Education And Debate

Use of decision aids to support informed choices about screening

BMJ 2004; 329 doi: http://dx.doi.org/10.1136/bmj.329.7464.507 (Published 26 August 2004) Cite this as: BMJ 2004;329:507
  1. Alexandra Barratt, senior lecturer in epidemiology (alexb@health.usyd.edu.au)1,
  2. Lyndal Trevena, lecturer1,
  3. Heather M Davey, PhD candidate1,
  4. Kirsten McCaffery, senior research fellow1
  1. 1 Screening and Test Evaluation Program, School of Public Health, University of Sydney, Sydney, NSW 2006, Australia
  1. Correspondence to: A Barratt
  • Accepted 31 May 2004

Decisions about screening can be more complex than those about treatment. Well designed decision aids could help patients understand the risks as well as the benefits

Introduction

Patients should be able to participate in health decisions, if they so choose. Decision aids have been developed to help patients make informed decisions about treatment and have been found to improve knowledge, reduce indecision, and improve agreement between values and choice.1 However, in screening, where informed choice is not common practice,2 decision aids are controversial and their effect is currently unknown.3 4 Nevertheless, the complexities of decisions about screening mean that decision aids could be of immense value. In this paper we highlight eight issues that are critically important for the development and use of high quality decision aids about screening. Some of these issues arise because of fundamental differences between screening and treatment interventions; other issues flow from widespread uncritical support for screening, as illustrated by the storm over PSA (prostate specific antigen) screening for prostate cancer.5 6

Problems with weighing the evidence

Weighing the evidence for and against a screening intervention is a complex task for policy makers and is likely to prove challenging for individual consumers too. In its latest edition, the US Preventive Services Taskforce has rated screening interventions on a five point scale, based on an assessment of whether benefits outweigh harms (or vice versa) and on the extent to which evidence is available to make that assessment.7 Unfortunately, the evidence available is often insufficient to make a recommendation.7 Even when evidence is available, policy makers have to judge whether the benefits outweigh the harms, and this decision is at least partly driven by the values of the people making the policy or recommendation. Their values may not accord with those of the individuals who are subsequently …

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