Do Decision Aids Promote Shared Decision-Making for Prostate Cancer Screening? Alex Krist MD Steven Woolf MD MPH Robert Johnson PhD Department of Family Medicine Virginia Commonwealth University Funded under the AAFP/F Junior Grant Awards Program

Prostate Cancer Screening Most men in the U.S. get screened (75%) 1 Screening can detect early stage cancer but inconclusive whether outcomes improved 2 Shared decision-making (SDM) is recommended before testing (USPSTF, ACS, AUA) A growing number of medical decisions require SDM 1 – JAMA 2003; 289: – Ann Int Med 2002; 137:

Prior Research on Decision Aids Patients generally have poor knowledge about the risks and benefits of PSA testing Multiple educational tools have been developed: videocassettes, scripts, booklets, and balance sheets Evaluations have demonstrated these aids decrease PSA testing and increase patient knowledge Unknown whether these aids facilitate SDM Patient Educ Couns 1999;37: Arch Fam Med 1999;8: Arch Intern Med 1996; 156:

Primary Hypothesis Review of educational material prior to a health maintenance examination will increase the rate with which patients and physicians jointly decide to perform PSA testing as a screen for prostate cancer Secondary Hypothesis The Internet provides an easy and acceptable format for pre-visit education that patients are more likely to use then a mailed brochure

Methods Single center, randomized, controlled trial Conducted between June 2002 and June 2004 Men 50 to 70 years age scheduled for a HME randomized to receive: –Invitation to view an educational Website –Invitation to review a mailed educational brochure (print version of Website) –No directed pre-visit education –In a 3:3:1 ratio, respectively No effort to blind physicians to intervention

Survey Instrument Preferred and experienced locus of decision making control (Control Preference Scale) 1 Patient knowledge 2 Frequency of PSA testing Decisional Conflict Score 3 Topics discussed Time spent Basic demographics 1 - J Clin Epidemiol 1994; 45: J Fam Pract. 1999; 48: , 3 - Decisional Conflict Scale, 4 th ed

Primary Outcome How was the decision made today on whether to order a PSA test? A. I made the decision on whether to order a PSA B. I made the decision after seriously considering my doctor’s opinion C. My doctor and I shared the decision on whether to order a PSA D. The doctor made the decision after seriously considering my opinion E. The doctor made the decision on whether to order a PSA test

1073 Scheduled WME 497 Patients Randomized 398 Unable to reach 79 Blood work before exam 33 Declined participation 30 History of prostate cancer 26 Previously enrolled 24 No 9 Enrolled in another study 75 Control196 Brochure226 Website 63 (84%) Patient responses 70 (93%) MD responses 174 (89%) Patient responses 182 (93%) MD responses 198 (88%) Patient responses 205 (91%) MD responses

Patient Report on Screening Decision Locus of Control % Responding each answer

Decisions by Degree of Sharing % Responding each answer

Concordance between Desired and Actual Decision Control % Responding each answer

Additional Outcomes ControlBrochureWebsite Time spent 4.9 min 5.0 min 5.1 min Number of PSA topics discussed (range 1-10) Percent correct on knowledge test 54% (p<0.01) 69%69% Mean decisional conflict score Frequency of PSA testing (per patient) 85%83%86% Frequency of PSA testing (per clinician) 94% (p=0.04) 85%86%

Did the Decision Aid Stimulate Shared Decision-Making? Elements of SDM 1 The patient… Understands the disease Understands the preventive service Weighs his values Is engaged in the decision at the desired level What we found… The aids increased patient knowledge All patients had low decisional conflict No increase in desired and actual decision control BUT, increased patient decision involvement 1 - Am J Prev Med 2004; 26:56-66

Limitations Outcomes measured by survey not observation Merenstein case occurred at study site (JAMA 2004; 291:15-6) Did we measure SDM? –Focused on one element – locus of control –Is a shift towards choice “C” ideal

Conclusions Patients exposed to a decision aid were more involved in their screening decision Patients exposed to a decision aid were more knowledgeable about screening Patients received less screening if exposed to a decision aid The mailed brochure and Internet-based decision aids had similar impacts on the decision process Unknown whether patient outcomes were improved

Thank You!