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211 Summary and general discussion 11 elaborate online-only DA as described in this dissertation. In the final empirical chapter of this dissertation ( Chapter 10 ), we reported the joint JIPPA assessment of patient evaluations and implementation results across the three DAs. Although the regions in which each of the three DAs was evaluated were not randomly allocated, and patient groups differed, each DA achieved comparable patient evaluations and implementation rates across hospitals. Implementation across participating hospitals ranged from low (<20%) to (almost) complete implementation (80-100%) in all three trials. All DAs were well received by patients. With the ‘concise paper only DA’ and the ‘very concise paper or online DA’, most patients (96-99%) were satisfied with the DA format. For our online only DA, 21% indicated to have preferred a paper format instead. All DAs were handed out most often by the urologist (71-78% of the cases), and most patients (79-82%) perceived the urologist was also the most suitable person to hand out the DA. However, the majority of patients who received a DA from a nurse, perceived the nurse as most suitable care provider to hand out the DA (60%). When the DA was received within the first week after diagnosis, the largest proportion of patients (93%) felt this was the best moment. GENERAL DISCUSSION Theresearchpresentedinthisdissertationincluded(1)development,(2)implementation, and (3) evaluation of a web-based DA for patients newly diagnosed with early-stage Pca in everyday care in multiple healthcare centers in the Netherlands. This included the description of an alternative development method of adapting a pre-existing, evidence- basedDA to a different language and cultural setting. In contrast to conclusions from the latest Cochrane review 2 , commonly found DA effects (e.g. less decisional conflict, more knowledge) were not replicated in the PCPCC trial. At a 12-months follow-up, also no beneficial patient-reported outcomes were found. Evaluation of the DA implementation included structured reporting on uptake and usage, and allowed linkage of DA usage to the patient-reported outcomes. This revealed that patients with anxiety and depression symptoms or a preference for an offline DA, were less supportive of the current DA version. Finally, our consortium approach allowed to evaluate implementation results for three different Pca DAs in Dutch routine Pca care, showing that for each DA alike, implementation rates between hospitals varied widely. Building on the results of the studies included in this dissertation, as summarized above, three themes require further discussion in this section. First, considerations about DA development will be discussed. Second, the most important methodological considerations (strengths and weaknesses) of the PCPCC trial will be reviewed here,