What Helps People Make Values-Congruent Medical Decisions? Eleven Strategies Tested across 6 Studies

Abstract

Background. High-quality health decisions are often defined as those that are both evidence informed and values congruent. A values-congruent decision aligns with what matters to those most affected by the decision. Values clarification methods are intended to support values-congruent decisions, but their effects on values congruence are rarely evaluated. Methods. We tested 11 strategies, including the 3 most commonly used values clarification methods, across 6 between-subjects online randomized experiments in demographically diverse US populations ( n1 = 1346, n2 = 456, n3 = 840, n4 = 1178, n5 = 841, n6 = 2033) in the same hypothetical decision. Our primary outcome was values congruence. Decisional conflict was a secondary outcome in studies 3 to 6. Results. Two commonly used values clarification methods (pros and cons, rating scales) reduced decisional conflict but did not encourage values-congruent decisions. Strategies using mathematical models to show participants which option aligned with what mattered to them encouraged values-congruent decisions and reduced decisional conflict when assessed. Limitations. A hypothetical decision was necessary for ethical reasons, as we believed some strategies may harm decision quality. Later studies used more outcomes and covariates. Results may not generalize outside US-based adults with online access. We assumed validity and stability of values during the brief experiments. Conclusions. Failing to explicitly support the process of aligning options with values leads to increased proportions of values-incongruent decisions. Methods representing more than half of values clarification methods commonly in use failed to encourage values-congruent decisions. Methods that use models to explicitly show people how options align with their values offer more promise for helping people make decisions aligned with what matters to them. Decisional conflict, while arguably an important outcome in and of itself, is not an appropriate proxy for values congruence.

Clarifying Values: An Updated and Expanded Systematic Review and Meta-Analysis

“…Methods that provided users with explicit feedback regarding how the decision options align with their stated values led to somewhat better outcomes, including greater values congruence. [48] When asked to compare methods to each other, study participants also preferred a values clarification method that explicitly showed them how the decision options align with their stated values. [72] Different values clarification methods yielded different patterns of attribute importance.…”

An Autonomy-Supportive Online Decision Aid to Assist Smokers in Choosing Evidence-Based Cessation Assistance: Development Process and Protocol of a Randomized Controlled Trial

“…The input of the experts was gathered through 2 Delphi studies (24 scientists and 38 clinicians completed the final round). The input of these 3 qualitative studies was used to inform the design and content of the DA, supplemented by the IPDAS background papers (eg, [31]) as well as other relevant literature in the field (eg, [23]) and in consultation with established experts in the field. The SDT served as the theoretical framework.…”

“…We decided to use an explicit VCM in the intervention group as VCMs are regarded as active ingredients by the IPDAS [20,37], and while conflicting evidence exists [46], an overwhelming amount of research has shown that interactive methods to clarify people's values seem to result in better decisional outcomes [22], especially in the long run [21] and if people are supported in understanding the implications of their clarified values [23,24]. This is why we decided to integrate individual tailored advice that is supplemented with information on how to obtain the different cessation assistance options to remove barriers for the users.…”

“…VCMs can either be explicit or implicit; the former refers to methods that involve the user actively engaging in an activity (eg, scoring certain statements), while the latter refers to the provision of information that is specifically linked to the decision at hand (similar to the aforementioned paper-based DA [14]), with the underlying belief that users will engage in cognitive processes themselves to reach a decision [21]. There is some evidence that shows that explicit VCMs are more effective than implicit VCMs (in terms of decisional processes) [22], especially in the long run [21] and when people are supported in understanding the implications of their clarified values for the decision [23,24]. One way to help users understand these implications is to show participants which options fit their clarified values [23] (ie, tailored advice following the VCMs based on the answers that were provided).…”

“…There is some evidence that shows that explicit VCMs are more effective than implicit VCMs (in terms of decisional processes) [22], especially in the long run [21] and when people are supported in understanding the implications of their clarified values for the decision [23,24]. One way to help users understand these implications is to show participants which options fit their clarified values [23] (ie, tailored advice following the VCMs based on the answers that were provided). Interestingly, the feasibility study of a digital DA for smoking cessation that did include an explicit VCM has shown promising results, both in terms of evidence-based cessation assistance uptake and smoking cessation outcomes [25].…”