A randomized trial of a computerized versus an audio-booklet decision aid for women considering post-menopausal hormone replacement therapy

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Abstract

Decision aids (DAs) are increasingly being developed to help patients make shared health care decisions with their practitioners. There are no formal comparisons of the efficacy of different delivery methods. Interactive computerized delivery methods have the advantage of allowing patients control over flow of information and to receive feedback on their comprehension. The purpose of this study was to compare the efficacy of an interactive computerized DA for women considering long-term hormone replacement therapy, to that of a validated audio-booklet version of the same intervention. Fifty-one peri-menopausal women were randomized to use either the computerized or the standard audio-booklet version of the DA. The computerized version presented identical information with the addition of feedback modules to reinforce the participant’s understanding. The patients were interviewed with a pre- and post-intervention questionnaire. The computerized DA improved realistic expectations by 52.7% over baseline versus 27.6% with the audio-booklet (P=0.015). Knowledge (Kn) scores improved by 17.5 and 8.4% for the computer and standard DA groups, respectively (P=0.019). The results of this study have implications for future DA design, and other areas where patient Kn and understanding are important, such as in the setting of informed consent.

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

References (33)

  • A. O’Connor et al.

    Physicians’ opinions about decision aids for patients considering systemic adjuvant therapy for axillary-node negative breast cancer

    Patient Educ. Counsel

    (1997)
  • E. Lehmann et al.

    Computer assisted diabetes care: a 6-year retrospective. Application of computers in diabetes care—a review. II. Computers for decision support and education

    Comput. Methods Programs Biomed.

    (1996)
  • O’Connor AM, Rostom A, Fiset V, Tetroe J, Entwistle V, Llewellyn-Thomas HA, et al. Decision aids for patients facing...
  • Hersey J, Matheson J, Lohr, K. The effects of informatics tools and decision aids to support patient decision making...
  • O’Connor A, Tugwell P, Wells G, Elmslie T, Jolly E, Hollingworth G, et al. A decision aid for women considering hormone...
  • O’Connor A, Tugwell P, Wells G, Elmslie T, Jolly E, Hollingworth G, et al. Randomized trial of a portable,...
  • Eddy D. A manual for assessing health practices and designing practice policies, the explicit approach. Philadelphia:...
  • A. O’Connor et al.

    Annotated bibliography: studies evaluating decision-support interventions for patients

    Can. J. Nurs. Res.

    (1997)
  • M. Barry et al.

    A randomized trial of a mulitmedia shared decision-making program for men facing a treatment decision for benign prostatic hyperplasia

    Dis. Manage. Clin. Outcomes

    (1997)
  • S. Bernstein et al.

    A randomized controlled trial of information-giving to patients referred for coronary angiography: effects on outcomes of care

    Health Expect.

    (1998)
  • R. Dunn et al.

    Videotape increases parent knowledge about poliovirus vaccines and choices of polio vaccination schedules

    Pediatrics

    (1998)
  • Lerman C, Biesecker B, Benkendorf J, Kerner J, Gomez-Caminero A, Hughes C, et al. Controlled trial of pretest education...
  • ManSon Hing M, Laupacis A, O’Connor A, Biggs J, Drake E, Yetisir E, et al. A patient decision aid regarding...
  • Morgan MW. A randomized trial of the ischemic heart disease shared decision making program: an evaluation of a decision...
  • R. Volk et al.

    A randomized controlled trial of shared decision making for prostate cancer screening

    Arch. Fam. Med.

    (1999)
  • A. Wolf et al.

    Does informed consent alter elderly patients’ preferences for colorectal cancer screening? Results of a randomized trial

    J. Gen. Intern. Med.

    (2000)
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