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Application of patient decision aids in treatment selection of cardiac surgery patients: a scoping review

  • Duo Zhang
    Affiliations
    Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China

    School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Yanrong Zhou
    Correspondence
    Corresponding author: Yanrong Zhou, Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
    Affiliations
    Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Juan Liu
    Affiliations
    Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Lisi Zhu
    Affiliations
    Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Qiansheng Wu
    Affiliations
    Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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  • Youmin Pan
    Affiliations
    Division of Cardiothoracic and Vascular Surgery, Sino-Swiss Heart-Lung Transplantation Institute, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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  • Zhi Zheng
    Affiliations
    Division of Cardiothoracic and Vascular Surgery, Sino-Swiss Heart-Lung Transplantation Institute, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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  • Zhengbiao Zha
    Affiliations
    Division of Cardiothoracic and Vascular Surgery, Sino-Swiss Heart-Lung Transplantation Institute, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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  • Jie Zhang
    Affiliations
    Division of Cardiothoracic and Vascular Surgery, Sino-Swiss Heart-Lung Transplantation Institute, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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  • Zelin Chen
    Affiliations
    School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Open AccessPublished:July 07, 2022DOI:https://doi.org/10.1016/j.hrtlng.2022.06.023

      Abstract

      Background

      The choice of treatment is an unavoidable challenge faced in the day to day medical decision making pertaining to patients with organic heart disease. As a professional discipline, cardiac surgery focuses on creating and using the most advanced evidence-based patient decision aids (PtDAs) to achieve high-quality decision-making.

      Objectives

      To describe the basic situation, influencing factors, and the outcome of indicators of PtDAs among cardiac surgery patients.

      Methods

      Seven electronic databases were systematically searched for relevant reviews on the application of PtDAs among cardiac surgery patients. The methodological framework proposed by Arskey and O'Malley was used to guide the scoping review. The extracted data was analyzed qualitatively and quantitatively.

      Results

      After dual, blinded screening of titles and abstracts, 12 articles were included in the review. 10 were quantitative studies, 1 was a mixed study, 1 was a qualitative study.

      Conclusions

      Compared with the burden of heart disease and the huge evidence base, the application of PtDAs in cardiac surgery is obviously insufficient. The published literature mainly provide information about the factors to be solved from the perspective of researchers, and also summarize obstacle factors. This is the basis for the application and construction of PtDAs in cardiac surgery patients.

      Keywords

      Introduction

      Heart disease (HD) includes coronary heart disease, heart failure, atrial fibrillation, valvular disease, sudden cardiac death, cardiomyopathy, aortic aneurysms and so on.
      • Kokubo Y
      • Matsumoto C.
      Hypertension Is a Risk Factor for Several Types of Heart Disease: Review of Prospective Studies.
      The WHO estimated that HD now represents 16% of total deaths from all causes.
      In the United States, approximately 790, 000 men and women have a heart attack each year, and a person has a heart attack every 40 seconds.
      • Mozaffarian D
      • Benjamin EJ
      • et al.
      Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association.
      ,
      • Benjamin EJ
      • Blaha MJ
      • Chiuve SE
      • et al.
      Heart Disease and Stroke Statistics-2017 Update: A Report From the American Heart Association.
      With an aging population and changes in people's lifestyle, HD is estimated to remain the most important death cause for a while and leads to tremendous socio-economic burden.
      • Karakurt P
      • Aşılar RH
      • Yildirim A
      • Memiş Ş.
      Determination of Hopelessness and Quality of Life in Patients with Heart Disease: An Example from Eastern Turkey.
      Medicine and surgery are the main treatment modalities for HD. The maturity of modern medicine and biotechnology has contributed to the development of cardiac surgery and also made it become one of the main treatment methods for some organic HD.
      • Zilla P
      • Yacoub M
      • Zühlke L
      • et al.
      Global Unmet Needs in Cardiac Surgery.
      Heart surgery patients often face the risk of death, whether surgical procedures are most often planned or emergent.
      • Birriel B
      • D'Angelo K
      End-of-Life Care in Cardiothoracic Surgery.
      Many patients and their families face great pressure in decision-making.
      • Simeone S
      • Pucciarelli G
      • Perrone M
      • et al.
      The lived experiences of the parents of children admitted to a paediatric cardiac intensive care unit.
      These pressures come from concerns about death or quality of life, as well as anxiety about medical costs and surgical plans.
      • Zilla P
      • Yacoub M
      • Zühlke L
      • et al.
      Global Unmet Needs in Cardiac Surgery.
      ,
      • Poole J
      • Ward J
      • DeLuca E
      • et al.
      Grief and loss for patients before and after heart transplant.
      Therefore, the decision-making process is complicated for patients requiring cardiac surgery. They need to fully understand the information regarding these diseases and make medically sound decisions with their doctors. Objective expression of disease conditions, proper communication of treatment benefits and risks is all related to reducing their decision-making conflicts and anxiety.
      • Knops AM
      • Legemate DA
      • Goossens A
      • Bossuyt PMM
      • Ubbink DT.
      Decision aids for patients facing a surgical treatment decision: a systematic review and meta-analysis.
      Understanding patients' values is conducive to establishing a good trusting relationship between doctors and patients. The important issue facing healthcare workers is how to help patients understand their diseases and how to guide surgical patients to express their values. It is well known that patients’ health literacy plays an important role.
      • Nutbeam D.
      The evolving concept of health literacy.
      However, to date, studies have consistently shown that there is a low level of health literacy in the surgical population.
      • Chang ME
      • Baker SJ
      • Dos Santos Marques IC
      • et al.
      Health Literacy in Surgery.
      Lack of health literacy means they have a poor understanding of information, which makes it easier to ignore the expression of their wishes, especially in patients with emergency cardiac surgery. These are the problems that we encounter and need to handle in our clinical practice.
      Patient decision aids (PtDAs) are tools to help patients understand the details of different options through manuals, web pages, etc when they face medical choices, and finally make the best decision-making.
      • Rahn AC
      • Jull J
      • Boland L
      • et al.
      Guidance and/or Decision Coaching with Patient Decision Aids: Scoping Reviews to Inform the International Patient Decision Aid Standards (IPDAS).
      It can not only protect patients' right to know and independent choice, but also alleviating patients’ decision-making difficulties, improving decision-making satisfaction.

      Niburski K, Guadagno E, Mohtashami S, Poenaru D. Shared decision making in surgery: A scoping review of the literature. Health Expect. 2020;23(5):1241-1249. https://doi.org/10.1111/hex.13105

      As a professional discipline, cardiology focuses on creating and using the most advanced evidence-based PtDAs to reduce decision-making conflict and promote shared decision-making.
      • Coylewright M
      • O'Neill E
      • Sherman A
      • et al.
      The Learning Curve for Shared Decision-making in Symptomatic Aortic Stenosis.
      The 2017 ACC/ AATS/ AHA/ ASE/ ASNC/ SCAI/ SCCT/ STS recommended that the treatment of coronary artery disease should be individualized based on patient's wishes.
      • Patel MR
      • Calhoon JH
      • Dehmer GJ
      • et al.
      ACC/AATS/AHA/ASE/ASNC/SCAI/SCCT/STS 2017 Appropriate Use Criteria for Coronary Revascularization in Patients With Stable Ischemic Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society of Thoracic Surgeons.
      The Heart Failure Society of America, American Association of Heart Failure Nurses endorsed the "critical" need to improve the informed consent process and increase shared decision making.
      • Allen LA
      • Stevenson LW
      • Grady KL
      • et al.
      Decision making in advanced heart failure: a scientific statement from the American Heart Association.
      Although PtDAs are important in the treatment process for HD, the development and application of PtDAs for HD is still in the initial stage. PtDAs related to patients with HD have not been systematically reviewed, especially those patients who need heart surgery. Therefore, the scoping review aims to explore the use of PtDAs in patients undergoing cardiac surgery.

      Methods

      We followed the reporting framework of the scoping review presented by Arksey and O'Malley in 2005.
      • Arksey H
      • O'Malley L
      Scoping studies: towards a methodological framework.
      It has 5 steps: (1) identification of research questions and clarification of concepts; (2) development of literature search plan; (3) study selection; (4) charting the data; (5) collating, summarizing, and reporting the results. The scoping review applies to our study as it helps us to understand the current use of PtDAs in patients undergoing surgery for HD. It generally does not require strict quality evaluation of the literature, its evidence level is lower than the systematic evaluation in Cochrane and JBI guidelines. This study has been approved by the Bioethics Committee of Tongji Medical College of Huazhong University of Science and Technology.

      Identification of research questions and clarification of concepts

      This study aimed to clarify the application of PtDAs in patients undergoing HD surgery. We identified 3 questions: (1) what PtDAs were available for patients undergoing cardiac surgery? (2) what factors may affect their use? (3) how to evaluate the effects of PtDAs? The core concept involved in this study was Patient Decision Aids: Patient decision aids (PtDAs) were defined by the International Patient Decision Aids Standards (IPDAS) as “tools designed to help people participate in decision making about health care options”, providing “information on the options” and helping patients “clarify and communicate the personal value they associate with different features of the options”.
      • Rahn AC
      • Jull J
      • Boland L
      • et al.
      Guidance and/or Decision Coaching with Patient Decision Aids: Scoping Reviews to Inform the International Patient Decision Aid Standards (IPDAS).

      Development of literature search plan

      The document search plan was formulated by a research librarian and 5 research group members. The initial search was conducted in PubMed and Web of Science databases. Then, we analyzed the text words and index words in the retrieved paper title and abstract, which are the key terms to be used in the next step. All identified keywords and index words were used to search on PubMed, EMBASE, CINAHL, Web of Science, Cochrane Library, CNKI, and Wan Fang database. All databases were searched from their inception to January 2022. Grey literature was searched using Google Scholar, professional society's websites, as well as clinical trials registries (Clinical Trial. gov, World Health Organization International Clinical Trials Registry Platform). The final search strategy is shown in Appendix A.

      Study selection

      Inclusion criteria: (1) The research object was the personnel involved in decision-making; (2) PtDAs used for disease treatment modality selection; (3) PtDAs provided information about the decision at hand and helped to choose between at least two options; (4) Articles were published in English or Chinese; (5) Quantitative research, qualitative research, and mixed research. Exclusion criteria: (1) Only the PtDAs development process was recorded; (2) Articles on medicinal decisions alone were excluded; (3) Studies were systematic or narrative reviews. We removed the duplicated literature using the Zotero software, then reviewed the title, abstract and content of the article in strict accordance with the inclusion and exclusion criteria. A full‐text screen was then performed to determine acceptability into the final review. In instances of disagreement, a third reviewer adjudicated. Fig. 1 illustrates the search process.
      Fig 1
      Fig. 1Search strategy outcomes and numbers of papers assessed.

      Charting the data

      Data extraction was a process that clearly displays the basic characteristics and other information of articles. Both reviewers independently charted the data from eligible studies using a standardized data charting form. Discrepancies in data extracted were negotiated until consensus was reached. A third reviewer reviewed all extracted data. The following study characteristics were extracted from studies:authors, years of publication and country of origin, aims/objectives of the study, sample and sample characteristics, etc.

      Collating, summarizing, and reporting the results

      We discussed the data extraction results of all articles, which were undertaken by the entire research team in an iterative process until agreement was reached on the impact of the thematic findings and scoping review. Two data analysis methods were used in this study: (1) Descriptive analysis: It mainly includes the research scope, distribution, and numerical analysis of the results extracted from the literature. In this study, we mostly use constants and percentages for description; (2) Qualitative thematic analysis: It is mainly used to present the current situation or theme of the included literature. We incorporated the literature into NVivo software for management. After getting familiar with the content of the article, we analyzed and encoded the content of the article word by word according to our research problems. For the text with given coding, we checked and considered whether it needs to be changed. Then we compared the similarities and differences between codes, integrated them, and constructed descriptive topics. Finally, based on several rounds of repeated analysis, everyone needed to agree on the theme.

      Results

      What PtDAs were available for patients undergoing cardiac surgery?

      We retrieved a total of 1309 pieces of literature and finally included 12 of them. The basic characteristics of the included literature are shown in Tables 1 and 2. There were quantitative studies (83.33%), mixed studies (8.33%), and qualitative studies (8.33%). These studies were conducted in the United States (58.33%), Canada (25%), the Netherlands (8.33%), and China (8.33%). Sample size varied from 13 to 581. In addition, these studies were related to coronary artery disease (33.33%), heart failure (16.67%), valvular heart disease (16.67%), arrhythmia (16.67%), ischemic heart disease (8.33%) and autologous pre-donation in cardiac surgery (8.33%). The most common setting of the studies was hospital (58.33%). Most studies were single center studies (58.33%) and had followed-up (83.33%), and the maximum time was 6 months. The use of PtDAs mainly included whether surgery was needed and uncertain surgical plans. The forms of PtDAs included paper-based (66.67%), website (16.67%), video (16.67%), CD (8.33%), magnetic tape (8.33%). In terms of PtDAs implementers, the most common implementers were cardiologists (100%) and nurses (41.67%).
      Table 1Overview of included Quantitative studies
      #Authors, (year),CountryKey issuesSample (IG/CG) and settingsInterventionData collectionResults
      1Kostick et al, (2018), USA
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).


      Advanced Heart Failure (Left Ventricular Assist Device (LVAD))N=98 (47/51) Hospital, Medical, Center, Clinic and Health CarePatients received the PtDAs (booklets and videos) after formal evaluation for LVAD eligibility but before standard education (SE) and implantation. All patients received 1 week and 1 month follow-up.A questionnaire survey was conducted on patients' knowledge, quality of the decision process, outcome of decision choices, and acceptability of decision aids.Improved knowledge at 1-week follow-up (68% vs 59%, P = 0.02) no significant difference at 1-month follow-up (64% vs 61%, P = 0.29), Increased life satisfaction (28 vs 23 out of 30; P = 0.006), Improved quality of life (P = 0.02; P = 0.03), High acceptance of decision aids (83%-94%), No significant improvement in the quality of decision making.
      2Chhatriwalla et al, (2020), USA
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.


      Coronary Artery Disease (stent selection in PCI)N=581 (332/136/113), Medical Center and

      Heart Institute
      The PtDAs were administered in the catheterization laboratory “preparatory” area prior to the patient's procedure, some of these patients have been coached by a decision coach. Their intervention was carried out under the principle of motivational interview.Patients were interviewed and questionnaires were administered on their knowledge, choice of treatment options, perception of decision making, quality of the decision process, and physical condition.Under the guidance of the decision-making coach, patients have a higher level of knowledge (4.3 ± 1.5 vs 2.3 ± 1.4, P <0.001), are more willing to express their values (68.9% vs 35.6%, P < 0.001), and improve their autonomy to participate in medical decision-making (P < 0.001).
      3Coylewright et al, (2016), USA
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.


      PCI choice decision aid for Stable Coronary Artery DiseaseN=124(65/59),

      outpatient clinic

      The PtDA (

      paper-based decision aid

      ) delivered upstream from diagnostic coronary angiography. All patients were followed up for 3 months.
      A questionnaire survey was conducted on patients' knowledge, decision-making conflict and participation.Improved knowledge (60.3% vs 39.6%, P = 0.034), but did not improve patients' decision-making conflict (P > 0.05) and decision-making participation. (21.3% vs 16.0%; mean difference 5.2%; 95% CI, −0.5 to 10.9; P = 0.071)
      4Doll et al, (2019), USA
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.


      Coronary Artery Disease (medical therapy, coronary artery bypass graft surgery, percutaneous coronary intervention)N=203(103/100) Hospital and outpatient clinic

      Patients used a web-based decision aid to explore their treatment options after diagnostic coronary angiography and all were followed up for 3 months.The patients' knowledge, value preference, symptom burden and quality of the decision process were investigated by questionnaire.Improved knowledge and control preferences (P < 0.01), but had no impact on decision-making quality and treatment choice.
      5Anaya et al, (2019), USA
      • Anaya J
      • Moonsamy P
      • Sepucha KR
      • et al.
      Pilot Study of a Patient Decision Aid for Valve Choices in Surgical Aortic Valve Replacement.
      Valve Choices in Surgical Aortic Valve ReplacementN=23(10/13) Hospital

      Cardiac surgeons consider whether patients need decision aids. All patients were followed up for 12 weeks.The knowledge, treatment preference and decision conflict of patients were investigatedImproved knowledge (100% vs 25%, P = 0.02), reduced decision-making conflict (P = 0.04), and did not change treatment options.
      6Laupacis et al, (2006), Canada
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      autologous pre-donation in cardiac surgeryN=120(60/60),

      Heart Institute

      Patients received the PtDAs (a 25-min audiotape and accompanying 19-page booklet) before the patients saw the surgeons when they had not yet made a decision.The knowledge, choice, quality of the decision process were investigated by questionnaire.Improved knowledge (t = 5.171, P = 0.001), Improved risk perception (t = 4.989, P = 0.001), Improved satisfaction with decision making (P <0.05), play a more independent role (P = 0.001 versus P = 0.454), Reduced decisional conflict (t = 2.072, P = 0.041, effect size = 0.41)
      7Morgan et al, (2000), Canada
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      Ischemic Heart Disease (medical therapy, bypass surgery and angioplasty)N=187(90/97),

      Hospital

      Decision aids (Interactive Videodisc) were used to assist patients at least 4 weeks before surgery, all patients were followed up for 6 monthsA questionnaire survey was conducted on knowledge, quality of the decision process and health status.Improved knowledge (75% vs 62%, P <0.001), Increased patient decision-making autonomy, no difference in decision satisfaction and health status.
      8Carroll et al, (2017), Canada
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      Arrhythmia (implantable cardioverter defibrillator)N=82(41/41),

      Care center

      Patients used decision-making aids(booklets) to understand relevant knowledge before consulting with experts, all patients were followed up for 3 months.A questionnaire survey was conducted on knowledge, decisional conflict and preparation.Improved knowledge (47.5% vs 23.09%), reduced decision-making conflict (95% confidence interval (CI)] was − 22. 1[− 30.23, − 13.97).
      9Korteland

      et al, (2017), Netherlands
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      Heart valve disease (Prosthetic Heart Valve Selection)Hospital

      N=138(67/71)
      Identify patients undergoing surgery to use decision aids before preoperative consultation, all patients were followed up for 3 months.A questionnaire was used to investigate the patients' decision-making quality, knowledge, preferred role, anxiety and depression, quality of life.Improved knowledge (85% vs 68%, P =0.004), Improved mental health (54 vs 50, P = 0.032), other results were not statistically significant.
      10Shi Runze (2018), China
      Shi Runze Development and application of decision aid tool for patients with implantable cardioverter defibrillator.
      Implantable Cardioverter DefibrillatorN=54(27/27),

      Hospital

      Patients used decision-making aids to understand information at admission, preoperative conversation and after operation.A questionnaire was used to investigate the patients' decision-making conflict, knowledge and ICD acceptance.Improved knowledge (U = 32.000, P <0.005), Reduced decision-making conflict (18. 98 ± 8.19 vs 23.59 ± 7.63, P <0.05), ICD acceptance was not statistically significant
      11Matlock

      et al, (2020), USA
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      (Quantitative component)
      Advanced Heart Failure (Left Ventricular Assist Device (LVAD)N=248(113/135), Medical Center

      Decision aids (Interactive Videodisc) were used to assist patients before formal LVAD education, all patients were followed up for 1 and 6 months.The patients' knowledge, quality of the decision process, control preference, illness acceptance, depression and quality of life were investigated by questionnaire.Improved knowledge (P= 0.03), more obvious preferences

      (P < 0.001), other results were not statistically significant.
      IG: Intervention Group
      CG: Control Group
      Table 2Overview of included Qualitative research
      #Authors, (year),CountryStudy aim/sSample/participantsData collection method and analysis resultsResults; key themes
      1Coylewrigh et al, (2016), USA
      • Coylewright M
      • O'Neill ES
      • Dick S
      • Grande SW
      PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease.
      Describe cardiovascular clinicians' perceptions following use of a decision aid for Left Ventricular Assist Device.

      cardiologists and physician extenders (n=13)

      semi-structured qualitative interview, theory-driven interview guide, using a researcher-developed codebook(1) Gaps exist in clinician knowledge around SDM; (2) Clinicians are often uncomfortable with modifying baseline practice; (3) Clinicians express interest in using DAs after initial exposure within a research setting

      2Matlock

      et al, (2020), USA
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      (Qualitative component)
      Describe cardiovascular clinicians' perceptions following use of a decision aid for stable coronary artery disease (CAD) "PCI Choice".

      A total of 69 interviews were conducted with 48 clinicians at 3 time points.

      RE-AIM framework, qualitative Content Analysis methodology, using a researcher-developed codebook(1) clinician-level interactions with the DA; (2) team-level experiences with implementation, and (3) system-level observations.

      What factors may affect their use?

      A total of 11 studies (91.67%) described the factors affecting the use of PtDAs. We read and coded these contents. These factors were classified into three categories: the quality problem of the PtDAs, medical environment, and patients. (Table 3)
      Table 3Factors affecting the application of PtDAs in cardiac surgery
      Primary ThemeSecondary Themes
      No. of studies (n (%))
      quality problem
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      • Anaya J
      • Moonsamy P
      • Sepucha KR
      • et al.
      Pilot Study of a Patient Decision Aid for Valve Choices in Surgical Aortic Valve Replacement.
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      ,
      • Coylewright M
      • O'Neill ES
      • Dick S
      • Grande SW
      PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease.
      (11/11, 100%)Content
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      ,
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      ,
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      ,
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Coylewright M
      • O'Neill ES
      • Dick S
      • Grande SW
      PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease.
      (6/11, 54.55%)
      objectivity
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      ,
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Coylewright M
      • O'Neill ES
      • Dick S
      • Grande SW
      PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease.
      readability
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      timeliness
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      ,
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      ,
      • Coylewright M
      • O'Neill ES
      • Dick S
      • Grande SW
      PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease.
      Form
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      ,
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      ,
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      ,
      • Coylewright M
      • O'Neill ES
      • Dick S
      • Grande SW
      PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease.
      (5/11, 45.45%)
      individualization
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      ,
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      ,
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      ,
      • Coylewright M
      • O'Neill ES
      • Dick S
      • Grande SW
      PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease.
      complex design
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      Implementation process
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      • Anaya J
      • Moonsamy P
      • Sepucha KR
      • et al.
      Pilot Study of a Patient Decision Aid for Valve Choices in Surgical Aortic Valve Replacement.
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      ,
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      ,
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      (9/11, 81.82%)
      lack of standardized application process
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      • Anaya J
      • Moonsamy P
      • Sepucha KR
      • et al.
      Pilot Study of a Patient Decision Aid for Valve Choices in Surgical Aortic Valve Replacement.
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      ,
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      impact of failure cases
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      ,
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      medical environment
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      • Anaya J
      • Moonsamy P
      • Sepucha KR
      • et al.
      Pilot Study of a Patient Decision Aid for Valve Choices in Surgical Aortic Valve Replacement.
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      ,
      • Coylewright M
      • O'Neill ES
      • Dick S
      • Grande SW
      PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease.
      (11/11, 100%)Medical staff
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      • Anaya J
      • Moonsamy P
      • Sepucha KR
      • et al.
      Pilot Study of a Patient Decision Aid for Valve Choices in Surgical Aortic Valve Replacement.
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      ,
      • Coylewright M
      • O'Neill ES
      • Dick S
      • Grande SW
      PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease.
      (10/11, 90.91%)
      knowledge
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      ,
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      ,
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      skill
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      ,
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      ,
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      ,
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      time
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      ,
      • Anaya J
      • Moonsamy P
      • Sepucha KR
      • et al.
      Pilot Study of a Patient Decision Aid for Valve Choices in Surgical Aortic Valve Replacement.
      ,
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      ,
      • Coylewright M
      • O'Neill ES
      • Dick S
      • Grande SW
      PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease.
      working pressure
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      ,
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      prejudice
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      ,
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      ,
      • Coylewright M
      • O'Neill ES
      • Dick S
      • Grande SW
      PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease.
      doctor's treatment preference
      • Anaya J
      • Moonsamy P
      • Sepucha KR
      • et al.
      Pilot Study of a Patient Decision Aid for Valve Choices in Surgical Aortic Valve Replacement.
      unclear division of labor among users
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      ,
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      ,
      • Coylewright M
      • O'Neill ES
      • Dick S
      • Grande SW
      PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease.
      Hospital
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      ,
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      ,
      • Coylewright M
      • O'Neill ES
      • Dick S
      • Grande SW
      PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease.
      (8/11, 72.73%)
      imperfect system
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      ,
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      ,
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      ,
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      managers do not pay attention
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      ,
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      human resources
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      ,
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      ,
      • Coylewright M
      • O'Neill ES
      • Dick S
      • Grande SW
      PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease.
      insufficient financial support
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      ,
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      patients
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      ,
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      ,
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      ,
      • Coylewright M
      • O'Neill ES
      • Dick S
      • Grande SW
      PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease.
      (9/11, 81. 82%)Demographic characteristics
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      ,
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      ,
      • Coylewright M
      • O'Neill ES
      • Dick S
      • Grande SW
      PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease.
      (7/11, 63.64%)
      age
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      education
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      ,
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      preference
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      personal schedule
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      economics
      • Coylewright M
      • O'Neill ES
      • Dick S
      • Grande SW
      PCI Choice: Cardiovascular clinicians’ perceptions of shared decision making in stable coronary artery disease.
      disease situation
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      ,
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      Psychology
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      ,
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      (2/11, 18.18%)
      anxious
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      distrust
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      Social relations
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      (2/11, 18.18%)
      paternalistic decision making
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      family influence
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      Eleven studies (100%) described the quality problems of PtDAs. Six studies (54.55%) related to the auxiliary content of PtDAs, and five studies (45.45%) related to the form of PtDAs. Nine studies (81.82%) involved the problems existing in the implementation process at this stage. The most common problem was lack of standardized application process.
      Eleven studies (100%) related to the influencing factors of medical environment. In addition to low user participation enthusiasm (90.91%), they also related to the impact of hospitals on the use of PtDAs (72.73%). The most common influencing factor was the lack of human resources (such as the lack of decision-making coach, etc), the second was the lack of skills (such as communication skills).
      Nine studies (81.82%) related to the patient's impact on PtDAs. Seven studies (63.64%) paid attention to the demographic characteristics of patients. Only two studies (18.18%) related to the psychological factors and mentioned the impact of social relations.

      How to evaluate the effects of PtDAs?

      ODSF and International PtDA Standards were used to guide the development process of PtDAs.
      • Stacey D
      • Légaré F
      • Boland L
      • et al.
      20th Anniversary Ottawa Decision Support Framework: Part 3 Overview of Systematic Reviews and Updated Framework.
      Even for researchers who do not develop their PtDAs using the ODSF, they often evaluate it using the ODSF-based Scale to determine patients’ decision-making process.
      • Durand MA
      • Stiel M
      • Boivin J
      • Elwyn G.
      Evaluating the theoretical frameworks described in decision support technologies.
      We used this framework to summarize the results section of the included literature. Eleven studies (91.67%) involved quantitative studies with twenty-eight quantitative outcome measures. According to the “DECISIONAL OUTCOMES” section of ODSF, we divided them into three main themes: quality of the decision-making, quality of the decision-making process, impact. We manually classified the specific content and coded into 8 secondary themes (Table 4). The most commonly used outcome indicators are knowledge (39.29%), decision conflict (32.14%), decision-making role preference (25%).
      Table 4Outcome indicators of PtDAs in cardiac surgery patients
      Primary ThemeSecondary ThemesNo. of studies (n (%))
      Quality of the decision-making
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      • Anaya J
      • Moonsamy P
      • Sepucha KR
      • et al.
      Pilot Study of a Patient Decision Aid for Valve Choices in Surgical Aortic Valve Replacement.
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      Shi Runze Development and application of decision aid tool for patients with implantable cardioverter defibrillator.
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.


      11(11/11, 100%)
      Knowledge
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      • Anaya J
      • Moonsamy P
      • Sepucha KR
      • et al.
      Pilot Study of a Patient Decision Aid for Valve Choices in Surgical Aortic Valve Replacement.
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      Shi Runze Development and application of decision aid tool for patients with implantable cardioverter defibrillator.
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      11(100%)
      disease knowledge
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      • Anaya J
      • Moonsamy P
      • Sepucha KR
      • et al.
      Pilot Study of a Patient Decision Aid for Valve Choices in Surgical Aortic Valve Replacement.
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      Shi Runze Development and application of decision aid tool for patients with implantable cardioverter defibrillator.
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      risk perception
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      Personal preference
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      • Anaya J
      • Moonsamy P
      • Sepucha KR
      • et al.
      Pilot Study of a Patient Decision Aid for Valve Choices in Surgical Aortic Valve Replacement.
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      ,
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      9(81.82%)
      consistency between expectation and reality
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      role preference
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      ,
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      ,
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      treatment preference
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      ,
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      ,
      • Anaya J
      • Moonsamy P
      • Sepucha KR
      • et al.
      Pilot Study of a Patient Decision Aid for Valve Choices in Surgical Aortic Valve Replacement.
      ,
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      consistency between patients and doctors
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      whether there is a pre-established medical treatment
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      degree of participation
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      attitude towards decision-making
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      Quality of the decision-making process

      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      • Anaya J
      • Moonsamy P
      • Sepucha KR
      • et al.
      Pilot Study of a Patient Decision Aid for Valve Choices in Surgical Aortic Valve Replacement.
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      Shi Runze Development and application of decision aid tool for patients with implantable cardioverter defibrillator.
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.


      11(11/11, 100%)
      Decision preparation
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      • Anaya J
      • Moonsamy P
      • Sepucha KR
      • et al.
      Pilot Study of a Patient Decision Aid for Valve Choices in Surgical Aortic Valve Replacement.
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      ,
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      Shi Runze Development and application of decision aid tool for patients with implantable cardioverter defibrillator.
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      9(81.82%)
      decision conflict
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      • Anaya J
      • Moonsamy P
      • Sepucha KR
      • et al.
      Pilot Study of a Patient Decision Aid for Valve Choices in Surgical Aortic Valve Replacement.
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      ,
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      Shi Runze Development and application of decision aid tool for patients with implantable cardioverter defibrillator.
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      degree of decision preparation
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      Decision satisfaction
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      ,
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      ,
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      ,
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      6(54.55%)
      degree of decision satisfaction
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      ,
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      decision regret
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      shared decision evaluation
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Coylewright M
      • Dick S
      • Zmolek B
      • et al.
      PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial.
      Decision support
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      3(27.27%)
      autonomous support perception
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      pressure perception
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      perception of nursing quality
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      Impact
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      ,
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      Shi Runze Development and application of decision aid tool for patients with implantable cardioverter defibrillator.
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.


      9(9/11, 81. 82%)
      Health
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      ,
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      ,
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      ,
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.


      6(54.55%)
      symptom burden
      • Doll JA
      • Jones WS
      • Lokhnygina Y
      • et al.
      PREPARED Study: A Study of Shared Decision-Making for Coronary Artery Disease.
      general health
      • Morgan MW
      • Deber RB
      • Llewellyn-Thomas HA
      • et al.
      Randomized, controlled trial of an interactive videodisc decision aid for patients with ischemic heart disease.
      depression and anxiety
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      quality of life
      • Korteland NM
      • Ahmed Y
      • Koolbergen DR
      • et al.
      Does the Use of a Decision Aid Improve Decision Making in Prosthetic Heart Valve Selection? A Multicenter Randomized Trial.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      life satisfaction
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      treatment options
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      ,
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.
      Feasibility
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      ,
      Shi Runze Development and application of decision aid tool for patients with implantable cardioverter defibrillator.
      ,
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      4(36.36%)
      PtDAs acceptance
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      ,
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      equipment acceptance 28
      disease acceptance
      • Matlock DD
      • McIlvennan CK
      • Thompson JS
      • et al.
      Decision Aid Implementation among Left Ventricular Assist Device Programs Participating in the DECIDE-LVAD Stepped-Wedge Trial.
      scheme completion rate and quality
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      Others
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      1(9.09%)
      referral rate
      • Carroll SL
      • Stacey D
      • McGillion M
      • et al.
      Evaluating the feasibility of conducting a trial using a patient decision aid in implantable cardioverter defibrillator candidates: a randomized controlled feasibility trial.
      Eleven studies (100%) explored the impact of PtDAs on decision quality including the evaluation of patients' disease knowledge (100%) and personal preference (81.82%). Although the content of knowledge scale was different, all studies showed that the application of PtDAs can improve the level of knowledge. In terms of patient preferences, the most commonly used was the Control Preferences Scale, which was used to evaluate the expected and actual roles of patients in the decision-making process.
      Eleven studies (100%) explored the impact of PtDAs on the quality of decision-making process, including decision preparation, decision support and decision satisfaction. Decision conflict was the most commonly used outcome indicators in decision quality evaluation (81.82%), and the second was decision satisfaction (27.27%) and decision regret (27.27%).
      Nine studies (81.82%) explored the impact of decision support on patients, including health, feasibility and others. Three studies (27.27%) have explored whether PtDAs have an impact on treatment choice, and the result of 2 of them was “Yes”.
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      ,
      • Laupacis A
      • O'Connor AM
      • Drake ER
      • et al.
      A decision aid for autologous pre-donation in cardiac surgery–a randomized trial.

      Discussion

      This scoping review demonstrates the application status of PtDAs in cardiac surgery patients, influence factors and outcome indicators. Despite numerous scope reviews on PtDAs, this is the first scoping review on the treatment options of cardiac surgery patients.

      Application status

      Patient participation in medical decision-making has been recognized as an important part of high-quality health care services.
      • Grad R
      • Légaré F
      • Bell NR
      • et al.
      Shared decision making in preventive health care: What it is; what it is not.
      The development and application of PtDAs are effective ways to achieve win-win between doctors and patients.
      • O'Connor AM
      • Wennberg JE
      • Legare F
      • et al.
      Toward the “tipping point”: decision aids and informed patient choice.
      In this study, we included twelve articles on the treatment options of cardiac surgery patients, more than half of the studies (58.33%) have been conducted in the United States and have received financial support. These studies involved heart failure, coronary artery disease and heart valve disease. In addition, ten studies (83.33%) were published after 2015, and eleven studies (91.67%) were conducted in developed countries, with obvious temporal and spatial distribution characteristics.
      Cardiac surgery is a suitable field for studying medical decision-making. Doctors often discuss the results of surgery according to the patient's age and complications in the dialogue of informed consent.
      • Coylewright M
      • O'Neill E
      • Sherman A
      • et al.
      The Learning Curve for Shared Decision-making in Symptomatic Aortic Stenosis.
      The content of PtDAs for cardiac surgery patients involves not only the treatment methods such as open surgery and minimally invasive surgery, but also the selection of some surgical equipment. However, their decision-making is more than that, intraoperative risk and postoperative rehabilitation are related to the quality of life attracting their attention.
      • Kitko LA
      • Hupcey JE
      • Birriel B
      • Alonso W.
      Patients’ decision making process and expectations of a left ventricular assist device pre and post implantation.
      As mentioned in table 1, only one study involves the decision-making assistance implementation of special treatment during cardiac surgery, the application of PtDAs in cardiac surgery patients still has a lot of room for development.
      Our review showed that the PtDAs used in the included studies were developed by their team. They included doctors, nurses, statisticians, research assistants, and others who were also involved in the application of PtDAs. The role of PtDAs was to supplement and then conduct high-quality conversations, and who leaded the conversation matters. Doctors had specialized medical knowledge and communication skills, eleven studies highlighted their dominant role in the decision-making process. Interestingly, one study included the role of a decision coach.
      • Chhatriwalla AK
      • Decker C
      • Gialde E
      • et al.
      Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design.
      Due to the effectiveness of a decision coach still being uneven, it is unclear that how much it contributes to the results when combined with PtDAs and compared with routine care.
      • Rahn AC
      • Jull J
      • Boland L
      • et al.
      Guidance and/or Decision Coaching with Patient Decision Aids: Scoping Reviews to Inform the International Patient Decision Aid Standards (IPDAS).
      In addition, we found that these PtDAs had the following characteristics. First of all, all tools needed to make decision-makers clear about the medical decisions they need to make. Second, they needed to provide evidence-based information. Finally, patients should be assisted in understanding the relevance of different decisions to personal values. Lack of localized PtDAs limited their scope of use. To ensure that the contents of PtDAs meet the actual decision-making needs, it is necessary to develop them in multiple languages according to national practice.

      Influence factors

      The development of cardiac surgery was inseparable from the innovation of doctors, leading to the slight difference between the content of PtDAs and doctors' technology. It was difficult to ensure that the content involved in the latest medical achievements. “Easy-to-understand language” was listed as one of the most important quality indicators by PtDAs.
      • Volk RJ
      • Llewellyn-Thomas H
      • Stacey D
      • Elwyn G.
      Ten years of the International Patient Decision Aid Standards Collaboration: evolution of the core dimensions for assessing the quality of patient decision aids.
      It was important to use images to express patients’ subjective feelings, reduce or avoid using words like “high risk” alone and prevent patients from being confused due to vague expression.
      • Zipkin DA
      • Umscheid CA
      • Keating NL
      • Allen E
      • Feldstein DA
      Evidence-Based Risk Communication A Systematic Review.
      In terms of the form, the network PtDAs had the advantages of high interaction with patients and no location restrictions compared with paper materials.
      • Deyo RA.
      Tell It Like It Is: Patients as Partners in Medical Decision Making.
      However, some elderly patients in cardiac surgery had difficulties in using computers and the network in general, and this resulted into poor or no use of the resources provided on those platforms.
      Although PtDAs were usually used in elective surgery decision-making, they still lack a standardized process. 1-week time period after eligibility was a crucial decision-making period for patients,
      • Kostick KM
      • Bruce CR
      • Minard CG
      • et al.
      A Multisite Randomized Controlled Trial of a Patient-Centered Ventricular Assist Device Decision Aid (VADDA Trial).
      especially those in critical or near-critical condition. The time between diagnosis and surgery is uncertain because we cannot accurately determine the trajectory of HD. Intervening too early often leads to patients forgetting the information, while intervening too late leads to patients being unfamiliar with that information. In addition, the application of PtDAs in cardiac surgery is likely to be repeated. Taking coronary heart disease as an example, preoperative patients are faced with the choice of surgical scheme, and the use of postoperative anticoagulants and antithrombotic drugs, doctors need to repeatedly communicate these choices, depending on each patient's personal situation.
      Two qualitative studies showed that most cardiac surgeons had a positive attitude towards PtDAs. Adequate discussion time can promote patients' participation in medical decision-making, but the workload of cardiac surgery and the driving of doctors' interests may lead to doctors' less time in using PtDAs. Most studies emphasized the impact of communication skills on the use of PtDAs, because effective communication can enhance the trust relationship between doctors and patients. Some communication models have been developed and used:Communication-centered Epistemic Model of Shared Decision Making (CEM-SDM),
      • Mikesell L
      • Bromley E
      • Young AS
      • Vona P
      • Zima B.
      Integrating Client and Clinician Perspectives on Psychotropic Medication Decisions: Developing a Communication-Centered Epistemic Model of Shared Decision Making for Mental Health Contexts.
      and Model of collaborative decision making.
      • Politi MC
      • Street RL.
      The importance of communication in collaborative decision making: facilitating shared mind and the management of uncertainty.
      Our review also highlights the impact of the organizational level. Timely updating PtDAs requires not only time and human resources, but also the coordination and support of medical and health systems and policies, such as formulating reasonable update strategies, ensuring adequate funding sources and the continuity of medical decision-making, etc.
      The use of PtDAs is inseparable from the participation of patients. Patients with high education level are more willing to participate in medical decision-making.
      • Arora Neeraj
      • McHorney K.
      • Colleen A.
      Patient Preferences for Medical Decision Making.
      Heart surgery is a source of emotional distress for the patient.
      • Miller JL
      • Chung ML
      • Etaee F
      • et al.
      Missed opportunities! End of life decision making and discussions in implantable cardioverter defibrillator recipients.
      Individuals in different emotional states have different clinical decisions. Mentality and emotion can have a negative impact on personal information processing ability.
      • Lerner JS
      • Li Y
      • Valdesolo P
      • Kassam KS.
      Emotion and decision making.
      Two studies (16.67%) investigated the effects of social relationships on decision-making. The first is the paternalistic decision-making dominated by doctors that is applicable in some clinical situations. For example, when a heart disease patient in need of rescue is admitted to the emergency department, we may first let the doctor dominate rescue process, and discuss the next medical decision after the condition is relieved. The second is the influence of family members. Some heart disease patients undergoing elective surgery have a long time understanding the treatment information. In this process, they will inevitably receive suggestions from their families. We encourage family members to supervise the decision-making process, but too much participation may weaken the effect of PtDAs. We cannot guarantee that the final decision-making result is truly in line with the patient's values.

      Treatment outcome

      In the process of medical decision-making, patients need knowledge to make informed decisions about their health. Eleven studies (91.67%) involving quantitative outcome measurement used knowledge as an outcome indicator. Interestingly, these studies have confirmed the important role of PtDAs in improving the knowledge level of cardiac surgery patients. However, the core of high-quality decision-making is to choose whether it is in line with the patient's values and preferences. Knowledge alone is not enough to ensure high-quality decisions, especially in surgery. The risk of cardiac surgery is high and the treatment effect varies across different patients, showing that the improvement of decision-making quality must not rely solely on the evaluation of surgical effect. Combining the objectivity of medicine with the values of patients and making decisions that are most in line with the interests of patients is a high-quality decision.
      The scoping review also summarizes the outcome indicators related to the quality of the decision-making process. We should recognize that PtDAs are auxiliary tools, but they are not necessarily implemented in the decision-making process, let alone the implementation of shared decision-making. Ideally, if PtDAs were widely accepted and became part of medical decision-making, the first thing needed to prove is that they can help provide decision support to patients. Our scope review found that most studies did not have an important impact on the quality of decision-making process in cardiac surgery patients. Not surprisingly, it is still a serious problem to integrate reliable decision support standards and SDM framework into the development of PtDAs. Although the use of ODSF-based Scales contributed much to understanding the quality of decision-making, we need to rationally comprehend the results of th