Understanding why decision aids work: linking process with outcome
Introduction
Decision aids are interventions that help individuals focus on a deliberative choice between two or more treatment options [1], [2], [3], [4]. A decision aid has a minimum of two components (a) a visual representation of the risks, benefits and consequences of all decision options relevant to the individual’s health, and (b) an explicit discussion of the individual’s values or attitudes about the decision options and consequences. The theoretical grounding of decision aids varies along a continuum from intuitive choice models to classical decision theory [2], [3]. Those aids underpinned by expected utility theory usually include a third component, an activity that enables the individual to integrate values with full information and encourage trade-offs between options during the decision making process [5], [6].
Decision aids are more effective than routine information in enabling patients to make difficult treatment choices [1]. Their effectiveness can be explained in terms of either the facilitation of cognitive strategies or changes to emotional processes. The mechanisms through which decision aids impact on cognitive strategies are addressed briefly. The visual representations or decision diagrams provide a memory prompt that summarises all the relevant information during decision making [2]. These prompts reduce the cognitive load during decision making [6], [7] and ensure patients’ judgments are made on complete information rather than memory-accessed and/or biased details [8], [9]. The elicitation of normally unarticulated cognitive mechanisms helps patients generate more reasons for and against the decision options by encouraging them to integrate verbally the decision information with their beliefs [2], [5], [6]. It is likely that together these techniques (a) enable patients to justify these difficult choices to themselves and others [8], and (b) ensures patients explore fully the reasons associated with the options, so reducing the gap between decision making and decision experience [10]. As this more systematic evaluation of the decision information leads patients to develop more stable cognitions, they are less likely to change their beliefs over time [9], [11]. These more robust cognitions are associated with less decisional conflict and/or greater decisional satisfaction post-decision making [2], [12].
The mechanisms by which decision aids impact on emotions are less clearly understood. It is accepted that difficult choices create feelings of conflict [8], that these emotions impact adversely on decision making [6], [8] and that evaluating emotions about a decision in retrospect results in greater discontent [9]. The use of decision aids is associated with lower decisional conflict [1] and their effectiveness attributed to the introduction of a ‘dispassionate arbitrator into a decision setting that is distorted by emotion’ [6]. However, there is little explanation as to how or why the ‘dispassionate arbitrator’ diffuses these emotions during decision making. One explanation may be that the decision aid encourages patients to evaluate the decision-relevant information rather than focus on emotions or feelings [2], [6], [8], [9], [11]. An alternative explanation is that as decision aids explicitly elicit patient values about decision options and consequences, this activity increases patients’ expression of emotion during decision making [5]. There is evidence that expression of affect about stressful events is associated with better long-term health outcomes [13], [14]. It is feasible, then that a decision aid may facilitate patient decision making by increasing the expression of affect during decision making.
Despite the increase in studies evaluating decision aid effectiveness [1], there is little evidence to suggest which of the above arguments explain how or why decision aids facilitate patient decision making. Most studies evaluate decision aid effectiveness by measuring outcomes such as choice, utility, knowledge, satisfaction, decisional conflict and anxiety [1], [7] and a handful measure changes in the patient–professional interaction [1], [15]. However, few, if any, studies have assessed patients’ cognitive and emotional processes during decision making, evaluated how these differed by routine or decision-aided consultations, and investigated how such decision process were associated with decision outcome. Until these factors are understood, the decision aid intervention will remain a ‘black box’ [3] with little evidence to explain what and why components of the decision aid are effective.
This paper aims (a) to describe differences in the cognitive and emotional processes of women receiving either routine or a decision-aided consultation about prenatal diagnosis options, and (b) to investigate the relationship between decision processes and outcomes.
Section snippets
Design
A randomised controlled trial with two consultation modes.
Decision context
Upon receipt of a screen positive result for Down’s syndrome, women choose to have or not have a prenatal diagnostic test. The screening test in this study was an analysis of maternal blood. The blood was analysed for hormones that are known to differ slightly between women having and not having Down’s affected pregnancies. Calibrating the blood test result with individual factors generates a risk figure for Down’s syndrome likelihood.
Results
Eighty-nine percent (117/132) of women agreed to take part in the study. Eleven women were lost post-randomisation either because they screened negative following identification of an error on their result sheet (n=6) or failed to complete the post-consultation questionnaire (n=5) (56/58 routine: 50/59 decision aid). Follow-up questionnaires were not sent to five women receiving a positive diagnostic result and one that miscarried. 68/100 posted, follow-up questionnaires were returned (38/53
Discussion
This study provides evidence that decision aids do impact on both the cognitive strategies and emotional mechanisms women employ when making difficult healthcare choices. During decision making, decision-aided women (a) used more cognitive terms, raised more metaphysical terms and evaluated more information about the decision alternatives both positively and negatively, and (b) expressed more negative emotion words and tended to express fewer positive emotion words than women receiving routine
Acknowledgements
We thank Dr. Anna Middleton for her time and insight when carrying out the inter-rater checks, Professor Jamie Pennebaker for his assistance in analysing these data, and the Medical Research Counsel for supporting Hilary Bekker’s studentship.
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