A randomized trial of a computerized versus an audio-booklet decision aid for women considering post-menopausal hormone replacement therapy
Introduction
Decision aids (DAs) are increasingly being developed and disseminated to help patients make shared health care decisions with their practitioners [1], [2]. These interventions are intended to help patients gain a greater understanding of their particular disease, their medical choices, alternative treatment options, as well as the risks and benefits of these alternatives, and aim to empower patients to participate actively in a shared decision-making process with their practitioner [1], [2], [3], [4], [5]. DAs are most useful when there is uncertainty about the scientific evidence regarding the benefits and risks of the various options, or if there is no single “best” treatment since patients vary in the importance that they place on the benefits versus risks of the available treatment options [1], [6]. DAs differ from general educational interventions by helping patients consider both the probabilities of benefits and risks, and the values of the specific options.
The efficacy of DAs at improving patients’ knowledge (Kn) and expectations of the benefits and risks of their available treatment options is now well-established [1], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16]. However, O’Connor et al. have found that despite improvements in expectations, a significant proportions of those using DAs still have expectations of outcomes that are inconsistent with the estimates from the best available evidence for their clinical risk category [1], [4], [5]. Other research in the area of patient education and informed consent has also noted gaps in patient understanding after educational interventions [17], [18]. This evidence suggests that further gains can be made in DA design to address this issue.
Currently available DA aids have utilized different delivery methods such as pamphlets and booklets or less commonly interactive videodisc or computer-based systems [1]. Computerized delivery methods have the advantage of allowing patients control over the flow of information, focusing attention through synchronized multimedia, and providing feedback to reinforce their comprehension. In the related patient education field, interactive computer-based educational interventions have gained considerable interest, and show significant improvements in patient Kn scores, and in some clinical outcomes. The field of computerized patient education has recently been reviewed [18], [19], [20], [21].
Programmed instruction is a behavioral learning technique that presents information to patients in a graded self-paced manner, and follows each learning segment with a series of questions that reinforces the learning. This technique can be implemented using various delivery methods ranging from booklets to interactive computer systems. Programmed instruction has not been utilized in the DA field [1], but is increasingly being utilized, though not always by computer, in the patient education field with documented efficacy [22], [23], [24], [25].
There are currently no formal comparisons of standard versus computerized DA delivery methods. Therefore we developed an interactive computerized version of a previously validated DA for women considering hormone replacement therapy, a clinical area where the importance of decision support has been documented [5]. The purpose of this investigation was to test the hypothesis that a computerized DA with programmed instructional feedback could improve further on the gains in Kn and expectations obtained with the standard audio-booklet based DA.
Section snippets
Methods
This study was approved by the Ottawa Hospital research ethics committee.
Baseline characteristics
Fifty-one participants fulfilled the inclusion criteria, and were randomized to either the computerized DA (n=25) or the audio-booklet DA (n=26). A complete data set was available for all randomized patients with no loss to follow-up. The baseline characteristics for the included patients are presented in Table 1. The groups were similar except that, on average, participants in the computer group were more likely to be still menstruating, and therefore not taking HRT. Factorial analysis showed
Discussion
The results of this study demonstrate that the addition of an interactive programmed self-assessment and feedback module to an otherwise factually identical DA can significantly improve RE and Kn scores over levels obtained with a standard DA. In particular, the increase in the RE score with the computerized DA is greater than previously reported with other DA formats [4], [5].
This study is the first trial comparing a computerized DA with a standard DA in the setting of patient health-related
Practice implications
This study offers important insight into the use of computerized technology with tailored feedback and reinforcement of learning. The results suggest that this technology can significantly improve patient Kn and expectations of benefits and harms over levels achieved with standard delivery methods. This technology is most useful in areas were it is desirable for patients to recall the presented information with little error, such as in comparing the risks and benefits of competing treatment
Conclusion
The addition of a computer-controlled programmed Kn assessment and feedback system to an otherwise identical DA results in improvements in RE and Kn. These improvements are most marked when participants are required to recall risk data with little error (<15%). These results now open the door for further study on the impact of these improved scores on actual decision-making. As well, the results of this study suggest potential application of this type of feedback system in other areas of
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A Review of Decision Aids for Patients Considering More Than One Type of Invasive Treatment
2019, Journal of Surgical ResearchShared decision making in endocrinology: present and future directions
2016, The Lancet Diabetes and EndocrinologyCitation Excerpt :Most decision aids can be found and used freely online (panel 3). Of the available decision aids, a few have been tested in randomised trials (table 3).51–67 Overall, in agreement with the results of the Cochrane review,10 these trials show that decision aids improve the ability of patients to make decisions, increase the patients' knowledge and quality (assessed using the 16-item Decisional Conflict Scale)68 of their decisions, increase the accuracy of perceived risk and confidence to make a decision, and reduce decisional conflict and facilitate a more active role for the patient in the decision-making process.
The impact of medical informatics on patient satisfaction: A USA-based literature review
2013, International Journal of Medical InformaticsComputerised decision aids: A systematic review of their effectiveness in facilitating high-quality decision-making in various health-related contexts
2012, Patient Education and CounselingCitation Excerpt :Compared with a simpler DA [47], no superior effects of the CDA were evident at 3-months post-intervention; however, a programming error which misinformed 48% of intervention participants underestimating their baseline breast cancer risk, may have contributed [47]. In contrast, compared with a factually identical DA [19], a CDA including a risk calculator based on published risk data and a feedback module was superior in facilitating realistic expectations immediately post-intervention [19]. From this limited evidence no conclusions can be drawn regarding the efficacy of CDAs on this outcome.
A systematic review of menopausal symptom management decision aid trials
2011, MaturitasCitation Excerpt :In a UCT, knowledge and risk expectations improved over time [17] but, in other RCT, knowledge outcomes were not consistently superior with decision aids [18,24,30,31]. More complicated decision aid formats (e.g., computer or lecture/discussion) did not consistently result in greater knowledge [19,22,27,28]. Additional outcomes included decision consistency with personal values (1 UCT, 1 RCT), decision made or treatment preference (7 RCT), and persistence or adherence to the preferred treatment (2 RCT).