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199 JIPPA evaluation 10 paper format. One solution might be to provide concise, paper add-ons to online tools, which can be introduced during consultation and may enhance the user friendliness of online tools. The joint implementation efforts by the JIPPA consortium may have contributed to raising national awareness for SDM in both urology and oncology in the Netherlands. Many care providers have been introduced to the DA and to the principles of SDM, and during the course of the projects, consortium members contributed to national Pca treatment guidelines with a section on SDM and DAs (www.oncoline.nl ). Therefore, the study in itself increased awareness for SDM and the existence of DAs and educated many teams in using DAs in clinical routine. However, it may also have caused a barrier, as clinical practice was unclear about which DA should be applied, and what the differences between the available DAs entailed. To the best of our knowledge, no earlier studies have reported (national) implementation rates for Pca DAs, and comparability to other DA implementations studies is difficult to interpret as they were aiming at different patient populations (e.g. womenwith breast cancer, or orthopedic patients) and settings (e,g, screening decisions often include the general practitioner) 10, 11, 32 Further research is needed to determine if having different types of DA can help implementation since patients and care providers can select the DA they prefer most, or that the variety in available DAs hinders implementation since each DA has its specific characteristics and usability aspects that require training. Moreover, future research could study if specific DA characteristics have an effect on implementation rates, by randomizing distribution of different DA types across hospitals. A strength of the current study was that we were able to investigate implementation of three DAs by using a similar questionnaire at a similar point in time. As a consequence of studying three different DAs, sample size and number of participating hospitals was higher than most previous Pca DA studies 9, 33 . Eventually, one in three Dutch hospitals was exposed to one of the three DAs. Hospitals from different levels (academic and non-academic) and from different regions were included in the study, increasing the generalizability of our findings. A limitation of the current study is that the implementation rate was calculated based on actual receivers of a DA as proportion of an estimation of the total number of eligible patients. Since the number of patients eligible for study inclusion were not systematically registered by each of the three DA studies, we relied on the hospital specific retrospective cohorts of PCa patients from the cancer registry. This ensured the sample was determined via the same method for every hospital. However, since the total number of patients eligible for DA receipt was estimated, this entailed that