Decision Aids for Patients Facing Health Treatment or Screening Decisions

Study Population: 107,698 adults who make decisions for themselves, for a child, or as a proxy

Efficacy End Points: Congruence between informed values and choice, knowledge, accurate risk perceptions, and participation in decision-making

Harm End Points: Decision regret

Narrative: Medical advances often improve life expectancy but have also complicated medical decision-making due to increased screening and treatment options. The U.S. Preventive Services Task Force recommends shared decision-making for eight preventive services (e.g., prostate cancer screening).¹ Major payors also have weighed in. The Centers for Medicare & Medicaid Services mandate the use of patient decision aids during discussions of several preventive services (e.g., lung cancer screening).² Tailoring patient care to individual values plays an essential role in clinical practice, and decision aids can assist in navigating communication between physicians and patients.

A 2024 Cochrane review evaluated decision aids for adults who make decisions for themselves, for a child, or as a proxy for a significant other.³ This review included 209 randomized controlled trials (RCTs) with 107,698 participants in 19 countries (106 studies in the United States). A total of 71 different decisions were covered in this review, most commonly decisions regarding cardiovascular treatment (22 studies), cancer screening (colorectal, 17 studies; prostate, 15 studies; and breast, 12 studies), and cancer treatment (breast, 15 studies; prostate, 11 studies). The comparison was usual care, defined as general patient information, risk assessment, guideline summaries, placebo intervention, or no intervention.³

The primary outcomes in the review included congruence between a patient's informed values and the patient's choice (most often determined using the multidimensional measure of informed choice, which assesses a patient's knowledge, attitude, and uptake⁴), knowledge (scale from 0 [no knowledge] to 100 [perfect knowledge]), accurate risk perceptions, and participation in decision-making. All outcomes were assessed immediately after exposure to the decision aids. For an adverse event, decision regret was measured weeks to months after decision-making using the five-item Decision Regret Scale from 0 (no regret) to 100 (high regret).⁵

The review showed moderate-certainty evidence that compared with usual care, decision aids improved congruence between informed values and choice (risk ratio [RR] = 1.75; 95% CI, 1.44 to 2.13; absolute risk difference [ARD] = 18.6%; number needed to treat [NNT] = 6; RCTs = 21; n = 9,377). High-certainty evidence showed that compared with usual care, decision aids increased knowledge scores (11.9% higher mean knowledge score; 95% CI, 10.6 to 13.9; RCTs = 107; n = 25,492), increased accurate risk perceptions (RR = 1.94; 95% CI, 1.61 to 2.34; ARD = 25.1%; NNT = 4; RCTs = 25; n = 7,796), and decreased the rate of clinician-controlled decision-making (RR = 0.72; 95% CI, 0.59 to 0.88; ARD = 6.9%; NNT = 15; RCTs = 21; n = 4,348). High-certainty evidence demonstrated that use of decision aids did not increase decision regret compared with usual care.³