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Engaging Patients in Decisions About Cancer Screening: Exploring the Decision Journey Through the Use of a Patient Portal

Published:December 11, 2017DOI:https://doi.org/10.1016/j.amepre.2017.10.027

      Introduction

      Engaging patients to make informed choices is paramount but difficult in busy practices. This study sought to engage patients outside the clinical setting to better understand how they approach cancer screening decisions, including their primary concerns and their preferences for finalizing their decision.

      Methods

      Twelve primary care practices offering patients an online personal health record invited eligible patients to complete a 17-item online interactive module. Among 11,458 registered users, invitations to complete the module were sent to adults aged 50–74 years who were overdue for colorectal cancer screening and to women aged 40–49 years and men aged 55–69 who had not undergone a recent mammogram or prostate-specific antigen test, respectively.

      Results

      The module was started by 2,355 patients and completed by 903 patients. Most respondents (76.8%) knew they were eligible for screening. Preferred next steps were talking to the clinician (76.6%), reading/research (28.6%), and consulting trusted friends/family (16.4%). Priority topics included how much screening improves life expectancy, comparative test performance, and the prevalence/health risks of the cancer. Leading fears were getting cancer/delayed detection (79.2%), abnormal results (40.5%), and testing complications (39.1%), the last referring to false test results, medical complications, or unnecessary treatments. Men eligible for prostate-specific antigen screening were more likely than women eligible for mammography to express concerns about testing complications and to prioritize weighing pros and cons over gut feelings (p<0.05).

      Conclusions

      Although this sample was predisposed to screening, most patients wanted help in finalizing their decision. Many wanted to weigh the pros and cons and expressed fears of potential harms from screening. Understanding how patients approach decisions may help design more effective engagement strategies.
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      References

        • Elwyn G.
        • Frosch D.
        • Thomson R.
        • et al.
        Shared decision making: a model for clinical practice.
        J Gen Intern Med. 2012; 27: 1361-1367https://doi.org/10.1007/s11606-012-2077-6
        • Stiggelbout A.M.
        • Van der Weijden T.
        • De Wit M.P.
        • et al.
        Shared decision making: really putting patients at the centre of healthcare.
        BMJ. 2012; 344: e256https://doi.org/10.1136/bmj.e256
        • Blanc X.
        • Collet T.H.
        • Auer R.
        • et al.
        Publication trends of shared decision making in 15 high impact medical journals: a full-text review with bibliometric analysis.
        BMC Med Inform Decis Mak. 2014; 14: 71https://doi.org/10.1186/1472-6947-14-71
        • Chewning B.
        • Bylund C.L.
        • Shah B.
        • Arora N.K.
        • Gueguen J.A.
        • Makoul G.
        Patient preferences for shared decisions: a systematic review.
        Patient Educ Couns. 2012; 86: 9-18https://doi.org/10.1016/j.pec.2011.02.004
        • Alston C.
        • Paget L.
        • Halvorson G.
        • et al.
        Communicating with patients on health care evidence. Discussion paper.
        National Academy of Medicine, Washington, DC2012
        • Légaré F.
        • Stacey D.
        • Turcotte S.
        • et al.
        Interventions for improving the adoption of shared decision making by healthcare professionals.
        Cochrane Database Syst Rev. 2014; 9: CD006732https://doi.org/10.1002/14651858.CD006732.pub3
        • Braddock 3rd, C.H.
        • Edwards K.A.
        • Hasenberg N.M.
        • Laidley T.L.
        • Levinson W.
        Informed decision making in outpatient practice: time to get back to basics.
        JAMA. 1999; 282: 2313-2320https://doi.org/10.1001/jama.282.24.2313
        • Woolf S.H.
        Shared decision-making: the case for letting patients decide which choice is best.
        J Fam Pract. 1997; 45: 205-208
        • Rimer B.K.
        • Briss P.A.
        • Zeller P.K.
        • Chan E.C.
        • Woolf S.H.
        Informed decision making: what is its role in cancer screening?.
        Cancer. 2004; 101: 1214-1228https://doi.org/10.1002/cncr.20512
        • Sheridan S.L.
        • Harris R.P.
        • Woolf S.H.
        • Shared Decision-Making Workgroup of the U.S. Preventive Services Task Force
        Shared decision making about screening and chemoprevention. A suggested approach from the U.S. Preventive Services Task Force.
        Am J Prev Med. 2004; 26: 56-66https://doi.org/10.1016/j.amepre.2003.09.011
        • Makoul G.
        • Clayman M.L.
        An integrative model of shared decision making in medical encounters.
        Patient Educ Couns. 2006; 60: 301-312https://doi.org/10.1016/j.pec.2005.06.010
        • Hoffman R.M.
        • Elmore J.G.
        • Fairfield K.M.
        • Gerstein B.S.
        • Levin C.A.
        • Pignone M.P.
        Lack of shared decision making in cancer screening discussions: results from a national survey.
        Am J Prev Med. 2014; 47: 251-259https://doi.org/10.1016/j.amepre.2014.04.011
        • Peters E.
        • Dieckmann N.
        • Dixon A.
        • Hibbard J.H.
        • Mertz C.K.
        Less is more in presenting quality information to consumers.
        Med Care Res Rev. 2007; 64: 169-190https://doi.org/10.1177/10775587070640020301
        • Tariman J.D.
        • Berry D.L.
        • Cochrane B.
        • Doorenbos A.
        • Schepp K.
        Preferred and actual participation roles during health care decision making in persons with cancer: a systematic review.
        Ann Oncol. 2010; 21: 1145-1151https://doi.org/10.1093/annonc/mdp534
        • Schwartz P.H.
        Questioning the quantitative imperative: decision aids, prevention, and the ethics of disclosure.
        Hastings Cent Rep. 2011; 41: 30-39https://doi.org/10.1353/hcr.2011.0029
        • Epstein R.M.
        Whole mind and shared mind in clinical decision-making.
        Patient Educ Couns. 2013; 90: 200-206https://doi.org/10.1016/j.pec.2012.06.035
        • U.S. Preventive Services Task Force
        Breast cancer recommendation statement from the U.S. Preventive Services Task Force.
        Ann Intern Med. 2016; 164: 448https://doi.org/10.7326/L16-0404
      1. American Urological Association. Early detection of prostate cancer. www.auanet.org/guidelines/early-detection-of-prostate-cancer-(2013-reviewed-and-validity-confirmed-2015). Accessed October 17, 2017.

        • American Cancer Society
        Testing for Prostate Cancer: “Should I Be Tested? Is it the Right Choice for Me?”.
        American Cancer Society, Atlanta, GA2010
        • Moyer V.A.
        • U.S. Preventive Services Task Force
        Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement.
        Ann Intern Med. 2012; 157: 120-134https://doi.org/10.7326/0003-4819-157-2-201207170-00459
        • Levin B.
        • Lieberman D.A.
        • McFarland B.
        • et al.
        Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the U.S. Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology.
        Gastroenterology. 2008; 134: 1570-1595https://doi.org/10.1053/j.gastro.2008.02.002
      2. Final Recommendation Statement: Colorectal Cancer: Screening. U.S. Preventive Services Task Force. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/colorectal-cancer-screening. October 2014. Accessed December 6, 2017.

        • Longo D.R.
        • Woolf S.H.
        Rethinking the information priorities of patients.
        JAMA. 2014; 311: 1857-1858https://doi.org/10.1001/jama.2014.3038
        • Frank S.H.
        • Stange K.C.
        • Langa D.
        • Workings M.
        Direct observation of community-based ambulatory encounters involving medical students.
        JAMA. 1997; 278: 712-716https://doi.org/10.1001/jama.1997.03550090036029
        • Krist A.H.
        • Woolf S.H.
        A vision for patient-centered health information systems.
        JAMA. 2011; 305: 300-301https://doi.org/10.1001/jama.2010.2011
        • Agoritsas T.
        • Heen A.F.
        • Brandt L.
        • et al.
        Decision aids that really promote shared decision making: the pace quickens.
        BMJ. 2015; 350: g7624https://doi.org/10.1136/bmj.g7624
        • Krist A.H.
        • Woolf S.W.
        • Hochheimer C.
        • et al.
        Harnessing information technology to inform patients facing routine decisions.
        Ann Fam Med. 2017; 15: 217-224https://doi.org/10.1370/afm.2063
        • Krist A.H.
        • Woolf S.H.
        • Bello G.
        • et al.
        Engaging primary care patients to use a patient-centered personal health record.
        Ann Fam Med. 2014; 12: 418-426https://doi.org/10.1370/afm.1691
        • Krist A.H.
        • Peele E.
        • Woolf S.H.
        • et al.
        Designing a patient-centered personal health record to promote preventive care.
        BMC Med Inform Decis Mak. 2011; 11: 73https://doi.org/10.1186/1472-6947-11-73
        • Krist A.H.
        • Woolf S.H.
        • Rothemich S.F.
        • et al.
        Interactive preventive health record to enhance delivery of recommended care: a randomized trial.
        Ann Fam Med. 2012; 10: 312-319https://doi.org/10.1370/afm.1383
        • Woolf S.H.
        • Zimmerman E.
        • Haley A.
        • Krist A.H.
        Authentic engagement of patients and communities can transform research, practice, and policy.
        Health Aff (Millwood). 2016; 35: 590-594https://doi.org/10.1377/hlthaff.2015.1512
      3. O’Connor AM, Stacey D, Jacobsen M. Ottawa Personal Decision Guide. http://decisionaid.ohri.ca/decguide.html. Accessed August 5, 2011.

        • Légaré F.
        • Kearing S.
        • Clay K.
        • et al.
        Are you SURE? Assessing patient decisional conflict with a 4-item screening test.
        Can Fam Physician. 2010; 56: e308-e314
        • Degner L.F.
        • Sloan J.A.
        • Venkatesh P.
        The Control Preferences Scale.
        Can J Nurs Res. 1997; 29: 21-43
        • O’Connor A.M.
        Validation of a decisional conflict scale.
        Med Decis Mak. 1995; 15: 25-30https://doi.org/10.1177/0272989X9501500105
        • O’Connor A.M.
        Ottawa Decision Support Framework to Address Decisional Conflict.
        Ottawa Hospital Research Institute, Ottawa, ON2006
        • Longo D.R.
        Understanding health information, communication, and information seeking of patients and consumers: a comprehensive and integrated model.
        Health Expect. 2005; 8: 189-194https://doi.org/10.1111/j.1369-7625.2005.00339.x
      4. International Patient Decision Aids Standards (IPDAS) Collaboration. IPDAS 2005: Criteria for judging the quality of patient decision aids. www.ipdas.ohri.ca/IPDAS_checklist.pdf. Accessed October 17, 2017.

        • Hochheimer C.J.
        • Sabo R.T.
        • Krist A.H.
        • Day T.
        • Cyrus J.
        • Woolf S.H.
        Methods for evaluating respondent attrition in web-based surveys.
        J Med Internet Res. 2016; 18: e301https://doi.org/10.2196/jmir.6342
        • Schwartz L.M.
        • Woloshin S.
        • Fowler Jr, F.J.
        • Welch H.G.
        Enthusiasm for cancer screening in the United States.
        JAMA. 2004; 291: 71-78https://doi.org/10.1001/jama.291.1.71
        • Torke A.M.
        • Schwartz P.H.
        • Holtz L.R.
        • Montz K.
        • Sachs G.A.
        Older adults and forgoing cancer screening: “I think it would be strange.”.
        JAMA Intern Med. 2013; 173: 526-531https://doi.org/10.1001/jamainternmed.2013.2903
        • Aronowitz R.A.
        Do not delay: breast cancer and time, 1900–1970.
        Milbank Q. 2001; 79: 355-386https://doi.org/10.1111/1468-0009.00212
        • Royce T.J.
        • Hendrix L.H.
        • Stokes W.A.
        • Allen I.M.
        • Chen R.C.
        Cancer screening rates in individuals with different life expectancies.
        JAMA Intern Med. 2014; 174: 1558-1565https://doi.org/10.1001/jamainternmed.2014.3895
        • Jones R.M.
        • Woolf S.H.
        • Cunningham T.D.
        • et al.
        The relative importance of patient-reported barriers to colorectal cancer screening.
        Am J Prev Med. 2010; 38: 499-507https://doi.org/10.1016/j.amepre.2010.01.020
        • Jones R.M.
        • Devers K.J.
        • Kuzel A.J.
        • Woolf S.H.
        Patient-reported barriers to colorectal cancer screening: a mixed-methods analysis.
        Am J Prev Med. 2010; 38: 508-516https://doi.org/10.1016/j.amepre.2010.01.021
        • Medina G.G.
        • McQueen A.
        • Greisinger A.J.
        • Bartholomew L.K.
        • Vernon S.W.
        What would make getting colorectal cancer screening easier? Perspectives from screeners and nonscreeners.
        Gastroenterol Res Pract. 2012; 2012: 895807https://doi.org/10.1155/2012/895807
        • Zikmund-Fisher B.J.
        • Couper M.P.
        • Fagerlin A.
        Disparities in patient reports of communications to inform decision making in the DECISIONS survey.
        Patient Educ Couns. 2012; 87: 198-205https://doi.org/10.1016/j.pec.2011.08.002
        • Protière C.
        • Moumjid N.
        • Bouhnik A.D.
        • Le Corroller Soriano A.G.
        • Moatti J.P.
        Heterogeneity of cancer patient information-seeking behaviors.
        Med Decis Making. 2012; 32: 362-375https://doi.org/10.1177/0272989X11415114
        • Chaiken S.
        • Trope Y.
        Dual-Process Theories in Social Psychology.
        Guilford Press, New York, NY1999
        • Reyna V.F.
        How people make decisions that involve risk: a dual-processes approach.
        Curr Dir Psychol Sci. 2004; 13: 60-66https://doi.org/10.1111/j.0963-7214.2004.00275.x
        • Sloman S.A.
        The empirical case for two systems of reasoning.
        Psychol Bull. 1996; 119: 3-22https://doi.org/10.1037/0033-2909.119.1.3
        • Epstein S.
        Integration of the cognitive and the psychodynamic unconscious.
        Am Psychol. 1994; 49: 709-724https://doi.org/10.1037/0003-066X.49.8.709
        • Slovic P.
        • Peters E.
        • Finucane M.L.
        • Macgregor D.G.
        Affect, risk, and decision making.
        Health Psychol. 2005; 24: S35-S40https://doi.org/10.1037/0278-6133.24.4.S35
        • Zajonc R.B.
        Feeling and thinking: preferences need no inferences.
        Am Psychol. 1980; 35: 151-175https://doi.org/10.1037/0003-066X.35.2.151
        • Cameron L.D.
        • Leventhal H.
        The Self-Regulation of Health and Illness Behaviour.
        Routledge, New York2003
        • Loewenstein G.F.
        • Weber E.U.
        • Hsee C.K.
        • Welch N.
        Risk as feelings.
        Psychol Bull. 2001; 127: 267-286https://doi.org/10.1037/0033-2909.127.2.267
        • Gasper K.
        • Clore G.L.
        The persistent use of negative affect by anxious individuals to estimate risk.
        J Pers Soc Psychol. 1998; 74: 1350-1363https://doi.org/10.1037/0022-3514.74.5.1350
        • Peters E.
        • Slovic P.
        The springs of action: Affective and analytical information processing in choice.
        Person Soc Psychol Bull. 2000; 26: 1465-1475https://doi.org/10.1177/01461672002612002
        • Finucane M.L.
        • Alhakami A.
        • Slovic P.
        • Johnson S.M.
        The affect heuristic in judgments of risks and benefits.
        J Behav Decis Making. 2000; 13: 1-17https://doi.org/10.1002/(SICI)1099-0771(200001/03)13:1<1::AID-BDM333>3.0.CO;2-S
        • Schwartz B.
        The Paradox of Choice: Why More is Less.
        Harper Collins, London2004
        • Epstein R.M.
        • Peters E.
        Beyond information: exploring patients’ preferences.
        JAMA. 2009; 302: 195-197https://doi.org/10.1001/jama.2009.984
        • Baruch F.
        Chapter 18: Cognitive processes in stated preference methods.
        in: Mäler K. Vincent J.R. Handbook of Environmental Economics. Vol 2 - Valuing Environmental Changes. Elsevier, Amsterdam2005: 937-968
        • Shay L.A.
        • Lafata J.E.
        Understanding patient perceptions of shared decision making.
        Patient Educ Couns. 2014; 96: 295-301https://doi.org/10.1016/j.pec.2014.07.017
        • Legare F.
        • Ratte S.
        • Gravel K.
        • Graham I.D.
        Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals’ perceptions.
        Patient Educ Couns. 2008; 73: 526-535https://doi.org/10.1016/j.pec.2008.07.018
        • Torrey W.C.
        • Drake R.E.
        Practicing shared decision making in the outpatient psychiatric care of adults with severe mental illnesses: redesigning care for the future.
        Community Ment Health J. 2010; 46: 433-440https://doi.org/10.1007/s10597-009-9265-9
        • Wunderlich T.
        • Cooper G.
        • Divine G.
        • et al.
        Inconsistencies in patient perceptions and observer ratings of shared decision making: the case of colorectal cancer screening.
        Patient Educ Couns. 2010; 80: 358-363https://doi.org/10.1016/j.pec.2010.06.034
        • Woolf S.H.
        • Krist A.
        The liability of giving patients a choice: shared decision making and prostate cancer.
        Am Fam Physician. 2005; 71: 1871-1872
        • Edwards M.
        • Davies M.
        • Edwards A.
        What are the external influences on information exchange and shared decision-making in healthcare consultations: a meta-synthesis of the literature.
        Patient Educ Couns. 2009; 75: 37-52https://doi.org/10.1016/j.pec.2008.09.025
        • Levinson W.
        Patient-centred communication: a sophisticated procedure.
        BMJ Qual Saf. 2011; 20: 823-825https://doi.org/10.1136/bmjqs-2011-000323
        • Fagerlin A.
        • Sepucha K.R.
        • Couper M.P.
        • Levin C.A.
        • Singer E.
        • Zikmund-Fisher B.J.
        Patients’ knowledge about 9 common health conditions: the DECISIONS survey.
        Med Decis Making. 2010; 30: 35S-52Shttps://doi.org/10.1177/0272989X10378700
        • Street Jr., R.L.
        Aiding medical decision making: a communication perspective.
        Med Decis Making. 2007; 27: 550-553https://doi.org/10.1177/0272989X07307581
        • Ling B.S.
        • Trauth J.M.
        • Fine M.J.
        • et al.
        Informed decision-making and colorectal cancer screening: is it occurring in primary care?.
        Med Care. 2008; 46: S23-S29https://doi.org/10.1097/MLR.0b013e31817dc496
        • Gourlay M.L.
        • Lewis C.L.
        • Preisser J.S.
        • Mitchell C.M.
        • Sloane P.D.
        Perceptions of informed decision making about cancer screening in a diverse primary care population.
        Fam Med. 2010; 42: 421-427
        • Lafata J.E.
        • Divine G.
        • Moon C.
        • Williams L.K.
        Patient-physician colorectal cancer screening discussions and screening use.
        Am J Prev Med. 2006; 31: 202-209https://doi.org/10.1016/j.amepre.2006.04.010
        • Hoffman R.M.
        • Couper M.P.
        • Zikmund-Fisher B.J.
        • et al.
        Prostate cancer screening decisions: results from the National Survey of Medical Decisions (DECISIONS study).
        Arch Intern Med. 2009; 169: 1611-1618https://doi.org/10.1001/archinternmed.2009.262
        • Flocke S.A.
        • Stange K.C.
        • Cooper G.S.
        • et al.
        Patient-rated importance and receipt of information for colorectal cancer screening.
        Cancer Epidemiol Biomarkers Prev. 2011; 20: 2168-2173https://doi.org/10.1158/1055-9965.EPI-11-0281
        • Woolf S.H.
        • Krist A.H.
        • Johnson R.E.
        • Stenborg P.S.
        Unwanted control: how patients in the primary care setting decide about screening for prostate cancer.
        Patient Educ Couns. 2005; 56: 116-124https://doi.org/10.1016/j.pec.2003.12.002
        • Guerra C.E.
        • Jacobs S.E.
        • Holmes J.H.
        • Shea J.A.
        Are physicians discussing prostate cancer screening with their patients and why or why not? A pilot study.
        J Gen Intern Med. 2007; 22: 901-907https://doi.org/10.1007/s11606-007-0142-3
        • Nekhlyudov L.
        • Li R.
        • Fletcher S.W.
        Informed decision making before initiating screening mammography: Does it occur and does it make a difference?.
        Health Expect. 2008; 11: 366-375https://doi.org/10.1111/j.1369-7625.2008.00514.x
        • Lafata J.E.
        • Cooper G.S.
        • Divine G.
        • et al.
        Patient-physician colorectal cancer screening discussions: delivery of the 5A’s in practice.
        Am J Prev Med. 2011; 41: 480-486https://doi.org/10.1016/j.amepre.2011.07.018
        • Schwartz P.H.
        • Edenberg E.
        • Barrett P.R.
        • Perkins S.M.
        • Meslin E.M.
        • Imperiale T.F.
        Patient understanding of benefits, risks, and alternatives to screening colonoscopy.
        Fam Med. 2013; 45: 83-89
        • Zikmund-Fisher B.J.
        • Couper M.P.
        • Singer E.
        • et al.
        Deficits and variations in patients’ experience with making 9 common medical decisions: the DECISIONS survey.
        Med Decis Making. 2010; 30: 85S-95Shttps://doi.org/10.1177/0272989X10380466
        • Frosch D.L.
        • May S.G.
        • Rendle K.A.
        • Tietbohl C.
        • Elwyn G.
        Authoritarian physicians and patients’ fear of being labeled ‘difficult’ among key obstacles to shared decision making.
        Health Aff (Millwood). 2012; 31: 1030-1038https://doi.org/10.1377/hlthaff.2011.0576
        • Joseph-Williams N.
        • Edwards A.
        • Elwyn G.
        Power imbalance prevents shared decision making.
        BMJ. 2014; 348: g3178https://doi.org/10.1136/bmj.g3178
        • Stacey D.
        • Bennett C.L.
        • Barry M.J.
        • et al.
        Decision aids for people facing health treatment or screening decisions.
        Cochrane Database Syst Rev. 2011; 10: CD001431https://doi.org/10.1002/14651858.CD001431.pub3
        • Lewis C.L.
        • Adams J.
        • Tai-Seale M.
        • et al.
        A randomized controlled effectiveness trial for PSA screening decision support interventions in two primary care settings.
        J Gen Intern Med. 2015; 30: 810-816https://doi.org/10.1007/s11606-015-3214-9
        • Jimbo M.
        • Rana G.K.
        • Hawley S.
        • et al.
        What is lacking in current decision aids on cancer screening?.
        CA Cancer J Clin. 2013; 63: 193-214https://doi.org/10.3322/caac.21180
        • Politi M.C.
        • Adsul P.
        • Kuzemchak M.D.
        • Zeuner R.
        • Frosch D.L.
        Clinicians’ perceptions of digital vs. paper-based decision support interventions.
        J Eval Clin Pract. 2015; 21: 175-179https://doi.org/10.1111/jep.12269
        • Politi M.C.
        • Street Jr., R.L.
        The importance of communication in collaborative decision making: facilitating shared mind and the management of uncertainty.
        J Eval Clin Pract. 2011; 17: 579-584https://doi.org/10.1111/j.1365-2753.2010.01549.x
        • Epstein R.M.
        • Street Jr., R.L.
        Shared mind: communication, decision making, and autonomy in serious illness.
        Ann Fam Med. 2011; 9: 454-461https://doi.org/10.1370/afm.1301
        • Quill T.E.
        • Brody H.
        Physician recommendations and patient autonomy: finding a balance between physician power and patient choice.
        Ann Intern Med. 1996; 125: 763-769https://doi.org/10.7326/0003-4819-125-9-199611010-00010
        • Kruse C.S.
        • Bolton K.
        • Freriks G.J.
        The effect of patient portals on quality outcomes and its implications to meaningful use: a systematic review.
        Med Internet Res. 2015; 17: e44https://doi.org/10.2196/jmir.3171
        • Eberth J.M.
        • Vernon S.W.
        • White A.
        • Abotchie P.N.
        • Coan S.P.
        Accuracy of self-reported reason for colorectal cancer testing.
        Cancer Epidemiol Biomarkers Prev. 2010; 19: 196-200https://doi.org/10.1158/1055-9965.EPI-09-0335
        • Zikmund-Fisher B.J.
        • Couper M.P.
        • Singer E.
        • et al.
        The DECISIONS study: a nationwide survey of United States adults regarding 9 common medical decisions.
        Med Decis Making. 2010; 30: 20S-34Shttps://doi.org/10.1177/0272989X09353792