EBPAssignWK89

Hi, Please carefully follow the instructions and the rubric to help you cover all the areas. I have also attached 3 journals from the school database.  Add other (more) resources. Citations should match References. Thank you.

Assignment: Evidence-Based Project, Part 5: Recommending an Evidence-Based Practice Change

The collection of evidence is an activity that occurs with an endgame in mind. For example, law enforcement professionals collect evidence to support a decision to charge those accused of criminal activity. Similarly, evidence-based healthcare practitioners collect evidence to support decisions in pursuit of specific healthcare outcomes.

In this Assignment, you will identify an issue or opportunity for change within your healthcare organization and propose an idea for a change in practice supported by an EBP approach.

To Prepare:

· Reflect on the four peer-reviewed articles you critically appraised in Module 4.

· Reflect on your current healthcare organization and think about potential opportunities for evidence-based change.

The Assignment: (Evidence-Based Project)

Part 5: Recommending an Evidence-Based Practice Change

Create an 8- to 9-slide PowerPoint presentation in which you do the following:

· Briefly describe your healthcare organization, including its culture and readiness for change. (You may opt to keep various elements of this anonymous, such as your company name.)

· Describe the current problem or opportunity for change. Include in this description the circumstances surrounding the need for change, the scope of the issue, the stakeholders involved, and the risks associated with change implementation in general.

· Propose an evidence-based idea for a change in practice using an EBP approach to decision making. Note that you may find further research needs to be conducted if sufficient evidence is not discovered.

· Describe your plan for knowledge transfer of this change, including knowledge creation, dissemination, and organizational adoption and implementation.

· Describe the measurable outcomes you hope to achieve with the implementation of this evidence-based change.

· Be sure to provide APA citations of the supporting evidence-based peer reviewed articles you selected to support your thinking.

· Add a lessons learned section that includes the following:

· A summary of the critical appraisal of the peer-reviewed articles you previously submitted

· An explanation about what you learned from completing the Evaluation Table within the Critical Appraisal Tool Worksheet Template (1-3 slides)

Submit Part 5 of your Evidence-Based Project.

Please Remember citations should match references. Thanks

RUBRIC

Part 5: Recommending an Evidence-Based Practice Change
Create an 8- to 9-slide PowerPoint presentation in which you do the following:
·   Briefly describe your healthcare organization, including its culture and readiness for change.
·   Describe the current problem or opportunity for change. Include in this description the circumstances surrounding the need for change, the scope of the issue, the stakeholders involved, and the risks associated with change implementation in general.

18 (18%) – 20 (20%)
The presentation clearly and accurately describes in detail a healthcare organization, including a detailed explanation of its culture and readiness for change.
The presentation clearly and accurately describes in detail a current problem or opportunity for change.
An accurate, specific, and detailed description of the circumstances surrounding the need for change, the scope of the issue, the stakeholders involved, and the risks associated with change implementation in general is provided.

16 (16%) – 17 (17%)
The presentation accurately describes a healthcare organization, including an accurate explanation of its culture and readiness for change.
The presentation accurately describes a current problem or opportunity for change.
An accurate description of the circumstances surrounding the need for change, the scope of the issue, the stakeholders involved, and the risks associated with the change implementation in general is provided.

14 (14%) – 15 (15%)
The presentation inaccurately or vaguely describes a healthcare organization, including an inaccurate or vague explanation of its culture and readiness for change.
The presentation inaccurately or vaguely describes a current problem or opportunity for change.
An inaccurate or vague description of the circumstances surrounding the need for change, the scope of the issue, the stakeholders involved, and the risks associated with the change implementation in general is provided.

0 (0%) – 13 (13%)
The presentation inaccurately and vaguely describes a healthcare organization, including an inaccurate and vague explanation of its culture and readiness for change, or is missing.
The presentation inaccurately and vaguely describes a current problem or opportunity for change or is missing.
An inaccurate and vague description of the circumstances surrounding the need for change, the scope of the issue, the stakeholders involved, and the risks associated with the change implementation in general is provided or is missing.

·   Propose an evidence-based idea for a change in practice using an evidence-based practice approach to decision making. Note that you may find further research needs to be conducted if sufficient evidence is not discovered.
·   Describe your plan for knowledge transfer of this change, including knowledge creation, dissemination, and organizational adoption and implementation.
·   Describe the measurable outcomes you hope to achieve with the implementation of this evidence-based change.
·   Be sure to provide APA citations of the supporting evidence-based peer-reviewed articles you selected to support your thinking.

32 (32%) – 35 (35%)
The presentation clearly and accurately proposes in detail an evidence-based idea for a change in practice that is fully aligned to an evidence-based practice approach for decision making.
The presentation clearly and accurately describes in detail a plan for knowledge transfer of this change, including a detailed plan for knowledge creation, dissemination, and organizational adoption and implementation that is specific.
The presentation clearly and accurately describes in detail the measurable outcomes desired for the implementation of the evidence-based change.
The presentation includes accurate, complete, and full APA citations of the supporting evidence-based peer-reviewed articles selected.

28 (28%) – 31 (31%)
The presentation accurately proposes an evidence-based idea for a change in practice that is adequately aligned to an evidence-based practice approach for decision making.
The presentation accurately describes a plan for knowledge transfer of this change, including a plan for knowledge creation, dissemination, and organizational adoption and implementation that is adequate.
The presentation accurately describes the measurable outcomes desired for the implementation of the evidence-based changes.
The presentation includes accurate APA citations of the supporting evidence-based peer-reviewed articles selected.

25 (25%) – 27 (27%)
The presentation inaccurately or vaguely proposes an evidence-based idea for a change in practice that may be aligned to an evidence-based practice approach for decision making.
The presentation inaccurately or vaguely describes a plan for knowledge transfer of this change, including a plan for knowledge creation, dissemination, and organizational adoption and implementation that may be relevant.
The presentation inaccurately or vaguely describes the measurable outcomes desired for the implementation of the evidence-based change.
Inaccurate and incomplete APA citations of the supporting evidence-based peer-reviewed articles selected are provided.

0 (0%) – 24 (24%)
The presentation inaccurately and vaguely proposes an evidence-based idea for a change in practice that is not aligned to an evidence-based practice approach for decision making or is missing.
The presentation inaccurately and vaguely describes a plan for knowledge transfer of this change, including a plan for knowledge creation, dissemination, and organizational adoption that implementation that is incomplete, or is missing.
The presentation inaccurately and vaguely describes the measurable outcomes desired for the implementation of the evidence-based change or is missing.
Inaccurate and incomplete APA citations of the supporting evidence-based peer-reviewed articles selected are provided or are missing.

Add a lessons learned section that includes:
·   A summary of the critical appraisal of the peer-reviewed articles you previously submitted.
·   What did you learn from completing the evaluation table?
·   What did you learn from completing the levels of evidence table?
·   What did you learn from completing the outcomes synthesis table?

27 (27%) – 30 (30%)
The presentation clearly and accurately summarizes in detail the critical appraisal process of the peer-reviewed articles previously submitted.
The presentation thoroughly describes in detail at least one lesson learned from completing the evaluation table that is specific.
The presentation thoroughly describes in detail at least one lesson learned from completing the levels of evidence table that is specific.
The presentation thoroughly describes in detail at least one lesson learned from completing the outcomes synthesis table that is specific.
The presentation provides a complete, detailed, and specific synthesis of two outside resources reviewed on the lessons learned explained. The presentation fully integrates at least two outside resources and two or three course-specific resources that fully support the presentation.

24 (24%) – 26 (26%)
The presentation accurately summarizes the critical appraisal process of the peer-reviewed articles previously submitted.
The presentation accurately describes at least one lesson learned from completing the evaluation table that may include some specificity.
The presentation accurately describes at least one lesson learned from completing the levels of evidence table that may include some specificity.
The presentation accurately describes at least one lesson learned from completing the outcomes synthesis table that may include some specificity.
The presentation provides an accurate synthesis of at least one outside resource reviewed related to the lessons learned explained. The presentation integrates at least one outside resource and two or three course-specific resources that may support the presentation.

21 (21%) – 23 (23%)
The presentation inaccurately or vaguely summarizes the critical appraisal process of the peer-reviewed articles previously submitted.
The presentation inaccurately or vaguely describes at least one lesson learned from completing the evaluation table and may lack some specificity.
The presentation inaccurately or vaguely describes at least one lesson learned from completing the levels of evidence table and may lack some specificity.
The presentation inaccurately or vaguely describes at least one lesson learned from completing the outcomes synthesis table and may lack some specificity.
The presentation provides a vague or inaccurate synthesis of outside resources reviewed related to the lessons learned explained. The response minimally integrates resources that may support the presentation.

0 (0%) – 20 (20%)
The presentation inaccurately and vaguely summarizes the critical appraisal process of the peer-reviewed articles previously submitted or is missing.
The presentation inaccurately and vaguely describes at least one lesson learned from completing the evaluation table and lacks specificity or is missing.
The presentation inaccurately and vaguely describes at least one lesson learned from completing the levels of evidence table that lacks specificity or is missing.
The presentation inaccurately and vaguely describes at least one lesson learned from completing the outcomes synthesis table that lacks specificity or is missing.
The presentation provides a vague and inaccurate synthesis of no outside resources related to the lessons learned explained or is missing. The presentation fails to incorporate any resources to support the responses provided.

Written Expression and Formatting—Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction is provided which delineates all required criteria.

5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
A clear and comprehensive purpose statement, introduction, and conclusion is provided which delineates all required criteria.

4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.
Purpose, introduction, and conclusion of the assignment is stated yet is brief and not descriptive.

3.5 (3.5%) – 3.5 (3.5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60–79% of the time.
Purpose, introduction, and conclusion of the assignment is vague or off topic.

0 (0%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time.
No purpose statement, introduction, or conclusion was provided.

Written Expression and Formatting—English Writing Standards:
Correct grammar, mechanics, and proper punctuation.

5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.

4 (4%) – 4 (4%)
Contains a few (one or two) grammar, spelling, and punctuation errors.

3.5 (3.5%) – 3.5 (3.5%)
Contains several (three or four) grammar, spelling, and punctuation errors.

0 (0%) – 3 (3%)
Contains many (five or more) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

Written Expression and Formatting—The paper follows correct format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list.

5 (5%) – 5 (5%)
Uses correct paper formatting with no errors.

4 (4%) – 4 (4%)
Contains a few (one or two) paper formatting errors.

3.5 (3.5%) – 3.5 (3.5%)
Contains several (three or four) paper formatting errors.

Copyright 2014 American Medical Association. All rights reserved.

The Connection Between Evidence-Based
Medicine and Shared Decision Making

Evidence-based medicine (EBM) and shared decision
making (SDM) are both essential to quality health care,
yet the interdependence between these 2 approaches
is not generally appreciated. Evidence-based medicine
should begin and end with the patient: after finding
and appraising the evidence and integrating its infer-
ences with their expertise, clinicians attempt a deci-
sion that reflects their patient’s values and circum-
stances. Incorporating patient values, preferences, and
circumstances is probably the most difficult and poorly
mapped step—yet it receives the least attention.1 This
has led to a common criticism that EBM ignore s
patients’ values and preferences—explicitly not its
intention.2

Shared decision making is the process of clinician
and patient jointly participating in a health decision af-
ter discussing the options, the benefits and harms, and
considering the patient’s values, preferences, and cir-
cumstances. It is the intersection of patient-centered
communication skills and EBM, in the pinnacle of good
patient care (Figure).

One Without the Other?
These approaches, for the most part, have evolved in
parallel, yet neither can achieve its aim without the other.
Without SDM, authentic EBM cannot occur.3 It is a
mechanism by which evidence can be explicitly brought
into the consultation and discussed with the patient.
Even if clinicians attempt to incorporate patient prefer-
ences into decisions, they sometimes erroneously
guess them. However, it is through evidence-informed

deliberations that patients construct informed prefer-
ences. For patients who have to implement the deci-
sion and live with the consequences, it may be more per-
tinent to realize that it is through this process that
patients incorporate the evidence and expertise of the
clinician, along with their values and preferences, into
their decision-making. Without SDM, EBM can turn into
evidence tyranny. Without SDM, evidence may poorly
translate into practice and improved outcomes.

Likewise, without attention to the principles of EBM,
SDM becomes limited because a number of its steps are
inextricably linked to the evidence. For example, discus-
sions with patients about the natural history of the con-
dition, the possible options, the benefits and harms of
each, and a quantification of these must be informed by

the best available research evidence. If SDM does not in-
corporate this body of evidence, the preferences that pa-
tients express may not be based on reliable estimates
of the risks and benefits of the options, and the result-
ing decisions not truly informed.

Why Is There a Disconnect?
A contributor to the existing disconnect between EBM
and SDM may be that leaders, researchers, and teach-
ers of EBM, and those of SDM, originated from, and his-
torically tended to practice, research, publish, and col-
laborate, in different clusters. Some forms of SDM have
emerged from patient communication, with much of its
research presented in conferences and journals in this
field. A seminal paper in 19974 conceptualized SDM as
a model of treatment decision making and as a patient-
clinician communication skill. However, it did so with-
out any connection to EBM—perhaps not surprisingly, be-
cause EBM was in its infancy.2

Conversely, with its origins in clinical epidemiology,
much of the focus of EBM has been on methods and
resources to facilitate locating, appraising, and synthe-
sizing evidence. There has been much less focus on dis-
cussing this evidence with patients and engaging with
them in its use (sometimes even disparagingly referred
to as “soft” skills). Most of the EBM attention has
involved scandals (eg, unpublished data, results “spin,”
conflicts of interest) and the high technology mile-
stones (eg, systems to make EBM better and easier).
Information about using evidence in decision-making
with patients has been scant.

D i s c o n n e c t b e t w e e n t h e 2 a p –
proaches is also evident in, and main-
tained by, the teaching provided to
clinicians and students, again often
ref lec ting the backgrounds of their
teachers. Opportunities to attend EBM
teaching abound with content largely

focused on forming questions and finding and criti-
cally appraising evidence.5 Learning how to apply and
integrate the evidence is usually absent, or mentioned
in passing without skill training.

Realizing the Connection Between EBM and SDM
A logical place to start is by incorporating SDM skill train-
ing into EBM training. This will help to address not only
the aforementioned deficits in EBM training but also the
lack of SDM training opportunities presently available.
Additionally, it may facilitate the uptake of SDM and,
more broadly, evidence translation. Recent calls for SDM
to be routinely incorporated into medical education pre-
sent an immediate opportunity to capitalize on closely
aligning the approaches.

Without shared decision making, EBM
can turn into evidence tyranny.

VIEWPOINT

Tammy C. Hoffmann,
PhD
Centre for Research in
Evidence-Based
Practice, Faculty of
Health Sciences and
Medicine, Bond
University, Queensland,
Australia; and
University of
Queensland, Brisbane,
Australia.

Victor M. Montori,
MD, MSc
Knowledge and
Evaluation Research
(KER) Unit, Mayo Clinic,
Rochester, Minnesota.

Chris Del Mar, MD,
FRACGP
Centre for Research in
Evidence-Based
Practice, Faculty of
Health Sciences and
Medicine, Bond
University, Queensland,
Australia.

Viewpoint page 1293

Corresponding
Author: Victor M.
Montori, MD, MSc,
Knowledge and
Evaluation Research
Unit, Mayo Clinic, 200
First St SW, Plummer
3-35, Rochester, MN
55905 (montori.victor
@mayo.edu).

Opinion

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Copyright 2014 American Medical Association. All rights reserved.

Another place to start to bring EBM and SDM together is the
development and implementation of clinical practice guidelines.
Whereas most guidelines fail to consider patients’ preferences in
formulating their recommendations,6 some advise clinicians to
talk with patients about the options but provide no guidance
about how to do this and communicate the evidence in a way
patients will understand. Shared decision making may be strongly

r e c o m m e n d e d i n g u i d e l i n e s w h e n t h e o p t i o n s a r e c l o s e l y
matched in their advantages and disadvantages, when uncer-
tainty in the evidence impairs determination of a clearly superior
approach, or when the balance of benefits and risks depends on
patient action, such as adherence to medication, monitoring, and
diet in patients using warfarin.

Conclusions
Links between EBM and SDM have until recently been largely ab-
sent or at best implied. However, encouraging signs of interaction
are emerging. For example, there has been some integration of the
teaching of both,7 exploration about how guidelines can be adapted
to facilitate SDM,8,9 and research and resource tools that recog-
nize both approaches. Examples of the latter include research agenda
and priority setting occurring in partnership with patients and cli-
nicians to help provide relevant evidence for decision making; and
a new evidence criterion for the International Patient Decision Aids
Standards requiring citation of systematically assembled and up-
to-date bodies of evidence, with their trustworthiness appraised,10

thus aligning the development of SDM tools with contemporary re-
quirements for the formulation of evidence-based guidelines. Also,
independent flagship conferences focused on the practice of evi-
dence-based health care and on the science of shared decision mak-
ing are now convening joint meetings.

Medicine cannot, and should not, be practiced without up-to-
date evidence. Nor can medicine be practiced without knowing
and respecting the informed preferences of patients. Clinicians,
researchers, teachers, and patients need to be aware of and
ac tively facilitate the interdependent relationship of these
approaches. Evidence-based medicine needs SDM, and SDM needs
EBM. Patients need both.

ARTICLE INFORMATION

Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest.
Dr Montori reported serving on the board of the
International Society for Evidence-based
Healthcare; serving as Chair of the Seventh
International Shared Decision Making Conference in
2013; that he is a member of the Steering
Committee of the International Patient Decision
Aids Standards; and that he is a member of the
GRADE Working Group. The KER Unit (Dr Montori’s
research group) produces and tests evidence-based
shared decision making tools that are freely
available at http://shareddecisions.mayoclinic.org.
Dr Hoffmann reported that she is supported by a
National Health and Medical Research Council of
Australia (NHMRC)/Primary Health Care Research
Evaluation and Development Career Development
Fellowship (1033038), with funding provided by
the Australian Department of Health and Ageing.
Drs Hoffmann and Del Mar reported that they are
coeditors of a book on evidence-based practice, for
which they receive royalties.

Additional Information: Additional information
abut evidence-based medicine and shared decision
making is available online in Evidence-Based
Medicine: An Oral History at http://ebm
.jamanetwork.com.

REFERENCES

1. Straus SE, Jones G. What has evidence based
medicine done for us? BMJ. 2004;329(7473):987-
988.

2. Sackett DL, Rosenberg WM, Gray JA, Haynes RB,
Richardson WS. Evidence based medicine: what it is
and what it isn’t. BMJ. 1996;312(7023):71-72.

3. Greenhalgh T, Howick J, Maskrey N; Evidence
Based Medicine Renaissance Group. Evidence
based medicine: a movement in crisis? BMJ. 2014;
348:g3725.

4. Charles C, Gafni A, Whelan T. Shared
decision-making in the medical encounter: what
does it mean? (or it takes at least two to tango).
Soc Sci Med. 1997;44(5):681-692.

5. Meats E, Heneghan C, Crilly M, Glasziou P.
Evidence-based medicine teaching in UK medical
schools. Med Teach. 2009;31(4):332-337.

6. Montori VM, Brito JP, Murad MH. The optimal
practice of evidence-based medicine: incorporating
patient preferences in practice guidelines. JAMA.
2013;310(23):2503-2504.

7. Hoffmann TC, Bennett S, Tomsett C, Del Mar C.
Brief training of student clinicians in shared decision
making: a single-blind randomized controlled trial.
J Gen Intern Med. 2014;29(6):844-849.

8. Decision Aids. MAGIC website. http://www
.magicproject.org/decision-aids/. Accessed July 24,
2014.

9. van der Weijden T, Pieterse AH,
Koelewijn-van Loon MS, et al. How can clinical
practice guidelines be adapted to facilitate shared
decision making? a qualitative key-informant study.
BMJ Qual Saf. 2013;22(10):855-863.

10. Montori VM, LeBlanc A, Buchholz A, Stilwell
DL, Tsapas A. Basing information on
comprehensive, critically appraised, and up-to-date
syntheses of the scientific evidence: a quality
dimension of the International Patient Decision Aid
Standards. BMC Med Inform Decis Mak. 2013;13
(suppl 2):S5.

Figure. The Interdependence of Evidence-Based Medicine and Shared
Decision Making and the Need for Both as Part of Optimal Care

Evidence-based
medicine

Optimal patient care

Patient-centered
communication skills

Shared decision
making

Opinion Viewpoint

1296 JAMA October 1, 2014 Volume 312, Number 13 jama.com

Copyright 2014 American Medical Association. All rights reserved.
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AUANEWS December 2014 23

In mCRPC therapy…

Is there more to the story?

INDICATION
ZYTIGA® (abiraterone acetate) in combination with prednisone is indicated for the treatment of patients with metastatic
castration-resistant prostate cancer (mCRPC).
IMPORTANT SAFETY INFORMATION
Contraindications—ZYTIGA® is not indicated for use in women. ZYTIGA® can cause fetal harm (Pregnancy Category X)
when administered to a pregnant woman and is contraindicated in women who are or may become pregnant.
Adverse Reactions—The most common adverse reactions (≥10%) are fatigue, joint swelling or discomfort, edema,
hot fl ush, diarrhea, vomiting, cough, hypertension, dyspnea, urinary tract infection, and contusion.
The most common laboratory abnormalities (>20%) are anemia, elevated alkaline phosphatase, hypertriglyceridemia,
lymphopenia, hypercholesterolemia, hyperglycemia, elevated AST, hypophosphatemia, elevated ALT, and hypokalemia.
Increased ZYTIGA® Exposures With Food—ZYTIGA® must be taken on an empty stomach. No food should be eaten
for at least two hours before the dose of ZYTIGA® is taken and for at least one hour after the dose of ZYTIGA® is taken.
Abiraterone Cmax and AUC0-∞ (exposure) were increased up to 17- and 10-fold higher, respectively, when a single dose of
abiraterone acetate was administered with a meal compared to a fasted state.
Adrenocortical Insuffi ciency (AI)—AI was reported in patients receiving ZYTIGA® in combination with prednisone,
after an interruption of daily steroids and/or with concurrent infection or stress. Use caution and monitor for symptoms
and signs of AI if prednisone is stopped or withdrawn, if prednisone dose is reduced, or if the patient experiences
unusual stress. Symptoms and signs of AI may be masked by adverse reactions associated with mineralocorticoid
excess seen in patients treated with ZYTIGA®. Perform appropriate tests, if indicated, to confi rm AI. Increased dosages
of corticosteroids may be used before, during, and after stressful situations.
Hypertension, Hypokalemia, and Fluid Retention Due to Mineralocorticoid Excess—Use with caution in patients
with a history of cardiovascular disease or with medical conditions that might be compromised by increases in blood
pressure, hypokalemia, or fl uid retention. ZYTIGA® may cause hypertension, hypokalemia, and fl uid retention as a
consequence of increased mineralocorticoid levels resulting from CYP17 inhibition. Safety has not been established
in patients with LVEF <50% or New York Heart Association (NYHA) Class III or IV heart failure (in Study 1) or NYHA Class II to IV heart failure (in Study 2) because these patients were excluded from these randomized clinical trials. Control hypertension and correct hypokalemia before and during treatment. Monitor blood pressure, serum potassium, and symptoms of fl uid retention at least monthly. mCRPC=metastatic castration-resistant prostate cancer; AST=aspartate aminotransferase; ALT=alanine aminotransferase.

Please see additional Important Safety Information on the next page.
Please see brief summary of full Prescribing Information on subsequent pages.

AUANEW816.indd 1 27/11/14 12:10 PM

▼ Continued on page 24

James E. Montie, MD
Ann Arbor, Michigan

Djulbegovic B
and Guyatt GH:
Evidence-based
practice is not

synonymous with
delivery of uniform health care.
JAMA 2014; 312: 1293-1294.

Hoffman TC, Montori VM and
Del Mar C: The connection be-
tween evidence-based medicine
and shared decision making. JAMA
2014; 312: 1295-1296.

Kane HL, Halpern MT, Squiers LB
et al: Implementing and evaluating
shared decision making in oncolo-
gy practice. Ca Cancer J Clin 2014;
64: 377–388.

Thompson IM Jr, Leach RJ and
Ankerst DP: Focusing PSA testing
on detection of high-risk prostate
cancers by incorporating patient
preferences into decision making.
JAMA 2014; 312: 995-996.

Vickers AJ, Edwards K, Cooperberg
MR et al: A simple schema for
informed decision making about
prostate cancer screening. Ann
Intern Med 2014; 161: 441-442.

The fi rst 3 articles deal with
general aspects of evidence-based
medicine (EBM). Djulbegovic and
Guyatt stress that attempts to achieve
uniformity of practice as an end are
misguided. “…If values and prefer-
ences differ widely across patients
(which is often if not uniformly the
case), the right decision for one pa-
tient may be the wrong decision for
another.” This is particularly true in
many urological conditions in which
the guideline recommendations are
unavoidably weak.

Hoffman et al add that practition-
ers need to recognize that EBM and
shared decision making (SDM) are
essential to quality health care. One
cannot achieve its aims without the
other. “Without SDM, EBM can turn
into evidence tyranny….Likewise,
without attention to the principles
of EBM, SDM becomes limited be-
cause a number of its steps are inextri-
cably linked to the evidence.”

Kane et al emphasize the patient
and physician factors that can make

HAVE YOU Read?
SDM successful. Decision aids are
tools to help patients make well-in-
formed and preference sensitive deci-
sions. It should be noted that decision
aids are “…designed to support—not
replace—provider counseling.”

The next articles focus specifi cally
on prostate specifi c antigen (PSA)
testing and SDM. There is no dis-
agreement that innovation is needed
to ensure that PSA testing does more
good than harm. Thompson et al
posit that a PSA result should not
be listed as normal or elevated, but
instead should be personalized, and

linked to the likelihood of no can-
cer, low grade cancer or high grade
cancer using the Prostate Cancer
Prevention Trial risk calculator 2.0.
Such information should assist the
patient in the decision about whether
to proceed with testing.

Vickers et al take a provocative
step further and suggest that after
the patient understands some basic
facts about prostate cancer, if he is
uncomfortable knowing that he has
a cancer and not treating it, then

24 December 2014 AUANEWS

More than 1,000 days.
And every day tells a story.

For men with mCRPC who progressed on ADT

In a clinical trial, patients had a median overall survival
on ZYTIGA® (abiraterone acetate) of…*

Please see brief summary of full Prescribing
Information on subsequent pages.

Janssen Biotech, Inc.
© Janssen Biotech, Inc. 2014 6/14 016819-140612

5.2
35.3

Co-primary end point—overall survival: hazard ratio (HR)=0.792; 95% CI: 0.655, 0.956; P=0.0151; prespecifi ed
value for statistical signifi cance not reached.

Co-primary end point—radiographic progression-free survival: median not reached for ZYTIGA® plus
prednisone vs a median of 8.28 months for placebo plus prednisone. HR=0.425; 95% CI: 0.347, 0.522; P<0.0001.

MONTHS IMPROVEMENT IN MEDIAN OVERALL SURVIVAL
compared with placebo plus prednisone.

MONTHS MEDIAN OVERALL SURVIVAL FOR ZYTIGA® plus prednisone†
vs 30.1 MONTHS with placebo plus prednisone (active compound).‡

IMPORTANT SAFETY INFORMATION (cont)
Increased ZYTIGA® Exposures With Food—ZYTIGA® must be taken on an empty stomach. No food should be eaten
for at least two hours before the dose of ZYTIGA® is taken and for at least one hour after the dose of ZYTIGA® is taken.
Abiraterone Cmax and AUC0-∞ (exposure) were increased up to 17- and 10-fold higher, respectively, when a single dose
of abiraterone acetate was administered with a meal compared to a fasted state.
Hepatotoxicity—Monitor liver function and modify, withhold, or discontinue ZYTIGA® dosing as recommended (see
Prescribing Information for more information). Measure serum transaminases (ALT and AST) and bilirubin levels prior
to starting treatment with ZYTIGA®, every two weeks for the fi rst three months of treatment, and monthly thereafter.
Promptly measure serum total bilirubin, AST, and ALT if clinical symptoms or signs suggestive of hepatotoxicity develop.
Elevations of AST, ALT, or bilirubin from the patient’s baseline should prompt more frequent monitoring. If at any time
AST or ALT rise above fi ve times the upper limit of normal (ULN) or the bilirubin rises above three times the ULN,
interrupt ZYTIGA® treatment and closely monitor liver function.
* Study Design: ZYTIGA®, in combination with prednisone, was evaluated in a phase 3, randomized, double-blind, placebo-controlled, multicenter trial in patients
with mCRPC who had not received prior chemotherapy (N=1,088). Patients were using a luteinizing hormone-releasing hormone (LHRH) agonist or were previously
treated with orchiectomy. In the ZYTIGA® arm, patients received ZYTIGA® 1,000 mg orally once daily + prednisone 5 mg orally twice daily. In the placebo arm, patients
received placebo orally once daily + prednisone 5 mg orally twice daily. In this study, the co-primary effi cacy end points were overall survival (OS) and radiographic
progression-free survival.

ADT=androgen-deprivation therapy.

AUANEW817.indd 1 27/11/14 3:21 PM

Have You Read?
▼ Continued from page 23

screening may not be for him. This
is based on the greater likelihood of
fi nding a cancer that does not need
treatment than one that does. On the
other hand, if the patient is confi dent
that he would accept treatment for
aggressive cancer and would not be
unduly worried about living with a
cancer that is low risk, then the pa-
tient would be a good candidate for
screening.

Smith-Bindman R, Aubin C,
Bailitz J et al: Ultrasonography
versus computed tomography for
suspected nephrolithiasis. N Engl J
Med 2014; 371: 1100-1110.

This article stimulated much
debate in social media. In this pro-
spective, randomized trial including
2,759 patients with suspected neph-
rolithiasis assigned to point of care
ultrasonography (US), radiology US
or computerized tomography (CT),
ultrasonography demonstrated “lower
cumulative radiation exposure than

initial CT, without signifi cant dif-
ferences in high-risk diagnoses with
complications, serious adverse events,
pain scores, return to emergency de-
partment visits, or hospitalizations.”

Surprisingly, time spent in the
emergency department was longer in
the radiology US group (7.0 hours)
than point of care US (6.3 hours) or
CT (6.4 hours). This fi nding suggests
that US should be the preferred ini-
tial study. Followup CT was needed
in 40.7% and 27% of the patients
receiving point of care US and radiol-
ogy US, respectively. In the initial CT

group only 5.1% of patients needed a
later US.

A noteworthy point was that the
sensitivity for the detection of neph-
rolithiasis was signifi cantly higher in
the CT group. Thus, for example, the
provider may learn that the patient
had hydronephrosis from US but CT
may be able to show that it was due to
a 3 mm calculus at the ureterovesical
junction. In addition, new generation
CT will deliver substantially less ra-
diation. ◆

Copyright of AUANews is the property of American Urological Association Education &
Research, Inc. (AUA E/R) and its content may not be copied or emailed to multiple sites or
posted to a listserv without the copyright holder’s express written permission. However, users
may print, download, or email articles for individual use.

Provider perspectives on the utility of a colorectal
cancer screening decision aid for facilitating shared
decision

making

Paul C. Schroy III MD MPH,* Shamini Mylvaganam MPH� and Peter Davidson MD�
*Director of Clinical Research, Section of Gastroenterology, Boston Medical Center, Boston, MA, �Study Coordinator, Section of
Gastroenterology, Boston Medical Center, Boston, MA and �Clinical Director, Section of General Internal Medicine,

Boston

Medical Center, Boston, MA,

USA

Correspondence

Paul C. Schroy III, MD MPH

Boston Medical Center

85 E. Concord Street

Suite 7715

Boston

MA 02118

USA

E-mail: paul.schroy@bmc.org

Accepted for publication

8 August 2011

Keywords: decision aids, informed
decision making, shared decision

making

Abstract

Background Decision aids for colorectal cancer (CRC) screening

have been shown to enable patients to identify a preferred screening

option, but the extent to which such tools facilitate shared decision

making (SDM) from the perspective of the provider is less well

established.

Objective Our goal was to elicit provider feedback regarding the

impact of a CRC screening decision aid on SDM in the primary care

setting.

Methods Cross-sectional survey.

Participants Primary care providers participating in a

clinical trial

evaluating the impact of a novel CRC screening decision aid on

SDM and adherence.

Main outcomes Perceptions of the impact of the tool on decision-

making and implementation issues.

Results Twenty-nine of 42 (71%) eligible providers responded,

including 27 internists and two nurse practitioners. The majority

(>60%) felt that use of the tool complimented their usual approach,

increased patient knowledge, helped patients identify a preferred

screening option, improved the quality of decision making, saved

time and increased patients� desire to get screened. Respondents
were more neutral is their assessment of whether the tool improved

the overall quality of the patient visit or patient satisfaction. Fewer

than 50% felt that the tool would be easy to implement into their

practices or that it would be widely used by their colleagues.

Conclusion Decision aids for CRC screening can improve the

quality and efficiency of SDM from the provider perspective but

future use is likely to depend on the extent to which barriers to

implementation can be addressed.

doi: 10.1111/j.1369-7625.2011.007

30

.x

� 2011 John Wiley & Sons Ltd 27
Health Expectations, 17, pp.27–

35

Introduction

Engaging patients to participate in the decision-

making process when confronted with prefer-

ence-sensitive choices related to cancer screening

or treatment is fundamental to the concept of

patient-centred care endorsed by the Institute of

Medicine, US Preventive Services Task Force

and the Centers for Disease Control and Pre-

vention.
1–3

Ideally, this process should occur

within the context of shared decision making

(SDM), whereby patients and their health-care

providers form a partnership to exchange

information, clarify values and negotiate a

mutually agreeable medical decision.
4,5

SDM,

however, has been difficult to implement into

routine clinical practice in part owing to lack of

time, resources, clinician expertise and suitabil-

ity for certain patients or clinical situations.
6,7

The use of patient-oriented decision aids outside

of the context of the provider–patient interac-

tion has been proposed as a potentially effective

strategy for circumventing several of these bar-

riers.
3,8

Decision aids are distinct from patient

education programmes in that they serve as

tools to enable patients to make an informed,

value-concordant choice about a particular

course of action based on an understanding of

potential benefits, risks, probabilities and sci-

entific uncertainty.
9–11

Besides facilitating

informed decision making (IDM), decision aids

also have the potential to facilitate SDM by

improving the quality and efficiency of the

patient–provider encounter and by empowering

users to participate in the decision-making

process.
11

Studies to date have demonstrated

that while decision aids enhance knowledge,

reduce decisional conflict, increase involvement

in the decision-making process and lead to

informed value-based decisions, their impact on

the quality of the decision, satisfaction with the

decision making process and health outcomes

remains unclear.
11

Besides enabling patients to make informed

choices, decision aids also have the potential to

facilitate SDM by improving the quality and

efficiency of the patient–provider encounter.

Relatively few studies have examined the utility

of decision aids for promoting effective SDM

from the perspective of the provider. Studies to

date have largely focused on provider perspec-

tives on the quality of the decision tools

themselves or issues related to implementation

into clinical practice.
11–15

The overall objective

of this study was to elicit provider feedback

regarding the extent to which the use of a novel

colorectal cancer (CRC) screening decision aid

facilitated SDM in the primary care setting

within the context of a randomized clinical

trial.

Methods

Brief overview of decision aid and randomized

clinical trial

Details of the decision aid, recruitment process,

study design and secondary outcome results

have been previously published.
16

The overall

objective of the trial was to evaluate the impact

of a novel computer-based decision aid on SDM

and patient adherence to CRC screening rec-

ommendations. The decision aid uses video-

taped narratives and state-of-the-art graphics in

digital video disc (DVD) format to convey key

information about CRC and the importance of

screening, compare each of five recommended

screening options using both attribute- and

option-based approaches, and elicit patient

preferences. A modified version of the tool also

incorporated the web-based �Your Disease Risk
(YDR)� CRC risk assessment tool (http://
www.yourdiseaserisk.wustl.edu). To assess its

impact on SDM and screening adherence,

average-risk, English-speaking patients 50–

75 years of age due for CRC screening were

randomized to one of the two intervention arms

(decision aid plus the YDR personalized risk

assessment tool with feedback or decision aid

alone) or a control arm, each of which involved

an interactive computer session just prior to a

scheduled visit with their primary care provider

at either the Boston Medical Center or the

South Boston Community Health Center. After

completing the computer session, patients met

with their providers to discuss screening and

Colorectal cancer screening decision aid, P C Schroy, S Mylvaganam and P Davidson

� 2011 John Wiley & Sons Ltd
Health Expectations, 17, pp.27–35

28

identify a preferred screening strategy. Although

providers were blinded to their patients� ran-
domization status, they received written notifi-

cation in the form of a hand-delivered flyer from

all study patients acknowledging that they were

participating in the �CRC decision aid study� to
ensure that screening was discussed. Outcomes

of interest were assessed using pre ⁄ post-tests,
electronic medical record and administrative

databases. The study to date has found that the

tool enables users to identify a preferred

screening option based on the relative values

they place on individual test features, increases

knowledge about CRC screening, increases sat-

isfaction with the decision-making process and

increases screening intentions compared to non-

users. The study also finds that screening

intentions and test ordering are negatively

influenced in situations where patient and pro-

vider preferences differ. The tool�s impact on
patient adherence awaits more complete follow-

up data, which should be available in early

2011.

Study design

We conducted a cross-sectional survey of

primary care providers participating in the ran-

domized clinical trial in January and February

of 2009. At the time of the survey, 725 eligible

patients had been randomized to one of the three

study arms. The surveys were distributed just

prior to monthly business meetings conducted

by the Sections of General Internal Medicine

and Women�s Health at Boston Medical Center
and Adult Medicine at the South Boston Com-

munity Health Center. Respondents were asked

to sign an attestation sheet if they completed the

survey to identify providers not in attendance.

For those who were not in attendance, the sur-

vey was distributed electronically as an email

attachment; respondents were asked to return

the survey via facsimile to preserve anonymity.

Two email reminders with attached surveys were

sent 2 weeks apart after the initial email to

optimize response. The study was deemed

exempt by the Institutional Review Boards at

both participating institutions.

Subjects

The survey sample included board-certified

primary care providers (general internists and

nurse practitioners) at Boston Medical Center

and the South Boston Community Health Center

who had referred patients to the randomized

clinical trial. Of the 50 providers who had referred

patients to the study since its commencement in

2005, 42 were still practicing at the participating

sites at the time of the survey. All had exposure to

at least one patient in an intervention arm and at

least one patient in the control arm; all but two of

the targeted providers had multiple patients in

each arm. None of the participants had formally

reviewed the content of the decision aid nor

received special training in SDM.

Practice settings

The Boston Medical Center is a private, non-profit

academic medical centre affiliated with the Boston

University School of Medicine, which serves a

mostly minority patient population (only 28%

White, non-Hispanic). The South Boston Com-

munity Health Center is a community health centre

affiliated with BMC, which serves a mostly White,

non-Hispanic, low-income patient population.

Survey instrument

The survey instrument included a cover letter, 23

closed-ended questions and two open-ended

questions. Much of the content was derived from

instruments used in previously published studies

by Holmes-Rovner et al. and Graham et al.
6,15

The cover letter briefly described the purpose of

the study, a statement that participation was

completely voluntary, the approximate amount

of time required to complete the survey, and a

statement that all responses are anonymous and

confidential. The closed-ended questions include

one item related to eligibility [confirmation of

participation in the clinical trial (yes ⁄ no)], two
items related to demographics (provider degree

and year of graduation), 12 items related to

perspectives on the impact of the tool on various

patient and provider components of SDM for

Colorectal cancer screening decision aid, P C Schroy, S Mylvaganam and P Davidson
� 2011 John Wiley & Sons Ltd
Health Expectations, 17, pp.27–35

29

CRC screening (see Table 1), and eight items

related to perspectives on implementation or

content modification (see Tables 2 and 3). The

framing of the questions inferred a comparison

between patients exposed to the decision aid and

those not exposed, i.e., standard care patients,

regardless of their involvement in the study. All

of the items related to SDM used a 5-point Likert

scale ranging from 1 (strongly disagree) to 5

(strongly agree). Six of the items related to

implementation or content modification also

used the same 5-point Likert scale, and two used

a single best answer format. The two open-ended

questions inquired about suggestions for

improving the decision aid and complaints. The

questionnaire took �10 min to complete.

Statistical analyses

Descriptive statistics were used to characterize

the study population and response data for all

closed-ended questions. Frequency data for the

5-point Likert scale items were collapsed into

three categories: �agreed ⁄ strongly agreed�, �neu-

tral� and �disagreed ⁄ strongly disagreed�. Mean
response scores ± standard deviations were

also calculated for the same data using Micro-

soft Excel functions. Responses to open-ended

questions were summarized according to themes.

Results

Study population

In total, 29 of the 42 (71%) possible providers,

including 27 physicians and two nurse practitio-

ners, responded to the survey and acknowledged

that they had referred patients to the randomized

clinical trial. Of the 29 respondents, 4 (14%) had

received their degrees between 2000 and 2009, 15

(52%) between 1990 and 1999, and 6 (28%)

before 1990; two declined to answer the question.

Perspectives on SDM

As shown in Table 2, the majority of providers

(>60%) agreed or strongly agreed that the

decision aid complemented their usual approach

Table 1 Provider perspectives on the utility of the decision aid for facilitating SDM

From my clinical perspective, the decision aid

Response category, n (%)

Mean item

score (SD)*

Strongly

agree ⁄ agree Neutral

Strongly

disagree ⁄
disagree

4. Complemented my usual approach to CRC screening 24 (86) 4 (14) 0 4.3 ± 0.7

5. Improved my usual approach to CRC screening 16 (59) 8 (30) 3 (11) 3.7 ± 1.0

6. Helped me tailor my counselling about CRC

screening to my patient�s needs
12 (44) 11 (41) 4 (15) 3.5 ± 1.0

7. Saved me time 18 (64) 6 (21) 4 (14) 3.8 ± 1.0

8. Improved the quality of patient visits 14 (52) 9 (

33

) 4 (15) 3.6 ± 1.0

9. Increased my patients� satisfaction with my care 10 (40) 13 (52) 2 (8) 3.4 ± 0.8
10. Is an appropriate use of my patient�s clinic time 27 (93) 1 (3) 1 (3) 4.1 ± 0.6
11. Increase patient knowledge about the different

CRC screening options

26 (90) 3 (10) 0 4.3 ± 0.6

12. Helped patients understand the benefits ⁄ risks
of the recommended screening options

24 (83) 5 (17) 0 4.1 ± 0.7

13. Helped patients in identifying preferred

screening option

21 (72) 7 (24) 1 (3) 4.0 ± 0.8

14. Improved the quality of the decision making 22 (79) 6 (21) 0 4.0 ± 0.7

15. Increased patients� desire to get screened 21 (75) 5 (18) 2 (7) 3.9 ± 0.9

CRC, colorectal cancer; SD, standard deviation; SDM, shared decision making.

*1 = strongly disagree; 5 = strongly agree.

Colorectal cancer screening decision aid, P C Schroy, S Mylvaganam and P Davidson
� 2011 John Wiley & Sons Ltd
Health Expectations, 17, pp.27–35
30

to CRC screening, was an appropriate use of

their patient�s clinic time, saved them time,
increased patient knowledge about the various

CRC screening options and their risks and

benefits, helped the patients identify a preferred

screening option, improved the quality of deci-

sion making, and increased their patients� desire
to get screened. Providers were more neutral in

their assessment of the decision aid�s utility for
improving their usual approach to CRC

screening, helping them tailor their counselling

style to their patients� needs, improving the
quality of patient visits, and increasing patient

satisfaction with their care. Relatively few pro-

viders disagreed or strongly disagreed with any

of these measures.

Perspectives on clinical use and content

modification

There was less consensus when asked about

implementation of the tool into routine clinical

practice. As shown in Table 2, <50% of

respondents agreed or strongly agreed that the

decision aid would be easy to use in their prac-

tice outside of a research setting or that it would

be used by most of their colleagues. A slim

majority (58%) also believed that implementa-

tion would require reorganization of their

practice. Respondents mostly agreed or were

neutral in their assessment of whether the deci-

sion aid should be disseminated as an Internet-

or DVD-based tool. When asked to identify a

preferred time for having their patients review

the tool (Table 3), 72% chose prior to initiating

the CRC screening discussion, 21% chose after

initiating the screening discussion, and 7% chose

both. Among the 21 providers who chose the

pre-visit approach, 13 preferred that the tool be

used in the office just prior to the pre-arranged

visit, five preferred at home use and three pre-

ferred both; among the six providers who chose

the post-visit approach, five preferred in-office

use and one preferred at home use.

There was also a lack of consensus when

asked about content modification. Whereas 50%

of respondents agreed or strongly agreed that

the decision aid should include a discussion of

costs,

31

% disagreed or strongly disagreed

Table 2 Provider perspectives on decision aid implementation

The decision aid

Response category, n (%)
Mean item
score (SD)*
Strongly
agree ⁄ agree Neutral
Strongly
disagree ⁄
disagree

16. Would be easy to use in my practice

outside of a research stetting

12 (48) 9 (36) 4 (16) 3.4 ± 1.0

17. Use would require reorganization of my

practice for routine clinical use

14 (58) 6 (25) 4 (17) 3.6 ± 1.1

18. Is likely to be used by most of my colleagues 11 (41) 12 (44) 4 (15) 3.4 ± 0.9

19. Should include a discussion of costs 13 (50) 5 (19) 8 (31) 3.5 ± 1.2

20. Should be disseminated as an Internet-based tool 17 (63) 8 (30) 2 (7) 3.7 ± 0.9

21. Should be disseminated as a DVD-based tool 15 (56) 8 (30) 4 (15) 3.6 ± 0.9

DVD, digital video disc; SD, standard deviation.

*1 = strongly disagree; 5 = strongly agree.

Table 3 Preferences for clinical use and content modification

Item N (%)

22. When would you want your patient to

view the decision aid:

Before initiating CRC screening discussion

(pre-visit)

21 (72)

After initiating CRC discussion (post-visit) 6 (21)

Both 2 (7)

23. Would you prefer the decision aid to

contain information about:

All of the recommended screening options 15 (52)

A more restricted list of options 12 (41)

No opinion 2 (7)

CRC, colorectal cancer.

Colorectal cancer screening decision aid, P C Schroy, S Mylvaganam and P Davidson
� 2011 John Wiley & Sons Ltd
Health Expectations, 17, pp.27–35
31

(Table 2). Similarly, whereas 52% of providers

preferred that the decision aid include a discus-

sion of all of the recommended screening

options, 41% preferred a more restricted list of

options and 7% had no opinion on the issue

(Table 3).

Only seven providers made suggestions for

improving the current decision aid. These

included creating non-English versions of the

tool (n = 2), clearly distinguishing colonoscopy

as the best screening option (n = 2), enabling

patients to print out their preferred screening

option (n = 2), and taking into consideration

that patients may not have access to the Internet

at home if the decision aid was to be dissemi-

nated as a web-based tool (n = 1). There were

no complaints.

Discussion

Decision aids are evidence-based tools that

enable patients to make informed, value-con-

cordant choices, but the extent to which such

tools facilitate SDM from the perspective of the

provider is less well established. In an effort to

gain new insight into the issue, we conducted a

survey of primary care providers participating in

a clinical trial evaluating the impact of a novel,

DVD-formatted decision aid on SDM and

adherence to CRC screening. Our study finds

that a majority of providers perceived that the

tool was a useful, time-saving adjunct to their

usual approach to counselling about CRC

screening and increased the overall quality of

decision making. Moreover, providers also felt

that review of the tool just prior to a scheduled

office visit was an appropriate use of patient�s
time as it enabled the patient to make an

informed choice among the different screening

options. Together, these findings suggest that

much of the tool�s perceived utility was related
to its ability to better prepare patients for the

screening discussion outside of the clinical

encounter and, in so doing, increased both the

efficiency and quality of the interaction.

Few studies have explored provider perspec-

tives on the utility of decision aids for improving

SDM. A trial by Green et al. evaluating the

effectiveness of genetic counselling vs. counsel-

ling preceded by use of a computer-based deci-

sion aid for breast cancer susceptibility found

that although there were no significant differ-

ences in perceived effectiveness, use of the tool

saved time and shifted the focus away from basic

education towards a discussion of personal risk

and decision making.
17

A second study by Sim-

inoff et al. found that a decision aid for breast

cancer adjuvant therapy facilitated a more

interactive, informed discussion and helped

physicians understand patient preferences.
13

Similarly, Brackett et al. also found that pre-

visit use of decision aids for prostate and CRC

screening was associated with greater physician

satisfaction, as it saved time during the visit and

changed the conversation from one of the

informational exchanges to one of the values

and preferences.
18

A fourth study by Graham

et al. explored provider perceptions of three

decision aids prior to their actual use.
15

Although responses were based on perceptions

alone and not on clinical experience, their find-

ings were similar to our own. A majority agreed

or strongly agreed that the decision aids could

meet patients� informational needs about risks
and benefits and enable patients to make

informed decisions. Similarly, although many

felt that the decision aids were likely to com-

plement their usual approach, responses were

more neutral when asked about the overall

impact of the tools on the quality of the patient

encounter, patient satisfaction and issues related

to implementation. The most striking difference,

however, was that relatively few of the respon-

dents in the study by Graham et al. felt that use

of the tool saved time, which could be a reflec-

tion of either the complexity of the decisions

under consideration and ⁄ or the lack of explicit
instructions regarding how the tools were to be

used with respect to the timing of the interven-

tion and ⁄ or need for provider involvement.
Our findings also corroborate a more exten-

sive body of literature on barriers to the imple-

mentation of decision aids into clinical

practice.
14

Even though our study design cir-

cumvented many of the barriers related to

workflow, accessibility and costs, only 48% of

Colorectal cancer screening decision aid, P C Schroy, S Mylvaganam and P Davidson
� 2011 John Wiley & Sons Ltd
Health Expectations, 17, pp.27–35

32

providers felt that actual implementation of the

decision aids into their practices outside of the

context of a clinical trial would be easy. Based

on their feedback, however, most preferred that

the tool be used prior to initiating the screening

discussion rather than after initiation of the

discussion. Moreover, regardless of the timing, a

majority preferred that the tool be used in the

office rather than at home. Although it is quite

possible that their preferences reflected their

personal experiences with our study protocol,

Brackett et al. also found that pre-visit use was

preferred over post-visit use.
18

One of the most commonly cited barriers to

implementation of SDM is the time requirement.

Although studies to date have provided con-

flicting data regarding the impact of decision

aids on consultation time for other condi-

tions,
17–22

we postulated that by educating

patients about the risks and benefits of the dif-

ferent screening options and facilitating IDM

prior to the provider–patient encounter, our

decision aid would have the potential of

improving the efficiency of SDM and thus save

time, as noted by Green et al. and Brackett

et al.
17,18

We found that although a majority of

providers agreed or strongly agreed that pre-visit

use of the tool saved time, 21% were neutral on

the issue and 14% disagreed or strongly dis-

agreed. It is conceivable that this diversity of

opinion might be a reflection of the extent to

which provider and patient preferences agreed or

disagreed. In instances where there was concor-

dance between preferences, as was often the case

that since colonoscopy was preferred by major-

ity of both patients and providers,
16

one would

expect that the time required for deliberation

and negotiation would be substantially shorter

than in situations where there was discordance.

Alternatively, these differences might reflect

differences in case mix with respect to patient

factors, such as literacy level or desired level of

participation in the decision-making process.

A secondary objective of our study was to

elicit provider feedback regarding content and

format preferences to gain insight into potential

modifications that might enhance future uptake.

Because of an ongoing debate in the CRC

screening literature,
23–27

we focused on content

issues related to cost information and number of

screening options to include in the decision aid.

Both questions elicited a divergence of opinions.

Whereas nearly 50% of respondents felt that

cost information should be included, the

remainder was either neutral or opposed to its

inclusion. Similarly, when asked about the

number of screening options to include, �50%
preferred the full menu of options and �40%
preferred a more limited menu. This diversity of

opinion highlights some of the key challenges in

designing tools with broad dissemination

potential. In the light of recent evidence sug-

gesting that the number of screening options

may influence test choice but not interest in

screening and that the importance of out-of-

pocket costs declines as the number of screening

options discussed increases,
26

one approach

would be to develop one tool that presents the

full menu of screening options without cost

information and a second that includes a more

limited set of options with cost information. A

more appealing approach would be to develop a

more comprehensive tool that includes both the

full menu of options and cost information in a

format that permits navigation so that patients

could tailor their use to fit their own informa-

tional needs and ⁄ or recommendations of their
provider. Internet-based tools are ideally suited

for this purpose but, as noted by several par-

ticipants in our study, access remains a potential

barrier for a sizeable, albeit declining, propor-

tion of the target population. Providers in our

study felt that both Internet- and DVD-for-

matted tools were viable options for dissemina-

tion, even though the DVD-formatted tool

offers less navigation potential.

Our study has several notable limitations.

First, the survey was conducted among primary

care providers at only two institutions, and

hence, the findings may not be generalizable to

providers in other health care settings. It is

noteworthy, however, that the study was con-

ducted among a diverse patient population with

respect to both race ⁄ ethnicity and educational
status.

16
Second, as participating providers

never formally reviewed the decision aid, we

Colorectal cancer screening decision aid, P C Schroy, S Mylvaganam and P Davidson
� 2011 John Wiley & Sons Ltd
Health Expectations, 17, pp.27–35
33

were unable to assess their opinions with respect

to actual content or format. Third, the content

of our survey instrument did not allow us to

tease out the extent to which use of the decision

aid impacted on individual steps of the SDM

process.
4,5

Even though satisfaction with the

decision-making process was universally high

among patients participating in the clinical

trial,
16

especially those in the intervention

groups, only a relative minority of providers felt

that use of the tool helped them tailor their

counselling about CRC screening to their

patients� needs or increased patient satisfaction
with their care. Fourth, the anonymous nature

of our survey precluded any attempt to correlate

response data with exposure rates. It is con-

ceivable that the perceptions of providers

exposed to multiple patients in the intervention

arms might differ from those exposed to only a

few patients. Lastly, we cannot rule out the

possibility of social response bias, whereby

respondents may have felt compelled to offer

more positive responses than they actually

believed.

In conclusion, our study finds that a majority

of providers perceived that pre-clinic use of our

decision aid for CRC screening was a useful,

time-saving adjunct to their usual approach to

counselling about CRC screening and increased

the overall quality of decision making. Never-

theless, many of the providers felt that imple-

mentation of the decision aid into their practices

outside of the context of a clinical trial would be

challenging, thus highlighting the need for cost-

effective strategies for addressing provider,

practice and organizational level barriers to

routine use. We speculate that Internet-based

tools with enhanced navigation functionality

have the greatest dissemination potential, as

they offer a feasible, low-cost solution to many

of the structural barriers to implementation, as

well as a way to reconcile the diversity of opin-

ion related to content.

Acknowledgement

None.

Conflicts of interest

The authors have no conflict of interests.

Funding

This study was supported by grant RO1

HS013912 from the Agency for Healthcare

Research and Quality.

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Copyright of Health Expectations is the property of Wiley-Blackwell and its content may not
be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s
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