Question

What are the effects of decision aids for people facing health treatment or screening decisions?

Relevance to nursing care

Patients often have difficulty in making decisions regarding the best treatment or screening option. Decision aids are evidence-based tools used to educate the patient about the options relevant to their decision, allowing them to make a fully informed choice. They are offered in conjunction with the usual counselling and consultation provided by clinicians, in order to support the patient fully during the decision-making process. Decision aids may be used to assist patients in making treatment or screening-related decisions when: there is more than one option to decide between; there is no clear advantage of one option over another in terms of health outcomes; or each available option has benefits and harms that may be valued differently by the patient. Decision aids may be provided to patients using a variety of modes of delivery including via pamphlets, videos or the internet, and are distinct from standard patient education materials in that they explicitly outline the decision being considered and provide detailed, specific and personalized information related to it, outlining the available options and potential outcomes in order to prepare the patient to make the decision that is right for them. It is important for all healthcare professionals, particularly nurses, to understand what the impact of decision aids is in assisting patients with medical decision-making, as this will give an indication of the significance of their use in healthcare.

Study characteristics

This Cochrane review update consisted of 33 new randomized controlled trials (RCTs), combined with those included in the original review to comprise a sample of 115 studies with 34 444 participants.1 Four studies were excluded from the sample that was included in the original review because they were of a quasi-experimental design, or the same intervention was delivered in both of the treatment arms, only using different formats. Most studies included in this review were at low risk of bias. The primary outcomes of the review, based on the International Patient Decision Aids Standards (IPDAS), included choice made attributes, which comprised knowledge, accuracy of risk perceptions and chosen option congruent with their values, and decision-making process attributes.

Across the 115 included studies, decision aids were provided to assist patients in making one of the 46 different treatment or screening-related decisions. The decision aids provided in the included studies adopted varying modes of delivery and were compared to a variety of different control groups including standard care, no intervention, guideline or placebo groups. For the purpose of analysis, all control group data were combined into a single group titled usual care in the review.

In general, decision aids containing 'choice made attributes' led to better decision-making outcomes. The review found that compared to usual care, the provision of decision aids increased patients' knowledge about the decision being made [mean difference 13.34 out of 100, 95% confidence interval (CI) 11.17-15.51, n = 42], with a significant improvement in knowledge between detailed compared with simplistic decision aids (mean difference 5.52 out of 100, 95% CI 3.90-7.15, n = 19). Additionally, for decision aids in which probabilities were expressed, the proportion of patients with accurate risk perceptions related to the decision increased (risk ratio 1.82, 95% CI 1.52-2.16, n = 19). Decision aids that explicitly clarified the available options in terms of values were found to be associated with a greater proportion of patients choosing the option most congruent with their own values (risk ratio 1.51, 95% CI 1.17-1.96, n = 13).

Similarly, decision aids possessing 'decision-making process attributes' also led to better outcomes in terms of the decision-making process, as well as post-decision and intervention. Compared to the usual care, the use of decision aids was associated with less conflict in selecting between options because the patient was well informed about the choice being made (mean difference -7.26 of 100, 95% CI -9.73 to -4.78, n = 22), and how it related to their personal values (mean difference -6.09, 95% CI -8.50 to -3.67, n = 18). In addition, patients who received decision aids were typically more active in the decision-making process (risk ratio 0.66, 95% CI 0.53-0.81, n = 14), and less likely to remain undecided following receipt of the treatment or screening test (risk ratio 0.59, 95% CI 0.47-0.72, n = 18).

Implications for nursing care

On the basis of this review, decision aids appear to be useful in increasing the knowledge of patients about the decision being made in an evidence-based, value-driven way. They may assist the patient in making their treatment or screening-related decision by minimizing the conflict between the alternative options and emphasizing how each option relates to their individual values. Decision aids are therefore an important tool for use in healthcare-related decision-making.

Implications for research

Further research is needed in terms of the use of decision aids within less educated and/or literate population groups, as well as into the cost effectiveness of decision aids, patient adherence to their decision based on the information provided in the decision aid and finally, the degree of detail required in the decision aid to make it an effective tool for use in the decision-making process.

Reference