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      Decision aids for people facing health treatment or screening decisions

      systematic-review

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          Abstract

          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.

          Decision aids to help people who are facing health treatment or screening decisions

          Review question

          We reviewed the effects of decision aids on people facing health treatment or screening decisions. In this update, we added 18 new studies for a total of 105.

          Background

          Making a decision about the best treatment or screening option can be hard. People can use decision aids when there is more than one option and neither is clearly better, or when options have benefits and harms that people value differently. Decision aids may be pamphlets, videos, or web‐based tools. They state the decision, describe the options, and help people think about the options from a personal view (e.g. how important are possible benefits and harms).

          Study characteristics

          For research published up to April 2015, there were 105 studies involving 31,043 people. The decision aids focused on 50 different decisions. The common decisions were about: surgery, screening (e.g. prostate cancer, colon cancer, prenatal), genetic testing, and medication treatments (e.g. diabetes, atrial fibrillation).The decision aids were compared to usual care that may have included general information or no intervention. In the 105 studies, 89 evaluated a patient decision aid used by people in preparation for the visit with the clinician, and 16 evaluated its use during the visit with the clinician.

          Key results with quality of the evidence

          When people use decision aids, they improve their knowledge of the options (high‐quality evidence) and feel better informed and more clear about what matters most to them (high‐quality evidence). They probably have more accurate expectations of benefits and harms of options (moderate‐quality evidence) and probably participate more in decision making (moderate‐quality evidence). People who use decision aids may achieve decisions that are consistent with their informed values (evidence is not as strong; more research could change results). People and their clinicians were more likely to talk about the decision when using a decision aid. Decision aids have a variable effect on the option chosen, depending on the choice being considered. Decision aids do not worsen health outcomes, and people using them are not less satisfied. More research is needed to assess if people continue with the option they chose and also to assess what impact decision aids have on healthcare systems.

          Related collections

          Most cited references388

          • Record: found
          • Abstract: found
          • Article: not found

          An integrative model of shared decision making in medical encounters.

          Given the fluidity with which the term shared decision making (SDM) is used in teaching, assessment and research, we conducted a focused and systematic review of articles that specifically address SDM to determine the range of conceptual definitions. In April 2005, we ran a Pubmed (Medline) search to identify articles published through 31 December 2003 with the words shared decision making in the title or abstract. The search yielded 681 citations, 342 of which were about SDM in the context of physician-patient encounters and published in English. We read and reviewed the full text of all 342 articles, and got any non-redundant references to SDM, which yielded an additional 76 articles. Of the 418 articles examined, 161 (38.5%) had a conceptual definition of SDM. We identified 31 separate concepts used to explicate SDM, but only "patient values/preferences" (67.1%) and "options" (50.9%) appeared in more than half the 161 definitions. Relatively few articles explicitly recognized and integrated previous work. Our review reveals that there is no shared definition of SDM. We propose a definition that integrates the extant literature base and outlines essential elements that must be present for patients and providers to engage in the process of SDM. The integrative definition of SDM is intended to provide a useful foundation for describing and operationalizing SDM in further research.
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            • Record: found
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            • Article: not found

            Decision making during serious illness: what role do patients really want to play?

            Two surveys were conducted to determine what roles people actually want to assume in selecting cancer treatments. 436 newly diagnosed cancer patients and 482 members of the general public participated. Preferences were elicited using two card sort procedures, each of which described five potential roles in decision making. Findings suggested that the impact of being diagnosed with a life-threatening illness may influence preferences to participate. The majority (59%) of patients wanted physicians to make treatment decisions on their behalf, but 64% of the public thought they would want to select their own treatment if they developed cancer. Most patients (51%) and members of the public (46%) wanted their physician and family to share responsibility for decision making if they were too ill to participate. Sociodemographic variables accounted for only 15% of variance in preferences. These variables are not particularly useful in making predictions about which groups want more or less active roles in medical decision making.
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              • Record: found
              • Abstract: not found
              • Article: not found

              Validation of a Decision Regret Scale

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                Author and article information

                Contributors
                dstacey@uottawa.ca
                Journal
                Cochrane Database Syst Rev
                Cochrane Database Syst Rev
                14651858
                10.1002/14651858
                The Cochrane Database of Systematic Reviews
                John Wiley & Sons, Ltd (Chichester, UK )
                1469-493X
                12 April 2017
                April 2017
                10 April 2017
                : 2017
                : 4
                : CD001431
                Affiliations
                University of Ottawa deptSchool of Nursing 451 Smyth Road Ottawa Canada
                Ottawa Hospital Research Institute deptCentre for Practice Changing Research 501 Smyth Rd Ottawa Canada K1H 8L6
                CHU de Québec Research Center, Université Laval deptPopulation Health and Optimal Health Practices Research Axis 10 Rue de l'Espinay, D6‐727 Québec City Canada G1L 3L5
                Informed Medical Decisions Foundation Boston USA
                Ottawa Hospital Research Institute deptClinical Epidemiology Program Administrative Services Building, Room 2‐0131053 Carling Avenue Ottawa Canada K1Y 4E9
                Oregon Health Sciences University deptDepartment of Medical Informatics and Clinical Epidemiology BICC 5353181 S.W. Sam Jackson Park Road Portland USA 97239‐3098
                Michigan State University College of Human Medicine deptCenter for Ethics and Humanities in the Life Sciences East Fee Road956 Fee Road Rm C203 East Lansing USA 48824‐1316
                Dartmouth College deptThe Dartmouth Center for Health Policy & Clinical Practice, The Geisel School of Medicine at Dartmouth Hanover USA 03755
                No affiliation 28 Greenwood Road Ingersoll Canada N5C 3N1
                Newcastle University deptInstitute of Health and Society Baddiley‐Clark BuildingRichardson Road Newcastle upon Tyne UK NE2 4AX
                The University of Sydney Room 322Edward Ford Building (A27) Sydney Australia 2006
                Author notes

                Editorial Group: Cochrane Consumers and Communication Group.

                Article
                PMC6478132 PMC6478132 6478132 CD001431 CD001431.pub5
                10.1002/14651858.CD001431.pub5
                6478132
                28402085
                b12e9362-5625-434e-8539-933b658900ee
                Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
                History
                : 28 January 2014
                : 30 April 2015
                Categories
                Medicine General & Introductory Medical Sciences

                Patient Education as Topic,Patient Participation,Elective Surgical Procedures,Patient Education as Topic/methods,Humans,Decision Support Techniques,Randomized Controlled Trials as Topic

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