Evidence
Alert

Decision aids including leaflets and computer programs help patients make treatment choices

Decision aids help patients choose between treatment options in obstetrics and gynaecology, and reduce uncertainty.

A systematic review of trials of decision aids used for choices of contraception, caesarean section and menopause treatment found that patients who used them felt more confident in their ability to make the decision that was right for them, and less uncertain about this decision. This was compared with usual care or an information aid.

Decision aids set out information about medical conditions, the treatments available, and the benefits and risks of these options. They help people consider which benefits and risks are most important to them, and to make a decision that reflects their own values. Aids can be online, apps, computer programmes or printed.

While the results suggest a useful role for decision aids, clinicians report worries about the additional time that their use may involve. Routine use of decision aids will require training and carefully designed processes to avoid this becoming an issue.

Why was this study needed?

Patient decision aids are intended to facilitate shared decision making, where patients make a decision about treatment in partnership with their clinician.

A Cochrane systematic review published in 2017 concluded: “People exposed to decision aids feel more knowledgeable, better informed, and clearer about their values, and they probably have a more active role in decision making and more accurate risk perceptions.” However, decision aids are still not widely used in clinical practice.

Obstetrics and gynaecology is an area where many decisions (such as whether to have a vaginal birth after a previous caesarean section) are amenable to shared decision making. This review looked at the evidence for the impact of decision aids for this specialty.

What did this study do?

Researchers carried out a systematic review which identified 35 eligible randomised controlled trials of decision aids, involving 9,790 women. They did a meta-analysis of the primary outcome, participants’ ‘decisional conflict’ over their decision.

Obstetric and gynaecological decisions included contraception, vaginal birth after caesarean section, and treatment for menopausal symptoms. Decision aids included printed material, interactive computer or online programmes, mobile apps and semi-structured interviews. Five studies were from the UK.

For all outcomes, the results need to be treated with caution because there was significant variation between the studies. This was partly explained by the fact that the decision aids covered a wide variety of conditions and decision options. Some conditions seemed to be more amenable than others to use of decision aids.

What did it find?

  • Decision aids led to a small reduction in participants’ decisional conflict, meaning they were more confident in their decision (standardised mean difference [SMD] -0.23, 95% confidence interval [CI] -0.36 to -0.11; 19 trials, 4,624 women).
  • Decision aids led to a moderate improvement in patients’ knowledge of their condition and treatment options (SMD 0.58, 95% CI 0.44 to 0.71; 17 trials, 4,375 women).
  • The researchers found no difference in patients’ levels of anxiety (SMD ‑0.04, 95% CI ‑0.14 to 0.06; 12 trials, 2,714 women) or satisfaction with their treatment (SMD 0.17, 95% CI 0.09 to 0.24; 6 trials, 2,718 women).
  • Only three trials included information about the cost-effectiveness of interventions, and they used different assessment methods. The researchers did not carry out a meta-analysis for this outcome, because of the small numbers, but said all trials reported cost savings from their use.

What does current guidance say on this issue?

While there is no specific NICE guideline on the use of patient decision aids, NICE has written a key therapeutic topic report about the importance of shared decision making, and provides links to NICE’s own patient decision aids.

The summary section on evidence around decision aids and shared decision-making states: “All NICE guidance recommends shared decision making, and several NICE quality standards identify and define shared decision making as part of good quality care.”

What are the implications?

This review adds to previous evidence which suggests that patient decision aids can help patients make better decisions, with less uncertainty. It adds to the pressure for decision aids to be adopted in clinical practice as part of shared decision making.

However, the review does not address the previously-observed reservations from clinicians, who may fear that decision aids will add to their workload. Useful adoption of decision aids will involve training of clinicians, and design of processes to ensure their use becomes an efficient part of routine practice.

Citation and Funding

Poprzeczny AJ, Stocking K, Showell M et al. Patient decision aids to facilitate shared decision making in obstetrics and gynecology. A systematic review and meta-analysis. Obstet Gynecol. 2020;135(2):479–80.

No funding information was available for this study.

Bibliography

NICE. Shared decision making. KTT23. London: National Institute for Health and Care Excellence; 2019.

Stacey D, Légaré F, Lewis K et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2017;(4):CD001431.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

Definitions

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Commentaries

Expert commentary

Creating patient decision aids appears to be time well spent as they improve knowledge and decisional conflict. These aids include apps, online bots (interactive computer programmes) and printed leaflets, but the benefit is dependent on clinical circumstance as results are variable.

There remains a need for clinical contact. Further work is required to assess the cost-effectiveness of such interventions.

As this discipline evolves, consideration as to the best method of dissemination is required.

Andrew Shennan, Professor of Obstetrics, St Thomas’ Hospital, King’s College London

Dr Lucie Giblin, Obstetrics and Gynaecology trainee, St George’s Hospital, London

The commentators declare no conflicting interests

 

Expert commentary

The authors showed that use of PDAs reduced decisional conflict and led to improved patient knowledge but without any reduction in anxiety or improvement in patient satisfaction. Studies have been confined to high-income settings.

My own experience has been mixed; I was involved in setting up an NHS online patient decision aid concerning the choice of mode of delivery after a previous Caesarean. The methodology was robust but the service was later withdrawn due to low use, most likely due to a lack of publicity and signposting of the facility.

The use of patient decision aids should be encouraged but this requires organisational support nationally or internationally.

Malcolm Griffiths, Obstetrician and Gynaecologist, Luton and Dunstable Hospital

The author was involved in the NHS shared decision making birth after caesarean section patient decision aid (PDA) Advisory Group (2012-2013). He acted as an advisor/contributor to this PDA, but it was removed from the internet by the organisation over two years ago. He had no financial interest in the project.