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Clinician Article

Decision aids for people facing health treatment or screening decisions.



  • Stacey D
  • Legare F
  • Lewis K
  • Barry MJ
  • Bennett CL
  • Eden KB, et al.
Cochrane Database Syst Rev. 2017 Apr 12;4:CD001431. doi: 10.1002/14651858.CD001431.pub5. (Review)
PMID: 28402085
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Disciplines
  • FM/GP/Mental Health
    Relevance - 7/7
    Newsworthiness - 5/7
  • Oncology - Gastrointestinal
    Relevance - 6/7
    Newsworthiness - 6/7
  • Hospital Doctor/Hospitalists
    Relevance - 6/7
    Newsworthiness - 5/7
  • Infectious Disease
    Relevance - 6/7
    Newsworthiness - 5/7
  • Internal Medicine
    Relevance - 6/7
    Newsworthiness - 5/7
  • Psychiatry
    Relevance - 6/7
    Newsworthiness - 5/7
  • Surgery - General
    Relevance - 6/7
    Newsworthiness - 5/7
  • Endocrine
    Relevance - 5/7
    Newsworthiness - 5/7
  • Oncology - Breast
    Relevance - 5/7
    Newsworthiness - 5/7
  • Surgery - Colorectal
    Relevance - 5/7
    Newsworthiness - 5/7
  • Cardiology
    Relevance - 5/7
    Newsworthiness - 4/7
  • Family Medicine (FM)/General Practice (GP)
    Relevance - 5/7
    Newsworthiness - 4/7
  • General Internal Medicine-Primary Care(US)
    Relevance - 5/7
    Newsworthiness - 4/7
  • Genetics
    Relevance - 5/7
    Newsworthiness - 4/7
  • Surgery - Cardiac
    Relevance - 5/7
    Newsworthiness - 4/7
  • Surgery - Gastrointestinal
    Relevance - 5/7
    Newsworthiness - 4/7
  • Oncology - General
    Relevance - 4/7
    Newsworthiness - 4/7

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.


Clinical Comments

Endocrine

Very complex study and not easy to read. This reviews data on screening for many, many medical and surgical conditions. Diabetes, hypertension, osteoporosis and menopausal symptoms all fall under endocrinology, but trying to tease out the conclusions for these from a very lengthy article is too time-consuming and not worth the effort.

Endocrine

This intuitively makes sense. Giving patients knowledge of their choices; value benefits of options; risks vs benefits all make sense and to a greater or lesser extent we all do this now. [I hope]. Doing this in a structured formal way seems to assist patients in making choices so we should study the methodology and apply it, especially since no harm. It seems to accrue. Unless structured, this appears to be an extension of the old informed consent process, which was catch-as-catch can and left to the individual practitioner. Clearly, the structured, more uniform approach would appear to be better. Further the trend to push this off to the least knowledgeable member of the team meant that the process was even more chaotic, so this approach makes excellent sense.

Family Medicine (FM)/General Practice (GP)

Evidence to be implemented immediately.

Genetics

The results of this article are useful, but practitioners in my discipline probably already know this.

Oncology - Gastrointestinal

I think clinician may find interesting information regarding some particular issues which are strictly pertinent to their specific area of practice.

Psychiatry

This article has no useful information.

Surgery - Colorectal

Cochrane review of decision aids for screening reported on 105 studies and 31,000 patients. The conclusion was that decision aids led to improved understanding and knowledge of options and participated more in decision making; discussion was improved; there was no disadvantage to using decision aids.

Surgery - General

As a surgeon, I found this paper interesting as it opens some new perspectives. The use of decision aids in the decision making process could help both the surgeon and the patient to share information, evaluate treatment options and make decisions in a more structured way.

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