title: Decision aids for people facing health treatment or screening decisions.
abstract: Decision aids are interventions that support patients by making their decisions explicit, providing information about options and associated benefits/harms, and helping clarify congruence between decisions and personal values.
  
  
  
  To assess the effects of decision aids in people facing treatment or screening decisions.
  
  
  
  Updated search (2012 to April 2015) in CENTRAL; MEDLINE; Embase; PsycINFO; and grey literature; includes CINAHL to September 2008.
  
  
  
  We included published randomized controlled trials comparing decision aids to usual care and/or alternative interventions. For this update, we excluded studies comparing detailed versus simple decision aids.
  
  
  
  Two reviewers independently screened citations for inclusion, extracted data, and assessed risk of bias. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made and the decision-making process.Secondary outcomes were behavioural, health, and health system effects.We pooled results using mean differences (MDs) and risk ratios (RRs), applying a random-effects model. We conducted a subgroup analysis of studies that used the patient decision aid to prepare for the consultation and of those that used it in the consultation. We used GRADE to assess the strength of the evidence.
  
  
  
  We included 105 studies involving 31,043 participants. This update added 18 studies and removed 28 previously included studies comparing detailed versus simple decision aids. During the 'Risk of bias' assessment, we rated two items (selective reporting and blinding of participants/personnel) as mostly unclear due to inadequate reporting. Twelve of 105 studies were at high risk of bias.With regard to the attributes of the choice made, decision aids increased participants' knowledge (MD 13.27/100; 95% confidence interval (CI) 11.32 to 15.23; 52 studies; N = 13,316; high-quality evidence), accuracy of risk perceptions (RR 2.10; 95% CI 1.66 to 2.66; 17 studies; N = 5096; moderate-quality evidence), and congruency between informed values and care choices (RR 2.06; 95% CI 1.46 to 2.91; 10 studies; N = 4626; low-quality evidence) compared to usual care.Regarding attributes related to the decision-making process and compared to usual care, decision aids decreased decisional conflict related to feeling uninformed (MD -9.28/100; 95% CI -12.20 to -6.36; 27 studies; N = 5707; high-quality evidence), indecision about personal values (MD -8.81/100; 95% CI -11.99 to -5.63; 23 studies; N = 5068; high-quality evidence), and the proportion of people who were passive in decision making (RR 0.68; 95% CI 0.55 to 0.83; 16 studies; N = 3180; moderate-quality evidence).Decision aids reduced the proportion of undecided participants and appeared to have a positive effect on patient-clinician communication. Moreover, those exposed to a decision aid were either equally or more satisfied with their decision, the decision-making process, and/or the preparation for decision making compared to usual care.Decision aids also reduced the number of people choosing major elective invasive surgery in favour of more conservative options (RR 0.86; 95% CI 0.75 to 1.00; 18 studies; N = 3844), but this reduction reached statistical significance only after removing the study on prophylactic mastectomy for breast cancer gene carriers (RR 0.84; 95% CI 0.73 to 0.97; 17 studies; N = 3108). Compared to usual care, decision aids reduced the number of people choosing prostate-specific antigen screening (RR 0.88; 95% CI 0.80 to 0.98; 10 studies; N = 3996) and increased those choosing to start new medications for diabetes (RR 1.65; 95% CI 1.06 to 2.56; 4 studies; N = 447). For other testing and screening choices, mostly there were no differences between decision aids and usual care.The median effect of decision aids on length of consultation was 2.6 minutes longer (24 versus 21; 7.5% increase). The costs of the decision aid group were lower in two studies and similar to usual care in four studies. People receiving decision aids do not appear to differ from those receiving usual care in terms of anxiety, general health outcomes, and condition-specific health outcomes. Studies did not report adverse events associated with the use of decision aids.In subgroup analysis, we compared results for decision aids used in preparation for the consultation versus during the consultation, finding similar improvements in pooled analysis for knowledge and accurate risk perception. For other outcomes, we could not conduct formal subgroup analyses because there were too few studies in each subgroup.
  
  
  
  Compared to usual care across a wide variety of decision contexts, 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. There is growing evidence that decision aids may improve values-congruent choices. There are no adverse effects on health outcomes or satisfaction. New for this updated is evidence indicating improved knowledge and accurate risk perceptions when decision aids are used either within or in preparation for the consultation. Further research is needed on the effects on adherence with the chosen option, cost-effectiveness, and use with lower literacy populations.
authors.affiliation: School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, ON, Canada.|Centre for Practice Changing Research, Ottawa Hospital Research Institute, 501 Smyth Rd, Ottawa, ON, Canada, K1H 8L6.
authors.forename: Dawn
authors.initials: D
authors.lastname: Stacey
authors.affiliation: Population Health and Optimal Health Practices Research Axis, CHU de Québec Research Center, Université Laval, 10 Rue de l'Espinay, D6-727, Québec City, QC, Canada, G1L 3L5.
authors.forename: France
authors.initials: F
authors.lastname: Légaré
authors.affiliation: School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, ON, Canada.
authors.forename: Krystina
authors.initials: K
authors.lastname: Lewis
authors.affiliation: Informed Medical Decisions Foundation, Boston, MA, USA.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Barry
authors.affiliation: Clinical Epidemiology Program, Ottawa Hospital Research Institute, Administrative Services Building, Room 2-013, 1053 Carling Avenue, Ottawa, ON, Canada, K1Y 4E9.
authors.forename: Carol L
authors.initials: CL
authors.lastname: Bennett
authors.affiliation: Department of Medical Informatics and Clinical Epidemiology, Oregon Health Sciences University, BICC 535, 3181 S.W. Sam Jackson Park Road, Portland, Oregon, USA, 97239-3098.
authors.forename: Karen B
authors.initials: KB
authors.lastname: Eden
authors.affiliation: Center for Ethics and Humanities in the Life Sciences, Michigan State University College of Human Medicine, East Fee Road, 956 Fee Road Rm C203, East Lansing, Michigan, USA, 48824-1316.
authors.forename: Margaret
authors.initials: M
authors.lastname: Holmes-Rovner
authors.affiliation: The Dartmouth Center for Health Policy & Clinical Practice, The Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, New Hampshire, USA, 03755.
authors.forename: Hilary
authors.initials: H
authors.lastname: Llewellyn-Thomas
authors.affiliation: No affiliation, 28 Greenwood Road, Ingersoll, ON, Canada, N5C 3N1.
authors.forename: Anne
authors.initials: A
authors.lastname: Lyddiatt
authors.affiliation: Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, UK, NE2 4AX.
authors.forename: Richard
authors.initials: R
authors.lastname: Thomson
authors.affiliation: The University of Sydney, Room 322, Edward Ford Building (A27), Sydney, NSW, Australia, 2006.
authors.forename: Lyndal
authors.initials: L
authors.lastname: Trevena
mesh_terms: D003142:Communication; D000072700:Conservative Treatment; D003661:Decision Support Techniques; D017558:Elective Surgical Procedures; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D010353:Patient Education as Topic / Q000379:methods*; D010358:Patient Participation; D010817:Physician-Patient Relations; D017594:Publication Bias; D016032:Randomized Controlled Trials as Topic