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Background: Female patients with pelvic organ prolapse and clinicians need to take decisions regarding treatment that are often unpredictable in relation to how they impact the future everyday lives of the patients. This study formed the developmental phase of a larger study to develop and test an online tool to support shared decision-making., Methods: Patients, health care professionals and other stakeholders participated in the development and evaluation process of this tool. The collected data was generated from observational studies, exploratory interviews with prompt cards and workshops with end users from four Danish gynecology outpatient clinics., Results: Content analysis led to important themes. For the patients three themes emerged: 1) how the impact of symptoms on everyday life affected the need for relief, 2) their bodily perception and sex life and 3) their worries about the future. For clinicians the different symptoms and their severity was a main theme., Conclusions: This article provides an overall description and discussion of the development methodology. It demonstrates how user involvement informed the prototyping process and how patients' preferences were included in the final prototype. Whether the tool actually increases SDM, remains to be tested in a pilot feasibility study.

Classification of a continuous risk score into risk levels is common. However, while the absolute risk score is essential, it is arguably unethical to label anyone at 'high, moderate or low risk' of a serious event, simply because management based on a single criterion (e.g. avoiding the target condition) has been determined to be effective or cost-effective at a population level. Legally, mono-criterial risk labeling can inhibit the obtaining of a fully-informed, preference-based consent, since multiple considerations (various benefits and harms) matter to most individuals, not only the single criterion that is the basis of the provided risk category. These ethical and legal challenges can be met by preference-sensitive multi-criteria decision support tools. In this future vision paper, we demonstrate, at a conceptual proof-of-method level, how such decision support can and should be developed without reference to risk-level classifications. The statin decision is used as illustration, without any empirical claims.

In this vision paper we envisage paradigmatic change transforming the health professional from the empowered agent of a dependent patient into the final decision supporter of an empowered person; a person who comes equipped with the preliminary opinion of an apomediative personalised decision support tool and the enhanced health decision literacy it produces. The anomalies in the current paradigm that will produce this change arise from unworkable attempts to combine multicriterial personal preferences and the best available evidence in a medical reasoning model. Multi-Criteria Decision Analysis (MCDA)-based decision support tools provide one mechanism for achieving this synthesis in a transparent way in a specific case whilst, simultaneously, increasing the generic health decision literacy and competencies of both person and clinician. The educational task for both is less than might be expected because of their familiarity, as consumers, with the many comparison websites and magazines for products and services using an informal version of MCDA. The educational task, particularly for the clinician, is primarily one of acknowledging that MCDA is a decision competence that has the potential, not only to enhance decision quality, but also facilitate communication between person and professional, who will now be talking the same decisional language. Experience from developing the MyBoneHealth tool confirms both the feasibility and challenges of delivering a MCDA-based decision support and educational tool.

In the health capital model, the main function of health services is not to produce health, but to support the person in their self-production investments. In the health context there are three types of decision support tools, depending on the role of the provider (e.g. clinician) and person. Non-mediative tools are designed to help the clinician decide what is best for the patient. Intermediative Patient Decision Aids are designed to help the clinician and patient decide together, in an encounter, what is best for the patient. Apomediative Personalised Decision Support Tools are designed to help the person decide what is best for themselves, including whether to seek a professional consultation and/or to prepare for, and engage in, an intermediative consultation. Only preference-sensitive apomediative support tools ensure that the key requirements of self-produced health are met, along with legally informed and preference-based consent to any subsequent provider action. The desirable form of apomediative support is a publicly accessible, direct-to-citizen, provider-independent, multi-criteria analysis-based decision support of the sort available in many other areas of self-production. Which (UK), Tænk (Denmark), Choice (Australia) and numerous other comparison magazines and websites provide independent multi-criterial support for decisions on, for example, which food and transport to buy to self-produce nutrition and movement. A personalised decision support tool for the statin decision is provided as illustration: Should I go to my general practitioner and ask for a statin prescription or go to discuss taking statins, in the light of the preliminary opinion of the tool?

Most guidelines for clinical practice, and especially those for the construction of decision support tools, assume that the individual person (the patient) needs to be in possession of information of particular sorts and amount in order to qualify as having made an 'informed decision'. This often implicitly segues into the patient having made a 'good decision'. In person-centred health care, whether, in what form, and with what weight, 'information' is included as a criterion of decision quality is a matter for the person involved, to decide in the light of their own values, preferences, and time and resource constraints., (© The Author(s) 2015.)

Graphic representation was used to explore to what extent the number needed to treat (NNT) conveys the appropriate notion of benefit for the individual patient in interventions aimed at delaying adverse events. A sample of the Danish population (n = 675) was interviewed face to face, and asked whether they would consent to a hypothetical drug that reduces the risk of heart attack. The benefit of the drug was expressed in terms of NNT and was randomly set at 10, 25, 50, 100, 200, and 400. NNT does not convey information on the proportion of patients being helped by an intervention or the size of the delay of the adverse event intended to be prevented. The proportion of people consenting to the hypothetical drug was about 80%, irrespective of NNT, and some of those who rejected the drug misinterpreted the meaning of NNT. Lay people may have difficulties in understanding the meaning of NNT, and clinicians may do well to use the NNT with caution until more is known about how patients comprehend it.

Modern healthcare research has only in recent years investigated the impact of health care workers' religious and other values on medical practice, interaction with patients, and ethically complex decision making. So far, only limited international data exist on the way such values vary across different countries. We therefore established the NERSH International Collaboration on Values in Medicine with datasets on physician religious characteristics and values based on the same questionnaire. The present article provides (a) an overview of the development of the original and optimized questionnaire, (b) an overview of the content of the NERSH data pool at this stage and (c) a brief review of insights gained from articles published with the questionnaire. The pool at this stage consists of data from 17 studies from research units in 12 different countries representing six continents with responses from more than 6000 health professionals. The joint data pool suggests that there are large differences in religious and other moral values across nations and cultures, and that these values contribute to the observed differences in health professionals' clinical practices—across nations and cultures! [ABSTRACT FROM AUTHOR]

Background: Deprescribing of proton pump inhibitors (PPIs) can be considered in situations where the drug may no longer be necessary; however, this requires a careful discussion between patients and healthcare providers, often general practitioners (GPs). The aim of our study was to explore how GPs discuss PPI deprescribing with patients and compare that to how older patients would like to discuss this decision. Methods: We conducted a qualitative study using semi-structured interviews with GPs (n = 11) and patients aged ≥65 years who were taking PPIs (n = 4). Analysis of interviews was based on systematic text condensation. Results: We identified four main themes: (1) Reasons PPI deprescribing comes up, (2) Considering PPI deprescribing, (3) Discussion topics, and (4) Incorporating patient preferences into PPI deprescribing decisions. We found that PPI deprescribing often comes up during consultations for other problems or due to concern about medication burden in general. GPs discussed topics related to symptom control, such as the possibility of rebound symptoms, the need to taper PPIs, and what to do if symptoms returned. This aligned with what patients felt was important to discuss. Some GPs routinely incorporated patient preferences into decisions, whereas others did not. Conclusion: When discussing PPI deprescribing, the GPs in our study generally focused on topics related to symptom control. There was variability in how and if patient preferences were discussed. Greater focus may be needed on developing mechanisms to elicit and incorporate patient preferences into PPI deprescribing decisions. Future research could also explore more systematic approaches to reassess ongoing PPI use in an effort to curb unnecessary long-term use of PPIs. [ABSTRACT FROM AUTHOR]

Background: Deprescribing of preventive medications may be considered in some nursing home residents. It is important to understand how to effectively communicate around this complex decision, from both a physician and resident perspective. Objective: The objective of this study was to explore how nursing home residents would like to discuss deprescribing of preventive medications with their physicians. Methods: We conducted a qualitative study with face-to-face, semi-structured interviews. Participants were Danish nursing home residents aged ≥70 years deemed cognitively able to participate by nursing staff. They were taking one or more of statins, antihypertensives, antihyperglycemics, or antiplatelets. Interviews were audio recorded and transcribed verbatim. Analysis was conducted based on systematic text condensation. Results: Nine nursing home residents (median age 85 years, seven female) were interviewed. Participants were generally aware of their overall number of medications but unaware of specific medications and why they were taking them. All participants displayed a high degree of trust in their physicians, preferring to defer decisions to them, and generally believed their medication was necessary if their physician had prescribed it. Residents would be open to deprescribing if their physician suggested it but were not aware of the possibility to be involved in the decision (e.g., discuss goals of care and treatment preferences) and had difficulty imagining what they could discuss with their physician about a deprescribing decision. Conclusion: The interviewed nursing home residents could not imagine how they might discuss potential deprescribing of preventive medications with their physician, and what topics would be important. Future work should explore how nursing home residents can be encouraged to be part of such discussions and investigate ways to have residents share their goals and preferences regarding deprescribing. [ABSTRACT FROM AUTHOR]

Background: Given uncertainty surrounding benefits and harms, shifts in patient health status, and changing patient goals and preferences, statin deprescribing may be considered in some older people. This decision should be carefully discussed between GPs and patients. Aim: To explore how GPs discuss deprescribing of statins with their older patients. Design & setting: A qualitative study was undertaken using face-to- face, semi-structured interviews with Danish GPs from the regions of Southern Demark and Zealand. Method: The GP participants belonged to group practices and were identified from personal networks and snowballing. The interviews lasted approximately 30 minutes and were conducted in English. They were analysed using systematic text condensation. Results: A total of 11 GPs were interviewed and three themes were identified. (1) Reason for initiating a discussion: statin deprescribing mainly came up when GPs reviewed medication lists. There were differences between GPs regarding when or if they brought up deprescribing. (2) Discussion topics: GPs often discussed their interpretation of evidence surrounding statin use in older people. There were differences in how and if GPs discussed patient preferences. GPs viewed uncertainty and life expectancy as difficult to discuss. (3) Depth of discussion: the perceived level of patient engagement, and clinical context, could influence the extent of discussion. Conclusion: GPs identified a range of topics that could be discussed with patients surrounding statin deprescribing. The depth and content of discussions varied according to the situation, and between GPs. Challenges may exist in communicating around certain topics, such as uncertainty and life expectancy. Further understanding of how to best communicate around challenging topics, and development of structured frameworks, may help facilitate statin deprescribing discussions. Identifying what patients think is important to discuss would provide necessary insight to promote quality discussions and shared understanding of the decision. [ABSTRACT FROM AUTHOR]

Background: It is important that patients are well-informed about risks and benefits of therapies to help them decide whether to accept medical therapy. Different numerical formats can be used in risk communication but It remains unclear how the different formats affect decisions made by real-life patients.Aim: To compare the impact of using Prolongation Of Life (POL) and Absolute Risk Reduction (ARR) information formats to express effectiveness of cholesterol-lowering therapy on patients' redemptions of statin prescriptions, and on patients' confidence in their decision and satisfaction with the risk communication.Design and Setting: Cluster-randomised clinical trial in general practices. Thirty-four Danish GPs from 23 practices participated in a primary care-based clinical trial concerning use of quantitative effectiveness formats for risk communication in health prevention consultations.Method: GPs were cluster-randomised (treating practices as clusters) to inform patients about cardiovascular mortality risk and the effectiveness of statin treatment using either POL or ARR formats. Patients' redemptions of statin prescriptions were obtained from a regional prescription database. The COMRADE questionnaire was used to measure patients' confidence in their decision and satisfaction with the risk communication.Results: Of the 240 patients included for analyses, 112 were allocated to POL information and 128 to ARR. Patients redeeming a statin prescription totalled six (5.4%) when informed using POL, and 32 (25.0%) when using ARR. The level of confidence in decision and satisfaction with risk communication did not differ between the risk formats.Conclusion: Patients redeemed statin prescriptions less often when their GP communicated treatment effectiveness using POL compared with ARR. [ABSTRACT FROM AUTHOR]

Background: Risk communication is an integral part of shared decision-making in health care. In the context of interventions for chronic diseases it represents a particular challenge for all health practitioners. By using two different quantitative formats to communicate risk level and effectiveness of a cholesterol-lowering drug, we posed the research question: how does the format of risk information influence patients' decisions concerning therapy, patients' satisfaction with the communication as well as confidence in the decision. We hypothesise that patients are less prone to accept therapy when the benefits of long-term intervention are presented in terms of prolongation of life (POL) in months compared to the absolute risk reduction (ARR). We hypothesise that patients presented with POL will be more satisfied with the communication and confident in their decision, suggesting understanding of the time-related term. Methods/Design: In 2009 a sample of 328 general practitioners (GPs) in the Region of Southern Denmark was invited to participate in a primary care-based clinical trial among patients making real-life clinical decisions together with their GP. Interested GPs were cluster-randomised to inform patients about cardiovascular disease (CVD) risk and the effectiveness of statin therapy using either POL or ARR. The GPs attended a training session before informing their patients. Before training and after the trial period they received a questionnaire about their attitudes to risk communication and the use of numerical information. Patients' redemptions of statin prescriptions will be registered in a regional prescription database to evaluate a possible association between redemption rates and effectiveness format. The Combined Outcome Measure for Risk Communication And Treatment Decision Making Effectiveness (COMRADE) questionnaire will be used to measure patients' confidence and satisfaction with the risk communication immediately after the conversation with their GPs. Discussion: This randomised clinical trial compares the impact of two effectiveness formats on real-life risk communication between patients and GPs, including affective patient outcomes and actual choices about acceptance of therapy. Though we found difficulties in recruiting GPs, according to the study protocol we have succeeded in engaging sufficient GPs for the trial, enabling us to perform the planned analyses. [ABSTRACT FROM AUTHOR]

Background: Shared decision-making and patients' choice of interventions are areas of increasing importance, not least seen in the light of the fact that chronic conditions are increasing, interventions considered important for public health, and still non-acceptance of especially risk-reducing treatments of cardiovascular diseases (CVD) is prevalent. A better understanding of patients' medication-taking behavior is needed and may be reached by studying the reasons why people accept or decline medication recommendations. The aim of this paper was to identify factors that may influence people's decisions and reasoning for accepting or declining a cardiovascularpreventive medication offer.Methods: From a random sample of 4,000 people aged 40-59 years in a Danish population, 1,169 participants were asked to imagine being at increased risk of cardiovascular disease and being offered a preventive medication.After receiving 'complete' information about effectiveness of the medication they were asked whether they would accept medication. Finally, they were asked about reasons for the decision.Results: A total of 725 (67%) of 1,082 participants accepted the medication offer. Even quite large effects of medication (up to 8 percentage points absolute risk reduction) had a smaller impact on acceptance to medication than personal experience with cardiovascular disease. Furthermore, increasing age of the participant and living with a partner were significantly associated with acceptance. Some 45% of the respondents accepting justified their choice as being for health reasons, and they were more likely to be women, live alone, have higher income and higher education levels. Among those who did not accept the medication offer, 56% indicated that they would rather prefer to change lifestyle.Conclusions: Medication effectiveness seems to have a moderate influence on people's decisions to accept preventive medication, while factors such as personal experience with cardiovascular disease may have an equally strong or stronger influence, indicating that practitioners could do well to carefully identify the reasons for their patients' treatment decisions. [ABSTRACT FROM AUTHOR]

A sample of 3,201 Danes was subjected to personal interviews in which they were asked to state their preferences for risk-reducing health care interventions based on information on absolute risk reduction (ARR) and relative risk reduction (RRR). The aim of the study was to measure the relative weighting of different types of risk information under various circumstances. The effect of presenting questions, and of explicitly formulating RRR, was analyzed. A preference for increases in RRR was demonstrated. There was a stronger inclination to choose the intervention that offered the highest RRR if RRR was explicitly stated. Individuals with more than 10 years of schooling also demonstrated a preference for increased ARR, but only when facing individually framed choices. In a social choice context, preferences for RRR remained intact, but the magnitude of ARR had no impact on choices. Results imply that social framing may induce a propensity to prefer interventions that target high-risk populations. Those respondents who had received ≤10 years of schooling demonstrated preferences for RRR but not ARR, and no impact of social framing was observed. [ABSTRACT FROM AUTHOR]