CAN INTEGRATION OF MULTIMEDIA FEATURES INTO DECISION AIDS IMPROVE PATIENT DECISION-MAKING? A SYSTEMATIC REVIEW AND META-ANALYSIS
Method: Relevant studies were located by searching MEDLINE, Embase, CINAHL and CENTRAL databases. The review focused on studies that tested multimedia DAs in adults faced with preference-sensitive decisions, and reported quality of decision-making outcomes, such as knowledge or decisional conflict scores. A thematic analysis was conducted to identify multimedia features and sub-classes. A meta-analysis was conducted based on standardized mean differences (SMDs) for improvements in quality of decision-making scores. Subgroup analyses compared pooled SMDs for DAs that incorporated a specific feature to other computer-based DAs that did not incorporate the feature to assess whether specific multimedia features were associated with improvements in quality of decision-making.
Result: Of 3,541 unique publications, 58 articles met all inclusion criteria. The thematic analysis identified six multimedia features: content control, tailoring, implicit values clarification, explicit values clarification, feedback, and social support. Overall, multimedia DAs performed significantly better than simple aids or usual care (SMD=0.43; 95%CI=0.31-0.56; p<0.00001). DAs that provided content control performed better than DAs that did not incorporate the feature (SMD=0.48 vs. 0.32; p=0.21); however, the association was only significant when providing control over clarifying (SMD=0.60 vs. 0.28; p=0.01) or supplemental information (SMD=0.65 vs. 0.32; p=0.03). Although DAs that tailored information performed better than usual care or simple aids (SMD=0.32; 95%CI=0.17-0.48; p<0.0001), inclusion of this feature was associated with reduced quality of decision-making when compared to other computer-based DAs (SMD=0.32 vs. 0.61; p=0.03). DAs providing implicit values clarification performed worse overall (SMD=0.36 vs. 0.51; p=0.25); however, the association was significant only when incorporating role modeling (SMD=0.16 vs. 0.50; p=0.006). DAs incorporating explicit values clarification, feedback or social support performed similar to DAs not including the feature with SMDs of 0.42 (vs. 0.47; p=0.72), 0.36 (vs. 0.49; p=0.92), and 0.45 (vs. 0.42; p=0.80), respectively.
Conclusion: Multimedia features should be integrated into DAs to improve quality of decision-making; however, some features perform better than others. Content control, specifically control over clarifying or supplemental information, should be integrated into DAs. Alternative implicit values clarification, such as patient testimonials, should be integrated over role modeling. Further analyses are necessary to assess why DAs that incorporated tailoring performed significantly worse than other computer-based DAs.