A decision aid for women considering hormone therapy after menopause: decision support framework and evaluation

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Abstract

Although postmenopausal women are advised to consider their values when deliberating about potential benefits and risks of hormone therapy (HRT), feasible, effective methods of decision support in primary care have yet to be established. Using an explicit decision support framework, we developed a self-administered HRT decision aid and evaluated it in a before/after study of 94 women from six family practices. An audiotape guided women through an illustrated booklet including: detailed information about HRT benefits and risks tailored to a woman's clinical risk, and a values clarification exercise to promote informed decision making consistent with personal values. After using the decision aid participants: had better general knowledge and more realistic personal expectations of HRT benefits and risks; and, felt more certain, informed, clear about values, and supported in decision making. Women's values elicited in the clarification exercise were 84% accurate in discriminating between decisions. Women with polarized preferences at baseline did not change their minds, but were better informed. Changes in preferences occurred in the uncertain group, with equal numbers accepting or declining HRT. Most participants found the decision aid comprehensible, acceptable in length and pace, and balanced. Decision aids are useful in preparing women for decision making about this complex, personal issue.

Section snippets

Decision support framework

Our decision support framework (DSF) is based on expectancy value, decisional conflict, and social support theories 8, 9, 10, 11, 12, 13, 14, 15. It was developed for health decisions that: (1) are stimulated by a new circumstance, diagnosis, or developmental transition; (2) require careful deliberation because of the uncertain and/or value-sensitive nature of the benefits and risks; and (3) need relatively more effort during the deliberation phase than the implementation phase. Therefore the

The HRT decision aid

The early prototypes of the HRT decision aid were developed using an iterative process with the research team and panels of clients, medical and nursing practitioners, and educators. These groups guided its development using criteria such as need, feasibility, and appropriateness and acceptability of the objectives, content, and decision support methods.

We structured the content of the decision aid according to the ACP counseling guidelines [1]and delivered it using a self-administered,

Before/after study design

Participants were screened and recruited over six months from 6 family practices in downtown Ottawa, Canada. Following a routine office visit, the participants completed a baseline questionnaire eliciting their knowledge, personal expectations and importance ratings of HRT benefits and risks, current leaning toward taking HRT, and decisional conflict. At the next office visit, before seeing their physician, participants completed the decision aid and another questionnaire. The timing of our

Results

Demographic and clinical characteristics (summarized in Table 2) show that participants were approximately equally distributed in terms of their age group, current use of HRT, and hysterectomy status. The majority of participants: had at least some post secondary education; preferred to share decision making with their practitioner; had at least one risk factor for CHD; and did not report having low bone density or a first degree relative with breast cancer. The characteristics of the sample

Discussion

This before/after study demonstrated that the decision aid performed according to the predictions of the DSF: reducing uncertainty, increasing knowledge, creating realistic expectations, clarifying values, and supporting decision making. It is promising that over half of the women exposed to a decision aid had good general knowledge and realistic expectations, and felt they had enough advice to make a decision. Considering the large numbers of women who will reach menopausal age over the next

Acknowledgements

This project was supported by the Institute of Clinical Evaluative Sciences in Ontario, Toronto, Ontario, Canada and the Medical Research Council of Canada.

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