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Background: Decision Aids (DAs) effectively translate medical evidence for patients but are not routinely used in clinical practice. Little is known about how DAs are used during patient-clinician encounters., Objective: To characterize the content and communicative function of high-quality DAs during diagnostic clinic visits for prostate cancer., Participants: 252 men newly diagnosed with localized prostate cancer who had received a DA, 45 treating physicians at 4 US Veterans Administration urology clinics., Methods: Qualitative analysis of transcribed audio recordings was used to inductively develop categories capturing content and function of all direct references to DAs (booklet talk). The presence or absence of any booklet talk per transcript was also calculated., Results: Booklet talk occurred in 55% of transcripts. Content focused on surgical procedures (36%); treatment choice (22%); and clarifying risk classification (17%). The most common function of booklet talk was patient corroboration of physicians' explanations (42%), followed by either physician or patient acknowledgement that the patient had the booklet. Codes reflected the absence of DA use for shared decision-making. In regression analysis, predictors of booklet talk were fewer years of patient education (P = .027) and more time in the encounter (P = .027). Patient race, DA type, time reading the DA, physician informing quality and physician age did not predict booklet talk., Conclusions: Results show that good decision aids, systematically provided to patients, appeared to function not to open up deliberations about how to balance benefits and harms of competing treatments, but rather to allow patients to ask narrow technical questions about recommended treatments., (© 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd.)

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.

Background: Optimal treatment for localized prostate cancer (LPC) is controversial. We assessed the effects of personality, specialists seen, and involvement of spouse, family, or friends on treatment decision/decision-making qualities., Methods: We surveyed a population-based sample of men ≤ 75 years with newly diagnosed LPC about treatment choice, reasons for the choice, decision-making difficulty, satisfaction, and regret., Results: Of 160 men (71 black, 89 white), with a mean age of 61 (±7.3) years, 59% chose surgery, 31% chose radiation, and 10% chose active surveillance (AS)/watchful waiting (WW). Adjusting for age, race, comorbidity, tumor risk level, and treatment status, men who consulted friends during decision-making were more likely to choose curative treatment (radiation or surgery) than WW/AS (OR = 11.1, p < 0.01; 8.7, p < 0.01). Men who saw a radiation oncologist in addition to a urologist were more likely to choose radiation than surgery (OR = 6.0, p = 0.04). Men who consulted family or friends (OR = 2.6, p < 0.01; 3.7, p < 0.01) experienced greater decision-making difficulty. No personality traits (pessimism, optimism, or faith) were associated with treatment choice/decision-making quality measures., Conclusions: In addition to specialist seen, consulting friends increased men's likelihood of choosing curative treatment. Consulting family or friends increased decision-making difficulty.

Background: There is evidence suggesting that active participation of patients in their health care can improve the quality of care and decrease health-care costs. Further, patient reports of their health-care experience are increasingly used to monitor health-care quality., Objective: This paper describes a systematic review of peer-reviewed studies to identify measures of patients' active participation in their encounters with health-care providers., Methods: A systematic literature review was conducted for publications indexed from 1975 to 2011. Of interest were self-reported measures of patient participation that were not limited to a specific health concern. All abstracts were reviewed independently by two authors, and the full paper was considered for those meeting inclusion criteria., Main Results: From a review of 4528 citations, ten measures were identified. The approaches to development of the measures varied considerably, as did their study samples and their psychometric quality., Discussion: These measures represented three conceptual frameworks: empowerment and self-efficacy, therapeutic alliance, and consumerism/satisfaction. They provide a more comprehensive perspective of patients' experiences of their provider encounters, and a better understanding patient behaviour enhanced the quality of health-care delivery or improved health outcomes. These measures underscore the continuing challenge of defining patient participation and the multiple theoretical approaches that underlie this form of patient behaviour., Conclusions: Current interest in quality-related physician report cards gives significant weight to patients' self-reported experiences as one dimension of physician performance. It is critical to identify the specific focus and quality of measures selected for this and research purposes., (© 2014 John Wiley & Sons Ltd.)

Background: We know little about patient-physician communication during visits to discuss diagnosis and treatment of prostate cancer., Objective: To examine the overall visit structure and how patients and physicians transition between communication activities during visits in which patients received new prostate cancer diagnoses., Participants: Forty veterans and 18 urologists at one VA medical centre., Methods: We coded 40 transcripts to identify major communication activities during visits and used empiric discourse analysis to analyse transitions between activities., Results: We identified five communication activities that occurred in the following typical sequence: 'diagnosis delivery', 'risk classification', 'options talk', 'decision talk' and 'next steps'. The first two activities were typically brief and involved minimal patient participation. Options talk was typically the longest activity; physicians explicitly announced the beginning of options talk and framed it as their professional responsibility. Some patients were unsure of the purpose of visit and/or who should make treatment decisions., Conclusion: Visits to deliver the diagnosis of early stage prostate cancer follow a regular sequence of communication activities. Physicians focus on discussing treatment options and devote comparatively little time and attention to discussing the new cancer diagnosis. Towards the goal of promoting patient-centred communication, physicians should consider eliciting patient reactions after diagnosis delivery and explaining the decision-making process before describing treatment options., (© 2013 John Wiley & Sons Ltd.)

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.

Recent guidelines on cancer screening have provided not only more screening options but also conflicting recommendations. Thus, patients, with their clinicians' support, must decide whether to get screened, which modality to use, and how often to undergo screening. Decision aids could potentially lead to better shared decision-making regarding screening between the patient and the clinician. A total of 73 decision aids concerning screening for breast, cervical, colorectal, and prostate cancers were reviewed. The goal of this review was to assess the effectiveness of such decision aids, examine areas in need of more research, and determine how the decision aids can be currently applied in the real-world setting. Most studies used sound study designs. Significant variation existed in the setting, theoretical framework, and measured outcomes. Just over one-third of the decision aids included an explicit values clarification. Other than knowledge, little consistency was noted with regard to which patient attributes were measured as outcomes. Few studies actually measured shared decision-making. Little information was available regarding the feasibility and outcomes of integrating decision aids into practice. In this review, the implications for future research, as well as what clinicians can do now to incorporate decision aids into their practice, are discussed., (Copyright © 2013 American Cancer Society, Inc.)

Background: Communication problems in health care may arise as a result of healthcare providers focusing on diseases and their management, rather than people, their lives and their health problems. Patient-centred approaches to care delivery in the patient encounter are increasingly advocated by consumers and clinicians and incorporated into training for healthcare providers. However, the impact of these interventions directly on clinical encounters and indirectly on patient satisfaction, healthcare behaviour and health status has not been adequately evaluated., Objectives: To assess the effects of interventions for healthcare providers that aim to promote patient-centred care (PCC) approaches in clinical consultations., Search Methods: For this update, we searched: MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), and CINAHL (EbscoHOST) from January 2000 to June 2010. The earlier version of this review searched MEDLINE (1966 to December 1999), EMBASE (1985 to December 1999), PsycLIT (1987 to December 1999), CINAHL (1982 to December 1999) and HEALTH STAR (1975 to December 1999). We searched the bibliographies of studies assessed for inclusion and contacted study authors to identify other relevant studies. Any study authors who were contacted for further information on their studies were also asked if they were aware of any other published or ongoing studies that would meet our inclusion criteria., Selection Criteria: In the original review, study designs included randomized controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series studies of interventions for healthcare providers that promote patient-centred care in clinical consultations. In the present update, we were able to limit the studies to randomized controlled trials, thus limiting the likelihood of sampling error. This is especially important because the providers who volunteer for studies of PCC methods are likely to be different from the general population of providers. Patient-centred care was defined as a philosophy of care that encourages: (a) shared control of the consultation, decisions about interventions or management of the health problems with the patient, and/or (b) a focus in the consultation on the patient as a whole person who has individual preferences situated within social contexts (in contrast to a focus in the consultation on a body part or disease). Within our definition, shared treatment decision-making was a sufficient indicator of PCC. The participants were healthcare providers, including those in training., Data Collection and Analysis: We classified interventions by whether they focused only on training providers or on training providers and patients, with and without condition-specific educational materials. We grouped outcome data from the studies to evaluate both direct effects on patient encounters (consultation process variables) and effects on patient outcomes (satisfaction, healthcare behaviour change, health status). We pooled results of RCTs using standardized mean difference (SMD) and relative risks (RR) applying a fixed-effect model., Main Results: Forty-three randomized trials met the inclusion criteria, of which 29 are new in this update. In most of the studies, training interventions were directed at primary care physicians (general practitioners, internists, paediatricians or family doctors) or nurses practising in community or hospital outpatient settings. Some studies trained specialists. Patients were predominantly adults with general medical problems, though two studies included children with asthma. Descriptive and pooled analyses showed generally positive effects on consultation processes on a range of measures relating to clarifying patients' concerns and beliefs; communicating about treatment options; levels of empathy; and patients' perception of providers' attentiveness to them and their concerns as well as their diseases. A new finding for this update is that short-term training (less than 10 hours) is as successful as longer training.The analyses showed mixed results on satisfaction, behaviour and health status. Studies using complex interventions that focused on providers and patients with condition-specific materials generally showed benefit in health behaviour and satisfaction, as well as consultation processes, with mixed effects on health status. Pooled analysis of the fewer than half of included studies with adequate data suggests moderate beneficial effects from interventions on the consultation process; and mixed effects on behaviour and patient satisfaction, with small positive effects on health status. Risk of bias varied across studies. Studies that focused only on provider behaviour frequently did not collect data on patient outcomes, limiting the conclusions that can be drawn about the relative effect of intervention focus on providers compared with providers and patients., Authors' Conclusions: Interventions to promote patient-centred care within clinical consultations are effective across studies in transferring patient-centred skills to providers. However the effects on patient satisfaction, health behaviour and health status are mixed. There is some indication that complex interventions directed at providers and patients that include condition-specific educational materials have beneficial effects on health behaviour and health status, outcomes not assessed in studies reviewed previously. The latter conclusion is tentative at this time and requires more data. The heterogeneity of outcomes, and the use of single item consultation and health behaviour measures limit the strength of the conclusions.

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.

Background: Decision aids prepare people to participate in 'close call' decisions that involve weighing benefits, harms, and scientific uncertainty., Objectives: To conduct a systematic review of randomised controlled trials (RCTs) evaluating the efficacy of decision aids for people facing difficult treatment or screening decisions., Search Strategy: We searched MEDLINE (Ovid) (1966 to July 2006); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library; 2006, Issue 2); CINAHL (Ovid) (1982 to July 2006); EMBASE (Ovid) (1980 to July 2006); and PsycINFO (Ovid) (1806 to July 2006). We contacted researchers active in the field up to December 2006. There were no language restrictions., Selection Criteria: We included published RCTs of interventions designed to aid patients' decision making by providing information about treatment or screening options and their associated outcomes, compared to no intervention, usual care, and alternate interventions. We excluded studies in which participants were not making an active treatment or screening decision, or if the study's intervention was not available to determine that it met the minimum criteria to qualify as a patient decision aid., Data Collection and Analysis: Two review authors independently screened abstracts for inclusion, and extracted data from included studies using standardized forms. The primary outcomes focused on the effectiveness criteria of the International Patient Decision Aid Standards (IPDAS) Collaboration: attributes of the decision and attributes of the decision process. We considered other behavioural, health, and health system effects as secondary outcomes. We pooled results of RCTs using mean differences (MD) and relative risks (RR) using a random effects model., Main Results: This update added 25 new RCTs, bringing the total to 55. Thirty-eight (69%) used at least one measure that mapped onto an IPDAS effectiveness criterion: decision attributes: knowledge scores (27 trials); accurate risk perceptions (11 trials); and value congruence with chosen option (4 trials); and decision process attributes: feeling informed (15 trials) and feeling clear about values (13 trials).This review confirmed the following findings from the previous (2003) review. Decision aids performed better than usual care interventions in terms of: a) greater knowledge (MD 15.2 out of 100; 95% CI 11.7 to 18.7); b) lower decisional conflict related to feeling uninformed (MD -8.3 of 100; 95% CI -11.9 to -4.8); c) lower decisional conflict related to feeling unclear about personal values (MD -6.4; 95% CI -10.0 to -2.7); d) reduced the proportion of people who were passive in decision making (RR 0.6; 95% CI 0.5 to 0.8); and e) reduced proportion of people who remained undecided post-intervention (RR 0.5; 95% CI 0.3 to 0.8). When simpler decision aids were compared to more detailed decision aids, the relative improvement was significant in knowledge (MD 4.6 out of 100; 95% CI 3.0 to 6.2) and there was some evidence of greater agreement between values and choice.In this review, we were able to explore the use of probabilities in decision aids. Exposure to a decision aid with probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.6; 95% CI 1.4 to 1.9). The effect was stronger when probabilities were measured quantitatively (RR 1.8; 95% CI 1.4 to 2.3) versus qualitatively (RR 1.3; 95% CI 1.1 to 1.5).As in the previous review, exposure to decision aids continued to demonstrate reduced rates of: elective invasive surgery in favour of conservative options, decision aid versus usual care (RR 0.8; 95% CI 0.6 to 0.9); and use of menopausal hormones, detailed versus simple aid (RR 0.7; 95% CI 0.6 to 1.0). There is now evidence that exposure to decision aids results in reduced PSA screening, decision aid versus usual care (RR 0.8; 95% CI 0.7 to 1.0) . For other decisions, the effect on decisions remains variable.As in the previous review, decision aids are no better than comparisons in affecting satisfaction with decision making, anxiety, and health outcomes. The effects of decision aids on other outcomes (patient-practitioner communication, consultation length, continuance, resource use) were inconclusive.There were no trials evaluating the IPDAS decision process criteria relating to helping patients to recognize a decision needs to be made, understand that values affect the decision, or discuss values with the practitioner., Authors' Conclusions: Patient decision aids increase people's involvement and are more likely to lead to informed values-based decisions; however, the size of the effect varies across studies. Decision aids have a variable effect on decisions. They reduce the use of discretionary surgery without apparent adverse effects on health outcomes or satisfaction. The degree of detail patient decision aids require for positive effects on decision quality should be explored. The effects on continuance with chosen option, patient-practitioner communication, consultation length, and cost-effectiveness need further evaluation.

Background: A hospital admission for a serious cardiac event offers a unique opportunity for smoking cessation. Understanding the factors that predict and enhance cessation among smoking cardiac inpatients is important for hospital physicians and clinical staff., Study Objective: To determine factors that predict smoking cessation, relapse, or continued smoking among posthospitalized cardiac patients who were smoking at the time of admission., Sample: Patients hospitalized with acute coronary syndrome (ACS) were recruited from 5 hospitals in Michigan to participate in a study assessing hospital quality improvement plus at-home health behavior change counseling., Measurements: Patient interview data were collected shortly after discharge and 3 and 8 months later to describe patient demographics, clinical characteristics, tobacco use, and other behaviors. Multinomial logit regression was used to predict smoking cessation, relapse, and continued smoking., Results: Of patients smoking at hospitalization who completed both follow-up interviews, 56.8% (n = 111) were not smoking at 8 months. A significant predictor of successful cessation was higher household income (odds ratio [OR] = 4.72; P = 0.003), while having other smokers in the household decreased the odds of cessation (OR = 0.20; P = 0.001). History of depression increased the odds of relapse (OR = 6.38; P = 0.002) and being a lighter smoker decreased the odds (OR = 0.16; P = 0.026)., Conclusions: Although approximately one-half of the smokers in this study reported successful cessation, interventions are still needed to assist all smokers to successfully quit smoking after an ACS hospitalization. Our data suggest targeting follow-up programs to include other family members and using specialized methods for heavy smokers., ((c) 2009 Society of Hospital Medicine.)

Objective: To examine men's interpretations of graphical information types viewed in a high-quality, previously tested videotape decision aid (DA). SETTING, PARTICIPANTS, DESIGN: A community-dwelling sample of men >50 years of age (N = 188) balanced by education (college/non-college) and race (Black/White) were interviewed just following their viewing of a videotape DA. A descriptive study design was used to examine men's interpretations of a representative sample of the types of graphs that were shown in the benign prostatic hyperplasia videotape DA., Main Variables Studied: Men provided their interpretation of graphs information presented in three formats that varied in complexity: pictograph, line and horizontal bar graph. Audiotape transcripts of men's responses were coded for meaning and content-related interpretation statements., Results: Men provided both meaning and content-focused interpretations of the graphs. Accuracy of interpretation was lower than hypothesized on the basis of literature review (85.4% for pictograph, 65.7% for line graph, 47.8% for horizontal bar graph). Accuracy for pictograph and line graphs was associated with education level, chi2(1) = 3.94, P = 0.047, and chi2(1) = 7.55, P = 0.006, respectively. Accuracy was uncorrelated with men's reported liking of the graphs, chi2(1) = 2.00, P = 0.441., Conclusion: While men generally liked the DA, accuracy of graphs interpretation was associated with format complexity and education level. Graphs are often recommended to improve comprehension of information in DAs. However, additional evaluation is needed in experimental and naturalistic observational settings to develop best practice standards for data representation.

Statistical models have been used to assess the influence of clinical and demographic factors on hospital charge and length of stay (LOS). Hospital costs constitute a significant proportion of overall expenditure in health care. With escalating costs, knowing the correlates of LOS and in-hospital cost is important for decisions on allocating resources. However, hospital charge and LOS are correlated. We describe two regression models that permit estimation of mean charges as a function of patient hospital stay and adjust for the influence of patient characteristics and treatment procedures on LOS and charge. In the first model, the mean charge over a specified duration is a weighted average of the expected cumulative charge, with weighting determined by the distribution of LOS. The second model for LOS and charge explicitly accounts for their correlation and yields estimates of the average charge per average LOS. The methods are applied to assess mean charges and mean charge per day by cardiac procedure in a cohort of patients hospitalized for acute myocardial infarction, while adjusting for the impact of patient demographic and clinical factors on LOS and charge. For relatively short hospital stays, and when only total hospital charges are available, these models provide a flexible approach to estimating summary measures on resource use while controlling for the effects of covariates on LOS and charge., (Copyright 2002 John Wiley & Sons, Ltd.)

Objective: To conduct a preliminary validation of the Satisfaction With Decision (SWD) scale with depressed primary care patients., Design: Cross-sectional observational pilot study using a postal survey., Setting and Participants: Depressed primary care patients (n = 97) who recently had made a new decision about antidepressant medication use completed surveys regarding their treatment decisions., Main Variables: Measures included patient-reported satisfaction with decision, decisional conflict, knowledge about depression and treatment, decision involvement, pain and health status, antidepressant medication efficacy, and satisfaction with health services., Results: The SWD scale had good internal consistency reliability (alpha = 0.85). Evidence for construct validity was confirmed via a hypothesized pattern of relationships between the SWD scale and other measures. Decision satisfaction was associated with several issues of relevance for designing patient-centred decision support interventions: (1) knowledge about depression and treatment; (2) involvement in health-related decisions; and (3) aiding evaluation of trade-offs among pros and cons of treatment., Conclusions: The results of this pilot study show that the SWD scale appears to be a psychometrically sound and practical measure for research with this population. Additional research is needed on the theoretical nature of decision satisfaction and developing and testing patient-centred decision support interventions for depression treatment.

Background: Decision aids prepare people to participate in preference-sensitive decisions., Objectives: 1. Create a comprehensive inventory of patient decision aids focused on healthcare options. 2. Review randomized controlled trials (RCT) of decision aids, for people facing healthcare decisions., Search Strategy: Studies were identified through databases and contact with researchers active in the field., Selection Criteria: Two independent reviewers screened abstracts for interventions designed to aid patients' decision making by providing information about treatment or screening options and their associated outcomes. Information about the decision aids was compiled in an inventory; those that had been evaluated in a RCT were reviewed in detail., Data Collection and Analysis: Two reviewers independently extracted data using standardized forms. Results of RCTs were pooled using weighted mean differences (WMD) and relative risks (RR) using a random effects model., Main Results: Over 200 decision aids were identified. Of the 131 available decision aids, most are intended for use before counselling. Using the CREDIBLE criteria to evaluate the quality of the decision aids: a) most included potential harms and benefits, credentials of the developers, description of their development process, update policy, and were free of perceived conflict of interest; b) many included reference to relevant literature; c) few included a description of the level of uncertainty regarding the evidence; and d) few were evaluated. Thirty of these decision aids were evaluated in 34 RCTs and another trial evaluated a suite of eight decision aids. An additional 30 trials are yet to be published. Among the trials comparing decision aids to usual care, decision aids performed better in terms of: a) greater knowledge (WMD 19 out of 100, 95% CI: 13 to 24; b) more realistic expectations (RR 1.4, 95%CI: 1.1 to 1.9); c) lower decisional conflict related to feeling informed (WMD -9.1 of 100, 95%CI: -12 to -6); d) increased proportion of people active in decision making (RR 1.4, 95% CI: 1.0 to 2.3); and e) reduced proportion of people who remained undecided post intervention (RR 0.43, 95% CI: 0.3 to 0.7). When simpler were compared to more detailed decision aids, the relative improvement was significant in: a) knowledge (WMD 4 out of 100, 95% CI: 3 to 6); b) more realistic expectations (RR 1.5, 95% CI: 1.3 to 1.7); and c) greater agreement between values and choice. Decision aids appeared to do no better than comparisons in affecting satisfaction with decision making, anxiety, and health outcomes. Decision aids had a variable effect on which healthcare options were selected., Reviewer's Conclusions: The availability of decision aids is expanding with many on the Internet; however few have been evaluated. Trials indicate that decision aids improve knowledge and realistic expectations; enhance active participation in decision making; lower decisional conflict; decrease the proportion of people remaining undecided, and improve agreement between values and choice. The effects on persistence with chosen therapies and cost-effectiveness require further evaluation. Finally, optimal strategies for dissemination need to be explored.

Background: Decision aids are interventions designed to help people make specific and deliberative choices among options (including status quo) by providing (at a minimum) information on the options and outcomes relevant to a person's health status. A systematic review is needed to summarize what is known about their efficacy., Objectives: 1. To create an inventory of existing decision aids. 2. To conduct a systematic review of randomized controlled trials of decision aids aimed at improving people's decision making and outcomes., Search Strategy: The following electronic databases were searched: MEDLINE, EMBASE, PsycINFO, CINAHL, Aidsline, Cancerlit, the Cochrane Controlled Trials Register. In addition, individuals known to be active in the field of decision support were contacted., Selection Criteria: We screened titles and abstracts for all interventions providing structured, detailed, and specific information on treatment or screening options and outcomes to aid decision making. Information about the decision aids was compiled in an inventory and those evaluated in a randomized controlled trial were reviewed in detail., Data Collection and Analysis: Using Cochrane review methods, two reviewers independently screened and extracted data on several evaluation criteria. Results of randomized trials were pooled using weighted mean differences and relative risks with all data analysed using a random effects model., Main Results: Eighty-seven decision aids were identified. Twenty-three of them had been evaluated in 24 randomized controlled trials. Among the trials comparing decision aids to usual care interventions, decision aids performed better in terms of: a) greater knowledge of options in seven of seven studies (weighted mean difference (WMD = 19 out of 100, 95% confidence interval (CI): 13,25); b) more realistic expectations in two of three studies (RR=1.48 95%CI 1.02, 2.14); c) lower decisional conflict related to feeling informed in three of three studies (WMD = -9.0 of 100 95%CI: -15, -3); d) reducing the proportion of people who were passive in decision making in three of four studies (RR = 0.63, 95% CI: 0.5, 0.8). When simpler decision aids were compared to more detailed ones, the relative improvement was significant in: a) improved knowledge in two of seven studies (WMD = 4 out of 100, 95% CI: 2, 5); b) realistic expectations in two of two studies (relative risk (RR ranged from 1.5 95%CI: 1.3,1.8); and c) decisional conflict in one of two studies (WMD= -4 95% CI -8,-0.2). There was a consistent trend for decision aids to do no better than comparison interventions in affecting: satisfaction with the decision in five of six studies, satisfaction with the decision making process in four of five studies, and anxiety in four of five studies. Decision aids had a variable effect on which screening or treatment options were selected. Exposure to decision aids relative to controls resulted in a consistent non-significant trend toward reduced preference for major surgery over conservative options by 21 to 42 per cent in five of five studies; however, they had no impact on circumcision in two of two studies. For colon and prostate cancer screening choices, the results were inconsistent. Two studies have shown no impact on persistence with chosen option and few studies have shown significant benefits on general health outcomes (two of three studies), or disease-specific health outcomes (one of four studies)., Reviewer's Conclusions: The number of decision aids is expanding, but there is considerable overlap in some areas leaving gaps in others. Trials of decision aids indicate that they are superior to usual care interventions in improving knowledge and realistic expectations of the benefits and harms of options; reducing passivity in decision making; and lowering decisional conflict stemming from feeling uninformed. When simpler versions of decision aids are compared to more detailed aids, the differences in knowledge are marginal but there are other benefits in terms of creating realistic expectations and in reducing decisional conflict. To date, decision aids have had little effect on anxiety or satisfaction with the decision making process or satisfaction with the decision. Their effects on choices vary with the decision. The effects on persistence with chosen therapies and health outcomes require further evaluation. The essential elements in decision aids for different groups and different types of decisions need to be established. Consensus needs to be reached regarding standards for developing and evaluating decision aids.

OBJECTIVE: Determine feasibility of shared decision-making programmes in fee-for-service hospital systems including physicians' offices and in-patient facilities. DESIGN: Survey and participant observation. Data obtained during Phase 1 of a patient outcome study. SETTINGS AND PARTICIPANTS: Three hospitals in Michigan: one 299-bed rural regional hospital, one 650-bed urban community hospital, one 459-bed urban and suburban teaching hospital. All nurses and physicians who agreed to use the programmes participated in the evaluation (n = 34). INTERVENTION: Two shared decision-making(R) (SDP) multimedia programmes: surgical treatment choice for breast cancer and ischaemic heart disease treatment choice. MAIN OUTCOME MEASURES: (1) clinicians' evaluations of programme quality; (2) challenges in hospital settings; and (3) patient referral rates. RESULTS: SDP programmes were judged to be clear, accurate and about the right length and amount of information. Programmes were judged to be informative and appropriate for patients to see before making a decision. Clinicians were neutral about patients' desire to participate in treatment decision-making. Referral volume to SDPs was lower than expected: 24 patients in 7 months across three hospitals. Implementation challenges centred on time pressures in patient care. CONCLUSIONS: Productivity and time pressure in US health care severely constrain shared decision-making programme implementation. Physician referral may not be a reliable mechanism for patient access. Possible innovations include: (1) incorporation into the informed consent process; (2) provider or payer negotiated requirement in the routine hospital procedure to use the SDP as a quality indicator; and (3) payer reimbursement to professional providers who make SDP programmes available to patients.

The purpose of this study was to develop and test a decision support intervention (DSI) to assist women to make and act on informed decisions that are consistent with their values in the area of menopause and hormone replacement therapy (HRT). Mode and intensity of intervention were tested in midlife women (N = 248), randomly assigned to one of three intervention formats: written information only, guided discussion, or personalized decision exercise. Data were collected over 12 months. Knowledge, decisional conflict, satisfaction with health care provider, and self-efficacy improved following intervention and were maintained for 12 months for all groups. Women's adherence to their own plans over 12 months was 59% (exercise), 76% (calcium intake), and 89% (HRT). Carefully written information is effective in promoting knowledge, adherence, and satisfaction among well-educated, interested women. It was concluded that women can understand complex information, including tradeoffs regarding treatment options. Women will adhere to their own plans, suggesting that consumer rather than provider plans may be the more appropriate gold standard for measuring adherence.