20th Anniversary Update of the Ottawa Decision Support Framework: Part 2 Subanalysis of a Systematic Review of Patient Decision Aids

Abstract

Background. The Ottawa Decision Support Framework (ODSF) has guided the development of patient decision aids (PtDAs) for 20 years and needs updating across a range of decisions and hypothesized outcomes. Purpose. To determine the effectiveness of ODSF-developed PtDAs on hypothesized outcomes and to recommend framework changes. Data Source. A subanalysis of randomized controlled trials included in the 2017 Cochrane review of PtDAs comparing PtDAs to usual care in adults considering health treatment or screening decisions (searched to 2015). Study Selection. Trials in the original review that evaluated ODSF-developed PtDAs. Data Synthesis. Meta-analyses of ODSF outcomes with similar measurements and descriptions of other reported outcomes. Results. Of 105 trials, 24 evaluated ODSF-developed PtDAs. Compared with usual care, ODSF PtDAs improved knowledge (mean difference [MD] 13.85; 95% confidence interval [CI] 10.32−17.37; 14 trials), increased accurate risk perceptions (risk ratio [RR] 2.41; 95% CI 1.66−3.48; 7 trials), and increased congruence between informed values and chosen options (RR 1.32; 95% CI 1.09−1.59; 4 trials). They reduced perceived decisional needs as measured using the Decisional Conflict Scale (MD −5.92; 95% CI −8.58 to −3.26; 15 trials) and the proportion of undecided patients (RR 0.65; 95% CI 0.50−0.83; 13 trials). Non-ODSF PtDAs, designed with or without a specific framework, also outperformed usual care. Few ODSF trials measured secondary outcomes. Limitations. The included trials had heterogeneity. Conclusion. ODSF PtDAs address decisional needs and improve decision quality; the best indicator of addressing perceived uncertainty is “proportion undecided.” Secondary ODSF outcomes should be reduced to adherence to one’s chosen option and use/costs of health services, which warrant further research.

20th Anniversary Ottawa Decision Support Framework: Part 3 Overview of Systematic Reviews and Updated Framework

“…This effect is consistent with trials of non-ODSF PtDAs that measured decision regret: 5 trials reported no effect (prenatal screening 3 to 6 weeks; antibiotics for respiratory infection at 2 weeks; feeding tube at 3 months; pelvic organ prolapse surgery at 3 months), and 1 reported a reduction of decisional regret (breast cancer surgery at 4 and 10 months). 20…”

“…ODSF-based PtDAs were superior to usual care in 1) reducing total DCS scores, 2) improving decision quality (e.g., improved knowledge, more accurate risk perceptions, greater congruence between informed values and the chosen option), and 3) helping the undecided to decide. 20 DCS subscores were significantly lower for the uninformed, unclear values, unsupported, and ineffective decision subscales but not for the uncertainty subscale ( Table 5). These results are consistent with non-ODSF trials, with the exception that the uncertainty subscale was also significantly lower in the group exposed to PtDAs.…”

“…The 4 eligible reviews (Table 2) described the following: 1) the decisional needs of people who face health and social decisions from the perspectives of patient/parent decision makers, practitioners, and families 19 ; 2) variations in DCS scores before and after decision making according to exposure to information interventions, clinical context, decision type, and decision-maker characteristics 17 ; 3) the effectiveness of PtDAs compared with usual care 20 ; and 4) the effectiveness of decision coaching compared with PtDAs. 26 There were no reviews of the effectiveness of clinical counseling.…”

“…33,54 Blame has never been measured in trials, possibly because it is a rare event. 20,36 Values-based outcomes replaced health outcomes in the 2009 framework 4 based on the Cochrane trial evidence that PtDAs do not affect health outcomes. The absence of effects on health outcomes for difficult decisions is not surprising as there is no clear health advantage of one option over another.…”

Feasibility of Rapidly Developing and Widely Disseminating Patient Decision Aids to Respond to Urgent Decisional Needs due to the COVID-19 Pandemic

“…6 A systematic review of 24 randomized trials evaluating PtDAs, developed according to the Ottawa Framework, revealed that they were superior to usual care in addressing decisional needs and improving decision quality. 7 PtDAs developed according to the Ottawa Framework also meet the International PtDA Standards (IPDAS). 8,9 However, PtDA development and evaluation often takes more than 1 y, which is too long to address urgent emerging decisional needs.…”