Step 5: Monitoring Use and Outcomes
Monitor use of decision aids, quality of decision support, and patient outcomes.

Are decision aids being used? How are they being used? What feedback do patients provide about the decision aid? What is the quality of the decision support provided? Are patients and their healthcare professionals reaching decisions that are informed and based on patients' preferences?

5.1 Are decision aids being used? How are they being used?

Determine the number of patients who were eligible to receive the decision aid and the proportion who received one. Ask patients how they are using the decision aid and if there are any other questions. Monitor patient feedback about the decision aid.

5.2 More formal approaches to monitoring the quality of decision support and patient outcomes include

1. What is the quality of decision support provided?
   Instruments for are available for monitoring the quality of the decision making process.
   • Decision Support Analysis Tool (DSAT-10) was developed to analyze the dialogue between patient and health professional.
   • Preparation for Decision Making scale was developed to measure patients’ perception of the way they were prepared for making decisions.
   • Decision Regret scale was developed to measure patients’ perception of regret for a decision made.
   • See Evaluation Measures for other instruments for measuring outcomes.
2. Are patients and their healthcare professionals reaching higher quality decisions: informed and based on patients’ preferences?
   Quality decisions are defined as informed with the best available scientific evidence and based on patients’ values for outcomes of options (e.g. what is most important to the informed patient). Decision quality can be measured using instruments developed by the Foundation for Informed Medical Decision Making. Their instruments include items relevant to knowledge of the options, strength of importance of outcomes of options (values), and patients’ preferred option.
3. Are patients more comfortable with the decision (without decisional conflict)?
   The SURE Test is 4-items that can be used to verify if the patient feels informed of their options, feels clear about what is most important to them, feels adequately supported with enough advice about the decision and feels sure of the best option. The SURE Test is a short version of the Decisional Conflict Scale intended for use in everyday clinical practice.
4. What are examples of other measures to monitor implementation?
   • Hits to web pages
   • Attendance at educational sessions
   • Frequency and duration of decision support or coaching
   • Qualitative interviews or focus groups to obtain feedback

5.3 How can findings be used to improve implementation?

Findings on the quality of decision support and patient outcomes (decision quality, decisional conflict. DSAT-10) can be used to provide feedback to health professionals and program managers. Audit and feedback is an effective intervention for changing the behaviour of health professionals (Cochrane Effective Practice and Organization of Care Group).

Examples of additional resources

Bennett C, Graham ID, Kristjansson E, Kearing SA, Clay KF, O'Connor AM. (2010). Validation of a Preparation for Decision Making Scale. Patient Educ Couns. 78(1):130-3.

Brehaut JC, O'Connor AM, Wood TJ, Hack TF, Siminoff L, Gordon E, Feldman-Stewart D. (2003). Validation of a Decision Regret Scale. Med Decis Making. 23(4):281-92.

Institute of Health Economics. (2008). Effective dissemination of findings from research. Alberta, Canada.

Légaré F, Kearing S, Clay K, Gagnon S, D'Amours D, Rousseau M, O'Connor A. (2010). Are you SURE? Assessing patient decisional conflict with a 4-item screening test. Can Fam Physician. 56(8):e308-14.

Sepucha KR, Levin CA, Uzogara EE, Barry MJ, O'Connor AM, Mulley AG. (2008). Developing instruments to measure the quality of decisions: early results for a set of symptom-driven decisions. Patient Educ Couns. 73(3):504-10.

Stacey D, Taljaard M, Drake ER, O'Connor AM. (2008). Audit and feedback using the brief Decision Support Analysis Tool (DSAT-10) to evaluate nurse-standardized patient encounters. Patient Educ Couns. 73(3):519-25.

Stacey D, Pomey MP, O'Connor AM, Graham ID. (2006). Adoption and sustainability of decision support for patients facing health decisions: an implementation case study in nursing. Implement Sci. 1:17.