Abstract

Decision support tools are frequently developed for preference-sensitive decisions in which there are no clear dominant choices (e.g. treatment of early stage prostate cancer). Less attention has been paid to supporting patient decision making for situations in which evidence-based guidelines strongly recommend a specific treatment approach that is likely to significantly benefit most, if not all, patients. A notable example is the underuse of disease modifying drugs in patients with rheumatoid arthritis (RA). American and European guidelines strongly recommend treat-to-target strategies to minimize inflammation based on strong evidence that patients treated according to these protocols have a substantially reduced risk of future disability and morbidity. Nonetheless, many patients are undertreated. Recent studies suggest that this may be, in part, due to ineffective risk communication and poor patient-physician communication. Risk communication is particularly challenging in this situation because of the large number of risks to disclose, the difficulty of explaining the risks of extremely rare, but dreaded, adverse events, and the tendency for people to discount future benefits. We developed a web-based decision support tool to effectively inform patients and promote high quality decision making in RA patients. The content and formatting of the tool were developed based on Fuzzy-trace theory (FTT) principles. FTT provides an evidence-based approach to help patients extract the central gist (essential bottom line) of available options and retrieve and apply relevant values in order to make value-concordant decisions. In a pre-post test study, using the tool resulted in improved knowledge, improved values clarity, and increased willingness to escalate care. Most importantly, the tool significantly increased the likelihood of making an informed, value-concordant choice.