Decision aids for people facing health treatment or screening decisions

  • Review
  • Intervention




Decision aids are intended to help people participate in decisions that involve weighing the benefits and harms of treatment options often with scientific uncertainty.


To assess the effects of decision aids for people facing treatment or screening decisions.

Search methods

For this update, we searched from 2009 to June 2012 in MEDLINE; CENTRAL; EMBASE; PsycINFO; and grey literature. Cumulatively, we have searched each database since its start date including CINAHL (to September 2008).

Selection criteria

We included published randomized controlled trials of decision aids, which are interventions designed to support patients' decision making by making explicit the decision, providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies of participants making hypothetical decisions.

Data collection and analysis

Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were:

A) 'choice made' attributes;

B) 'decision-making process' attributes.

Secondary outcomes were behavioral, health, and health-system effects. We pooled results using mean differences (MD) and relative risks (RR), applying a random-effects model.

Main results

This update includes 33 new studies for a total of 115 studies involving 34,444 participants. For risk of bias, selective outcome reporting and blinding of participants and personnel were mostly rated as unclear due to inadequate reporting. Based on 7 items, 8 of 115 studies had high risk of bias for 1 or 2 items each.

Of 115 included studies, 88 (76.5%) used at least one of the IPDAS effectiveness criteria: A) 'choice made' attributes criteria: knowledge scores (76 studies); accurate risk perceptions (25 studies); and informed value-based choice (20 studies); and B) 'decision-making process' attributes criteria: feeling informed (34 studies) and feeling clear about values (29 studies).

A) Criteria involving 'choice made' attributes:

Compared to usual care, decision aids increased knowledge (MD 13.34 out of 100; 95% confidence interval (CI) 11.17 to 15.51; n = 42). When more detailed decision aids were compared to simple decision aids, the relative improvement in knowledge was significant (MD 5.52 out of 100; 95% CI 3.90 to 7.15; n = 19). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.82; 95% CI 1.52 to 2.16; n = 19). Exposure to a decision aid with explicit values clarification resulted in a higher proportion of patients choosing an option congruent with their values (RR 1.51; 95% CI 1.17 to 1.96; n = 13).

B) Criteria involving 'decision-making process' attributes:

Decision aids compared to usual care interventions resulted in:

a) lower decisional conflict related to feeling uninformed (MD -7.26 of 100; 95% CI -9.73 to -4.78; n = 22) and feeling unclear about personal values (MD -6.09; 95% CI -8.50 to -3.67; n = 18);

b) reduced proportions of people who were passive in decision making (RR 0.66; 95% CI 0.53 to 0.81; n = 14); and

c) reduced proportions of people who remained undecided post-intervention (RR 0.59; 95% CI 0.47 to 0.72; n = 18).

Decision aids appeared to have a positive effect on patient-practitioner communication in all nine studies that measured this outcome. For satisfaction with the decision (n = 20), decision-making process (n = 17), and/or preparation for decision making (n = 3), those exposed to a decision aid were either more satisfied, or there was no difference between the decision aid versus comparison interventions. No studies evaluated decision-making process attributes for helping patients to recognize that a decision needs to be made, or understanding that values affect the choice.

C) Secondary outcomes

Exposure to decision aids compared to usual care reduced the number of people of choosing major elective invasive surgery in favour of more conservative options (RR 0.79; 95% CI 0.68 to 0.93; n = 15). Exposure to decision aids compared to usual care reduced the number of people choosing to have prostate-specific antigen screening (RR 0.87; 95% CI 0.77 to 0.98; n = 9). When detailed compared to simple decision aids were used, fewer people chose menopausal hormone therapy (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 shorter to 23 minutes longer (median 2.55 minutes longer) with 2 studies indicating statistically-significantly longer, 1 study shorter, and 6 studies reporting no difference in consultation length. Groups of patients receiving decision aids do not appear to differ from comparison groups in terms of anxiety (n = 30), general health outcomes (n = 11), and condition-specific health outcomes (n = 11). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive.

Authors' conclusions

There is high-quality evidence that decision aids compared to usual care improve people's knowledge regarding options, and reduce their decisional conflict related to feeling uninformed and unclear about their personal values. There is moderate-quality evidence that decision aids compared to usual care stimulate people to take a more active role in decision making, and improve accurate risk perceptions when probabilities are included in decision aids, compared to not being included. There is low-quality evidence that decision aids improve congruence between the chosen option and the patient's values.

New for this updated review is further evidence indicating more informed, values-based choices, and improved patient-practitioner communication. There is a variable effect of decision aids on length of consultation. Consistent with findings from the previous review, decision aids have a variable effect on choices. They reduce the number of people choosing discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, cost-effectiveness, use with lower literacy populations, and level of detail needed in decision aids need further evaluation. Little is known about the degree of detail that decision aids need in order to have a positive effect on attributes of the choice made, or the decision-making process.








為了此更新,我們搜尋了2006年1月到2009年12月 的MEDLINE (Ovid);考科藍對照試驗中央註冊(CENTRAL,考科藍圖書館2009年第4期); CINAHL (Ovid) (僅至2008年9月); EMBASE (Ovid); PsycINFO (Ovid); 與非正式發表之文獻。累計而言,我們自每一資料庫開始日期搜尋。





A) 決策屬性;

B) 決策制定程序屬性。



具有34,316獨特引用,86個研究涵蓋20,209名參與者,符合合格準則並被採用。這些研究中有31個是此次更新中新加入。29個試驗持續進行。所有研究中可能的偏誤風險具變化性。最有問題的兩個準則為(1)缺乏盲目方式與(2) 缺乏選擇成果報告的潛力。也因此造成大多數較早的試驗沒有註冊。

其中86個所含研究, 63 (73%)個研究至少採用一個測量,建構於IPDAS有效性準則上:

A) 準則涉及決策特性: 知識分數(51個研究); 準確的風險認知(16個研究); 與經告知的價值導向選擇 (12個研究); 與B) 準則涉及決策程序特性: 感覺受告知(30個研究) 與感覺價值相關為明確 (18個研究)。

A) 準則涉及決策特性:

藉由增加知識,決策輔助執行的較一般照護佳 (MD 100個中13.77; 95%信賴區間(CI) 11.40 to 16.15; n = 26)。當更多詳細決策輔助與較簡化的決策輔助比較時,知識上相對的改善為顯著 (MD 100個中4.97; 95% CI 3.22 to 6.72; n = 15)。得到給予明確的機率之決策輔助會導致民眾有精確風險知覺的比例較高(RR 1.74; 95% CI 1.46 to 2.08; n = 14)。機率以數字表示時(RR 1.93; 95% CI 1.58 to 2.37; n = 11) 會比文字表示之效果更好(RR 1.27; 95% CI 1.09 to 1.48; n = 3)。 得到明確數值之決策輔助,與無明確數值者相比,病患比較會做出與被告知之訊息一致之決策(RR 1.25; 95% CI 1.03 to 1.52; n = 8)。

B) 準則涉及決策程序特性:決策輔助與一般照護介入相比:

a) 降低未被告知之感覺有所相關的決策衝突(MD -6.43 of 100; 95% CI -9.16 to -3.70; n = 17);

b) 降低對個人價值感覺不明確有所相關的決策衝突(MD -4.81; 95% CI -7.23 to -2.40; n = 14);

c) 降低被動的決策制定 (RR 0.61; 95% CI 0.49 to 0.77; n = 11); 與d) 降低介入後仍舊無法做出決策的比例 (RR 0.57; 95% CI 0.44 to 0.74; n = 9)。

決策輔助在四個有測量此成果的研究中,似乎在病患-醫師之溝通上有正面效果。就決策滿意度(n = 12) 及/或決策制定程序而言 (n = 12),與沒有得到決策輔助者相比,這些得到決策輔助者,可能有更高之滿意度,也可能沒有差異。目前沒有研究有在評估協助病患認知必須制定的決策或是了解影響選擇的價值上相關的決策程序特性。

C) 次要成果

得到決策輔助者與一般照護比較,顯示出降低了選擇重大侵入性手術,偏好採用保守性選項(RR 0.80; 95% CI 0.64 to 1.00; n = 11)。得到決策輔助者與一般照護比較,也降低去選擇採用前列腺癌篩選(RR 0.85; 95% CI 0.74 to 0.98; n = 7)。詳細的決策輔助與的簡易決策輔助比較時,選擇採用更年期賀爾蒙治療的病患減少(RR 0.73; 95% CI 0.55 to 0.98; n = 3)。就其它決策而言,選擇相關的效果各有不同。

決策輔助在諮詢的時間有從減少8分鐘到增加23分鐘 (中位數2.5分鐘)各有不同。焦慮程度 (n = 20)、一般健康成果(n = 7)、與疾病特定健康成果 (n = 9)這三方面,兩者皆沒有差異。決策輔助在其他成果 (依從決策、成本/資源使用) 上的效果尚無法做出結論。


就此更新的審閱而言,為新的證據有: (1)得到給予明確的數值之決策輔助,可以改善經告知的價值導向之決策; (2)決策輔助似乎在病患-醫師溝通上有正面效果; (3)決策輔助在諮詢時間上有不同效果。

與先前審閱(包含2006年之前的研究) 的發現一致的有: (1)決策輔助增加民眾涉入並改善知識與實際成果知覺; (2)然而,影響規模在每個研究中各異。決策輔助在選擇上有不同影響。它們降低有彈性選擇之手術,即使如此在健康成果或滿意度上也沒有明顯之不良效果。奉行所選選擇、病患-醫師溝通、成本效益以及文化水平不高人口之使用等以上四種情況的影響,需要進一步之評估。對於決策輔助之需求,用於決策特性或決策制定程序上時,會產生何種正面效果的細節之程度,目前所知甚少。

Plain language summary

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

Identifying and making a decision about 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 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 make the decision explicit, describe the options available, and help people to understand these options as well as their possible benefits and harms. This helps patients to consider the options from a personal view (e.g., how important the possible benefits and harms are to them) and helps them to participate with their health practitioner in making a decision.

The updated review, with searches updated in June 2012, includes 115 studies involving 34,444 participants. Findings show that when patients use decision aids they: a) improve their knowledge of the options (high-quality evidence); b) feel more informed and more clear about what matters most to them (high-quality evidence); c) have more accurate expectations of possible benefits and harms of their options (moderate-quality evidence); and d) participate more in decision making (moderate-quality evidence). Patients who used decision aids that included an exercise to help them clarify what matters most to them, were more likely to reach decisions that were consistent with their values. However, the quality of the evidence was moderate for this outcome, meaning that further research may change these findings. Decision aids reduce the number of patients choosing prostate specific antigen testing and elective surgery when patients consider other options. They have a variable effect on most other actual choices. Decision aids improve communication between patients and their health practitioner. More detailed decision aids are better than simple decision aids for improving people's knowledge and lowering decisional conflict related to feeling uninformed and unclear about their personal values. Decision aids do not worsen health outcomes and people using them are not less satisfied. More research is needed to evaluate adherence with the chosen option, the associated costs, use with patients who have more limited reading skills, and the level of detail needed in a decision aid.




86個研究的更新審閱發現當病患利用決策輔助時,他們: a) 提升對選項的知識; b) 接受協助而對可能利弊有更精確的預期; c) 完成與他們得知的價值較一致的選擇; 與d) 更加參與決策制定。決策輔助在實際選擇上有不同影響,但當病患考慮其他選擇時,它們降低選擇性手術的選擇。病患利用決策輔助時,與他們的醫師溝通似乎有正面效果,而需要此諮商的時間各有不同效果。雖然與較簡易的決策輔助相比,利用更詳細的決策輔助有所改善,但跟決策輔助與一般照護相比時,改善的程度較小。健康成果或滿意度上沒有明顯不良效果。需要更多研究評估所選選項的奉行程度、病患-醫師間的溝通與相關成本。


翻譯: East Asian Cochrane Alliance
翻譯補助: 台灣衛生福利部/台北醫學大學實證醫學研究中心

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Заметки по переводу

Перевод: Кораблева Анна Александровна. Редактирование: Зиганшина Лилия Евгеньевна. Координация проекта по переводу на русский язык: Казанский федеральный университет. По вопросам, связанным с этим переводом, пожалуйста, свяжитесь с нами по адресу:

Laički sažetak

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Ovo je obnovljeni Cochrane sustavni pregled koji prikazuje podatke iz literature dostupne do lipnja 2012. godine, a obuhvaća 115 studija s 34.444 ispitanika. Rezultati pokazuju da pacijenti koji koriste alate za pomoć pri odlučivanju: a) poboljšavaju svoje znanje o mogućnostima (dokazi visoke kvalitete); b) osjećaju se bolje informiranima i bolje razaznaju što je njima samima najvažnije (dokazi visoke kvalitete); c) imaju točnija očekivanja što se tiče mogućih korisnih i štetnih posljedica odabira (dokazi umjerene kvalitete); i d) više sudjeluju u donošenju odluke (dokazi umjerene kvalitete). Pacijenti koji su koristili alate za pomoć pri odlučivanju, a koji omogućuju razjasniti što je njima osobno važno, imali su veću vjerojatnost donošenja odluke koja je u skladu s njihovim vrijednostima. Ipak, kvaliteta dokaza za ovu tvrdnju je umjerena što znači da daljnja istraživanja mogu promijeniti te rezultate. Korištenje smjernica smanjuje broj pacijenata koji biraju pretragu pomoću PSA (prostatični specifični antigen) za otkrivanje karcinoma prostate i elektivne operacije nakon što uzmu u obzir i ostale mogućnosti. Oni imaju promjenjivi učinak na većinu drugih stvarnih izbora. Takvi alati poboljšavaju komunikaciju između pacijenata i njihovih liječnika obiteljske medicine. Detaljniji alati za pomoć pri odlučivanju bolji su od jednostavnih jer povećavaju znanje pacijenata i smanjuju pojavu konflikta pri odlučivanju, a koji je povezan s osjećajem neinformiranosti i nerazumijevanja osobnih vrijednosti. Korištenje alata za pomoć pri donošenju odluke ne pogoršava zdravstvene ishode i oni koji ih koriste nisu manje zadovoljni. Potrebna su daljnja istraživanja na ovu temu kako bi se procijenila dosljednost nakon donošenja odluke, povezani troškovi, korisnost tih alata u pacijenata s ograničenom vještinom čitanja, i količina detalja koja treba biti zastupljena u takvim alatima.

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Laienverständliche Zusammenfassung

Entscheidungshilfen für Patienten, die Entscheidungen hinsichtlich medizinischer Behandlung oder Screening treffen müssen

Die Auswahl und Entscheidung für eine bestimmte medizinische Behandlung oder ein Screening kann für Patienten schwierig sein. Entscheidungshilfen können angewendet werden, wenn es mehr als eine relevante Option gibt, wenn keine der Optionen einen klaren Vorteil hinsichtlich Behandlungsergebnisse aufweist, oder wenn jede der Optionen Nutzen und Schäden birgt, die von verschiedenen Patienten unterschiedlich bewertet werden. Informationsbroschüren, Videos oder auf dem Internet basierende Hilfen können als Entscheidungshilfen dienen. Diese machen die Entscheidung explizit, beschreiben die verfügbaren Optionen und helfen Patienten, diese Optionen und deren potentielle Nutzen und Schäden zu verstehen. Sie unterstützen den Patienten dabei, alle Optionen aus persönlicher Sicht (z.B. wie wichtig die möglichen Nutzen und Schäden für den Einzelnen sind) abzuwägen und eine Entscheidung gemeinsam mit ihrem behandelnden Arzt zu treffen.

Der aktuelle Review, dessen Suchen im Juni 2012 aktualisiert wurden, umfasst 115 Studien mit 34.444 Teilnehmern. Die Ergebnisse zeigen, dass wenn Patienten Entscheidungshilfen nutzen sie a) ihr Wissen über die Alternativen verbessern (hohe Qualität der Evidenz); b) sich informierter über ihre eigenen Prioritäten fühlen (hohe Qualität der Evidenz); c) präzisere Erwartungen an die möglichen Nutzen und Schäden der Alternativen haben (moderate Qualität der Evidenz); und d) stärker an der Entscheidungsfindung teilnehmen (moderate Qualität der Evidenz). Patienten, die Entscheidungshilfen nutzen, in denen eine Übung zu ihren Prioritäten war, trafen eher Entscheidungen, die im Einklang mit ihren Wertvorstellungen waren. Jedoch war die Qualität der Evidenz für diesen Endpunkt moderat, was bedeutet, dass zukünftige Forschung dieses Ergebnis möglicherweise ändert. Entscheidungshilfen verminderten die Anzahl der Patienten, die ein Prostata-spezifisches Antigen Test (PSA-Test) und elektive Operationen wählten, wenn sie andere Optionen in Erwägung zogen. Auf die meisten anderen konkreten Entscheidungen haben Entscheidungshilfen eine unterschiedliche Wirkung. Entscheidungshilfen verbessern die Kommunikation zwischen Patienten und Ärzten. Detailliertere Entscheidungshilfen sind besser als einfache Entscheidungshilfen, wenn es darum geht das Wissen der Patienten zu verbessern und den Entscheidungskonflikt bezüglich des Gefühls, uninformiert und sich nicht im klaren über die eigenen Wertvorstellungen zu sein, zu vermindern. Entscheidungshilfen verschlechtern weder die Gesundheit noch die Patientenzufriedenheit. Mehr Forschung ist nötig, um die Einhaltung der gewählten Optionen, die damit zusammenhängenden Kosten, die Verwendung durch Patienten mit Leseschwäche und den benötigten Detaillierungsgrad zu untersuchen.

Anmerkungen zur Übersetzung

A. Lieder, Koordination durch Cochrane Schweiz