Basics of qualitative research: Grounded theory procedures and techniques

The outbreak of the 2019 novel coronavirus disease (COVID-19) has induced a considerable degree of fear, emotional stress and anxiety among individuals around t

An interactive web-based dashboard to track COVID-19 in real time.

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

These recommendations for human immunodeficiency virus (HIV) testing are intended for all health-care providers in the public and private sectors, including those working in hospital emergency departments, urgent care clinics, inpatient services, substance abuse treatment clinics, public health clinics, community clinics, correctional health-care facilities, and primary care settings. The recommendations address HIV testing in health-care settings only. They do not modify existing guidelines concerning HIV counseling, testing, and referral for persons at high risk for HIV who seek or receive HIV testing in nonclinical settings (e.g., community-based organizations, outreach settings, or mobile vans). The objectives of these recommendations are to increase HIV screening of patients, including pregnant women, in health-care settings; foster earlier detection of HIV infection; identify and counsel persons with unrecognized HIV infection and link them to clinical and prevention services; and further reduce perinatal transmission of HIV in the United States. These revised recommendations update previous recommendations for HIV testing in health-care settings and for screening of pregnant women (CDC. Recommendations for HIV testing services for inpatients and outpatients in acute-care hospital settings. MMWR 1993;42[No. RR-2]:1-10; CDC. Revised guidelines for HIV counseling, testing, and referral. MMWR 2001;50[No. RR-19]:1-62; and CDC. Revised recommendations for HIV screening of pregnant women. MMWR 2001;50[No. RR-19]:63-85). Major revisions from previously published guidelines are as follows: For patients in all health-care settings HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening). Persons at high risk for HIV infection should be screened for HIV at least annually. Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in health-care settings. For pregnant women HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women. HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines (opt-out screening). Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. Repeat screening in the third trimester is recommended in certain jurisdictions with elevated rates of HIV infection among pregnant women.

/pdf/revised-recommendations-for-hiv-testing-of-adults-2nmotmgow6.pdf

Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings

At a time when lesbian, gay, bisexual, and transgender individuals—often referred to under the umbrella acronym LGBT—are becoming more visible in society and more socially acknowledged, clinicians and researchers are faced with incomplete information about their health status. While LGBT populations often are combined as a single entity for research and advocacy purposes, each is a distinct population group with its own specific health needs. Furthermore, the experiences of LGBT individuals are not uniform and are shaped by factors of race, ethnicity, socioeconomic status, geographical location, and age, any of which can have an effect on health-related concerns and needs. While some research about the health of LGBT populations has been conducted, researchers still have a great deal to learn. To help assess the state of the science, the National Institutes of Health (NIH) asked the Institute of Medicine (IOM) to assess current knowledge of the health status of lesbian, gay, bisexual, and transgender populations; to identify research gaps and opportunities; and to outline a research agenda to help NIH focus its research in this area. A committee of experts was convened by the IOM to consider this task, and its findings are presented in its report, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding.

The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding

Contraceptive failure in the United States

Direct evidence on age patterns of infecundity and sterility cannot be obtained from contemporary populations because such large fractions of couples use contraception or have been sterilized. Instead, historical data are exploited to yield upper bounds applicable to contemporary populations on the proportions sterile at each age. Examination of recent changes in sexual behavior that may increase infecundity indicates that sexually transmitted infections, the prime candidate for hypothesized rises in infertility, are unlikely to have added to infecundity to any great extent. These results imply that a woman in a monogamous union faces only moderate increases in the probability of becoming sterile (or infecund) until her late thirties. Nevertheless, it appears that recent changes in reproductive behavior were guaranteed to result in the perception that infecundity is on the rise.

https://science.sciencemag.org/content/sci/233/4771/1389.full.pdf

Age and infertility

The risk of pregnancy after tubal sterilization: Findings from the U.S. collaborative review of sterilization

Estimates of contraceptive failure from the 2002 National Survey of Family Growth

This study computed life table probabilities of contraceptive failure discontinuation of use and return to contraceptive use in the US. Data were obtained from the 1995 National Survey of Family Growth (NSFG) among a nationally representative sample of 6867 contraceptive use intervals contributed by women 15-45 years old who began use or resumed use after discontinuation during 1991-95. Analysis was based on Kaplan-Meier product-limit single decrement life table probability methods. Findings indicate that the risk of failure during typical use of reversible methods was 9% within 1 year of starting. Women with continuous lifetime use will experience 1.8 contraceptive failures. Failure rates were 7% for the pill 9% for the male condom 8% for the diaphragm 20% for periodic abstinence and 15% for spermicides. Failure rates reflect imperfect use. 31% of women discontinued use within 6 months of starting use. 44% discontinued within 12 months. Women using reversible methods continuously will discontinue use nearly 10 times during the reproductive period. Most women resumed use shortly after discontinuation. Low income women had higher risk of unintended pregnancy for all methods and the pill and lower risk of resumption after discontinuation. Hispanics had a higher risk of contraceptive failure for all methods and the condom. Black women had a higher risk of discontinuation of oral pills and condoms.

/pdf/contraceptive-failure-method-related-discontinuation-and-5fknsw5y0z.pdf

James Trussell

Papers

Contraceptive failure in the United States

Age and infertility

The risk of pregnancy after tubal sterilization: Findings from the U.S. collaborative review of sterilization

Estimates of contraceptive failure from the 2002 National Survey of Family Growth

Contraceptive failure, method-related discontinuation and resumption of use: results from the 1995 National Survey of Family Growth.