Decision Aid Research Articles

Pilot study of a decision aid on BRCA1/2 genetic testing among Orthodox Jewish women.

Orthodox Jewish women face unique social, cultural, and religious factors that may influence uptake of BRCA1/2 genetic testing. We examined the impact of a web-based decision aid (DA) on BRCA1/2 genetic testing intention/completion among Orthodox Jewish women. We conducted a single-arm pilot study among 50 Orthodox Jewish women who were given access to a web-based DA entitled RealRisks and administered serial surveys at baseline and 1 and 6 months after exposure to the DA. Descriptive statistics were conducted for baseline characteristics and study measures. Comparisons were made to assess changes in study measures over time. Fifty Orthodox Jewish women enrolled in the study with a mean age of 43.9 years (standard deviation [SD] 14.6), 70% Modern Orthodox, 2% with personal history of breast cancer, and 68% and 16% with a family history of breast or ovarian cancer, respectively. At baseline, 27 (54%) participants intended to complete genetic testing. Forty-three participants (86%) completed RealRisks and the 1-month survey and 38 (76%) completed the 6-month survey. There was a significant improvement in BRCA1/2 genetic testing knowledge and decrease in decisional conflict after exposure to the DA. At 1 month, only 20 (46.5%) completed or intended to complete genetic testing (p = 0.473 compared to baseline). While the DA improved genetic testing knowledge and reduced decisional conflict, genetic testing intention/completion did not increase over time. Future interventions should directly address barriers to BRCA1/2 genetic testing uptake and include input from leaders in the Orthodox Jewish community. NCT03624088 (8/7/18).

Creation of a Shared Medical Decision Support Tool for the Management of Abdominal Aortic Aneurysms

ObjectivePatients with an unruptured abdominal aortic aneurysm (AAA) at the surgical threshold may benefit from aneurysmal exclusion either by open surgery or endovascular repair. A patient decision aid (PtDA) could be useful to help patients and their surgeons choose between the two techniques. The aim of this study was to develop a shared medical decision support tool, in french language, for the surgical treatment of AAA. MethodsFollowing the steps recommended by the International Patient Decision Aids Standards, we carried out a qualitative study using semi-structured interviews with patients and vascular surgeons and focus group with patients to identify their main points of interest. After analyzing the interviews using grounded theory with independent double coding, the verbatims were discussed at a steering committee, at the end of which a prototype of the tool was created. Results4 surgeons and 14 patients were interviewed. No new codes emerged from the last two interviews. At the end of the steering committee meeting, the informations selected for inclusion in the PtDA tool were the definition of an AAA, a description of the two surgical techniques (approach, duration of operation), the main complications, the peri-operative mortality rate, and post operative follow-up (length of hospital stay, monitoring frequency, risk of re-intervention). It had to be produced on a synthetic paper format, with six illustrations and a simple vocabulary. ConclusionWe developed a PtDA tool for use in a sharing decision making process with the patient during the consultation with the vascular surgeon and the general practitioner. Further studies are needed to validate the tool and to test it in clinical practice.

Usability and fitness testing for building performance simulation tools

Architects and engineers who seek design decision aid for sustainable building and city design frequently experience decisional conflict and require support across the design process. Building performance simulations have become central to supporting the design process, but little is known about the fit and usability of simulation tools and the factors influencing the implementation of simulation-based design in practice. This paper presents a novel framework for simulation tool usability called USER-FIT. The framework defines usability based on ISO definitions, a review of evidence in the literature, and our experience supporting the development of the framework. USER-FIT provides six measures for modelers and software developers to test how a simulation tool is useful, usable, and satisfactory for the intended users to inform sustainable design decision-making. Further research and testing are needed to support better the acquisition and implantation of usability testing for building performance simulation tools and applications.

Perioperative echocardiographic strain analysis: what anesthesiologists should know.

Echocardiographic strain analysis by speckle tracking allows assessment of myocardial deformation during the cardiac cycle. Its clinical applications have significantly expanded over the last two decades as a sensitive marker of myocardial dysfunction with important diagnostic and prognostic values. Strain analysis has the potential to become a routine part of the perioperative echocardiographic examination for most anesthesiologist-echocardiographers but its exact role in the perioperative setting is still being defined. This clinical report reviews the principles underlying strain analysis and describes its main clinical uses pertinent to the field of anesthesiology and perioperative medicine. Strain for assessment of left and right ventricular function as well as atrial strain is described. We also discuss the potential role of strain to aid in perioperative risk stratification, surgical patient selection in cardiac surgery, and guidance of anesthetic monitor choice and clinical decision-making in the perioperative period. Echocardiographic strain analysis is a powerful tool that allows seeing what conventional 2D imaging sometimes fails to reveal. It often provides pathophysiologic insight into various cardiac diseases at an early stage. Strain analysis is readily feasible and reproducible thanks to the use of highly automated software platforms. This technique shows promising potential to become a valuable tool in the arsenal of the anesthesiologist-echocardiographer and aid in perioperative risk-stratification and clinical decision-making.

A multi-site cultural and linguistic adaptation of a hypospadias decision aid for Latinx communities

Latinx, Spanish-speaking (LSS) patients are more likely to experience decisional conflict and regret about healthcare decisions than non-Hispanic, white, English-speaking patients. To adapt the Hypospadias Hub (Hub), a rigorously developed and tested web-based decision aid (DA), for LSS parents. Guided by the Ecological Validity Model (EVM), a heuristic framework was followed to culturally adapt the Hub (see Extended Summary Figure). In stage 1, recommendations were obtained from a focus group with members of the institution's Latinx Community Review Board (Latinx CRB) and semi-structured interviews with pediatricians with Latinx-focused practices. In stage 2, preliminary cultural modifications were made, the Hub was translated into Spanish, and a second focus group with the Latinx CRB was convened to review the revised Hub. In stage 3, semi-structured interviews with LSS parents of healthy boys (i.e., without hypospadias)≤5 years old were conducted to identify any cultural adaptations and/or usability issues regarding the revised Hub. In stage 4, based on parents' feedback, final revisions to the Hub were made. The focus groups and parent interviews were conducted in Spanish; then, the recordings were professionally transcribed in Spanish and translated into English. Interviews with pediatricians were conducted in English; then, the recordings were professionally transcribed. Three coders conducted a qualitative content analysis to identify areas for revision. Changes were applied iteratively. Participants included 3 Latinx CRB members (2 women, 1 did not disclose gender; mean age=48.3, SD=21.2), 3 non-Latinx pediatricians (2 women, 1 man; mean age=49.6, SD=9.1), and 5 Latinx mothers (mean age=34.0, SD=1.26). Participants recommended: 1) featuring video testimonials from Latinx families or including Spanish voice-overs/subtitles; 2) diversifying racial/ethnic/geographic representation and including extended families in photographs/illustrations; 3) adding information about health insurance coverage and circumcision, 4) reassuring parents that the condition is not their fault, 5) considering cultural values (e.g., reliance on expert advice), and 6) clarifying medical terminology. Feedback related to seven EVM dimensions: concepts, content, context, goals, language, metaphors, and methods. Participants perceived the Hub to be informative in guiding parents' treatment decisions. Revisions were reasonable and acceptable for a linguistic and cultural adaptation for LSS parents. We identified and implemented preliminary cultural modifications to the Hub and applied user-centered design methods to test and revise the website. The product is a culturally appropriate DA for LSS parents. Next, English and Spanish-versions of the Hub will be tested in a randomized controlled trial.

On the sigma-mu stochastic multicriteria analysis: Exact solutions for common particular cases

The sigma-mu approach is one of the recent innovations in the field of multicriteria decision aiding and composite indicators, extending the stochastic multicriteria acceptability analysis (SMAA) toolbox. The initial stage of this method involves computing the mean (mu) and standard deviation (sigma) for the composite value of the units under evaluation, considering a stochastic distribution on a set of admissible weights. This work develops closed-form formulas to obtain exact values for mu and sigma without needing approximations via Monte-Carlo simulations, which can be applied in some cases that are quite common. In terms of aggregation, these cases are characterized by an additive model, such as a weighted sum, a multiattribute value function, or PROMETHEE II. In terms of stochastic distributions, these cases include uniformly distributed unconstrained vectors of weights, rank-ordered vectors of weights, or lower-bounded weights. The developed formulas are applied to a didactic example and some open problems for future research are suggested.

Assessment of Multisensory Sensitivity May Assist With the Management of Children With Chronic Pain.

Chronic pain is a significant problem in adults; however, it can also be challenging to evaluate and manage effectively in pediatric and adolescent populations. Many theories implicate different factors that cause pain to become chronic, more severe, or more detrimental to function. There is emerging evidence for the role of generalized multisensory sensitivity (MSS) as a contributing factor to chronic pain in the adult population; however, similar evidence in the pediatric literature is lacking. Thus, the purpose of this case series is to highlight the clinical use of MSS assessment in children and adolescents with chronic pain to better phenotype and provide targeted treatment. In this case series, we reviewed 5 patients between 12 and 16 years of age who received evaluation for multifocal, chronic pain in a multidisciplinary pain clinic. During the initial consultations, we reviewed the medical records, completed a full medical history, performed a physical examination, and assessed for MSS. It is theorized that MSS is a marker of increased central nervous system sensitivity to sensory input that may also impact pain processing and, potentially, a poorer prognosis. Four patients with MSS appeared to benefit from the inclusion of additional therapies, such as desensitization and occupational therapy, which was in contrast to the patient without notable MSS. Based on anecdotal observation of these 5 cases, increased sensory hypersensitivity is 1 additional factor that may be used to delineate possible neurobiological mechanisms and aid in the treatment decision-making for this challenging population.

Multispectral Satellite Datasets for Detection and Mapping of Land Cover Change in a Mediterranean Area of North Africa, Belezma (Algeria)

Multispectral satellite images are valuable sources of information for ecologists, agriculture climatologists, or environmentalists. Handling satellite images represents a challenge for better understanding the global change. The Belezma massif by its exceptional geographical position in the Mediterranean region of Northeast Algeria constitutes a fragile hot spot ecosystem with all the degradation factors that directly affect all landcovers. The objective of this study is to determine the contribution of satellite images in the detection of land cover global changes between 1986 and 2021 and landscape monitoring in Belezma region. The methodology adopted is the spatial remote sensing of the evolution of forest stands and the change in land cover, from the processing of Landsat images (L05 TM 1986, L07 ETM+ 2001 and L08 OLI_TIRS 2021) and sampling work for confrontation with the reality on the ground. The outcomes of this investigation demonstrate a general regression rate in the natural vegetation cover that the cedar forest, the steppe, and the wetlands lost 42%, 49%, and 97%, respectively, of their areas between 1986 and 2021, while the degraded and anthropic occupations have increased in favor of market gardening, bare soil, urban areas, and arboriculture by 836%, 158%, 131%, and 50%, respectively, over the same period. This study made it possible to identify and analyze 13 main land uses and plant formations over a period of 35 years, which can be used as a decision-making aid model for the managers of these territories.

Predicting Nipple Necrosis with a "Lights-on" Indocyanine Green Imaging System: A Report of Two Patients.

Nipple-areolar complex (NAC) necrosis is a devastating complication in nipple-sparing mastectomies (NSMs) that significantly impacts patient's quality of life. The use of fluorescence angiography for intraoperative assessment of mastectomy skin flap perfusion in NSM has been successfully described and can be utilized to help guide surgical decision-making. Recently, a novel fluorescence-guided surgical imager was developed, OnLume Avata System (OnLume Surgical, Madison, WI), which provides intraoperative evaluation of vascular perfusion in ambient light. In this case report, we describe the use of OnLume fluorescence-guided surgery technology to help aid in clinical decision-making for two breast reconstruction cases with concern for intraoperative nipple hypoperfusion.

Low-value chronic prescription of acid reducing medication among Dutch general practitioners: impact of a patient education intervention

BackgroundDyspepsia is a commonly encountered clinical condition in Dutch general practice, which is often treated through the prescription of acid-reducing medication (ARM). However, recent studies indicate that the majority of chronic ARM users lack an indication for their use and that their long-term use is associated with adverse outcomes. We developed a patient-focussed educational intervention aiming to reduce low-value (chronic) use of ARM.MethodsWe conducted a randomized controlled study, and evaluated its effect on the low-value chronic prescription of ARM using data from a subset (n = 26) of practices from the Nivel Primary Care Database. The intervention involved distributing an educational waiting room posters and flyers informing both patients and general practitioners (GPs) regarding the appropriate indications for prescription of an ARM for dyspepsia, which also referred to an online decision aid. The interventions’ effect was evaluated through calculation of the odds ratio of a patient receiving a low-value chronic ARM prescription over the second half of 2021 and 2022 (i.e. pre-intervention vs. post-intervention).ResultsIn both the control and intervention groups, the proportion of patients receiving chronic low-value ARM prescriptions slightly increased. In the control group, it decreased from 50.3% in 2021 to 49.7% in 2022, and in the intervention group it increased from 51.3% in 2021 to 53.1% in 2022. Subsequent statistical analysis revealed no significant difference in low-value chronic prescriptions between the control and intervention groups (Odds ratio: 1.11 [0.84–1.47], p > 0.05).ConclusionOur educational intervention did not result in a change in the low-value chronic prescription of ARM; approximately half of the patients of the intervention and control still received low-value chronic ARM prescriptions. The absence of effect might be explained by selection bias of participating practices, awareness on the topic of chronic AMR prescriptions and the relative low proportion of low-value chronic ARM prescribing in the intervention as well as the control group compared to an assessment conducted two years prior.Trial registration10/31/2023 NCT06108817.

Analysis and mapping the research landscape on patient-centred care in the context of chronic disease management.

Patient-centred care has emerged as a transformative approach in managing chronic diseases, aiming to actively involve patients in their healthcare decisions. This study was conducted to analyse and map the research landscape on patient-centred care in the context of chronic disease management. This study used Scopus to retrieve the relevant articles. The analysis focused on the growth pattern, highly cited articles, randomised clinical trials, patients and providers perspectives, facilitators and barriers, frequent author keywords, emerging topics, and prolific countries and journals in the field. In total, 926 research articles met the inclusion criteria. There was a notable increase in the number of publications over time. Cancer had the highest number of articles (n = 379, 40.9%), followed by diabetes mellitus, and mental health and psychiatric conditions. Studies on patient-centred care in diabetic patients received the highest number of citations. The results identified 52 randomised controlled trials that covered four major themes: patient-centred care for diabetes management, shared decision-making in mental health and primary care, shared decision-making in cancer care, and economic evaluation and cost-effectiveness. The study identified 51 studies that examined the impact of tools such as computer-based systems, decision aids, smartphone apps, and online tools to improve patient-centred outcomes. A map of author keywords showed that renal dialysis, HIV, and atrial fibrillation were the most recent topics in the field. Researchers from the United States contributed to more than half of the retrieved publications. The top active journals included "Patient Education and Counselling" and "Health Expectations". This study provides valuable insights into the research landscape of patient-centred care within the context of chronic diseases. The current study provided a comprehensive overview of the research landscape on patient-centred care, which can empower patients by raising their awareness about clinical experiences and outcomes.

Estimating metabolic rate from ISO heart rate method and two walking equations.

Assigning a value for metabolic rate is central to heat stress assessment. ISO 8996 describes a predictive method for walking based on the American College of Sports Medicine (ACSM) method and another generalized method based on average heart rate. In addition, the US Army uses the load carriage decision aid (LCDA) predictive equation to estimate metabolic rate. The purpose of this study was to assess the accuracy/bias and precision of the ISO heart rate method and the ACSM and LCDA equations. The laboratory database included metabolic rate, heart rate, treadmill speed, and grade during a progressive heat stress protocol. Treadmill speed and grade were set to represent one of three metabolic rates. Accuracy and precision were assessed with Bland-Altman plots. All three methods had good accuracy (low bias). For precision, the ISO heart rate method had a root mean square error (RMSE) of 34 W and 11% when adjusted for repeated measures. The RMSE for two equations was 20 W and 7%. Although the heart method had less accuracy, its application is more generalizable. The heart rate method should be used below the occupational exposure limit for heat stress to avoid a bias toward higher predicted values due to heat strain.

Flood Risk Mapping during the Extreme February 2021 Flood in the Juruá River, Western Brazilian Amazonia, State of Acre

Cruzeiro do Sul, a municipality in Northwestern Brazil is recurrently impacted by floods, particularly along the Juruá River. This study presents a comprehensive flood risk analysis by integrating geoprocessing, remote sensing, and hydraulic modeling techniques. Our objectives are to simulate flood extents, identify high-risk areas, and guide sustainable territorial management. Our findings illustrate that the flood impacts are distributed across urban (27%), agricultural (55%), and forest/grassland (17%) landscapes. Historical records and literature reviews also underscore a recurring pattern of extreme floods in the municipality, notably during February’s La Niña events. Some vulnerable urban neighborhoods were identified: Vila Cruzeirinho, Centro, Miritizal, and Da Várzea. These areas are especially susceptible due to their proximity to the river and increased surface runoff during high flood events. By amalgamating various data sources and methods, this research aids decision making for flood mitigation and urban development, fostering resilience against recurrent flooding events in Cruzeiro do Sul.

Development of a patient decision aid for children and adolescents following anterior cruciate ligament rupture: an international mixed-methods study

AimTo develop and user test an evidence-based patient decision aid for children and adolescents who are considering anterior cruciate ligament (ACL) reconstruction.DesignMixed-methods study describing the development of a patient decision...

Preliminary testing of "roadmap to parenthood" decision aid and planning tool for family building after cancer: Results of a single-arm pilot study.

Many young adult female cancer survivors need to use reproductive medicine, surrogacy, or adoption to have a child. This study pilot tested Roadmap to Parenthood, a web-based, self-guided decision aid and planning tool for family building after cancer (disease agnostic). A single-arm pilot study tested feasibility, acceptability, and obtained effect size estimates of the Roadmap tool. Participants, recruited via hospital-based and social media strategies, completed a baseline survey (T1), accessed the Roadmap tool (website), then completed surveys at one- and 3-months (T2 and T3, respectively). Feasibility and acceptability were evaluated with rates of eligibility, enrollment, and survey completion, and feedback. Pairwise t-tests and repeated measures ANOVA evaluated usage effects. Effect size estimates were calculated. Participants (N=98) averaged 31years old (SD=5.61); 71% were nulliparous. Enrollment rate was 73%, T1-T2 completion rate was 80%, and 93% accessed the website. From T1-T2, participants reported improvements in decisional conflict (p<0.001; Cohen's d=0.85), unmet information needs (p<0.001; Cohen's d=0.70), self-efficacy (p=0.003; Cohen's d=0.40), and self-efficacy for managing negative emotions (p=0.03; Cohen's d=0.29); effects were sustained at T3. There was no change in reproductive distress (p=0.22). By T3, 94% reported increased consideration of preparatory actions and 20%-61% completed such actions. The Roadmap intervention was feasible to conduct, acceptable to users, and led to improvements in key psychosocial outcomes. Future directions will test intervention efficacy in a randomized controlled trial with a larger sample and over a longer period. A web-based tool may help women make decisions about family building after cancer and prepare for potential challenges.

Qualitative Analysis of Patient Decisional Needs for Medications to Treat Heart Failure.

The development of tools to support shared decision-making should be informed by patients' decisional needs and treatment preferences, which are largely unknown for heart failure (HF) with reduced ejection fraction (HFrEF) pharmacotherapy decisions. We aimed to identify patients' decisional needs when considering HFrEF medication options. This was a qualitative study using semi-structured interviews. We recruited patients with HFrEF from 2 Canadian ambulatory HF clinics and clinicians from Canadian HF guideline panels, HF clinics, and Canadian HF Society membership. We identified themes through inductive thematic analysis. Participants included 15 patients and 12 clinicians. Six themes and associated subthemes emerged related to HFrEF pharmacotherapy decision-making: (1) patient decisional needs included lack of awareness of a choice or options, difficult decision timing and stage, information overload, and inadequate motivation, support and resources; (2) patients' decisional conflict varied substantially, driven by unclear trade-offs; (3) treatment attribute preferences-patients focused on both benefits and downsides of treatment, whereas clinicians centered discussion on benefits; (4) quality of life-patients' definition of quality of life depended on pre-HF activity, though most patients demonstrated adaptability in adjusting their daily activities to manage HF; (5) shared decision-making process-clinicians' described a process more akin to informed consent; (6) decision support-multimedia decision aids, virtual appointments, and primary-care comanagement emerged as potential enablers of shared decision-making. Patients with HFrEF have several decisional needs, which are consistent with those that may respond to decision aids. These findings can inform the development of HFrEF pharmacotherapy decision aids to address these decisional needs and facilitate shared decision-making.

199 Early expansion and outcomes of a multilingual Latine review board for inclusive science

OBJECTIVES/GOALS: The NC Translational and Clinical Sciences (NC TraCS) Institute’s Latine Community Review Board (CRB) provides expertise to researchers seeking to culturally adapt interventions and improve language access in clinical and translational science. Early efforts aimed to expand CRB membership, build member capacity, and assess CRB impact. METHODS/STUDY POPULATION: Founded in 2021, the NC TraCS Latine CRB is an advisory group of natively Spanish-speaking, Latine North Carolinians who contract with research teams (RTs) to review Latine community-facing study materials (e.g., decision aids, scales, recruitment scripts) and provide feedback for improving or validating materials’ linguistic accuracy and cultural relevance. Bilingual staff facilitate members’ review of materials, use focus group methods to solicit feedback, and report key findings and suggested revisions to RTs. In 2023, we recruited new age-, gender-, and racially diverse members; and implemented process and impact evaluation, via (1) post surveys of RTs and (2) assessment of members’ experiences and visions for growth utilizing the Focused Conversation Method (Top-network, 2021). RESULTS/ANTICIPATED RESULTS: Since 2021, NC TraCS has conducted 11 Latine CRB review sessions to support 7 research studies. Current CRB members (n=8) report that (1) their work effectively supports Latine inclusion in research; (2) increased group size and diversity help ensure study materials are comprehensible to heterogenous Latine populations; and (3) an hourly member compensation rate equal to the hourly rate of TraCS’ staff accurately represents member contributions. Members also cited that they value open communication, continuous improvement, communication via email and group chat, periodic programming meetings, and RT updates on study outcomes. Post-session RT surveys to date (n=3) show that RTs would recommend this program to other researchers (pending survey responses from RTs this year will provide additional impact data). DISCUSSION/SIGNIFICANCE: Early data highlight the value of fairly compensated, bilingually coordinated input from diverse Latine community members for improving studies’ inclusion of heterogeneous, multilingual communities. Our approach can inform the development, growth, and continuous improvement of multilingual review boards at other research institutions.

Training on Addressing Patients’ Values (including Spirituality and Worldview) in Decision Making

IntroductionPatients’ values are relevant in patient-centred care (PCC) as awareness and recognition of these can lead to better decision making and improved outcomes. Training in decision making is sorely lacking, especially in the area of spirituality and worldview.ObjectivesOur poster describes a training workshop to provide such medical education to healthcare professionals. The half-day training covers: importance of addressing patients’ values in decision making; using decisional aids; role of spirituality and worldview of the patient.MethodsClinicians of the hospital, including doctors, nurses and allied healthcare professionals were invited to attend the training. The evaluations by the participants for the workshops conducted in 2021-2023 were collated and presented.ResultsFour workshops in 2021 to 2023 were conducted, with a total of 43 participants. We achieved overall ratings of above average and excellent in more than 80% of responses; content relevance and usefulness to work, presentation and facilitation were similarly rated. Most participants would recommend it to colleagues.ConclusionsThe “Addressing Patients’ Values in Decision Making” workshop for clinicians will allow the hospital to promulgate a culture of quality care through patient engagement.Disclosure of InterestNone Declared

Scoping review of interventions to de-implement potentially harmful non-steroidal anti-inflammatory drugs (NSAIDs) in healthcare settings

ObjectivesPotentially harmful non-steroidal anti-inflammatory drugs (NSAIDs) utilisation persists at undesirable rates worldwide. The purpose of this paper is to review the literature on interventions to de-implement potentially harmful NSAIDs in...

Qualitative user experience evaluation of the MS trust's online treatment decision aid tool's accommodation of planning pregnancy.

Decision-making about treatment when planning a pregnancy (family planning) is complex for women living with multiple sclerosis (MS). Decision tools can help this process, in 2016 MS Trust launched their online digital treatment decision tool to support people with MS. To evaluate user-experience of this tool by exploring women's opinions about its content, interface, and usefulness in the context of family planning; and to synthesize recommendations to improve the tool. Thirty participants qualitatively evaluated the tool using Think Aloud methodology. Sessions were conducted online using Microsoft Teams and were video recorded. Transcription was automated and data were thematically analyzed. Women's first impression was that the tool presented a lot of information at once, which was difficult to take in, and they found it difficult to navigate. Although the tool was helpful in allowing them to compare treatment options, the filters were confusing, and the information related to pregnancy sometimes contradicted advice from their healthcare practitioners. They suggested rewording the pregnancy recommendations and filters, updating some content, and making some changes to the interface to meet users' cognitive needs. The MS Trust treatment decision tool is excellent in helping women with treatment choices at initial diagnosis. However, it is not currently as useful when considering family plans. Recommendations were conveyed to MS Trust where some are now applied to the new live version and the rest are to be considered for future updating projects.