Lessons Learned from Shared Decision Making with Oral Anticoagulants: A Literature Review and Evidence-Based Guide for Development of Oral Chemotherapy Decision Aids

Background:Oral systemic treatment is becoming an increasingly common modality of chemotherapy. By providing patients with Decision Aids (DAs), clinicians can facilitate shared decision making (SDM) and aid patients in making a treatment choice aligned with their goals and values. Though considerable research exists on DAs in oncology overall, and some products exist commercially, there is little evidence to inform the development and efficacy of DAs targeting the unique challenges of oral anticancer therapy, including difficulties with adherence and self-administration. Our objective was to examine the literature on DAs developed for oral anticoagulation, as well as patient preferences and DAs in oncology, to guide the development of DAs for oral anticancer therapy.

Methods:We conducted an in-depth literature review using PubMed, MEDLINE, and Google Scholar with keywords “decision aids AND oral anticoagulation,” “shared decision-making AND oral anticoagulation,” “decision aids AND oral chemotherapy,” “shared decision-making AND oral chemotherapy,” “decision aids AND oncology,” and “shared decision-making AND oncology.” Selected articles addressed the development, efficacy, and/or patient experience of DAs for SDM in oral anticoagulation therapy and/or oncologic conditions.

Results & Discussion:Our focused search identified 57 potential articles related to our research question; of them, 25 were most relevant that met our inclusion criteria.Effective DAs in oral anticoagulation improved patient knowledge, lowered decisional conflict, and increased medication adherence. They covered a broad range of six SDM elements: situation diagnosis, choice awareness, option clarification, harms and benefits, patient preferences, and decision making. A common shortcoming was a lack of information on the day-to-day patient experience.

In oncology, DAs increased patient knowledge and lowered decisional conflict, aligning patients' ultimate decision with their personal values, especially when including a specific, value-eliciting survey. Ineffective oncology DAs included those that provided general, unclear, or overly optimistic information.

Patients with cancer preferred their DAs to be highly specific, including a list of treatment pros and cons, key questions to ask, information regarding side effects, and clear discussion of expected quality of life resulting from treatment. The concern that providing too much information may be overwhelming or distressing was largely empirical and not evidence-based, as no studies showed harm with DAs providing more information.

In addition to following these lessons, considerations in the development of oral chemotherapy DAs include involving patients in early-stage development and addressing barriers to implementation. The challenges presented by integrating a user-friendly interface with the sufficient detail required to make complex decisions can be addressed by including essential points on a single screen and incorporating links providing granular detail for those who seek it. Variable health literacy, computer experience, and language skills mandate consideration and can be addressed through user experience trials, audio-only pages, and placing open access, pre-downloaded healthcare content on mobile devices. Providing DAs ahead of appointments has also proven more effective than during appointments, improving SDM and facilitating discussion.

Conclusion: There is a need for evidence-based, effective decision aids to facilitate SDM for patients considering systemic oral chemotherapy. Developers can use lessons learned from oral anticoagulation DAs studies, the use of DAs in cancer care, and patient preference surveys to develop DAs for oral chemotherapy that can help optimize shared decision making.