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80 Chapter 4 nurses, radiotherapists) can then be adjusted accordingly. A cluster RCT is in progress to evaluate the efficacy of this DA and to test whether decision outcomes align with patients’ preferences and values 36 . Literature reportsmixed findings fromusingVCEs inDAs and provide no clear guidelines for VCE design 25, 26, 28, 37, 38 . However, there are indications to assume the benefit of VCEs emerge after the decision is made and that VCE design should at least incorporate trade-offs between treatment attributes 19, 29 . In the absence of design guidelines, further development of the VCE within the current DA was based on consensus within the development team. However, future research should look into the effectiveness of the VCE features used in this DA. A specific aspect that needs to be investigated further is the labeling of VCE outcomes. For the current DA, the development team decided to label VCEs outcomes with corresponding treatments. With a strong initial treatment preference (pre-DA) it could be that labeling may lead to patients seeking confirmation of their initial preference rather than achieving actual preference elicitation or misinterpreting information 39 . However, for clarity reasonswe believed theVCEs shouldhave labeledoutcomes tomake patients aware of the consequence of their preference (e.g. when valuing incontinence worse than bowel problems, a patient should place radiation therapy over surgery on this topic). With this insight the responses to the VCE contribute to the construction of an informed treatment preference. We expect labeled VCEs support this process better compared to unlabeled items. To gain more understanding on the development and usage of VCEs, more studies are needed to investigate VCE effectiveness and optimal presentation formats. A potential limitation of the current development and usability test was the relatively small sample used in usability testing (N=11). However, our sample included all relevant user groups; patients, urologists, nurses and a radiotherapist. All participants in usability testing consented on the usability and acceptability of the DA to a point where it seemed saturation was reached and it was not expected additional participants would have resulted in new insights. The point of saturation in qualitative research is often reached within 6 to 12 participants 40 . CONCLUSION The newly developed Dutch Pca treatment DA was evaluated positively by patients and care providers, both groups would recommend DA usage to others. Patients consented on easy usability and care providers confirmed the accuracy of the provided information.
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