Background
Decision aids are intended to help people participate in decisions that involve weighing the benefits and harms of treatment options often with scientific uncertainty.

Objectives
To assess the effects of decision aids for people facing treatment or screening decisions.

Search methods
For this update, we searched from 2009 to June 2012 in MEDLINE; CENTRAL; EMBASE; PsycINFO; and grey literature. Cumulatively, we have searched each database since its start date including CINAHL (to September 2008).

Selection criteria
We included published randomized controlled trials of decision aids, which are interventions designed to support patients' decision making by making explicit the decision, providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies of participants making hypothetical decisions.

Data collection and analysis
Two review authors independently screened citations for inclusion, extracted data, and assessed risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were:

A) 'choice made' attributes;

B) 'decision-making process' attributes.

Secondary outcomes were behavioral, health, and health-system effects. We pooled results using mean differences (MD) and relative risks (RR), applying a random-effects model.

Main results
This update includes 33 new studies for a total of 115 studies involving 34,444 participants. For risk of bias, selective outcome reporting and blinding of participants and personnel were mostly rated as unclear due to inadequate reporting. Based on 7 items, 8 of 115 studies had high risk of bias for 1 or 2 items each.

Of 115 included studies, 88 (76.5%) used at least one of the IPDAS effectiveness criteria: A) 'choice made' attributes criteria: knowledge scores (76 studies); accurate risk perceptions (25 studies); and informed value-based choice (20 studies); and B) 'decision-making process' attributes criteria: feeling informed (34 studies) and feeling clear about values (29 studies).

A) Criteria involving 'choice made' attributes:

Compared to usual care, decision aids increased knowledge (MD 13.34 out of 100; 95% confidence interval (CI) 11.17 to 15.51; n = 42). When more detailed decision aids were compared to simple decision aids, the relative improvement in knowledge was significant (MD 5.52 out of 100; 95% CI 3.90 to 7.15; n = 19). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.82; 95% CI 1.52 to 2.16; n = 19). Exposure to a decision aid with explicit values clarification resulted in a higher proportion of patients choosing an option congruent with their values (RR 1.51; 95% CI 1.17 to 1.96; n = 13).

B) Criteria involving 'decision-making process' attributes:

Decision aids compared to usual care interventions resulted in:

a) lower decisional conflict related to feeling uninformed (MD -7.26 of 100; 95% CI -9.73 to -4.78; n = 22) and feeling unclear about personal values (MD -6.09; 95% CI -8.50 to -3.67; n = 18);

b) reduced proportions of people who were passive in decision making (RR 0.66; 95% CI 0.53 to 0.81; n = 14); and

c) reduced proportions of people who remained undecided post-intervention (RR 0.59; 95% CI 0.47 to 0.72; n = 18).

Decision aids appeared to have a positive effect on patient-practitioner communication in all nine studies that measured this outcome. For satisfaction with the decision (n = 20), decision-making process (n = 17), and/or preparation for decision making (n = 3), those exposed to a decision aid were either more satisfied, or there was no difference between the decision aid versus comparison interventions. No studies evaluated decision-making process attributes for helping patients to recognize that a decision needs to be made, or understanding that values affect the choice.

C) Secondary outcomes

Exposure to decision aids compared to usual care reduced the number of people of choosing major elective invasive surgery in favour of more conservative options (RR 0.79; 95% CI 0.68 to 0.93; n = 15). Exposure to decision aids compared to usual care reduced the number of people choosing to have prostate-specific antigen screening (RR 0.87; 95% CI 0.77 to 0.98; n = 9). When detailed compared to simple decision aids were used, fewer people chose menopausal hormone therapy (RR 0.73; 95% CI 0.55 to 0.98; n = 3). For other decisions, the effect on choices was variable.

The effect of decision aids on length of consultation varied from 8 minutes shorter to 23 minutes longer (median 2.55 minutes longer) with 2 studies indicating statistically-significantly longer, 1 study shorter, and 6 studies reporting no difference in consultation length. Groups of patients receiving decision aids do not appear to differ from comparison groups in terms of anxiety (n = 30), general health outcomes (n = 11), and condition-specific health outcomes (n = 11). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive.

Authors' conclusions
There is high-quality evidence that decision aids compared to usual care improve people's knowledge regarding options, and reduce their decisional conflict related to feeling uninformed and unclear about their personal values. There is moderate-quality evidence that decision aids compared to usual care stimulate people to take a more active role in decision making, and improve accurate risk perceptions when probabilities are included in decision aids, compared to not being included. There is low-quality evidence that decision aids improve congruence between the chosen option and the patient's values.

New for this updated review is further evidence indicating more informed, values-based choices, and improved patient-practitioner communication. There is a variable effect of decision aids on length of consultation. Consistent with findings from the previous review, decision aids have a variable effect on choices. They reduce the number of people choosing discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, cost-effectiveness, use with lower literacy populations, and level of detail needed in decision aids need further evaluation. Little is known about the degree of detail that decision aids need in order to have a positive effect on attributes of the choice made, or the decision-making process.

/pdf/decision-aids-for-people-facing-health-treatment-or-1j1706q17l.pdf

Decision aids for people facing health treatment or screening decisions

Screening mammography aims to identify breast cancer at earlier stages of the disease, when treatment can be more successful1. Despite the existence of screening programmes worldwide, the interpretation of mammograms is affected by high rates of false positives and false negatives2. Here we present an artificial intelligence (AI) system that is capable of surpassing human experts in breast cancer prediction. To assess its performance in the clinical setting, we curated a large representative dataset from the UK and a large enriched dataset from the USA. We show an absolute reduction of 5.7% and 1.2% (USA and UK) in false positives and 9.4% and 2.7% in false negatives. We provide evidence of the ability of the system to generalize from the UK to the USA. In an independent study of six radiologists, the AI system outperformed all of the human readers: the area under the receiver operating characteristic curve (AUC-ROC) for the AI system was greater than the AUC-ROC for the average radiologist by an absolute margin of 11.5%. We ran a simulation in which the AI system participated in the double-reading process that is used in the UK, and found that the AI system maintained non-inferior performance and reduced the workload of the second reader by 88%. This robust assessment of the AI system paves the way for clinical trials to improve the accuracy and efficiency of breast cancer screening. An artificial intelligence (AI) system performs as well as or better than radiologists at detecting breast cancer from mammograms, and using a combination of AI and human inputs could help to improve screening efficiency.

/pdf/international-evaluation-of-an-ai-system-for-breast-cancer-4c1yg7x284.pdf

International evaluation of an AI system for breast cancer screening.

This guideline from the USPSTF is based on current evidence on mammography, digital breast tomography, and supplemental screening for breast cancer. The recommendations apply to asymptomatic women ...

/pdf/screening-for-breast-cancer-u-s-preventive-services-task-4hi5mt179k.pdf

Screening for Breast Cancer: U.S. Preventive Services Task Force Recommendation Statement

https://www.pure.ed.ac.uk/ws/files/8378925/The_benefits_and_harms_of_breast_cancer_screening.pdf

The benefits and harms of breast cancer screening: an independent review

Description: Update of the 2002 U. S. Preventive Services Task Force (USPSTF) recommendation statement on screening for breast cancer in the general population. Methods: The USPSTF examined the evidence on the efficacy of 5 screening modalities in reducing mortality from breast cancer: film mammography, clinical breast examination, breast self-examination, digital mammography, and magnetic resonance imaging in order to update the 2002 recommendation. To accomplish this update, the USPSTF commissioned 2 studies: 1) a targeted systematic evidence review of 6 selected questions relating to benefits and harms of screening, and 2) a decision analysis that used population modeling techniques to compare the expected health outcomes and resource requirements of starting and ending mammography screening at different ages and using annual versus biennial screening intervals. Recommendations: The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take into account patient context, including the patient's values regarding specific benefits and harms. (Grade C recommendation) The USPSTF recommends biennial screening mammography for women between the ages of 50 and 74 years. (Grade B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening mammography in women 40 years or older. (I statement) The USPSTF recommends against clinicians teaching women how to perform breast self-examination. (Grade D recommendation) The USPSTF concludes that the current evidence is insufficient to assess additional benefits and harms of either digital mammography or magnetic resonance imaging instead of film mammography as screening modalities for breast cancer. (I statement)

/pdf/screening-for-breast-cancer-us-preventive-services-task-3mgfmvx4oo.pdf

Screening for Breast Cancer: US Preventive Services Task Force Recommendation Statement

Competing interests: Marcello Tonelli, Michel Joffres, James Dickinson, Harminder Singh, Gabriela Lewin and Richard Birtwhistle have received support for travel to meetings from the Public Health Agency of Canada. Gabriela Lewin is an employee of Kemptville District Hospital. No other competing interests were declared.



This article has been peer reviewed.



Contributors: All of the authors made substantial contributions to the conception and design of the article, the acquisition, analysis and interpretation of data, drafted the article and revised it critically for important intellectual content and approved the final version submitted for publication.



Funding: Funding for the Canadian Task Force on Preventive Health Care is provided by the Public Health Agency of Canada and the Canadian Institutes of Health Research. The views of the funding bodies have not influenced the content of the guideline; competing interests have been recorded and addressed. The views expressed in this article are those of the authors and do not represent those of the Public Health Agency of Canada.



Guidelines writing group: Marcello Tonelli, Sarah Connor Gorber, Michel Joffres, James Dickinson, Harminder Singh, Gabriela Lewin, Richard Birtwhistle.



Systematic review writing group: Donna Fitzpatrick-Lewis, Nicole Hodgson, Donna Ciliska, Marcello Tonelli, Mary Gauld, Yan Yun Liu.

Recommendations on screening for breast cancer in average-risk women aged 40-74 years.

OBJECTIVE To determine the eff ectiveness of preventive primary care outreach interventions aimed at older people. Knowing whether such interventions are eff ective could help busy family physicians make choices about which preventive care services to provide. DATA SOURCES We searched MEDLINE, CINAHL, AgeLine, Cochrane Controlled Trials Register, and EMBASE databases and reviewed the reference lists of retrieved articles. STUDY SELECTION We included studies of preventive primary care interventions aimed at patients 65 years and older if the studies were randomized controlled trials and if any of the following outcomes was reported: mortality, living in the community, admission to acute care hospitals, and admission to long-term care. We defi ned preventive primary care outreach as proactive, provider-initiated care, which can be provided by nurses, physicians, other professionals, or volunteers, that is in addition to usual care and is provided in primary care settings. Such care can be provided through home visits, offi ce visits, telephone contacts, or a combination of these methods. SYNTHESIS We assessed the quality of studies and extracted descriptive information on study populations, interventions, and outcomes for 19 trials involving 14 911 patients. Summary odds ratios were estimated for each outcome using a random eff ects model. CONCLUSION This review showed that studies of preventive primary care outreach interventions aimed at older people were associated with a 17% reduction of mortality and a 23% increased likelihood of continuing to live in the community.

https://www.cfp.ca/content/cfp/51/9/1244.full.pdf

Effectiveness of preventive primary care outreach interventions aimed at older people: meta-analysis of randomized controlled trials.

Decision aids are mechanisms or interventions that have been developed to improve communication between health professionals and patients, and to help involve patients in making decisions regarding their health care. Decision aids can include brochures, videotapes or interactive computer programs. Recent reviews have suggested that decision aids may be effective in supporting general health care decisions. Cancer screening or treatment have been found to be particularly prone to difficulties in communication and decisionmaking between health professionals and their patients. There are a number of reasons for these problems, including difficulties in communicating information about poor prognoses and the modest benefits of the treatments used. The objective of this study was to conduct a comprehensive, systematic review of the literature to determine the impact of decision aids on cancer prevention, screening, and treatment decisions.

Impact of cancer-related decision aids.

CRD summary The authors concluded that pharmacotherapy can improve cognitive symptoms and outcomes, there is some evidence for delay in disease progression, and some agents were shown to be effective in patients with vascular dementia. However, few head-to-head studies were found and there were insufficient data relating to efficacy in different subgroups of patients. Despite some minor limitations, the authors' conclusions are likely to be reliable.

Pharmacological treatment of dementia.

Acute wound care distress among burn-injured pediatric patients is of major clinical concern. This systematic review evaluates the benefits of nonpharmacological interventions to reduce this distress. MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, and the Cochrane Library databases were searched using appropriate search terms for articles reporting overall psychological effects of pediatric burn injury. Key references were hand-searched. Searches yielded approximately 900 unique citations. Two authors reviewed each abstract, and 198 articles were retrieved, of which 34 were selected for full review. Of these 34 articles, 12 focused on acute wound care distress and nonpharmacological interventions. Critical appraisal of individual studies was conducted using the methods of the US Preventive Services Task Force, with a particular focus on assessing nonrandomized controlled trial designs. Twelve articles were reviewed and categorized according to intervention types child mediated (CM), parent mediated (PM), and health care provider mediated (HCPM). Using the US Preventive Services Task Force criteria, 7 of the 12 articles were rated "fair" or "good" and five were rated as having "poor" internal validity. The HCPM and CM intervention categories reported patient benefit. The two PM studies were both rated "poor." Studies of nonpharmacological interventions to reduce pediatric burn distress were few, with a significant proportion (5/12) having concerns about internal validity. Patient benefit was reported for HCPM and CM interventions. Research designs incorporating control groups in studies that are adequately powered are needed. Additional research is required in the area of PM interventions in particular.

Nonpharmacological interventions for acute wound care distress in pediatric patients with burn injury: a systematic review.

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