THE SURE TOOL: SCREENING FOR DECISIONAL CONFLICT IN PRIMARY CARE

Purpose: We aimed to assess the psychometric properties of the SURE test, a four-item tool designed to screen clinically significant decisional conflict in a large group of patients consulting for possible antibiotic treatment of acute respiratory infection (ARI) in primary care settings.

Method: This study was embedded within a clustered randomized trial assessing the effect of DECISION+2, a two-hour online tutorial followed by a two-hour interactive seminar on shared decision making (SDM), concerning the proportion of ARI patients reporting a decision to use antibiotics immediately after consultation. Using the Decisional Conflict Scale (DCS) as the external criterion, we asked patients to complete both SURE and DCS questionnaires after their consultation. We dichotomized DCS scores to identify patients presenting clinically significant decisional conflict (≥ 37.5 on a scale of 0-100). We computed internal reliability using the Kuder-Richardson 20 coefficient (KR-20). We assessed sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of the SURE tool using a cut-off score of ≥ 1 out of 4 compared to the dichotomized DCS.

Result: The recruitment of participants started in July 2010 and ended in April 2011. Of the 712 patients recruited during the trial, 654 completed both tools. The prevalence of clinically significant decisional conflict was 5.2% (95% CI: 3.7-7.3). SURE showed adequate internal reliability (KR-20 coefficient of 0.7). The sensitivity and specificity of SURE were 94.1% (95% CI: 78.9-99.0) and 89.8% (95% CI: 87.1-92.0), respectively. The negative predictive value was 99.6% (95% CI: 98.6-99.8) and positive predictive value was 33.7% (95% CI: 24.5-44.2). The positive likelihood ratio was moderately high (9.26), meaning that for a positive SURE test, a patient is nine times more likely than not to experience decisional conflict. The negative likelihood ratio was clinically more significant (0.07), meaning that for a negative SURE test, a patient is 14 times less likely than likely to experience decisional conflict.

Conclusion: SURE is a valid and reliable tool and is potentially useful for practitioners responding to the growing need to screen for decisional conflict in patients. Although it shows adequate psychometric properties in a primary care population with low decisional conflict prevalence, it should be tested in populations with high decisional conflict and in different clinical contexts.