Effect of adding a values clarification exercise to a decision aid on heart disease prevention: a randomized trial

Abstract

Background: Experts have called for the inclusion of values clarification (VC) exercises in decision aids (DAs) as a means of improving their effectiveness, but little research has examined the effects of such exercises.

Objective: To determine whether adding a VC exercise to a DA on heart disease prevention improves decision-making outcomes.

Design: Randomized trial.

Setting: UNC Decision Support Laboratory.

Patients: Adults ages 40 to 80 with no history of cardiovascular disease.

Intervention: A Web-based heart disease prevention DA with or without a VC exercise.

Measurements: Pre- and postintervention decisional conflict and intent to reduce coronary heart disease (CHD) risk and postintervention self-efficacy and perceived values concordance.

Results: The authors enrolled 137 participants (62 in DA; 75 in DA + VC with moderate decisional conflict (DA 2.4; DA + VC 2.5) and no baseline differences among groups. After the interventions, they found no clinically or statistically significant differences between groups in decisional conflict (DA 1.8; DA + VC 1.9; absolute difference VC-DA 0.1, 95% confidence interval [CI]: -0.1 to 0.3), intent to reduce CHD risk (DA 98%; DA + VC 100%; absolute difference VC-DA: 2%, 95% CI: -0.02% to 5%), perceived values concordance (DA 95%; DA + VC 92%; absolute difference VC-DA -3%, 95% CI: -11% to +5%), or self-efficacy for risk reduction (DA 97%; DA + VC 92%; absolute difference VC-DA -5%, 95% CI: -13% to +3%). However, DA + VC tended to change some decisions about risk reduction strategies.

Limitations: Use of a hypothetical scenario; ceiling effects for some outcomes.

Conclusions: Adding a VC intervention to a DA did not further improve decision-making outcomes in a population of highly educated and motivated adults responding to scenario-based questions. Work is needed to determine the effects of VC on more diverse populations and more distal outcomes.

Figure 1

Study Design

Figure 2

Implicit Values Clarification Embedded within Heart to Heart Decision Aid Figure 2a. Calculations of Risk Reductions Possible by Intervening with Various Combinations of Treatment Figure 2b. Summary of Treatment Options and their Pros/Cons Figure 2c. Encouragement to Consider Values and Make a Decision

Figure 3

Overview of Explicit Values Clarification Exercise Added to Heart to Heart Decision Aid Figure 3a. Ranking of Importance of Factors Related to Decision. Figure 3b. Rating Relevance of Decision Factor for Personally Relevant Treatment Options* * Rating proceeded in the order of importance of previously ranked decision factors. Figure 3c. Summary of Participant’s Responses to Ranking and Rating Exercise * The more hearts to the left or the more in a row, the more favorable the option.

Figure 3

Overview of Explicit Values Clarification Exercise Added to Heart to Heart Decision Aid Figure 3a. Ranking of Importance of Factors Related to Decision. Figure 3b. Rating Relevance of Decision Factor for Personally Relevant Treatment Options* * Rating proceeded in the order of importance of previously ranked decision factors. Figure 3c. Summary of Participant’s Responses to Ranking and Rating Exercise * The more hearts to the left or the more in a row, the more favorable the option.

Figure 4

Recruitment Flow Diagram