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

From best evidence to best practice: effective implementation of change in patients' care

From best evidence to best practice: effective implementation of change in patients' care. Commentary

OBJECTIVE — To systematically review the incidence of posttransplantation diabetes (PTD), risk factors for its development, prognostic implications, and optimal management. RESEARCH DESIGN AND METHODS — We searched databases (MEDLINE, EMBASE, the Cochrane Library, and others) from inception to September 2000, reviewed bibliographies in reports retrieved, contacted transplantation experts, and reviewed specialty journals. Two reviewers independently determined report inclusion (original studies, in all languages, of PTD in adults with no history of diabetes before transplantation), assessed study methods, and extracted data using a standardized form. Meta-regression was used to explain between-study differences in incidence. RESULTS — Nineteen studies with 3,611 patients were included. The 12-month cumulative incidence of PTD is lower (10% in most studies) than it was 3 decades ago. The type of immunosuppression explained 74% of the variability in incidence (P 0.0004). Risk factors were patient age, nonwhite ethnicity, glucocorticoid treatment for rejection, and immunosuppression with high-dose cyclosporine and tacrolimus. PTD was associated with decreased graft and patient survival in earlier studies; later studies showed improved outcomes. Randomized trials of treatment regimens have not been conducted. CONCLUSIONS — Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients. Randomized trials are needed to evaluate the use of oral glucose-lowering agents in transplant recipients, paying particular attention to interactions with immunosuppressive drugs. Diabetes Care 25:583–592, 2002

A systematic review of the literature

http://library.um.ac.id/free-contents/downloadpdf.php/buku/focus-groups-as-qualitative-research-by-morgan-david-l-11476.pdf

Focus groups as qualitative research / by Morgan, David L.

Ongoing negotiations on the general practitioner contract raise the question of remunerating general practitioners for increased workload resulting from the shift from secondary to primary care. A review of the literature shows that there is little evidence on whether a shift of services from secondary to primary care is responsible for general practitioners' increased workload, and scope for making generalisations is limited. The implication is that general practitioners have little more than anecdotal evidence to support their claims of greatly increased workloads, and there is insufficient evidence to make informed decisions about remunerating general practitioners for the extra work resulting from the changes. Lack of evidence does not, however, mean that there is no problem with workload. It will be increasingly important to identify mechanisms for ensuring that resources follow workload.

/pdf/what-will-a-primary-care-led-nhs-mean-for-gp-workload-the-18xz2nb8yf.pdf

What will a primary care led NHS mean for GP workload? The problem of the lack of an evidence base.

The purpose of this study was to estimate the costs and benefits of the use of erythropoietin (EPO) in the treatment of anaemia arising from chronic renal failure. Recurrent dialysis of chronic renal failure (CRF) patients results in their haemoglobin being depleted and the patient becoming listless and weak. The conventional method of mitigating these effects is blood transfusion at regular intervals. Recombinant human erythropoietin (EPO) maintains the haemoglobin of CRF patients at a satisfactory level, avoids the adverse effects of haemoglobin depletion on the patients’ quality of life, and removes the risks associated with transfusions. These obvious benefits can only be achieved using the new and expensive drug. However, some resources are saved as blood transfusions are no longer necessary for patients treated with EPO. To evaluate the costs and benefits of the use of EPO for CRF patients, a five nation study was funded by Emron Inc. (USDA) and managed from the Centre for Health Economics at The University of York, England. An identical research protocol was used by research groups in Italy, France, Spain and Germany and the UK to identify the costs if the use of EPO, the resource savings generated by such a treatment and the effects of this treatment on the patients’ quality of life. The impact on patients’ quality of life was measured using the Rosser matrix of disability-distress states. The movement between health states in response to the treatment was assessed using expert opinions of nephrologists and a limited amount of patient self-assessment. The results of the study in the five countries are reported in this paper and show that the use of EPO produces patient benefits at significant cost. Obviously, with such a new technology the cost-outcome (QALY) characteristics of the treatment may change as dosage rates are adjusted to patient responses. However, it seems at present that the use of EPO for patients with end stage renal failure is a high cost way of producing patient benefits, measured in terms of quality adjusted life years (QALYs).

The costs and benefits of the use of erythropoietin in the treatment of anaemia arising from chronic renal failure: a European study

BACKGROUND Continuity of care is widely regarded as a core value of primary care. Type 2 diabetes is a common chronic disease with major health, social and economic impacts. Primary health care professionals in many countries are involved in the management of patients with type 2 diabetes, but their perspectives on continuity remain neglected in research. OBJECTIVE To explore UK GPs' and nurses' experiences of continuity of care for patients with type 2 diabetes in primary care settings. METHODS Semi-structured individual interviews were conducted with 16 GPs and 18 practice nurses who manage patients with type 2 diabetes recruited from 20 practices with various organizational structures in Leeds, UK. RESULTS Three types of continuities were identified: relational continuity from the same health care professional, team continuity from a group of health care professionals and cross-boundary continuity across primary-secondary care settings. Relational continuity was influenced by the quality of the patient-health care professional relationship, policy of the National Health Service (NHS) in the UK (new General Medical Services contract), walk-in centres, the behaviour of receptionists and the structure and systems of the practice. Team and cross-boundary continuities were influenced by the relationship between team members and by effective communication. Relational continuity contributed to more 'personal care', but the usual health care professional might know less about diabetes. Team continuity was important in providing 'physical care', but patients could be confused by conflicting advice from different professionals. Cross-boundary continuity helps to provide 'expert advice', but is dependent upon effective communication. CONCLUSION GPs and practice nurses dealing with patients with type 2 diabetes identified three types of continuities, each influenced by several factors. Relational continuity deals better with psychosocial care while team continuity promotes better physical care; therefore, imposing one type of continuity may inhibit good diabetic care. Cross-boundary continuity between primary and secondary care is fundamental to contemporary diabetic services and ways should be found to achieve more effective communication.

/pdf/uk-gps-and-practice-nurses-views-of-continuity-of-care-for-1oj069btyl.pdf

UK GPs' and practice nurses' views of continuity of care for patients with type 2 diabetes

Purpose – The paper seeks to show that the new General Medical Services (GMS) contract will provide opportunities for NHS staff to enhance their roles, so it is important that adequate training assessment and quality control systems are set in place. This paper assesses the implications for NHS staff in primary care.Design/methodology/approach – In this paper a review of policy documents was undertaken.Findings – The paper finds that enhanced services set out in the new GMS contract may be provided by primary care organisations and healthcare professionals other than those located in general practitioner (GP) practices. As nurses and other healthcare professionals take on tasks previously conducted by GPs, so GPs will take on more consultant tasks previously confined to secondary care. Personal Medical Services (PMS) and GMS are converging in their contractual obligations and the opportunities offered to staff. As well as General Practitioners with Special Interests (GPwSIs), Practitioners with Special In...

New opportunities for nurses and other healthcare professionals? A review of the potential impact of the new GMS contract on the primary care workforce

This is the second in a series of five articles 

The government's plan for the NHS, published in July 2000, sets out an ambitious programme of investment, recognising that “the development of primary care services is key to the modernisation of the NHS.”1 Since the founding of the NHS primary care has been one of its greatest strengths but also its weakness. It has provided low cost, easily accessible care, but it has also been characterised by wide variability in quantity and quality, fragmentation, and a lack of coordination. The Labour government's 1997 white paper on the NHS proposed sweeping away the internal market and promoting a culture of collaboration and partnership.2

The establishment of primary care groups in England in 1999—which were charged with developing primary and community health services, commissioning hospital services, and improving the health of communities of around 100 000 people—represented a radical change in the organisation of primary and community health services. By 2004 all of these groups will become fully fledged primary care trusts, controlling most of the budget for providing health care to the populations that they serve. These organisations, led by local health professionals, will play a vital role in delivering the changes to primary and community services that the government sees as key to modernising the NHS. Within a framework of goals and performance standards set at the national level, the NHS plan asserts that the responsibility for decisions about services should be devolved to those who best understand local needs and circumstances.1 In this article, we focus on three key components of the government's strategy for modernising primary and community services: promoting a more efficient use of resources through collaboration and sharing, improving access to primary care, and enhancing the capacity of the workforce.

#### Summary points

Developing primary and …

https://www.bmj.com/content/bmj/322/7301/1522.full.pdf

Brenda Leese

Papers

What will a primary care led NHS mean for GP workload? The problem of the lack of an evidence base.

The costs and benefits of the use of erythropoietin in the treatment of anaemia arising from chronic renal failure: a European study

UK GPs' and practice nurses' views of continuity of care for patients with type 2 diabetes

New opportunities for nurses and other healthcare professionals? A review of the potential impact of the new GMS contract on the primary care workforce

Modernising primary and community health services.