International Patient Decision Aid
Standards (IPDAS) Collaboration

IPDAS Collaboration Background Document

February 17, 2005

Editors:
Annette O’Connor PhD
Hilary Llewellyn-Thomas PhD
Dawn Stacey PhD(c)Note: This collection of papers is intended to supplement the summarized
information provided in the IPDAS Collaboration Voting Document: Draft VIII,
February 1, 2005.

Table of Contents
Page
A. Using a systematic development process

3

B. Providing information about options

6

C. Presenting probabilities

11

D. Clarifying and expressing values

17

E. Using personal stories

24

F. Guiding/Coaching in deliberation and communication

28

G. Disclosing conflicts of interest

36

H. Delivering decision aids on the Internet

39

I. Balancing the presentation of options

41

J. Using plain language

45

K. Basing information on up-to-date scientific evidence50

L. Establishing the effectiveness

52

IPDAS Collaboration Background Document

2Section A: Using a systematic development process_______________________________________________________________________

Section A: Using a systematic development process
Authors
Aileen Clarke (lead)
MJ Jacobsen
Mary Ann O’Connor
Diana Stilwell
Deb Feldman-Stewart

Institute of Community Health Sciences, Queen
Mary, University of London
University of Ottawa, Ontario
Dartmouth Medical School, DartmouthCollege, New Hampshire
Foundation for Informed Medical Decision
MakingQueen’s University, Kingston

UK
CA
US
US
CA

Rationale/Theory
Patient decision aids are meant to support informed values-based decision making. They areusually developed when there is more than one reasonable option and there is considerable
variation in how patients value the features of different options. Practitioners and patients may
find it challenging to arrive at a good decision without advance preparation using a patientdecision aid that helps patients understand the options and clarify the personal value of theirdifferent features.
Patient decision aids take considerable effort to develop, and can have an important effect ondecision quality and the use of health services. Therefore, it is important that they are developed
using a systematic and replicable process.
Specific developmental steps common to many patient decision aids (O’Connor et al., 2003;
Bekker et al., 1999) include:
Assessing decisional needs. Groups with relevant perspectives and expertise areassembled and engaged in a rigorous social process to analyze:• The characteristics of the decision such as: all potentially relevant health care
options; protocols involved in each option; evidence regarding outcomes,
probabilities, and variation in patients’ values for different features of options;sensitivity of the decision to variation in values and probabilities; and othercharacteristics such as the burden of condition and costs.
• Patients’ information needs. Although, information needs vary widely from one
patient to the next, in general all patients require information that includes thenatural course of the condition, the procedures involved in the treatments or tests,
the potential consequences, their severity, and their likelihoods of occurring (e.g.
Feldman-Stewart, Brundage & Van Manen, 2004).
•

Patients’ decisional needs such as: current perceptions of options; salience ofoutcomes, probabilities, and values in decision making; the degree of difficulty
making the decision and factors contributing to that difficulty; usual and preferred

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Section A: Using a systematic development process_______________________________________________________________________
decision making roles; decisional barriers and facilitators; feasibility and local
attitudes regarding the use of patient decision aids.
Formation of groups to develop and review patient decision aids. Patient decision aid
developers usually include experts in clinical care, evidence-based decision making,patient education, and patient experience. Patient decision aid reviewers usually include
potential users such as patients who are experienced with the decision and thepractitioners who counsel them about the decision.
Drafting, reviewing, and revising. The elements included in patient decision aids (e.g.
information about the condition, options, and outcomes; values clarification; examples ofothers’ experiences with decision making; and guidance in decision making andcommunication) are described elsewhere. Through an iterative process, a patient decision
aid is drafted, reviewed, and revised until it is ready for field testing. At this stage, part of
the review may include acceptability questionnaires eliciting, for example: reviewers’
perceptions of the appropriateness and amount of information; ability to help patientsdecide what is most important to them; appropriate length; balanced presentation of
options and outcomes; ability to hold their interest; ability to help them understand thevarious patient roles in decision making; and usefulness for decision making.
Field testing is conducted with patients at the point of decision making. The objectives
focus on feasibility, acceptability to users, potential to improve knowledge, and potential
to clarify personal values regarding the features of options.
External peer review. The patient decision aid undergoes critical appraisal by those who
were not involved in its development and evaluation.
Evidence
Patients’ information needs. Of the 14 screening patient decision aids verified by the
Cochrane Review (O’Connor et al., 2003), 10 developers described how they arrived at
the content of their aids. Of these 10, 5 (50%) consulted their respective patient
populations about their information needs using interviews (with individual patients
and/or focus groups) or through surveys. Of these 5 populations, 20% wanted information
about the health condition, 83% on the “no test” option, 83% on the test procedure(s),80% on the risks of the procedures, 80% on the rates of true/false positives and oftrue/false negatives, 67% on the potential consequences of a positive test result, and 40%
on the potential consequences of a negative test result.
Of the 45 treatment patient decision aids verified by the Cochrane Review (O’Connor etal., 2003), 32 developers described how they arrived at the content of their aid. Of these32, 21 (66%) developers consulted their respective patient populations about theirinformation needs, using interviews (either with individuals and/or focus groups) or
surveys. Of these 21 populations, 96% wanted information about the health condition,
81% on the multiple options, 50% on the ‘no treatment’ option, 100% on the treatment
procedures, 100% on the potential benefits, and 100% on the potential risks of the various
treatment options.

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Section A: Using a systematic development process_______________________________________________________________________
RCT’s involving patients facing actual choices. Of the 29 individual patient decision
aids, evaluated in the 34 RCTs included in the Cochrane Review, 19 were available forreview (O’Connor et al., 2003). Of these:• 89% (17 of 19) listed the credentials of developers; and• 58% (11 of 19) reported a published or easily accessible description of thedevelopment process.
Overall, there is limited evidence about how these development processes affect decisionquality.
References
Bekker H. Thornton JG. Airey CM. Connelly JB. Hewison J. Robinson MB. Lilleyman J. MacIntosh M.
Maule AJ. Informed Decision Making an Annotated Bibliography and Systematic Review. Health Tech.
Assess. 1999;3(1):1-156.
Feldman-Stewart D, Brundage MD, Van Manen L & Svenson O. Patient-focussed decision-making inearly-stage prostate cancer: Insights from a cognitively based decision aid. Health Expectations 2004;
7(2):126-141.
O'Connor AM, Stacey D, Entwistle V, Llewellyn-Thomas H, Rovner D, Holmes-Rovner M, Tait V,
Tetroe J, Fiset V, Barry M, Jones J. Decision aids for people facing health treatment or screening decisions[Cochrane Review]. In: The Cochrane Library, 2003: Issue 2. Oxford: Update Software.

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5Section B: Providing information about options_______________________________________________________________________

Section B: Providing information about options
Authors
Deb Feldman-Stewart(lead)
Joan Austoker
Agathe Charvet
Paul Hewitson
Sara Knight
Karen Sepucha
Tim Whelan

Associate Professor, Oncology, Adjunct Professor Psychology,
Cancer Research Institute, Queen’s University, Kingston

CA

Cancer Research UK Primary Care Education Research Group,
University of Oxford
Psychologue à l'Institut de Médecine Sociale et Préventive à Genève
Cancer Research UK Primary Care Education Research Group,
University of Oxford
Assistant Adjunct Professor, University of California, San Francisco
and Research Health Science Specialist, VA Medical Centre, San
Francisco
Harvard Medical School, Boston
Director, Supportive Cancer Care Research Unit and Associate
Professor, Department of Medicine, McMaster University,
Hamilton

UK
Sw
UK
US
US
CA

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 and ethicalobligations of informed consent.
Patients’ information needs. Although information needs vary widely from one patient to
the next, in general all patients require information that includes how the untreatedcondition is expected to develop, the procedures involved in the treatment(s), the potential
benefits of the treatment(s), and the severity 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 oftrue/false positive and true/false negative results, and about the recommended follow-up
actions that could include treatment options for true positive results.
4.4.1

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 thepatient understands their condition, the procedure being recommended, its potential
benefits and harms, and what alternate procedures are available. Health professionals arealso bound by the ethical doctrine of informed consent that is founded on three principles:(1) autonomy (which obligates the professionals to ensure that the patient can act in theirown 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); andIPDAS Collaboration Background Document

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Section B: Providing information about options_______________________________________________________________________(3) justice (which obligates the professionals to treat all patients equally) (Appelbaum,
Lidz & Meisel, 1987; Faden & Beauchamp, 1986). Ensuring that patients understand theircondition, all medically reasonable options, and the potential outcomes of each option is
intrinsic to all of these principles.
Evidence
Inventory of available patient decision aids. Information about options was assessed inpatient 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 of patient decision aids on
knowledge. Nine of these compared a patient decision aid to usual care, and ninecompared 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 groupcompared to those of the usual care group. Of the 9 that compared more detailed patientdecision aids to simpler 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 detect a 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 patientdecision aid in all six RCTs (100%) had a statistically significant reduction (ranging frommean of 5 to 16 points out of 100) in feeling uninformed about options, benefits, andharms. Four RCTs compared a more detailed patient decision aid to a simpler version. Of
the four, three (75%) showed a reduction in feeling uninformed (from 3 to 5 points out of100), that was not statistically reliable due to insufficient power.
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.

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Section B: Providing information about options_______________________________________________________________________
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.
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.

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Section B: Providing information about options_______________________________________________________________________
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 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.
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.
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.

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Section B: Providing information about options_______________________________________________________________________
Rostom A, O'Connor A, Tugwell P & Wells G. A randomized trial of a computerized versus an audiobooklet 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.
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.

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Section C: Presenting probabilities_______________________________________________________________________

Section C: Presenting probabilities
Authors
Alex Barratt

University of Sydney, School of Public HealthAU

Adrian Edwards

University of Wales, College of Medicine, Swansea

UK

Lyndal Trevena

University of Sydney, School of Public Health

AU

Kirsten McCaffery

University of Sydney, School of Public Health

AU

Steve Woloshin

Dartmouth Medical School, Dartmouth Collage, New HampshireUSA

Hilary Bekker

Behavioural Sciences, University of Leeds

UK

Danielle Timmermans

Department of Social Medicine, Vrije Universiteit, Amsterdam

NL

Agathe Charvet

Research Psychologist, Geneva University Hospitals

Switz

Rationale/Theory
A key objective of patient decision aids is to provide information to help patients understand thepossible benefits and harms of their choice, and the chances that these will occur. Since nointervention is 100% effective in all patients without harms (including side-effects), probabilities
must be presented in patient decision aids. However, presenting risk information (probabilities) is
problematic because most individuals -- including patients and professionals -- have difficulty inprocessing and accurately evaluating probabilities and statistics. The evidence suggests that
individuals would rather use a heuristic such as someone else's evaluation of the risks than attend
to the figures in order to make a decision. Some strategies for effectively communicating
probabilities in health have been proposed (see, for example, Schwartz, 1999), but few have beentested empirically in patient decision aids. Therefore, recommendations in this document arelargely made on theoretical grounds, borrowing heavily from work in clinical epidemiology andevidence based health care, psychology (prospect theory, Tversky & Kahneman, 1974;1981), risk
communication and risk perception research (Loewenstein et al., 2001; Slovic et al., 2002), anddecision theory (theory of expected utility, Neumann & Morganstern).
Presenting numbers. Although many patients prefer to read words rather than numbers,
numerical probabilities improve the accuracy of understanding. Event rates (natural
frequencies) are the recommended way to present these probabilities. Event rates for all
relevant options and for each relevant outcome should be given, and appropriate timeframes and denominators should be provided. For example, a patient decision aid on
stroke prevention in atrial fibrillation should give the number out of 100 men who will
have a stroke over 10 years if they take warfarin, the number out of 100 men who will
have a stroke over 10 years if they take aspirin, and the number out of 100 men who will
have a stroke over 10 years if they take no treatment. For situations in which risks are
small, such as screening and other preventive interventions, denominators of 1000 or
10,000 may be needed.

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Section C: Presenting probabilities_______________________________________________________________________
Events rates are intuitively interpretable because they are natural frequencies with clearlystated reference classes. Some patient decision aids use other presentation formats
including relative risk reduction, absolute risk reduction, number needed to screen, or
number needed to treat. These may help when patients have to compare many options,because they allow summarization of data but they are less likely to be well understood.
Furthermore, none of these formats (relative risk reduction, absolute risk reduction,
number needed to screen, or number needed to treat) make the baseline risk of disease as
explicit as simply presenting event rates for all intervention options being compared.
Constant denominators (e.g. 1 in 100, 5 in 100) rather than constant numerators (e.g., 1 in
100, 1 in 20) are more readily understood (Woloshin et al., 2000). For information to bemeaningful, it is important to present the timeframe over which events occur, and to use atimeframe that patients find useful for planning health management -- for example,“Imagine 1000 patients. Over the next 10 years, 150 of them will die of …”. Although
lifetime risk is often used, 10 year time frames are often more appropriate (Woloshin etal., 2002).
Visual aids. Presenting event rates with visual aids such as 100 faces diagrams, bar charts,
human figure representations, or flow diagrams may aid accurate understanding ofprobabilities. By using more than one presentation format, patients are able to choose theformat that works best for them. As well, analogies may be especially useful forpresenting small risks – e.g. one person in a football stadium crowd, etc (Edwards, 2003).
Any visual aids to be used should be pilot tested for understanding, and developers shouldtake care to avoid using misleading images (such as graphs with misleading scales) or
using different scales within the same patient decision aid. There is evidence that theformats which are perceived most accurately and easily by patients are vertical bars,
horizontal bars and systematic ovals. Pie charts and random ovals lead to slower and lessaccurate estimates (Feldman-Stewart et al., 2000).
Probabilities for tests and screening decisions. The mortality benefit from screening
should be presented as the probability of death with and without screening; e.g. theprobability of dying of breast cancer in 1000 women who regularly participate inscreening and in 1000 women who decline screening. It is very important that the survival
times are NOT used as these are likely to be affected by lead time bias (Barratt et al.,
1999; Welch et al., 2000).
Patient decision aids for screening should also present the probability of having the target
condition detected with and without screening, because many cancer screening programs
lead to over-detection of disease. Disease aids should therefore alert readers to thepossibility of screening leading to detection and treatment of disease that might never
have caused symptoms had it not been for screening. For example, the chance of having
breast cancer or prostate cancer diagnosed is substantially higher in screened compared to
unscreened populations because some or many of these cancers would never have become
symptomatic (and therefore diagnosed) in the absence of screening.

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Section C: Presenting probabilities_______________________________________________________________________
Patient decision aids about tests or screening programs also need to present information
about the chances of receiving a false positive (false alarm) or false negative result.
Although these data have traditionally been presented as specificity and sensitivity, these
are not readily understood. Such conditional probabilities should be avoided and natural
frequencies (event rates) used instead. For example, “over 10 mammography screening
rounds, 160 out of 1000 women participating in screening will experience a false positive
result” is more readily interpreted than the specificity (the proportion of patients who test
positive among those who do not have disease) of mammography screening.
Screening may lead to a cascade of events (including follow-up tests and treatments), andthe probability of each of these events occurring should also be presented.
Tailoring probabilities. Whenever possible, individualised risks should be used. Although
there is little evidence specifically examining the degree to which individualised risk
information facilitates patients’ understanding and decisions, it is likely that personally
relevant risks will be evaluated more accurately in accord with a patients' values than lessrelevant risk information. For example, individualized risk estimates (using tables,
computerized algorithms, or risk estimates for groups of patients) depending on importantrisk factors such as age, gender, family history, smoking status might be used. As aminimum, it should be clear to the user of the patient decision aid whether the
probabilities apply to them based on their gender, age, medical history, or other risk
factors.
Framing probabilities. The way information is framed can affect preferences anddecision making (Edwards et al., 2001; Tversky et al., 1981). Thus, patient decision aid
developers should be aware of potential framing effects. Framing effects are minimized if
visual aids such as 100--faces diagrams are used, because they show the number ofpatients experiencing the outcome and the number of patients not experiencing theoutcome for each option being considered all at once. Simply giving the percentage (x %)of patients who experience an event (e.g., death) does not achieve this as clearly, because
the reader has to do mental arithmetic (100-x) to calculate the percentage who do notexperience it (e.g., survive). Event rates presenting both positive and negative frames canbe used, but may lead to information overload. An alternative is for writers to
acknowledge explicitly the frame used and encourage patients to reformat the information
for themselves.
Formats such as relative risk reduction, absolute risk reduction, and numbers need to treat
can be misleading, because they do not make explicit the baseline risk of the target
condition. For example, a 50% reduction in risk sounds very impressive, but it might referto a treatment that reduces the risk of death from 40 out of 100 to 20 out of 100 OR to atreatment that reduces the risk of death from 4 out 10,000 to 2 out of 10,000. Relative risk
reduction generally is more impressive -- and potentially misleading -- than absolute risk
reduction, particularly for rare events.
Probabilities in context. Disease-specific probabilities (or the benefits of various diseasespecific interventions) are hard to understand in isolation. Therefore, patient decision aids

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Section C: Presenting probabilities_______________________________________________________________________
need to help patients put disease- (or intervention-) specific information into context. One
way is to provide estimates of the 10-year chance of developing or dying from various
diseases (or dying from any causes) for men/women, smokers/non-smokers at various
ages. Other anchors, such as commonly and not so commonly occurring events, have beenused.
Conveying uncertainty. It’s very important to acknowledge uncertainty in probability
estimates. Often the uncertainty is large, especially if evidence is scarce or events are rare.
It’s probably wise to do simple things such as rounding off numbers (to avoid false
illusions of precision), using phrases like "our best guess is...”, give ranges, or provide
95% confidence intervals.
Even with the best evidence from large studies (thus with high accuracy and precision),
the issue of stochastic uncertainty remains (Edwards, Elwyn, Mulley, 2002). Essentially,
we never quite know who are the patients who are going to be affected, and who thetreatment is going to be most useful for. One way to deal with this uncertainty might be tosay: "If 100 patients like you are given no treatment for five years, 92 will live and eight
will die. Whether you are one of the 92 or one of the eight, I do not know. Then, if 100
patients like you take a certain drug every day for five years, 95 will live and five will die.
Again, I do not know whether you are one of the 95 or one of the five." (Skolbekken,
1998)
Despite these limitations from uncertainty, practitioners generally feel that we can still try
to make decisions about what the best treatment plan is for an individual person, based onwhat happens to these groups of patients in the studies. Hence the value, it is thought, ofpresenting the information about benefits and harms to aid the decision making process.
Both sources of uncertainty should be acknowledged in comprehensive discussions ofrisks in patient decision aids.
Evidence for probabilities used. To enhance transparency and allow patients andpractitioners to see for themselves where the probabilities come from, a technicalappendix or something similar should be provided. This can outline the data sources, thepopulations from which the probabilities were obtained, and any calculations or modelingthat was done to derive the probabilities in the patient decision aid. Developers may want
to include a decision analyst or other experienced modeler on their team to help obtain
useful probability estimates. In some instances, developers may use decision analysis to
structure the patient decision aid. In such cases, if the probabilities used in the decision
analysis are presented, they should be presented in accordance with these criteria.
Evidence
RCTs involving patients facing actual choices. Of 29 individual patient decision aids
evaluated in the 34 RCTs included in the Cochrane Review, 19 were available for content
review (O’Connor et al., 2003). Of these, 19, 17 (89%) patient decision aids containedsome sort of information about outcome probabilities. There were some differences in theway this information was provided:
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Section C: Presenting probabilities_______________________________________________________________________
•
•
•
•
•

11 of 19 (58%) patient decision aids provided numerical data with outcomes reported
as “x out of 100” and/or percentages (with consistent denominator of 100).
5 of 19 (26%) patient decision aids provided numerical data with outcomes reported as“x out of y” (denominators were not necessarily consistent).
4 of 19 (21%) patient decision aids provided graphical display of the data using pie
charts, bar charts, or line graphs.
3 of 19 (16%) patient decision aids provided graphical display of the data using 100
faces diagram.
1 of 19 (5%) patient decision aids provided numerical data using a tabular format.

The Cochrane Review identified 7 randomized controlled trials that evaluated the effect ofpatient decision aids on patients’ perceived probabilities of outcomes: 4 of thesecompared a patient decision aid to usual care and 3 compared a simpler to a more detailed
patient decision aid (O’Connor et al., 2003). Perceived outcome probabilities wereclassified according to the percentage of individuals whose judgments corresponded to thescientific evidence about the chances of an outcome for similar patients.
All 7 studies (100%) showed a trend toward more realistic expectations in patients who
received a detailed patient decision aid (i.e., included descriptions of outcomes andprobabilities) compared to those who did not receive patient decision aids with thisinformation included. However, only 6 of the studies had the power to detect astatistically significant difference (RR ranged from 1.3 to 2.3).
References
Barratt AL, Irwig L, Glasziou P, Cumming R, Raffle A, Hicks N, Gray JAM, Guyatt GH. Users’ guides to the
medical literature. XVII How to use guidelines and recommendations about screening. JAMA 1999; 281:2029-2034.
Edwards A, Elwyn G, Covey J, Matthews E, Pill R. Presenting risk information- a review of the effects of“Framing”and other manipulations on patient outcomes J Health Communication 2001 6 61-82.
Edwards, A., G. Elwyn, and A.G. Mulley, Explaining risks: turning numerical data into meaningful
pictures. British Medical Journal, 2002. 324: p. 827-830.
Edwards A: Communicating risks through analogies [letter]. British Medical Journal 2003, 327:749
Feldman-Stewart D, Kocovski N, McConnell BA, Brundage MD, Mackillop WJ. Perception ofquantitative information for treatment decisions. Medical Decision Making 2000;20:228-238.
Gigerenzer G, Edwards A. Simple tools for understanding risks: from innumeracy to insight. BMJ
2003;327:741-4.
Huff D. How to lie with statistics. WW Norton & Co. New York: Reissued 1993.
Loewenstein G, Weber EU, Hsee CK, Wech N. Risk as feelings. Psychological Bulletin 2001;127:267286.
O'Connor, A.M., Stacey, D., Entwistle, V., Llewellyn-Thomas, H., Rovner, D., Holmes-Rovner, M., Tait,
V., Tetroe, J., Fiset, V., Barry, M., Jones, J. Decision aids for people facing health treatment or screening
decisions [Cochrane Review]. In: The Cochrane Library, 2003: Issue 2. Oxford: Update Software.

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Section C: Presenting probabilities_______________________________________________________________________
Skolbekkan JA. Communicating the risk reduction achieved by cholesterol reducing drugs. BMJ
1998;316:1956-1958.
Slovic P, Finucane M, Peters E, MacGregor DG. The affect heuristic. In T. Gilovich, D Griffin & D
Kahneman (Eds). Heuristics and biases (pp. 397-420). New York: Cambridge University Press, 2002.
Schwartz LM. Woloshin S. Welch HG. Risk communication in clinical practice: putting cancer in context.
Journal of the National Cancer Institute Monographs 1999; (25):124-133.
Tversky A, Kahneman D. Judgement under uncertainty: heuristics and biases. Science 1974; 185:11241131.
Tversky A. Kahneman D. The framing of decisions and the psychology of choice. Science.
211(4481):453-8, 1981 Jan 30.
Users Guides to the Medical Literature A manual for evidence based practice. Jaeschke R, Guyatt G,
Barratt A et al. Therapy and understanding the results. Measures of association (pp. 351-368). American
Medical Association 2002.
Von Neumann J, Morgenstern O. Theory of games and economic behaviour. Princeton: Princeton
University Press, 1947.
Welch HG, Schwartz LM, Woloshin S. Are increasing 5-year survival rates evidence of success against
cancer? JAMA 2000;283:2975-2978.
Woloshin S, Schwartz LM, Byram S, Fischhoff B, Welch HG. A new scale for assessing perceptions ofchance: a validation study. Medical Decision Making 2000;20: 298-307.
Woloshin S, Schwartz LM, Welch HG. Risk charts: putting cancer in context. Journal National Cancer
Institute 2002;94: 799-804.

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Section D: Clarifying and expressing values_______________________________________________________________________

Section D: Clarifying and Expressing Values
Authors
Annette O’Connor (co-lead)

University of Ottawa

CA

Hilary Llewellyn-Thomas (co-lead)

Dartmouth Medical School, Dartmouth College,
New Hampshire

James Dolan, M.D.

Unity Health System

US

Miriam Kupperman

University of California at San Fran.

US

Celia Wills

Michigan State University, East Lansing

US

CA/US

Rationale/ Theory
A key objective of patient decision aids is to help patients to clarify and communicate the personalvalue of options, in order to improve the match between what is personally most desirable and which
option is actually selected. Several mechanisms explain how patient decision aids may accomplish thisgoal.
Most patient decision aids describe the options and outcomes in sufficient detail for decision making(O’Connor et al., 2003). This helps patients understand what it is like to undergo the procedures
involved and to face the physical, emotional, and social consequences. Fishhoff and colleagues (1980)
found that patients are better able to judge the value of consequences when they are familiar, simple,
and directly experienced. Providing detailed descriptions of experiences makes the features of an
option more vivid for individuals.
Some patient decision aids use balanced examples of how others value the features of each option, inorder to illustrate how different values may lead to different choices. Patients may be able to sort
through their personal values by considering which examples most closely match their own and which
do not.
Some patient decision aids explicitly measure values. They guide patients to rate or trade-off
different features of options. This engaging process may increase awareness of personal values andprovide insight into the trade-offs that need to be made in choosing one option over another.
Some patient decision aids not only encourage patients to clarify their values, but also to share themwith others involved in the decision. Strategies may range from recording values, guiding/coaching
patients in values communication, training practitioners in values communication, or sending recorded
values to providers. Strategies that facilitate communication may increase the chances that they are
discussed in counselling sessions and that patients receive the most valued option (Dodin et al., 2001;
Guimond et al., 2003; Holmes-Rovner et al., 1999; O’Connor et al., 1999; Rothert et al., 1997).

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Section D: Clarifying and expressing values_______________________________________________________________________
Evidence
RCTs Involving Patients Facing Actual Choices (O’Connor, et al., 2003). Data were obtained
from the Cochrane Systematic Review of patient decision aids in which 29 different patientdecision aids were evaluated in 34 trials. Of these 19, 11 measured the match between personalvalues and choices (n = 3), and self-reports about feeling clear about the personal importanceof benefits versus harms (n = 10). One trial explored the effects on practitioner’s discussion ofvalues.
Ways to clarify values. The most frequently used values clarification techniques in patientdecision aids are:Describing features: 100% (19 of 19) patient decision aids described the features of options
and their outcomes. However, there was considerable variability in the level of detail about
what it is like to undergo the procedures and to live with the physical, emotional, and social
consequences. Some used detailed scenarios or testimonials; others briefly described key
features.
Examples of others’ values: 72% (13 of 18) provided examples of how other patients’ values
led them to make different choices;
Measuring values of features: 42% (8 of 19) explicitly guided patients to rate or trade-off
different features of options using: personal balance scales (4 of 8); non-directive counsellingwith standardized questions (2 of 8); relevance charts (1 of 8); and the analytic hierarchy
process (1 of 8).
Communicating values: 47% (9 of 19) of patient decision aids used strategies to facilitate
the communication of values, such as personal worksheets (5 of 9); and personal coachingor encouragement to communicate values (4 of 9).
Primary endpoints:
Match between values and choices: 3 randomized trials (Dodin et al., 2001; O’Connor, Wells
et al., 1999; Rothert et al., 1997), all focused on menopause hormone decisions, evaluated theeffects of a basic method of clarifying values in a DA (feature description) compared to DAs
with multiple methods (feature description + examples; feature description + examples +rating, feature description +examples + rating + guidance in communicating values). All threestudies measured the match between values and choices differently.
Are more values clarification methods better than the single method of feature description?
All three trials found that more methods are usually better than a single method. When the
single method of describing experience with options was brief, there was an overall benefit ofadding one other method (examples) or several other methods (examples, rating values,
guidance in communicating values). However, when the single method of describing
consequences was a detailed description of physical, emotional, and social consequences, thebenefit was large but of borderline statistical significance (p = 0.06), and was confined only tothose who were considering changing from not taking hormones to taking them. In those who
were not on hormones and would remain that way, there was no added benefit from having
more than one method.
Feeling clear about personal values. Ten trials used a subscale of the Decisional Conflict
Scale (O’Connor, 1995) to measure the extent to which patients feel clear about personal
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Section D: Clarifying and expressing values_______________________________________________________________________
values (Davison et al., 1999; Dodin et al., 2001; Dolan et al., 2002; Goel et al., 2001;
Man-Son Hing et al., 1999; Morgan, 1997; Murray et al., 2001a; 2001b, O’Connor et al.,
1998; O’Connor et al., 1999). Scores that combine 3 items (e.g., “I am clear about thepersonal importance of positive versus negative features of the options”) in the subscale
can range from 0 (“strongly agree”) to 100 (“strongly disagree”).
Are values clarification methods better than usual practices? 6 trials compared patientdecision aids with one or more values clarification methods to usual practices (Davison etal., 1999; Dolan et al., 2002; Man-Son Hing et al., 1999; Morgan et al., 1997; Murray etal., 2001a; 2001b). In 3 of these 6 trials, there were statistically significant differences infavour of patient decision aids. The overall improvement, combining results from all 6
trials, was statistically significant (the weighted average difference in favour of patientdecision aids was 5.48 points out of 100; we are confident that if this study were repeatedseveral times, 95% of the time the improvement would fall between 1.44 and 9.53 points).
The importance of this small improvement in scores needs to be evaluated further.
Are more methods or more detailed methods better than fewer or less detailed methods?
Of the 4 trials making this comparison (O’Connor et al., 1999; Dodin et al., 2001; Goel etal., 2001), 3 showed no significant differences and 1 showed differences in favour of moremethods (O’Connor et al., 1998). When the results of all 4 trials were combined, theoverall improvement was not statistically significant. The one trial that did show
improvement (7.5 points out of 100) had feature descriptions that were very brief. In three
trials whose basic feature descriptions were more detailed, there was no significant
improvement.
Communication of values in discussions with others. One trial (Guimond et al., 2003) involved
tape recording the dialogue between patients and doctors after patients were either prepared
with: 1) a patient decision aid with brief information about consequences (n = 18); or 2) apatient decision aid with detailed information about consequences, examples of others’ values,
rating of values, and guidance in recording and communicating values (n = 16). The groupprepared using the simpler patient decision aid had less discussion of values (median = 16)
than did the group prepared using the more detailed patient decision aid with a written recordof values (n = 22), but the difference was not statistically significant from 0 (p=0.10).
References
Davison BJ, Kirk P, Degner LF, Hassard, TH. Information and patient participation in screening forprostate cancer. Patient Educ Counsel. 1999;37:255-263.
Dodin S, Legare F, Daudelin G, Tetroe J, O’Connor A. Prise de decision en matiere d’hormonotherapie deremplacement. Can Fam Physician. 2001;47:1586-1593.
Dolan JG, Frisina S. Randomized controlled trial of a patient decision aid for colorectal cancer screening.
Med Decis Making. 2002;22:125-139.
Fischhoff, B, Slovic P, Lichtenstein S. Knowing what you want: measuring labile values. In Wallsten TS(ed.), Cognitive processes in choice and decision behavior. Hillsdale, New Jersey: Lawrence Erlbaum
Associates, 1980.
Goel V, Sawka CA, Thiel EC, Gort EH, O'Connor AM. Randomized trial of a patient decision aid for
choice of surgical treatment for breast cancer. Med Decis Making. 2001;21:1-6.

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Section D: Clarifying and expressing values_______________________________________________________________________
Guimond P, Bunn H, O’Connor A, Jacobsen MJ, Tait V, Drake E, Graham I, Stacey D, Elmslie T.
Validation of a tool to assess health practitioners’ decision support and communication skills. Patient
Education and Counseling 2004;50(3):235-245.
Holmes-Rovner M, Kroll J, Rovner D, et al. Patient decision support intervention: Increased consistency
with decision analytic models. Medical Care, 1999; 37:270-284.
Man-Son-Hing M, Laupacis A, O’Connor AM, et al. A patient decision aid regarding antithrombotic
therapy for stroke prevention in atrial fibrillation: a randomized controlled trial. JAMA 1999; 282:737-43.
Morgan MW. A randomized trial of the ischemic heart disease shared decision making program: anevaluation of a decision aid [Master’s Thesis]. Toronto, ON: University of Toronto, 1997.
Morgan MW, Deber RB, Llewellyn-Thomas HA, et al. Randomized, controlled trial of an interactive
videodisc decision aid for patients with ischemic heart disease. J Gen Intern Med 2000;15:685-699.
Murray E, Davis H, Tai SS, Coulter A, Gray A, Haines A. Randomized controlled trial of an interactive
multimedia decision aid on benign prostatic hypertrophy in primary care. BMJ. 2001a; 323:493-496.
Murray E, Davis H, Tai SS, Coulter A, Gray A, Haines A. Randomized controlled trial of an interactive
multimedia decision aid on hormone replacement therapy in primary care. BMJ. 2001b; 323:490-493.
O’Connor AM. Validation of a decisional conflict scale. Med Dec Making. 1995;15:25-30.
O'Connor AM, Stacey D, Entwistle V, Llewellyn-Thomas H, Rovner D, Holmes-Rovner M, Tait V,
Tetroe J, Fiset V, Barry M, Jones J. Decision aids for people facing health treatment or screening decisions(Cochrane Review). In: The Cochrane Library, Issue 2 2003. Oxford: Update Software.
http://www.cochrane.org/cochrane/revabstr/ab001431.htm
O'Connor AM, Tugwell P, Wells GA, et al. Randomized trial of a portable, self-administered decision aid
for postmenopausal women considering long-term preventive hormone therapy. Med Decis Making.
1998;18:295-303.
O'Connor AM, Wells G, Tugwell P, Laupacis A, Elmslie T, & Drake E. The value of an explicit values
clarification exercise in a women's decision aid regarding postmenopausal hormone therapy. Health
Expectations 1999; 2:21-32.
Rothert ML, Holmes-Rovner M, Rovner D, et al. An educational intervention as decision support formenopausal women. Res Nursing Health. 1997;20:377-387.

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Section D: Clarifying and expressing values_______________________________________________________________________
Appendix: Technical Descriptions
Values Clarification: Detailed Concepts:
Overall value attributed to options: A holistic judgment of the relative desirability /undesirability that an individual assigns to an option.
Values attributed to specific features of options: The relative desirability/undesirability that anindividual assigns to an option’s specific elements, including: i) the procedure/process involved;ii) the consequences or outcomes; and iii) the probabilities of the consequences.
Value of Procedure/Process: The relative desirability / undesirability that an individualassigns to the procedures, mode of delivery, timing, and/or duration involved in undergoinga particular option.
Value of Consequences/Outcomes: The relative desirability / undesirability that anindividual assigns to the expected physical, emotional, and social effects of an option.
Value of Probabilities: The relative desirability / undesirability that an individual assigns tothe chances of experiencing a particular physical, emotional, or social outcome if a particular
option is chosen.
Evaluative scores can be elicited to indicate the strength of desirability / undesirability assigned
to an option or its attributes.
Values Clarification Methods: Specific Types
Implicit Methods: Non-interactive. Balanced illustrative examples of what it is like toexperience specific features of an option, including the procedures involved, the consequences(e.g., physical, emotional, and social functioning), or the probabilistic uncertainties. Underlying
assumption is that these examples allow viewers to formulate personal value judgments.
Viewers’ values are not revealed as collectible data points.
Descriptive “Scenarios” Illustrative examples provided in text form. E.g. patientdecision aid audio-guided booklets produced by the Ottawa group or decision boards
provided by the McMaster group (e.g. O’Connor et al., 1998; Whelan et al., 2004).
“Patient Testimonials” Illustrative examples provided in video form. E.g. patientdecision aid videos produced by the Foundation for Informed Medical Decision
Making (e.g. Barry et al., 1997).
Explicit Methods: Interactive. After considering the relevant information about each option, theviewer engages in judgment tasks deliberately designed to reveal the viewer’s overall
evaluations and/or attribute evaluations as collectible data points.
Utility assessments: Relies on axioms of rationality. A person’s values for outcomesare elicited [using standard gamble (yields SG utilities), time tradeoff (yields TTO
utilities), or visual analogue scales (yields VAS scores)] (Kupperman et al., 2003).
Social Matching: Like implicit Patient Testimonials, but: a) illustrative examples
show how other patients evaluate options’ protocols, consequences, and probabilities,
as well as how other patients use evaluations to arrive at choice; and b) viewer thenasked to explicitly indicate which person’s evaluations most closely match their own.

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Section D: Clarifying and expressing values_______________________________________________________________________
Balancing Techniques: Simplest form involves evaluating whether or not to selectoption ‘A’. Steps:a) Standard features of option ‘A’ are visually displayed on a “weighing scale”
in which the ‘benefits/pros/advantages/reasons to choose Option A’ are listedon the left, and the ‘harms/cons/disadvantages/reasons to forgo Option A’ arelisted on the right.
b) Person reviews standard features and adds others that are important in theirsituation.
c) Person rates desirability / undesirability of each feature by shading or
assigning stars (0 stars = not at all important to me; 5 stars = very important tome).
d) Person makes an overall value judgment using a “leaning scale” anchored by‘Yes A’ and ‘No A’, with ‘unsure’ situated in the middle.
More complex forms involve evaluating option ‘A’ relative to other option(s) B, C,
etc. E.g. patient decision aid audio-guided workbooks produced and evaluated by the
Ottawa group (e.g. O’Connor et al., 1998).
Threshold Techniques: Simplest form involves evaluating whether to choose option‘A’ or option ‘B’. Steps:a) Standard features of both options (their procedures, consequences,chances) are visually displayed in parallel columns.
b) After considering this information, the viewer indicates initially preferred
option.
c) Then relative strength of preference for initially preferred option is gauged
by hypothetically altering the level of one of the features (e.g., probability ofa positive or a negative outcome) in either the preferred or the rejected option,
until viewer gives up initially preferred option and switches to other option.
E.g. patient decision aids evaluated by Llewellyn-Thomas (1996; 1997).
Analytic Hierarchy Process: Steps:a) Begins with explicit definitions of the decision goal, the alternative
options, and the criteria used to compare the options’ abilities to meet thegoal.
b) These elements then organized into hierarchical decision model with thegoal at top, alternatives at bottom, and criteria in middle.
c) Elements on each level then compared relative to the element(s) on next
higher level to derive ratio-level scale: for criteria, ratio-level scale indicates
their importance relative to the decision goal; for options, ratio-level scale
indicates how well they can be expected to meet the criteria.
d) Finally, the information about the relationships among the elements oneach horizontal level of the hierarchy is combined vertically to determine therelative abilities of the alternative options to meet the decision goal.
E.g. patient decision aids produced and evaluated by Dolan (1995).

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Section D: Clarifying and expressing values_______________________________________________________________________
Appendix References
Barry MJ, Cherkin DC, Chang Y, Fowler F, Skates S. A randomized trial of a multi-media shareddecision-making program for men facing a treatment decision for benign prostatic hyperplasia. Dis
Manage Clin Outcomes.1997;1:5-14.
Dodin S, Legare F, Daudelin G, Tetroe J, O’Connor A. Prise de decision en matiere d’hormonotherapie deremplacement. Can Fam Physician. 2001;47:1586-1593.
Dolan, JG et al., The analytic hierarchy process in medical decision making: a tutorial. Medical decision
making, 1989; 9 :40-50.
Dolan, JG Are patients capable of using the analytic hierarchy process and willing to use it to help makeclinical decisions? Med Decis Making 1995; 15:76-80.
Dolan JG, Frisina S. Randomized controlled trial of a patient decision aid for colorectal cancer screening.
Med Decis Making. 2002;22:125-139.
Holmes-Rovner M, Kroll J, Rovner D, et al. Patient decision support intervention: increased consistency
with decision analytic models. Med Care. 1999;37:270-284.
Kupperman, M. Prenatal testing decision aid. Paper presented at the annual meeting of Shared Medical
Decision Making, 2003.
Llewellyn-Thomas, HA. Investigating patients’ preferences for different treatment options. Can J nsg
Research, 1997; 29:45-64.
Llewellyn-Thomas, HA et al., Benign prostatic hyperplasia: using a trade-off technique to assess patients’treatment preferences. Med Decision Making. 1996; 16:162-72.
Kennedy ADM, Sculpher MJ, Coulter A, et al. Effects of decision aids for menorrhagia on treatment
choices, health outcomes, and costs. A randomized controlled trial. JAMA. 2002;288:2701-2708.
Michie S, Smith D, McClennan A, Marteau TM. Patient decision making: an evaluation of two different
methods of presenting information about a screening test. Br J Health Psychol. 1997;2:317-326.
O'Connor AM, Tugwell P, Wells GA, et al. Randomized trial of a portable, self-administered decision aid
for postmenopausal women considering long-term preventive hormone therapy. Med Decis Making.
1998;18:295-303.
Ottawa Group: www.ohri.ca/decisionaid
Rothert M, Talarcyzk GJ. Patient compliance and the decision making process of clinicians and patients.
J Compliance Health Care. 1987;2:55-71.
Whelan T, Levine M, Willan A, Gafni A, Sanders K, Mirsky D, Chambers S, O’Brien MA, Reid S,
Dubois S. Effect of a decision aid on knowledge and treatment decision making for breast cancer surgery.
JAMA 2004; 292(4): 435-441.

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Section E: Using personal stories__________________________________________________________________

Section E: Using personal stories
Authors
Phyllis Butow (lead)

Medical Psychology Research Unit, University of Sydney

AU

Jack Fowler

Foundation for Informed Medical Decision Making, Boston, MA

US

Sue Ziebland

University of Oxford Division of Public Health and Primary Health Care

UK

Rationale/Theory
Examples of others’ experiences with decision making are used for four main reasons:• to provide factual information to help patients understand the options and their associatedoutcomes;• to demonstrate how patients value decisions differently;• to share a range of opinions; and• to exemplify the steps others have used to make decisions.
Traditionally, it has been argued that, to achieve informed consent, patients need evidence-based
information about outcomes associated with all of the options and an opportunity to weigh up theseoutcomes in the context of their own values and lives. This approach assumes that information aboutoutcomes is meaningful to patients. However, patients who are unfamiliar with a health state may find
it difficult to imagine that health state, and the extent that it may affect their lives. An important part ofprocessing evidence-based information is developing a vivid and authentic picture of the health states
under consideration. A primary method that patients use to develop such a picture is to read about orlisten to the stories of others who have experienced that state.
Most patients find such stories easier to process and recall than statistics. For example, facts andfigures -- such as the mean number of times side-effects occur and the average intensity or severity ofthese side-effects -- are harder for many patients to understand than the stories of patients who haveexperienced these side-effects. The stories of patients who have actually experienced a health state areseen as having a level of authenticity that health professionals who have never experienced that healthstate cannot provide, even if they have particular expertise in that health state. For example, womenwith breast cancer suggested that the severity of lymphoedema was under-represented for many years
by health professionals, who did not measure it correctly, or follow-up women for long enough toperceive the true prevalence of lymphoedema-related distress.
Furthermore, provision of balanced examples of how and why other patients have chosen certain
options is seen as important for effective decision-making. It allows patients to learn not only what
others choose, but also the reasoning or values behind these choices, with the different cases
reinforcing the notion that decision-making is variable. As well, stories can exemplify the steps orprocess others have used in making the decisions. Whether or not stories are provided in patientdecision aids, patients are likely to seek individuals who have experienced the decision
Although we know very little about the role of patient stories in patient decision aids compared to themany other sources of patient experiences’ available, the inclusion of these stories in patient decision
aids appears to be widely supported. However, a number of concerns about the inclusion of patient
stories have been expressed. These include:Section E: Using personal stories_____________________________________________________________________

•
•

•

•
•
•

The stories of a few individuals can never represent the experience of the majority, and yet these
may over-ride consideration of more representative facts and figures.
The selection of patient stories may provide a biased view. For example, only patients who are
articulate, have strong motivations to tell their story, and speak the same language may be included.
As well, even a “balanced” presentation of views can potentially give false impressions that there isan equal split in opinion about treatment, when in fact 90% of patients recommend or accept aparticular option.
Patients who have chosen a particular option are committed to supporting that option, for fear ofregret. This has been called “cognitive dissonance” (i.e. the description of negative experiences
arising from an option would be in conflict with the patients’ desire to believe that they had chosen
the best option). Thus, the accounts of any patients who have already chosen a treatment option arelikely to be biased.
Long-term experiences when the disease is life-threatening can only be provided by patients who
survived; by default, the experiences of those who benefited less are not available because thesepatients are no longer alive.
Some patients’ stories may be elicited by unethical means. For example, drug companies may pay
patients to provide a positive description of the outcomes of certain treatment options.
There is often a mismatch between the rigor involved in the collection and presentation ofevidence-based information about the effects of treatments, and limiting “patient stories’” to a very
few accounts from patients who are available, photogenic, or sufficiently literate to share theirexperiences.

Finally, appropriate, rigorous methods exist for researching and selecting patients’ experiences withhealth and illness (e.g. Popay, Rogers, & Williams, 1998) to ensure that the stories are evidence-based,cover the full range of experiences, disclose the context in which the decision was made, minimize thepotential limitations of using patient stories, and maximize their value. With attention to the rigorous
methods used to select patient stories, patients should find a perspective akin to their own that canfacilitate rather than impede high quality decision making.
Evidence
Patients’ decision making needs. A cross-sectional telephone survey of 635 Canadians was
conducted to describe decision-making needs of patients when faced with complex healthdecisions characterized by the need to balance benefits versus risks of various options(O’Connor, Drake et al., 2003). Over half of the participants reported obtaining support andinformation about what others decided. Of these, most cited their personal doctor (32%), friends(29%), other patients (27%), or other doctors (27%). Respondents were also presented witheight factors (including knowing what others decide or recommend) that could be consideredessential criteria for concluding that a decision is satisfactory. Interestingly, all factors werestrongly endorsed by participants (>89%), except for the factor referring to “others’ experience”(22%) (O’Connor A, personal communication, January 26, 2004). These observations suggest
that, although patients value and desire others’ experiences to be included in patient decision
aids, other aspects of patient decision aids -- such as knowing the main options and their pros
and cons, or being satisfied with the choice made -- are considered more important patientdecision aid components.
RCT’s involving patients facing actual choices. Of 29 individual patient decision aids
evaluated in 34 RCTs in the Cochrane Review, 19 were available for review of their content(O’Connor, Stacey et al., 2003).
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Section E: Using personal stories_____________________________________________________________________•

74% (14 of 19) included examples of others’ experience. Of these 14, 8 provided
testimonials, 4 provided examples of balance scales completed by others, 1 used group
discussion, and 1 supplied regression weights.

Available evidence concerning inclusion of others’ experience in patient decision aids is sparse,
though increasing (Ubel, 2002).
Use of narratives. The use of narratives can make information more salient, easily imaginable,
memorable, and more readily evaluated (Price & Czilli, 1996; Sanfrey & Hastie, 1998;
Satterfield, 2001). Michielutte et al (1992) reported that a narrative style of text significantly
improved comprehension, particularly among readers with low literacy skills.
Use of patient testimonials. Ubel, Jepson & Baron (2001) investigated whether the inclusion ofpatient testimonials in patient decision aids affects patients’ treatment choices. Prospective
American jurors were presented with hypothetical statistical information about the percentagesof angina patients who benefit from angioplasty and bypass surgery (50% and 75%
respectively). This information was supplemented by written testimonials from hypotheticalpatients, which had benefited or had not benefited from each of the two treatments. The
numbers of patients benefiting/not benefiting were varied to be either proportionate or
disproportionate to the statistical information. It was found that the percentage of participants
expressing a preference for bypass surgery over angioplasty varied from 58% (among
participants receiving no testimonials) to 30% (among participants receiving 1 positive and 1
negative testimonial for each treatment), even though all participants received identicalstatistical information about the effectiveness of the treatments. It was concluded that inclusionof written patient testimonials, when presented with statistical summary data on treatment
effectiveness, significantly influenced hypothetical treatment choices. The number of
testimonials in favour of either option strongly influenced choice.
Current research. Since the majority of studies concerning the inclusion of others’ experiences
have been conducted with non-patient populations, outcomes of similar studies within clinicalsettings still need to be ascertained. Associate Professor Peter A. Ubel and co-investigators are
currently conducting a study to delineate the effect of patient testimonials on patients’ treatment
choices, and to find ways to minimize the chance that testimonials will distract patients fromprobabilistic information.
Simon Whitney and Michael Crouch, funding by a K-08 Career Development Award from
AHRQ, are currently conducting a randomized controlled trial of a patient decision aid forstatin therapy ("Statin Therapy Informed Choice"). In the self-administered version, a section
entitled "What would my experience be like if I took a statin cholesterol medicine?", ten "ministories" depict the main foreseeable outcomes of the statin therapy decision. The likelihood thatan individual's experience would be like that of the person in each mini-story is provided interms of odds and "chances in 1,000” (based on data from the large statin trials). Thus, theinvestigators have tried to combine the hypothesized value of stories (for making possible
scenarios seem more real) with a fact-based estimate of the likelihood that the stories areapplicable to the individual.
In conclusion, the current evidence about this topic is limited and conflicting. It remains to be clarified
whether it is possible to identify a ‘best strategy’ for the inclusion of others experiences in patientdecision aids. It is likely that different conditions and types of decision will require different
combinations of material, suggesting that the evidence will never be applicable to all, even if based on
appropriate clinical populations. However, common issues include how to present balanced patients’
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Section E: Using personal stories_____________________________________________________________________

stories representing each outcome, and how to integrate the priorities expressed in the patients’ stories
with the statistical information about health outcomes.
References
Michielutte R, Bahnson J, Dignan MB, Schroeder EM. The use of illustrations and narrative text style toimprove readability of health education brochure. J Cancer Education 1992; 7(3): 251-60.
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. BMJ, 1999,
319:731-4.
O'Connor, A.M., Stacey, D., Entwistle, V., Llewellyn-Thomas, H., Rovner, D., Holmes-Rovner, M., Tait, V.,
Tetroe, J., Fiset, V., Barry, M., Jones, J. Decision aids for people facing health treatment or screening decisions[Cochrane Review]. In: The Cochrane Library, 2003: Issue 2. Oxford: Update Software.
O’Connor AM, Drake ER, Wells GA, Tugwell P, Laupacis A & Elmslie T. A survey of the decision-making
needs of Canadians faced with complex health decisions. Health Expectations, 2003, 6:97-109.
O’Connor AM, Drake ER, Fiset V, Graham ID, Laupacis A & Tugwell P. The Ottawa patient decision aids.
Effective Clinical Practice, 1999, 2(4):163-170.
O’Connor AM & Jacobsen MJ Workbook on developing and evaluating patient decision aids. Ottawa HealthResearch Institute, 2003.
O’Connor AM, Llewellyn-Thomas HA, Sawka C, Pinfold SP, To T & Harrison DE. Physicians’ opinions about
decision aids for patients considering systemic adjuvant therapy for axillary-node negative breast cancer. Patient
Education and Counseling, 1997, 30:143-153.
Popay J, Rogers A, Williams G. Rational and standards for the systematic review of qualitative literature in
health services research. Qualitative Health Research 1998; 8: 341-351.
Price V & Czilli EJ. Modeling patterns of news recognition and recall. Journal of Communication 1996; 46(2):55-78.
Sanfrey A & Hastie R. Does evidence presentation format affect judgment? An experimental evaluation of
displays of data for judgments. Psychological Science 1998; 9(2): 99-103.
Satterfield D. Stories connect science to souls. Diabetes Educator 2001; 27(2): 176-9
Ubel PA. Is information always a good thing? Helping patients make “good” decisions. Medical Care 2002;
40(Suppl): V-39-V-44.
Ubel PA, Jepson C & Baron J. The inclusion of patient testimonials in decision aids: Effects on treatment
choice. Medical Decision Making, 2001, 21(1):60-68.

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Section F: Guiding/Coaching in deliberation and communication____________________________________________________________________

Section F: Guiding/Coaching in deliberation and communication
Authors
Sepucha, Karen PhD (lead)
Jeff Belkora PhD
Bruce Ling MD MPH
Joyce Davison PhD

Harvard Medical School and Foundation for Informed
Medical Decision Making, Boston
Director, Decision Services and Assistant Adjunct
Professor, University of California San Francisco Cancer
Center, San Francisco
University of Pittsburgh
Prostate Centre and Assistant Professor, Department ofSurgery, University of British Columbia, Vancouver

US
US
US
CA

Rationale/Theory
The objective of a patient decision aid is to help patients make a good decision — one that is wellinformed, reflects the patients’ values, and is implemented. To support this goal, guidance andcoaching methods may seek to do one or more of the following:• Improve understanding by providing information, tailoring information, brainstorming andanswering questions, and checking understanding;• Clarify values by facilitating reflection, taking someone through values clarification
exercises, and sharing others’ experiences;• Improve deliberation by anticipating and avoiding common pitfalls (e.g. anchoring, misimagining, etc.) that can undermine effective decision-making, and taking someone throughthe steps of decision making.
• Improve patient - practitioner communication by helping patients prepare questions andconcerns, by teaching skills for raising difficult subjects, and by providing a worksheet orlist to share with doctor;• Improve follow-through by helping patients anticipate and overcome barriers to
implementing desired options• Reduce emotional distress and anxiety and improve ability to use skills for coping andproblem solving.
Avoiding decision traps. Patients and practitioners do not naturally follow the axioms ofnormative decision theory; however, when inconsistencies are highlighted, many willingly
change their choices to be more aligned with the principles. Thus, explicit guidance in the stepsof deliberation is often beneficial to help overcome some of common decision-making traps.
Quality of patient-provider communication. Open communication is essential for shareddecision making. However, many studies have documented that, the quality of communication
between patients and providers is poor. Good communication and strong patient-provider
relationships have been linked to greater satisfaction and positive health outcomes. Poor
communication, conversely, has been linked to dissatisfaction, conflict, and worse outcomes.
Patients and practitioners may benefit from guidance in more open communication.
Ways of learning. Patients learn in different ways. Many patients prefer and find it more
effective to learn from others as opposed to a book, video or pamphlet. Many researchers argue
that learning and skill acquisition does not happen when individuals simply receive factual
information but happens most effectively by actually engaging in the process, often withsupport of a mentor or coach.
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Section F: Guiding/Coaching in deliberation and communication____________________________________________________________________

Emotional distress. A new diagnosis can cause significant distress and anxiety, and can disrupt
coping and problem solving skills. Coaching or counselling that can help patients reduce thisemotional distress. Furthermore, anxiety may increase patients’ desire and capability toparticipate effectively in decision making.
There is no single theory or method that has been used consistently or evaluated extensively to address
all of these goals. Theories of decision making often do not address emotional or communicationneeds. Likewise, theories of communication, coping, and self-efficacy do not address issues of decision
making under risk and uncertainty. Most guidance/coaching with patient decision aids has a limited
focus – for example in, either enhancing understanding of information or clarifying values. There arevery few data on the relative impact of the different methods on the quality of decisions, and thus
limited evidence to support or refute any of the different theories for using guidance or coaching
methods in patient decision aids.
Evidence
RCT’s involving patients facing actual choices. Of the 29 individual patient decision aids,
evaluated in the 34 RCTs included in the Cochrane Review, 19 were available for review of
their content (O'Connor et al., 2003). Of these, 17 (89%) patient decision aids contained some
sort of guidance/coaching in deliberation and/or communication. The amount of guidance
varied considerably:• 4 patient decision aids with a worksheet only were evaluated in 9 trials (Barry et al.,
1997; Bernstein et al., 1998; Holmes-Rovner et al., 1999; Kennedy et al., 2002; Murray etal., 2001a; 2001b; Morgan et al., 2000; O’Connor et al., 1998; O’Connor et al., 1999;
Rothert et al., 1997)• 5 patient decision aids with a list of the steps of decision making and a worksheet were
evaluated in 5 trials (Dodin et al., 2001; Goel et al., 2001; Man-son-Hing et al., 1999;
McBride 2002; Rostom et al., 2002)• 2 patient decision aids with a worksheet plus coaching were evaluated in 3 trials(Kennedy et al., 2002; Rothert et al., 1997; Holmes-Rovner et al., 1999)• 6 patient decision aids with coaching only were evaluated in 7 trials (Davison et al., 1999;
Davison et al., 1997; Dolan et al., 2002; Green et al., 2001; Holmes-Rovner et al., 1999;
Lerman et al., 1997; Rothert et al., 1997)
The Cochrane Review found that more complex patient decision aids produced higher gains inknowledge, more realistic expectations, and a greater match between patients’ values andchoice. One trial found that patients in the study arm involving a patient decision aid plus
coaching by a nurse had fewer hysterectomies and incurred lower costs than either of the othertwo study arms (patient decision aid only and control) (Kennedy et al. 2002). For the most part,the trials of patient decision aids do not compare varying intensities of coaching/guidance, andtherefore the relative effectiveness of these methods is not clear.
Other evaluative studies. Many studies have documented poor quality of communication
during medical consultations (Braddock et al., 1999; Marvel, Epstein et al. 1999). Examples ofpoor communication include: a) physicians tend to dominate the discussion and patients tend towithdraw; b) the focus is on medical facts, not thoughts or feelings; and c) the traditional
medical interview that gets documented with the SOAP note does not leave room for shareddecision making (Donnelley, 1992; Lipkin et al., 1995; Singer, 1992). A systematic review of
RCTs found that the quality of patient-physician communication influences health outcomes
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Section F: Guiding/Coaching in deliberation and communication____________________________________________________________________

such as emotional status, symptom resolution, functional and physiologic status, and pain
(Stewart, 1995). Some of the characteristics of quality communication included engaging
patient in discussion of problem, encouraging questions and participation in decision-making
about management, and discussion of emotions and feelings. Interventions designed to increase
these behaviours have been shown to positively affect outcomes.(Greenfield et al., 1985; 1988)
Without good communication, patients tend to become dissatisfied and disenroll from healthplans (Davies et al., 1986), to change physicians (Kasteler et al., 1976; Kaplan et al., 1996), toinitiate complaints against physicians (Roter, 1977), and to be non-compliant with medical
recommendations (Korsch et al., 1968; Francis et al., 1969).
However, interventions that focus only on patients (such as many patient decision aids) or only
on physicians (Keller & Carroll, 1994; Joos et al., 1996; Fallowfield et al., 1998) may have
limited impact. Studies that engage both patients and physicians may have the biggest impact(Brown et al., 1999; Sepucha et al., 2000).
A review of psychosocial interventions in cancer care found that different psychosocial
interventions (including education, behavior training, coping techniques and group support)
may positively affect psychosocial outcomes, and increase participation in decision making(Fawzy et al., 1995).
Other relevant literature. The adult learning literature, as well as theories in organizational
behavior and management science, suggests that learning is a social process, not merely thereceipt of knowledge. Patients are more apt to learn when messages and information are
targeted or tailored to their situation, their needs, and their concerns (Knowles, 1990; Knowles
et al., 1998; Krueter & Ricardo, 2003). In addition, patients may be more apt to learn whenhelped by others, and when actually engaged in actions. ( Argyris & Schon, 1978; Argyris etal., 1985; Bandura, 1982; Knowles et al., 1998; Lave & Wenger, 1991; Lewin, 1952).
References
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Francisco, Jossey-Bass Inc, 1985.
Argyris C & Schon, D. Organization Learning: A Theory of Action Perspective. Reading, Addison-Wesley,1978.
Bandura A. Self-Efficacy mechanism in human agency. American Psychologist 1982; 37: 122-47.
Barry J, Fowler FJ, Mulley AG, Henderson JV, Wennberg JE. Patient reactions to a program designed tofacilitate patient participate in treatment decision for benign prostatic hyperplasia. Medical Care. 1995; 33: 771782.
Bernstein, S. J., Skarupski, K. A., Grayson, C. E., Starling, M. R., Bates, E. R., & Eagle, K. A. (1998). A
randomized controlled trial of information-giving to patients referred for coronary angiography: effects on
outcomes of care. Health Expectations, 1, 50-61.
Braddock CH, Edwards KA et al. Informed Decision Making in Outpatient Practice: Time to Get Back to
Basics. JAMA 1999; 282: 2313-2320.
Brown R, Butow P, et al. Promoting patient participation in the cancer consultation: evaluation of a prompt sheet
and coaching in question asking. British Journal of Cancer 1999; 80(1/2): 242-8.
Davies A, Ware J, et al. Consumer Acceptance of Prepaid and Fee-for-Service Medical Care: Results from a
Randomized Controlled Trial. Health Serv Res 1986; 21: 429.

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Davison, B. J. & Degner, L. F. (1997). Empowerment of men newly diagnosed with prostate cancer. Cancer
Nursing, 20, 187-196.
Davison, B. J., Krik, P., Degner, L. F., & Hassard, T. H. (1999). Information and patient participant in screening
for prostate cancer. Patient Education and Counseling, 37, 255-263.
Dodin S, Legare F, Daudelin G, Tetroe J, O’Connor A. Prise de decision en matiere d’hormonotherapie deremplacement. Can Fam Physician. 2001;47:1586-1593.
Dolan JG, Frisina S. Randomized controlled trial of a patient decision aid for colorectal cancer screening. Med
Decis Making. 2002;22:125-139.
Donnelley W. Why SOAP is bad for the medical record commentary. Arch internal Medicine 1992; 152(March):
481-484.
Fallowfield L, Lipkin M, et al. Teaching Senior Oncologists Communication Skills: Results from Phase I of aComprehensive Longitudinal Program in the United Kingdom. Journal of Clinical Oncology 1998; 16(5): 19611968.
Fawzy I, Fawzy N, et al. Critical Review of Psychosocial Interventions in Cancer Care. Arch Gen Psychiatry
1995;52(2): 100-113.
Fishburn P. Normative Theories of Decision Making Under Risk and Under Uncertainty (pp.78-98). In D Bell,H Raiffa, & A Tversky. Decision making: Descriptive, Normative and Prescriptive Interactions. New York,
Cambridge University Press, 1988.
Francis V, Korsch B et al. Gaps in doctor patients communication : patients’ response to medical advice. N Engl
J Med 1969;42: 855.
Goel V, Sawka CA, Thiel EC, Gort EH, O'Connor AM. Randomized trial of a patient decision aid for choice of
surgical treatment for breast cancer. Med Decis Making. 2001;21:1-6.
Green, M. J., Biesecker, B. B., McInerney, A. M., 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.
Greenfield S, Kaplan S et al. Expanding Patient Involvement in Care. Annals of Internal Medicine 1885;102:
520-528.
Greenfield S, Kaplan S et al. Patient's Participation in Medical Care: Effects on Blood Sugar Control and Qualityof Life in Diabetes. Journal of Internal Medicine 1988; 3(Sept/Oct): 448-457.
Education and Counseling 2004;50(3):235-245.
Holmes-Rovner M, Kroll J, Rovner D, et al. Patient decision support intervention: Increased consistency withdecision analytic models. Medical Care, 1999; 37:270-284.
Howard RA & Matheson JE (Eds). The Principles and Applications of Decision Analysis. Menlo Park, Strategic
Decision Group, 1989.
Janis I & Mann L Decision Making. New York, The Free Press, 1977.
Joos S, Hickam D et al. Effects of a Physician Communication Intervention on Patient Care Outcomes. Journalof General Internal Medicine 1996;11(March): 147-155.
Kahneman D & Tversky A (Eds). Choices, Values and Frames. New York, Cambridge University Press, 2000.
Kaplan S, Greenfield S et al. Characteristics of Physicians with Participatory Decision-Making Styles. Annals ofInternal Medicine 1996;124: 497-504.
Kasteler J, Kane, et al. Issues underlying the prevalence of “doctor- shopping” behavior. J Health Soc Behavior
1976; 17: 328.

IPDAS Collaboration Background Document31Section F: Guiding/Coaching in deliberation and communication____________________________________________________________________

Keller VF & Carroll JG. A New Model for Physician-Patient Communication.” Patient Education andCounseling 1994; 23: 131-140.
Kennedy A, Sculpher M et al. Effects of Decision Aids for Menorrhagia on Treatment Choices, Health
Outcomes, and Costs: A Randomized Controlled Trial. JAMA 2002; 288: 2701-8.
Knowles MS. The adult learner: A neglected species. Houston, Gulf Pub. Co, 1990.
Knowles MS, Holton E et al. The adult learner: the definitive classic in adult education and human resource
development. Houston, Tex., Gulf Pub. Co, 1998.
Korsch B, Gozzi E et al. Gaps in doctor patient communication: I. Doctor -patient interaction and patientsatisfaction. Pediatrics 1968; 42: 855.
Krueter M & Ricardo W. Tailored and Targeted Health Communication: Strategies for Enhancing Information
Relevance. Am J Health Behav 2003; 27(Suppl 3): S227-32.
Lave J & Wenger E. Situated learning. Legitimate peripheral participation. New York, Cambridge University
Press, 1991.
Lerman, C., Biesecker, B., Benkendorf, J. L., Kerner, J., Gomez-Caminero, A., Hughes, C., & Reed, M. M.
(1997). Controlled trial of pretest education approaches to enhance informed decision-making for BRCA1 Genetesting. Journal of National Cancer Institute, 89, 148-157.
Lewin K. Group Decisions and Social Change. Readings in Social Psychology. E. E. Maccoby, T. M. Newcomb
and E. L. Hartley. New York, Holt, Rinehart, and Winston, 1952.
Lipkin MJ, Putnam SM et al. (Eds). The Medical Interview. New York, Springer-Verlag, 1995.
Man-Son-Hing M, Laupacis A, O’Connor AM, et al. A patient decision aid regarding antithrombotic therapy forstroke prevention in atrial fibrillation: a randomized controlled trial. JAMA 1999; 282:737-43.
Marvel MK, Epstein R et al. Soliciting the Patient's Agenda: Have We Improved? JAMA 1999; 281(3):283-287.
McBride CM, Bastian LA, Halabi S, Fish L, Lipkus IM, Bosworth HB et al., A tailored intervention to aid
decision making about hromone replacement therapy. American Journal of Public Health 2002; 92(7); 112-4.
Murray E, Davis H, Tai SS, Coulter A, Gray A, Haines A. Randomized controlled trial of an interactive
multimedia decision aid on benign prostatic hypertrophy in primary care. BMJ. 2001a; 323:493-496.
Murray E, Davis H, Tai SS, Coulter A, Gray A, Haines A. Randomized controlled trial of an interactive
multimedia decision aid on hormone replacement therapy in primary care. BMJ. 2001b; 323:490-493.
Morgan MW, Deber RB, Llewellyn-Thomas HA, et al. Randomized, controlled trial of an interactive videodisc
decision aid for patients with ischemic heart disease. J Gen Intern Med 2000;15:685-699.
O’Connor AM, Tugwell P, Wells GA, Elmslie T, Jollly E, et al. Randomized trial of a portable self-administereddecision aid for postmenopausal women considering long-term preventive hormone therapy. Medical Decision
Making, 1998; 18: 295-303
O'Connor AM, Wells G, Tugwell P, Laupacis A, Elmslie T, & Drake E. The value of an explicit values
clarification exercise in a women's decision aid regarding postmenopausal hormone therapy. Health
Expectations 1999; 2:21-32.
O'Connor A, Stacey D et al. Decision aids for people facing health treatment or screening decisions. In CochraneLibrary. Issue 2 2003. Oxford: Update Software. http://www.cochrane.org/cochrane/revabstr/ab001431.htm
Platte F & Keller V. Empathic Communication: A teachable and learnable skill. Journal of General Internal
Medicine 1994; 9(April): 222-226.
Redelmeier D, Rozin P et al. Understanding patients' decisions. Cognitive and emotional perspectives.” JAMA
1993; 270(1): 72-6.

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Rostom, A., O'Connor, A., Tugwell, P., & Wells, G. (2004). A randomized trial of a computerized versus anaudio-booklet decision aids for women considering post-menopausal hormone replacement therapy. Patient
Education and Counseling, 46, 67-74.
Roter D. Patient participation in patient-provider interactions: effects of patient question asking on the quality ofinteractions, satisfaction, and compliance.” Health Educ Monographs 1977; 280: 535.
Rothert ML, Holmes-Rovner M, Rovner D, et al. An educational intervention as decision support formenopausal women. Res Nursing Health. 1997;20:377-387.
Russo J & Schoemaker P. Decision Traps. Top Ten Barriers to Brilliant Decision-Making and How toOvercomeThem. New York, Fireside, 1989.
Sepucha K, Belkora J et al. Consultation Planning to Help Patients Prepare for Medical Consultations: Effect on
Communication and Satisfaction for Patients and Physicians. J Clin Oncol 2002; 20(11): 2695-2700.
Sepucha K, Belkora J et al. Building Bridges Between Physicians and Patients: Results of a Pilot Study
Examining New Tools for Collaborative Decision Making. Journal of Clinincal Oncology 2000;18(6): 1230-8.
Singer E. Why SOAP is good for the medical record?: Another view. Arch Internal Medicine 1992;
152(December): 2511.
Stewart M. Effective physician-patient communication and health outcomes: a review. Can Med Assoc J
1995;152(9): 1423-33.
Tversky A & Kahneman D. The framing of decisions and the psychology of choice. Science 1981; 211(4481):453-8.

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APPENDIX: Technical Descriptions
Detailed Concepts:
 Theories – Specific Types:a) Normative Decision Theory (i.e. expected utility theory or subjective expected utility theory)
posits a set of axioms to which decision makers should subscribe, in order to ensure that theiractions are most likely to generate the results they desire (Fishburn, 1988; Howard & Matheson
1989).
b) Psychological Decision Theory attempts to explain the cognitive pitfalls that can lead todecisions that violate one or more of the axioms of rationality. One pitfall involves the heuristics
commonly used by patients when they make judgements about events (Kahneman & Tversky,
2000; Redelmeier et al., 1993; Russo & Schoemaker, 1989; Tversky & Kahneman, 1981). Anotherpitfall involves the preference reversal phenomenon, which is a fairly pervasive inconsistency inpatients’ choices under uncertainty. The preference reversal phenomenon is explained by Prospect
Theory (perhaps the most commonly-cited psychological decision theory), which argues that theseinconsistencies depend on whether the options in a choice situation are framed in terms of theprospect of relative gains or relative losses.
c) Decisional Conflict Theory: Although the majority of behavioral decision theory highlights
how often patients stray from the normative ideals, Decisional Conflict Theory took a slightly
different approach by trying to define those conditions under which decision makers seem to follow
a more vigilant process. Janis and Mann (Janis & Mann, 1977) studied emergency decision making,and found that decision makers tended to be more vigilant when they (a) realized a threat if they
stay with the status quo, (b) realized a threat if they changed to the first alternative, (c) hoped thatthey could find some better options, and (d) believed that they have sufficient time to search anddeliberate. This means that there needs to be some anxiety or conflict in order to motivate patientsto deliberate, but not too much, or else it will interfere with cognitive processing. Anis and Mannalso developed some interventions designed to promote vigilance and improve the quality ofdecisions. Some patient decision aids incorporate these techniques (e.g. balance sheet exercise).
 Methods – Specific Types:a) Health Coaching: Greenfield, Kaplan, and colleagues (1985; 1988) pioneered the concept ofhealth coaching. In their model, the coach’s goals are to encourage patients during their clinic visit
with their practitioner to: (1) ask questions, (2) recognize relevant medical decisions, and (3)negotiate these decisions with their provider. In addition, techniques were taught to have patients
overcome potential barriers in discussions with their provider such as embarrassment, fear of
appearing foolish, forgetting to bring up an issue, and intimidation by the provider. In several
controlled trials of patients with different conditions (such as diabetes, hypertension, and cancer),they found that patients who underwent an intervention to better understand their medical condition
and were coached to better talk with their provider were more active in the conversation with theirprovider, more assertive during these conversations, and elicited twice the number of factual
statements from their provider. Patients in the intervention group also expressed a significantly
stronger desire to participate in the medical decision making process.
b) Consultation Planning and Recording: Sepucha, Belkora and colleagues developed andevaluated a series of interventions designed to facilitate deliberation and improve communication in
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medical consultations concerning decisions about treatment of breast cancer. The interventions(called Consultation Planning (CP) and Consultation Recording (CR)) are based in three
disciplines: decision analysis, action research, and action science. They use a trained facilitator toelicit and structure a patient’s questions and concerns (in CP), to share them with the practitioner,
and then to use them as an agenda to guide the consultation, which is also facilitated and recorded(in CR). A notable aspect of these decision support methods is that the focus is not on information
provision; instead, the goals are to uncover, order, and prioritize the understanding of patients andpractitioners, to promote more open communication, and to facilitate a consensus that addresses thepatient’s values and needs. Two small controlled trials suggest that these methods significantly
increase the quality of communication, the quality of decisions, and both patient and practitioner
satisfaction with the process. (Sepucha et al. 2000; 2002) A large, multi-site randomized trial will
evaluate CP/CR with or without shared decision making videos (developed by the Foundation for
Informed Medical Decision Making), to explore the relative impact of information-focused andcommunication-focused support for patients with breast cancer.
c) The “E4” model rejects paternalistic and consumer-driven roles for physicians, and embraces
the interpretive and deliberative visions of how patients and physicians should interact (Keller &Carroll, 1994). Further, this model encourages physicians to engage the patient, empathize with thepatient, educate the patient, and enlist the patient. Keller and Carroll prescribe a specific class ofinterpretive and deliberative responses and run workshops to teach empathic communications tophysicians (Platte & Keller, 1994). Physicians find these workshops useful; however, there is noevidence that their intervention improves the quality of communication in consultations withpatients, or improves the quality of the patient-physician relationship.

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Section G: Disclosing conflicts of interest_________________________________________________________________________

Section G: Disclosing conflicts of interest
Authors
Michael Barry (lead)

Harvard Medical School, Boston

US

Tony Hope

Ethox: Oxford Centre for Ethics and Communication in Health CareUK

Evelyn ChanInternal medicine and Director of Bioethics, Houston Medical School, Texas

USClarence Braddock

Stanford University School of Medicine, California

US

Rationale/Theory
Patient decision aids should present unbiased information about the pros and cons of different
management options for a medical problem. Bias can influence a patient decision aid’s content either
intentionally or unintentionally. Often, decisions about screening, diagnostic testing or treatment havefinancial implications for practitioners, their institutions, and for commercial companies that make andsell diagnostic or therapeutic products. These financial interests have the potential to bias the content ofa patient decision aid, particularly when individuals or groups who stand to gain (or lose), dependingon the management decision, are involved with the development and production of the patient decisionaid. Ideally, individuals and groups with a financial interest in the management decisions addressed bya patient decision aid should not be involved in the development and production of that patient decisionaid. However, at minimum, individuals or groups who had a potential financial interest in the content
of the patient decision aid should be clearly and prominently acknowledged to users (patients andpractitioners).
A definition of conflict of interest that is commonly used by medical journals is, “a set of conditions inwhich professional judgment concerning a primary interest (such as patients’ welfare or the validity of
research) tends to be unduly influenced by secondary interest (such as financial gain)”(Thompson,
1993). Practitioners and scientists who read research reports and reviews in medical journals represent
a relatively well-educated audience, yet journal editors remain concerned about adequate disclosure ofpotential conflicts of interest by the authors of those papers. Users of patient decision aids often comefrom the lay public, and their ability to detect and evaluate the influence of potential conflicts ofinterests on the content of the programs they use may be poorer compared with medical professionals.
Thus, patients may be more vulnerable to any bias incorporated into patient decision aids than medical
professionals are to biases that may enter into scientific papers in medical journals. Moreover, patientdecision aids may be developed and disseminated for use by patients or members of the public without
the benefit of scrutiny by independent peer reviewers or an independent editor, as would generally be
the case for papers in most peer-reviewed medical journals. Therefore, it seems reasonable that
requirements for disclosure of potential conflicts of interests should be at least as stringent as
disclosure requirements for medical journals. In addition, for a lay audience, explaining how thefinancial interests of any commercial funders relate to the patient decision aid’s content seems like areasonable approach to help patients and practitioners decide whether a program is likely to be biased
by such interests. While a professional viewer might know that a particular funder makes or sells a
product described as an option in the patient decision aid, a lay viewer might not.
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Section G: Disclosing conflicts of interest_________________________________________________________________________

Financial interests and professional biases may not be the only concerning influences on the content ofpatient decision aids. Practitioners-investigators may have built their academic careers by espousing aparticular point of view that may then be reflected in a patient decision aid. Moreover, the scientificcontent on which a patient decision aid is based is itself subject to myriad potential conflicts of interest.
However, these subtler forms of bias may be harder for lay viewers of patient decision aids to evaluate
and understand based on an increasingly complex disclosure statement.
Evidence
Inventory of available patient decision aids. One of the CREDIBLE criteria for the evaluationof patient decision aids asks, “Was sponsorship free from perceived conflicts of interest?” In themost recent Cochrane review inventory of patient decision aids, reviewers rated 131 recently
updated patient decision aids on this criterion. The ratings were as follows: ‘yes’ 96.2%, ‘no’
0.8%, ‘not ascertainable’ 3.1% (O’Connor et al., 2003). These data suggest the reviewers
usually found enough information about the funding sources of the patient decision aids tomake a judgment regarding potential conflicts of interest, and that it was unusual to identify
potential conflicts when funders were identified.
There are essentially no data on the impact of funding sources or specialty orientation on theperceived balance of patient decision aids. In fact, in the Cochrane review, data on ratings ofpatient decision aid balance could not be ascertained for 90.8% of patient decision aids.
Other evaluative studies. However, data from the world of medical scientific publishing andthe relationships between professional specialty and variations in medical practice strongly
suggest that financial interests or specialty-specific management preferences could bias patientdecision aids. For example, in scientific articles, an analysis by Stelfox and colleagues (1998)
found that journal articles about the use of calcium channel blockers were more positive about
those uses when the authors had financial relationships with pharmaceutical companies thatmake and sell calcium channel blockers. While Barnes and Bero (1998) found that authors ofreviews about the health effects of passive smoking were less likely to describe a negative
relationship if the authors were funded by tobacco companies. Most remarkably, in both thesecases, only the minority of relevant financial relationships on the part of the original authors
were actually disclosed as part of the publication process; the authors of systematic reviews
usually had to root them out through direct contact with the original authors. Specialty
perspective can also have a strong effect on views regarding optimal medical management. For
example, for clinically localized prostate cancer (a common topic for patient decision aids),
urologic surgeons are much more positive about radical prostatectomy while radiation
oncologists are much more positive about radiation therapy as a treatment option (Fowler et al.,2000). In cardiovascular care, cardiologists are more likely to recommend diagnostic modalities
such as exercise tests and coronary angiography than primary care physicians are for the same
patients.

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Section G: Disclosing conflicts of interest_________________________________________________________________________

References
Barnes DE, Bero LA. Why review articles on the health effects of passive smoking reach different conclusions.
JAMA 1998;279:1566-1570.
Fowler FJ, McNaughton Collins M, Albertsen PC, Zietman A, Elliott DB, Barry MJ. Comparison ofrecommendations by urologists and radiation oncologists for treatment of clinically localized prostate cancer.
JAMA 2000;283:3217-3222.
O’Connor AM, Stacey D, Entwistle V, Llewellyn-Thomas H, Rovner d, Holmes-Rovner M, Tait V, Tetroe J,
Fiset V, Barry M, Jones J. Decision aids for people facing health treatment or screening decisions (Cochrane
Review). In: The Cochrane Library, Issue 2 2003. Oxford: Update Software.
Stelfox HT, Chua G, O’Rourke K, Detsky AS. Conflict of interest in the debate over calcium channel
antagonists. New Engl J Med 1998;338:101-105.
Thompson DF. Understanding financial conflicts of interest. New Engl J Med 1993;329:573-576.
Wennberg DE, Dickens JD, Biener L, Fowler FJ, Soule DN, Keller RB. Do physicians do what they say? The
inclination to test and its association with coronary angiography rates. J Gen Intern Med 1997; 12(3): 172-176.

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Section H: Delivering decision aids on the Internet_________________________________________________________________________

Section H: Delivering decision aids on the Internet
Authors
Cornelia Ruland PhD (lead)
Dominick Frosch PhD

Director, Center for Shared Decision Making & Nursing NO
Research, Rikshospitalet National Hospital, Oslo
US
University of California, San Diego

Rationale/Theory
The Internet is one of several ways in which patient decision aids are made available. Other methods
include video-cassettes, computer programs, decision boards, booklets, and audio-guided workbooks.
The use of the Internet for making patient decision aids available is becoming more popular because of
the increased accessibility for patients and the decreased costs for producing and distributing them.
Patients go increasingly to the Internet to find answers to their health concerns and to get assistance inmaking health related decisions. However, information on the Internet needs not only to be valid andreliable, but also easily accessible and comprehensible. The design, usability, interface, logicalorganisation, and interactivity of an Internet site are crucial factors to enable patients to obtain theinformation they need.
Evidence
Inventory of available patient decision aids. Although patient decision aids have been
available since the early 1980’s, the use of the Internet as the medium of delivery has
dramatically increased over the last 5 years. However, there has been little evaluation of theeffectiveness of the Internet as the medium of delivery.
Of 131 patient decision aids that were available, updated within the last 5 years, and registeredin the Cochrane Review of patient decision aids inventory (O’Connor et al., 2003):• 73% (of 131) were available only on the Internet. Several other patient decision aids
developed and evaluated as booklets or leaflets were also available on the Internet.
RCTs involving patients facing actual choices. None of the 29 individual patient decision aidsthat were evaluated in 34 RCTS included in the Cochrane review used the Internet as themedium of delivery in the study (O’Connor et al., 2003).
A recently published trial by Frosch and colleagues (2003) compared men considering prostatecancer antigen (PSA) screening a) who viewed a patient decision aid video in the clinic
immediately prior to their practitioners’ appointment with b) those who accessed the Internetbased patient decision aid at home. There was no difference between the groups in terms ofparticipants' ratings of the convenience, effort, or satisfaction related to using the patientdecision aids. Compared to the Internet group, men in the video group were more likely to use
the patient decision aid (98.2% versus 53.5%), had significantly improved knowledge, and weremore likely to decline PSA screening. Men in the Internet group who reviewed the entire online
patient decision aid showed knowledge improvements similar to the video group.

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Section H: Delivering decision aids on the Internet_________________________________________________________________________

Other relevant literature. The National Cancer Institute (NCI) provides Web design andusability guidelines based on research studies and supporting information from the field. Eachguideline provides:• A brief statement of the overarching principle that is the foundation of the guideline• Comments that further explain the research/supporting information• Source(s) of the research/supporting information• A score indicating the "Strength of the Evidence" that supports the guideline• One or more graphic examples of the guideline in practice.
(http://usability.gov/guidelines/intro.html#1)
References
Criteria for Evaluating Web Resources from Kent State University including A Website evaluation form.
Available at : http://www.library.kent.edu/internet/evalform.html;
http://www.library.kent.edu/internet/criteria.html
EU Joins Standards Setting Movement with Publication of Quality Criteria and HON Code of Conduct(HONcode) for medical and health Web sites. Available at: http://www.hon.ch/HONcode/HON_CCE_en.htm,
http://www.hon.ch/HONcode/HON_CCE_intro.htm
Frosch DL, Kaplan RM, Felitti VJ. A randomized controlled trial comparing internet and video to facilitate
patient education for men considering the prostate specific antigen test. J Gen Intern Med 2003;18(10):781-7.
Health Summit Working Group: Criteria for Assessing the Quality of Health Information on the Internet - Policy
Paper. Available at: http://hitiweb.mitretek.org/docs/policy.html
Inaccurate consumer health information on the Internet. Available at:
http://www.amia.org/pubs/symposia/D005366.PDF
Lenert LA, Cher DJ. Use of meta-analytic results to facilitate shared decision-making. J Am Med Inform Assoc
1999; 6: 412-419.
National Cancer Institute Usability Guidelines. Available at: http://usability.gov
http://usability.gov/basics/index.html
Nielsen, J. Usability Engineering. New York, Academic Press, 1993.
Schneiderman, B. Designing the User Interface: Strategies for Effective Human-Computer Interaction: Third
Edition, Addison-Wesley Publ. Co., Reading, MA, 1998.
Smith AG. Testing the Surf: Criteria for Evaluating Internet Information Resources." The Public-Access
Computer Systems Review 1997; 8 (no.3).

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Section I: Balancing the presentation of options_______________________________________________________________________

Section I: Balancing the presentation of options
Authors
Nora Moumjid (lead)

La Fédération Nationale des Centres de Lutte Contre leCancer, Centre Léon Bérard, Lyon

FR

Dawn Stacey CA

University of Ottawa

CAAngela Raffle

Bristol North Primary Care Trust

UK

Elissa Ozanne

Massachussetts General Hospital Institute for Technology
Assessment

US

Rationale/Theory
The goal in patient decision making is to enable the patient to make an informed autonomous decisionthat reflects their personal preferences. To this end, patient decision aids provide patients withinformation about options and their consequences (benefits/harms) to help them clarify personal
preferences. However, the goal of an autonomous decision also implies that the presentation of
information should not favor a specific option (Hope, 1996). There is empirical evidence that variationsin the presentation of information affects how health is perceived, and how therapeutic choices are
made and acted upon (Herrin, 2001; Jorgensen & Gotzsche, 2004). For example, depending on theframing of the data (e.g. using mortality or survival rates), patients make different treatment choices(Bohmer & Sepucha, 2003). Furthermore, the way in which information is presented influences
patients’ satisfaction, knowledge, understanding, participation in decision-making, continuance ofchosen options, coping with their situation, and search for further information (Christensen-Szalanski
et al., 1987; Broyles et al., 1992; Inglis & Farnill, 1993; Phatouros & Blake, 1995; Michie et al., 1999).
When unbalanced, information can create therapeutic expectations that are impossible to meet, and canlead patients to unwittingly undertake interventions that carry chances of harms that they would notwillingly accept. Since it is not only dishonest but unethical to create unrealistic expectations or to
obscure the chances of harm (Raffle 1997; 1999; 2001), patient decision aids must aim to present
information in a balanced manner that does not inadvertently persuade the user to accept or reject aparticular option.
Evidence
Inventory of available patient decision aids. Balanced presentation of information wasassessed 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:• 97.7% (of 131) presented potential harms as well as potential benefits;• 8.0 % (of 131) measured the degree of balanced presentation of benefits and harms from theuser perspective; of these, the majority of patients found the patient decision aid balanced;

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Section I: Balancing the presentation of options_______________________________________________________________________

RCT’s involving patients facing actual choices. Of the 29 individual patient decision aids,
evaluated in 34 RCTs included in the Cochrane Review, 19 were available for review of content(O’Connor et al., 2003). Of these:• All 19 (100%) presented potential harms as well as potential benefits;• 4 (21%) measured the degree to which patients thought the presentation of benefits andharms was balanced. Three of these four reported that more than 2/3 of patients found theinformation balanced (see table 10.1). All four studies used a scale that was similar to thescale first reported by Barry and colleagues (1995).
Other evaluative studies. In 1995, Barry and colleagues asked men to indicate whether the
information in a patient decision aid about the treatment of benign prostatic hyperplasia wasslanted toward surgery, balanced, or slanted toward watchful waiting. Ratings were obtained ona five-point scale. As reported in table 10.1, 74% thought the patient decision aid wascompletely balanced. Of those who thought it was slanted, most indicated that it was slanted in
the same direction to which they were leaning, which raises questions about the ability toaccurately measure patients’ perspective of information balance.
Barry et al.’s acceptability tool was also used in developing breast screening patient decision
aids for women in out-of-target age groups (women 40 to 49 and women 70 and older)(O’Connor, Stacey, Barratt, Mai, 2003). Women within the target age group as well aspractitioners affiliated with breast screening programs reviewed the patient decision aids. Abouthalf of the women found the patient decision aids slanted in favour of starting screening (40 to49) or continuing screening (70 and older), while the others found them balanced. In contrast,
several practitioners thought the patient decision aids were slanted against screening. These
conflicting observations reinforce the uncertainty about whose perspective “counts” whenassessing information balance and the challenges in obtaining an objective measure of balance.
Jorgensen & Gotzsche (2004) conducted a cross sectional study of mammographic screening
information presented by major interest groups on 27 Scandinavian and English websites todetermine if there were balanced accounts of screening’s possible benefits and harm. They
found that most websites omitted information about important harms and emphasised benefits ina way that would be expected to increase uptake of screening. For example, 12 sites mentioned
the lifetime risk of developing breast cancer, usually followed by the annual number ofdiagnoses. In contrast, only three sites mentioned that women have a more than 50% chance ofsurviving breast cancer and only four stated that the lifetime risk of dying from breast cancer isabout 3-4%.
Results of evaluations of balanced presentation of information presented in patient decision aids
Author(year)

Evaluation

Barry et al.,
1995
BPH treatment
O’Connor etal., 1998; HRT
Phelan et al.,
2001; Backsurgery
Volk et al.,
1999; PSA
testing

N=373;
prospective
cohort study
n=81 ; within RCTn= 41; within RCT
n=80 with in
RCT

Clearly slanted
to favour mostinvasiveintervention
1%

Slightlyslanted tofavour mostintensive
7%

Completely
Balanced

Slightlyslanted to
no favour

74%

14%

Not reported

Not reported

76%

Not reported

Not reported

Not reported

60%

Not
reportedNotreported

6%

10%

79%

4%

1%

IPDAS Collaboration Background Document

Clearly slanted to
NOT favour
invasiveintervention
4%

Not reported

42Section I: Balancing the presentation of options_______________________________________________________________________

References
Barry J, Fowler FJ, Mulley AG, Henderson JV, Wennberg JE. Patient reactions to a program designed tofacilitate patient participate in treatment decision for benign prostatic hyperplasia. Medical Care 1995;33: 771782.
Bohmer RM, Sepucha K. Shared decision-making (N9-604-001). Boston: Harvard Business School, 2003.
Broyles S, Sharp C, Tyson J, Sadler J. How should parents be informed about major procedures? An exploratory
trial in the neonatal period. Early Hum Dev, 1992 ; 31(1) :67-75.
Christensen-Szalanski JJ, Boyce WT, Harrel H, Gardner MM. Circumcision and informed consent. Is more
information always better? Medical Care, 1997; 25(9):856-67.
EthicAd. DTC Regulations, FDA Regulations. Available:www.ethicad.org/health/dtc/fda.html
Herrin J. Interventions for improving the presentation of empirical evidence about health. Cochrane Review,
2001.
Inglis S, Farnill D. The effects of providing preoperative statistical anaesthetic-risk information. Anaesth
Intensive Care. 1993; 21(6):799-805.
Jorgensen KJ, Gotzsche PC. Presentation on websites of possible benefits and harms from screening for breast
cancer: cross sectional study. BMJ, 2004;328:148.
Michie S, Smith D, Marteau TM. Prenatal tests: how are women deciding? Prenat Diagn, 1999; 19(8) : 743-8.
O'Connor AM, RostomA, Fise 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. BMJ. 1999.
Phatouros CC, Blake MP. How much now to tell? Patients' attitudes to an information sheet prior to angiography
and angioplasty. Australas Radiol. 1995; 39(2):135-9.
O’Connor AM, Stacey D, Barratt A, Mai V. Decision aids for women, in out-of-target age groups, consideringbreast cancer screening mammography. Paper presented at the Reasons for Hope 2003: new developments inbreast cancer research 3rd scientific conference sponsored by the Canadian Breast Cancer Research Initiative,
Ottawa, October 2003.
O'Connor, A.M., Stacey, D., Entwistle, V., Llewellyn-Thomas, H., Rovner, D., Holmes-Rovner, M., Tait, V.,
Tetroe, J., Fiset, V., Barry, M., Jones, J. Decision aids for people facing health treatment or screening decisions[Cochrane Review]. In: The Cochrane Library, 2003: Issue 2. Oxford: Update Software.
O’Connor AM, Tugwell P, Wells GA, Elmslie T, Jollly E, et al. Randomized trial of a portable self-administereddecision aid for postmenopausal women considering long-term preventive hormone therapy. Medical Decision
Making, 1998; 18: 295-303.
Phelan EA, Deyo RA, Cherkin DC, Weinstein JN, Ciol MA, Kreuter W, Howe JF. Helping patients decide aboutback surgery. A randomized trial of an interactive video program. Spine, 2001; 26(2): 206-212.
Raffle AE. Informed participation in screening is essential. BMJ, 1997; 314:1762-3.
Raffle AE. Honesty about new screening programmes is best policy. BMJ, 2000;320:872.
Raffle AE. Information about screening : is it to achieve high uptake or to ensure informed choice? Health
Expectations, 2001; 4(2) : 92-8.
Thornton H, Edwards A, Baum M. Women need better information about routine mammography. BMJ,
2003;327:101-3.
Volk RJ, Cass AR, Spann SJ. A randomized controlled trial of shared decision making for prostate cancer
screening. Archives Fam Med, 1999: 8, 333-340.
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43Section I: Balancing the presentation of options_______________________________________________________________________

Appendix: Measuring balanced presentationa) When measuring the degree of balance in the presentation of options and consequences (benefits,harms), the users (patients, practitioners) personal predisposition towards an option should beelicited at baseline.
b) For only two options:
A single question can be used to ask users (patients/practitioners) to rate whether the decision
aid is slanted from strongly favouring option A through completely balanced to strongly
favouring option B. For example:
How balanced and fair did you find the information presented in the decision aid (please check
one)?
□
Clearly slanted to option A□
Slightly slanted to option A□
Completely balanced□
Slightly slanted to option B□
Clearly slanted to option Bc) For three or more options, there are two approaches that could be used to measure balance.
i) For each option presented, ask users to rate whether the decision aid is strongly in favour ofthat one specific option through balanced to strongly in favour of the other options. For
example:How balanced and fair did you find the information presented in the decision aid (pleasecheck one)?
□
Clearly slanted to option A□
Slightly slanted to option A□
Completely balanced□
Slightly slanted to the other options□
Clearly slanted to the other optionsii) Ask users to respond to a single question as an indication of biasing the user in one
direction. For example:
Did the program present one option as the best overall choice?
□
Yes
□
No
Appendix: Interpreting the Results of Balancea) Calculate the percentage of users who rate it as completely balanced.
b) Check the distribution of options that were identified as not balanced.
If the users are roughly equally scattered, this implies that the patient decision aid offers abalanced presentation. If there is agreement that the patient decision aid is slanted either
consistently toward or consistently against an option, it is likely that the presentation of
information needs to be revised. However, before making revisions, it is important to consider
users baseline choice predisposition. Previous evaluation has found that users who already have apreferred option in advance of seeing a patient decision aid are more likely to rate it as “slanted”
either in the same direction or away from their own preferences. They may have found thearguments that support their views to be more compelling or they may not have wanted to bemade aware of or reminded of facts that are counter to their choice.
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44Section J: Using plain language________________________________________________________________________

Section J: Using plain language
Authors
Margaret Holmes-Rovner (lead)

Michigan State University

US

Angie Fagerlin

University of Michigan Health System

US

Kirsten McCaffery

University of Sydney

AU

Lisa Schwartz

Dartmouth Medical School, Dartmouth College, New Hampshire

US

Stacey Sheridan

University of North Carolina

US

Sue Stableford

University of New England, AHEC Health Literacy Center

US

Rationale/Theory
Patient decision aids are designed to present medical evidence that assists patients to identify screening,
diagnostic testing, and treatment options, to determine their values associated with the potential harms
and benefits of these options, and to participate in medical decisions. It is therefore, crucial that the text
and graphics used to present this information are written in language that is easily understood. Ideally,
patient decision aids should be comprehensible to everyone in the target audience, regardless of literacy
level. However, medical detail required to describe harms and benefits is, by definition, technicallanguage that is more challenging for readers to understand and particularly difficult for readers withlimited literacy skills. These types of resources can be improved by applying the principles of plain
language to a document’s design, and by measuring readability.
Plain language. There is no gold standard for what constitutes plain language, although there is
wide agreement about many attributes, based on research evidence, about reading, cognitive
psychology, social marketing, usability, and document design. The 3 major categories of
attributes are: 1) the use of everyday language and other clear writing styles; 2) well-structured,
logically sequenced, and focused information; and 3) effective document design. When these
attributes are used, even good readers have demonstrated improvements in speed and accuracyof reading. As well, in medical situations many adults lack the context necessary to understandand apply the information which further impairs the use of new information. Finally, patients
faced with health decisions frequently experience heightened emotional stress which interfereswith cognitive abilities. Therefore, developing patient decision aids using attributes of plain
language is important for patients of all literacy levels.
Readability. The most valid and reliable measure of the level of a text’s comprehensiondifficulty is its readability. Patient decision aids need to be as transparent as possible indescribing the literacy level required to read or listen to the information provided. The majority(50% or more) of “the target population” should be able to understand the patient decision aid.
Therefore, in general, the readability of patient decision aids should be at the level equivalent tograde 7 or 8 in the US. However, when patient decision aids are specifically targeted to lower
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Section J: Using plain language________________________________________________________________________

literacy populations, the readability level should be adjusted accordingly. Finally, the method
used to assess readability should be reported with the readability levels.
Evidence
Literacy rates. According to the 1992 National Adult Literacy survey, about half of US adults
read at or below the 7-8th grade level. The issue of literacy is of ongoing concern across many
countries that include Australia, Canada, Germany, New Zealand, Sweden, the United
Kingdom, and The US.
Plain language. There is some evidence that increasing reading ease improves comprehension,and emerging evidence of the effect on health outcomes. Poor literacy has been found to berelated to lack of preventive health behaviors (e.g., cervical and breast cancer screening,
influenza and pneumococcal immunization), increased risk of hospitalization, decreased ability
to follow medical instructions (e.g., use of inhaler), and less control of chronic illness (e.g.,
glycemic control). However, several studies have shown that health outcomes can be responsive
to interventions designed to improve the readability of materials. While the evidence is weak,
and it is unclear whether interventions directed at improving readability will lead to better
health outcomes, low literacy may be part of a complex of problems relating to poor healthoutcomes. A recent review identified 24 studies that examined interventions to improve healthfor persons with low literacy. These studies found mixed results about the interventions’ ability
to affect knowledge, intermediate markers of disease, disease prevalence and incidence, healthbehaviors, and use of health services. Few studies examined each type of literacy intervention(text, videotape, computer, oral presentation), therefore it is not clear which types of tools aremost effective. Additional limitations included variability in the study designs, the interventions
tested, and the outcomes assessed.
Readability measurement. There are well-validated tools for readability (e.g. SMOG, Fry).
However, the easily accessible readability measures in word processing software are not very
accurate or acceptable. Readability measures focus on the text, while more recent work on
health literacy has focused on the abilities of the persons reading the text. Despite theirlimitations, these existing tools are helpful to good document design and should be used; in themeantime, investigators should re-validate them with various populations and develop moresensitive and specific tools to predict informed decision-making and health outcomes.
Inventory of available patient decision aids. There is no evidence found on the assessment of
readability of patient decision aids and their suitability for particular audiences. Most of the 131
patient decision aids, in the Cochrane review inventory, were developed for general audiences(O’Connor et al., 2003). Further research should focus on: a) demonstrating whichcharacteristics of patient decision aids enhance readability and improve comprehension
resulting in better health outcomes; b) examining the use of patient decision aids in both low
and high literacy groups to determine whether the intervention ameliorates differences
according to literacy status; and c) determining whether interventions work directly to improve
patients’ knowledge and understanding or indirectly through other mechanisms.
Current initiatives. The research agenda in health literacy should be enhanced by the work of
the Institute of Medicine in this field. The Institute of Medicine's report Health Literacy: A

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Section J: Using plain language________________________________________________________________________

Prescription to End Confusion, released in April 2004, highlights the scope of the problem andoutlines a research and policy agenda with key recommendations.
References
Importance of health literacy generally
IOM report on Health Literacy (pending)
IOM report: Speaking of Health: Assessing health communication strategies for diverse populations.
National Academies Press, Washington DC, 2002.
Williams MV, Davis T, Parker RM, et al. The Role of Health Literacy in Patient-Physician Communication.
Communicating with special populations 2002; 34(5):383-389.
Parker RM: Health Literacy: a challenge for American patients and their health care providers. Health
Promotion International 2000; 15(4):277-283.
Gazmararian JA, Williams MV, Peel J, et al. Health literacy and knowledge of chronic disease. Patient
Education and Counseling 2003; 51:267-275.
Linking reading and other research to plain language criteria
Felder D, et al. (Eds) Document Design: A Review of the Relevant Research. Washington DC: Document
Design Center, American Institutes for Research, National Institute of Education, DHEW. April 1980.
Reprinted 1989.
Felder D, Pickering F, Charrow V, et al. Guidelines for Document Designers. Washington DC: Document
Design Center, American Institutes for Research, November 1981.
Spyridakis J, Wenger M. Writing for Human Performance: Relating Reading Research to Document Design.
Technical Communication. 1991; 202-215 (second quarter).
Hibbard J, Peters E. Supporting Informed Consumer Health Care Decisions: Data Presentation Approaches
that Facilitate the Use of Information in Choice. Annual Review of Public Health 2003; 24:413-433
Linking plain language with increased comprehension (selected sample)
Baker GC, Newton DE, Bergstresser PR. Increased Readability Improves the Comprehension of Written
Information for Patients with Skin Disease. Journal American Academy Dermatology 1988;19:1135-41.
Davis T, Bocchini JA Jr, Fredrickson D, et al. Parent Comprehension of Polio Vaccine Information
Pamphlets. Pediatrics 1996; 97:804-810.
Jolly B, Scott JL, Sanford SM. Simplification of Emergency Department Discharge Instructions Improves
Patient Comprehension. Annals of Emergency Medicine 1995; 26:443-446.
Meade C, Byrd J, Lee M. Improving Patient Comprehension of Literature on Smoking. American Journal of
Public Health 1989;79:1411-1412.
Effects of literacy on health outcomes
DeWalt DA, Berkman N, Sheridan SL, et al. Literacy and Health Outcomes: a systematic review of theliterature (personal communication).
Pignone MP, DeWalt DA, Sheridan SL, et al. Interventions to Improve Health Outcomes for Patients with
Low Literacy: Systematic Review (personal communication).
Measures of readability and suitability: description and validation
Chall J, Dale E. Readability Revisited: The new Dale-Chall Readability Formula. Brookline Books, 1995.
Fry, EB. Readability Scale. Providence, RI, Jamestown Publishers, 1976.

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Section J: Using plain language________________________________________________________________________

Mailloux S, Johnson ME, Fisher DG, et al. How Reliable is Computerized Assessment of Readability?
Computers in Nursing 1995; 13(5):221-225.
Ley P, Florio T. The use of readability formulas in health care. Psychology, Health & Medicine 1996;
1(1):7-28.
Computerized readability software. Available at www.micropowerandlight.com
Doak C, Doak L, Root J. Teaching Patients with Low Literacy Skills (2nd ed). Philadelphia: Lippincott,
1996.
SMOG scoring directions: Harvard School of Public Health website. Available at:www.hsph.harvard.edu/healthliteracy
Literacy status of populations
National Assessment of Adult Literacy 2003 (NAAL) project will produce several published reports that
address the status of literacy among adults in the U.S. and literacy trends over time. The working title of theprincipal NAAL 2003 national and state reports is: Literacy Skills of America's Adults in Workplace,
Family, and Community Settings. Available at: http://nces.ed.gov/naal/
ABS (Australian Bureau of Statistics), Aspects of Literacy: assessed skill levels in Australia 1996. 1997,
Canberra: Australian Government Publishing Service.
Literacy in the Information Age: Final Report of the International Adult Literacy Survey OECD, Paris andthe Minister of Industry, Canada, 2000.
National Needs and Impact Survey of Literacy, Numeracy and ICT Skills, October 2003. Department for
Education and Skills, DfES Research Report 490. HMSO.

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Section J: Using plain language________________________________________________________________________

Appendix: Measuring readability
Using a readability formula is a good first evaluation of any patient decision aid. The result, usually
expressed in a grade level, gives an estimate of the level of reading difficulty. The formulas (e.g.
SMOG, Fry) are generally valid within 1-2 grade levels and have good inter-formula correlation.
Variation is largely due to different assumptions about level of reader comprehension. All formulas,
however, are just indicators of reading ease or difficulty and should be used within a larger context ofusing plain language writing and design techniques.
Directions for using the SMOG are at this Harvard School of Public Health website:www.hsph.harvard.edu/healthliteracy. Directions for using the Fry are in “Doak, Doak, and Root
(1996). Teaching Patients with Low Literacy Skills.”
If developers of patient decision aids want to use their computers to assess readability, they need topurchase software designed especially for this purpose (see references). The assessment software built
into MS Word is not accurate and the Flesch-Kincaid formula as programmed in the software does notreport a grade level above grade 12.
If using a computer program, the document must be “cleaned up” prior to running the readability
analysis program. This includes deleting all titles and subtitles, extraneous periods (for example, after“Dr.”), and all bulleted lists. There may be other software instructions to follow as well.
Appendix: Resources for plain language writing
The following are several governmental and not-for-profit organizations’ guidelines for plain languagethat would be helpful to patient decision aid developers:• www.plainlanguagenetwork.org• www.plainlanugage.gov• www.cdc.gov/publications.htm (publication at end of list titled “Simply Put” for CDC
standards)• http://oc.nci.nih.gov/services/Clear_and_Simple/HOME.HTM (These are NIH guidelines)• www.usability.gov/guidelines/usability/guidelines.pdf (federal standards for website usability)• www.discern.org.uk• www.clear.nald.ca

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Section K: Basing information on up-to-date scientific evidence______________________________________________________________________

Section K: Basing information on up-to-date scientific evidence
Authors
Tim Whelan (lead)

McMaster University

CA

Michael Pignone

University of North Carolina

US

Rationale
Use of accurate information. There is an expectation by patients and health professionals thatpatient decision aids are based on the most accurate information available. For a particularclinical decision, the patient decision aid should use the best available evidence to describe all
the relevant health care options and their associated outcomes (benefits and risks). Ideally, thepatient decision aid’s evidence should be based on data from a systematic review(s), in which
the published and unpublished literature is systematically searched for the highest quality
studies, then summarized, if applicable, using meta-analyses. Normally, practice guidelines will
carefully outline the quality of evidence of the benefits of different health care options. Ideally,
the harms associated with the health care options described in the patient decision aid should
also be supported by the highest quality of evidence available. On occasion, patient decision aid
developers will have to perform their own systematic reviews to adequately identify the best
available option/outcome evidence. In this situation, details of these reviews should be
described in the patient decision aid’s background material.
Source for accurate information. The quality of the information used in the patient decision
aid has implications for the level of certainty placed on that information; patients have a right toknow the limitations of the evidence supporting the effectiveness of different options. The best
available option/outcome evidence should be characterized in terms of its quality, so that users(patients and practitioners) can appreciate the level of uncertainty regarding the likelihood that a
particular screening/treatment option causes a particular therapeutic/harmful outcome. There
are many rating systems for quality of evidence, ranging from high grade (usually a metaanalysis or randomized trial) to relatively low grade (often a cohort study or a case series)(Oxman et al., 2005). For example, data from a non randomized comparison cohort study
regarding the efficacy of treatment is likely to be less certain than data from a large randomized
trial.
• For studies of treatments, the highest quality of evidence regarding effectivenesscomes from rigorous meta-analyses or large randomized trials.
• Observational studies (e.g. cohort studies or case control studies) are less likely toprovide high quality evidence about the relationship between a particular
screening/treatment option and a therapeutic effect.
• Descriptive studies, including case series, provide lower quality evidence about therelationship between an option and an outcome.
• With respect to the incidence of adverse effects, observational and descriptive studies
may provide as good or better evidence than data from randomized trials.

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Relevance of evidence. Information describing the therapeutic effectiveness of different
treatment options in the patient decision aid should be directly applicable to the patients andpractitioners who use it. This pertains not only to the population who will use the instrument,
but also, in particular, to the intervention being described. For example, a patient decision aid
describing the benefits and harms of adjuvant chemotherapy in women with breast cancer
should be based on data from randomized trials or systematic reviews involving patients ofsimilar age and stage of disease as the women who will be using the patient decision aid.
Tailored information to individual characteristics. When outcome probabilities are tailored tothe clinical risk for different patient populations, evidence for the different risk groups or therisk assessment tool employed in the patient decision aid should be provided. Such evidence
might include data from those studies and any secondary validation studies.
Regular updating of evidence. Information supporting different health care options can quickly
become out-dated. Ideally, evidence supporting the information contained in the patientdecision aid should be regularly updated at least every two to three years and preferably on a
yearly basis. The process used for the update (i.e. whether a systemic review was performed)
should be described. By providing a statement regarding the update policy, patients andpractitioners can form their own opinions about the degree of confidence to be placed in thepatient decision aid’s information.
Evidence
RCTs involving patients facing actual choices. Of 29 individual patient decision aids,
evaluated in 34 RCTs included in the Cochrane review, 19 were available for review of theircontent (O’Connor et al., 2003). Of these,• 13 of 19 (68%) of DAs provided specific citation either within the patient decision aid (3of 13) or in a separate resource (10 of 13).
• 5 of 19 (26%) described the quality of the evidence with 3 patient decision aids that werebased on clinical practice guidelines• 3 of 19 (16%) described the uncertainty in the evidence presented within the patientdecision aid.
Two studies described how different risk groups used in the patient decision aid were identified.
References
O’Connor AM, Stacey D, Entwistle V, Llewellyn-Thomas H, Rovner D, Holmes-Rovner M, Tait V, Tetroe J,
fiset V, Barry M, Jones J. DAs for people facing health treatment or screening decisions (Cochrane Review). In:
The Cochrane Library, Issue 2 2003. Oxford: Update Software.
http://www.cochrane.org/cochrane/revabstr/ab001431.htm.
Oxman A, et al and the GRADE Working Group. Grading evidence and formulating recommendations.
Submitted for publication

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Section L: Establishing the effectiveness______________________________________________________________________

Section L: Establishing the effectiveness
Authors
Vikki Entwistle (co-lead)

University of Aberdeen, Health Services Research UnitUK

Al Mulley (co-lead)

Harvard Medical School, Boston

US

Annette O’Connor

University of Ottawa

CA

Theresa Marteau

King's College London Research Group

UK

Andrew Kennedy

Council on Health Research for Development (COHRED)

Karen Sepucha

Harvard Medical School, Boston

Switzerland
US

Rationale / Theory
There is a reasonable consensus that: a) patient decision aids aim to improve the quality of decision
making; and b) quality decisions are those that result in individuals choosing and/or receiving thehealth care interventions that are most consistent with their informed and considered values (Briss etal., 2004; O’Connor et al., 1997; O’Connor, Stacey et al., 2003; Ratliff et al., 1999; Sepucha et al.,2004).
An assessment of the effectiveness of a patient decision aid should, therefore, comprises evaluation of
the extent to which it improves the proportion of patients who choose and/or receive health careinterventions that are consistent with their individual values. There is, as yet, no 8 approach or metricfor measuring the congruence between an individual’s values and the health care options they choose
and/or receive.
Given the current state of methodological knowledge and experience, two strategies might now be
pursued to further the evaluation of the effectiveness of patient decision aids:
1) The development of methods and measures for assessing the primary endpoint criterion (e.g.
decisions that are consistent with the individual’s informed and considered attitudes towards
health states that might be affected by the decision; attitudes towards the risks associated withthe relevant options; willingness to make trade-offs over time; and position in relation to othervalue–relevant issues involved in the decision);
2) The assessment of process criteria that are likely to support the achievement of the primary
endpoint criterionFirst we outline here one promising approach for measuring the primary endpoint criterion. Then we
identify some process criteria that are likely to support the achievement of the primary endpoint
criterion.
An approach for measuring the primary endpoint criterion
For most, if not all, of the decisions that patient decision aid developers seek to support, it will bepossible to identify a number of option attributes, risk considerations, time trade off considerations, andother value-relevant issues that are most usually salient for patients facing the decision of interest.
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Section L: Establishing the effectiveness______________________________________________________________________(This identification step would require a rigorous social process involving a group representing all
relevant perspectives and sources of expertise relating to the particular decision that the patientdecision aid is intended to support),
Then the quality of decision-making could be reasonably estimated for a population of patients facing
the decision. This could be done by gauging the (aggregate) proportion of patients for whom the healthcare option selected and/or received is consistent with their attitudes towards the most usually salient
attributes and considerations.
We recognize that there will probably always be some individuals for whom the most usually salient
option attributes and value considerations are not the ones on which their decision turns, because otherattributes and value considerations are more important to them. However, assuming all other things
are equal, when populations of patients that did and did not use a patient decision aid when facing thedecision are compared, the odds ratio of the aggregate proportion of patients for whom the option
chosen and/or received was consistent with their attitudes towards the most usually salient attributes
and considerations should serve as a reasonable measure of the decision quality achieved with andwithout the patient decision aid.
Methodological development will be needed to refine both (a) the basic approach to this kind of
measurement, as well as (b) the decision-specific measures of the options chosen, individuals’
knowledge about the most usually salient option attributes (in order to ensure that patients’ attitudes arewell informed), and individuals’ attitudes towards the most usually salient option attributes and value
considerations.
Process criteria likely to support the achievement of the primary endpoint criterion
Process criteria that are likely to support the achievement of the primary endpoint criterion include theknowledge assessment mentioned above and also the extent to which patients: recognise there is a
decision to be made; understand that no single option is best for everyone because patients havedifferent values and preferences; appreciate that their own goals, values, and preferences matter in thedecision; and have reflected on and discussed their attitudes towards the most usually salient option
attributes and value considerations with the practitioner(s) with whom they are making the decision.
Other outcome criteria of interest
The use of patient decision aids in practice may affect a number of health care processes and outcomesin addition to the ones mentioned above. The focus in this document on decision quality as the primary
endpoint criterion is not meant to imply that other outcomes are unimportant. Patients’ perceptions of
the decision making process and confidence in the decisions made are, for example, important aspectsof the quality of health care that may be affected by the use of patient decision aids. However, they are
not the best indicators of whether a patient decision aid has fulfilled its aim of improving decisionquality; for example, patients who are not well informed about their health care options may express
confidence in a particular choice even if it is not consistent with their reported values.
Evidence
There is a reasonable consensus that (a) patient decision aids aim essentially to improve the quality ofdecision making, and (b) good decisions are those that result in individuals choosing and/or receiving
the health care interventions that are most consistent with their informed and considered values.

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Section L: Establishing the effectiveness______________________________________________________________________For example, a national survey of the public endorsed the criteria of being informed about options,outcomes and probabilities, having clear values, making a choice that is congruent with values, andbeing satisfied with the choice (O’Connor, Drake et al., 2003). A survey of oncologists place thehighest endorsement (>95%) on the patient criteria of being clear about the values tradeoffs in thedecision and being informed of treatment alternatives, harms, and benefits (O’Connor et al., 1997).
Trials of patient decision aids also frequently assess these criteria. In 34 trials of individual patientdecision aids, 18 measured knowledge, 10 measured feeling clear about values, and 3 measured
agreement between values and choices (O’Connor, Stacey et al., 2003).
References
Bekker HL, Legare F, Stacey D, O'Connor A, Lemyre L. Is anxiety an appropriate measure of decision aid
effectiveness: a systematic review? Patient Education and Counselling. 2003; 50: 255-262.
Briss P, Rimer B, Reilley B, Coates R, Lee N, Mullen P et al. Promoting Informed Decisions About Cancer
Screening in Communities and Healthcare Systems. Am J Prev Med 2004;26:67-80.
O'Connor AM, Drake ER, Wells GA, Tugwell P, Laupacis A, Elmslie T. A survey of the decision-making needsof Canadians faced with complex health decisions. Health Expectations 2003;6:97-109.
O'Connor A, Llewellyn-Thomas H, Sawka C, Pinfold S, To T, Harrison D. Physicians' opinions about decision
aids for patients considering systemic adjuvant therapy for axillary-node negative breast cancer. Patient
Education & Counseling 1997;30:143-53.
O’Connor AM, Stacey D, Entwistle V, Llewellyn-Thomas H, Rovner D, Holmes-Rovner M, Tait V, Tetroe J,
fiset V, Barry M, Jones J. DAs for people facing health treatment or screening decisions (Cochrane Review). In:
The Cochrane Library, Issue 2 2003. Oxford: Update Software.
http://www.cochrane.org/cochrane/revabstr/ab001431.htm.
Ratliff A, Angell M, Dow R, Kupperman M, Nease R, Fisher R et al. What is a good decision? Effective Clinical
Practice 1999;2:185-97.
Sepucha, KR, Fowler, FJ, Mulley AG. Policy support for patient-centered care: The need for measurable
improvements in decision quality. Health Affairs 2004.

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