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

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines. Objectives To evaluate the effect of proactive and reactive telephone support via helplines and in other settings to help smokers quit. Randomized or quasi-randomized controlled trials in which proactive or reactive telephone counselling to assist smoking cessation was offered to smokers or recent quitters were used. Sixty-five trials met the inclusion criteria. Among smokers who contacted helplines, quit rates were higher for groups randomized to receive multiple sessions of proactive counselling (nine studies, >24,000 participants, risk ratio (RR) for cessation at longest follow up 1.37, 95% confidence interval (CI) 1.26 to 1.50). There was mixed evidence about whether increasing the number of calls altered quit rates but most trials used more than two calls. Two studies comparing different counselling approaches during a single quitline contact did not detect significant differences. Of three studies that provided access to a hotline two detected a significant benefit and one did not. Telephone counselling not initiated by calls to helplines also increased quitting (44 studies, >24,000 participants, RR 1.29, 95% CI 1.20 to 1.38). In the subgroup of studies offering 1-2 calls the effect was small and not significant. A further seven studies were too diverse to contribute to meta-analyses and are discussed separately.

Telephone counselling for smoking cessation.

Objectives The aim of this study was to summarize and systematically review the literature on the prevalence of different research diagnostic criteria for temporomandibular disorders (RDC/TMD) version 1.0 axis I diagnoses in patient and in the general populations. Study design For each of the relevant papers, the following data/information were recorded for meta-analysis and discussion: sample size and demographic features (mean age, female-to-male ratio); prevalence of the assigned diagnoses; prevalence of the diagnoses assigned to the left and right joints, if available; prevalence of the diagnoses assigned to the 2 genders, if available; prevalence of the different combinations of multiple diagnoses, if available; and prevalence of TMD (only for community studies). Results Twenty-one (n = 21) papers were included in the review (15 dealing with TMD patient populations and 6 with community samples). The studies on TMD patients accounted for a total of 3,463 subjects (mean age 30.2-39.4 years, female-to-male ratio 3.3), with overall prevalences of 45.3% for group I muscle disorder diagnoses, 41.1% for group II disc displacements, and 30.1% for group III joint disorders. Studies on general populations accounted for a total of 2,491 subjects, with an overall 9.7% prevalence for group I, 11.4% for group IIa, and 2.6% for group IIIa diagnoses. Conclusions Prevalence reports were highly variable across studies. Myofascial pain with or without mouth opening limitation was the commonest diagnosis in TMD patient populations, and disc displacement with reduction was the commonest diagnosis in community samples.

http://www.lucaguarda.it/wp-content/uploads/2012/03/141-1-Research-diagnostic.pdf

Research diagnostic criteria for temporomandibular disorders: a systematic review of axis I epidemiologic findings

Smokers have a substantially increased risk of postoperative complications. Preoperative smoking intervention may be effective in decreasing this incidence, and surgery may constitute a unique opportunity for smoking cessation interventions.
 
The objective of this review was to assess the effect of preoperative smoking intervention on smoking cessation at the time of surgery and 12 months postoperatively and on the incidence of postoperative complications.

Interventions for preoperative smoking cessation.

Persistent and disabling pain is the hallmark of osteoarthritis, rheumatoid arthritis, fibromyalgia, and various other rheumatologic conditions However, disease severity (as measured by 'objective' indices such as those that employ radiography or serology) is only marginally related to patients' reports of pain severity, and pain-related presentation can differ widely between individuals with ostensibly similar conditions (for example, grade 4 osteoarthritis of the knee) Increasing evidence in support of the biopsychosocial model of pain suggests that cognitive and emotional processes are crucial contributors to inter-individual differences in the perception and impact of pain This Review describes the growing body of literature relating depression and catastrophizing to the experience of pain and pain-related sequelae across a number of rheumatic diseases Depression and catastrophizing are consistently associated with the reported severity of pain, sensitivity to pain, physical disability, poor treatment outcomes, and inflammatory disease activity, and potentially with early mortality A variety of pathways, from cognitive to behavioral to neurophysiological, seem to mediate these deleterious effects Collectively, depression and catastrophizing are critically important variables in understanding the experience of pain in patients with rheumatologic disorders Pain, depression, and catastrophizing might all be uniquely important therapeutic targets in the multimodal management of a range of such conditions

Pain, catastrophizing, and depression in the rheumatic diseases

Cigarette smoke, which serves as a nicotine delivery vehicle in humans, produces profound changes in physiology. Experimental studies suggest that nicotine has analgesic properties. However, epidemiologic evidence shows that smoking is a risk factor for chronic pain. The complex relationship between smoking and pain not only is of scientific interest, but also has clinical relevance in the practice of anesthesiology and pain medicine. This review will examine current knowledge regarding how acute and chronic exposure to nicotine and cigarette smoke affects acute and chronic painful conditions. It will cover the relevant pharmacology of nicotine and other ligands at the nicotinic acetylcholine receptor as related to pain, explore the association of cigarette smoking with chronic painful conditions and potential mechanisms to explain this association, and examine clinical implications for the care of smokers with pain.

/pdf/smoking-and-pain-pathophysiology-and-clinical-implications-283q1m1y0k.pdf

Smoking and pain: pathophysiology and clinical implications.

Background A "teachable moment" is an event that motivates spontaneous behavior change. Some evidence suggests that major surgery for a smoking-related illness can serve as a teachable moment for smoking cessation. This study tested the hypotheses that surgery increases the likelihood of smoking cessation and that cessation is more likely after major surgical procedures compared with outpatient surgery. Methods Secondary analyses were performed of longitudinal biennial survey data (1992-2004) from the nationally representative Health and Retirement Study of U.S. adults older than 50 yr, determining the relationship between the incidence of smoking cessation and the occurrence of surgery. Results Five thousand four hundred ninety-eight individuals reported current smoking at enrollment, and 2,444 of them (44.5%) quit smoking during the period of examination. The incidence of quitting in smokers undergoing major surgery was 20.6/100 person-years of follow-up and 10.2/100 person-years in those undergoing outpatient surgery. In a multivariate negative binomial regression model, the incidence rate ratio of quitting associated with major surgery was 2.02 (95% CI: 1.67-2.44) and that of those associated with outpatient surgery was 1.28 (95% CI: 1.09-1.50). Estimates derived from national surgical utilization data show that approximately 8% of all quit events in the United States annually can be attributed to the surgical procedures analyzed. Conclusions Undergoing surgery is associated with an increased likelihood of smoking cessation in the older U.S. population. Cessation is more likely in association with major procedures compared with outpatient surgery. These data support the concept that surgery is a teachable moment for smoking cessation.

/pdf/surgery-as-a-teachable-moment-for-smoking-cessation-21wnmdulxr.pdf

Surgery as a teachable moment for smoking cessation.

Depression and smoking are common comorbid conditions among adults with chronic pain. The aim of this study was to determine the independent effects of depression on clinical pain and opioid use among patients with chronic pain according to smoking status. A retrospective design was used to assess baseline levels of depression, clinical pain, opioid dose (calculated as morphine equivalents), and smoking status in a consecutive series of patients admitted to a 3-week outpatient pain treatment program from September 2003 through February 2007. Depression was assessed using the Centers for Epidemiologic Studies-Depression scale, and clinical pain was assessed using the pain severity subscale of the Multidimensional Pain Inventory. The study cohort (n=1241) included 313 current smokers, 294 former smokers, and 634 never smokers. Baseline depression (P=.001) and clinical pain (P=.001) were greater among current smokers compared to former and never smokers, and the daily morphine equivalent dose was greater among smokers compared to never smokers (P=.005). In multivariate linear regression analyses, baseline pain severity was independently associated with greater levels of depression, but not with smoking status. However, status as a current smoker was independently associated with greater opioid use (by 27mg/d), independent of depression scores. The relationship between depression, smoking status, opioid use, and chronic pain is complex, and both depression and smoking status may be potentially important considerations in the treatment of patients with chronic pain who utilize opioids. This study found that pain severity was associated with greater depression but not smoking; however, smoking was associated with greater opioid use, independent of depression.

/pdf/the-effects-of-depression-and-smoking-on-pain-severity-and-58axviz931.pdf

The effects of depression and smoking on pain severity and opioid use in patients with chronic pain

Although previous studies suggest that the clinical setting of an interdisciplinary pain treatment program may provide an optimal environment to promote smoking cessation, currently available smoking cessation interventions may be less effective for adults with chronic pain due, in part, to unrecognized clinical factors related to chronic pain. The specific aim of this qualitative study was to solicit information from adult smokers with chronic pain participating in an interdisciplinary pain treatment program regarding their perceptions of how smoking affects pain symptoms, and how these beliefs, cognitions, and emotions may either impede or facilitate smoking cessation. Similar information was solicited from a group of pain specialty physicians. The study involved 18 smokers with chronic pain, and seven physicians. Patients reported that smoking was an important coping strategy for pain and distress, primarily by offering an opportunity for distraction and avoidance, respectively. The majority of patients using opioids reported that opioid consumption stimulated smoking. Important barriers were identified toward making a quit attempt during pain treatment including quitting smoking while making changes in opioid use, and perceived difficulty managing multiple treatment-related stressors. Several pain-related benefits of smoking cessation were identified by physicians, but important barriers to providing smoking cessation services were recognized including lack of time and knowledge about how to help patients quit smoking. The findings of this study identified several novel and important clinical factors that should be incorporated into a targeted smoking cessation intervention for adults with chronic pain.

/pdf/smoking-cessation-and-chronic-pain-patient-and-pain-medicine-40338fkisq.pdf

Smoking Cessation and Chronic Pain: Patient and Pain Medicine Physician Attitudes

Pain symptoms in aging populations have significant public health impact. The aim of this study was to determine risk factors for the incidence of pain in older adults, focusing on those factors that can be modified. Secondary analyses were performed of survey data from the nationally representative Health and Retirement Study of US adults older than 50 years. Generalized estimating equations logistic regressions were used to evaluate the effect of selected variables on the incidence of pain using biennial (1992 through 2006) data, determining the relationship between the incidence of pain and the potential risk factors. Of the 18,439 survey respondents in 2006, 34.1% (95% CI: 33.2%, 35.0%) reported that they were often troubled by pain; 24.3% reported having moderate to severe pain; and 22.3% reported that their daily life was affected by pain. Between 1992 and 2006, 7967 individuals reported new onset of pain in 169,762 person-years of follow-up, an incidence of 4.69 (4.59, 4.80) per 100 person-years. Depression and being overweight were independent predictors associated with an increased likelihood of incident pain. Current smoking increased the likelihood of incident pain only in those subjects who also reported depression. In conclusion, pain is a common symptom in older adults. Depression, smoking, and overweight are potentially modifiable risk factors and could be considered in the prevention and management of pain in older adults.

Yu Shi

Papers

Smoking and pain: pathophysiology and clinical implications.

Surgery as a teachable moment for smoking cessation.

The effects of depression and smoking on pain severity and opioid use in patients with chronic pain

Smoking Cessation and Chronic Pain: Patient and Pain Medicine Physician Attitudes

Modifiable risk factors for incidence of pain in older adults