Intervention Review

Decision aids for people facing health treatment or screening decisions

  1. Dawn Stacey1,*,
  2. Carol L Bennett2,
  3. Michael J Barry3,
  4. Nananda F Col4,
  5. Karen B Eden5,
  6. Margaret Holmes-Rovner6,
  7. Hilary Llewellyn-Thomas7,
  8. Anne Lyddiatt8,
  9. France Légaré9,
  10. Richard Thomson10

Editorial Group: Cochrane Consumers and Communication Group

Published Online: 5 OCT 2011

Assessed as up-to-date: 30 DEC 2009

DOI: 10.1002/14651858.CD001431.pub3

Database Title

Additional Information

How to Cite

Stacey D, Bennett CL, Barry MJ, Col NF, Eden KB, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Légaré F, Thomson R. Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No.: CD001431. DOI: 10.1002/14651858.CD001431.pub3.

Author Information

  1. 1

    University of Ottawa, School of Nursing, Ottawa, Ontario, Canada

  2. 2

    Ottawa Health Research Institute, Clinical Epidemiology Program, Ottawa, Ontario, Canada

  3. 3

    Foundation for Informed Medical Decision Making, Boston, MA, USA

  4. 4

    Shared Decision Making Resources, Cumberland, ME, USA

  5. 5

    Oregon Health Sciences University, Department of Medical Informatics and Clinical Epidemiology, Portland, Oregon, USA

  6. 6

    Michigan State University College of Human Medicine, Center for Ethics and Humanities in the Life Sciences, East Lansing, Michigan, USA

  7. 7

    Dartmouth College, The Dartmouth Center for Health Policy & Clinical Practice, Dartmouth Medical School, Hanover, New Hampshire, USA

  8. 8

    Ingersoll, ON, Canada

  9. 9

    St-François d'Assise Hospital, Centre de recherche du Centre hospitalier universitaire de Québec (CHUQ), Québec, Québec, Canada

  10. 10

    Newcastle University, Institute of Health and Society, Newcastle upon Tyne, UK

*Dawn Stacey, School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada. dstacey@uottawa.ca.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 5 OCT 2011

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

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 methods

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 outcomes

Exposure 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.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Decision aids to help people who are facing health treatment or screening decisions

Identifying and making a decision on the best health treatment or screening option can be difficult for patients. Decision aids can be used when there is more than one reasonable option, when no option that has a clear advantage in terms of health outcomes, and when each option has benefits and harms that patients may value differently. Decision aids may be pamphlets, videos, or web-based tools. They describe the options available and help people to understand these options as well as the possible benefits and harms. This allows patients to consider the options from a personal view (e.g. how important the possible benefits and harms are to them) and prepares them to participate with their health practitioner in making a decision.

The updated review of 86 studies found that when patients use decision aids they: a) improve their knowledge of the options; b) are helped to have more accurate expectations of possible benefits and harms; c) reach choices that are more consistent with their informed values; and d) participate more in decision making. Decision aids have a variable effect on actual choices but they reduce the choice of elective surgery when patients consider other options. When patients use decision aids, there appears to be a positive effect on communication with their health practitioner, and a variable effect on the time required for this consultation. Decision aids with more detail compared to simpler decision aids showed smaller improvements. There are no apparent adverse effects on health outcomes or satisfaction. More research is needed to evaluate adherence with the chosen option, patient-practitioner communication, and the associated costs.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

醫療決策輔助用於患者的治療或篩檢決策

決策輔助規劃讓患者參與 ‘驚險萬分’ 的決策,使其衡量效益、傷害以及科學上的不確定性。

目標

系統性回顧決策輔助用於患者面臨困難的治療或篩檢決策時功效之隨機對照試驗 (randomised controlled trials;RCTs) 。

搜尋策略

我們搜尋了MEDLINE (Ovid) (1966年 到2006年7月); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library; 2006, 第2期); CINAHL (Ovid) (1982年 到2006年7月); EMBASE (Ovid) (1980年到2006年7月) 以及PsycINFO (Ovid) (1806年到2006年7月) 等資料庫。截至2006年12月，我們聘請了這個領域的研究者進行這項工作。在資料的搜尋上沒有語言限制。

選擇標準

我們納入已發表、提供治療或篩檢各種資訊以協助患者決策的介入性研究 (RCTs) ，將相關結果與沒有介入、常規性照護以及其他替代方案做比較。如果參與研究的患者並未主動對治療或篩檢做出決策，或是該研究所採用的方法並未符合我們對患者決策輔助定義所訂的最低標準，則將予以排除。

資料收集與分析

兩位作者分別閱讀摘要以篩選是否納入，並且以標準化格式摘錄所納入研究的相關資訊。主要結果指標是International Patient Decision Aid Standards (IPDAS) Collaboration所制定的效果標準：決策本身以及決策過程的屬性。我們把其他包括行為、健康以及健康體系之影響列為次要的結果指標。藉由運用隨機效果模式(random effects model) ，我們以平均差(mean differences ；MD) 和相對危險性(relative risks ；RR) 整合了各項研究的結果。

主要結論

這次更新共新增了25個RCTs，使得我們所納入的試驗數總計達55個，其中有38個試驗(69%) 採用了至少1項IPDAS的效果標準:屬於決策屬性的包括知識分數 (27個試驗採用) 、正確風險認知(11個試驗採用) 以及對所選項目的價值ㄧ致性(4個試驗採用); 而屬於決策過程屬性的則包括覺得自己已經清楚了解 (15個試驗採用) 以及覺得自己清楚認識所選項目的價值 (13個試驗採用) 。我們這一次的回顧證實了先前 (2003) 的發現，亦即相較於常規性照護，決策輔助有更加良好的表現,包括: a) 更加豐富的知識 (100分中平均差為15.2;95% 信賴區間為11.7至18.7); b) 因為覺得未被告知而衍生的決策衝突減少因為覺得未被告知而衍生的決策衝突減少 (100分中平均差為 −8.3;95% 信賴區間為 −11.9至 −4.8); c) 因為覺得個人價值不清楚而衍生的決策衝突減少 (100分中平均差為 −8.3;95% 信賴區間為 −11.9至 −4.8); d) 對於決策採被動消極態度的患者比例降低 (RR為0.6;95% 信賴區間為0.5至0.8); 以及即使在接受決策輔助後仍難以作出決定的患者比例減少 (RR為0.5;95% 信賴區間為0.3至0.8) 。相較於詳細的決策輔助系統，簡單的方式明顯對提升知識更有助益 (100分中平均差為4.6;95% 信賴區間為3.0至6.2) ，且某些證據也顯示簡單的方式使得價值和選擇間的ㄧ致性更佳。在這份回顧中，我們還探討將機率的概念運用於決策輔助系統。在決策輔助中加入機率的概念使得具備正確風險認知的患者比例提高了((RR 為1.6; 95% 信賴區間為 1.4 至1.9) ，而且當機率被量化衡量時，其效應會比質化的衡量來得更為明顯 (RR 為1.3; 95% 信賴區間為1.1 至1.5) 。如同早先的回顧，相較於常規性照護，決策輔助可顯著降低在非急需的侵襲性手術中作出保守選擇的比率 (RR為0.8; 95% 信賴區間為0.6 至 0.9); 如果和簡單的方式相比,則詳細的決策輔助會讓選擇服用更年期賀爾蒙的比率顯著減少 ((RR為0.7; 95% 信賴區間為0.6至1.0) 。和常規性照護相比，沒有證據顯示決策輔助會減少PSA篩檢的比率 ((RR為0.8; 95% 信賴區間為0.7 至1.0) 。對其他的決策而言，決策輔助的效應依舊變化極大，如同早先的回顧，醫療輔助並未改善決策的滿意度、焦慮以及醫療預後。醫療輔助對於其他效果指標(醫病溝通、諮詢時間長短、持續性以及資源耗用)的影響仍尚未有定論。目前還沒有研究嘗試評估IPDAS的決策過程標準中,有關協助患者意識到自己必須作出決定、了解會影響決策的價值，或是和醫師討論這些價值等部份。

作者結論

決策輔助強化了患者的參與，同時患者將更有可能作出知情且以價值為基礎的決定，然而，決策輔助的效益多寡則隨研究而有差異。決策輔助對於決策有各種不同的影響，在不影響醫療預後和滿意度的前提下，決策輔助減少了非必要手術的進行。接下來應深入探討患者決策輔助應該詳細到何種程度方能符合良好決策品質所需。對於已作出決策的持續性效應、醫病溝通以及成本效果分析等也應該更進一步評估。

翻譯人

本摘要由成功大學附設醫院邱曉萱翻譯。

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

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