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

Decision aids for people facing health treatment or screening decisions

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Potential effects of virtual interventions for menopause management: a systematic review

IMPORTANCE

Menopausal women are one of the fastest growing demographic groups globally. Virtual interventions have emerged as alternate avenues for menopausal women to manage and cope with their symptoms.

OBJECTIVE

The purpose of this review is to summarize existing research on the potential effects of virtual interventions for menopause management.

EVIDENCE REVIEW

This systematic review was written in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. MEDLINE, PsychINFO, CINAHL, AgeLine, ERIC, ProQuest, Nursing and Allied Health Database, PsychARTICLES, and Sociology Database were used for literature search and searched from conception to December 2021. Original studies, including randomized controlled trials and quasi-experimental studies, were included if they evaluated a virtual intervention for menopause management and investigated the effects of these interventions on physical and psychosocial outcomes and/or the feasibility of these interventions among menopausal women. Included studies were published in peer-reviewed journals and assessed for quality using the Critical Appraisal Skills Program Checklists.

FINDINGS

A total of 16 articles were included in this review. Virtual interventions have the potential to improve physical health outcomes including body weight/body mass index/waist circumference, pain, blood pressure, and cholesterol. However, conflicting results were identified for the outcomes of vasomotor and endocrine symptoms, sleep, and sexual functioning. Virtual interventions might also improve psychosocial outcomes, including knowledge and patient-physician communication, although conflicting results were again identified for treatment decision-making ability, quality of life, and anxiety and depression. Virtual interventions were feasible in terms of being usable and cost-effective, and eliciting satisfaction and compliance among menopausal women.

CONCLUSIONS AND RELEVANCE

Virtual interventions might have the potential to improve the physical and psychosocial health outcomes of menopausal women, although some conflicting findings arose. Future studies should focus on including diverse menopausal women and ethnic minorities, conducting research within low- to middle-income countries and communities, further exploring intervention design to incorporate features that are age and culture sensitive, and conducting full randomized controlled trials to evaluate the effects of the interventions.

Does audio-visual information result in improved health-related decision-making compared with audio-only or visual-only information? Protocol for a systematic review and meta-analysis

INTRODUCTION

Making health-related decisions can be difficult due to the amount and complexity of information available. Audio-visual information may improve memory for health information but whether audio-visual information can enhance health-related decisions has not been explored using quantitative methods. The objective of this systematic review is to understand how effective audio-visual information is for informing health-related decision-making compared with audio-only or visual-only information.

METHODS AND ANALYSIS

Randomised controlled trials (RCTs) will be included if they include audio-visual and either audio-only or visual-only information provision and decision-making in a health setting. Studies will be excluded if they are not reported in English. Twelve databases will be searched including: Ovid MEDLINE, PubMed and PsychINFO. The Cochrane Risk of Bias tool (V.7) will be used to assess risk of bias in included RCTs. Results will be synthesised primarily using a meta-analysis; where quantitative data are not reported, a narrative synthesis will be used.

ETHICS AND DISSEMINATION

No ethical issues are foreseen. Data will be disseminated via academic publication and conference presentations. Findings may also be published in scientific newsletters and magazines. This review is funded by the Economic and Social Research Council.

PROSPERO REGISTRATION NUMBER

CRD42021255725.

Does the use of patient decision aids lead to cost savings? a systematic review

OBJECTIVES

To update a previous systematic review to determine if patient decision aid (PDA) interventions generate savings in healthcare settings, and if so, from which perspective (ie, patient, organisation providing care, society).

DESIGN

Systematic review.

DATA SOURCES

MEDLINE, CINAHL, PsycINFO, Web of Science, Cochrane Library, Embase, Campbell Collaboration Library, EconLit, Business Source Complete, Centre for Reviews and Dissemination: NHS Economic Evaluations Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA) from 15 March 2013 to 25 January 2019. The references of studies that met the eligibility criteria and any publications related to conference abstracts or registered clinical trials were reviewed to increase the sensitivity of the search.

ELIGIBILITY CRITERIA

Full and partial economic evaluations with an experimental, quasi-experimental or randomised controlled design were included. The intervention had to satisfy the pre-determined minimum conditions necessary to be defined as a PDA, and (for full evaluations) provide details on the comparator used.

DATA EXTRACTION AND SYNTHESIS

All study outcomes and economic data were extracted. The reporting and quality of the economic analyses were independently assessed by two health economists.

RESULTS

Of 5066 studies, 22 studies were included, including the 8 studies from the previous review. Twelve studies reported cost-savings (range=US$10 to US$81 156; US dollars in 2020), primarily from the organisational or health system perspective, and 10 studies did not. However, due to the quality of the economic analyses, and the related issues with the interpretative validity of results it would be inappropriate to say that PDAs will generate savings, from any perspective.

CONCLUSIONS

It is unclear whether PDAs will generate savings. Greater consensus on what constitutes a PDA and the need to compare them against usual care over a sufficient time horizon to allow valid assessment of costs and outcomes is required.

PROSPERO REGISTRATION NUMBER

CRD42019118457.

The Role of Images on Illness Behaviour: Interdisciplinary Theory, Evidence, and Ideas

If illness behaviour is to be fully understood, the social and behavioural sciences must work together to understand the wider forms in which illness is experienced and communicated with individuals and society. The current paper synthesised literature across social and behavioural sciences exploring illness experience and communication through physical and mental images. It argues that images may have the capacity to embody and influence beliefs, emotions, and health outcomes. While four commonalities exist, facilitating understandings of illness behaviour across the fields (i.e., understanding the importance of the patient perspective; perception of the cause, sense of identity with the illness, consequences, and level of control; health beliefs influencing illness experience, behaviours, and outcomes; and understanding illness beliefs and experiences through an almost exclusive focus on the written or spoken word), we will focus on exploring the fourth commonality. The choice to focus on the role of images on illness behaviour is due to the proliferation of interventions using image-based approaches. While these novel approaches show merit, there is a scarcity of theoretical underpinnings and explorations into the ways in which these are developed and into how people perceive and understand their own illnesses using image representations. The current paper identified that the use of images can elucidate patient and practitioner understandings of illness, facilitate communication, and potentially influence illness behaviours. It further identified commonalities across the social and behavioural sciences to facilitate theory informed understandings of illness behaviour which could be applied to visual intervention development to improve health outcomes.

Framework for Pharmacy Services Quality Improvement-A Bridge to Cross the Quality Chasm

OBJECTIVE

To review the literature on the subject of quality improvement principles and methods applied to pharmacy services and to describe a framework for current and future efforts in pharmacy services quality improvement and effective drug therapy management.

BACKGROUND

The Academy of Managed Care Pharmacy produced the Catalog of Pharmacy Quality Indicators in 1997, followed by the Summary of National Pharmacy Quality Measures in February 1999. In April 2002, AMCP introduced Pharmacy's Framework for Drug Therapy Management in the 21st Century. The Framework documents include a self-assessment tool that details more than 250 specific "components" that describe tasks, behaviors, skills, functions, duties, and responsibilities that contribute to meeting customer expectations for effective drug therapy management.

FINDINGS

There are many opportunities for quality improvement in clinical, service, and cost outcomes related to drug therapy management. These may include patient safety; incidence of medical errors; adverse drug events; patient adherence to therapy; attainment of target goals of blood pressure, glucose, and lipid levels; risk reduction for adverse cardiac events and osteoporotic-related fractures; patient satisfaction; risk of hospitalization or mortality; and cost of care. Health care practitioners can measure improvements in health care quality in several ways including (a) a better patient outcome at the same cost, (b) the same patient outcome at lower cost, (c) a better patient outcome at lower cost, or (d) a significantly better patient outcome at moderately higher cost. Measurement makes effective management possible. A framework of component factors (e.g., tasks) is necessary to facilitate changes in the key processes and critical factors that will help individual practitioners and health care systems meet customer expectations in regard to drug therapy, thus improving these outcomes.

CONCLUSIONS

Quality improvement in health care services in the United States will be made in incremental changes that rely on a structure-process-outcome model. The structure is provided by evidence created from controlled randomized trials and other studies of care and system outcomes that are based on the scientific method. The process portion is created by the application of evidence in the form of clinical practice guidelines, clinical practice models, and self-assessment tools such as Pharmacy's Framework for Drug Therapy Management. Incremental changes in structure and process will result in the desirable outcome of meeting customer needs for more effective drug therapy and disease management.

DISCLOSURES

Authors Richard N. Fry and Steven G. Avey are employed by the Foundation for Managed Care Pharmacy, a nonprofit charitable trust that serves as the educational and philanthropic arm of the Academy of Managed Care Pharmacy; author Frederic R. Curtiss performed the majority of work associated with this manuscript prior to becoming editor-in-chief of the Journal of Managed Care Pharmacy. This manuscript underwent blinded peer review and was subject to the same standards as every article published in JMCP.

Menopause uncertainty: the impact of two educational interventions among women during menopausal transition and beyond

Introduction

Menopause is a natural part of women's lives, which is associated with physical and mental changes and can lead to uncertainty and consequent undesirable effects in the lives of menopausal women. The present study was conducted to compare the impact of multimedia and booklet educational methods on the uncertainty about menopause during this transition period.

Materials and methods

In a cluster randomized trial 68 women aged 45-55 years were randomly allocated into two groups: multimedia and booklet. Data were collected using knowledge and uncertainty questionnaires about menopause in three stages, i.e. before intervention, immediately after intervention (two weeks later), and one month later. Repeated-measures analysis of variance (rANOVA) was used to compare knowledge and uncertainty scores between two groups for the duration of the study. Data were analysed using SPSS software and p values < 0.05 were considered as statistically significant.

Results

The results of the study indicated a high level of uncertainty in both groups before the implementation of the educational program. There was no significant difference between groups in terms of knowledge and uncertainty about menopause over time (p > 0.05). However, we found a significant increase in knowledge and a significant decrease in uncertainty scores in both groups (p < 0.001) after the interventions.

Conclusions

Although the findings of this study did not show a significant difference between the effect of multimedia and booklet educational methods in postmenopausal women, the high level of uncertainty of women before intervention and its significant reduction after the implementation of the educational programs indicated the importance of education throughout this period.

A Review of Decision Aids for Patients Considering More Than One Type of Invasive Treatment

With continuous advances in medicine, patients are faced with several medical or surgical treatment options for their health conditions. Decision aids may be useful in helping patients navigate these options and choose based on their goals and values. We reviewed the literature to identify decision aids and better understand the effect on patient decision-making. We identified 107 decision aids designed to help patients make decisions between medical treatment or screening options; 39 decision aids were used to help patients choose between a medical and surgical treatment, and five were identified that aided patients in deciding between a major open surgical procedure and a less invasive option. Many of the decision aids were used to help patients decide between prostate, colorectal, and breast cancer screening or treatment options. Although most decision aids were not associated with a significant effect on the actual decision made, they were largely associated with increased patient knowledge, decreased decisional conflict, more accurate perception of risks, increased satisfaction with their decision, and no increase in anxiety surrounding their decision. These data identify a gap in use of decision aids in surgical decision-making and highlight the potential to help surgical patients make value-based, knowledgeable decisions regarding their treatment.

Informed consent for a neonatal clinical trial: parental experiences and perspectives

OBJECTIVE

There is a variability regarding timing of consent and personnel used in patient recruitment for neonatal research. We explored the associations between the study personnel and timing of consent with parents' decisional conflict and ultimately their decision to enroll.

STUDY DESIGN

This was a multi-site, cross-sectional survey conducted between August 2015 and October 2017. Participants were parents approached to enroll their 24-28-week infant in a clinical trial. Parents completed an interviewer-administered 61-item questionnaire.

RESULTS

Overall, 163 surveys were completed; 105 by parents of enrolled infants and 58 by parents of non-enrolled infants (54.5% participation rate). Neither the individual requesting nor timing of consent was associated with parents' knowledge score, decisional conflict, or decision to enroll. Parents preferred to be approached prenatally and by their infant's doctor.

CONCLUSION

Study designers and IRBs may allow flexibility in personnel and timing of consent as it is respectful of parents and may enhance trial enrollment.

Patient centred care for the medical treatment of lower urinary tract symptoms in patients with benign prostatic obstruction: a key point to improve patients' care - a systematic review

Background

Even though evidence based medicine, guidelines and algorithms still represent the pillars of the management of chronic diseases (i.e: hypertension, diabetes mellitus), a patient centred approach has been recently proposed as a successful strategy, in particular to improve drug adherence. Aim of the present review is to evaluate the unmet needs in LUTS/BPH management and the possible impact of a patient centered approach in this setting.

Methods

A National Center for Biotechnology Information (NCBI) PubMed search for relevant articles published from January 2000 until December 2016 was performed by combining the following MESH terms: patients centred medicine, patient centered care, person centered care, patient centered outcomes, value based care, shared decision making, male, Lower Urinary Tract Symptoms, Benign Prostatic Hyperplasia, treatment. We followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). All studies reporting on patient centred approach, shared decision making and evidence-based medicine were included in the review. All original article, reviews, letters, congress abstracts, and editorials comments were included in the review. Studies reporting single case reports, experimental studies on animal models and studies not in English were not included in the review.

Results

Overall 751 abstracts were reviewed, out of them 87 full texts were analysed resulting in 36 papers included. The evidence summarised in this systematic review confirmed how a patient centred visit may improve patient’s adherence to medication. Although a patient centred model has been rarely used in urology, management of Low Urinary Tract Symptoms (LUTS) and Benign Prostatic Obstruction (BPO) may represent the perfect ground to experiment and improve this approach. Notwithstanding all the innovations in LUTS/BPO medical treatment, the real life picture is far from ideal.

Conclusions

Recent evidence shows a dramatical low drug adherence and satisfaction to medical treatment in LUTS/BPH patients. A patient centred approach may improve drug adherence and some unmet needs in this area, potentially reducing complications and costs. However further well designed studies are needed to confirm this data.

Cost-effectiveness of the BRECONDA decision aid for women with breast cancer: Results from a randomized controlled trial

OBJECTIVE

To report on the cost-effectiveness of BRECONDA (Breast RECONstruction Decision Aid), a web-based decision aid to facilitate decisions regarding breast reconstruction surgery, with usual care for women with breast cancer.

METHODS

The economic evaluation was conducted alongside a randomized controlled trial. Women diagnosed with breast cancer or ductal carcinoma in situ and eligible for breast reconstruction following mastectomy were randomized to access BRECONDA for 6 months + usual care (n = 106) or usual care (n = 116) and were assessed at baseline preintervention, and then 1-month and 6-months post-randomization. Decisional conflict, satisfaction with information, decisional regret, and utilities were assessed by using maximum-likelihood linear mixed effects models. Costs included the fixed costs of BRECONDA, health care provider time, and health care resource use. Nonparametric bootstrapping was used to estimate incremental cost-effectiveness ratios.

RESULTS

BRECONDA resulted in significantly less decisional conflict and greater satisfaction with information over time. Quality-adjusted life years did not differ between participants who received the decision aid compared with usual care. The cost of BRECONDA was estimated to be small (AUD$10) relative to other health care interventions and resulted in decreased health care costs overall (AUD$764). Based on the point estimates, the decision aid was more effective and less costly (dominant) for all measures of effectiveness. It was estimated that the decision aid has an 87% probability of being cost-effective at $60 000 per quality-adjusted life year gained.

CONCLUSIONS

The BRECONDA web-based intervention designed to facilitate decisions regarding breast reconstruction surgery is likely to be cost-effective compared with usual care for women with breast cancer.

Video-based patient decision aids: A scoping review

OBJECTIVE

This study reviews the published literature on the use of video-based decision aids (DA) for patients. The authors describe the areas of medicine in which video-based patient DA have been evaluated, the medical decisions targeted, their reported impact, in which countries studies are being conducted, and publication trends.

METHOD

The literature review was conducted systematically using Medline, Embase, CINAHL, PsychInfo, and Pubmed databases from inception to 2016. References of identified studies were reviewed, and hand-searches of relevant journals were conducted.

RESULTS

488 studies were included and organized based on predefined study characteristics. The most common decisions addressed were cancer screening, risk reduction, advance care planning, and adherence to provider recommendations. Most studies had sample sizes of fewer than 300, and most were performed in the United States. Outcomes were generally reported as positive. This field of study was relatively unknown before 1990s but the number of studies published annually continues to increase.

CONCLUSION

Videos are largely positive interventions but there are significant remaining knowledge gaps including generalizability across populations.

PRACTICE IMPLICATIONS

Clinicians should consider incorporating video-based DA in their patient interactions. Future research should focus on less studied areas and the mechanisms underlying effective patient decision aids.

Use of the Menopause-Specific Quality of Life (MENQOL) questionnaire in research and clinical practice: a comprehensive scoping review

OBJECTIVE

The Menopause-Specific Quality of Life (MENQOL) questionnaire was developed as a validated research tool to measure condition-specific QOL in early postmenopausal women. We conducted a comprehensive scoping review to explore the extent of MENQOL's use in research and clinical practice to assess its value in providing effective, adequate, and comparable participant assessment information.

METHODS

Thirteen biomedical and clinical databases were systematically searched with "menqol" as a search term to find articles using MENQOL or its validated derivative MENQOL-Intervention as investigative or clinical tools from 1996 to November 2014 inclusive. Review articles, conference abstracts, proceedings, dissertations, and incomplete trials were excluded. Additional articles were collected from references within key articles. Three independent reviewers extracted data reflecting study design, intervention, sample characteristics, MENQOL questionnaire version, modifications and language, recall period, and analysis detail. Data analyses included categorization and descriptive statistics.

RESULTS

The review included 220 eligible papers of various study designs, covering 39 countries worldwide and using MENQOL translated into more than 25 languages. A variety of modifications to the original questionnaire were identified, including omission or addition of items and alterations to the validated methodological analysis. No papers were found that described MENQOL's use in clinical practice.

CONCLUSIONS

Our study found an extensive and steadily increasing use of MENQOL in clinical and epidemiological research over 18 years postpublication. Our results stress the importance of proper reporting and validation of translations and variations to ensure outcome comparison and transparency of MENQOL's use. The value of MENQOL in clinical practice remains unknown.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Age-related macular degeneration: what do patients find on the internet?

Objective

To assess the quality of information and readability of the top internet sites for age-related macular degeneration (AMD).

Design

An examination of the technical information provision, quality and readability of websites found during an internet search for ‘age-related macular degeneration’.

Setting

Six internet search engines were used to find 26 unique sites on AMD.

Main outcome measures

Technical information and quality were assessed using a simple grading system. Readability was assessed using a Simple Measure Of Gobbledygook (SMOG) rating.

Results

Twelve organizational, seven academic and seven commercial sites were identified. The average technical scores were 82.3%, 67.9% and 65.2% for each type of site, respectively ( P=0.097, one way ANOVA). The average quality scores were 62.2%, 62.6%, and 49.5% for each type of site, respectively ( P=0.356, one-way ANOVA). The average SMOG ratings were 16.3, 16.1, and 16.2 for each type of site, respectively ( P=0.983, one-way ANOVA). Fifteen of the sites provided details of new and emerging treatments, with seven providing a detailed discussion.

Conclusions

Many websites are now meeting the challenge of providing comprehensive information about AMD and its new treatments. Quality scores were disappointing, with sites needing to provide more evidence of authorship and attribution of information. The majority of sites had SMOG scores above 10, making them difficult for the average person to understand. As physicians we need to help design and direct patients to sites that provide high quality, current information.

Web-based interventions for menopause: A systematic integrated literature review

Advances in computer and Internet technologies have allowed health care providers to develop, use, and test various types of Web-based interventions for their practice and research. Indeed, an increasing number of Web-based interventions have recently been developed and tested in health care fields. Despite the great potential for Web-based interventions to improve practice and research, little is known about the current status of Web-based interventions, especially those related to menopause. To identify the current status of Web-based interventions used in the field of menopause, a literature review was conducted using multiple databases, with the keywords "online," "Internet," "Web," "intervention," and "menopause." Using these keywords, a total of 18 eligible articles were analyzed to identify the current status of Web-based interventions for menopause. Six themes reflecting the current status of Web-based interventions for menopause were identified: (a) there existed few Web-based intervention studies on menopause; (b) Web-based decision support systems were mainly used; (c) there was a lack of detail on the interventions; (d) there was a lack of guidance on the use of Web-based interventions; (e) counselling was frequently combined with Web-based interventions; and (f) the pros and cons were similar to those of Web-based methods in general. Based on these findings, directions for future Web-based interventions for menopause are provided.

Shared decision making in endocrinology: present and future directions

In medicine and endocrinology, there are few clinical circumstances in which clinicians can accurately predict what is best for their patients. As a result, patients and clinicians frequently have to make decisions about which there is uncertainty. Uncertainty results from limitations in the research evidence, unclear patient preferences, or an inability to predict how treatments will fit into patients' daily lives. The work that patients and clinicians do together to address the patient's situation and engage in a deliberative dialogue about reasonable treatment options is often called shared decision making. Decision aids are evidence-based tools that facilitate this process. Shared decision making is a patient-centred approach in which clinicians share information about the benefits, harms, and burden of different reasonable diagnostic and treatment options, and patients explain what matters to them in view of their particular values, preferences, and personal context. Beyond the ethical argument in support of this approach, decision aids have been shown to improve patients' knowledge about the available options, accuracy of risk estimates, and decisional comfort. Decision aids also promote patient participation in the decision-making process. Despite accumulating evidence from clinical trials, policy support, and expert recommendations in endocrinology practice guidelines, shared decision making is still not routinely implemented in endocrine practice. Additional work is needed to enrich the number of available tools and to implement them in practice workflows. Also, although the evidence from randomised controlled trials favours the use of this shared decision making in other settings, populations, and illnesses, the effect of this approach has been studied in a few endocrine disorders. Future pragmatic trials are needed to explore the effect and feasibility of shared decision making implementation into routine endocrinology and primary care practice. With the available evidence, however, endocrinologists can now start to practice shared decision making, partner with their patients, and use their expertise to formulate treatment plans that reflect patient preferences and are more likely to fit into the context of patients' lives. In this Personal View, we describe shared decision making, the evidence behind the approach, and why and how both endocrinologists and their patients could benefit from this approach.

Decision Aids for Benign Prostatic Hyperplasia: Applicability across Race and Education

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

A Randomized Controlled Trial to Evaluate the Benefits of a Multimedia Educational Program for First-Time Hearing Aid Users

OBJECTIVES

The aims of this study were to (1) develop a series of short interactive videos (or reusable learning objects [RLOs]) covering a broad range of practical and psychosocial issues relevant to the auditory rehabilitation for first-time hearing aid users; (2) establish the accessibility, take-up, acceptability and adherence of the RLOs; and (3) assess the benefits and cost-effectiveness of the RLOs.

DESIGN

The study was a single-center, prospective, randomized controlled trial with two arms. The intervention group (RLO+, n = 103) received the RLOs plus standard clinical service including hearing aid(s) and counseling, and the waitlist control group (RLO-, n = 100) received standard clinical service only. The effectiveness of the RLOs was assessed 6-weeks posthearing aid fitting. Seven RLOs (total duration 1 hr) were developed using a participatory, community of practice approach involving hearing aid users and audiologists. RLOs included video clips, illustrations, animations, photos, sounds and testimonials, and all were subtitled. RLOs were delivered through DVD for TV (50.6%) and PC (15.2%), or via the internet (32.9%).

RESULTS

RLO take-up was 78%. Adherence overall was at least 67%, and 97% in those who attended the 6-week follow-up. Half the participants watched the RLOs two or more times, suggesting self-management of their hearing loss, hearing aids, and communication. The RLOs were rated as highly useful and the majority of participants agreed the RLOs were enjoyable, improved their confidence and were preferable to written information. Postfitting, there was no significant between-group difference in the primary outcome measure, overall hearing aid use. However, there was significantly greater hearing aid use in the RLO+ group for suboptimal users. Furthermore, the RLO+ group had significantly better knowledge of practical and psychosocial issues, and significantly better practical hearing aid skills than the RLO- group.

CONCLUSIONS

The RLOs were shown to be beneficial to first-time hearing aid users across a range of quantitative and qualitative measures. This study provides evidence to suggest that the RLOs may provide valuable learning and educational support for first-time hearing aid users and could be used to supplement clinical rehabilitation practice.

Features of Computer-Based Decision Aids: Systematic Review, Thematic Synthesis, and Meta-Analyses

Background

Patient information and education, such as decision aids, are gradually moving toward online, computer-based environments. Considerable research has been conducted to guide content and presentation of decision aids. However, given the relatively new shift to computer-based support, little attention has been given to how multimedia and interactivity can improve upon paper-based decision aids.

Objective

The first objective of this review was to summarize published literature into a proposed classification of features that have been integrated into computer-based decision aids. Building on this classification, the second objective was to assess whether integration of specific features was associated with higher-quality decision making.

Methods

Relevant studies were located by searching MEDLINE, Embase, CINAHL, and CENTRAL databases. The review identified studies that evaluated computer-based decision aids for adults faced with preference-sensitive medical decisions and reported quality of decision-making outcomes. A thematic synthesis was conducted to develop the classification of features. Subsequently, meta-analyses were conducted based on standardized mean differences (SMD) from randomized controlled trials (RCTs) that reported knowledge or decisional conflict. Further subgroup analyses compared pooled SMDs for decision aids that incorporated a specific feature to other computer-based decision aids that did not incorporate the feature, to assess whether specific features improved quality of decision making.

Results

Of 3541 unique publications, 58 studies met the target criteria and were included in the thematic synthesis. The synthesis identified six features: content control, tailoring, patient narratives, explicit values clarification, feedback, and social support. A subset of 26 RCTs from the thematic synthesis was used to conduct the meta-analyses. As expected, computer-based decision aids performed better than usual care or alternative aids; however, some features performed better than others. Integration of content control improved quality of decision making (SMD 0.59 vs 0.23 for knowledge; SMD 0.39 vs 0.29 for decisional conflict). In contrast, tailoring reduced quality of decision making (SMD 0.40 vs 0.71 for knowledge; SMD 0.25 vs 0.52 for decisional conflict). Similarly, patient narratives also reduced quality of decision making (SMD 0.43 vs 0.65 for knowledge; SMD 0.17 vs 0.46 for decisional conflict). Results were varied for different types of explicit values clarification, feedback, and social support.

Conclusions

Integration of media rich or interactive features into computer-based decision aids can improve quality of preference-sensitive decision making. However, this is an emerging field with limited evidence to guide use. The systematic review and thematic synthesis identified features that have been integrated into available computer-based decision aids, in an effort to facilitate reporting of these features and to promote integration of such features into decision aids. The meta-analyses and associated subgroup analyses provide preliminary evidence to support integration of specific features into future decision aids. Further research can focus on clarifying independent contributions of specific features through experimental designs and refining the designs of features to improve effectiveness.

The impact of a computerized decision aid on empowering pregnant women for choosing vaginal versus cesarean section delivery: study protocol for a randomized controlled trial

Background

Cesarean delivery on maternal request (CDMR) is one of the main reasons for cesarean delivery in Iran, and women often need help in making a decision about the delivery options available to them. The main objective of this study is to evaluate the effect of a computerized decision aid (CDA) system on empowering pregnant women in choosing an appropriate mode of delivery. This CDA contrasts the advantages and disadvantages of vaginal versus cesarean section delivery in terms of their value to the individual woman.

Methods/Design

The protocol concerns a randomized trial study that will be performed among Iranian women. Four hundred pregnant women will be recruited from two private and two public prenatal centers in Mashhad, Iran. They will be randomly assigned to either an intervention or a control group. The designed CDA will be provided to the intervention group, whereas the control group will only receive routine care. The CDA provides educational contents as well as some recommendations. The CDA’s knowledge base is obtained from the results of studies on predictors of cesarean delivery. The CDA’s software will be installed on women’s computers for use at home.

The two primary outcomes for the study are O’Connor’s Decisional Conflict Scale and knowledge as measured by true/false questions. Actual mode of delivery (vaginal versus cesarean) will be compared in the two groups.

Discussion

We investigate the effect of a CDA on empowering pregnant women in terms of reducing their decisional conflict as well as on improving their clinical knowledge pertaining to mode of delivery.

Trial registration

This trial is registered with the Iran Trial Registrar under registration number IRCT2015093010777N4 and registration date 26 October 2015.

Cost effectiveness of a web-based decision aid for parents deciding about MMR vaccination: a three-arm cluster randomised controlled trial in primary care

BACKGROUND

Levels of measles in England and Wales are at their highest for 18 years, and strategies targeting the different groups of parents who do not vaccinate their children continue to be needed. Decision aids for decisions regarding childhood immunisation appear to be effective in achieving an increase in vaccine uptake but their cost effectiveness is unknown.

AIM

To assess the cost effectiveness of a web-based decision aid to increase uptake of the MMR vaccine.

DESIGN AND SETTING

Economic evaluation conducted alongside a cluster randomised controlled trial using urban GP practices in the north of England.

METHOD

Fifty GP practices in the north of England were randomised to one of three trial arms: decision aid, leaflet, usual practice. A total of 220 first-time parents (child aged 3-12 months) were recruited. Parents self-reported their contacts with the NHS and other previous/expected resource utilisation; associated costs were calculated. Vaccine-uptake data were collected from GP practices. A cost-effectiveness analysis was undertaken and provided the incremental cost per first-vaccine uptake. Multiple imputation was used to account for missing data and findings were adjusted for baseline differences in parents' levels of decisional conflict regarding MMR vaccination.

RESULTS

Of the 220 first-time parents recruited to the study, 179 completed the baseline and post-intervention questionnaires. MMR uptake was highest for those receiving the decision aid (42 out of 42, 100%) versus usual practice (61 out of 62, 98%) and leaflet arm (69 out of 75, 92%), and was associated with lower cost (-£9.20 versus usual practice and -£7.17 versus leaflet).

CONCLUSION

The decision aid has a high chance of being cost effective, regardless of the value placed on obtaining additional vaccinations. It also appears to offer an efficient means of decision support for parents.

Design and efficacy of a multilingual, multicultural HPV vaccine education intervention

BACKGROUND

The human papillomavirus (HPV) is the precursor and the single, most important risk factor for cervical cancer. It is also the most commonly sexually transmitted infection in the United States. An estimated 20 million persons are currently infected with the virus, with an estimated 6 million new infections occurring annually and 12,000 new cervical cancer cases and 4,000 cervical cancer deaths annually. The human papillomavirus (HPV) vaccine is thus an especially important preventive measure for racial/ethnic groups who bear an unequal burden of cervical cancer mortality.

PURPOSE

This study aimed to develop a culturally and linguistically appropriate intervention to educate and empower Latino and Korean Americans to make an informed HPV vaccination decision for their minor children.

METHODS

A parent-focused HPV vaccine education DVD was developed through focus groups and cognitive interviews with Latino and Korean Americans parents of children ages 11-17. A randomized controlled efficacy trial was subsequently conducted with 708 Latino and Korean Americans parents to assess knowledge gains, decisional conflict, decision self-efficacy and informed decision-making resulting from viewing the intervention DVD.

RESULTS

Differences between treatment and control groups for pre-post changes in knowledge, informed decision-making and decisional conflict were statistically significant among the parents exposed to the education intervention DVD.

CONCLUSION

The study demonstrated that a culturally and linguistically appropriate intervention DVD designed to educate parents about the risks and benefits of the HPV vaccine promoted informed decision-making regarding HPV vaccination among at-risk populations.

Shared decision-making and decision support: their role in obstetrics and gynecology

PURPOSE OF REVIEW

To discuss the role for shared decision-making in obstetrics/gynecology and to review evidence on the impact of decision aids on reproductive health decision-making.

RECENT FINDINGS

Among the 155 studies included in a 2014 Cochrane review of decision aids, 31 (29%) addressed reproductive health decisions. Although the majority did not show evidence of an effect on treatment choice, there was a greater uptake of mammography in selected groups of women exposed to decision aids compared with usual care; and a statistically significant reduction in the uptake of hormone replacement therapy among detailed decision aid users compared with simple decision aid users. Studies also found an effect on patient-centered outcomes of care, such as medication adherence, quality-of-life measures, and anxiety scores. In maternity care, only decision analysis tools affected final treatment choice, and patient-directed aids yielded no difference in planned mode of birth after cesarean.

SUMMARY

There is untapped potential for obstetricians/gynecologists to optimize decision support for reproductive health decisions. Given the limited evidence-base guiding practice, the preference-sensitive nature of reproductive health decisions, and the increase in policy efforts and financial incentives to optimize patients' satisfaction, it is increasingly important for obstetricians/gynecologists to appreciate the role of shared decision-making and decision support in providing patient-centered reproductive healthcare.

Patients or Volunteers? The Impact of Motivation for Trial Participation on the Efficacy of Patient Decision Aids: A Secondary Analysis of a Cochrane Systematic Review

Background. Efficacy of patient decision aids (PtDAs) may be influenced by trial participants’ identity either as patients seeking to benefit personally from involvement or as volunteers supporting the research effort. Aim. To determine if study characteristics indicative of participants’ trial identity might influence PtDA efficacy. Methods. We undertook exploratory subgroup meta-analysis of the 2011 Cochrane review of PtDAs, including trials that compared PtDA with usual care for treatment decisions. We extracted data on whether participants initiated the care pathway, setting, practitioner interactions, and 6 outcome variables (knowledge, risk perception, decisional conflict, feeling informed, feeling clear about values, and participation). The main subgroup analysis categorized trials as “volunteerism” or “patienthood” on the basis of whether participants initiated the care pathway. A supplementary subgroup analysis categorized trials on the basis of whether any volunteerism factors were present (participants had not initiated the care pathway, had attended a research setting, or had a face-to-face interaction with a researcher). Results. Twenty-nine trials were included. Compared with volunteerism trials, pooled effect sizes were higher in patienthood trials (where participants initiated the care pathway) for knowledge, decisional conflict, feeling informed, feeling clear, and participation. The subgroup difference was statistically significant for knowledge only ( P = 0.03). When trials were compared on the basis of whether volunteerism factors were present, knowledge was significantly greater in patienthood trials ( P < 0.001), but there was otherwise no consistent pattern of differences in effects across outcomes. Conclusions. There is a tendency toward greater PtDA efficacy in trials in which participants initiate the pathway of care. Knowledge acquisition appears to be greater in trials where participants are predominantly patients rather than volunteers.

Minimum standards for the certification of patient decision support interventions: feasibility and application

OBJECTIVE

Patient decision support interventions are not currently subject to standardized quality control. The current study aims to assess the feasibility of applying a proposed set of minimum standards (previously developed as part of a possible certification process) to a selection of existing patient decision support interventions.

METHODS

A convenience sample of interventions selected from those included in the 2009 Cochrane systematic review of patient decision aids was scored by trained raters using the International Patient Decision Aids Standards (IPDAS) instrument. Scores were then evaluated against the published proposed minimum standards.

RESULTS

Twenty-five out of thirty included interventions met all qualifying criteria while only three met the proposed certification criteria. The changes required for an intervention to meet the proposed certification standards were relatively minor. There was considerable variation between raters' mean scores.

CONCLUSIONS

Most interventions did not meet the certification criteria due to lack of information on modifiable items such as update policy and funding source.

PRACTICE IMPLICATIONS

Specifying minimum standards for patient decision support interventions is a feasible development. However, it remains unclear whether the minimum standards can be applied to interventions designed for use within clinical encounters and to those that target screening and diagnostic tests.

Exploring the Potential Cost-Effectiveness of Patient Decision Aids for Use in Adults with Obstructive Sleep Apnea

Background. There is increasing evidence highlighting the effectiveness of patient decision aids (PtDAs), but evidence supporting their cost-effectiveness is lacking. We consider patients with obstructive sleep apnea (OSA), in whom a PtDA may decrease nonadherence to treatment by empowering patients to receive the option that is most congruent with their own values. Objective. To determine the potential costs and benefits of delivering a PtDA to patients with moderate OSA. Methods. A Markov cohort decision-analytic model was developed for patients with moderate OSA, comparing a PtDA to usual care over 5 years from a societal perspective. Data for patient preference for treatment options was taken from a recent randomized crossover trial, event data (cardiovascular, motor vehicle accidents) came from national databases and published literature. Potential improvements in adherence are unknown, so we considered a realistic range of values. Outcome measures were 5-year costs (in 2010 Canadian dollars), quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER). Results. When adherence to treatment was unchanged, the PtDA strategy was dominated by incurring lower QALYs and higher costs. When nonadherence was decreased by 20% in the PtDA arm (corresponding to an increase in adherence from 63% to 70% for continuous positive airway pressure and from 77% to 82% for mandibular advancement splints in year 1), the ICER fell to $62,414/QALY. Costs associated with the treatment devices and delivering the PtDA had the greatest effect on cost-effectiveness. Limitations. The model relies on surrogate measures and opinions for key parameters. Conclusions: The cost-effectiveness of PtDAs will depend on contextual factors, but a framework is described for properly considering their long-term cost-effectiveness. A number of important questions around the appropriateness of benefit measurement for PtDA trials are highlighted.

The cost-effectiveness of patient decision aids: A systematic review

The Affordable Care Act includes provisions to encourage patient-centered care through the use of shared decision making (SDM) and patient decision aids (PtDA). PtDAs are tools that can help encourage SDM by providing information about competing treatment options and elucidating patients׳ values and preferences. Implementing PtDAs into routine practice may incur additional costs through training or increases in physician time. Prominent commentaries have proposed that these costs might be offset if patients choose less expensive options than their providers. However, the cost-effectiveness of PtDAs to date is unclear. The aim of this study was to review the economic evidence from PtDA trials. Our search identified 5347 articles, with 29 included following full-text review. Only one economic evaluation of a PtDA has been completed, which found a PtDA to be cost-saving in women with menorrhagia. Other studies included in the review indicated that PtDAs will likely increase up-front costs, but in some contexts may reduce short-term costs by reducing the uptake of invasive treatments, such as elective surgery. Few studies comprehensively captured long-term costs or measured benefits in a manner conducive to economic evaluation (QALYs or general health utilities). Our review suggests that policy makers currently have insufficient economic evidence to appropriately consider their investments in PtDAs.

Use of an interactive, faith-based kiosk by congregants of four predominantly, african-american churches in a metropolitan area

Chronic diseases are prevalent in ethnic communities. Churches represent a potent resource for targeted health promotion. A faith-based kiosk was developed as an informational tool and placed in four predominantly (>80%) African-American churches. Congregants were surveyed to describe kiosk-use, kiosk-user characteristics, health status, and self-reported behavior changes attributed to the kiosk. We analyzed 1,573 questionnaires. Mean age of respondents was 46.4 years and >70% were women. “Older” congregations (mean age ≥46.1 years) had more reports of diabetes (p = 0.002) and heart diseases (p = 0.01) than younger churches (mean age ≤44.1), whereas asthma was more prevalent in the latter (p < 0.001). Prevalence of obesity (40%) was similar across churches (p = 0.570). Kiosk-use was reported by 420 (26.7%) respondents. Compared to non-users, kiosk-users were >40 years (p < 0.001), and reported >two health conditions, adjusted Odds Ratio (95% Confidence Interval) = 1.43 (1.0–2.0), p = 0.05. Male kiosk-users preferred to select disease-specific content, aOR = 1.87 (1.10–3.17), p = 0.02, while females tended to select information about supportive community resources, aOR = 0.49 (0.23–1.04), p = 0.062. Knowledge of kiosk-user characteristics and the “health status” of a congregation, provide an opportunity for targeted, church-based health promotion.

An interprofessional approach to shared decision making: an exploratory case study with family caregivers of one IP home care team

BACKGROUND

Within the context of an exploratory case study, the authors assessed the perceptions of family caregivers about the decision-making process regarding relocating their relative and about the applicability of an interprofessional approach to shared decision making (IP-SDM). They also assessed perceptions of health professionals and health managers about IP-SDM.

METHODS

From November 2010 to October 2011, we worked with one IP home care team dedicated to older adults (the case) from a large primary health care organization in Quebec City, Canada. We identified six of their clients who had faced a decision about whether to stay at home or move to a long-term care facility in the past year and interviewed their family caregivers. We explored the decision-making process they had experienced regarding relocating their relative and their perceptions about the applicability of IP-SDM in this context. Attitudes towards IP-SDM and potential barriers to this approach were explored using a focus group with the participating IP home care team, individual interviews with 8 managers and a survey of 272 health professionals from the primary care organization. A hybrid process of inductive and deductive thematic analysis was used and data were triangulated across all sources.

RESULTS

Family caregivers reported lack of agreement on the nature of the decision to be made, a disconnection between home care services and relatives' needs, and high cost of long-term care alternatives. Factors influencing their decision included their ability to provide care for their relative. While they felt somewhat supported by the IP home care team, they also felt pressured in the decision. Overall, they did not perceive they had been exposed to IP-SDM but agreed that it was applicable in this context. Results from the survey, focus group and interviews with health professionals and managers indicated they all had a favourable attitude towards IP-SDM but many barriers hampered its implementation in their practice.

CONCLUSIONS

The family caregivers in this study did not experience IP-SDM when relocating their relative. Added to results obtained with health professionals and managers, this highlights the need for an effective intervention targeting identified barriers to implementing IP-SDM in this context.

Informed public choices for low-carbon electricity portfolios using a computer decision tool

Reducing CO2 emissions from the electricity sector will likely require policies that encourage the widespread deployment of a diverse mix of low-carbon electricity generation technologies. Public discourse informs such policies. To make informed decisions and to productively engage in public discourse, citizens need to understand the trade-offs between electricity technologies proposed for widespread deployment. Building on previous paper-and-pencil studies, we developed a computer tool that aimed to help nonexperts make informed decisions about the challenges faced in achieving a low-carbon energy future. We report on an initial usability study of this interactive computer tool. After providing participants with comparative and balanced information about 10 electricity technologies, we asked them to design a low-carbon electricity portfolio. Participants used the interactive computer tool, which constrained portfolio designs to be realistic and yield low CO2 emissions. As they changed their portfolios, the tool updated information about projected CO2 emissions, electricity costs, and specific environmental impacts. As in the previous paper-and-pencil studies, most participants designed diverse portfolios that included energy efficiency, nuclear, coal with carbon capture and sequestration, natural gas, and wind. Our results suggest that participants understood the tool and used it consistently. The tool may be downloaded from http://cedmcenter.org/tools-for-cedm/informing-the-public-about-low-carbon-technologies/ .

Decision aids for people facing health treatment or screening decisions

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Undetermined impact of patient decision support interventions on healthcare costs and savings: systematic review

OBJECTIVE

To perform a systematic review of studies that assessed the potential of patient decision support interventions (decision aids) to generate savings.

DESIGN

Systematic review.

DATA SOURCES

After registration with PROSPERO, we searched 12 databases, from inception to 15 March 2013, using relevant MeSH terms and text words. Included studies were assessed with Cochrane's risk of bias method and Drummond's quality checklist for economic studies. Per patient costs and projected savings associated with introducing patient decision support interventions were calculated, as well as absolute changes in treatment rates after implementation.

ELIGIBILITY CRITERIA

Studies were included if they contained quantitative economic data, including savings, spending, costs, cost effectiveness analysis, cost benefit analysis, or resource utilization. We excluded studies that lacked quantitative data on savings, costs, monetary value, and/or resource utilization.

RESULTS

After reviewing 1508 citations, we included seven studies with eight analyses. Of these seven studies, four analyses predicted system-wide savings, with two analyses from the same study. The predicted savings range from $8 (£5, €6) to $3068 (£1868, €2243) per patient. Larger savings accompanied reductions in treatment utilization rates. The impact on utilization rates was mixed. Authors used heterogeneous methods to allocate costs and calculate savings. Quality scores were low to moderate (median 4.5, range 0-8 out of 10), and risk of bias across the studies was moderate to high (3.5, range 3-6 out of 6), with studies predicting the most savings having the highest risk of bias. The range of issues identified in the studies included the relative absence of sensitivity analyses, the absence of incremental cost effectiveness ratios, and short time periods.

CONCLUSION

Although there is evidence to show that patients choose more conservative approaches when they become better informed, there is insufficient evidence, as yet, to be confident that the implementation of patient decision support interventions leads to system-wide savings. Further work-with sensitivity analyses, longer time horizons, and more contexts-is required to avoid premature or unrealistic expectations that could jeopardize implementation and lead to the loss of already proved benefits.

REGISTRATION

PROSPERO registration CRD42012003421.

Multimedia educational interventions for consumers about prescribed and over-the-counter medications

BACKGROUND

Health consumers increasingly want access to accurate, evidence-based information about their medications. Currently, education about medications (that is, information that is designed to achieve health or illness related learning) is provided predominantly via spoken communication between the health provider and consumer, sometimes supplemented with written materials. There is evidence, however, that current educational methods are not meeting consumer needs. Multimedia educational programs offer many potential advantages over traditional forms of education delivery.

OBJECTIVES

To assess the effects of multimedia patient education interventions about prescribed and over-the-counter medications in people of all ages, including children and carers.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2011, Issue 6), MEDLINE (1950 to June 2011), EMBASE (1974 to June 2011), CINAHL (1982 to June 2011), PsycINFO (1967 to June 2011), ERIC (1966 to June 2011), ProQuest Dissertation & Theses Database (to June 2011) and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of multimedia-based patient education about prescribed or over-the-counter medications in people of all ages, including children and carers, if the intervention had been targeted for their use.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of included studies. Where possible, we contacted study authors to obtain missing information.

MAIN RESULTS

We identified 24 studies that enrolled a total of 8112 participants. However, there was significant heterogeneity in the comparators used and the outcomes measured, which limited the ability to pool data. Many of the studies did not report sufficient information in their methods to allow judgment of their risk of bias. From the information that was reported, three of the studies had a high risk of selection bias and one was at high risk of bias due to lack of blinding of the outcome assessors. None of the included studies reported the minimum clinically important difference for the outcomes that were measured. We have therefore reported results from the studies but have been unable to interpret whether differences were of clinical importance.The main findings of the review are as follows.Knowledge: There is low quality evidence that multimedia education was more effective than usual care (non-standardised education provided as part of usual clinical care) or no education (standardised mean difference (SMD) 1.04, 95% confidence interval (CI) 0.49 to 1.58, six studies with 817 participants). There was considerable statistical heterogeneity (I(2) = 89%), however, all but one of the studies favoured the multimedia group. There is moderate quality evidence that multimedia education was not more effective at improving knowledge than control multimedia interventions (i.e. multimedia programs that do not provide information about the medication) (mean difference (MD) of knowledge scores 2.78%, 95% CI -1.48 to 7.0, two studies with 568 participants). There is moderate quality evidence that multimedia education was more effective when added to a co-intervention (written information or brief standardised instructions provided by a health professional) compared with the co-intervention alone (MD of knowledge scores 24.59%, 95% CI 22.34 to 26.83, two studies with 381 participants).Skill acquisition: There is moderate quality evidence that multimedia education was more effective than usual care or no education (MD of inhaler technique score 18.32%, 95% CI 11.92 to 24.73, two studies with 94 participants) and written education (risk ratio (RR) of improved inhaler technique 2.14, 95% CI 1.33 to 3.44, two studies with 164 participants). There is very low quality evidence that multimedia education was equally effective as education by a health professional (MD of inhaler technique score -1.01%, 95% CI -15.75 to 13.72, three studies with 130 participants).Compliance with medications: There is moderate quality evidence that there was no difference between multimedia education and usual care or no education (RR of complying 1.02, 95% CI 0.96 to 1.08, two studies with 4552 participants).We could not determine the effect of multimedia education on other outcomes, including patient satisfaction, self-efficacy and health outcomes, due to an inadequate number of studies from which to draw conclusions.

AUTHORS' CONCLUSIONS

This review provides evidence that multimedia education about medications is more effective than usual care (non-standardised education provided by health professionals as part of usual clinical care) or no education, in improving both knowledge and skill acquisition. It also suggests that multimedia education is at least equivalent to other forms of education, including written education and education provided by a health professional. However, this finding is based on often low quality evidence from a small number of trials. Multimedia education about medications could therefore be considered as an adjunct to usual care but there is inadequate evidence to recommend it as a replacement for written education or education by a health professional. Multimedia education may be considered as an alternative to education provided by a health professional, particularly in settings where provision of detailed education by a health professional is not feasible. More studies evaluating multimedia educational interventions are required in order to increase confidence in the estimate of effect of the intervention.Conclusions regarding the effect of multimedia education were limited by the lack of information provided by study authors about the educational interventions, and variability in their content and quality. Studies testing educational interventions should provide detailed information about the interventions and comparators. Research is required to establish a framework that is specific for the evaluation of the quality of multimedia educational programs. Conclusions were also limited by the heterogeneity in the outcomes reported and the instruments used to measure them. Research is required to identify a core set of outcomes which should be measured when evaluating patient educational interventions. Future research should use consistent, reliable and validated outcome measures so that comparisons can be made between studies.

Patient decision aids in knee replacement surgery

Arthroplasty is an effective intervention for symptomatic knee osteoarthritis refractory to conservative therapy. However, recent data highlights regional variations in service provision unrelated to disease severity and a low, but not insignificant, rate of patient dissatisfaction. The variation in knee arthroplasty provision is in part also due to the clinical decision-making of orthopaedic surgeons. The management of osteoarthritis is an example of a preference-sensitive clinical pathway, and possible explanations for poor patient satisfaction include unrealistic expectations and poor perception of potential benefits and risks. In addition to the individual impact, this represents an inefficient use of resources by healthcare providers during a challenging economic period. Improved shared-decision making between patients and clinicians would potentially address these issues. Patient decision aids provide relevant personalized evidence-based information to facilitate the shared decision-making process. Orthopaedic surgeons are receptive to the use of patient decision aids to support shared decision-making, but there are a number of issues to overcome before they are routinely adopted. The number of decision aids and the literature supporting their effectiveness is growing rapidly. NHS Direct has launched online patient decision support for knee osteoarthritis. The use of patient decision aids in clinical practice is gathering pace and may soon become the ethical and legal standard. This article provides a narrative review of patient decision aids in the context of knee replacement surgery from a UK perspective.

Computerised decision aids: a systematic review of their effectiveness in facilitating high-quality decision-making in various health-related contexts

OBJECTIVE

To systematically review existing empirical evidence regarding the effectiveness of computerised decision aids (CDAs) in enabling high-quality decision-making in preference-sensitive health-related contexts.

METHODS

Relevant studies were identified via Medline, CINAHL, and PsycINFO databases (1990-October 2010). Only randomised controlled trials with at least one decision quality or decision process variable outcome were included.

RESULTS

Of 1467 identified articles, 28 studies met all inclusion criteria, evaluating 26 unique CDAs. CDAs performed better than standard consultations/education regarding improved knowledge and lower decisional conflict, and were found not to increase anxiety. CDAs facilitated greater satisfaction with the decision-making process than standard education. The effects on risk perceptions, value congruence with the chosen option, preferred roles in decision-making and decisional self-efficacy need further evaluation. A paucity of CDAs adhered to decision theories.

CONCLUSIONS

CDAs showed similar effects as non-computerised DAs on various outcomes. Further research into the potentially superior effects of CDAs on feeling informed, values-clarity, and decisional conflict is required.

PRACTICE IMPLICATIONS

The more remarkable effects on knowledge and risk perceptions were reported when unique features of interactive computerised media were used. The potential benefit of tailored information, values-clarification, and integration of CDAs into shared decision-making consultations remains unresolved.

Psychometric testing of the decisional conflict scale: genetic testing hereditary breast and ovarian cancer

BACKGROUND

: Hereditary breast and ovarian cancer (HBOC) syndrome is attributed mostly to mutations in the Breast Cancer 1 and Breast Cancer 2 genes (BRCA1/2). Mutation carriers of BRCA1/2 genes have significantly higher risk for developing breast cancer compared with the general population (55%-85% vs. 12%) and for developing ovarian cancer (20%-60% vs. 1.5%). The availability of genetic testing enables mutation carriers to make informed decisions about managing their cancer risk (e.g., risk-reducing surgery). However, uptake of testing for HBOC among high-risk individuals is low, indicating the need to better understand and measure the decisional conflict associated with this process.

OBJECTIVE

: The aim of this study was to evaluate the reliability and validity of the modified Decisional Conflict Scale for use in decisions associated with genetic testing for HBOC.

METHODS

: This cross-sectional cohort study, recruited women who pursued genetic testing for HBOC in two genetic risk assessment clinics affiliated with a large comprehensive cancer center and one of their female relatives who did not pursue testing. The final sample consisted of 342 women who completed all 16 items of the Decisional Conflict Scale. The psychometric properties of the scale were assessed using tests of reliability and validity, including face, content, construct, contrast, convergent, divergent, and predictive validity.

RESULTS

: Factor analysis using principal axis factoring with oblimin rotation elicited a three-factor structure: (a) Lack of Knowledge About the Decision (α = .97), (b) Lack of Autonomy in Decision Making (α = .94), and (c) Lack of Confidence in Decision Making (α = .87). These factors explained 82% of the variance in decisional conflict about genetic testing. Cronbach's alpha coefficient was .96.

DISCUSSION

: The instrument is an important tool for researchers and healthcare providers working with women at risk for HBOC who are deciding whether genetic testing is the right choice for them.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Decision aids prepare people to participate in decisions that involve weighing benefits, harms, and scientific uncertainty.

OBJECTIVES

To evaluate the effectiveness of decision aids for people facing treatment or screening decisions.

SEARCH STRATEGY

For this update, we searched from January 2006 to December 2009 in MEDLINE (Ovid); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, issue 4 2009); CINAHL (Ovid) (to September 2008 only); EMBASE (Ovid); PsycINFO (Ovid); and grey literature. Cumulatively, we have searched each database since its start date.

SELECTION CRITERIA

We included published randomised controlled trials (RCTs) of decision aids, which are interventions designed to support patients' decision making by providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies in which participants were not making an active treatment or screening decision.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

Of 34,316 unique citations, 86 studies involving 20,209 participants met the eligibility criteria and were included. Thirty-one of these studies are new in this update. Twenty-nine trials are ongoing. There was variability in potential risk of bias across studies. The two criteria that were most problematic were lack of blinding and the potential for selective outcome reporting, given that most of the earlier trials were not registered.Of 86 included studies, 63 (73%) used at least one measure that mapped onto an IPDAS effectiveness criterion: A) criteria involving decision attributes: knowledge scores (51 studies); accurate risk perceptions (16 studies); and informed value-based choice (12 studies); and B) criteria involving decision process attributes: feeling informed (30 studies) and feeling clear about values (18 studies).A) Criteria involving decision attributes:Decision aids performed better than usual care interventions by increasing knowledge (MD 13.77 out of 100; 95% confidence interval (CI) 11.40 to 16.15; n = 26). When more detailed decision aids were compared to simpler decision aids, the relative improvement in knowledge was significant (MD 4.97 out of 100; 95% CI 3.22 to 6.72; n = 15). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.74; 95% CI 1.46 to 2.08; n = 14). The effect was stronger when probabilities were expressed in numbers (RR 1.93; 95% CI 1.58 to 2.37; n = 11) rather than words (RR 1.27; 95% CI 1.09 to 1.48; n = 3). Exposure to a decision aid with explicit values clarification compared to those without explicit values clarification resulted in a higher proportion of patients achieving decisions that were informed and consistent with their values (RR 1.25; 95% CI 1.03 to 1.52; n = 8).B) Criteria involving decision process attributes:Decision aids compared to usual care interventions resulted in: a) lower decisional conflict related to feeling uninformed (MD -6.43 of 100; 95% CI -9.16 to -3.70; n = 17); b) lower decisional conflict related to feeling unclear about personal values (MD -4.81; 95% CI -7.23 to -2.40; n = 14); c) reduced the proportions of people who were passive in decision making (RR 0.61; 95% CI 0.49 to 0.77; n = 11); and d) reduced proportions of people who remained undecided post-intervention (RR 0.57; 95% CI 0.44 to 0.74; n = 9). Decision aids appear to have a positive effect on patient-practitioner communication in the four studies that measured this outcome. For satisfaction with the decision (n = 12) and/or the decision making process (n = 12), those exposed to a decision aid were either more satisfied or there was no difference between the decision aid versus comparison interventions. There were no studies evaluating the decision process attributes relating to helping patients to recognize that a decision needs to be made or understand that values affect the choice.C) Secondary outcomesExposure to decision aids compared to usual care continued to demonstrate reduced choice of: major elective invasive surgery in favour of conservative options (RR 0.80; 95% CI 0.64 to 1.00; n = 11). Exposure to decision aids compared to usual care also resulted in reduced choice of PSA screening (RR 0.85; 95% CI 0.74 to 0.98; n = 7). When detailed compared to simple decision aids were used, there was reduced choice of menopausal hormones (RR 0.73; 95% CI 0.55 to 0.98; n = 3). For other decisions, the effect on choices was variable. The effect of decision aids on length of consultation varied from -8 minutes to +23 minutes (median 2.5 minutes). Decision aids do not appear to be different from comparisons in terms of anxiety (n = 20), and general health outcomes (n = 7), and condition specific health outcomes (n = 9). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive.

AUTHORS' CONCLUSIONS

New for this updated review is evidence that: decision aids with explicit values clarification exercises improve informed values-based choices; decision aids appear to have a positive effect on patient-practitioner communication; and decision aids have a variable effect on length of consultation.Consistent with findings from the previous review, which had included studies up to 2006: decision aids increase people's involvement, and improve knowledge and realistic perception of outcomes; however, the size of the effect varies across studies. Decision aids have a variable effect on choices. They reduce the choice of discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, patient-practitioner communication, cost-effectiveness, and use with developing and/or lower literacy populations need further evaluation. Little is known about the degree of detail that decision aids need in order to have positive effects on attributes of the decision or decision-making process.

Effectiveness of multimedia interactive patient education on knowledge, uncertainty and decision-making in patients with end-stage renal disease

AIM

This study tested the efficacy of a multimedia interactive DVD as an education tool for patients with end-stage renal disease in terms of enhancing patient knowledge and decision-making skills and decreasing uncertainty.

BACKGROUND

End-stage renal case numbers in Taiwan are growing by approximately 6000 new patients per year. Helping patients choose an optimal treatment method to maximise quality of life is an important healthcare issue for this patient population.

DESIGN

This study adopted a quasi-experimental design and focused on subjects being treated at one medical centre in southern Taiwan. The study divided subjects into experimental and control groups.

METHODS

The experimental group received three multimedia interactive DVD nursing-guided interventions. The control group received only normal hospital health education. The study gathered data using several scales addressing knowledge, uncertainty perception and decision regret. Scales were implemented immediately before and after the multimedia interactive DVD nursing guidance intervention and at four and eight weeks postintervention. This study used an independent t-test, chi-square test and repeated measures analysis of variance.

RESULTS

This study found significant improvements in the experimental group in terms of knowledge, pre-dialysis uncertainty and decision regret. Experimental group subjects scored particularly less in terms of decision regret than those in the control group.

RELEVANCE TO CLINICAL PRACTICE

This study demonstrated the efficacy of the developed multimedia interactive DVD in significantly improving end-stage renal patient knowledge and reducing patient uncertainties and postdecision regret. Study findings can be used as a reference guide for clinical nursing education efforts in hospital and other healthcare settings.

The Internet and the therapeutic education of patients: A systematic review of the literature

OBJECTIVES

To evaluate from a review of the literature the interest of using the Internet as a tool for the therapeutic education of patients.

METHOD

A systematic review of Pubmed was carried out using the key words: the Internet, or World Wide Web and patient education, or patient preference, or self-care. The search was restricted to articles in English published between 1990 and 2009. References to the selected articles were also analyzed. Only randomized controlled studies were retained.

RESULTS

Thirty-nine articles concerning 20 different diseases met the inclusion criteria and were analyzed. Different types of programs were proposed: informative, interactive, cognitive-behavioral and programs concerning self-management of the disease and the treatment. These different approaches were sometimes compared. The use of quality Internet sites made it possible to induce beneficial changes in lifestyle habits, and to diminish subjective and/or objective symptom severity in chronic invalidating diseases when used as a complement to traditional management. By using the Internet, patients were also able to improve decision-making skills to a degree that was at least as good as that obtained using traditional paper documents.

CONCLUSION

The Internet is an effective complementary tool that can contribute to improving therapeutic education. Nonetheless, healthcare professionals should work with patients to create quality sites that correspond more closely to their expectations. It is also essential for learned societies such as the SOFMER to invest in therapeutic education on the Internet to make quality therapeutic education modules based on factual medical data and complying with good practices available on line.

Adherence and decision AIDS: a model and a narrative review

BACKGROUND

Patient adherence to medication or lifestyle interventions is a serious concern. Interventions to improve adherence exist, but their effects are usually small. Several authors suggested that decision aids may positively affect adherence.

OBJECTIVE

. This presentation examines the role of decision aids in adherence research through development of a model and a narrative review.

METHODS

and

RESULTS

. I: A model was developed to organize pathways relating decision aids and adherence. There is clinical evidence for these pathways, suggesting that decision aids may potentially improve adherence. The model is helpful when considering measures to study decision aids and adherence. II: A narrative review of decision aids and adherence was done. A systematic search resulted in 11 randomized studies. Two studies, both in the hypertension management domain, were positive. Shortcomings were identified regarding the range of adherence measures, the sample size, and the

STUDY DESIGN

It is argued that outcomes for the option "nonadherent" behavior should be described explicitly in the decision aid to inform patients about the costs and benefits of nonadherent behavior.

CONCLUSIONS

. A relation between decision aids and adherence is plausible in view of the psychological and medical literature. A systematic search showed that experimental evidence relating decision aids and adherence is inconclusive. Rigorous trials on this topic are worthwhile. Such trials should employ adequate sample sizes, multiple adherence measures, and a control arm delivering usual care. The decision aid should describe the option "being nonadherent" and its outcomes.

Interventions for improving the adoption of shared decision making by healthcare professionals

BACKGROUND

Shared decision making (SDM) is a process by which a healthcare choice is made jointly by the practitioner and the patient and is said to be the crux of patient-centred care. Policy makers perceive SDM as desirable because of its potential to a) reduce overuse of options not clearly associated with benefits for all (e.g., prostate cancer screening); b) enhance the use of options clearly associated with benefits for the vast majority (e.g., cardiovascular risk factor management); c) reduce unwarranted healthcare practice variations; d) foster the sustainability of the healthcare system; and e) promote the right of patients to be involved in decisions concerning their health. Despite this potential, SDM has not yet been widely adopted in clinical practice.

OBJECTIVES

To determine the effectiveness of interventions to improve healthcare professionals' adoption of SDM.

SEARCH STRATEGY

We searched the following electronic databases up to 18 March 2009: Cochrane Library (1970-), MEDLINE (1966-), EMBASE (1976-), CINAHL (1982-) and PsycINFO (1965-). We found additional studies by reviewing a) the bibliographies of studies and reviews found in the electronic databases; b) the clinicaltrials.gov registry; and c) proceedings of the International Shared Decision Making Conference and the conferences of the Society for Medical Decision Making. We included all languages of publication.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or well-designed quasi-experimental studies (controlled clinical trials, controlled before and after studies, and interrupted time series analyses) that evaluated any type of intervention that aimed to improve healthcare professionals' adoption of shared decision making. We defined adoption as the extent to which healthcare professionals intended to or actually engaged in SDM in clinical practice or/and used interventions known to facilitate SDM. We deemed studies eligible if the primary outcomes were evaluated with an objective measure of the adoption of SDM by healthcare professionals (e.g., a third-observer instrument).

DATA COLLECTION AND ANALYSIS

At least two reviewers independently screened each abstract for inclusion and abstracted data independently using a modified version of the EPOC data collection checklist. We resolved disagreements by discussion. Statistical analysis considered categorical and continuous primary outcomes. We computed the standard effect size for each outcome separately with a 95% confidence interval. We evaluated global effects by calculating the median effect size and the range of effect sizes across studies.

MAIN RESULTS

The reviewers identified 6764 potentially relevant documents, of which we excluded 6582 by reviewing titles and abstracts. Of the remainder, we retrieved 182 full publications for more detailed screening. From these, we excluded 176 publications based on our inclusion criteria. This left in five studies, all RCTs. All five were conducted in ambulatory care: three in primary clinical care and two in specialised care. Four of the studies targeted physicians only and one targeted nurses only. In only two of the five RCTs was a statistically significant effect size associated with the intervention to have healthcare professionals adopt SDM. The first of these two studies compared a single intervention (a patient-mediated intervention: the Statin Choice decision aid) to another single intervention (also patient-mediated: a standard Mayo patient education pamphlet). In this study, the Statin Choice decision aid group performed better than the standard Mayo patient education pamphlet group (standard effect size = 1.06; 95% CI = 0.62 to 1.50). The other study compared a multifaceted intervention (distribution of educational material, educational meeting and audit and feedback) to usual care (control group) (standard effect size = 2.11; 95% CI = 1.30 to 2.90). This study was the only one to report an assessment of barriers prior to the elaboration of its multifaceted intervention.

AUTHORS' CONCLUSIONS

The results of this Cochrane review do not allow us to draw firm conclusions about the most effective types of intervention for increasing healthcare professionals' adoption of SDM. Healthcare professional training may be important, as may the implementation of patient-mediated interventions such as decision aids. Given the paucity of evidence, however, those motivated by the ethical impetus to increase SDM in clinical practice will need to weigh the costs and potential benefits of interventions. Subsequent research should involve well-designed studies with adequate power and procedures to minimise bias so that they may improve estimates of the effects of interventions on healthcare professionals' adoption of SDM. From a measurement perspective, consensus on how to assess professionals' adoption of SDM is desirable to facilitate cross-study comparisons.

Economic Evaluation of the DiAMOND Randomized Trial: Cost and Outcomes of 2 Decision Aids for Mode of Delivery among Women with a Previous Cesarean Section

Background. Maternal preferences should be considered in decisions about mode of delivery following a previous cesarean, but risks and benefits are unclear. Decision aids can help decision making, although few studies have assessed costs in conjunction with effectiveness. Objective. Economic evaluation of 2 decision aids for women with 1 previous cesarean. Design. Cost-consequences analysis. Materials and Methods. Data sources were self-reported resource use and outcome and published national unit costs. The target population was women with 1 previous cesarean. The time horizon was 37 weeks’ gestation and 6 weeks postnatal. The perspective was health care delivery system. The interventions were usual care, usual care plus an information program, and usual care plus a decision analysis program. The outcome measures were costs to the National Health Service (NHS) in the United Kingdom (UK), score on the Decisional Conflict Scale, and mode of delivery. Results of Main Analysis. Cost of delivery represented 84% of the total cost; mode of delivery was the most important determinant of cost differences across the groups. Mean (SD) total cost per mother and baby: 2033 (677) for usual care, 2069 (738) for information program, and 2019 (741) for decision analysis program. Decision aids reduced decisional conflict. Women using the decision analysis program had fewest cesarean deliveries. Results of Sensitivity Analysis. Applying a cost premium to emergency cesareans over electives had little effect on group comparisons. Conclusions were unaffected. Limitations. Disparity in timing of outcomes and costs, data completeness, and quality. Conclusions. Decision aids can reduce decisional conflict in women with a previous cesarean section when deciding on mode of delivery. The information program could be implemented at no extra cost to the NHS. The decision analysis program might reduce the rate of cesarean sections without any increase in costs