Getty Images/iStockphoto
What are patient decision aids in shared decision-making?
Patient decision aids (PDAs) are key tools to help support patient education during the shared decision-making process.
Healthcare professionals practicing shared decision-making with their patients may want to consider using patient decision aids (PDAs) to support that work.
This is because shared decision-making relies on strong patient education and access to information, and PDAs can help support that. Through written and visual content displayed either on paper or over digital modules, PDAs help explain the key diagnostic and treatment information necessary to help patients collaborate on a treatment decision with their healthcare providers.
These tools come as more providers are looking to practice shared decision-making, or the process of a patient and provider bringing their own expertise—personal preference for the patient and clinical for the provider—to make a medical decision. Shared decision-making is useful, particularly when patients have multiple treatment options or are deciding to get a more invasive screening or test.
But shared decision-making relies on an informed patient, and the time it takes to fully inform the patient can deter some clinicians from the practice. PDAs can help clinicians get around the issue of time by supplementing some of the clinical counseling providers do during the encounter.
Below, PatientEngagementHIT describes patient decision aids, how to use them, and the benefits and challenges associated with the tools.
Defining patient decision aids
Patient decision aids, sometimes called PDAs, are patient education tools that help empower patients to make their own healthcare decisions, according to the National Quality Forum (NQF).
“As people increasingly take a more active role in making decisions about their healthcare, many use decision aids,” NQF wrote in a recent resource about accrediting decision aids.
“Decision aids are evidence-based tools designed to inform patients about their options (including known pros and cons) and help them to participate in making specific, deliberate choices among viable healthcare options. A large body of research shows that the use of decision aids to facilitate shared decision making (SDM) improves patient outcomes.”
PDAs need to include enough information to help patients understand a certain treatment or procedure, the pros and cons, and how the procedure could potentially impact their lifestyle and journey toward health and well-being, according to a 2018 article reviewing the pros and cons of PDAs published in JCO Clinical Cancer Informatics.
Specifically, PDAs include information about:
- Disease type
- Treatment options
- Risks, benefits, and uncertainties with each treatment option
- Value clarification exercises (patients are asked to make choices based on tradeoffs associated with each treatment option)
Some experts have also called for price transparency to be a part of patient decision aids.
PDAs can come in many different forms, according to Cochrane Review, an independent body that reviews various PDAs and publishes evidence about the efficacy of patient decision aids. PDAs can be paper pamphlets, videos, or web-based resources. Increasingly, health IT developers are creating PDAs that can be integrated into the patient portal or EHR.
Right now, there’s no standard for certifying PDAs, but NQF has done some investigative work in this area. A panel of 21 experts recommended PDAs be assessed when they adequately describe the health condition or problem for which the decision is required, the potential health service options, and the risks and benefits.
Other areas that could sway certification is transparency about how the PDA was made, updates to the PDA, and the process by which the tool was developed. When the PDA is tailored for shared decision-making about a screening or diagnostic test, it should include next steps for a normal or abnormal result, consequences of disease detection, the test’s positive predictive value, and the test’s negative predictive value.
As healthcare providers continue to explore the use of PDAs, they will need to assess how they can best integrate them into their patient engagement strategies.
How to use patient decision aids
Patient decision aids are key tools in facilitating shared decision-making. Because shared decision-making relies on strong patient education, these tools have emerged to help inform patients about their treatment options and the risks and benefits of each.
The Center for Collaborative Care Decisions, out of the Washington University School of Medicine in St. Louis, advises healthcare professionals to use PDAs as a part of, not a replacement for, clinical counseling during shared decision-making.
Shared decision-making can be broken down into a handful of seemingly simple steps: identify the patient’s condition, discuss treatment options, elicit patient preferences and values, and carry out the care decision.
Healthcare providers should be sure to invite patients to participate in shared decision-making (not all patients may want to do so) and help patients follow through on the care decision, according to ONC.
So, where do decision aids fit into the picture?
Healthcare professionals can deploy PDAs during any part of the shared decision-making process. The patient education tools may be helpful in supporting clinician education about certain treatment outcomes, especially for patients who are visual learners.
And, being that patients forget about half of what they hear during a clinical encounter, PDAs may be helpful as a take-home aid, especially for patients who need more time to think.
Efficacy of patient decision aids
When healthcare providers integrate PDAs into shared decision-making, the patient tends to have a better healthcare experience, data has shown.
In the study by Cochrane Review, researchers found that PDAs increased “the congruence between informed values and care choices compared to usual care,” meaning PDAs helped patients make a treatment decision that aligned with their personal values.
The study also showed PDAs increased patient knowledge about their treatment options and accuracy of risk perceptions. The tools also decreased decisional conflict between patients and providers, indecision about personal values, and the proportion of patients who were passive in decision-making, the researchers said.
Separate data from FAIR Health have indicated that PDAs could increase health equity in shared decision-making. Historically, populations of color have had less engagement in shared decision-making than their White counterparts, but the FAIR Health assessment of PDAs for conditions that disproportionately affect minority populations showed these tools could reverse that trend.
Overall, patients and providers agreed that PDAs were useful, with 80 percent of healthcare consumers saying the tools made decision-making “easier” or “much easier.” Another 76 percent noted that cost information included in the PDA was “helpful” or “very helpful,” while the same proportion said they would recommend the tools to others.
But despite the promise of patient decision aids, they still haven’t reached universal adoption, with key barriers standing in the way.
Challenges to using patient decision aids
By and large, patient decision aids still face an awareness problem that’s keeping more healthcare providers and patients from using the tools, according to the Cochrane Review article.
“Despite the recommended use of decision aids in so many guidelines, as well as policies and legislation to ensure that decision aids are enacted in several countries, there is still a long delay in their adoption in many health systems,” the report authors said. “Many people are not aware of decision aids, nor are they straightforward for people to use on their own. Instead, they require larger systems, support and training to be in place to enable health professionals to use them together with their patients.”
It is no surprise that these barriers exist; the entire movement toward patient-centered care has been slow-moving. Shared decision-making and the use of the tools that support it are clearly no exception, the Cochrane Review authors pointed out.
Moreover, using decision aids can take time, and that’s not something clinicians have a lot of. In one feasibility study, a clinical staff member delivered a PDA to 268 patients over a five-month period. That work included more discussion during the clinical encounter and review of patient medical records. All said, implementing the PDA process added 292 hours, or 65 minutes per patient, in added work.
A 2019 literature review exploring provider perceptions of using patient decision aids corroborated this. The literature showed clinicians appreciate how PDAs help patients through healthcare decision-making. And although the literature did not indicate that PDAs added any extra time to the clinical consultation, clinicians did express some worry about how PDAs could affect the length of visit.
Still, data about the time and labor costs associated with PDAs are scant. Some experts have found they only add a bit more time to the clinical encounter, and the associated cost savings could be considerable. In one Commonwealth Fund study from 2007, researchers found that using PDAs in 11 different treatment areas yielded $7 billion in savings over ten years.
As more healthcare providers consider using PDAs in shared decision-making, they’ll have to weigh potential workflow changes alongside key benefits to patient experience, clinical outcomes, activation levels, and potential overall healthcare cost savings.
