Decision aids: challenges for practice when we have confidence in effectiveness

In Cochrane's 30th year, it is fitting that the seminal review, 'Decision aids for people facing health treatment or screening decisions' has been updated again, to include analysis of 209 studies involving 107,698 participants.[1] This 2024 update almost doubles the size of the review, last published in 2017.[2] It provides clear evidence of benefits for the use of decision aids over usual care across a huge array of health options, ranging from choices about cancer screening to decisions about major elective surgery. The review continues to provide the foundation for extensive research and ongoing changes in practice and health service improvement. Decision aids are one type of tool that can be used to support the process of shared decision making between patients and their health professionals, a key element of person‐centred care and health system improvements.[3] In this update, the largest and most consistent improvements seen with the use of decision aids include people having better knowledge, more accurate risk perceptions, feeling more informed, and having a clearer match between their values and the option they have chosen. There are also benefits to be seen across other outcomes, such as more people being actively engaged in decision making with their doctors and being more satisfied with the process of making decisions, without indications of increased distress or regret related to the health decisions made. All of these findings are convincingly positive and indicate – as previous versions of the review have suggested – that decision aids are effective strategies for improving shared decision making between people and their health professionals. This review, in all its cumulative forms, has had a significant impact on practice around the world. For instance, it has been referred to in more than 90 clinical practice guidelines. Its influence on research is evident by its being one of the most cited reviews published on the Cochrane Library for over a decade. This update sees an increase in both the quality of evidence and the precision of estimates of the effects of decision aids for many key outcomes. This means that we, as users of evidence, are in a stronger position than ever to make informed decisions about using decision aids, with clear benefits for patient care associated with their adoption in decision making in practice. The author team has regularly updated this review over time and has done so in a thoughtful way, informed by their extensive knowledge of shared decision making and their engagement with the evolving practice of evidence synthesis. This has meant that updating the review has not simply been a linear accumulation of trials. Instead, each update has been considered within, and adjusted to the wider context of the evolving understanding of shared decision making at that point in time, ensuring that the most important practice implications have been a focus of the evidence synthesis. For example, the 2009 version[4] saw substantial changes to the outcomes sought by the review, to align with the original effectiveness criteria of the International Patient Decision Aids Standards (IPDAS) collaboration.[5] Comparisons have also been adapted over time to reflect what was most meaningful for practice. For instance, investigating the effects of detailed versus simple decision aids in earlier versions (now redundant), or exploring the differences between pre‐ and in‐consult decision aids. The operational definition of decision aids has been monitored and the review adjusted as this has evolved.[5, 6] Some uncertainties still remain for several outcomes, such as adherence to the chosen option, and some gaps persist in the evidence, for example, we do not have enough evidence from low‐ and middle‐income countries. How should we respond to such a review and its findings? Despite the recommended use of decision aids in so many guidelines, as well as policies and legislation to ensure that decision aids are enacted in several countries, there is still a long delay in their adoption in many health systems.[3, 7] Many people are not aware of decision aids, nor are they straightforward for people to use on their own. Instead, they require larger systems, support and training to be in place to enable health professionals to use them together with their patients.[3, 8] This situation therefore mimics the wider challenges in putting person‐centred health care into practice. Despite movement worldwide towards recognition of the central role of people in health care and decisions about their health and treatment, the challenges of implementing interventions like decision aids, within a broader purpose of supporting shared decision making, therefore remain substantial and likely require redesign at clinical, organisational and health‐system levels to support patient‐doctor partnerships.[3, 7, 9] Considering changes in context will continue to be necessary. Over the last 30 years there has been growth in support for, and development of many good systems to provide health and treatment information to people formally. This formal approach is often complemented with informal information sharing amongst consumers, which may be contradictory. If people increasingly look to other health consumers for information, this will remain a challenge for developers and implementers of decision aids. Alongside better health information for healthcare consumers, there has been the promotion of more active roles for people in health service design, planning and research, and increasingly, policies and legislation, to ensure that shared decision making is enacted. A promising approach both in the decision aids area and more generally in the pursuit of truly person‐centred health systems may be to involve people – the end user of decision aids, together with their health professionals – in designing, planning, implementing and measuring the effects of such tools in the many different contexts where they could be used.[3, 7, 10] Promoting and building capacity for shared decision making through evidence on effective interventions remains an important goal ‐ one that has been steadfastly pursued by the author team of this review. In the next 10 years, we hope to see its findings not only reflected in many guidelines but implemented across many health systems.