1.
Welcome!
Decision aids for people
facing health treatment or
screening decisions:
What's the Evidence?
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2.
What’s the evidence?
Stacey D, Legare F, Col NF, Bennett CL,
Barry MJ, Eden KB, et al. (2014). Decision
aids for people facing health treatment or
screening decisions. Cochrane Database of
Systematic Reviews, 2014(1), CD001431.
http://www.healthevidence.org/view-
article.aspx?a=21567

3.
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4.
Welcome!
You will be placed on hold until the webinar begins.
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Decision aids for people
facing health treatment or
screening decisions:
What's the Evidence?

5.
The Health Evidence Team
Maureen Dobbins
Scientific Director
Heather Husson
Manager
Susannah Watson
Project Coordinator
Robyn Traynor
Publications Consultant
Research Assistants
Yaso Gowrinathan
Kelly Graham
Kristin Read
Emily Sully
Alice Wang
Students
Reza Yousefi Nooraie
PhD candidate)
Jennifer Yost
Assistant Professor

6.
What is www.healthevidence.org?
Evidence
Decision
Making
inform

7.
Why use www.healthevidence.org?
1. Saves you time
2. Relevant & current evidence
3. Transparent process
4. Supports for EIDM available
5. Easy to use

8.
A Model for Evidence-
Informed Decision Making
National Collaborating Centre for Methods and Tools. (revised 2012). A
Model for Evidence-Informed Decision-Making in Public Health (Fact
Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

9.
Stages in the process of
Evidence-Informed Public Health
National Collaborating Centre for Methods and Tools. Evidence-Informe
Public Health. [http://www.nccmt.ca/eiph/index-eng.html]

10.
Poll Question #1
Have you heard of a PICO(S) question
before?
1. Yes
2. No

11.
Searchable Questions Think “PICOS”
1.Population (situation)
2.Intervention (exposure)
3.Comparison (other group)
4.Outcomes
5.Setting

12.
Dawn Stacey RN PhD CON(C) holds a Research Chair in
Knowledge Translation to Patients and is a Full Professor in the
School of Nursing at the University of Ottawa.
Dr. Stacey is a Scientist at the Ottawa Hospital Research Institute where she is Director
of the Patient Decision Aids Research Group. She is the principal-investigator for the
Cochrane Review of Patient Decision Aids, co-chair of the Steering Committee for the
International Patient Decision Aid Standards Collaboration (IPDAS), and co-investigator
for the Cochrane Review of Interventions to Improve the Adoption of Shared Decision
Making.
Her research includes: knowledge translation to patients; patient decision aid
development, evaluation and appraisal; decision coaching; implementation of decision
aids and decision coaching into practice; telephone-based care, and interprofessional
approaches to shared decision making. She is collaborating with the Ministry of Health
in Saskatchewan to implement shared decision making and patient decision aids across
the province. Her research program website is http://decisionaid.ohri.ca.
Dawn Stacey

13.
Should men have screening for
prostate cancer?
yes
no

14.
Is congruent
Choice
With the
best
available
evidence
and
informed
patient
values
International Patient Decision Aids Standards 2006 & 2013; http://ipdas.ohri.ca/
Quality decision

15.
(College des Médecins
du Quebec, 2013)

16.
Inform
• Provide facts: Condition, options, benefits, harms
• Communicate probabilities
Clarify values
• Ask which benefits/harms matters most
• Share patient experiences
Support
• Guide in steps in
deliberation/communication
• Worksheets, list of questions
Patient Decision Aids adjuncts to counseling
Stacey et al., Cochrane Library, 2014

17.
If 100 men are screened If 100 men are not screened
18 diagnosed with prostate ca
(15 due to screening, 3 due to symptoms)
11 diagnosed with prostate ca after
developing symptoms (most >70 yr)
3 develop metastases 4 develop metastases
2 die of prostate cancer
16 with prostate cancer die of
something else
3 die of prostate cancer
8 with prostate cancer die of
something else
6 would never have known they had
prostate cancer (overdiagnosis)
9 would die of other causes anyway
1 does not die of prostate ca because
he was screened
FACTS: 100 men screened yearly 55-
70 and followed to end of life
VERSUS 100 men not screened
(College des Médecins
du Quebec, 2013)

18.
Reasons to get screened Reasons not to be screened
Be reassured that you don’t have
prostate ca
Being worried that you might have
cancer when you don’t (false alarms) –
most positive screening is simply
enlarged due to age
Not having metastases and not dying
of prostate ca
Being diagnosed with ca and having
unnecessary treatments
Willing to accept the side effects of a
prostate biopsy if needed
I don’t want the risks of side effects
from a prostate biopsy
Willing to accept side effects of tx or
to live with knowing I have prostate ca
I don’t want to take the risk of having
side effects from treatment
Willing to accept that cancer found by
screening would never have caused
problems during my life if it hadn’t
been found
I don’t think screening tests are
reliable enough
What matters most?
(College des Médecins
du Quebec, 2013)

19.
http://www.boitedecision.ulaval.ca
/index.php?id=810&L=0

20.
Review
Stacey D, Legare F, Col NF, Bennett CL, Barry MJ,
Eden KB, et al. (2014). Decision aids for people
facing health treatment or screening
decisions. Cochrane Database of Systematic
Reviews, 2014(1), CD001431.
Acknowledgements: A Saarimaki, S Beach, R Wu
Funded by University of Ottawa Research Chair in KT to Patients

21.
PICO Eligible Ineligible
Population
Adults making decision
for themselves or family
member
Decisions: hypothetical,
lifestyle, clinical trial
entry, advance directives
Intervention
Patient decision aid for
treatment or screening
decisions
Patient education;
promotes compliance;
passive informed consent
Comparison
Usual care or alternate
intervention
Same decision aid in both
groups
Outcomes
Decision quality; decision
making process; patient,
practitioner, system level
Study design RCT only All other designs

22.
PICO Eligible Ineligible
Population
Adults making decision
for themselves or family
member
Decisions: hypothetical,
lifestyle, clinical trial
entry, advance directives
Intervention
Patient decision aid for
treatment or screening
decisions
Patient education;
promotes compliance;
passive informed consent
Comparison
Usual care or alternate
intervention
Same decision aid in both
groups
Outcomes
Decision quality; decision
making process; patient,
practitioner, system level
Study design RCT only All other designs

23.
• Medline (1966 to June 2012)
• CINAHL (1982 to Sept 2008*)
• Embase (1980 to June 2012)
• PsychINFO (1806 to June 2012)
• Cochrane Central Register of
Controlled Trials (June 2012)
* Not indexed on OVID after Sept 2008
Methods: Data Sources

24.
• 2 reviewers independently screened and
extracted data using structured forms
• RCT quality was assessed using Cochrane’s
criteria for judging risk of bias:
– sequence generation
– allocation concealment
– blinding
– Completeness of outcome data
– selective outcome reporting (published/registered protocols)
– other potential threats to validity
• Inconsistencies resolved by consensus
Data Screen & Extraction

25.
Cochrane Review PtDAs Updates
17
35
55
86
115
0
20
40
60
80
100
120
140
1999 2003 2009 2011 2014
International
patient
decision aid
standards
(IPDAS)
Criteria
2005

26.
Search Results (Jan 2010 - Jun 2012)
38,069 + 247 citations
2,072 abstract screen
358 full-text screen
186 excluded
30 ongoing
82 + 33 =115 trials
(142 citations)

27.
Topics of Decision Aids (N=115)
• Medical (n=27+9)
– 10 HRT
– 3 atrial fib anti-coag
– 2+1 cardiovascular (Sheridan)
– 2+1 diabetes (Mann D)
– 1 hypertension
– 1+1 osteoporosis (Montori)
– 1+1 chemotherapy (Leighl)
– 1 multiple sclerosis
– 1 schizophrenia
– 1 depression
– 1 natural health products
– 1 ovarian risk management
– 1+1 breast ca prevention (Fagerlin)
– 1+1 osteoarthritis knee (de Achaval)
– (1) acute respiratory infection (Légaré)
– (1) contraceptives (Langston)
– coronary angiogram access site (Schwalm)
• Screening (n=31+15)
– 11+4 PSA (Allen, Evans, Myers, Rubel)
– 7 BRCA1/2 genetic
– 6+5 colon cancer (Lewis, Miller, Schroy, Smith, Steckelberg)
– 5+1 prenatal (Björklund)
– 1 colon ca genetic
– 1+1 mammography (Mathieu 2010)
– 2 diabetes (Mann E, Marteau)
– 1 cervix ca (McCaffery)
– Stress testing for chest pain (Hess)
• Surgical (n=17+6)
– 4+1 mastectomy (Jibaja-Weiss)
+1 reconstruction
– 3+1 prostatectomy (Berry)
– 3+1 hysterectomy (Solberg)
– 2 prophylactic BRCA1/2
– 1 dental
– 2 coronary revascularization
– 1 orchiectomy for prostate ca
– 1 back
– (1) bariatric (Arterburn)
– (1) vasectomy (Labrecque)
– (1) long term feeding tube placement
(Hanson)
• Obstetrics (n=4+2)
– 2 VBAC
– 1 termination
– 1 breech
– (1) labour analgesia (Raynes-Greenow)
– (1) embryo transplant (van Peperstraten)
• Vaccine (n=1+1)
– 1 Hep B
– (1) influenza (Chambers)
• Other (n=2)
– 1 autologous blood donation
– 1 CF referral for transplant

28.
To Find Decision Aids
Google: ‘decision aid’

29.
Elements in Patient Decision Aids
(N=115)
100% Options, outcomes, implicit values clarification
91% Clinical condition
88% Probabilities of benefits and harms
63% Guidance in steps of decision making
59% Explicit values clarification
50% Examples of others/ others’ opinions

30.
Trials Reporting Attributes of Decision Quality
77% Used at Least 1 Measure

31.
34
13% Higher Knowledge
RR 13.29 [11.3, 15.3] – 42 studies
Sub-analysis
- Screening 12.76 [9.7, 15.7] – 19 studies
- Treatment 13.75 [11.1, 16.4] – 23 studies

32.
82% More Accurate Risk Perceptions
RR 1.82 [1.5, 2.2] – 19 studies
• Screening 2.03 [1.4, 2.9] – 7 studies
• Treatment 1.72 [1.5, 2.0] – 12 studies

33.
51% More Informed Values-Based Choices
RR 1.51 [1.17, 1.96] – 13 studies
• Screening 1.56 [1.2, 2.1] – 10 studies (used MMIC approach)
• Treatment 1.35 [0.8, 2.3] – 3 studies (used other measures)

34.
-14% Uptake of PSA testing
RR 0.87 [0.77, 0.98] – 9 studies

35.
Compared to Usual Care, PtDAs…
 13% higher
knowledge scores
(14% 2011)
 82% more
accurate risk
perception (74%
2011)
 51% better match
between values &
choices (25% 2011)
 6% Reduce decisional conflict (6% 2011)
 Help undecided to decide (41%) (43% 2011)
 Patients 34% less passive in decisions
(39% 2011)
 Improved patient-practitioner
communication
 Potential to reduce over-use
• 20% surgery (same 2011)
• 14% PSA (-15% 2011)
• 27% HRT (no new studies )
Findings similar for screening and treatment
 Improve decision quality

36.
Other Outcomes (N=115)

37.
2 (of 6) Trials Showed Savings $$$
• Kennedy 2002 - hysterectomy
– ↓ invasive surgical procedures resulting in PtDA with nurse coaching having
lowest mean cost compared to DA alone or usual care
• van Peperstraten 2010 – IVF
– Saved $219.12 per patient in decision aid group compared to usual care
• Montgomery 2007/Hollinghurst 2010
– No difference in costs for decision about delivery mode after cesarean
• Murray 2001a, 2001b – HRT use, prostatectomy
– No difference in health service resource use; higher cost with expensive
interactive videodisc PtDA but if substitute lower cost internet access, no diff
• Vuorma 2003 - hysterectomy
– No difference in health service resource use; no difference between PtDA and
usual care for treatment costs and productivity loss

38.
Summary of findings
• Patients exposed to PtDAs
– more involved in making health decisions (+34%)
– fewer are undecided (-41%)
– improve knowledge (+13%) and expectations
– enhance values-choice agreement (+51%)
• PtDAs may reduce the use of discretionary surgery
(-20%) or screening (-14% PSA) particularly when base
rates are higher
• More research: cost-effectiveness, adherence to chosen option,
health outcomes linked to preferred outcomes, influence of context

39.
Other research findings on…
• Sub-analysis
– coaching (Stacey et al 2013);
– context (Brown et al. in press);
– low literacy (McCaffery et al 2013)
– adherence (Trenaman et al. submitted)
– values- choice measures (Munro et al. submitted)
– Elements in the decision aid (IPDAS series of 13
papers, 2013)

40.
Importance of this Review
• Patient decision aids are effective
interventions for people facing treatment or
screening decisions
• A to Z inventory
• BUT they are not being used!
http://healthydebate.ca/2015/01/topic/quality/decision-aids
• Current research is focused on implementing
them within health care services

41.
USA: R. 3590 The Patient Protection
and Affordable Care Act (March 2010)

42.
http://decisionaid.ohri.ca

43.
A Model for Evidence-
Informed Decision Making
National Collaborating Centre for Methods and Tools. (revised 2012). A
Model for Evidence-Informed Decision-Making in Public Health (Fact
Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

44.
Poll Question #2
Did you find the information presented
today helpful?
1. Yes
2. No

45.
Poll Question #3
Was this information new to you?
1. Yes
2. No

46.
Questions?

47.
Thank you!
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info@healthevidence.org
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