant hand, comorbidities, history of previous operations, perceived disability, and provision of the video clip.

Results

The test group showed significantly lower DCS scores than the control group (19.6 vs. 32.1, p = 0.001). In multivariate analysis, younger age and provision of the video clip were associated with lower DCS scores.

Conclusions

This study has demonstrated that providing information through audiovisual media such as video clips could reduce decisional conflict in patients who chose to undergo plate fixation for DRFs. This study also suggests that older patients may need more careful doctor-patient communication as they have more decisional conflict than younger patients.

Measuring psychosocial outcomes of men living with prostate cancer: feasibility of regular assessment of patient-reported outcomes

OBJECTIVE

To trial collecting patient-reported outcome measures (PROMs) to assess psychosocial outcomes in men with prostate cancer (PC).

METHODS

A cross-sectional postal survey was sent to three groups of 160 men with PC (6, 12 and 24 months post-initial treatment; n_total  = 480), through the South Australian Prostate Cancer Clinical Outcomes Collaborative (SAPCCOC) registry (2017). Outcomes were as follows: response rate, completeness, general and disease-specific quality of life, distress, insomnia, fear of recurrence, decisional difficulties and unmet need.

RESULTS

A response rate of 57-61% (n = 284) was achieved across groups. Data completeness was over 90% for 88% of survey items, with lower response (76-78%) for EPIC-26 urinary and sexual functioning subscales, sexual aid use (78%) and physical activity (68%). In general, higher socio-economic indicators were associated with higher completion of these measures (absolute difference 12-26%, p < 0.05). Lower unmet need on the sexuality domain (SCNS-SF34) was associated with lower completion of the EPIC-26 sexual functioning subscale [M (SD) = 12.4 (21.6); M (SD) = 26.3 (27.3), p < .001]. Worse leaking urine was associated with lower completion of urinary pad/diaper use question (EPIC-26) [M (SD) = 65.9 (26.5), M (SD) = 77.3 (23.9), p < .01].

CONCLUSION

Assessment of psychosocial PROMs through a PC registry is feasible and offers insight beyond global quality of life assessment, to facilitate targeting and improvements in services and treatments.

Decisional conflict in breast cancer patients considering immediate breast reconstruction

Background

Breast cancer (BC) patients who are treated with mastectomy are frequently offered immediate breast reconstruction. This study aimed to assess decisional conflict in patients considering immediate breast reconstruction, and to identify factors associated with clinically significant decisional conflict (CSDC).

Methods

Baseline data of a multicenter randomized controlled trial evaluating the impact of an online decision aid for BC patients considering immediate breast reconstruction after mastectomy were analyzed. Participants completed questionnaires assessing sociodemographic and clinical characteristics, decisional conflict and other patient-reported outcomes related to decision-making such as breast reconstruction preference, knowledge, information resources used, preferred involvement in decision-making, information coping style, and anxiety. Multivariable logistic regression analysis was performed to identify factors associated with CSDC (score > 37.5 on decisional conflict).

Results

Of the 250 participants, 68% experienced CSDC. Patients with a slight preference for breast reconstruction (odds ratio (OR) = 6.19, p < .01), with no preference for or against breast reconstruction (OR = 11.84, p < .01), and with a strong preference for no breast reconstruction (OR = 5.20, p < .05) were more likely to experience CSDC than patients with a strong preference for breast reconstruction. Furthermore, patients with more anxiety were more likely to experience CSDC (OR = 1.03, p = .01).

Conclusion

A majority of BC patients who consider immediate breast reconstruction after mastectomy experience clinically significant decisional conflict. The findings emphasize the need for decision support, especially for patients who do not have a strong preference for breast reconstruction.

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A majority of patients considering immediate breast reconstruction experience decisional conflict.

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Patients without a strong preference for breast reconstruction are more likely to experience decisional conflict.

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Patients with more anxiety are more likely to experience decisional conflict.

Evaluation of the Decision Aid for Genital Surgery in Transmen

BACKGROUND

Multiple options of genital gender-affirming surgery are available to transmen. The transman should be able to weigh these options based on the outcomes, risks, and consequences that are most important to him. For this reason, a decision aid for genital surgery in transmen (DA-GST) was developed. It aims to support the transman in making thoughtful choices among treatment options and facilitate shared decision-making between the healthcare professionals and the transindividual.

AIM

The aim of this study was to evaluate the newly developed DA-GST.

METHODS

This was a cross-sectional study using mixed methods. Transmen considering to undergo genital surgery were eligible to partake in the study. The questionnaires used in this study were developed by adapting the validated Dutch translation of the "Decisional Conflict Scale," the "Measures of Informed Choice," and the "Ottawa Preparation for Decision-Making Scale." Qualitative interviews were conducted querying their subjective experience with the DA-GST. The data from the questionnaires were statistically analyzed, and the data from the interviews were thematically analyzed.

OUTCOMES

The main outcome measures were decisional conflict and decisional confidence measured via self-report items and qualitative data regarding the use of the DA-GST via interviews.

RESULTS

In total, 51 transmen participated in the questionnaires study, 99 questionnaires were analyzed, and 15 interviews were conducted. Although confident in their decision, most transmen felt responsible to collect the necessary information themselves. The ability to go through the decision aid independently aided the decision-making process by providing information and highlighting their subjective priorities. Suggested additions are pictures of postoperational outcomes and personal statements from experienced transmen.

CLINICAL TRANSLATION

The DA-GST could be implemented as an integral part of transgender health care. Clinicians could take the individual personal values into account and use it to accurately tailor their consult. This would ultimately improve the doctor-patient relationship and decrease decisional regret by enhancing effective shared decision-making.

STRENGTHS & LIMITATIONS

This mixed-method design study confirmed the use of the DA-GST while taking a broad range of decisional factors into account. Limitations include the absence of a baseline analysis and the limited power for the comparison of treatment groups.

CONCLUSIONS

This study suggests that the DA-GST helped transmen feel more prepared for their personal consult with the surgeon, reduced decisional conflict, and increased their decisional confidence. Mokken SE, Özer M, van de Grift TC, et al. Evaluation of the Decision Aid for Genital Surgery in Transmen. J Sex Med 2020;17:2067-2076.

Health-related quality Of Life n patients with advanced Soft TIssue sarcomas treated with Chemotherapy (The HOLISTIC study): protocol for an international observational cohort study

INTRODUCTION

Chemotherapy is the mainstay of treatment for patients with advanced soft tissue sarcomas (STS). Treatment intent is usually palliative, aiming to improve symptoms, stabilise or reduce tumour burden and extend life. Clinical trials have traditionally used radiological response, time to progression and survival as measures of treatment efficacy. Health-related quality of life (HRQoL) is at least equally important or more important than survival for many patients with advanced cancer. Systematically collecting HRQoL data during chemotherapy can provide greater insight into treatment efficacy from the patient perspective.The primary aims of this study are to evaluate HRQoL in patients with advanced STS treated with chemotherapy over time, explore the decision-making process and patient reflection post-treatment.

METHODS AND ANALYSIS

This is an observational, international cohort study for 132 patients aged ≥18 years with advanced STS treated at eight centres (three in the UK, five in the Netherlands). Patients will be recruited prior to starting first-line or third-line chemotherapy and invited to complete questionnaires using the Patient-Reported Outcomes Following Initial treatment and Long-term Evaluation of Survivorship registry (PROFILES); an established international registry for collection of cancer patient-reported outcomes. Online (or paper) questionnaires will be completed at baseline, each cycle of chemotherapy and 2-3 monthly during follow-up. The questionnaire package includes the Decisional Conflict Scale, Control Preferences Scale, Quality-Quantity Questionnaire, treatment expectations, European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC-QLQ-C30), EORTC financial toxicity items, Work Ability Index, Functional Assessment of Cancer Therapy-General (FACT-G) items and Decisional Regret Scale. Clinical data will be extracted from patient records and linked with questionnaire responses. The primary outcome measure is the change in global HRQoL from baseline to after cycle 4 of first-line chemotherapy (based on published data showing that patients with advanced STS complete a median number of four cycles of first-line chemotherapy).

ETHICS AND DISSEMINATION

Heath Research Authority and Research Ethics Committee (REC 17/NI/0197). Results from the Health-related quality Of Life In patients with advanced Soft TIssue sarcomas treated with Chemotherapy (HOLISTIC) study will be published in peer-reviewed journals and disseminated at local, national and international conferences. We will also present our findings at any appropriate patient meetings and involve patients in study-related publications.

TRIAL REGISTRATION NUMBER

NCT03621332.

The influence of spirituality on decision-making in palliative care outpatients: a cross-sectional study

BACKGROUND

Decision-making in palliative care can be complex due to the uncertain prognosis and general fear surrounding decisions. Decision-making in palliative care may be influenced by spiritual and cultural beliefs or values. Determinants of the decision-making process are not completely understood, and spirituality is essential for coping with illness. Thus, this study aims to explore the influence of spirituality on the perception of healthcare decision-making in palliative care outpatients.

METHODS

A cross-sectional study was developed. A battery of tests was administered to 95 palliative outpatients, namely: sociodemographic questionnaire (SQ), Decisional Conflict Scale (DCS), Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being scale (FACIT-Sp), and a semi-structured interview (SSI) to study one's perception of spirituality and autonomy in decision-making. Statistical analyses involved descriptive statistics for SQ and SSI. The Mann-Whitney test was used to compare scale scores between groups and correlations were used for all scales and subscales. The analysis of patients' definitions of spirituality was based on the interpretative phenomenological process.

RESULTS

Spiritual wellbeing significantly correlated with greater levels of physical, emotional and functional wellbeing and a better quality of life. Greater spiritual wellbeing was associated with less decisional conflict, decreased uncertainty, a feeling of being more informed and supported and greater satisfaction with one's decision. Most patients successfully implemented their decision and identified themselves as capable of early decision-making. Patients who were able to implement their decision presented lower decisional conflict and higher levels of spiritual wellbeing and quality of life. Within the 16 themes identified, spirituality was mostly described through family. Patients who had received spiritual care displayed better scores of spiritual wellbeing, quality of life and exhibited less decisional conflict. Patients considered spirituality during illness important and believed that the need to receive spiritual support and specialised care could enable decision-making when taking into consideration ones' values and beliefs.

CONCLUSION

The impact of spiritual wellbeing on decision-making is evident. Spirituality is a key component of overall wellbeing and it assumes multidimensional and unique functions. Individualised care that promotes engagement in decision-making and considers patients' spiritual needs is essential for promoting patient empowerment, autonomy and dignity.

Cross-cultural adaptation and psychometric assessment of the statement format Decisional Conflict Scale for Mandarin version

Background

The statement format of the Decisional Conflict Scale (sf-DCS) is designed and widely used to assess patients’ state of uncertainty during health related decision making. As yet no Mandarin version of the sf-DCS has been produced. This study aims to produce the first Mandarin version of the sf-DCS and test its validity and reliability in mainland China.

Methods

The translation and cross-cultural adaptation of the original English version of the sf-DCS into Mandarin was carried out in accordance with previously published guidelines. The psychometric properties of sf-DCS were assessed in two hypothesized decision-making contexts through online surveys.

Results

In the online survey designed to test scale validity and reliability, 437 people responded to the influenza immunization survey and 238 responded to the breast cancer screening survey. The results confirm that the Mandarin version of sf-DCS has good criteria validity and the exploratory factor analysis suggested a fitted revised five factors model by removing three items. Respondents who were “unsure” about their decisions/intentions, had read less information, and reported lower self-perceived prior knowledge level scored higher on sf-DCS. The Cronbach’s alpha for the sf-DCS total score was 0.963 and that for each subscale ranged from 0.784 to 0.937 in both decision making contexts, and the test-retest correlation coefficient was 0.528.

Conclusions

The Mandarin version of sf-DCS has good criteria validity and its internal consistency is satisfactory. Our analysis suggests a refinement of the original sf-DCS’s factor structure is needed.

Effect of a Skills Training for Oncologists and a Patient Communication Aid on Shared Decision Making About Palliative Systemic Treatment: A Randomized Clinical Trial

BACKGROUND

Palliative systematic treatment offers uncertain and often limited benefits, and the burden can be high. Hence, treatment decisions require shared decision making (SDM). This trial examined the independent and combined effect of an oncologist training and a patient communication aid on SDM.

METHODS

In this multicenter randomized controlled trial with four parallel arms (2016-2018), oncologists (n = 31) were randomized to receive SDM communication skills training or not. The training consisted of a reader, two group sessions, a booster session, and a consultation room tool (10 hours). Patients (n = 194) with advanced cancer were randomized to receive a patient communication aid or not. The aid consisted of education on SDM, a question prompt list, and a value clarification exercise. The primary outcome was observed SDM as rated by blinded observers from audio-recorded consultations. Secondary outcomes included patient-reported SDM, patient and oncologist satisfaction, patients' decisional conflict, patient quality of life 3 months after consultation, consultation duration, and the decision made.

RESULTS

The oncologist training had a large positive effect on observed SDM (Cohen's d = 1.12) and on patient-reported SDM (d = 0.73). The patient communication aid did not improve SDM. The combination of interventions did not add to the effect of training oncologists only. The interventions affected neither patient nor oncologist satisfaction with the consultation nor patients' decisional conflict, quality of life, consultation duration, or the decision made.

CONCLUSION

Training medical oncologists in SDM about palliative systemic treatment improves both observed and patient-reported SDM. A patient communication aid does not. The incorporation of skills training in (continuing) educational programs for medical oncologists is likely to stimulate the widely advocated uptake of shared decision making in clinical practice.

TRIAL REGISTRATION

Netherlands Trial Registry NTR 5489.

IMPLICATIONS FOR PRACTICE

Treatment for advanced cancer offers uncertain and often small benefits, and the burden can be high. Hence, treatment decisions require shared decision making (SDM). SDM is increasingly advocated for ethical reasons and for its beneficial effect on patient outcomes. Few initiatives to stimulate SDM are evaluated in robust designs. This randomized controlled trial shows that training medical oncologists improves both observed and patient-reported SDM in clinical encounters (n = 194). A preconsultation communication aid for patients did not add to the effect of training oncologists. SDM training effectively changes oncologists' practice and should be implemented in (continuing) educational programs.

Introducing a time out consultation with the general practitioner between diagnosis and start of colorectal cancer treatment: Patient-reported outcomes

Objective

To evaluate the introduction of a “time out consultation” with the general practitioner (GP) recommended to patients following the diagnosis of colorectal carcinoma (CRC) before start of treatment.

Methods

A prospective study using questionnaires to compare the number of GP consultations, with their content and outcomes before and after the introduction of an additional consultation with the GP to improve decision‐making and adequate support.

Results

72 patients before and 98 patients after the introduction of the “time out consultation” participated. Introduction of the consultation increased the number of patients to contact their GP from 67% to 80%, but did not change kind or content of the consultations. Patients felt the consultation was comforting and were more satisfied with the GP after the introduction. There was no difference in outcomes measured by the questionnaires in all patients combined, but men, older patients and patients with palliative treatment options only did improve on specific outcomes after the introduction.

Conclusion

The introduction of the “time out consultation” did not change the kind or content of GP consultations before start of CRC treatment, but patients did feel more comforted and satisfied. Subgroups of patients benefited on specific outcomes.

The impact of an online patient decision aid for women with breast cancer considering immediate breast reconstruction: study protocol of a multicenter randomized controlled trial

Background

Most breast cancer patients undergoing mastectomy are candidates for breast reconstruction. Deciding about breast reconstruction is complex and the preference-sensitive nature of this decision requires an approach of shared decision making between patient and doctor. Women considering breast reconstruction have expressed a need for decision support. We developed an online patient decision aid (pDA) to support decision making in women considering immediate breast reconstruction. The primary aim of this study is to assess the impact of the pDA in reducing decisional conflict, and more generally, on the decision-making process and the decision quality. Additionally, we will investigate the pDA’s impact on health outcomes, explore predictors, and assess its cost-effectiveness.

Methods

A multicenter, two-armed randomized controlled trial (1:1) will be conducted. Women with breast cancer or ductal carcinoma in situ who will undergo a mastectomy and are eligible for immediate breast reconstruction will be invited to participate. The intervention group will receive access to the online pDA, whereas the control group will receive a widely available free information leaflet on breast reconstruction. Participants will complete online questionnaires at: baseline (T0), 1 week after consultation with a plastic surgeon (T1), and 3 (T2) and 12 months (T3) after surgery. The primary outcome is decisional conflict. Secondary outcomes include other measures reflecting the decision-making process and decision quality (e.g., decision regret), patient-reported health outcomes (e.g., satisfaction with the breasts) and costs.

Discussion

This study will provide evidence about the impact of an online pDA for women who will undergo mastectomy and are deciding about breast reconstruction. It will contribute to the knowledge on how to optimally support women in making this difficult decision.

Trial registration

This study is retrospectively registered at ClinicalTrials.gov (NCT03791138).

How to foster informed decision making about food supplements: results from an international Delphi study

Food supplement use can have beneficial and detrimental effects, making informed decisions about supplement use important. How these decisions are made and which communication strategies can stimulate informed decision making is unclear. This study identified the important characteristics of (i) informed decision making about food supplement use and (ii) important factors indicating how to communicate about food supplements to foster informed decision making. An online three-round Delphi study was conducted. International experts within the field of (risk) communication about food supplements or related fields were recruited via email. The participants' age ranged from 25 to 69 years, and sample sizes for the three rounds were 38, 89 and 51, respectively. Experts indicated that for making an informed decision about food supplement use one needs to have knowledge of their positive and negative effects, the ability to compare these effects, knowing alternatives besides supplements, feeling informed, and feeling able (self-efficacious) to make the decision and making the decision voluntarily. Important communication strategies mentioned were: provision of information about positive and negative effects and the nature of these effects including scientific evidence, ensuring information is easily accessible, well ordered, tailored and provided by a trustworthy, credible and independent source.

Item response theory analysis and properties of decisional conflict scales: findings from two multi-site trials of men with localized prostate cancer

Background

Decisional conflict is associated with decision quality and may affect decision outcomes. In the health sciences literature, the Decisional Conflict Scale is widely used to measure decisional conflict, yet limited research has described the psychometric properties of the Decisional Conflict Scale subscales and of the low literacy version of the scale. The purpose of this secondary data analysis was therefore to examine properties of the original (DCS-12) and low literacy (LL DCS-10) Decisional Conflict Scales using Classical Measurement Theory and Item Response Theory.

Methods

Data from two multi-site trials of men with prostate cancer were used to analyze the DCS-12, LL DCS-10, and an aggregated DCS-12 dataset in which five response options were aggregated into three. Internal consistency was estimated with Cronbach’s alphas. Subscale correlations were evaluated with Pearson’s correlation coefficient. Item difficulty, item discrimination, and test information were evaluated using Graded Response Modeling (GRM). The likelihood ratio test guided model selection.

Results

Cronbach’s alphas for the total scales and three of four subscales were ≥ 0.85. Alphas ranged from 0.34–0.57 for the support subscales. Subscale correlations ranged from 0.42–0.71 (P < 0.001). Items on the DCS-12 exhibited the widest range of difficulty. Two items on the support subscale had low to moderate discrimination and contributed little information. Only the DCS-12 was informative across the full range of decisional conflict values.

Conclusions

Lack of precision in the support subscale raises concerns about subscale validity. The DCS-12 is most capable of discriminating between respondents with high and low decisional conflict. Evaluation of interventions to reduce decisional conflict must consider the above findings.

Electronic supplementary material

The online version of this article (10.1186/s12911-019-0853-5) contains supplementary material, which is available to authorized users.

Patient explicit consideration of tradeoffs in decision making about rectal cancer treatment: benefits for decision process and quality of life

Introduction: Patient preferences are often not discussed in treatment decisions in oncology. We introduced an online values clarification method (VCM) to help newly diagnosed rectal cancer patients participate in shared decision making about short-course preoperative radiotherapy. Material and Methods: We offered a link to the VCM to a subset of consecutive patients before the pretreatment consultation with the radiation oncologist. Consultations were audiotaped and coded for expressions of patient preferences. Patients were asked to complete pre- and post-consultation questionnaires. Questionnaires assessed values clarity, decision regret and presence and impact of fecal incontinence and sexual problems. Results: Of 135 patients who had their consultation audiotaped and completed questionnaires, 35 received and accessed the VCM-link. Patients in the VCM-group slightly more often expressed preferences during consultations. Questionnaire data showed that patients in the VCM-group did not differ in how clear their values were, but experienced lower regret and less impact of treatment harms at 6 months follow-up; differences were non-significant but in the same direction at 12 months. Discussion: This is the first study to assess the effect of an adaptive conjoint analysis-based VCM on actual patient-clinician communication, and long-term decision regret and impact of treatment harms. Being explicitly invited to think about treatment benefits and harms seems to help patients to live with treatment consequences.

Decisional Conflict Scale Use over 20 Years: The Anniversary Review

Background. The Decisional Conflict Scale (DCS) measures 5 dimensions of decision making (feeling: uncertain, uninformed, unclear about values, unsupported; ineffective decision making). We examined the use of the DCS over its initial 20 years (1995 to 2015). Methods. We conducted a scoping review with backward citation search in Google Analytics/Web of Science/PubMed, followed by keyword searches in Cochrane Library, PubMed, Ovid MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, PRO-Quest, and Web of Science. Eligible studies were published between 1995 and March 2015, used an original experimental/observational research design, concerned a health-related decision, and provided DCS data (total/subscales). Author dyads independently screened titles, abstracts, full texts, and extracted data. We performed narrative data synthesis. Results. We included 394 articles. DCS use appeared to increase over time. Three hundred nine studies (76%) used the original DCS, and 29 (7%) used subscales only. Most studies used the DCS to evaluate the impact of decision support interventions (n = 238, 59%). The DCS was translated into 13 languages. Most decisions were made by people for themselves (n = 353, 87%), about treatment (n = 225, 55%), or testing (n = 91, 23%). The most common decision contexts were oncology (n = 113, 28%) and primary care (n = 82, 20%). Conclusions. This is the first study to descriptively synthesize characteristics of DCS data. Use of the DCS as an outcome measure for health decision interventions has increased over its 20-year existence, demonstrating its relevance as a decision-making evaluation measure. Most studies failed to report when decisional conflict was measured during the decision-making process, making scores difficult to interpret. Findings from this study will be used to update the DCS user manual.

Improving shared decision-making in advanced Parkinson's disease: protocol of a mixed methods feasibility study

BACKGROUND

In advanced stages of Parkinson's disease (PD), patients and neurologists regularly face complex treatment decisions. Shared decision-making (SDM) can support the process where evidence, the clinician's expertise and the patient's preferences jointly contribute to reach an optimal decision. Here, we describe the rationale of our feasibility study protocol.The aim of the study is to test the feasibility of the SDM intervention by (1) analysing the acceptability of the intervention by users (i.e. professionals and patients), (2) assessing the level of implementation, (3) testing efficacy on a small scale and (4) evaluating the study procedures.

METHODS

Using an uncontrolled before-after mixed methods design, patients in the pre-intervention group will receive information and decisional support as usual. Patients in the post-intervention group will receive the SDM intervention, consisting of an Option Grid™ patient decision aid and a website with supplementary information plus a value clarification tool for both patients and professionals. An Option Grid is a one-page, evidence-based summary of available options, listing the frequently asked questions that patients consider when making treatment decisions. A value clarification tool helps patients identify which option he/she prefers based on attributes in the treatment decision context. Neurologists and PD nurse specialists will receive a 1-h instruction on SDM and how to use the SDM intervention.Through purposive sampling, neurologists and PD nurse specialists will be recruited from both specialised neurology clinics and community-based hospitals. Included professionals will invite consecutive patients who are eligible for the advanced therapies.Data will be collected using questionnaires, interviews and audio observations of the consultations and by tracking users' logging behaviour of the website. Data will be analysed using a mixed methods design.

DISCUSSION

The mixed methods design will create a deeper understanding of how the SDM intervention affects the interactions between professionals (a neurologist and/or a PD nurse specialist) and the patient, when an advanced treatment is chosen. The results of the study will inform the design of an RCT to test the effectiveness of the SDM intervention.

TRIAL REGISTRATION

NTR6649, retrospectively registered 28 August 2017.

Impact of a web-based prostate cancer treatment decision aid on patient-reported decision process parameters: results from the Prostate Cancer Patient Centered Care trial

Purpose

To compare patients’ evaluation of the treatment decision-making process in localized prostate cancer between counseling that included an online decision aid (DA) and standard counseling.

Methods

Eighteen Dutch hospitals were randomized to DA counseling (n = 235) or the control group with standard counseling (n = 101) in a pragmatic, cluster randomized controlled trial. The DA was provided to patients at, or soon after diagnosis. Decisional conflict, involvement, knowledge, and satisfaction with information were assessed with a questionnaire after treatment decision-making. Anxiety and depression served as covariates.

Results

The levels of decision involvement and conflict were comparable between patients in both groups. Patients with a DA felt more knowledgeable but scored equally well on a knowledge test as patients without a DA. Small significant negative effects were found on satisfaction with information and preparation for decision-making. A preference for print over online and depression and anxiety symptoms was negatively associated with satisfaction and conflict scores in the DA group.

Discussion

The DA aimed to support shared decision-making, while outcomes for a majority of DA users were comparable to patients who received standard counseling. Patients, who are less comfortable with the online DA format or experience anxiety or depression symptoms, could require more guidance toward shared decision-making. To evaluate long-term DA effects, follow-up evaluation on treatment satisfaction and decisional regret will be done.

Evidence-Based Medicine in Otolaryngology, Part 8: Shared Decision Making—Impact, Incentives, and Instruments

In our previous installment, we introduced shared decision making (SDM) as a collaborative process in which patients, families, and clinicians develop a mutually optimized treatment plan when more than 1 reasonable treatment option exists. In this subsequent installment of our Evidence-Based Medicine in Otolaryngology Series, we expand on the topic of SDM, including the related current state of clinical decision making, the impact of SDM on health care utilization and patient satisfaction, the potential role of system and society changes, the experience with SDM as it relates to race and ethnicity, existing financial incentives, and the validated instruments that assess the extent to which SDM occurs.

Shared Decision Making in Prostate Cancer Care-Encouraging Every Patient to be Actively Involved in Decision Making or Ensuring the Patient Preferred Level of Involvement?

PURPOSE

The aims of this study were to 1) describe preferred and experienced roles in treatment decision making among patients with localized prostate cancer, 2) identify how often the roles experienced by patients matched their preferred roles and 3) determine whether active involvement in decision making regardless of role preferences or concordance between preferred and experienced roles would be the strongest predictor of more favorable patient reported outcomes.

MATERIALS AND METHODS

In this prospective, multicenter, observational study we obtained serial questionnaire data from 454 patients with newly diagnosed, localized prostate cancer (cT1-cT2, or Gleason 7 or less and prostate specific antigen 20 ng/ml or less). Questionnaires were completed prior to treatment and at the 3, 6 and 12-month posttreatment followups. Clinical data were obtained from the patient medical records. Active involvement and role concordance were operationalized using the CPS (Control Preferences Scale). ANOVA and effect sizes (small and medium Cohen d = 0.2 and 0.5, respectively) were used to compare patient knowledge of prostate cancer, decision conflict, decision regret and overall health related quality of life.

RESULTS

Of the patients 393 (87%) reported having been actively involved in treatment decision making. However, 78 patients (17%) indicated having had less or more involvement than preferred. Active involvement was significantly associated with more prostate cancer knowledge (d = 0.30), less decision conflict (d = 0.52) and less decision regret (d = 0.34). Role concordance was also but less strongly associated with less decision conflict (d = 0.41).

CONCLUSIONS

Our findings support a policy of encouraging all patients with localized prostate cancer regardless of their stated role preferences to be actively involved in the treatment decision.

Treatment selection of early stage non-small cell lung cancer: the role of the patient in clinical decision making

BACKGROUND

The objective of this study is to investigate the role and experience of early stage non-small cell lung cancer (NSCLC) patient in decision making process concerning treatment selection in the current clinical practice.

METHODS

Stage I-II NSCLC patients (surgery 55 patients, SBRT 29 patients, median age 68) were included in this prospective study and completed a questionnaire that explored: (1) perceived patient knowledge of the advantages and disadvantages of the treatment options, (2) experience with current clinical decision making, and (3) the information that the patient reported to have received from their treating physician. This was assessed by multiple-choice, 1-5 Likert Scale, and open questions. The Decisional Conflict Scale was used to assess the decisional conflict. Health related quality of life (HRQoL) was measured with SF-36 questionnaire.

RESULTS

In 19% of patients, there was self-reported perceived lack of knowledge about the advantages and disadvantages of the treatment options. Seventy-four percent of patients felt that they were sufficiently involved in decision-making by their physician, and 81% found it important to be involved in decision making. Forty percent experienced decisional conflict, and one-in-five patients to such an extent that it made them feel unsure about the decision. Subscores with regard to feeling uninformed and on uncertainty, contributed the most to decisional conflict, as 36% felt uninformed and 17% of patients were not satisfied with their decision. HRQoL was not influenced by patient experience with decision-making or patient preferences for shared decision making.

CONCLUSIONS

Dutch early-stage NSCLC patients find it important to be involved in treatment decision making. Yet a substantial proportion experiences decisional conflict and feels uninformed. Better patient information and/or involvement in treatment-decision-making is needed in order to improve patient knowledge and hopefully reduce decisional conflict.

Tablet-Based Patient-Centered Decision Support for Minor Head Injury in the Emergency Department: Pilot Study

Background

The Concussion or Brain Bleed app is a clinician- and patient-facing electronic tool to guide decisions about head computed tomography (CT) use in patients presenting to the emergency department (ED) with minor head injury. This app integrates a patient decision aid and clinical decision support (using the Canadian CT Head Rule, CCHR) at the bedside on a tablet computer to promote conversations around individualized risk and patients’ specific concerns within the ED context.

Objective

The objective of this study was to describe the use of the Concussion or Brain Bleed app in a high-volume ED and to establish preliminary efficacy estimates on patient experience, clinician experience, health care utilization, and patient safety. These data will guide the planning of a larger multicenter trial testing the effectiveness of the Concussion or Brain Bleed app.

Methods

We conducted a prospective pilot study of adult (age 18-65 years) patients presenting to the ED after minor head injury who were identified by participating clinicians as low risk by the CCHR. The primary outcome was patient knowledge regarding the injury, risks, and CT use. Secondary outcomes included patient satisfaction, decisional conflict, trust in physician, clinician acceptability, system usability, Net Promoter scores, head CT rate, and patient safety at 7 days.

Results

We enrolled 41 patients cared for by 29 different clinicians. Patient knowledge increased after the use of the app (questions correct out of 9: pre-encounter, 3.3 vs postencounter, 4.7; mean difference 1.4, 95% CI 0.8-2.0). Patients reported a mean of 11.7 (SD 13.5) on the Decisional Conflict Scale and 92.5 (SD 12.0) in the Trust in Physician Scale (both scales range from 0 to 100). Most patients were satisfied with the app’s clarity of information (35, 85%), helpfulness of information (36, 88%), and amount of information (36, 88%). In the 41 encounters, most clinicians thought the information was somewhat or extremely helpful to the patient (35, 85%), would want to use something similar for other decisions (27, 66%), and would recommend the app to other providers (28, 68%). Clinicians reported a mean system usability score of 85.1 (SD 15; scale from 0 to 100 with 85 in the “excellent” acceptability range). The total Net Promoter Score was 36.6 (on a scale from –100 to 100). A total of 7 (17%) patients received a head CT in the ED. No patients had a missed clinically important brain injury at 7 days.

Conclusions

An app to help patients assess the utility of CT imaging after head injury in the ED increased patient knowledge. Nearly all clinicians reported the app to be helpful to patients. The high degree of patient satisfaction, clinician acceptability, and system usability support rigorous testing of the app in a larger multicenter trial.

Patient-centered approaches to creating understandable health information

As care delivery shifts to further include patients in shared decision-making, patient-centered health information can balance the information asymmetry between patients and providers. Patient health literacy, numeracy, and graph literacy must match that of health information materials to create understandable health information that empowers patients to participate in shared decision-making. We consider an iterative approach focused on three key steps: assessment of the specific information needs of the selected patient community, assessment of that community's ability to receive and understand health information, and evaluation of the materials developed to assess effectiveness. This structured approach using validated tools maximizes the likelihood of meeting patient needs to improve health outcomes.

Reducing Decisional Conflict and Enhancing Satisfaction with Information among Women Considering Breast Reconstruction following Mastectomy: Results from the BRECONDA Randomized Controlled Trial

BACKGROUND

Deciding whether or not to have breast reconstruction following breast cancer diagnosis is a complex decision process. This randomized controlled trial assessed the impact of an online decision aid [Breast RECONstruction Decision Aid (BRECONDA)] on breast reconstruction decision-making.

METHODS

Women (n = 222) diagnosed with breast cancer or ductal carcinoma in situ, and eligible for reconstruction following mastectomy, completed an online baseline questionnaire. They were then assigned randomly to receive either standard online information about breast reconstruction (control) or standard information plus access to BRECONDA (intervention). Participants then completed questionnaires at 1 and 6 months after randomization. The primary outcome was participants' decisional conflict 1 month after exposure to the intervention. Secondary outcomes included decisional conflict at 6 months, satisfaction with information at 1 and 6 months, and 6-month decisional regret.

RESULTS

Linear mixed-model analyses revealed that 1-month decisional conflict was significantly lower in the intervention group (27.18) compared with the control group (35.5). This difference was also sustained at the 6-month follow-up. Intervention participants reported greater satisfaction with information at 1- and 6-month follow-up, and there was a nonsignificant trend for lower decisional regret in the intervention group at 6-month follow-up. Intervention participants' ratings for BRECONDA demonstrated high user acceptability and overall satisfaction.

CONCLUSIONS

Women who accessed BRECONDA benefited by experiencing significantly less decisional conflict and being more satisfied with information regarding the reconstruction decisional process than women receiving standard care alone. These findings support the efficacy of BRECONDA in helping women to arrive at their breast reconstruction decision.

Decisional conflict between treatment options among end-stage renal disease patients evaluated for kidney transplantation

Although kidney transplantation provides a significant benefit over dialysis, many patients with end-stage renal disease (ESRD) are conflicted about their decision to undergo kidney transplant. We aimed to identify the prevalence and characteristics associated with decisional conflict between treatment options in ESRD patients presenting for transplant evaluation. Among a cross-sectional sample of patients with ESRD (n=464) surveyed in 2014 and 2015, we assessed decisional conflict through a validated 10-item questionnaire. Decisional conflict was dichotomized into no decisional conflict (score=0) and any decisional conflict (score>0). We investigated potential characteristics of patients with decisional conflict using bivariate and multivariable logistic regression. The overall mean age was 50.6 years, with 62% male patients and 48% African American patients. Nearly half (48.5%) of patients had decisional conflict regarding treatment options. Characteristics significantly associated with decisional conflict in multivariable analysis included male sex, lower educational attainment, and less transplant knowledge. Understanding characteristics associated with decisional conflict in patients with ESRD could help identify patients who may benefit from targeted interventions to help patients make informed, value-based, and supported decisions when deciding how to best treat their kidney disease.

Use of a decision aid did not decrease decisional conflict in patients with carpal tunnel syndrome

Background

Although a model for shared decision-making is important for patient-centered care, decisional conflict can emerge when patients participate in the decision-making. A decision aid is proposed to provide information and to involve patients more comfortably in the decision-making process. We aimed to determine whether a decision aid helps patients with carpal tunnel syndrome (CTS) experience less decisional conflict regarding their decision-making for surgery.

Methods

Eighty patients with CTS were randomized into two groups. The test group was given a decision aid in addition to regular information and the control group regular information only. The decision aid consisted of a 6-min videoclip that explains diagnosis and information regarding surgery for CTS with other treatment options. We evaluated patients’ decisional conflict regarding surgery, knowledge about CTS, and symptom severity as measured by the Disabilities of Arm, Shoulder, and Hand (DASH) Questionnaire.

Results

There was no difference in the decisional conflict scale (DCS) between both groups (p = 0.76). The test group had significantly better knowledge than the control group (p = 0.04). There was no correlation between the knowledge score and the DCS (p = 0.76). However, less severe symptoms were correlated with greater decisional conflict (r = −0.29, p = 0.02).

Conclusions

We found that a decision aid does not reduce decisional conflict in patients with CTS, although it can help them be better informed. This study suggests that although a decision-aid is effective for patient education, doctor-patient communication should be more emphasized for patients with less severe symptoms, as they can have greater decisional conflict.

Trial Registration

SNUBH Registry 1510/317-003 Registered November 13, 2015

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1478-4) contains supplementary material, which is available to authorized users.

Trial by Dutch laboratories for evaluation of non-invasive prenatal testing. Part II-women's perspectives

Objective

To evaluate preferences and decision‐making among high‐risk pregnant women offered a choice between Non‐Invasive Prenatal Testing (NIPT), invasive testing or no further testing.

Methods

Nationwide implementation study (TRIDENT) offering NIPT as contingent screening test for women at increased risk for fetal aneuploidy based on first‐trimester combined testing (>1:200) or medical history. A questionnaire was completed after counseling assessing knowledge, attitudes and participation following the Multidimensional Measure of Informed Choice.

Results

A total of 1091/1253 (87%) women completed the questionnaire. Of these, 1053 (96.5%) underwent NIPT, 37 (3.4%) invasive testing and 1 (0.1%) declined testing. 91.7% preferred NIPT because of test safety. Overall, 77.9% made an informed choice, 89.8% had sufficient knowledge and 90.5% had positive attitudes towards NIPT. Women with intermediate (odds ratio (OR) = 3.51[1.70–7.22], p < 0.001) or high educational level (OR = 4.36[2.22–8.54], p < 0.001) and women with adequate health literacy (OR = 2.60[1.36–4.95], p = 0.004) were more likely to make an informed choice. Informed choice was associated with less decisional conflict and less anxiety (p < 0.001). Intention to terminate the pregnancy for Down syndrome was higher among women undergoing invasive testing (86.5%) compared to those undergoing NIPT (58.4%) (p < 0.001).

Conclusions

The majority of women had sufficient knowledge and made an informed choice. Continuous attention for counseling is required, especially for low‐educated and less health‐literate women. © 2016 The Authors. Prenatal Diagnosis published by John Wiley & Sons, Ltd.

What's already known about this topic?

NIPT is offered as alternative to invasive testing to screen pregnant women at high risk for fetal aneuploidy.

Although NIPT has many advantages, concerns have been raised about the consequences for informed decision‐making.

What does this study adds?

Implementation of NIPT in a national healthcare‐funded prenatal screening program, accompanied by pre‐test counseling, results in most women having sufficient knowledge and making an informed choice

Compared to women choosing invasive testing, women undergoing NIPT have less intention to terminate the pregnancy for Down syndrome.

Feasibility and effects of a decision aid about fertility preservation

This paper reports on the feasibility and preliminary effects of a decision aid (DA) about female fertility preservation (FP). We conducted a pilot multicentre randomized controlled trial of women with breast cancer aged 18-40 who were randomized to brochures or the DA. Over 18 months, 62 women were eligible, of which 42 were invited by their healthcare provider (74%) to participate in the study. A total of 36 women signed up for participation and 26 (72%) were randomized to brochures (n = 13) or the DA (n = 13). In both groups, many women (87%) read the brochures and eight women used all available brochures. In the intervention group, 7/13 women logged in to the DA. Women who received brochures had slightly less decisional conflict, whereas knowledge improved in both groups. Our results indicate that both brochures about FP and a detailed DA have beneficial effects with regard to knowledge, but the DA seemed to introduce slightly more decisional conflict (DC) than the brochures. Although we encountered challenges with recruitment, our design and measurements seem feasible and the effects of the information materials seem promising, hence justifying conducting a larger study.

Impact of advance care planning on the care of patients with heart failure: study protocol for a randomized controlled trial

Background

Despite the promise and popularity of advance care planning, there is insufficient evidence that advance care planning helps patients to meet their end-of-life care preferences, especially in Asian settings. Thus, the proposed study aims to assess whether patients with advanced heart failure who are receiving advance care planning have a greater likelihood of receiving end-of-life care consistent with their preferences compared to patients receiving usual care. Secondary objectives are to compare differences in health care expenditures, quality of life, anxiety and depression, understanding of own illness, participation in decision-making and concordance with their caregiver’s preferences for end-of-life care, between patients with advanced heart failure receiving advance care planning and usual care.

Methods/design

This is a two-arm randomized controlled trial of advance care planning versus usual care (control) conducted at two institutions in Singapore. Two hundred and eighty-two patients with advanced heart failure (n = 94 in the advance care planning arm; n = 188 in the control arm receiving usual care) will be recruited from these centers and followed for 1 year or until they die, whichever is earlier. Additionally, the study will include up to one caregiver per patient enrolled.

Discussion

If advance care planning is proven to be effective, the results will help to promote its uptake among health care providers and patients both within Singapore and in other countries.

Trial registration

NCT02299180. Registered on 18 November 2014.

The effect of a decision aid on informed decision-making in the era of non-invasive prenatal testing: a randomised controlled trial

Early in pregnancy women and their partners face the complex decision on whether or not to participate in prenatal testing for fetal chromosomal abnormalities. Several studies show that the majority of pregnant women currently do not make informed decisions regarding prenatal testing. As the range of prenatal tests is expanding due to the development of new techniques such as non-invasive prenatal testing (NIPT), autonomous reproductive decision-making is increasingly challenging. In this study, a randomised controlled trial was conducted to evaluate the effect of a web-based multimedia decision aid on decision-making regarding prenatal testing. The decision aid provided both written and audiovisual information on prenatal tests currently available, that is, prenatal screening by first-trimester combined testing, NIPT and invasive diagnostic testing through chorionic villus sampling or amniocentesis. Furthermore, it contained values clarification exercises encouraging pregnant women to reflect on the potential harms and benefits of having prenatal tests performed. The use of the decision aid improved informed decision-making regarding prenatal testing. Of pregnant women allocated to the intervention group (n=130) 82.3% made an informed choice compared with 66.4% of women in the control group (n=131), P=0.004. As the vast majority of pregnant women made decisions consistent with their attitudes towards having prenatal testing performed, this improvement in informed decision-making could be attributed mainly to an increase in decision-relevant knowledge. This study shows that the implementation of a web-based multimedia decision aid directly facilitates the ultimate goal of prenatal testing for fetal chromosomal abnormalities, which is enabling informed autonomous reproductive choice.

Knowledge and Informed Decision-Making about Population-Based Colorectal Cancer Screening Participation in Groups with Low and Adequate Health Literacy

Objective. To analyze and compare decision-relevant knowledge, decisional conflict, and informed decision-making about colorectal cancer (CRC) screening participation between potential screening participants with low and adequate health literacy (HL), defined as the skills to access, understand, and apply information to make informed decisions about health. Methods. Survey including 71 individuals with low HL and 70 with adequate HL, all eligible for the Dutch organized CRC screening program. Knowledge, attitude, intention to participate, and decisional conflict were assessed after reading the standard information materials. HL was assessed using the Short Assessment of Health Literacy in Dutch. Informed decision-making was analyzed by the multidimensional measure of informed choice. Results. 64% of the study population had adequate knowledge of CRC and CRC screening (low HL 43/71 (61%), adequate HL 47/70 (67%), p > 0.05). 57% were informed decision-makers (low HL 34/71 (55%), adequate HL 39/70 (58%), p > 0.05). Intention to participate was 89% (low HL 63/71 (89%), adequate HL 63/70 (90%)). Respondents with low HL experienced significantly more decisional conflict (25.8 versus 16.1; p = 0.00). Conclusion. Informed decision-making about CRC screening participation was suboptimal among both individuals with low HL and individuals with adequate HL. Further research is required to develop and implement effective strategies to convey decision-relevant knowledge about CRC screening to all screening invitees.