Low Marks for Decision Aids in Prostate Cancer Screening - MedPage Today
Decision aids appeared to have no measurable effect on prompting patient-physician discussions about prostate cancer screening or on influencing whether men actually underwent prostatic specific antigen (PSA) testing, a systematic review and meta-analysis found.
In analyzing results from 19 randomized controlled trials, the median frequency with which men discussed PSA testing with their doctor was 52% in studies where decision aids were used compared with 47% in usual care groups (risk ratio [RR] 1.12, 95% CI 0.90-1.39, I2 = 60%), Kari Tikkinen, MD, PhD, of Helsinki University Hospital in Finland, and colleagues reported.
Furthermore, regarding patients' decision to undergo PSA testing, no association was seen between use of a decision aid versus usual care (RR 0.95, 95% CI 0.88-1.03, I2 = 36%), as described in JAMA Internal Medicine.
At best, the meta-analysis found evidence that use of decision aids "probably" decreased patient conflict about screening and "possibly" increased patient knowledge compared with usual care.
"The available evidence does not provide a compelling rationale for clinicians to use existing decision aids to facilitate shared decision-making in their discussions with men considering undergoing prostate cancer screening," Tikkinen and colleagues concluded. "Future decision aids should include provision for continuous updating and not only provide education to patients but also promote shared decision-making in the patient-physician encounter."
Commenting on the findings, Laura Scherer, PhD, of the University of Colorado in Denver, and Grace Lin, MD, of the University of California San Francisco, agreed with the authors that the meta-analysis does not provide a persuasive case to use decision aids to facilitate discussions about PSA testing, at least not for those included in the current study.
To know the true potential of these tools will require systematic testing of their design, implementation strategies, and patients' attributes and preferences on shared decision-making outcomes. Some men are so-called "medical maximizers," the editorialists explained, preferring to participate actively in their own healthcare and will choose to undergo screening despite being warned of potential harms. Conversely, others are "medical minimizers" and will forego screening once informed about its potential downsides.
"We must ask whether we are giving the decision aid to the right people, in the right setting, and at the right moment in the decision-making process," they said.
Also, the fact that a decision aid does not change the decision of an individual does not indicate that the tool has failed, Scherer and Lin argued. In general, men may decide whether to undergo screening because their spouse or loved one urged them one way or the other, they pointed out. And recommendations from physicians can be "highly persuasive" and have the potential to override a patient's preference.
The meta-analysis from Tikkinen and colleagues included 19 studies and involved a total of 12,781 men. All but three of the studies were carried out in the U.S. The median of mean patient ages was 59 years.
There was moderate-quality evidence that these aids improved decisional conflict (-4.19 mean difference on a 100-point scale, 95% CI -7.06 to -1.33, I2 = 75%) and low-quality evidence of an improvement in patient knowledge (RR 1.38, 95% CI 1.09-1.73, I2 = 67%).
Scherer and Lin said it would be "premature" to conclude that these aids do not affect prostate cancer screening decisions based on the current analysis and highlighted the "considerable variation" in the format in which these decision aids were presented, from a 1-page mailed flyer to an in-clinic intervention that included a video and a pre-visit coaching session. Some decision aids also recommended that patients talk with their doctor while others did not and still others made sure men were as well prepared as they could be to overcome communication barriers.
Tikkinen had no conflicts of interest to declare but many of his co-investigators did which are included in the publication.
Neither Scherer nor Lin had any conflicts of interest to declare.
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