15250-m-cuypers

219 Summary and general discussion 11 directly measure the impact from the DA on SDM. Although both patients and care providers evaluated the current DA positively in their respective evaluations (chapter 6 and chapter 8), we did not measure the degree of SDM occurring before or after the DA intervention. Moreover, we had no direct observations of how consultations looked like when the DA was introduced, or when the DA summary was discussed. That DAs and SDM are beneficial to patients and overall quality of care, is well supported by scientific literature, however, DAs are not SDM and vice versa, more studies are needed that investigate the role DAs have in SDM outcomes 2, 24, 48, 49 . General conclusion TreatmentdecisionsinPcacarearepreference-sensitiveandrequirecarefulconsideration by patients and care providers to select the best suiting treatment. To support patients, and guide both patients and care providers during the treatment decision- making process, a Dutch web-based DA was developed to help patients construct an informed treatment preference. The DA was positively evaluated by patients and care providers. However, no substantial effects from the DA on patient-reported outcomes were detected within our PCPCC trial. The pragmatic approach of our trial allowed to investigate the DA in the context of routine clinical care, but also introduced a risk for selection and performance bias into the study. DA effects could be more subtle when the DA is part of routine care instead of what has been found in more controlled clinical trials. Methodological limitations prevented a meaningful investigation of hospital specific effects or specific patient subgroups, and should be addressed in future studies. However, following the results, the most important implications for clinical practice relate to DA development and implementation. Future DA developments and adjustments to the current DA should consider their format and the construction of VCEs, and incorporate the possibility to tailor according to specific patient needs (e.g. anxiety and depression). Achieving high implementation rates inmany hospitals proved to be difficult, and this finding was confirmed in parallel implementation studies from two other Pca DAs within the JIPPA consortium. Froman ethical perspective, patients should be offered all available resources -including DAs- in order to be fully informed about all treatment options. Clinical guidelines, patient and professional associations, and health insurers should therefore advice that all preference-sensitive (treatment) decisions should include a DA. This ensures individual treatment decision-making processes are less dependent on the performance and engagement of individual care providers. Moreover, it helps patients and care providers