Developing a quality criteria framework for patient decision aids: online international Delphi consensus process

In the era were we move from informed consent to informed choice
Elwyn et al1 has produced a timely article on decision aids for the
patient. The quality criteria will no doubt help future decision aid
developers. The Delphi consensus process involved fewer practitioners and
patients as raters compared to researchers. Practitioners constituted only
8% of the raters whereas researchers were 59%. Informed choice should be
considered as an outcome of a communication between the patient and the
health provider. McNutt 2 suggested that, patient is like a pilot and the
doctor, with the evidence through decision aids, help the patient to
navigate to the decision. Disproportionately less number of doctors or
other health care providers is likely to have skewed the rating process.

Informed choice is definitely the way forward for screening
procedures in genetic diseases and cancers. O’Connor et al 3 ,in their
systematic review on decision aids found that decision aids compared to
usual care help people feel more comfortable with their choices. While the
quality criteria will ensure quality of the communication, it may not be
always possible to assess the comprehension of the patient. In striving
for quality, information overload should be avoided. This will not only
overwhelm the decision maker but will also cause them to make a flawed
decision.

The role of decision aids helping patients choose a treatment
intervention may be less important. 60-70% of patients want their doctor
to give them the options and allow the patient to decide 4 . But, in
reality, most often than less clinicians hear patients saying –‘ You do
what is best doctor’. Again, the group of patients who would want
empowerment in decision making seem to be the educated and of the upper
socioeconomic class. The process of arriving at an informed decision
requires resources. Policy makers will have to ensure that there is equal
distribution of delivering information among the various social classes
and not just an elite few. Consultation time spend providing information
to one patient should not affect another patient who is less demanding.
This is a concern in a public funded, equally distributed health delivery
system like the British National Health Services. O’Connor AM et al3 in
their systematic review found that if low cost internet access substituted
expensive interactive videodisc equipment, the process is cost effective.
Finally, one should not forget that the vast majority of people in this
planet do not have access to proper medical care and the luxury of
decision aids is beyond their reach.

References

1. Elwyn G, O’Connor A, Stacey D, Volk R, Edwards A, Coulter A.
Developing a quality criteria framework for patient decision aids: online
international Delphi consensus process. BMJ 2006; doi 10.1136/bmj

2. McNutt RA. Shared medical decision making: problems, process,
progress. JAMA 2004; 292: 2516-8.

3. O’Connor AM, Stacey D, Entwistle V, Llewellyn-Thomas H, Rovner D,
Holmes- Rovner M, Tait V, Tetrol J, Fiest V, Barry M, Jones J. Decision
aids for people facing health treatment or screening decisions. Cochrane
database Syst Rev 2003; (1): CD001431.

4. O’Connor AM, Llewellyn- Thomas HA, Flood AB. Modifying unwarranted
variations in Health care: shared decision making using patient decision
aids. Health Aff (Millwood) 2004.

Competing interests:
None declared