Providing Information About Options
2012 UPDATED CHAPTER B:
Providing Information About Options

SECTION 1:
AUTHORS/AFFILIATIONS
Deb FeldmanStewart (lead)
Mary Ann O’Brien(co-lead)
Marla Clayman

Queen’s University, Kingston

CanadaUniversity of Toronto, Toronto

CanadaNorthwestern University, Chicago

USA

Joyce Davison

University of Saskatchewan, Saskatoon

CanadaMasahito Jimbo

University of Michigan, Ann Arbor

USA

Michel Labrecque

Laval University, Quebec City

CanadaRichard W. Martin

Michigan State University, Grand Rapids

USA

Heather Shepherd

Family Planning New South Wales, Ashfield

Australia

SECTION 2:
CHAPTER SUMMARY
What is this dimension?
In patients’ decision aids, information should be provided pertaining to the patient's healthcondition and all medically reasonable options to address the health condition. The information
should be based on the best available evidence, patient information needs, and the ethical/legal
principles of informed consent, and be presented in a balanced manner.
What is the theoretical rationale for including this dimension?
Patients choosing among various screening / diagnostic / treatment options need this informationin order to arrive at an informed choice. Ethical and legal obligations along with decisionmaking theory make clear that patients require information in order to ensure that the decision
made is consistent with their values and preferences.
What is the evidence to support including or excluding this dimension?
At least 60 RCT studies have evaluated the effect of patient decision aids on knowledge;knowledge is measured in a variety of ways in these trials. However, the evidence indicates thatwell-designed decision aids generate improvement in mean knowledge scores. Issues that need
to be studied in greater depth include questions about information presentation, populationspecific effects, and information media.
Suggested Citation:
Feldman-Stewart D, O’Brien MA, Clayman M, Davison J, Jimbo M, Labrecque M, Martin RW, Shepherd H. (2012). Providing
information about options. In Volk R & Llewellyn-Thomas H (editors). 2012 Update of the International Patient Decision Aids
Standards (IPDAS) Collaboration's Background Document. Chapter B. http://ipdas.ohri.ca/resources.html.

Providing Information About Options

SECTION 3:
DEFINITION (CONCEPTUAL/OPERATIONAL) OF THIS QUALITY DIMENSIONa)

Updated Definition

Patient decision aids aim to facilitate informed, value-based decisions about health. This isaccomplished by helping each patient determine what is personally important so that they canparticipate in the decision to the extent that they would like. Therefore, information should be
provided pertaining to the patient's health condition and to all medically reasonable options toaddress the health condition. The information should be based on the best available evidence
and be presented in a balanced presentation (both of potential harms and potential benefits, andof the options). The selection of information to provide should be guided by a) patients'
identification of the information that they need in order to make the decision (which may include
psychosocial needs—e.g., extent I can manage on my own after treatment--- logistical concerns,
or other non-biomedical matters), in addition to b) the legal and ethical obligations of informed
consent.
b)

Changes from Original Definition

The updated definition includes the same fundamental concepts as the old, but it now places
more emphasis on patients’ information needs that are beyond that typically identified in the“informed consent” paradigm. Further, the new definition specifies qualities that should
characterize the information that is selected – that is, be based on best-available evidence and bebalanced across both a) harms and benefits, and b) options.
c)Emerging Issues/Research Areas in Definition

None.

SECTION 4:
THEORETICAL RATIONALE FOR INCLUDING THIS QUALITY DIMENSIONa)

Updated Theoretical Rationale

Patients’ Information Needs
Patients’ information needs for decision making often differ from the information priorities of
their healthcare providers (Capirci et al., 2005; Turner et al., 1996). Therefore, it is important to
identify empirically the information that patients need in order to make their decisions. In
addition, because the needs often vary considerably from one patient to the next (FeldmanStewart, Brundage, Nickel, & Mackillop, 2001; Jenkins, Fallowfield & Saul, 2004; Sheridan,
Felix, Pignone, & Lewis, 2004; Feldman-Stewart et al., 2010), it is important to quantify theprevalence of each need in a population of the patients of interest—e.g., through a survey.

2

Providing Information About Options
Further, both prescriptive theories of decision making (e.g., Expected Utility Theory, von
Neuman and Morgenstern, 1953) and descriptive theories of decision making (e.g., Behavioral
Decision Framework, Frisch & Clemen, 1994; Conflict Model, Janis & Mann, 1977;
Differentiation and Consolidation, Svenson, 1992; Fuzzy Trace Theory, Reyna, 2008; Image
Theory, Beach & Mitchell, 1987; Parallel Constraint Satisfaction, Glöckner & Betsch, 2008; andSearch for Dominance Structure, Montgomery, 1994) suggest that to make a decision, thedecision maker needs to establish their preference for particular aspect(s) of the options or for an
option as a whole. For patients to determine their values and preference(s), they need to have therelevant information. Hence, the implication of all these theories is that for patients to makedecisions, they need to be provided with appropriate information.
Legal and Ethical Obligations of Informed Consent
In most jurisdictions, there is a legal obligation of informed consent, making the healthcare
professional responsible for ensuring that the patient understands their condition, the procedure
being recommended, its potential benefits and harms, and any alternate procedures that areavailable. Healthcare professionals are also bound by the ethical doctrine of informed consent,
which is founded on three principles: 1) autonomy (which obligates the professionals to ensurethat the patient can act in her or his own best interest without undue pressure); 2) benevolence
and non-malevolence (which obligates the professionals to choose to do good and to avoid doing
harm to patients); and 3) justice (which obligates the professionals to treat all patients equally)(Appelbaum, Lidz & Meisel, 1987; Faden & Beauchamp, 1986).
Legal and ethical obligations require that healthcare professionals explain, for treatment
decisions, how the untreated condition is expected to develop, the procedures involved in thetreatment(s), the potential benefits of the treatment(s), and the severity and likelihood of thevarious treatment side effects. For screening or diagnostic tests, additional information should be
provided about the frequency of true/false positive and true/false negative results, and about therecommended follow-up actions that could include treatment options for true positive results.
Patients’ information needs that are outside these content areas should be addressed.
b)Changes to Original Rationale

The fundamental rationale currently provided is the same as the original. Recent evidence
highlights, in particular decision-making contexts, a) the extent of difference between patient
information needs and the priorities of their health-care professionals, and b) wide differences in
information affecting the decisions amongst the patients.
c)

Emerging Issues/Research Areas in Theory/Rationale

Identifying Information Details
Research is emerging that focuses on details that affect patient decisions, and clarifies what
information should be provided. For example, patients with early-stage prostate cancer
concerned about “the cancer spreading” (when choosing between watchful waiting and active
treatment) are often concerned about one of two very different issues: some patients are3

Providing Information About Options
concerned about the chances of the cancer spreading while others are concerned about where thecancer will spread (i.e., wanting to avoid brain metastases more than metastases to other parts ofthe body). For each decision, investigation of the details that affect patients’ decisions will help
clarify the information that should be provided in a patient decision aid for that decision.
Identifying Prevalence of Information Needs in Patient Populations
Research is emerging that prevalence estimates of individual information needs are required
within a population of patients in order to determine a) which needs are most prevalent, and b)
the extent of variability in particular needs across patients. Further research is needed inindividual decisions to establish the prevalence of particular information needs amongst a
population of patients.
How Best to Address the Information Needs of Individual Patients
Because patient decision aids are intended to help the individual patient with her/his decision, it
is important to be able to accommodate wide variability in information needs when it occurs
within a patient population. Research is needed to determine best ways of tailoring patientdecision aids to address the information needs of the individual patient.

SECTION 5:
EVIDENCE BASE UNDERLYING THIS QUALITY DIMENSIONa)

Updated Evidence Base

The following evidence comes from the updated Cochrane Collaboration Review of patientdecision aids (Stacey et al., 2011), which includes publications until the end of 2009, augmented
by a search of OvidSP, including all databases (e.g., Medline, AMED, EBM Reviews,
EMBASE, Global Health, Ovid Healthstar, PsycExtra, PsychInfo) for 2010 publications. The
following search terms were used for the 2010 search: (“decision aid” or “decision support” or“decision making”) AND (“randomized trial” or “controlled trial” or “comparison”).
RCTs Involving Patients Facing Actual Choices
The 2011 Cochrane Review identified 50 randomized controlled trials and the 2010 search
identified an additional 10, totaling 60 trials that evaluated the effect of patient decision aids on
knowledge. Of the 60 comparisons, 39 compared a patient decision aid to “usual care”, which we
defined as no intervention beyond that usually given in the study setting. Twenty-one of the 60
compared a simpler to a more detailed patient decision aid; we defined “more detailed” asproviding information (with or without other additions) that was not provided in the “simple
decision aid”.

4

Providing Information About Options
Knowledge Scores –Decision Aid versus Usual Care
Stacey et al. (2011) reported that 39 trials compared patient decision aids to usual care. They
conducted a meta-analysis of 26 studies and found that patients using decision aids had mean
knowledge scores that were, on average, 14 out of 100 points higher (95%CI 11 to 16) than themean scores of patients who received usual care. They also identified an additional 8 studies that
could not be included in the meta-analysis. Of these, 5 reported statistically significant
improvement in knowledge scores in DA groups compared to usual care, although one(Weymiller, 2007) only showed the advantage if the DA was used during the consultation but notwhen used prior to it. The other 3 studies reported a statistically significant improvement frombaseline for DA groups. Of the five additional trials published in 2010, all reported statisticallysignificantly improved knowledge for the DA group compared to the usual care group: 2 studies
reported higher mean knowledge scores (Evans et al., 2010 and Mathieu et al. , 2010), 2 reported
larger mean improvement from baseline scores (Rubel et al., 2010 and van Peperstraten et al.,2010). The fifth study reported that a larger percentage of DA patients as compared to usual carepatients improved their knowledge scores, and the mean improvement in scores was larger for
DA group compared to that in the usual care group (Allen et al., 2010). Thus, overall, it appears
that providing patients with a decision aid results in higher knowledge scores than those who justreceive usual care.
Knowledge Scores - Simple versus More Detailed Decision Aids
Stacey et al. (2011) reported that 20 studies compared more detailed patient decision aids tosimpler versions. Their meta-analysis of 14 trials suggested that, on average, the more detailed
decision aids resulted in an improvement in mean knowledge scores over usual care of 5 out of
100 points (95% CI 3 to 7), which is considered a small effect. One study that could not be
included in the analysis found no difference between the groups (Volk et al. , 2008). Of the five2010 reports, three found some statistically significant evidence of higher knowledge scores forthe more detailed decision aid but often the difference was limited: one found a higher mean
knowledge score (Raynes-Greenow et al., 2010), one found a significant improvement in the
more detailed decision aid group but not in the simpler decision aid group (Jibaja-Weiss et al.,2010), and one found no difference in mean overall knowledge scores but the more-detailed
group had more accurate perceptions of the risks deemed most important to the decision (Mannet al. , 2010). One study reported no difference in mean knowledge scores between the groups(Labrecque et al., 2010). The final study was designed for low literacy patients, so theintervention decision aid actually had less information but also used simpler language andgraphic illustrations compared to the standard information provided to the control group. The
authors also reported that the group who received less information (in simpler language withgraphics) had higher mean knowledge scores and a larger proportion who reached the knowledge
threshold the authors defined for “informed decision making” (Smith et al., 2010). Thus,
generally, it appears that the more detailed decision aids seem to result in slightly higher
knowledge scores than the simpler decision aids, but the differences are very small, often
isolated and it appears that they can be eliminated by presentation strategies.

5

Providing Information About Options
Feeling Informed Scores – Decision Aids versus Usual Care
Although the evidence related to objective knowledge scores is considered the gold standard,
evidence around how informed patients feel leads to the same conclusions as those of objective
data. Most frequently the subjective feelings have been measured by the “feeling uninformed”
subscale of the Decisional Conflict Scale (DCS, O’Connor et al., 1995). The Cochrane
Collaboration Review (Stacey et al., 2011) identified 25 studies that reported the Decisional
Conflict Scale subscale. Sixteen of those studies compared DA to usual care, and a meta-analysisof those data suggests a reduction in feeling uninformed of -7 out of 100 points (95% CI -9 to 4). Of the five 2010 decision aid versus usual care comparisons, none reported the “feelinguninformed” subscale even if they used the Decisional Conflict Scale.
Feeling Informed Scores – Simple versus More Detailed Decision Aids
The Cochrane Collaboration Review’s (Stacey et al., 2011) meta-analysis of the 9 studies thatcompared a more detailed patient decision aid to a simpler version suggests that the moredetailed decision aids resulted in a slight reduction of feeling uninformed of -3 out of 100 points(95% CI -5 to 0). Of the five 2010 reports comparing simple to more detailed decision aids, twofound the more detailed decision aid reduced feeling uninformed scores significantly more than
the simple one (Jibaja-Weiss et al., 2010 & Mann et al., 2010). In the study of patients with low
literacy patients, the decision aid had less information with simpler language and graphic
illustrations in the intervention. Use of the decision aid resulted in patients feeling more
informed on the low-literacy version of the subscale (65% versus 52%) (Smith et al., 2010).
Two studies did not find a difference between the groups’ scores on the DCS Feeling
Uninformed subscale (Labrecque et al., 2010, Raynes-Greenow et al., 2010). However, one ofthose studies did find that a significantly higher percentage of the more-detailed decision aidgroup reported having enough information to make a decision (89% versus 80%) (RaynesGreenow et al., 2010).
b)
Changes from Original Evidence Base
The types of evidence have not changed from the original. Studies from 2005 until the end of2010 have been added.
c)Emerging Issues/Research Areas in Evidence Base

Information Presentation
Evidence suggests that many aspects of how the information is presented can affect patients’ability to use it. Many aspects of text presentation can affect comprehension including its
structure (Vaiana & McGlynn, 2002; Hartley & Burnhill, 1977), layout (Wilson & Wolf, 2009;
Sanfey & Hastie, 1998), language (Rudd, Kaphingst, Colton, Gregoire, & Hyde, 2010), and font
(Vaiana et al., 2002). See also IPDAS Chapter J “Addressing Health Literacy”. Presentation ofquantitative information, including potential benefits and risks, is addressed in IPDAS Chapter C“Presenting Probabilities”. Aspects beyond how the text itself is presented can affectcomprehension. Text and numeric presentations can interact to affect comprehension (Fagerlin
et al., 2005). And, if graphics do not directly reinforce the textual information, they can distract

6

Providing Information About Options
from core information and reduce recall accuracy (Martin, Brower, Geralds et al., in press).
Finally, although evidence presented above suggests that more detailed decision aids, generally,
can result in small improvements in the amount of relevant information understood by patients,
there are times when less information results in greater comprehension (Peters, Dieckmann,
Dixon et al., 2007). See Population-Specific Effects, below, for further information.
Presentation format can also affect decision-making processes. Presenting information in tableformat helps readers make direct comparisons which, in turn, helps decision making(Sundstroem, 1989; Feldman-Stewart & Brundage, 2004). It should also be noted that, when
options are presented sequentially (i.e., one after the other), the order in which they are presented
can shift preferences (Ubel et al., 2010).
Further research is needed to clarify how to present information in patient decision aids to assist
patients’ understanding and their decision making processes.
Population-Specific Effects
While some generalities appear around how information presentation affects its potential to beunderstood, there is evidence suggesting that these effects may be population-specific. In
addition to literacy levels being an important consideration [see also IPDAS Chapter J“Addressing Health Literacy”], age may also be an important consideration, such as when using
illustrations (Liu C-J et al., 2007). Further research is needed to clarify what population-related
factors are important considerations for how information is presented.
MediumMedium-specific considerations can also affect how well information is understood by patients.
For example, multi-media presentation can result in poorer comprehension than when theinformation is presented in a single medium (Sundar, 2000). Evidence from a systematic
research program on multi-media learning provides guiding principles on how to maximize theeffectiveness of multi-media presentations (Mayer, 2001). Multi-media can be used to
implement “entertainment education” which has resulted in higher knowledge gains for low
literacy patients than audio-booklet presentation; it has no apparent differential impact on highliteracy patients (Volk et al., 2008) [see also IPDAS Chapter J “Addressing Health Literacy”]b) Bibliography
Below we list some references that provide evidence as specified in that section. Readers canfind a more complete list of papers reporting randomized controlled trials of patient decision aidsin the Cochrane Collaboration Review identified at the top of the list.

7

Providing Information About Options
Update to Cochrane Collaboration Review of Patient Decision Aids
Stacey D, Bennet CL, Barry MJ, Col NF, Eden KB, Holmes-Rovner M, Llewellyn-Thomas
HA, Lyddiatt A, Légaré F, Thomspon R. Decision aids for people facing health treatment orscreening decisions. Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No.:
CD001431. DOI: 10.1002/14651858.CD001431.pub3. Published Online: 5 OCT 2011
http://www2.cochrane.org/reviews/en/ab001431.html
Patients’ Information Needs Differ From The Information Priorities of Their HealthProfessionals
Capirci C, Feldman-Stewart D, Mandoliti G, Brundage M, Belluco G, Magnani K.
Information priorities of Italian early-stage prostate cancer patients and of their health-care
professionals. Patient Education and Counseling 2005;56:174-81.
Turner S, Maher EJ, Young T, Young J, Hudson GV. What are the information priorities forcancer patients involved in treatment decisions? An experienced surrogate study in Hodgkin's
disease. British Journal of Cancer 1996;73:222-7.
Patients’ Information Needs Vary Amongst Themselves
Feldman-Stewart D, Brundage MD, Nickel JC, Mackillop WJ. The information required bypatients with early-stage prostate cancer in choosing their treatment. British Journal of
Urology International 2001;87:218-23.
Feldman-Stewart D, Capirci C, Brennenstuhl S et al.. Information needed for decision
making by early-stage prostate cancer patients: A comparison of information needs in ninecountries. Medical Decision Making 2010;In Press, Nov 2010.
Jenkins V, Fallowfield L, Saul J. Information needs of patients with cancer: results from alarge study in UK cancer centres. British Journal of Cancer 2001 January 5;84(1):48-51
Sheridan SL, Felix K, Pignone MP, Lewis CL. Information needs of men regarding prostatecancer screening and the effect of a brief decision aid. Patient Education and Counseling2004;54:345-51
Information That Patients Say They Want For Screening Decisions
Barratt A, Trevena L, Davey HM, McCaffery K. Use of decision aids to support
informed choices about screening. BMJ 2004; 329: 507-510.

8

Providing Information About Options
Chan ECY & Sulmasy DP. What should men know about prostate-specific antigen
screening before giving informed consent? American Journal of Medicine 1998; 105, 266274.
Pignone M, Bucholtz D, & Harris R. Patient preferences for colon cancer screening.
Journal of General Internal Medicine 1999; 14(7): 432-437.
Taylor KL, Turner RO, Davis JD, Johnson L, Schwartz MD, & Leak C. Improving
knowledge of the prostate cancer screening dilemma among African American men: an
academic-community partnership in Washington, DC. Public Health Reports 2001; 116,590-598.
Information That Patients Say They Want For Treatment Decisions
Bastian LA, McBride CM, Fish L, Lyna P, Farrell D, Lipkus IM, Rimer BK. & Siegler IC.
Evaluating participants’ use of a hormone replacement therapy decision–making
intervention. Patient Education and Counseling 2002; 48: 283-291.
Brink SG, Birney AJ & McFarren AE. Charting Your Course: Formative evaluation of a
prostate cancer treatment decision. International Electronic Journal of Health Education
2000;3: 44-54.
Davison BJ, Degner LF & Morgan TR. Information and decision-making preferences ofmen with prostate cancer. Oncology Nursing Forum 1995;22:1401-1407.
Feldman-Stewart D, Brundage MD, Hayter C, Groome P, Nickel JC, Downes H &Mackillop WJ. What questions do patients with curable prostate cancer want answered?
Medical Decision Making 2000; 20: 7-19.
Feldman-Stewart D, Brundage MD, Nickel JC & Mackillop WJ. The information required bypatients with early-stage prostate cancer in choosing their treatment. British Journal of
Urology International, 2001; 87: 218-223.
Hallowell N. A qualitative study of the information needs of high-risk women undergoingprophylactic oophorectomy. Psycho-oncology, 2000;9:486-495.
Newton KM, LaCroix AZ, Leveille SG, Rutter C, Keenan NL & Anderson LA. Women's
beliefs and decisions about hormone replacement therapy. Journal of Women's Health 1997;
6: 459-465.
Rothert M, Rovner D, Holmes M, Schmitt N, Talarczyk G, Kroll J & Gogate J. Women's
use of information regarding hormone replacement therapy. Research in Nursing and
Health 1990;13:355366.

9

Providing Information About Options
Sawka CA, Goel V, Mahut CA, Taylor GA, Thiel EC, O'Connor AM, Ackerman I, Burt
JH & Gort EH. Development of a patient decision aid for choice of surgical treatment forbreast cancer. Health Expectations 1998; 1: 23-36.
Stacey D, DeGrasse C & Johnston L. Addressing the support needs of woman at high risk
for breast cancer: Evidence-based care by advanced practice nurses. Oncology Nursing
Forum 2002; 29: E77E84.
Whelan T, Levine M, Gafni A, Sanders K, Willan A, Mirsky D, Schnider D, McCready D,
Reid S, Kobylecky A & Reed K. Mastectomy or Lumpectomy? Helping women makeinformed choices. Journal of Clinical Oncology 1999;17: 1727-1735.
Legal And Ethical Obligations
Appelbaum PS, Lidz CW & Meisel A. Informed consent: Legal theory and clinicalpractice. New York: Oxford University Press, 1987.
Faden RR & Beauchamp TL. A history and theory of informed consent. New York, N.Y.:
Oxford University Press, 1986.
Decision Making Theory
Beach, L. R. & Potter, R. E. (1992). The pre-choice screening of options. Acta Psychologica,
81, 115-126.
Frisch, D. & Clemen, R. T. (1994). Beyond expected utility: Rethinking behavioral decisionresearch. Psychological Bulletin, 116, 46-54.
Glöckner, A. & Betsch, T. (2008). Do people make decisions under risk based on ignorance?
An empirical test of the priority heuristic against cumulative prospect theory. Organization
Behavior and Human Decision Processes, 107, 75-96.
Janis, I. L. & Mann, L. (1977). A conflict model of decision making. In Decision Making: A
psychological analysis of conflict: choice and commitment ( London: Collier Macmillan
Publishers.
Montgomery, H. (1994). Toward a perspective theory of decision making and judgment. Acta
Psychologica, 87, 155-178.
Reyna, V. F. (2008). A theory of medical decision making and health: Fuzzy Trace Theory.
Medical Decision Making, 28, 850-865.
Svenson, O. (1992). Differentiation and Consolidation Theory of human decision making: A
frame of reference for the study of pre- and post-decision processes. Acta Psychologica, 80,
143-168.

10

Providing Information About Options
Von Neumann, J. & Morgenstern, D. (1953). The theory of games and economic behavior. (3ed.) New York: John Wiley and Sons.
Higher Knowledge Test Scores With Decision Aids Compared To Usual PracticeAllen JD, Othus MKD, Hart Jr A et al.. A randomized trial of a computer-tailored decision
aid to improve prostate cancer screening decisions: results from the Take the Wheel trial.
Cancer Epidemiology, Biomarkers & Prevention 2010;19(9):2172-86.
Barry MJ, Cherkin DC, Chang YC, Fowler FJ & Skates S. A randomized trial of amultimedia shared decision-making program for men facing a treatment decision for benign
prostatic hyperplacia. Disease Management and Clinical Outcomes 1997; 1: 5-14.
Bernstein SJ, Skarupski KA, Grayson CE, Starling MR, Bates ER & Eagle KA. A
randomized controlled trial of information-giving to patients referred for coronary
angiography: effects on outcomes of care. Health Expectations 1998; 1: 50-61.
Dunn RA, Shenouda PE, Martin DR & Schultz AJ. Videotape increases parent
knowledge about poliovirus vaccines and choices of polio vaccination schedules.
Pediatrics 1998;102:e26.
Evans R, Joseph-Williams N, Edwards A et al. Supporting informed decision making forprostate specific antigen (PSA) testing on the web: an online randomized controlled trial.
Journal of Medical Internet Research 2010;12(3):e27-doi: 10.2196/jmir.1305
Green MJ, Biesecker BB, McInerney AM, Mauger D & Fost N. An interactive computer
program can effectively educate patients about genetic testing for breast cancer
susceptibility. American Journal of Medical Genetics 2001;103:16-23.
Lerman C, Biesecker B, Benkendorf JL, Kerner J, Gomez-Caminero A, Hughes C &Reed MM. Controlled trial of pretest education approaches to enhance informed
decision-making for BRCA1 Gene testing. Journal of National Cancer Institute 1997;
89: 148-157.
Man-Son-Hing M, Laupacis A, O'Connor A, Biggs J, Drake E, Yetisir E & Hart RG. A
patient decision aid regarding antithrombotic therapy for stroke prevention in atrial
fibrillation: a randomized controlled trial. Journal of the American Medical Association
1999;282: 737-743.
Mathieu E, Barratt AL, McGeechan K, Davey HM, Howard K, Houssami N. Helping womenmake choices about mammography screening: An online randomized trial of a decision aid
for 40-year-old women. Patient Education and Counseling 2010;81:63-72

11

Providing Information About Options
Morgan MW, Deber RB, Llewellyn-Thomas HA, Gladstone P, Cusimano RJ, O'Rourke K,
Tomlinson G & Detsky AS. Randomized, controlled trial of an interactive videodisk decision
aid for patient with ischemic heart disease. Journal of General Internal Medicine 2000; 15:685-693.
Rubel SK, Miller JW, Stephens RL et al. Testing the effects of a decision aid for prostatecancer screening. Journal of Health Communication 2010;15:307-21.
Schwartz MD, Benkendorf J, Lerman C, Isaacs C, Ryan-Robertson A & Lenora J.
Impact of educational print materials on knowledge, attitudes, and interest in
BRACA1/BRACA2. Cancer 2001; 92: 932-940.
van Peperstraten A, Nelen W, Grol R et al. The effect of a multifaceted empowerment
strategy on decision making about the number of embryos transferred in in vitro
fertilisation: randomised controlled trial. British Medical Journal
2010;340(c2501):doi:10.1136/bmj.c2501.
Volk RJ, Cass AR & Spann SJ. A randomized controlled trial of shared decision making forprostate cancer screening. Archives of Family Medicine 1999; 8: 333-340.
Whelan T, Sawka C, Levine M, Gafni A, Reyno L, Willan A, Julian J, Dent S, Abu-Zahra
H, Chouinard E, Tozer R, Pritchard K & Bodendorfer I. Helping patients make informed
choices: A randomized trial of a decision aid for adjuvant chemotherapy in lymph nodenegative breast cancer. Journal of the National Cancer Institute 2003; 95: 581-587.
Higher Knowledge Test Scores With Detailed Decision Aids Compared To Simpler Aids
Dodin S, Legare F, Daudelin G, Tetroe J, O’Connor A. Prise de decision en matiered’hormonotherapie de remplacement. Canadian Family Physician 2001;47:1586-1593.
Jibaja-Weiss ML, Volk RJ, Granchi TS et al. Entertainment education for breast cancer
surgery decisions: a randomized trial among patients with low health literacy. Patient
Education and Counseling. 2010; 84(1). E-Pub 7/2010. PMID:20609546.
Phelan EA, Deyo RA, Cherkin DC, Weinstein JN, Ciol MA, Kreuter W & Howe JF.
Helping patients decide about back surgery. Spine 2001; 26: 206-212.
Raynes-Greenow CH, Nassar N, Torvaldsen S, Trevena L, Roberts CL. Assisting informed
decision making for labour analgesia: a randomised controlled trial of a decision aid forlabour analgesia versus a pamphlet. BMC Pregnancy and Childbirth 2010;10(15):doi:
10.1186/1471-2393-10-15.
Rostom A, O'Connor A, Tugwell P & Wells G. A randomized trial of a computerized versus
an audio-booklet decision aids for women considering post-menopausal hormone
replacement therapy. Patient Education and Counseling 2004; 46: 67-74.
12

Providing Information About Options
Rothert M, Rovner D, Holmes M, Schmitt N, Talarczyk G, Kroll J & Gogate J. Women's
use of information regarding hormone replacement therapy. Research in Nursing and
Health 1990; 13: 355366.
Schapira MM & VanRuiswyk J. The effect of an illustrated pamphlet decision-aid on the useof prostate cancer screening tests. Journal of Family Practice 2000; 49: 418-424.
Higher Knowledge Scores In The Simpler Compared To More Detailed Decision Aids
For low education patients - Smith SK, Trevena L, Simpson JM, Barratt A, Nutbeam D,
McCaffery KJ. A decision aid to support informed choices about bowel cancer screening
among adults with low education: randomised controlled trial. British Medical Journal
2010;341(c5370):doi:10.1136/bmj.c5370
No Difference In Knowledge Test Scores Between Simpler Compared To More Detailed
Decision Aids
Goel V, Sawka C, Thiel EC, Gort EH & O'Connor AM. Randomized trial of a patientdecision aid for choice of surgical treatment for breast cancer. Medical Decision Making
2001; 21: 1-6.
Labrecque M, Paunescu C, Plesu I, Stacey D, Légaré F. Evaluation of the effect of a patientdecision aid about vasectomy on the decision-making process: a randomized trial.
Contraception 2010;82:556-62.
Mann DM, Ponieman D, Montori VM, Arciniega J, McGinn T. The Statin Choice decision
aid in primary care: A randomized trial. Patient Education and Counseling 2010;80 :138-40.
Michie S, Smith D, McClennan A & Marteau TM. Patient decision making: An
evaluation of two different methods of presenting information about a screening test.
British Journal of Health Psychology 1997; 2: 317-326.
O'Connor AM, Tugwell P, Wells GA, Elmslie T, Jolly E, Hollingworth G, McPherson R,
Bunn H, Graham I & Drake E. A decision aid for women considering hormone therapy
after menopause: decision support framework and evaluation. Patient Education &Counseling 1997; 33: 267-279.
Street RL, Voigt B, Geyer C, Manning T & Swanson GP. Increasing patient involvement inchoosing treatment for early breast cancer. Cancer 1995; 76: 2275-2285.
Volk RJ, Jibaja-Weiss ML, Hawley ST et al. Entertainment education for prostate cancer
screening: A randomized trial among primary care patients with low health literacy. Patient
Education and Counseling 2008;73:482-9.

13

Providing Information About Options
Comprehension and IllustrationsPeters E, Dieckmann N, Dixon A, Hibbard JH, Mertz CK. Less is more in presenting quality
information to consumers. Medical Care Research and Review 2007;64(2):169-90.
Reduction In Feeling Uninformed With Decision Aids Compared To Usual Practice –Decisional Conflict Scale “Uninformed Subscale” (unless otherwise stated)
Davison BJ, Krik P, Degner LF & Hassard TH. Information and patient participant inscreening for prostate cancer. Patient Education and Counseling 1999; 37: 255-263.
Dolan JG & Frisina S. Randomized controlled trial of a patient decision aid forcolorectal cancer screening. Medical Decision Making 2002;22:125-139.
Man-Son-Hing M, Laupacis A, O'Connor A, Biggs J, Drake E, Yetisir E & Hart RG. A
patient decision aid regarding antithrombotic therapy for stroke prevention in atrial
fibrillation : a randomized controlled trial. Journal of the American Medical Association
1999; 282: 737-743.
Murray E, Davis H, Tai SS, Coulter A, Gray A & Haines A. Randomised controlled trial of
an interactive multimedia decision aid on benign prostatic hypertrophy in primary care.
British Medical Journal 2001a; 323: 493-496
Higher “Experienced” Knowledge
van Peperstraten A, Nelen W, Grol R et al. The effect of a multifaceted empowerment
strategy on decision making about the number of embryos transferred in in vitro
fertilisation: randomised controlled trial. British Medical Journal 2010; 340 (c2501):
doi:10.1136/bmj.c2501.
Reduction In Feeling Uninformed With More Detailed Decision Aids Compared To Simple
Jibaja-Weiss ML, Volk RJ, Granchi TS et al. Entertainment education for breast cancer
surgery decisions: a randomized trial among patients with low health literacy. Patient
Education and Counseling. 2010; 84(1). E-Pub 7/2010. PMID:20609546.
Mann DM, Ponieman D, Montori VM, Arciniega J, McGinn T. The Statin Choice decision
aid in primary care: A randomized trial. Patient Education and Counseling 2010;80 :138-40.
Reduction In Feeling Uninformed With Simpler Compared To More Detailed Decision Aids
For low education patients - Smith SK, Trevena L, Simpson JM, Barratt A, Nutbeam D,
McCaffery KJ. A decision aid to support informed choices about bowel cancer screening
among adults with low education: randomised controlled trial. British Medical Journal
2010;341(c5370):doi:10.1136/bmj.c5370.

14

Providing Information About Options
No Difference In Feeling Uninformed Between Simpler Compared To More Detailed Decision
Aids
Labrecque M, Paunescu C, Plesu I, Stacey D, Légaré F. Evaluation of the effect of a patientdecision aid about vasectomy on the decision-making process: a randomized trial.
Contraception 2010;82:556-62.
Raynes-Greenow CH, Nassar N, Torvaldsen S, Trevena L, Roberts CL. Assisting informed
decision making for labour analgesia: a randomised controlled trial of a decision aid forlabour analgesia versus a pamphlet. BMC Pregnancy and Childbirth 2010;10(15):doi:
10.1186/1471-2393-10-15.
Presentation Designed To Facilitate Understanding
Text structure
Hartley J, Burnhill P. Fifty guidelines for improving instructional text. Programmed
Learning and Educational Technology 1977;14(1):65-73.
Vaiana ME, McGlynn EA. What cognitive science tells us about the design of reports for
consumers. Medical Care Research and Review 2002;59:3-35
LayoutWilson EAH, Wolf MS. Working memory and the design of health materials: A cognitive
factors perspective. Patient Education and Counseling 2009;74:318-22.
Sanfey A, Hastie R. Does evidence presentation format affect judgment? An experimental
evaluation of displays of data for judgments. Psychological Science 1998;9:99-103.
Schwartz LM, Woloshin S, Welch HG. Using a drug facts box to communicate drug benefits
and harms: Two randomized trials. Annals of Internal Medicine 2009;150:516-27.
Language
Rudd RE, Kaphingst K, Colton T, Gregoire J, Hyde J. Rewriting public health information inplain language. Journal of Health Communication 2010;9(3):195-206.

15

Providing Information About Options
Font
Vaiana ME, McGlynn EA. What cognitive science tells us about the design of reports for
consumers. Medical Care Research and Review 2002;59:3-35.
Use of Illustrations
Fagerlin A, Wang C, and Ubel PA. Reducing the influence of anecdotal reasoning on
people’s health care decisions: Is a picture worth a thousand statistics? Medical Decision
Making 2005; 25: 398-405.
Liu C-J, Kemper S, McDowd J. The use of illustration to improve older adults'
comprehension of health-related information: Is it useful? Patient Education and Counseling2009;76:283-8.
Martin RW, Brower ME, Geralds A, Gallagher PJ, Tellinghuisen DJ. An experimental
evaluation of patient decision aid design to communicate the effects of medications on therate of progression of structural joint damage in rheumatoid Arthritis, Patient Education andCounseling, In press 2011.
AmountPeters E, Dieckmann N, Dixon A, Hibbard JH. Less is more in presenting quality information
to consumers. Medical Care Research and Review 2007;10:1-22.
Text Presentation Affects Decision Making
Feldman-Stewart D, Brundage MD. Challenges for designing and implementing decision
aids. Patient Education & Counseling 2004 September;54(3):265-73.
Sundstroem GA. Information search and decision making: The effects of information
displays. In: Montgomery H, Svenson O, editors. Process and structure in human decision
making. Chichester: John Wiley & Sons; 1989. p. 209-23..
Ubel PA, Smith DM, Zikmund-Fischer B et al. Testing whether decision aids introduce
cognitive biases: Results of a randomized trial. Patient Education and Counseling2010;80:158-63.

16

Providing Information About Options
Multimedia Presentations
Mayer RE. Multi-media learning. Cambridge, UK: Cambridge University Press; 2001
Sundar SS. Multimedia effects on processing and perception of online news: A study of
picture, audio and video downloads. Journalism and Mass Communication Quarterly
2000;77(3):480-99.
Volk RJ, Jibaja-Weiss ML, Hawley ST et al. Entertainment education for prostate cancer
screening: A randomized trial among primary care patients with low health literacy. Patient
Education and Counseling 2008;73:482-9.

17

Providing Information About Options
APPENDIX:
ORIGINAL CHAPTER B
Original Authors
Deb FeldmanStewart (lead)
Joan Austoker

Queen’s University, Kingston

CanadaUniversity of Oxford

UK
Switzerland

Paul Hewitson

Psychologue à l'Institut de Médecine Sociale et Préventive
à Genève
University of Oxford

UK

Sara Knight

University of California, San Francisco

USA

Karen Sepucha

Harvard Medical School, Boston

USA

Tim Whelan

McMaster University, Hamilton

CanadaAgathe Charvet

Original Rationale/Theory
Patient decision aids aim to facilitate informed, value-based decisions about health. This isaccomplished by helping each patient determine what is personally important so that they canparticipate in the decision to the extent that they would like. Therefore, the patient needs tounderstand their health condition, and all medically reasonable options to address the condition,
including each option’s potential benefits, harms and side effects. The selection of information to
be included is guided by patients.’ identification of their needs, in addition to the legal andethical obligations of informed consent.
Patients’ Information Needs
Although information needs vary widely from one patient to the next, in general all patientsrequire information that includes how the untreated condition is expected to develop, theprocedures involved in the treatment(s), the potential benefits of the treatment(s), and theseverity and likelihood of the various treatment side effects (e.g. Feldman-Stewart, Brundage &Van Manen, 2004). For screening or diagnostic tests, additional information should be provided
about the frequency of true/false positive and true/false negative results, and about therecommended follow-up actions that could include treatment options for true positive results.
Legal and Ethical Obligations of Informed Consent
In most jurisdictions, there is a legal obligation of informed consent making the practitioner
responsible for ensuring that the patient understands their condition, the procedure being
recommended, its potential benefits and harms, and what alternate procedures are available.

18

Providing Information About Options
Health professionals are also bound by the ethical doctrine of informed consent that is foundedon three principles: (1) autonomy (which obligates the professionals to ensure that the patient can
act in their own best interest without undue pressure); (2) benevolence and non-malevolence(which obligates the professionals to choose to do good and to avoid doing harm to patients); and(3) justice (which obligates the professionals to treat all patients equally) (Appelbaum, Lidz &Meisel, 1987; Faden & Beauchamp, 1986). Ensuring that patients understand their condition, all
medically reasonable options, and the potential outcomes of each option is intrinsic to all of theseprinciples.
Original Evidence
Inventory Of Available Patient Decision Aids
Information about options was assessed in patient decision aids registered in the Cochrane
Review inventory (O’Connor et al., 2003).
Of 131 patient decision aids that were available and updated within the last 5 years:
 100% (of 131) presented information about options and their potential benefits andharms.
RCTs Involving Patients Facing Actual Choices
The Cochrane Review identified 18 randomized controlled trials that evaluated the effect ofpatient decision aids on knowledge. Nine of these compared a patient decision aid to usual care,and nine compared a simpler to a more detailed patient decision aid (O’Connor et al., 2003). Of
the 9 trials that compared patient decision aids to usual care, all (100%) showed statisticallysignificantly higher mean knowledge test scores in the patient decision aid group compared tothose of the usual care group. Of the 9 that compared more detailed patient decision aids tosimpler versions, 8 (89%) showed a trend toward higher mean knowledge test scores in the group
receiving the more detailed patient decision aid; however, only 4 studies had the power to detecta statistically significant difference.
Similar results were observed in the trials that measured “feeling uninformed” on a subscale of
the Decisional Conflict Scale. Compared to usual care, patients using a patient decision aid in all
six RCTs (100%) had a statistically significant reduction (ranging from mean of 5 to 16 points
out of 100) in feeling uninformed about options, benefits, and harms. Four RCTs compared amore detailed patient decision aid to a simpler version. Of the four, three (75%) showed areduction in feeling uninformed (from 3 to 5 points out of 100), that was not statistically reliable
due to insufficient power.

19

Providing Information About Options
Original References
Cochrane Review Of Decision Aids
O'Connor AM, Fiset V, Rostom A, Tetroe JM, Entwistle V, Llewellyn-Thomas HA, Holmes-Rovner
M, Barry M, & Jones J. Decision aids for people facing health treatment or screening decisions.
Cochrane Collaboration: Consumers and Communication Cochrane Review Group, 1999a. Contact
Paola Rio: rio@hna.ffh.vic.gov.au.
O'Connor AM, Rostom A, Fiset V, Tetroe J, Entwistle V, Llewellyn-Thomas H, Holmes-Rovner M,
Barry M & Jones J. Decision aids for patients facing health treatment or screening decisions:systematic review. British Medical Journal, 1999b; 319: 731-734.
Empirical Evidence Of Information Actually Used In Decision Making
Feldman-Stewart D, Brundage MD, van Manen L & Svenson O. Patient-focused decision-making inearly-stage prostate cancer: Insights from a cognitively based decision aid. Health Expectations 2004;
7(2): 126-141.
Information That Patients Say They Want For Screening Decisions
Barratt A, Trevena L, Davey HM, McCaffery K. Use of decision aids to support informed choices
about screening. BMJ 2004; 329: 507-510.
Chan ECY & Sulmasy DP. What should men know about prostate-specific antigen screening before
giving informed consent? American Journal of Medicine 1998; 105, 266-274.
Pignone M, Bucholtz D, & Harris R. Patient preferences for colon cancer screening. Journal of
General Internal Medicine 1999; 14(7): 432-437.
Taylor KL, Turner RO, Davis JD, Johnson L, Schwartz MD, & Leak C. Improving knowledge of theprostate cancer screening dilemma among African American men: an academic-community
partnership in Washington, DC. Public Health Reports 2001; 116, 590-598.
Information That Patients Say They Want For Treatment Decisions
Bastian LA, McBride CM, Fish L, Lyna P, Farrell D, Lipkus IM, Rimer BK. & Siegler IC. Evaluating
participants.’ use of a hormone replacement therapy decision.–making intervention. Patient Education
and Counseling 2002; 48: 283-291.
Brink SG, Birney AJ & McFarren AE. Charting Your Course: Formative Evaluation of a Prostate
Cancer Treatment Decision. International Electronic Journal of Health Education 2000;3: 44-54.
Davison BJ, Degner LF & Morgan TR. Information and decision-making preferences of men withprostate cancer. Oncology Nursing Forum 1995;22:1401-1407.
Feldman-Stewart D, Brundage MD, Hayter C, Groome P, Nickel JC, Downes H & Mackillop WJ.
What questions do patients with curable prostate cancer want answered? Medical Decision Making
2000; 20: 7-19.

20

Providing Information About Options
Feldman-Stewart D, Brundage MD, Nickel JC & Mackillop WJ. The information required by patientswith early-stage prostate cancer in choosing their treatment. British Journal of Urology International,
2001; 87: 218-223.
Hallowell N. A qualitative study of the information needs of high-risk women undergoingprophylactic oophorectomy. Psycho-oncology, 2000;9:486-495.
Newton KM, LaCroix AZ, Leveille SG, Rutter C, Keenan NL & Anderson LA. Women's beliefs anddecisions about hormone replacement therapy. Journal of Women's Health 1997; 6: 459-465.
Rothert M, Rovner D, Holmes M, Schmitt N, Talarczyk G, Kroll J & Gogate J. Women's use of
information regarding hormone replacement therapy. Research in Nursing and Health 1990;13:355366.
Sawka CA, Goel V, Mahut CA, Taylor GA, Thiel EC, O'Connor AM, Ackerman I, Burt JH & Gort
EH. Development of a patient decision aid for choice of surgical treatment for breast cancer. Health
Expectations 1998; 1: 23-36.
Stacey D, DeGrasse C & Johnston L. Addressing the support needs of woman at high risk for breast
cancer: Evidence-based care by advanced practice nurses. Oncology Nursing Forum 2002; 29: E77E84.
Whelan T, Levine M, Gafni A, Sanders K, Willan A, Mirsky D, Schnider D, McCready D, Reid S,
Kobylecky A & Reed K. Mastectomy or lumpectomy? Helping women make informed choices.
Journal of Clinical Oncology 1999;17: 1727-1735.
Legal And Ethical Obligations
Appelbaum PS, Lidz CW & Meisel A. Informed consent: Legal theory and clinical practice. New
York: Oxford University Press, 1987.
Faden RR & Beauchamp TL. A history and theory of informed consent. New York, N.Y.: Oxford
University Press, 1986.
Higher Knowledge Test Scores With Decision Aids Compared To Usual PracticeBarry MJ, Cherkin DC, Chang YC, Fowler FJ & Skates S. A randomized trial of a multimedia shareddecision-making program for men facing a treatment decision for benign prostatic hyperplasia.
Disease Management and Clinical Outcomes 1997; 1: 5-14.
Bernstein SJ, Skarupski KA, Grayson CE, Starling MR, Bates ER & Eagle KA. A randomized
controlled trial of information-giving to patients referred for coronary angiography: effects on
outcomes of care. Health Expectations 1998; 1: 50-61.
Dunn RA, Shenouda PE, Martin DR & Schultz AJ. Videotape increases parent knowledge about
poliovirus vaccines and choices of polio vaccination schedules. Pediatrics 1998;102:e26.
Green MJ, Biesecker BB, McInerney AM, Mauger D & Fost N. An interactive computer program caneffectively educate patients about genetic testing for breast cancer susceptibility. American Journal of
Medical Genetics 2001;103:16-23.

21

Providing Information About Options
Lerman C, Biesecker B, Benkendorf JL, Kerner J, Gomez-Caminero A, Hughes C & Reed MM.
Controlled trial of pretest education approaches to enhance informed decision-making for BRCA1
Gene testing. Journal of National Cancer Institute 1997; 89: 148-157.
Man-Son-Hing M, Laupacis A, O'Connor A, Biggs J, Drake E, Yetisir E & Hart RG. A patientdecision aid regarding antithrombotic therapy for stroke prevention in atrial fibrillation : a randomized
controlled trial. Journal of the American Medical Association 1999;282: 737-743.
Morgan MW, Deber RB, Llewellyn-Thomas HA, Gladstone P, Cusimano RJ, O'Rourke K, Tomlinson
G & Detsky AS. Randomized, controlled trial of an interactive videodisk decision aid for patientwith ischemic heart disease. Journal of General Internal Medicine 2000; 15: 685-693.
Schwartz Md, Benkendorf J, Lerman C, Isaacs C, Ryan-Robertson A & Lenora J. Impact ofeducational print materials on knowledge, attitudes, and interest in BRACA1/BRACA2. Cancer
2001; 92: 932-940.
Volk RJ, Cass AR & Spann SJ. A randomized controlled trial of shared decision making for prostatecancer screening. Archives of Family Medicine 1999; 8: 333-340.
Whelan T, Sawka C, Levine M, Gafni A, Reyno L, Willan A, Julian J, Dent S, Abu-Zahra H,
Chouinard E, Tozer R, Pritchard K & Bodendorfer I. Helping patients make informed choices: A
randomized trial of a decision aid for adjuvant chemotherapy in lymph node-negative breast cancer.
Journal of the National Cancer Institute 2003; 95: 581-587.
Higher Knowledge Test Scores With Detailed Decision Aids Compared To Simpler Aids
Dodin S, Legare F, Daudelin G, Tetroe J, O.’Connor A. Prise de decision en matiered.’hormonotherapie de remplacement. Canadian Family Physician 2001;47:1586-1593.
Phelan EA, Deyo RA, Cherkin DC, Weinstein JN, Ciol MA, Kreuter W & Howe JF. Helping patientsdecide about back surgery. Spine 2001; 26: 206-212.
Rostom A, O'Connor A, Tugwell P & Wells G. A randomized trial of a computerized versus anaudiobooklet decision aids for women considering post-menopausal hormone replacement therapy.
Patient Education and Counseling 2004; 46: 67-74.
Rothert M, Rovner D, Holmes M, Schmitt N, Talarczyk G, Kroll J & Gogate J. Women's use of
information regarding hormone replacement therapy. Research in Nursing and Health 1990; 13: 355366.
Schapira MM & VanRuiswyk J. The effect of an illustrated pamphlet decision-aid on the use of
prostate cancer screening tests. Journal of Family Practice 2000; 49: 418-424.
No Difference In Knowledge Test Scores Between Detailed And Simpler Decision Aids
Goel V, Sawka C, Thiel EC, Gort EH & O'Connor AM. Randomized trial of a patient decision aid
for choice of surgical treatment for breast cancer. Medical Decision Making 2001; 21: 1-6.
Michie S, Smith D, McClennan A & Marteau TM. Patient decision making: An evaluation of two
different methods of presenting information about a screening test. British Journal of Health
Psychology 1997; 2: 317-326.

22

Providing Information About Options
O'Connor AM, Tugwell P, Wells GA, Elmslie T, Jolly E, Hollingworth G, McPherson R, Bunn H,
Graham I & Drake E. A decision aid for women considering hormone therapy after menopause:decision support framework and evaluation. Patient Education & Counseling 1997; 33: 267-279.
Street RL, Voigt B, Geyer C, Manning T & Swanson GP. Increasing patient involvement in choosing
treatment for early breast cancer. Cancer 1995; 76: 2275-2285.
Reduction In Feeling Uninformed With Decision Aids Compared To Usual Practice
Davison BJ, Krik P, Degner LF & Hassard TH. Information and patient participant in screening forprostate cancer. Patient Education and Counseling 1999; 37: 255-263.
Dolan JG & Frisina S. Randomized controlled trial of a patient decision aid for colorectal cancer
screening. Med Decis Making. 2002;22:125-139.
Man-Son-Hing M, Laupacis A, O'Connor A, Biggs J, Drake E, Yetisir E & Hart RG. A patientdecision aid regarding antithrombotic therapy for stroke prevention in atrial fibrillation : a randomized
controlled trial. Journal of the American Medical Association 1999; 282: 737-743.
Murray E, Davis H, Tai SS, Coulter A, Gray A & Haines A. Randomised controlled trial of aninteractive multimedia decision aid on benign prostatic hypertrophy in primary care. British Medical
Journal 2001a; 323: 493-496
Increased Desire For Patient Involvement In Decision Making
Davison BJ & Degner LF. Empowerment of men newly diagnosed with prostate cancer. Cancer
Nursing 1997; 20: 187-196.
Frosch DL, Kaplan RM & Felitti V. The evaluation of two methods to facilitate shared decision
making for men considering the prostate-specific antigen test. Journal of General Internal Medicine
2001; 16: 391-398.

23