Excerpt

Decisions about cancer screening have become increasingly complex. Patients must decide whether to get screened, which screening modality to use, and how often to undergo and when to stop screening. Some cancer screening decisions are considered “preference-sensitive,” meaning that, due to closely-balanced benefits and harms, the “right” decision is in part dependent on an individual's values and preferences for particular outcomes. Most organizations publishing clinical practice guidelines for cancer screening now recommend that preference-sensitive cancer screening decisions be made individually, using a process that considers the available evidence on the benefits and harms of particular options, and incorporates patient values and preferences relevant to those options. This approach is sometimes referred to as shared decision making (SDM). The goal of SDM interventions is to facilitate this approach. Adjuncts for the usual counseling for specific decisions, SDM interventions may include: (1) tools to help patients comprehend information about the risks and benefits of options, clarify their personal values related to these options, and participate in decisions consistent with these values and preferences (sometimes referred to as “decision aids”) and (2) other interventions to prepare health care providers and/or systems to support this process. SDM interventions differ from many health-related interventions in that they primarily seek to elicit and support patient values and preferences in making health care-related decisions rather than to promote a particular health care strategy per se.

In this review we examine the effects of SDM interventions for cancer screening in adults on constructs from the Ottawa Decision Support Framework, a commonly-used theoretical model of decision making. We examined the constructs of Decision Quality, Decision Impact, and, for studies reporting those outcomes, Decision Action. Decision Quality includes knowledge, values clarity (patients' clarity of their personal values regarding the risks and benefits of decision options), and the patients' participatory role in decision making. Decision Impact includes decisional conflict (personal uncertainty about which course of action to take), use of services (eg, consultation length), and satisfaction with the decision. Decision Action includes screening intention and behavior. The ideal SDM intervention would enhance Decision Quality (ie, increase knowledge and values clarity) and Impact (ie, increase satisfaction, reduce decision conflict, and have minimal impact on service utilization). The desired impact on Decision Action depends on the screening decision. For decisions about how to screen (such as colorectal cancer screening), the ideal SDM intervention would exert the desired effects on Decision Quality and Impact without reducing measures of Decision Action such as screening intention and behavior. For decisions about whether to screen (such as breast, cervical, and prostate cancer in some age groups and risk categories), the goal is to facilitate personalized decision making based on values and preferences. Hence, there are no desired effects on Decision Action per se in this context. We examine patient, provider, system, and multi-level SDM interventions, and therefore do not restrict this review to the most commonly employed SDM intervention of patient-directed decision aids.

This topic was nominated by Linda Kinsinger, MD, MPH, VA Chief Consultant for Preventive Medicine at the VA National Center for Health Promotion and Disease Prevention (NCP). The evidence review is intended to examine the effects of SDM interventions for cancer screening practices and to inform what types of interventions NCP will disseminate with their cancer screening guidelines.

Contents

• PREFACE
• EXECUTIVE SUMMARY
  • INTRODUCTION
  • METHODS
  • RESULTS
  • DISCUSSION
  • ABBREVIATIONS TABLE
• INTRODUCTION
  • BACKGROUND
  • SHARED DECISION MAKING INTERVENTIONS
  • OBJECTIVES
• METHODS
  • TOPIC DEVELOPMENT
  • SEARCH STRATEGY
  • STUDY SELECTION
  • DATA ABSTRACTION
  • QUALITY ASSESSMENT
  • DATA SYNTHESIS
  • RATING THE BODY OF EVIDENCE
  • PEER REVIEW
• RESULTS
  • LITERATURE FLOW
  • KEY QUESTION #1 In adults, what are the effects of shared decision making interventions FOR CANCER SCREENING on 1) Decision Quality; 2) Decision Impact; and 3) Decision Action?
  • KEY QUESTION #1A Are there differential effects of the interventions based on: 1) The intervention target; 2) Key content/elements of the intervention; 3) Patient characteristics; AND 4) Cancer type?
  • KEY QUESTION #2 Within the included studies, what is the receptivity to shared decision making interventions for cancer screening for: 1) patients and 2) providers?
  • KEY QUESTION #3 Within the included studies, what are the resources required to implement a shared decision making intervention for cancer screening?
• SUMMARY AND DISCUSSION
  • KEY MESSAGES
  • SUMMARY OF EVIDENCE BY KEY QUESTION
  • PREVIOUS REVIEWS
  • CLINICAL SIGNIFICANCE
  • LIMITATIONS
  • APPLICABILITY OF FINDINGS TO THE VA POPULATION
  • RESEARCH GAPS/FUTURE RESEARCH
  • CONCLUSIONS
• REFERENCES
• APPENDIX A SEARCH STRATEGIES
• APPENDIX B EXCLUDED ARTICLES
• APPENDIX C PEER REVIEW COMMENTS/AUTHOR RESPONSES
• APPENDIX D EVIDENCE TABLES
• APPENDIX E DECISION QUALITY AND DECISION IMPACT MEASURE PATTERNS IN INCLUDED STUDIES
• APPENDIX F STRENGTH OF EVIDENCE
• APPENDIX G FOREST PLOTS FOR STRENGTH OF EVIDENCE ANALYSIS

Prepared for: Department of Veterans Affairs, Veterans Health Administration, Quality Enhancement Research Initiative, Health Services Research and Development Service, Washington, DC 20420. Prepared by: Evidence-based Synthesis Program (ESP) Center, Minneapolis VA Health Care System, Minneapolis, MN, Timothy J. Wilt, M.D., M.P.H., Director

Suggested citation:

Lillie SE, Partin MR, Rice K, Fabbrini AE, Greer NL, Patel S, MacDonald R, Rutks I, Wilt, TJ. The Effects of Shared Decision Making on Cancer Screening - A Systematic Review. VA ESP Project #09-009; 2014

This report is based on research conducted by the Evidence-based Synthesis Program (ESP) Center located at the Minneapolis VA Medical Center, Minneapolis, MN, funded by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. The findings and conclusions in this document are those of the author(s) who are responsible for its contents; the findings and conclusions do not necessarily represent the views of the Department of Veterans Affairs or the United States government. Therefore, no statement in this article should be construed as an official position of the Department of Veterans Affairs. No investigators have any affiliations or financial involvement (eg, employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in the report. Drs. Partin and Wilt have previously received research support (that included salary support for Dr. Partin) from the Department of Veterans Affairs HSR&D Office to develop and compare the effectiveness of share decision making interventions for prostate cancer screening.