15250-m-cuypers

184 Chapter 9 search behavior compared to patients who need information about more options 23-25 . Therefore, the DA could have been perceived as less needed by patients with a Gleason grade 7 tumor. DA users differed in the amount of information that they read and which VCEs they answered within the DA. This could indicate that DA users differed in their information needs or did not fully understand how to navigate within the DA. However, in the questionnaire, a large majority of responders (both DA users and non-DA users) felt the DA was sufficiently explained and in previous usability tests, easy navigation was confirmed 16 . It is therefore more likely that the DA was used for specific information, beyond the information that was already known from other sources. The selective answering of VCEs could be because patients were undecided on the VCEs that were not answered, or instead, already had a clear treatment preference and did not feel the need to provide an explicit answer to the VCEs. This is confirmed by the large majority of DA users who were able to indicate a treatment preference. Follow-up research is needed to determine if the degree of DA completion has led to differences in patient reported outcomes (e.g. information satisfaction and regret). A majority of DA users indicated that the DA summary was discussed with their clinician in a subsequent consultation. The summary reported the patient’s VCE responses and treatment preference. With such a summary on paper during consultation, patients were encouraged to overcome the barrier of feeling unable to engage in SDM 13 . To further stimulate SDM in routine clinical care and engage patients and care providers in discussing preferences and values, distribution of the DA among eligible patients should be further optimized. One way to increase delivery could be to automate DA delivery, for example by having the electronic medical record automatically signal if a patient should receive a DA 26 . Alternatively, eligibility for the DA could be included as part of the multidisciplinary team meeting, where all newly diagnosed patients are discussed, and in the preparation of the consultation (e.g. ‘did the patient already receive a DA?’). Amajor strength of this study is that it is one of the first to analyze DA implementation in a structured manner, with data on every step from DA distribution to treatment choice (number of DAs distributed, log file data on DA usage, and a post-decision evaluation). This study covers a largely neglected area in (Pca) DA implementation studies, that is, actual DA usage data 27 . Our results showed that implementation of DAs should not only be evaluated based on the number of distributed DAs, but require a more thorough investigation of the distribution procedures (e.g. role of nurses) and usage of specific DA elements (e.g. VCEs completed).