Decision aids for people facing health treatment or screening decisions.

BACKGROUND: Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017. OBJECTIVES: To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach. SEARCH METHODS: We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022. SELECTION CRITERIA: We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention. DATA COLLECTION AND ANALYSIS: Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence. MAIN RESULTS: This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015. AUTHORS' CONCLUSIONS: Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.

Long-term cost-effectiveness of a melanoma prevention program using genomic risk information compared with standard prevention advice in Australia.

PURPOSE: Evidence indicates that a melanoma prevention program using personalized genomic risk provision and genetic counseling can affect prevention behaviors, including reducing sunburns in adults with no melanoma history. This analysis evaluated its longer-term cost-effectiveness from an Australian health system perspective. METHODS: The primary outcome was incremental cost effectiveness ratio (ICER) of genomic risk provision (intervention) compared with standard prevention advice. A decision-analytic Markov model was developed using randomized trial data to simulate lifetime cost-effectiveness. All costs were presented in 2018/19 Australian dollars (AUD). The intervention effect on reduced sunburns was stratified by sex and traditional risk, which was calculated through a validated prediction model. Deterministic and probabilistic sensitivity analyses were undertaken for robustness checks. RESULTS: The per participant cost of intervention was AUD$189. Genomic risk provision targeting high-traditional risk individuals produced an ICER of AUD$35,254 (per quality-adjusted life year gained); sensitivity analyses indicated the intervention would be cost-effective in more than 50% of scenarios. When the intervention was extended to low-traditional risk groups, the ICER was AUD$43,746 with a 45% probability of being cost-effective. CONCLUSION: Genomic risk provision targeted to high-traditional melanoma risk individuals is likely a cost-effective strategy for reducing sunburns and will likely prevent future melanomas and keratinocyte carcinomas.

Australian recommendations on perioperative use of disease-modifying anti-rheumatic drugs in people with inflammatory arthritis undergoing elective surgery.

Disease-modifying anti-rheumatic drugs (DMARDs) are effective treatments for inflammatory arthritis but carry an increased risk of infection. For patients undergoing surgery, there is a need to consider the trade-off between a theoretical increased risk of infection with continuation of DMARDs perioperatively versus an increased risk of disease flare if they are temporarily withheld. We used the Grading of Recommendations Assessment, Development and Evaluation methodology to develop recommendations for perioperative use of DMARDs for people with inflammatory arthritis undergoing elective surgery. The recommendations form part of the National Health and Medical Research Council-endorsed Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis. Conditional recommendations were made against routinely discontinuing conventional synthetic and biologic (b) DMARDs in the perioperative period but to consider temporary discontinuation of bDMARDs in individuals with a high risk of infection or where the impact of infection would be severe. A conditional recommendation was made in favour of temporary discontinuation of targeted synthetic DMARDs in the perioperative period.

Biological age calculators to motivate lifestyle change: Environmental scan of online tools and evaluation of behaviour change techniques.

OBJECTIVE: "Biological age" calculators are widely used as a way of communicating health risk. This study evaluated the behaviour change techniques (BCTs) within such tools, underlying algorithm differences and suitability for people with varying health literacy. METHODS: Two authors entered terms into Google (eg, biological/heart age) and recorded the first 50 results. A standard patient profile was entered into eligible biological age calculators. Evaluation was based on Michie et al's BCT taxonomy and a readability calculator. RESULTS: From 4000 search results, 20 calculators were identified: 11 for cardiovascular age, 7 for general biological age and 2 for fitness age. The calculators gave variable results for the same 65-year-old profile: biological age ranged from younger to older (57-87 years), while heart age was always older (69-85+ years). Only 11/20 (55%) provided a reference explaining the underlying algorithm. The average reading level was Grade 10 (range 8.7-12.4; SD 1.44). The most common BCTs were salience of consequences, information about health consequences and credible source. CONCLUSIONS: Biological age tools have highly variable results, BCTs and readability. PRACTICE IMPLICATIONS: Developers are advised to use validated models, explain the result at the average Grade 8 reading level, and incorporate a clear call to action using evidence-based behaviour change techniques.

A Brief Shared Decision-Making Intervention for Acute Respiratory Infections on Antibiotic Dispensing Rates in Primary Care: A Cluster Randomized Trial.

PURPOSE: To determine whether acute respiratory infection (ARI) decision aids and a general practitioner (GP) training package reduces antibiotic dispensing rate and improves GPs' knowledge of antibiotic benefit-harm evidence. METHODS: A cluster randomized trial of 27 Australian general practices (13 intervention, 14 control) involving 122 GPs. Intervention group GPs were given brief decision aids for 3 ARIs (acute otitis media, acute sore throat, acute bronchitis) and video-delivered training. Primary outcome was dispensing rate of target antibiotic classes (routinely used for ARIs), extracted for 12 months before, and following, randomization. Secondary outcomes were GPs' knowledge of antibiotic benefit-harm evidence; prescribing influences; acceptability, usefulness, and self-reported resource use; and dispensing rate of all antibiotics. RESULTS: The baseline mean dispensing rate of ARI-related antibiotics was 3.5% (intervention GPs) and 3.2% (control GPs) of consultations. After 12 months, mean rates decreased (to 2.9% intervention; 2.6% control): an 18% relative reduction from baseline but similar in both groups (rate ratio 1.01; 95% CI, 0.89-1.15). Greater increases in knowledge were seen in the intervention group than control; a significant increase (average 3.6; 95% CI, 2.4-4.7, P <.001) in the number of correct responses to the 22 knowledge questions. There were no between-group differences for other secondary outcomes. The intervention was well received, perceived as useful, and reported as used by about two-thirds of intervention GPs. CONCLUSIONS: A brief shared decision-making intervention provided to GPs did not reduce antibiotic dispensing more than usual care, although GPs' knowledge of relevant benefit-harm evidence increased significantly.

Australian recommendations on tapering of biologic and targeted synthetic disease-modifying anti-rheumatic drugs in inflammatory arthritis.

Biological and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARD) have been an important advance in the management of inflammatory arthritis, but are expensive medications, carry a risk of infection and other adverse effects, and are often perceived as a burden by patients. We used GRADE methodology to develop recommendations for dose reduction and discontinuation of b/tsDMARD in people with rheumatoid arthritis (RA), axial spondyloarthritis (AxSpA) and psoriatic arthritis (PsA) who have achieved a low disease activity state or remission. The recommendations form part of the Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis, an NHMRC-endorsed 'living' guideline, in which recommendations are updated in near real-time as new evidence emerges. Conditional recommendations were made in favour of dose reduction in RA and AxSpA but not in PsA. Abrupt discontinuation of b/tsDMARD is not recommended in any of the three diseases.

Exploring the expectations, experiences and tensions of refugee patients and general practitioners in the quality of care in general practice.

BACKGROUND: Refugees and asylum seekers arrive in the Australian community with complex health needs and expectations of healthcare systems formed from elsewhere. Navigating the primary healthcare system can be challenging with communication and language barriers. In multicultural societies, this obstacle may be removed by accessing language-concordant care. Emerging evidence suggests language-concordance is associated with more positive reports of patient experience. Whether this is true for refugees and asylum seekers and their expectation of markers of quality patient-centred care (PCC) remains to be explored. This study aimed to explore the expectations around the markers of PCC and the impacts of having language-concordant care in Australian primary healthcare. METHODS: We conducted semi-structured individual in-language (Arabic, Dari, and Tamil) remote interviews with 22 refugee and asylum seekers and 9 general practitioners (GPs). Interview transcripts were coded inductively and deductively, based on the research questions, using Thematic Analysis. Extensive debriefing and discussion took place within the research team throughout data collection and analysis. RESULTS: Community member expectations of markers of PCC are constantly evolving and adapting based on invisible and visible actions during clinical encounters. Challenges can occur in the clinical encounter when expectations are 'unsaid' or unarticulated by both community members and GPs due to the assumption of shared understanding with language concordant care. Expectations of what constitutes satisfactory, quality PCC are dynamic outcomes, which are influenced by prior and current experiences of healthcare. CONCLUSION: This study highlights the importance of understanding that language concordant care does not always support aligned expectations of the markers of quality PCC between community members and their GP. We recommend that GPs encourage community members to provide explicit descriptions about how their prior experiences have framed their expectations of what characterizes quality PCC. In addition, GPs could develop a collaborative approach, in which they explain their own decision-making processes in providing PCC to refugees and asylum seekers. PATIENT OR PUBLIC CONTRIBUTION: Bilingual researchers from multicultural backgrounds and experience working with people from refugee backgrounds were consulted on study design and analysis. This study included individuals with lived experiences as refugees and asylum seekers and clinicians as participants.

The role of Primary Health Networks in cardiovascular disease prevention: A qualitative interview study.

BACKGROUND: Since the inception of PHNs in Australia, their role in implementing chronic disease prevention activities in general practice has been unclear. This study aimed to qualitatively explore the views of PHN staff on the role of PHNs in promoting prevention, with a focus on cardiovascular disease (CVD) prevention. METHODS: Content analysis of PHN Needs Assessments was conducted to inform interview questions. Twenty-nine semi-structured interviews were conducted with 32 PHN staff, between June and December 2020, in varied roles across 18 PHNs in all Australian states and territories. Transcribed audio recordings were thematically coded, using the Framework Analysis method to ensure rigour. RESULTS: We identified three main themes: (a) Informal prevention: All respondents agreed the role of PHNs in prevention was indirect and, for the most part, outside the formal remit of PHN Key Performance Indicators (KPIs.) Prevention activities were conducted in partnership with external stakeholders, professional development and quality improvement programs, and PHN-funded data extraction and analysis software for general practice. (b) Constrained by financial incentives: Most interviewees felt the role of PHNs in prevention was contingent on the financial drivers provided by the Commonwealth government, such as Medicare funding and national quality improvement programs. (c) Shaped through competing priorities: The role of PHNs in prevention is a function of competing priorities. There was strong agreement amongst participants that the myriad competing priorities from government and local needs assessments impeded prevention activities. CONCLUSIONS: PHNs are well-positioned to foster prevention activities in general practice. However, we found that PHNs role in prevention activities was informal, constrained by financial incentives and shaped through competing priorities. Prevention can be improved through a more explicit prevention focus at the Commonwealth government level. To optimise the role of PHNs, therefore, requires prioritising prevention, aligning it with KPIs and supporting stakeholders like general practice.

Impact of personal genomic risk information on melanoma prevention behaviors and psychological outcomes: a randomized controlled trial.

PURPOSE: We evaluated the impact of personal melanoma genomic risk information on sun-related behaviors and psychological outcomes. METHODS: In this parallel group, open, randomized controlled trial, 1,025 Australians of European ancestry without melanoma and aged 18-69 years were recruited via the Medicare database (3% consent). Participants were randomized to the intervention (n = 513; saliva sample for genetic testing, personalized melanoma risk booklet based on a 40-variant polygenic risk score, telephone-based genetic counseling, educational booklet) or control (n = 512; educational booklet). Wrist-worn ultraviolet (UV) radiation dosimeters (10-day wear) and questionnaires were administered at baseline, 1 month postintervention, and 12 months postbaseline. RESULTS: At 12 months, 948 (92%) participants completed dosimetry and 973 (95%) the questionnaire. For the primary outcome, there was no effect of the genomic risk intervention on objectively measured UV exposure at 12 months, irrespective of traditional risk factors. For secondary outcomes at 12 months, the intervention reduced sunburns (risk ratio: 0.72, 95% confidence interval: 0.54-0.96), and increased skin examinations among women. Melanoma-related worry was reduced. There was no overall impact on general psychological distress. CONCLUSION: Personalized genomic risk information did not influence sun exposure patterns but did improve some skin cancer prevention and early detection behaviors, suggesting it may be useful for precision prevention. There was no evidence of psychological harm.

Health Literacy and Shared Decision-making: Exploring the Relationship to Enable Meaningful Patient Engagement in Healthcare.

Research into health literacy and shared decision-making has largely developed along parallel, but distinct lines over the past two decades. There is little evidence that the concepts and related practice have intersected except in the most functional way, for example, to simplify shared decision-making tools by improving readability scores of decision aids. This paper presents an integrated model to strengthen and sustain patient engagement in health care by drawing on the strengths of both concepts. This includes addressing patients' skills and capacities, alongside modifications to written and verbal information. We propose an expanded model of shared decision-making which incorporates health literacy concepts and promotes two-tiered intervention methods to improve the targeting and personalization of communication and support the development of transferable health literacy skills among patients.

'Every medicine is part poison': a qualitative inquiry into the perceptions and experiences of choosing contraceptive methods of migrant Chinese women living in Australia.

BACKGROUND: In Australia, ethnic Chinese people are one of the largest, youngest and fastest growing overseas-born groups. Yet, little is known about their perceptions of contraceptive methods and their experiences with choosing one. Decisions about contraceptive methods are preference sensitive. Understanding the influencing factors of Chinese migrant women's contraceptive method choice and practices will help cater to their decision-making needs in a culturally sensitive and responsive way. METHODS: A qualitative study design underpinned by critical realism approach was used to explore Chinese migrant women's perceptions and experiences of choosing contraceptive methods. Semi-structured interviews were conducted with 22 women who self-identified as being ethnically Chinese and had been living in Australia for no more than 10 years. The interview guide was adapted from the Ottawa Decision Support Framework. Majority of the interviews were conducted in Mandarin Chinese. Transcribed data was analysed using thematic analysis method. RESULTS: Four major themes were identified, including: 'every medicine is part poison: hormonal contraceptives cause harm to the body'; 'intrauterine device, a device used in the past for married women'; 'it takes two (or one) to decide, depending on the relationship dynamics and contraception preferences'; and 'it is not necessary to seek medical advice in choosing contraceptive methods'. CONCLUSIONS: Our findings suggest that Chinese migrant women's perceptions and experiences of choosing contraceptive methods are influenced by complex personal, cultural, societal and inter-relational factors. Chinese migrant women were cautious of using hormonal methods due to fears of side-effects, including reduced or absent menstrual bleeding. Women were also reluctant to consider intrauterine devices as options due to associating them with past experiences of other women and themselves and also fears of potential complications. There was a reluctant attitude towards seeking medical advice regarding contraception due to beliefs that needing to use contraception is not an illness requiring treatment. Such findings are likely to be useful in increasing healthcare professionals' and policy makers' understanding of Chinese migrant women's contraceptive method preferences, beliefs and behaviours. They also help to develop culturally and linguistically sensitive strategies, which goes beyond the provision of contraceptive counselling, in assisting Chinese migrant women's decision-making needs.

Exploring the Vast Choice of Question Prompt Lists Available to Health Consumers via Google: Environmental Scan.

BACKGROUND: There is increasing interest in shared decision making (SDM) in Australia. Question prompt lists (QPLs) support question asking by patients, a key part of SDM. QPLs have been studied in a variety of settings, and increasingly the internet provides a source of suggested questions for patients. Environmental scans have been shown to be useful in assessing the availability and quality of online SDM tools. OBJECTIVE: This study aimed to assess the number and readability of QPLs available to users via Google.com.au. METHODS: Our environmental scan used search terms derived from literature and reputable websites to search for QPLs available via Google.com.au. Following removal of duplicates from the 4000 URLs and 22 reputable sites, inclusion and exclusion criteria were applied to create a list of unique QPLs. A sample of 20 QPLs was further assessed for list length, proxy measures of quality such as a date of review, and evidence of doctor endorsement. Readability of the sample QPL instructions and QPLs themselves was assessed using Flesch Reading Ease and Flesch-Kincaid Grade Level scores. RESULTS: Our environmental scan identified 173 unique QPLs available to users. Lists ranged in length from 1 question to >200 questions. Of our sample, 50% (10/20) had a listed date of creation or update, and 60% (12/20) had evidence of authorship or source. Flesch-Kincaid Grade Level scores for instructions were higher than for the QPLs (grades 10.3 and 7.7, respectively). There was over a 1 grade difference between QPLs from reputable sites compared with other sites (grades 4.2 and 5.4, respectively). CONCLUSIONS: People seeking questions to ask their doctor using Google.com.au encounter a vast number of question lists that they can use to prepare for consultations with their doctors. Markers of the quality or usefulness of various types of online QPLs, either surrogate or direct, have not yet been established, which makes it difficult to assess the value of the abundance of lists. Doctor endorsement of question asking has previously been shown to be an important factor in the effectiveness of QPLs, but information regarding this is not readily available online. Whether these diverse QPLs are endorsed by medical practitioners warrants further investigation.

Healthcare providers' perceptions of the challenges and opportunities to engage Chinese migrant women in contraceptive counselling: a qualitative interview study.

Background In Australia, there are many culturally and linguistically diverse communities and Chinese migrants make up one of the largest. Yet, little is known about healthcare providers' (HCPs) unique experiences in providing contraceptive care for Chinese migrant women. There is minimal research into the HCPs' perceptions of challenges or opportunities in engaging Chinese migrant women in informed and shared decision-making processes during contraceptive counselling. The aim of this study is to explore HCPs' experiences of providing contraceptive care for Chinese migrant women, their perceptions of women's care needs when choosing contraceptive methods, as well as their own needs in supporting women's decision-making. METHODS: Semi-structured interviews were conducted with 20 HCPs in Sydney, Australia who had substantial experience in providing contraceptive services to Chinese women who were recent migrants. Transcribed audio-recorded data were analysed using thematic analysis. RESULTS: Four main themes were identified, including: 'Are you using contraception?': the case for being proactive and opportunistic; 'Getting the message across': barriers to communication; 'Hormones are unnatural?': women favouring non-hormonal methods; and 'Word of mouth': social influence on contraceptive method choice. CONCLUSIONS: In order to facilitate informed choice and shared decision-making with Chinese migrant women during contraceptive counselling, broader health system and community-level strategies are needed. Such strategies could include improving HCPs' cultural competency in assessing and communicating women's contraceptive needs; providing professional interpreting services and translated materials; and improving women's health literacy, including their contraceptive knowledge and health system awareness.

A cluster randomized controlled trial of an online psychoeducational intervention for people with a family history of depression.

BACKGROUND: People with a family history of major depressive disorder (MDD) or bipolar disorder (BD) report specific psychoeducational needs that are unmet by existing online interventions. This trial aimed to test whether an interactive website for people at familial risk for depression (intervention) would improve intention to adopt, or actual adoption of, depression prevention strategies (primary outcome) and a range of secondary outcome measures. METHODS: In this cluster randomised trial, primary care practises were randomised to either provide the link to the intervention or the control website. Primary health care attendees were invited by letter to opt into this study if they had at least one first-degree relative with MDD or BD and were asked to complete online questionnaires at baseline and 2-week follow-up. RESULTS: Twenty general practices were a randomized, and 202 eligible patients completed both questionnaires. Thirty-nine (19.3%) of participants were male and 163 (80.7%) female. At follow-up, compared to controls, the intervention group: (i) were more likely to intend to undergo, or to have actually undergone, psychological therapies (OR = 5.83, 95% CI: 1.58-21.47, p = .008); (ii) had better knowledge of depression risk factors and prevention strategies (mean difference = 0.47, 95% CI: 0.05-0.88, p = .029); and (iii) were more likely to accurately estimate their lifetime risk of developing BD (mean difference = 11.2, 95% CI: -16.52- -5.73, p < .001). There were no statistically significant between-group differences in change from baseline to follow up for any of the remaining outcome measures (Patient Health Questionnaire, Perceived Devaluation-Discrimination Questionnaire and Perceived Risk of Developing MDD). CONCLUSION: The opt-in nature of the study may have led to participation bias, e.g. underrepresentation of males, and hence may limit generalisability to the broader population at familial risk for depression. This is the first website internationally focusing specifically on informational needs of those at familial risk of depression. Our interactive website can play an important role in improving the outcomes of individuals at familial risk for depression. Testing the intervention in other settings (e.g. psychology, psychiatry, genetic counselling) appears warranted. TRIAL REGISTRATION: The study was prospectively registered with the Australian and New Zealand Clinical Trials Group (Registration no: ACTRN12613000402741 ).

Interventions to improve participation in health-care decisions in non-Western countries: A systematic review and narrative synthesis.

BACKGROUND: Patients' participation in medical decision making is an important aspect of patient-centred care. However, there is often uncertainty about its applicability and feasibility in non-Western countries. OBJECTIVE: To provide an overview and assessment of interventions that aimed to improve patients' participation in decision making in non-Western countries. METHOD: Ovid Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, Ovid MEDLINE(R) Epub Ahead of Print, In-Process, Other Non-Indexed Citations, without Revisions and Daily Update and Database of Abstracts of Reviews of Effects, were searched from respective inception to February 2018. Studies were included if they (a) were randomized controlled trials, before-and-after studies and interrupted time series studies; (b) were conducted in non-Western countries; (c) aimed to improve patients' participation in dyadic decision making; and (d) reported outcomes relevant to patient participation in decision making. Studies were excluded if they included children, were about triadic decision making or solely focused on information provision without reporting outcomes related to patient participation. Narrative synthesis method was used for data analysis and presentation. RESULTS: A total of 17 studies, 6 RCTs and 11 non-RCTs, were included across ten countries. Intervention strategies included patient and/or provider communication skills training, decision aids and a question prompt material. Whilst most of the studies reported increased patient participation, those interventions which had provider or patient training in communication skills were found to be more effective. CONCLUSION: Interventions to improve patient participation, within the context of dyadic decision making, in non-Western countries can be feasible and effective if communication skills training is provided for health-care providers and/or patients.

Evidence for underuse of effective medical services around the world.

Underuse-the failure to use effective and affordable medical interventions-is common and responsible for substantial suffering, disability, and loss of life worldwide. Underuse occurs at every point along the treatment continuum, from populations lacking access to health care to inadequate supply of medical resources and labour, slow or partial uptake of innovations, and patients not accessing or declining them. The extent of underuse for different interventions varies by country, and is documented in countries of high, middle, and low-income, and across different types of health-care systems, payment models, and health services. Most research into underuse has focused on measuring solutions to the problem, with considerably less attention paid to its global prevalence or its consequences for patients and populations. Although focused effort and resources can overcome specific underuse problems, comparatively little is spent on work to better understand and overcome the barriers to improved uptake of effective interventions, and methods to make them affordable.

α-Blockers for uncomplicated ureteric stones: a clinical practice guideline.

OBJECTIVE: To develop an evidence-based recommendation concerning the use of α-blockers for uncomplicated ureteric stones based on an up-to-date Cochrane review, as the role of medical expulsive therapy for uncomplicated ureteric stones remains controversial in the light of new contradictory trial evidence. METHODS: We applied the Rapid Recommendations approach to guideline development, which represents an innovative approach by an international collaborative network of clinicians, researchers, methodologists and patient representatives seeking to rapidly respond to new, potentially practice-changing evidence with recommendations developed according to standards for trustworthy guidelines. RESULTS: The panel suggests the use of α-blockers in addition to standard care over standard care alone in patients with uncomplicated ureteric stones (weak recommendation based on low-quality evidence). The panel judged that the net benefit of α-blockers was small and that there was considerable uncertainty about patients' values and preferences. This means that the panel expects that most patients would choose treatment with α-blockers but that a substantial proportion would not. This recommendation applies to both patients in whom the presence of ureteric stones is confirmed by imaging, as well as patients in whom the diagnosis is made based on clinical grounds only. CONCLUSION: The Rapid Recommendations panel suggests the use of α-blockers for patients with ureteric stones. Shared decision-making is emphasised in making the final choice between the treatment options.

Administrative encounters in general practice: low value or hidden value care?

OBJECTIVE: To determine the frequency of general practice administrative encounters, and to determine whether they represent low value care. DESIGN: Secondary analysis of data from the Bettering Evaluation and Care of Health (BEACH) dataset. SETTING: 1 568 100 GP-patient encounters in Australia, 2000-01 to 2015-16. PARTICIPANTS: An annual nationally representative random sample of about 1000 GPs, who each recorded the details of 100 consecutive encounters with patients. MAIN OUTCOME MEASURES: Proportions of general practice encounters that were potentially low value care encounters (among the patient's reasons for the encounter was at least one administrative, medication, or referral request) and potentially low value care only encounters (such reasons were the sole reason for the encounter). For 2015-16, we also examined other health care provided by GPs at these encounters. RESULTS: During 2015-16, 18.5% (95% CI, 17.7-19.3%) of 97 398 GP-patient encounters were potentially low value care request encounters; 7.4% (95% CI, 7.0-7.9%) were potentially low value care only encounters. Administrative work was requested at 3.8% (95% CI, 3.5-4.0%) of GP visits, 35.4% of which were for care planning and coordination, 33.5% for certification, and 31.2% for other reasons. Medication requests were made at 13.1% (95% CI, 12.4-13.7%) of encounters; other health care was provided at 57.9% of medication request encounters, counselling, advice or education at 23.4%, and pathology testing was ordered at 16.7%. Referrals were requested at 2.8% (95% CI, 1.7-3.0%) of visits, at 69.4% of which additional health care was provided. The problems managed most frequently at potentially low value care only encounters were chronic diseases. CONCLUSION: Most patients requested certificates, medications and referrals in the context of seeking help for other health needs. Additional health care, particularly for chronic diseases, was provided at most GP administrative encounters. The MBS Review should consider the hidden value of these encounters.

Improving women's knowledge about prenatal screening in the era of non-invasive prenatal testing for Down syndrome - development and acceptability of a low literacy decision aid.

BACKGROUND: Access to information about prenatal screening is important particularly in light of new techniques such as non-invasive prenatal testing (NIPT). This study aimed to develop and examine the acceptability of a low literacy decision aid (DA) about Down syndrome screening among pregnant women with varying education levels and GPs. METHODS: We developed a DA booklet providing information about first-trimester combined testing, maternal serum screening, and NIPT. GPs and women participated in a telephone interview to examine the acceptability of the DA and measure screening knowledge before and after reading the DA. The knowledge measure was designed to assess whether women had understood the gist of the information presented in the decision aid. It comprised conceptual questions (e.g. screening tells you the chance of having a baby with Down syndrome) and numeric questions (e.g. the accuracy of different screening tests). RESULTS: Twenty-nine women and 18 GPs participated. Regardless of education level, most women found the booklet 'very' clearly presented (n = 22, 76%), and 'very' informative (n = 23, 80%). Overall, women's conceptual and numeric knowledge improved after exposure to the DA, from 4% having adequate knowledge to 69%. Women's knowledge of NIPT also improved after receiving the decision aid, irrespective of education. Most GPs found it 'very' clearly presented (n = 13, 72%), and that it would 'very much' facilitate decision-making (n = 16, 89%). CONCLUSIONS: The DA was found to be acceptable to women as well as GPs. A comprehensive evaluation of the efficacy of the decision aid compared to standard information is an important next step. Strategies are needed on how to implement the tool in practice.

Clinical Validity, Understandability, and Actionability of Online Cardiovascular Disease Risk Calculators: Systematic Review.

BACKGROUND: Online health information is particularly important for cardiovascular disease (CVD) prevention, where lifestyle changes are recommended until risk becomes high enough to warrant pharmacological intervention. Online information is abundant, but the quality is often poor and many people do not have adequate health literacy to access, understand, and use it effectively. OBJECTIVE: This project aimed to review and evaluate the suitability of online CVD risk calculators for use by low health literate consumers in terms of clinical validity, understandability, and actionability. METHODS: This systematic review of public websites from August to November 2016 used evaluation of clinical validity based on a high-risk patient profile and assessment of understandability and actionability using Patient Education Material Evaluation Tool for Print Materials. RESULTS: A total of 67 unique webpages and 73 unique CVD risk calculators were identified. The same high-risk patient profile produced widely variable CVD risk estimates, ranging from as little as 3% to as high as a 43% risk of a CVD event over the next 10 years. One-quarter (25%) of risk calculators did not specify what model these estimates were based on. The most common clinical model was Framingham (44%), and most calculators (77%) provided a 10-year CVD risk estimate. The calculators scored moderately on understandability (mean score 64%) and poorly on actionability (mean score 19%). The absolute percentage risk was stated in most (but not all) calculators (79%), and only 18% included graphical formats consistent with recommended risk communication guidelines. CONCLUSIONS: There is a plethora of online CVD risk calculators available, but they are not readily understandable and their actionability is poor. Entering the same clinical information produces widely varying results with little explanation. Developers need to address actionability as well as clinical validity and understandability to improve usefulness to consumers with low health literacy.