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Table 3 The development of the PANDAs insulin PtDA based on needs, evidence and theory

From: A `combined framework’ approach to developing a patient decision aid: the PANDAs model

Five steps in decision making Description Needs based Evidence based Theory based
1. Background information • This section aims to provide information about the decision of starting insulin; how diabetes could affect the patient personally; adherence to current diabetes treatment; and the range of treatment options available. • In the needs assessment study, the patients wanted and the clinicians felt that the patients needed information on: insulin and its pros and cons; particularly the impact on their lives, symptoms, long term complications, • The information on the benefits and risks of insulin was based on the NICE guidelines [14], UKPDS study [12] • The ODSF proposed that patients should be `knowledgeable about the issues (of treatment)’ so that they would make an informed decision.
• `Make no change’ was rarely offered to the patients; the healthcare professionals recognised that this was an option some patients preferred. • A description of insulin therapy, pros and cons, its impact on quality of life, in sufficient detail during the first part of the PtDA would familiarise patients who were previously unfamiliar with the decision [15].
2. Learn about the choices • This section describes each of the three treatment choices in detail, including the advantages and disadvantages of each option • The selection of the information regarding the advantages and disadvantages of each treatment options was based the patients’ decisional needs and what the healthcare professionals felt was important for the patient to know before making the decision. • The evidence used in this section (diabetic complications, hypoglycaemia, weight gain) were derived from best available evidence. • Two theories were used when developing this section of the PtDA: the `theory of expected utility’ and the `prospect theory’.
• The patients’ chance of getting diabetic complications is personalised according to their HbA1c. • However, the strength of available evidence varied and this was reflected in the `evidence battery indicator’. • The outcome probabilities presented in this PtDA include the risk of diabetic complications and the chance of experiencing the side effects of insulin.
• The level of evidence is graded and presented as `number of bars in a battery’. • The risk of complications of poor glycaemic control is personalised according to patients’ individual HbA1c. • The risk of diabetic complications is presented both as the chance of the patient `getting the complications’ (`negative framing’) as well as `not getting the complications’ (`positive framing’).
3. Thinking about what is important to you • This section clarifies patients’ values attached to the attributes of each treatment option. • The patients had expressed the need for the healthcare professionals to address their concerns about insulin injections and the side effects.   • The ODSF proposes the importance of supporting patients in clarifying their values to ensure that the treatment option patients choose are in congruence with what is important to them (values).
• They were asked to indicate whether the reasons for `choosing insulin’ and `not choosing insulin’ were important to them. • This section on value clarification helped the healthcare professionals to understand patients’ values and priorities.
• The `reasons for choosing insulin’ reflected what the healthcare professionals felt was necessary for the patients to be aware of before making their decision.   • The `value clarification exercise’ in this PtDA focuses on the values related to the advantages and disadvantages of starting or not starting insulin.
4. What else do you need to help you make a decision? • This section explores the support the patient needs before including information, values, support from the family and clinician, and certainty about the diagnosis • The patients wanted the healthcare professional to address their concerns about the treatment options before making a decision.   • The ODSF postulates that a PtDA should address patients’ decisional needs which include: balanced and accurate information; clarity about values associated with the treatment options; support from healthcare professionals, family and friends to reduce their decisional conflict.
• The healthcare professionals wanted to know why the patients were hesitant to start insulin.
• This section was designed to help bridge this gap by allowing the patients to communicate their concerns to the healthcare professionals effectively.   • This section of the PtDA was developed based on this theoretical framework.
5. What’s next? • This is the final step and it asks the patients to indicate whether they are ready to make a decision and, if so, which option they preferred.    
• For those who chose` add insulin’ as the option, they would complete an additional section which explored: their motivation; self-efficacy; barriers and facilitators in starting insulin.