Are decision aids for patients really ready for prime time?
In recent years much effort has been dedicated to creating decision-making tools that help patients make better choices based on clear information and their own values. There are published materials, videos, websites and charts. Whatever the format, the idea is to have materials available that support shared decision-making between physicians and patients when the best treatment is not clear-cut.
The academic enthusiasm for decision aids, however, has not translated into practice; they are infrequently used and there is a paucity of evidence available about their effectiveness. Two recent JAMA Internal Medicine articles try to address both the utility of various decision aids and the barriers to their use.
A study by C. Adrian Austin and colleagues provides the first systematic review of decision aids designed specifically to help patients with serious illness.
Some of the aids focus on advance care planning and others on particular treatment choices, such as options for intervention in lung cancer. The reviewers only included articles describing tools that patients and caregivers could use themselves, not tools that needed to be administered by a physician. The review includes data from 38 published trials of different decision aids. Seventeen of these were randomized controlled trials and 21 were smaller pilot studies.
Overall, Austin et al. found evidence that a few decision aids moderately improved patient engagement and, in some cases, may lead to different trends in decision-making (e.g., more patients choosing comfort-oriented care over life-prolonging care). Whether the decision aids actually lead to a change in what type of care a patient receives from their physician is not at all clear.
The second study surveyed urologists and radiation oncologists about their use of decision aids for treatment options when counseling patients with localized prostate cancer.
Interestingly, about a third of the urologists said that they do routinely use some decision aid in their practice. Most urologists did not use decision aids because they believed their own risk estimations were better than those provided in the decision aids, they didn't have enough time, and aids were too difficult for their patient populations to use.
In editorials, James Tulsky and Michael Barry both address reasons that decision aids are not more commonly used in practice.
Tulsky explains that, “Most seriously ill patients will never see any decision tool, and those who do are as (or more) likely to see one that has not been rigorously tested for effectiveness." Barry makes several suggestions for how to increase the usability of decision aids in clinical practice, including paying for dedicated shared decision-making visits, encouraging patients to use decision aids in advance of a visit so they come prepared with reactions and questions, and creating more granular decision aids that can address the specific concerns of different patient populations.
The Slow Medicine take: Simply using decision aids is a surrogate outcome and does not necessarily lead to improved care. While we see the promise of decision aids as a concept and while we sometimes use decision aids in our practices, we realize that there is little evidence to suggest that these tools change the outcomes that we really care about — empowering patients to make decisions that are best aligned with their personal values and improving clinical outcomes.
[Photo by John Norris via Flickr.]
