A Systematic Review and Meta-Analysis of Patient Decision Aids for Socially Disadvantaged Populations: Update from the International Patient Decision Aid Standards (IPDAS)

Abstract

Background The effectiveness of patient decision aids (PtDAs) and other shared decision-making (SDM) interventions for socially disadvantaged populations has not been well studied. Purpose To assess whether PtDAs and other SDM interventions improve outcomes or decrease health inequalities among socially disadvantaged populations and determine the critical features of successful interventions. Data Sources MEDLINE, CINAHL, Cochrane, PsycINFO, and Web of Science from inception to October 2019. Cochrane systematic reviews on PtDAs. Study Selection Randomized controlled trials of PtDAs and SDM interventions that included socially disadvantaged populations. Data Extraction Independent double data extraction using a standardized form and the Template for Intervention Description and Replication checklist. Data Synthesis Twenty-five PtDA and 13 other SDM intervention trials met our inclusion criteria. Compared with usual care, PtDAs improved knowledge (mean difference = 13.91, 95% confidence interval [CI] 9.01, 18.82 [I2 = 96%]) and patient-clinician communication (relative risk = 1.62, 95% CI 1.42, 1.84 [I2 = 0%]). PtDAs reduced decisional conflict (mean difference = −9.59; 95% CI −18.94, −0.24 [I2 = 84%]) and the proportion undecided (relative risk = 0.39; 95% CI 0.28, 0.53 [I2 = 75%]). PtDAs did not affect anxiety (standardized mean difference = 0.02, 95% CI −0.22, 0.26 [I2 = 70%]). Only 1 trial looked at clinical outcomes (hemoglobin A1C). Five of the 12 PtDA studies that compared outcomes by disadvantaged standing found that outcomes improved more for socially disadvantaged participants. No evidence indicated which intervention characteristics were most effective. Results were similar for SDM intervention trials. Limitations Sixteen PtDA studies had an overall unclear risk of bias. Heterogeneity was high for most outcomes. Most studies only had short-term follow-up. Conclusions PtDAs led to better outcomes among socially disadvantaged populations but did not reduce health inequalities. We could not determine which intervention features were most effective. [Box: see text]

Decision aids linked to the recommendations in clinical practice guidelines: results of the acceptability of a decision aid for patients with generalized anxiety disorder

“…Recent research suggests that psychiatric patients (with several cognitive deficits) are capable of using the PtDA and can benefit from doing so [ 60 , 61 ]. A recent systematic review reported that for socially disadvantaged patients in particular, with a lower level of digital health literacy, the use of PtDA leads to better health outcomes [ 62 ]. Future projects should examine whether the level of digital health literacy is a key factor that could influence the health outcomes of patients with GAD.…”

The Impact of Health Literacy–Sensitive Design and Heart Age in a Cardiovascular Disease Prevention Decision Aid: Randomized Controlled Trial and End-User Testing

“…A recent review of DAs for people with lower health literacy [ 57 , 58 ] showed that DAs that use health literacy design strategies lead to improved knowledge, decisional conflict, and decision-making outcomes. Furthermore, DAs that used explicit strategies to reduce cognitive burden showed greater improvements in knowledge for people with low health literacy and from disadvantaged backgrounds [ 58 ]. The review highlighted the need for more consideration of health literacy in DA development.…”

Systematic review of effectiveness and quality assessment of patient education materials and decision aids for breathlessness

“…PEMs written at a level too high for the average adult may increase the risk of promoting health disparities as shown by Sentell et al [ 33 ]. However, a recent review by Yen et al showed that the use of patient decision aids in socially disadvantaged populations has the potential to improve patient outcomes [ 34 ]. Hence it is of concern that our results show that breathlessness PEMs are written at a level too high for the average population.…”