15250-m-cuypers

198 Chapter 10 DISCUSSION Many DA initiatives struggle to get structurally embedded in clinical routine, despite ample evidence revealing the benefits of using DAs when making medical decisions 7, 13 . At the onset of a multi-regional implementation initiative of three new Pca treatment DAs in Dutch clinical practice, a consortium was formed to jointly measure implementation rates and patient evaluations (i.e., barriers and facilitators from the patients’ perspective) from these three DAs. Overall, 40% of eligible Pca patients received a DA. For all DAs alike, implementation was quite successful (implementation rate >80%) in a limited number of hospitals, whereas uptake varied widely at other sites (2-80%). Overall, patient evaluations were supportive of implementation of each DA, however, the online DA3 was evaluated as having the least facilitators. The format of the implemented DAs as well as their level of information density varied 24-26 . DA1 and DA2 could be incorporated in clinical consultation, or used at home, while DA3 was, by design, supposed to be used outside of consultations. Despite the variation between DAs, implementation results showed the same variation between hospitals with each DA, and successful implementation (>80%) was only achieved in a limited number of hospitals. Increasing the number of hospitals for implementation, as DA2 was implemented at 16 hospitals, compared to 8 and 9 hospitals for DA1 and DA3, did not result in more hospitals with successful implementation. This could suggest that for each DA support was present in some hospitals prior to the start of implementation, and that for upscaling implementation more structural encouragement and monitoring of implementation progress is needed in hospitals were the baseline support (in terms of care providers attitude or available resources) for DAs might be lower. When patient-perceived barriers were reported, most were related to DA characteristics (unpractical, unadjusted to needs) or expectations (no confidence, expected no benefits or reduction of uncertainty). Although overall report of barriers was low, barriers were reported most often for the online, elaborate DA3, and least for the very concise hybrid DA2. However, both DAs achieved similar implementation rates that were lower than the concise paper DA (DA1). This finding seems inconsistent with previous studies concluding that web-based DAs are the most promising modality for improving implementation 28, 29 . However, care providers have also shown hesitance towards online tools 30, 31 . Future research is needed to gain a deeper understanding of how the benefits of online tools, such as tailoring to patient information needs and enabling interactive VCEs, can be balanced with patients’apparent preference for a more concise,