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Abstract
BackgroundTools to support clinical or patient decision-making in the treatment/management of a health condition are used in a range of clinical settings for numerous preference-sensitive healthcare decisions. Their impact in clinical practice is largely dependent on their quality across a range of domains. We critically analysed currently available tools to support decision making or patient understanding in the treatment of acute ischaemic stroke with intravenous thrombolysis, as an exemplar to provide clinicians/researchers with practical guidance on development, evaluation and implementation of such tools for other preference-sensitive treatment options/decisions in different clinical contexts.MethodsTools were identified from bibliographic databases, Internet searches and a survey of UK and North American stroke networks. Two reviewers critically analysed tools to establish: information on benefits/risks of thrombolysis included in tools, and the methods used to convey probabilistic information (verbal descriptors, numerical and graphical); adherence to guidance on presenting outcome probabilities (IPDASi probabilities items) and information content (Picker Institute Checklist); readability (Fog Index); and the extent that tools had comprehensive development processes.ResultsNine tools of 26 identified included information on a full range of benefits/risks of thrombolysis. Verbal descriptors, frequencies and percentages were used to convey probabilistic information in 20, 19 and 18 tools respectively, whilst nine used graphical methods. Shortcomings in presentation of outcome probabilities (e.g. omitting outcomes without treatment) were identified. Patient information tools had an aggregate median Fog index score of 10. None of the tools had comprehensive development processes.ConclusionsTools to support decision making or patient understanding in the treatment of acute stroke with thrombolysis have been sub-optimally developed. Development of tools should utilise mixed methods and strategies to meaningfully involve clinicians, patients and their relatives in an iterative design process; include evidence-based methods to augment interpretability of textual and probabilistic information (e.g. graphical displays showing natural frequencies) on the full range of outcome states associated with available options; and address patients with different levels of health literacy. Implementation of tools will be enhanced when mechanisms are in place to periodically assess the relevance of tools and where necessary, update the mode of delivery, form and information content.
Highlights
Tools to support clinical or patient decision-making in the treatment/management of a health condition are used in a range of clinical settings for numerous preference-sensitive healthcare decisions
Clinicians and patients are frequently faced with making a decision about medical or surgical treatment when there are multiple reasonable options with different balances of short- and long-term benefits, risks and resultant consequences, which are sensitive to individual patient preferences and values [1,2,3]
In contrast to decisions about effective care, evidencebased tools such as clinical decision support tools [4], patient decision aids [5], patient information leaflets [6] and risk communication tools [7] are warranted to help clinicians weigh-up the pros and cons of available ‘preference-sensitive’ options by presenting them with evidencebased summaries of the likely magnitude of benefit to risk ratios. Such tools warranted to (i) promote patient understanding of the available options and probabilistic information on the different balances of benefits, risks and consequences to support choice; and (ii) support clinicians in communicating the latter information to patients, in order to facilitate the process of informed consent, including engagement of patients in shared decision making with clinicians [1]
Summary
Tools to support clinical or patient decision-making in the treatment/management of a health condition are used in a range of clinical settings for numerous preference-sensitive healthcare decisions. In contrast to decisions about effective care, evidencebased tools such as clinical decision support tools [4], patient decision aids [5], patient information leaflets [6] and risk communication tools [7] are warranted to help clinicians weigh-up the pros and cons of available ‘preference-sensitive’ options by presenting them with evidencebased summaries of the likely magnitude of benefit to risk ratios Such tools warranted to (i) promote patient understanding of the available options and probabilistic information on the different balances of benefits, risks and consequences to support choice; and (ii) support clinicians in communicating the latter information to patients, in order to facilitate the process of informed consent, including engagement of patients in shared decision making with clinicians [1]. Tools such as structured patient decision aids, designed to engage patients in shared decision making, impact positively on patients’ knowledge of available options, perception of risk, decisional conflict, clarity about their preferences on available options, patient-practitioner communication and patient involvement in decision making, including reductions in unwarranted variation in rates of preference-sensitive treatment and care [5]
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