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17 General introduction 1 For dissemination of the DA in clinical routine we followed the Ottawa Hospital Research Institute (OHRI) Implementation Toolkit, which is based on the Knowledge to Action Framework 65-67 . The OHRI Toolkit describes five steps to implement DAs in clinical routine; 1. Identify the decision; 2. Find patient DAs; 3. Identify implementation barriers and explore ways to overcome them; 4. Implement DAs; 5. Monitor use and outcomes. In the research and implementation project presented in this dissertation, the decision that should be supported is the treatment choice in early-stage Pca (step 1). A suitable DA to be used within Dutch clinical care was developed as part of the current research project, building on a pre-existing, patient DA for Canadian patients with early-stage Pca (step 2). The third step from the OHRI Toolkit, concerns barriers (as well as facilitators) to DA use and SDM implementation. Important implementation barriers that are known from the literature 8, 50 include that patients do not feel knowledgeable enough and perceive a power imbalance in the patient-doctor relation. Doctors are insufficiently trained to initiate SDM and use DAs during clinical counseling, and often report time constraints to introduce and use DAs. Facilitators include that tools must not be disruptive of common routines, and easy to use 8, 50, 55 . To assess the extent to which the current DA was still prone to these barriers and facilitators, patients and care providers evaluated them in questionnaires as part of the studies included in this dissertation. Implementation of DAs (step 4), followed a pragmatic approach in the current study, by allowing hospitals to include the DA within existing information routines. The DAs web- based design allowed to track and link usage to reported outcomes (step 5). Next to the number of DAs distributed, usage of the DA, and patient and care providers´ evaluations of barriers and facilitators, evaluation of implementation requires a broader approach. Besides the tool itself, and its users (patients and care providers), also the organization (e.g. hospital management) and external context (e.g. legislation, clinical guidelines) in which the DA is embedded, should be taken into account. Such a broad evaluation approach is provided by the Measurement Instrument for Determinants of Innovation (MIDI), which identifies barriers and facilitators at these four levels 68 . The first level consists of the innovation itself. In case of a DA this relates to aspects such as flawless functioning, and user-friendliness. The second level focuses on the user. With a DA, this relates to both the care provider who introduces the DA (e.g., received training), and the patient who actively engages with the tool (e.g., expectations prior to usage). At the third level is the hospital management that should provide sufficient resources (e.g. time, people, money) to work properly with the DA. Finally, the fourth level is the socio- political level to which the DA should comply. With the DA this relates to the content that should be consistent with relevant clinical guidelines and to the technical usage aspects which should comply with privacy legislations.