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07-02-2013 | Article

Impartiality in decision aids not always in patient’s favor


Free abstract

medwireNews: Under certain circumstances, patient decision aids may do a disservice to patients if they adhere too strictly to neutrality and non-bias, according to a Health Affairs analysis and commentary.

Author Jennifer Blumenthal-Barby (Baylor College of Medicine, Houston, Texas) and colleagues argue that balance is not the be-all and end-all in developing patient aids, despite criteria from the International Patient Decision Aids Standards Collaboration demanding impartiality.

"One of the requirements as laid out by this collaboration is that the aids be as balanced as possible in terms of presentation of options," Blumenthal-Barby explained to medwireNews. "We're sort of challenging that criteria specifically as well as the general norm that exists around such aids and neutrality. We just feel that it has been applied rather inflexibly when it comes to the design of decision aids."

The push for aid neutrality stems from concern over their wrongful use as marketing tools or ways for a center or surgeon to potentially bias a patient to opt for a service they provide. Yet decision aids were also created to counter doctors' intentional - or unintentional - biasing of patients towards a particular direction. "We're saying that it is OK for decision aids to also nudge in one direction to potentially counterbalance the nudges that patients might be receiving from their physicians - without suggesting a specific option."

The researchers noted three therapeutic situations that exemplify when developers should not strive to make decision aids that are "neutral, unbiased, and nondirective as possible."

The first scenario concerns treatment options that patients do not often consider or are not informed about despite the clinical evidence, such as active surveillance for the management of early-stage prostate cancer.

Colorectal cancer screening typifies a procedure that an aid could convey as a high-benefit, low-risk treatment or prevention decision. "Including a 'no screening' option would fulfill a requirement for balance but would be counter to the standard of care for cancer screening," the authors write.

Lastly, the researchers explain that various anticoagulant therapies for deep vein thrombosis illustrate the value-based choices that decision aids should identify and encourage, as the treatments have varying effects on the habits, concerns, preferences, or goals of a patient.

"By laying out these three specific situations, we hope to start building some guidelines that would help develop consensus of when nudging might be appropriate," Blumenthal-Barby said. "In these situations, neutrality might not be a good idea."

By Peter Sergo, medwireNews Reporter