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  1. Decision Aids For Selection Problems
  2. Decision Aids for Selection Problems - David L. Olson - Google книги
  3. A systematic development process for patient decision aids

Shared decision-making is challenging because of time constraints and the specific skills that it requires. We performed the search, developed in collaboration with an experienced research librarian R. We included RCTs conducted among men who were potentially considering undergoing prostate cancer screening that compared decision aid interventions for prostate cancer screening with usual care. We evaluated decision aids and study protocols and judged interventions as either decision aids, information material, or usual care not overlapping categories.

We defined the interventions as decision aids if the material helped men making individual choices and included information regarding the association of screening with the following patient-important outcomes: risk of dying, risk of urinary or bowel symptoms, and risk of erectile dysfunction. We defined the intervention as usual care if clinicians provided no formal, structured presentation of information and informative material if interventions provided some structured information but did not meet our definition of a decision aid eAppendix 2 in the Supplement.

We excluded studies comparing one decision aid with another and those that did not report on any of our specified outcomes see the Outcomes subsection.

Decision aids: The ideal

We evaluated the following outcomes: knowledge regarding prostate cancer screening, decisional conflict, discussions regarding screening between men and their physicians screening discussion , decisions determining whether screening took place actual screening decision , and satisfaction with screening decision. We assessed the risk of bias using a modified version of the Cochrane Collaboration risk of bias tool addressing 5 criteria eAppendix 3 in the Supplement.

For each criterion, studies were judged to be at either high or low risk of bias. Studies with a high risk of bias for 3 or more criteria were classified as being at high risk of bias overall. We identified decision aids used in the studies by following a multistep approach: 1 we first reviewed original articles to identify links or references to electronically available decision aids or those provided as appendices; 2 if unavailable, we conducted electronic searches for decision aids online; and 3 we contacted study authors by email, requesting access to the decision aid. We evaluated the available decision aids using a modified version of the International Patient Decision Aid Standards instrument IPDASi , version 3 for screening 17 by assessing 10 criteria eAppendix 4 in the Supplement.

We rated each criterion as met or unmet and summed the number of criteria met.

Decision Aids For Selection Problems

We developed standardized forms with detailed instructions for screening of abstracts and full texts, risk of bias, quality of assessments of decision aids, and data extraction. Independently and in duplicate, 2 methodologically trained reviewers J. Reviewers resolved disagreement through discussion and, if necessary, through consultation with an adjudicator K.

We sent our consensus data extraction to the original authors for confirmation or correction and asked for clarification regarding missing or unclear information. For continuous outcomes in which investigators used different instruments to measure a construct, we standardized scores on a range from 0 to 18 , 19 and summarized the data as means and SDs or, for skewed distributions, medians and interquartile ranges. We conducted meta-analyses when data for a particular outcome were available from at least 3 trials.

The dependent variable was the outcome mean and the independent variables were the intervention, the follow-up term, the interaction of intervention and follow-up term, the random effects in study, and the baseline data. We reported the pooled analyses separately by length of follow-up if the interaction effect was significant; if not, we reported analyses using the longest follow-up.

We hypothesized that effects would be larger in high-risk-of-bias trials. To assess the quality of evidence, we used the Grading of Recommendations, Assessment, Development and Evaluations GRADE approach that classifies evidence as high, moderate, low, or very low quality.

Decision Aids for Selection Problems - David L. Olson - Google книги

Of 12 potentially relevant reports, proved potentially eligible; after full-text screening, 19 articles 27 - 45 proved eligible Figure 1. Trials were published between and eFigure 1 in the Supplement and randomized 12 men; the median of mean ages was 59 years interquartile range, years. Investigators used several types of decision aids: 13 of 19 studies used printed material 8 used booklets of pages 29 , 30 , 34 , 35 , 38 - 40 , 42 and 5 used leaflets of pages 27 , 28 , 41 , 43 , 45 , 5 studies used education 2 used group sessions 33 , 37 and 3 used individual education 30 , 31 , 44 , 5 studies used computer-based tools, 29 , 32 , 34 , 36 , 39 and 4 studies used videos.

We identified 12 decision aids: 5 by reviewing original articles, 28 , 30 , 31 , 41 , 43 4 by electronic searches, 29 , 34 , 38 , 40 and 3 from the authors. Of the 13 studies reporting short-term knowledge, 8 reported data as a continuous variable and 5 reported the proportion of correct items.

A systematic development process for patient decision aids

Because the SDs of the latter are much smaller owing to the nature of binomial distribution , they would dominate a pooled result of all 13 studies; therefore, we analyzed them separately. Pooled estimates from 8 studies reporting data as a continuous variable showed an increase in knowledge for decision aids mean difference, Studies failed to demonstrate an association with knowledge in the long term mean difference, 5.

The pooled analysis from 6 studies failed to demonstrate an association with whether physicians and patients discussed prostate cancer screening risk ratio, 1. In 4 studies, 28 , 39 , 42 , 43 the decision aid was distributed 1 to 2 weeks before the visit or assessment; in 1 study, 31 the decision aid was distributed 1 hour before the assessment; and in 1 study, 30 the decision aid was distributed 8 months before the visit. Two studies reported no difference in satisfaction between the intervention and control groups. This difference persisted compared with the usual care group for the printed decision aid group OR, 1.

Furthermore, participants with printed material reported significantly greater satisfaction than with web material at 1 month OR, 1. None of these studies examined whether satisfaction varied by whether the decision was to undergo prostate cancer screening or not to undergo screening.

For no outcome did risk of bias explain the variability in results eTable 2 in the Supplement.

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To examine the association of prostate cancer screening decision aids with decisional outcomes and screening decisions, we pooled data from 19 trials. The decision aids used in these studies provided most of the crucial information benefits and harms of screening but typically omitted test properties of the screening tests. Strengths of our study include a comprehensive search, duplicate assessment of eligibility and data extraction, appraisal of risk of bias, use of outcomes that are important to patients, and evaluation of decision aids using the IPDASi instrument.

To increase the precision of estimates, whenever possible, we conducted meta-analyses using appropriate statistical methods.


Limitations of our review are largely those of the available literature. First, we were not able to use all studies: in 26 studies, there was no usual care control group, 5 studies did not report on any of our outcomes, and 1 study had very low adherence to the decision aid eTable 3 in the Supplement. Fourth, different instruments were used for assessment of knowledge. Furthermore, many available decision aids have not undergone formal testing in randomized trials.

Three previous systematic reviews have investigated decision aids for prostate cancer screening. A systematic review published in concluded that decision aids increase patient knowledge and confidence in decision-making regarding prostate cancer testing.

Trouble With Making Decisions?

The authors failed to conduct a meta-analysis. Ivlev and colleagues 49 have published the most recent systematic review on prostate cancer screening patient decision aids and concluded that integration of decision aids in clinical practice may result in a decrease in the number of men who elect to undergo PSA testing, which may in turn reduce screening uptake. Support for this statement came from an analysis of intent to screen risk ratio, 0. The review by Ivlev et al 49 included 13 RCTs and 5 observational studies; to avoid bias associated with prognostic imbalance, we restricted our eligible studies to RCTs.

Of the RCTs that Ivlev and colleagues 49 included, we did not include 3 studies 54 - 56 because they did not have a standard care control group and 1 study 57 because it lacked our prespecified outcomes. The review by Ivlev et al 49 failed to include 10 of our 19 eligible trials: 3 trials 28 , 31 , 33 were considered—contrary to our judgment—as not having a decision aid group, 3 trials 29 , 35 , 38 were excluded because they did not meet their eligibility criteria of reporting immediate or deferred intention or utilization data, 1 trial 44 was excluded without explanation, and 3 trials 37 , 40 , 43 were either not identified by their search or were excluded during title and abstract screening not possible to distinguish which reason.

Other differences included our measuring of screening discussions and reporting a meta-analysis of decisional conflict, which were not in the review by Ivlev et al. Our judgments applying the GRADE approach 21 included all outcomes and differed from the review by Ivlev et al 49 regarding knowledge because we considered the failure to use blinded assessments as a reason to rate the quality of evidence downward and they did not.

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Many prostate cancer screening decision aids are available online, but only a few have undergone formal testing. All decisions aids included in our review provided education to patients, and all but 1 decision aid 27 failed to show clear facilitation of screening discussions ie, shared decision-making. The best available evidence suggests that PSA screening may have a small, although uncertain, benefit on prostate cancer mortality.

Although these 2 trials 27 , 28 reported results similar to our pooled results, it is possible that decision aids with new, updated evidence summaries may have more benefit than earlier decision aids in which results were more uncertain. There is therefore a call for new trials with updated decision aids. The available evidence does not provide a compelling rationale for clinicians to use existing decision aids to facilitate shared decision-making in their discussions with men considering undergoing prostate cancer screening. Future decision aids should include provision for continuous updating and not only provide education to patients but also promote shared decision-making in the patient-physician encounter. Published Online: June 24, Corresponding Author: Kari A. Author Contributions: Drs Riikonen and Tikkinen had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Critical revision of the manuscript for important intellectual content: All authors. Conflict of Interest Disclosures: Dr Riikonen reported receiving reimbursement from Astellas and Ferring for attending scientific meetings and participating in trials for Astellas, Bayer, Ferring, Myovant, and Pfizer. Dr Dahm reported receiving reimbursement from Intuitive for attending a training course.

Dr Richard reported receiving reimbursement from Janssen for attending a scientific meeting; receiving honoraria from AbbVie, Astellas, Ferring, and Sanofi; and serving as a company consultant for Sanofi and Bristol-Myers Squibb. Dr Santti reported receiving honoraria from Astellas; receiving reimbursement from Astellas, Orion, Ferring, and Intuitive Surgical for attending scientific meetings; and participating in a trial for Astellas. Dr Violette reported receiving honoraria from Janssen, Astellas, and Sanofi.

No other disclosures were reported. They were not compensated for their contributions. All Rights Reserved.