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

Statistical methods in cancer research

Background: Depression and anxiety are common in medical patients and are associated with diminished health status and increased health care utilization. This article presents a quantitative review and synthesis of studies correlating medical patients’ treatment noncompliance with their anxiety and depression.

/pdf/depression-is-a-risk-factor-for-noncompliance-with-medical-9vxhnlno2c.pdf

Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence.

The literature of social psychology contains a number of phenomena that appear to be paradoxical. For example, persons who face a threatening experience prefer to affiliate with threatened others rather than with nonthreatened others (Schachter, 1959), and persons in groups in which reward is equally distributed are less satisfied compared with persons in groups that include one particularly unfortunate member (Brickman, 1975). The purpose of this article is to show that these phenomena are best construed as social comparison processes and that various phenomena derive from one basic process termed downward comparison; the essence of this process is that persons can enhance their own subjective well-being by comparing themselves with a less fortunate other. In this article I show that downward comparison is a process evoked by negative affect, that there is considerable evidence for self-enhancing comparison processes, and that downward comparison effects are involved in several areas of social-psycho logical research.

Downward Comparison Principles in Social Psychology

Effect of psychosocial treatment on survival of patients with metastatic breast cancer

Cancer patients receiving chemotherapeutic treatments routinely experience a wide range of distressing side effects, including nausea, vomiting, and dysphoria. Such symptoms often compromise patients1 quality of life and may lead to the decision to postpone or even reject future, potentially life-saving, treatments. In this article, we discuss the hypotheses that have been offered to explain the development of such symptoms. We also review, in greater detail, the research evidence for the efficacy of five treatments for such symptoms: hypnosis, progressive muscle relaxation training with guided imagery, systematic desensitization, attentional diversion or redirection, and biofeedback. We discuss the implications of this treatment research, paying particular attention to factors associated with treatment outcome, mechanisms of treatment effectiveness, and issues associated with clinical application.

/pdf/etiology-and-treatment-of-the-psychological-side-effects-1wqem83szy.pdf

Etiology and treatment of the psychological side effects associated with cancer chemotherapy: a critical review and discussion.

Efficacy of relaxation training and guided imagery in reducing the aversiveness of cancer chemotherapy.

Cancer patients who had developed negative conditioned responses to their chemotherapy either did (relaxation training) or did not (no relaxation training) receive progressive muscle relaxation training and guided relaxation imagery instructions immediately before and during their chemotherapy treatments. Physiological (blood pressure and pulse rate) measures of arousal, frequency of vomiting, and patient-reported and nurse-reported indices of negative affect and nausea were collected during pretraining, training and posttraining chemotherapy sessions. Results indicated that during both the training and the posttraining sessions, patients in the relaxation training condition reported feeling less emotionally distressed and nauseated, and showed less physiological arousal following the chemotherapy infusion, than patients in the no relaxation training condition. The attending nurses' observations confirmed the patients' self-reports. No differences were found in frequency of vomiting between conditions. These data clearly suggest that the use of relaxation procedures may be an effective means of reducing several of the adverse side effects of cancer chemotherapy.

Effectiveness of relaxation training in reducing adverse reactions to cancer chemotherapy

Conditioned Side Effects Induced by Cancer Chemotherapy: Prevention Through Behavioral Treatment.

Questionnaires assessing a range of quality of life (QOL) outcomes were completed by 200 adult bone marrow transplant (BMT) recipients from five BMT treatment centres. Respondents had undergone allogeneic (46%) or autologous BMT (54%) for a haematological malignancy and were disease free and at least 12 months post BMT (mean 43 months). Variability in post-BMT QOL was reported with deficits in physical, sexual and occupational functioning particularly likely. Allogeneic recipients reported poorer QOL than autologous recipients. Greater age at BMT, lower level of education and more advanced disease at BMT were consistent risk factors for poorer QOL. Contrary to previous research, evidence for improved functional status with the passage of time post BMT was obtained. Factors generally not associated with post-BMT QOL included disease diagnosis, dose of total body irradiation, presence of chronic graft-versus-host disease (GVHD), type of GVHD prophylaxis and extent of marrow graft match. In conclusion, while many BMT recipients reported normal QOL, the majority indicated that their QOL was compromised relative to premorbid status. Prospective, longitudinal research will be necessary to further identify risk factors for poor post-BMT QOL and identify the temporal trajectory of post-BMT QOL.

Thomas G. Burish

Papers

Etiology and treatment of the psychological side effects associated with cancer chemotherapy: a critical review and discussion.

Efficacy of relaxation training and guided imagery in reducing the aversiveness of cancer chemotherapy.

Effectiveness of relaxation training in reducing adverse reactions to cancer chemotherapy

Conditioned Side Effects Induced by Cancer Chemotherapy: Prevention Through Behavioral Treatment.

Quality of life following bone marrow transplantation: findings from a multicentre study.