15250-m-cuypers

183 Decision aid uptake and usage in clinical practice 9 DISCUSSION This study structurally evaluated implementation of a web-based Pca treatment DA in nine Dutch hospitals. All hospitals included the DA as part of their information routine following Pca diagnosis. On average, one in every three newly diagnosed Pca patients received a DA, but large differences were observed in implementation rates per hospital. Once a DA was distributed, most patients accessed the DA, indicated a treatment preference, and discussed the summary obtained from the DA with their urologist. Implementation was highest in hospitals of care providers who were also involved in the development of the DA, and by random assignment enrolled in the intervention arm. Involvement during DA development may have increased intrinsic motivation to implement the DA. This motivational approach is identified as an important driver for implementing change in health care and applied in other DA development processes as well 19, 20 . To increase intrinsic motivation for care providers from institutions who were not involved in the DA development, it could be useful to offer opportunities to become more involved with the DA. For example, customization of the DA to match hospital layout, as well as the possibility to integrate the DA with existing hospital materials could improve adoption of the DA by care providers in other hospitals. Most patients received the DA from their urologist within the first week after diagnosis and felt that the DA was sufficiently explained to them. In most hospitals the role of nurses in this process of distributing DAs was limited. In an earlier study among care providers we found that nurses and urologists consider themselves equally suitable to provide patients with a DA, and that distributing DAs should not be an exclusive clinician task 21 . Therefore, overall implementation could be further improved if nurses become more involved in the process of distributing DAs. As in hospitals that implemented best, nurses either prepared DA distribution prior to the diagnosis consultation, or handed out the DA themselves in a subsequent follow up consultation (Figure 2). Respondents with a Gleason grade 6 tumor used the DA more often compared to respondents with a Gleason grade 7 tumor. Gleason scores provide a prognosis of oncological outcomes; a Gleason 6 score (or lower) represents the most favorable condition 22 . Consequently, patients with a Gleason grade 6 more often had all four available treatment options to choose from, while the choice set of eligible treatments for patients with a higher Gleason grade 7 tumor, was often reduced. Choosing from a smaller choice set can be perceived as less difficult, resulting in a different information