The effects of process-focused versus experience-focused narratives in a breast cancer treatment decision task

Objective

To examine the effect of patient narratives that discuss decision processes versus patient experiences on decisions about treatments for early stage breast cancer.

Methods

We recruited 300 women with no previous history of breast cancer to imagine that they had been diagnosed with early stage breast cancer and to choose between mastectomy and lumpectomy with radiation. Before learning about their treatment options, participants were randomly assigned to one of four conditions with videotaped stories from fictitious cancer survivors, using a 2 (content: experience versus process) × 2 (emotional valence: positive only vs. positive and negative) factorial design, or a control condition with no stories. We measured information search, treatment intentions, and decision satisfaction.

Results

Participants viewing process narratives spent more time searching for information. Participants viewing experience narratives reported a greater ability to imagine what it was like to experience the treatments; they also evaluated their decision more positively on several dimensions.

Conclusions

Process narratives appeared to guide information search, and experience narratives improved evaluations of the decision process.

Practice implications

There is no evidence that process and experience narratives ‘bias’ decisions in the same manner as outcome narratives. Further, their potential to focus patient attention on key information and increase patient confidence in decision making appears significant.     

Improving knowledge and decision readiness to participate in cancer clinical trials: Effects of a plain language decision aid for minority cancer survivors

ObjectiveTo evaluate the impact of a web-based, plain language decision aid (CHOICES DA) on minority cancer survivors’ knowledge of cancer clinical trials (CCTs), readiness for making decisions about clinical trial participation, and willingness to participate in a clinical trial.MethodsParticipants were 64 Black and Hispanic cancer survivors from Miami, Florida. In a single arm intervention study, participants completed self-report assessments of CCT knowledge, decision readiness regarding clinical trial participation, and willingness to participate at three time points.ResultsBlack and Hispanic participants did not differ on demographic characteristics. Post-test and follow-up measures of CCT knowledge and decision readiness were significantly greater than pre-test measures for the sample overall, and for Black and Hispanic participants separately. Few significant differences were observed between Black and Hispanic participant outcomes at each survey time point, and willingness to participate did not change overall and for either group independently.ConclusionsReviewing the CHOICES DA was associated with significantly improved knowledge and decision readiness to participate in a CCT immediately and at 2-week follow-up.Practical ImplicationsThese findings suggest that CHOICES DA may support informed decision making about CCT participation within an acute, yet clinically relevant window of time for minority cancer patients who are substantially under-represented in cancer research.     

Effect of a decision aid with patient narratives in reducing decisional conflict in choice for surgery among early-stage breast cancer patients: A three-arm randomized controlled trial

ObjectiveWe aimed to evaluate the effect of a decision aid (DA) with patient narratives on decisional conflict in surgery choice for Japanese women with early-stage breast cancer.MethodsTwo hundred ten women with early-stage breast cancer were randomly assigned to an intervention or control group. Groups 1 and 2 received standard information and a DA, with or without patient narratives, and Group 3 received standard information (control) before surgery choice. At baseline, post-intervention (Time 2), and 1 month after surgery (Time 3), we evaluated decisional conflict as the primary outcome using a decisional conflict scale (DCS). Sidak corrections for multiple comparisons in analysis of covariate were used to compare Time 2 and Time 3 DCS mean scores between each pair of groups.ResultsAt Time 3, decisional conflict was significantly reduced for Group 1 vs control (P = 0.021, Cohen’s d  = 0.26) and Group 2 vs control (P = 0.008, Cohen’s d = 0.40).ConclusionThe DAs with and without patient narratives are equivalently effective at reducing postoperative decisional conflict in Japanese women with early-stage breast cancer.Practice implicationsThe DAs with and without patient narratives can be used in clinical practice for women with early-stage breast cancer.     

Longitudinal regret and information satisfaction after deciding on treatment for localized prostate cancer with or without a decision aid. Results at one-year follow-up in the PCPCC trial

Objective

To investigate the effect of including an online decision aid (DA) during prostate cancer treatment counseling on decisional regret and information satisfaction in a one-year follow-up.

A computerized decision support system for patient selection in dental education

A computerized decision support system is presented. The system is used to aid in the situation of patient selection for the purpose of dental education and utilizes the PERT/CPM methodology and decision tables. It runs on a microcomputer and written in Basic. The input is a list of patient's needs, and the output is a tentative treatment plan, the chair time needed to complete the treatment, its cost, and the probability that the student will finish it on time.     

A prospective cohort study of shared decision making in lung cancer diagnostics: Impact of using a patient decision aid

ObjectiveThe objective of this study was to describe the impact on patient-reported outcomes of introducing Shared Decision Making (SDM) and a Patient Decision Aid (PtDA) in the initial process of lung cancer diagnostics.MethodsWe conducted a prospective cohort study, where a control cohort was consulted according to usual clinical practice. After introducing SDM through a PtDA and training of the staff, the SDM cohort was enrolled in the study. All patients completed four questionnaires: the Decisional Conflict Scale (DCS) before and after the consultation, the CollaboRATE scale after the consultation, and the Decision Regret Scale (DRS).ResultsPatients exposed to SDM and a PtDA had significantly improved DCS scores after the consultation compared to the control group (a difference of 10.26, p = 0.0128) and significantly lower DRS scores (a difference of 8.98, p = 0.0197). Of the 82 control patients and 52 SDM patients 29% and 54%, respectively, gave the maximum score on the CollaboRATE scale (Pearson’s chi² 8.0946, p = 0.004).ConclusionThe use of SDM and a PtDA had significant positive impact on patient-reported outcomes.Practice implicationsOur results may encourage the increased uptake of SDM in the initial process of lung cancer diagnostics.     

Disparities in patient reports of communications to inform decision making in the DECISIONS survey

Objective

To identify patient- and decision-type predictors of two key aspects of informed decision making: discussing the cons (not just the pros) of medical interventions and asking patients what they want to do.

Methods

Using data from 2473 members of the DECISIONS survey, a nationally representative sample of U.S. adults age 40+, we used logistic regression analysis to identify which patient characteristics predicted patient reports of healthcare providers discussing cons or eliciting preferences about one of 9 common medical decisions.

Results

Multiple demographic characteristics predicted both discussions of cons and elicitations of preferences, although the specific characteristics varied between decision contexts. In particular, African-American respondents reported being more likely to receive a discussion of the cons of cancer screening (OR = 1.69, p < 0.05) yet less likely to have been asked their opinion about either getting a cancer screening test (OR = 0.56, p < 0.05) or initiating medications (OR = 0.53, p < 0.05). Significant cross-decision variations remained even after controlling for patient characteristics.

Conclusions

Important disparities in patient communication and involvement appear to exist both between different types of medical decisions and between different types of patients.

Practice implications

Providers must make sure to consistently discuss the cons of treatment and to solicit input from all patients, especially African-Americans.     

Promoting shared decision making in advanced cancer: Development and piloting of a patient communication aid

Objective

To learn how to configure a patient communication aid (PCA) to facilitate shared decision-making (SDM) about treatment for advanced cancer.

Shared decision making: prostate cancer patients' appraisal of treatment alternatives and oncologists' eliciting and responding behavior, an explorative study

Objective

To assess clinicians’ use of shared decision making (SDM) skills, enabling patient treatment evaluations (appraisals); and varieties of patient appraisals and clinicians’ preceding and following utterances.

Methods

Two coders rated videotaped initial visits of 25 early-stage prostate cancer patients to their radiation oncologist. SDM skills were assessed using the Decision Analysis System for Oncology (DAS-O); appraisals and clinicians’ utterances were labeled using qualitative methodology.

Results

Clinicians offered a treatment choice to 10 patients. They informed 15/25 about pros and 20/25 about cons of options. Patients expressed 67 appraisals (median/visit = 2; range, 0-12). Half of appraisals were favorable and one-fourth was unfavorable toward treatment options. One-fifth referred to explicit tradeoffs. One-third of appraisals followed clinician requests; 58% followed clinician information. Clinicians approved almost half of appraisals. They contested, ignored or highlighted a minority.

Conclusion

Clinicians infrequently offered patients a choice or explored appraisals. Most appraisals supported rather than challenged treatment options. Clinicians most often legitimized appraisals, thereby helping patients to feel good about the decision. Exploring appraisals may help patients in forming more stable preferences, thus benefiting patients in the long run.

Practice implication

Clinicians should request patient appraisals and ascertain whether these seem well-informed before making treatment recommendations.     

The impact and utility of encounter patient decision aids: Systematic review,meta-analysis and narrative synthesis

Objective

To determine the effect of encounter patient decision aids (PDAs) as evaluated in randomized controlled trials (RCTs) and conduct a narrative synthesis of non-randomized studies assessing feasibility, utility and their integration into clinical workflows.

Perceived facilitating and limiting factors for healthcare professionals to adopting a patient decision aid for breast cancer aftercare: A cross-sectional study

ObjectiveEffective healthcare innovations are often not adopted and implemented. An implementation strategy based on facilitators and barriers for use as perceived by healthcare professionals could increase adoption rates. This study therefore aimed to identify the most relevant facilitators and barriers for use of an innovative breast cancer aftercare decision aid (PtDA) in healthcare practice.MethodsFacilitators and barriers (related to the PtDA, adopter and healthcare organisation) were assessed among breast cancer aftercare health professionals (n = 81), using the MIDI questionnaire. For each category, a backward regression analysis was performed (dependent = intention to adopt). All significant factors were then added to a final regression analysis to identify to most relevant determinants of PtDA adoption.ResultsExpecting higher compatibility with daily practice and clinical guidelines, more positive outcomes of use, higher perceived relevance for the patient and increased self-efficacy were significantly associated with a higher intention to adopt. Self-efficacy and perceived patient relevance remained significant in the final model.ConclusionsLow perceived self-efficacy and patient relevance are the most important barriers for health professions to adopt a breast cancer aftercare PtDA.Practice implicationsTo target self-efficacy and perceived patient relevance, the implementation strategy could apply health professional peer champions.     

Promoting decision aid use in primary care using a staff member for delivery

Objective

To determine the feasibility and effectiveness of in-clinic decision aid distribution using a care assistant.

Methods

We identified potentially eligible patients scheduled for upcoming appointments in our General Internal Medicine Clinic (n = 1229). Patients were deemed eligible for two decision aids: prostate cancer screening and/or weight loss surgery. Patients were approached to view the decision aid in-clinic. Our primary measures were the proportion of decision aids distributed to eligible patients, and the proportion of decision aids viewed.

Results

Among 913 patients who attended their scheduled appointments, 58% (n = 525) were approached and eligibility was assessed by the staff member. Among the 471 who remained eligible, 57% (n = 268) viewed at least a portion of the target decision aid. The mean viewing time for patients who watched less than the complete decision aid was 13 min.

Conclusions

In clinic viewing of decision aids may be a feasible and effective distribution method in primary care.

Practice implications

In clinic distribution requires an electronic health information system to identify potentially eligible patients, and a staff member dedicated to DA distribution. Brief decision aids (less than 10 min) are needed so patients can complete their use prior to the visit to facilitate patient-physician decision making.     

Fostering informed decisions: A randomized controlled trial assessing the impact of a decision aid among men registered to undergo mass screening for prostate cancer

Objective

Screening asymptomatic men for prostate cancer is controversial and informed decision making is recommended. Within two prostate cancer screening programs, we evaluated the impact of a print-based decision aid (DA) on decision-making outcomes.

Methods

Men (N = 543) were 54.9 (SD = 8.1) years old and 61% were African-American. The 2(booklet type: DA vs. usual care (UC)) × 2(delivery mode: Home vs. Clinic) randomized controlled trial assessed decisional and screening outcomes at baseline, 2-months, and 13-months.

Results

Intention-to-treat linear regression analyses using generalized estimating equations revealed that DA participants reported improved knowledge relative to UC (B = .41, p < .05). For decisional conflict, per-protocol analyses revealed a group by time interaction (B = −.69, p < .05), indicating that DA participants were less likely to report decisional conflict at 2-months compared to UC participants (OR = .49, 95% CI: .26–.91, p < .05).

Conclusion

This is the first randomized trial to evaluate a DA in the context of free mass screening, a challenging setting in which to make an informed decision. The DA was highly utilized by participants, improved knowledge and reduced decisional conflict.

Practice implications

These results are valuable in understanding ways to improve the decisions of men who seek screening and can be easily implemented within many settings.     

Helping women make choices about mammography screening: An online randomized trial of a decision aid for 40-year-old women

Objective

To evaluate the effect of a decision aid (DA) on women's knowledge of the benefits and harms of screening and on their ability to make an informed decision.

Methods

An online randomized controlled trial among 321 women aged 38-45 years was conducted. Participants were randomized to either immediate or delayed access to the online DA which (i) explained the benefits and harms, (ii) included a values clarification exercise and a worksheet to support decision making. The primary outcome, knowledge of benefits and harms of screening, and secondary outcomes, informed choice (composite of knowledge, values and intention), anxiety and acceptability of the DA were measured using online questionnaires.

Results

Women in the intervention group were more knowledgeable (mean score out of 10, 7.35 vs 6.27, p < 0.001) and were more likely to have made a decision (82% vs 61% p < 0.001). Of those who made a decision, women in the intervention group were less likely to start screening now (52% vs 65% p = 0.05). There was no significant difference in the proportion of women who made an informed choice (71% intervention group vs 64% control group, p = 0.24). The DA was helpful, balanced and clear, and did not make women anxious.

Conclusions

The DA increased knowledge and reduced indecision, without increasing feelings of anxiety.

Practice Implications

This decision aid is easy to access online and could be an inexpensive way of supporting women aged 40 who are considering whether to start screening now, or wait until they are 50. The results of this study demonstrate the potential of DAs to help inform women about both the benefits and risks of screening at this age and to support women and clinicians in this decision making process.     

Evaluation of a natural health product decision aid: A tool for middle aged women considering menopausal symptom relief

Objective

To evaluate the effectiveness of a self-administered decision aid for menopausal women facing decisions about natural health products.

Study design

This pre-/post-test study included peri- or post-menopausal women, aged 45–64 considering the use of a natural health product for management of menopausal symptoms. They were recruited from a Women's Health Center.

Outcome measures

The primary outcome was decisional conflict and secondary outcomes included knowledge, strength of values, and decision preference.

Results

Of 24 women, the typical participant was 50–64 years of age, Caucasian, married, and well educated. Compared to baseline, after using the decision aid, women's total decisional conflict was reduced from 63% to 24% (p < 0.001) and knowledge improved from 76% to 87% (p = 0.001). Of the 24 women, 10 were unsure of their choice at baseline and 3-post use of the decision aid (p = 0.015). There was a trend for women preferring natural health products (n = 12) to be more likely to rate the non-chemical aspect as important and the cost of the natural health product as less important; women who preferred not to take natural health products (n = 3) rated the non-chemical aspect as less important and the costs as more important.

Conclusions

The natural health product decision aid improved the quality of decisions by enhancing knowledge and reducing decisional conflict. As well, women were more likely to make a choice that was consistent with their values.     

Strategies for distributing cancer screening decision aids in primary care

Objective

Decision aids (DAs) have been shown to facilitate shared decision making about cancer screening. However, little data exist on optimal strategies for dissemination. Our objective was to compare different decision aid distribution models.

Methods

Eligible patients received video decision aids for prostate cancer (PSA) or colon cancer screening (CRC) through 4 distribution methods. Outcome measures included DA loans (N), % of eligible patients receiving DA, and patient and provider satisfaction.

Results

Automatically mailing DAs to all age/gender appropriate patients led to near universal receipt by screening-eligible patients, but also led to ineligible patients receiving DAs. Three different elective (non-automatic) strategies led to low rates of receipt. Clinician satisfaction was higher when patients viewed the DA before the visit, and this model facilitated implementation of the screening choice. Regardless of timing or distribution method, patient satisfaction was high.

Conclusions

An automatic DA distribution method is more effective than relying on individual initiative. Enabling patients to view the DA before the visit is preferred.

Practice implications

Systematically offering DAs to all eligible patients before their appointments is the ideal strategy, but may be challenging to implement.