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79 Decision aid development and usability testing 4 DISCUSSION This paper describes the development of a Dutch Pca treatment DA, based on an evidence-based Canadian Pca treatment DA and the subsequent usability testing among relevant user groups. Results of usability testing show that the DA was evaluated positively by patients and care providers and both groups would recommend use of the DA in clinical practice. The described development method could be useful for adaptation of other pre-existing and validated tools to different cultural or local circumstances. Development of DAs is an effortful process and usually involves multiple rounds of assessing needs, required content and preferred structure among patients and care providers 33 . An important benefit of the proposed model of adapting a pre-existing tool is that these steps are already taken. For the current DA, the content was previously validated 15-19 , and a cross-cultural comparison also confirmed importance of the included topics to Dutch patients 21 . The availability of validated content made it possible to focus more on the fit between DA structure and typical conversation flow in routine clinical practice. Many DAs have been developed for use independent from the consultation 34 , which may have led to a suboptimal fit between conversation flow during consultation and DA structure. A known barrier related to limited DA uptake in clinical practice is that clinicians often find DAs impractical to use or that other consultation specific factors limit structural DA implementation 35 . Therefore, additional observations of clinical consultations and role playing took place and identified a two-step approach in discussing Pca treatment alternatives with patients. Instead of offering four alternative treatments simultaneous, a first step contains choosing between active surveillance and curative treatment and a second step discusses curative treatments in more detail. By also transferring this two- step approach from consultation into the DA, it is expected that patients experience a more natural fit between consultation and DA usage. Moreover, the DA provides direct support to the clinician’s explanation. To further improve facilitation of SDMwe added two features to the DA. First, VCEs were developed and added to the DA. Second, the DA ends with a printable summary of preferences and responses to the VCEs that the patient can bring to his clinician for discussion. The summary provides the clinician with insight on what matters most to the patient and to what extent the patient has formed a preference or is still undecided. The following consultation and additional decisional support (e.g. consultations with