Evolution of Information Technology and Its Emergence in...

Evolution of Information Technology and its Emergence in India ITM-IB PP6 EXECUTIVE SUMMARY Information Technology today is what runs businesses worldwide. It is what drives the industries and is an irreplaceable element of our routine lives. But where did it all begin? Why has it gained so much importance over time, so much so that we study an entire subject on it? Through this paper we have traced the path of evolution of IT from its nascent stages, globally as well as from the Indian perspective. We have tried to take into account the tremendous growth of the IT sector in India and single out the advantages faced by the Indian IT sector. We have also looked into the performance of the Indian IT industry and its†¦show more content†¦The margins of these IT service players are very high and their growth rate has been envied by other sectors. According to a Nasscom forecast, there will be 21-24 % growth rate in software and services revenue in this financial year. Soon our software exports will touch the magical figure of $50 billion. The software and services exports segment grew by 29 % to register revenues of $40.4 billion this year from $31.4 billion in last year. So from statistics point of view, everything is fine for this industry. It will employ 4 million people in 2008 and account for 7% of gross domestic product and 33% of India’s foreign-exchange inflows, says the Nasscom report. However, there are quite some challenges which the IT industry faces. i.) Resource retention - Indian IT sector has become an HR manager’s nightmare. Their biggest challenge is marinating good people in organisation and keeping the attrition rate in control. ii.) Lack of trained people- The supply and demand of quality engineers who are capable of working in the IT field is having a huge gap. Companies have started looking for additional options of hiring science graduates and providing them adequate training to enable them to work in IT sector, but still the quality of talent is declining which in turn means lack of quality in work. iii.) US slowdown - Most of the revenue of IT and ITes ccompanies comes from US. A slowdown in US would impact their growth andShow MoreRelatedThe Transformation Of Domestic Companies Into Transnational Company1457 Words   |  6 Pages1. INTRODUCTION Liberalization of capital, goods, services, information and people has unprecedentedly and irrevocably transformed the world economic systems named â€Å"globalization† particularly aftermath Second World War. 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In short, the text brings about the study of globalization at its forefront. Moreover, Friedman analyzes the evolution of business and importance of information with respect not only to the 21st century, but with regards to the history of trade as we know it. It is from this study and understanding that Friedman engages in a detailed thought process as to how an institution, government, or individual can remain competitiveRead MoreEmerging Trends in Retail Marketing1856 Words   |   8 PagesEmerging Sectors: Retailing, one of the largest sectors in the world economy, is going through a transition phase, not only in India but the world over. For the long time, the corner general store was the only choice available to the customer, especially in the urban areas. This is slowly giving way to global format of retailing. The emergence of new retail sector have accomplished by changes in existing formats as well as the beginning of new formats. The changing RetailRead MoreE Commerce And The Internet Essay1842 Words   |  8 Pagesprocess of execution of commercial transactions electronically with the help of the leading technologies such as Electronic Data Interchange (EDI) and Electronic Funds Transfer (EFT) which gave an opportunity for users to exchange business information and do electronic transactions. Electronic commerce is a term for any type of business, or commercial transaction that involves the transfer of information across the Internet. It covers a range of different types of businesses, from consumer basedRead MoreRelationship Marketing Approach and Strategiesin Retailing3357 Words   |  14 Pagesrelationship marketing literature and considering its application to the retail industry. This paper shows how the relationship marketing principle underpins the implementation of retailing strategies. Keywords: Retailing, Relationship Marketing, Evolution, Application, Strategies. INTRODUCTION The retail industry is generally a very dynamic, fast changing sector. It constitutes one of the main sectors in the economy, in terms of transactions and turnover; as a consequence, it is a highlyRead MoreEmerging Trends in Entrepreneurship4541 Words   |  19 PagesResponsibility (CSR) as some people would want us to believe, it is a conscious effort to contribute to a Social cause and the business enterprise is merely a medium for achieving the end results. Early beginnings The story of the entrepreneurship in India is full of ups and downs. During the pre British and British era, the entrepreneur was seen more as a broker or money lender, bound by caste affiliations, religious, cultural and social forces right from the philosophy of dharma down to the joint family

Globalization Is A Positive Way Or Negative Way - 1034 Words

Sharyu Bharat Jakhariya JAKSC1402 POLS1040 Mr. Emmanuel Goffi 3rd Dec 2015 Essay on Has Globalization Changed Global Politics in a Positive Way or a Negative way Globalization- Positive or Negative Globalization is one of the 21st century’s most important politics topic. I have heard the term globalization in my economics lecture and in political debates. Some of my friends argued when I asked them if globalization is changed global politics in a positive way or negative way. Some of them argued saying that globalization is a positive development as it gives rise to new industries and more job opportunities in developing countries, to which I agreed to. As the world grows more connected through the internet and greater international trade, globalization is becoming more important and more controversial. Controversial in the sense that the developing countries of the world will do whatever the developed countries will tell them to do, without thinking if it is going to result into a good thing or a bad thing. It is easy to assume that globalization is an entirely modern phenomenon driven by inventions like the telegraph or the internet. In many ways, globalization has been taking place for centuries like outsourcing most manufacturing jobs in the developed countries, involving Canada and obtaining goods from outside sources which are the developing countries. Which is a good thing for the developing countries as they are getting moreShow MoreRelatedThe Positive and Negative Effects of Globalization1570 Words   |  7 PagesThe Positive and Negative Effects of Globalization Is Globalization ultimately positive or negative, or somewhere in between? I believe it depends on who you ask the question, and how it affects their life. 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It is however the writer’s view that globalization has had a largely negative impact on Zimbabwean culture as Rodrik(1971:8) points out that â€Å"globalization creates social and political tensions within andRead MoreTheorizing globalization (Doughlas Kellner) Essay693 Words   |  3 Pageshopes to understand globalization as a dialectic between the progressive and emancipatory features and negative attributes.   His articulation of globalization also recognizes that change in globalized systems is not only imposed from above but can also be contested and reconfigured from below.   Taking all of these elements into account, Keller argues for an understanding of globalization that moves beyond technological and economic optics toward an understanding of globalization as an ambiguous, contradictoryRead MoreGlobalization: the Bad939 Words   |  4 PagesGlobalization: the bad and the bad Sargon Lazar (Serge) 100443573 GHUM 1058 Professor Adeesha Hack Globalization defined is the worldwide movement toward economic, financial, trade, and communications integration. 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Contribution Margin and Break Even Analysis Free Essays

Many factors come into play in determining business success. One of them is the financial factor. For a company to set financial goals it is crucial that its management know in detail the products or services they sale or provide. We will write a custom essay sample on Contribution Margin and Break Even Analysis or any similar topic only for you Order Now This is the analysis of two different scenarios at Aunt Connie’s Cookies Simulation (University of Phoenix, 2011) and the financial performance of Jamestown Electric Supply Company (Heiter, et. al. 2008). During both analysis I applied concepts like fixed and variable costs, contribution margin, break-even point, indifference point, and operating leverage. Aunt Connie’s Cookies Scenario Simulation  The Aunt Connie’s brand grew successfully producing Lemon Creme and Mint cookies. Maria Villanueva is the current chief executive officer of this family-owned company (University of Phoenix, 2011). She faces critical decisions to make because both the lemon creme and mint cookies prices increased and sales volume decreased. Maria should apply several accounting concepts to reach her goal of increasing sales and revenue for the company. Some opportunities and challenges lined up for Aunt Connie’s Cookies like large bulk orders and the buyout of a competitor’s factory (University of Phoenix, 2011). A confectioner commissioned Aunt Connie’s Cookies to fill a bulk order of one million packages of the Real Mint cookies delivered in one month’s time. The stipulations of the order weights greatly on the company as the confectioner will only pay $1. 20 per package, which is much cheaper than the mass market selling at $1. 50 per packet. Rejecting the order may seem foolish as Aunt Connie’s Cookies has the capacity to produce the order, and could be missing out on a good opportunity if she declines to fill the order (University of Phoenix, 2011). In deciding which cookie’s production to reduce, Maria took into account the concepts of contribution margin, unit contribution margin, and operating profits. This decision was necessary to create sufficient capacity to accommodate the mint cookies bulk order. The contribution margin is the amount of money that remians from the revenue obtained after sales to pay for fixed expenses and to contribute to the operating profits after deducting variable expenses. Alternatively, the unit contribution margin of each unit sales, in this case each pack of cookies adds to profit. Finally, operating profit is the profit earned from a company’s core business operations, also known as earnings before interest and tax (EBIT). Maria calculated the contribution margin and the unit contribution margin for each type of cookie, determined to reduce the production of lemon creme cookies and to increase the production capacity for the bulk order of real mint cookies. Maria can sell mint cookies at $1. 20 per package, below the selling price of $1. 50 because the real mint cookies provide a greater total contribution margin and that the lemon cream cookies provides a greater unit contribution margin. Maria knew that Aunt Connie’s Cookies should produce more of the cookies with the greater contribution margin per unit to maximize the shop’s operating profit. If the scenario changed, and the bulk order was for lemon cookies, Maria would have to turn over the order to the confectioner. The unit contribution margin for the lemon cookies is smaller and Maria would have to increase the production capacity to make the same operating profit as for the mint cookies, to the point of going beyond the factory’s production capacity. Maria faced the opportunity to buy a peanut butter cookie plant. She could use this plant to make more lemon creme cookies because the near-term demand exceeded 600,000 packs. The challenge for Maria is to make a decision about going forward or not with this business (University of Phoenix, 2011). If the new plant has a break-even volume of creme cookies of 650,000 packs, Maria must ensure that Aunt Connie’s Cookie shop sales the same amount of packs or more. If the business sales less, it will make a loss, if it sells more, it will be a profit. The break-even point in volume is the point where the plant’s fixed expenses are covered. In the case that Maria considers Aunt Connie’s Cookie shop cannot sell that much, she may ensure viability of the plant by (1) trying to reduce the fixed costs (e. g. renegotiating rent, reducing telephone bills, insurance, etc. ), (2) trying to reduce variable costs (e. g. purchasing at lower cost the ingredients used to make cookies), or (3) increasing the selling price of the cookies. Any of these strategies can reduce the break-even point in volume. In the worst of the scenarios, Maria should not buy the peanut butter cookie plant. Key Learning Points. During the simulation I applied several concepts such as contribution margin, break-even point, fixed and variable costs, indifference point, and operating leverage. All these concepts interrelate and form part of the cost volume profit analysis tool. The application of these concepts by managers help organizations attain good financial performance. Cost volume profit analysis (CVP analysis) is a powerful tool that can help managers in understanding better the relationship that exists among the cost, the volume, and the profit in a business. Managers can make good business decision if they concentrate in trying to understand the interaction that exists among (1) the prices of product or services, (2) the level of activity, (3) the volume of product , (4) the variable cost per unit, (4) the total fixed costs and (5) and the mixture of the product or services. Business decision may be about changes to company’s pricing policy, selection of a marketing strategy to use, choosing which products to manufacture or services to provide, and even about the acquision of new companies. The break-even point (BEP) is one element of CVP analysis. BEP is the level of output at which the profit is zero. Break even analysis helps managers determine how far sales can decline before their companies start to lose money. The indifference point is the volume at which costs for both labor-intensive operations and equipment intensive operations are equal. When volumes increase, revenues increase. However, the presence of lower variable costs per unit in equipment-intensive operations ensures that the operating profits increase more significantly when compared to labor-intensive operations. Equipment-intensive operations have higher fixed costs and lower variable costs per until when compared to labor -intensive operations. Jamestown Electric Supply Company. Jamestown Electric Supply Company has been in business for 45 years. The company designs, manufactures, and delivers electrical supplies in various forms to different type of businesses. Jamestown invested heavily in research and development of automotive electronic technology to provide its customers with modern functionality, safety, and performance. Jamestown products have outstanding features that create competitive advantage to commodities that customers regard as standard features on all automobiles. Jamestown has hundreds of diverse contracts with different divisions and plants of each of the major automobile manufacturers. Most of the contracts show good gross profit margin on sales, but others do not show acceptable bottom-line profits or show no profit. Although Jamestown’s sales, continue to rise, profit declined in the period under analysis from 2003 to 2007 as showed on Exhibit One. Jamestown top managers believe that if sales growth remained positive, the problems with the profit would resolve. Warehousing and shipping managers think that customer service expenses are out of control and causing significant cost increases for the company. Jamestown customer services include overnight delivery of electronic component products, just-in-time inventory deliveries to client’s plants, warehousing of client parts, special part support services, and many other customer services designed to gain and maintain clients. Exhibit One. Jamestown Electric Supply Company Income Statements for 2003 to 2007. Electric Supply Company financial performance is in jeopardy and top management have to change its customer service policy and marketing strategy after carefully analyzing the information obtained after performing a CVP analysis. The focus of the analysis should be in understanding the relationship between product price, volume, per unit variable cost, and the mix of products sold by Jamestown Electric. Calculating the contribution margin on the products which Jamestown Electric sales will allow management to know more in detail how much each unit sale will contribute to the company profit. Calculating the break-even point will provide information about which products do not bring either profit or loss, and about how far sales can decrease before Jamestown Electric starts to lose money. James Electric product cost structure has a higher percentage of variable costs than in fixed costs, which involves less operating leverage or risk. One of he options management should consider is to closely monitor the variable expenses incurred by customer service in order to increase the company profits. Jamestown Electrical Supply Company management will definitely benefit from setting a regular schedule to analyze contribution margins either monthly or quarterly to track product margin performance more accurately. Conclusion Managers can help their organizations achieve a good financial performance when they apply basic accounting concepts in their business strategic plans. Knowing the existing relationship between these concepts contribute to ensure their organization’s financial success. How to cite Contribution Margin and Break Even Analysis, Essay examples

Cultural Shock Lack of Awareness about the Foreign Culture free essay sample

Culture could be known as a learned norm based on values, attitudes and beliefs of a group of people, and it is learned, shared, transmitted from one generation to another. The scholar Geert Hofstede and defined culture as the collective programming of human mind that distinguishes the members of one human group from those of another. CITATION Hof l 1033 (Hofstede, n.d. ) The scholar Hofstede has looked through a different aspect to define the term culture. However, the scholar Campbell has defined culture as a complex web of information that a person learns and which guides each persons actions, experiences, and perceptions. CITATION Cam l 1033 (Campbell, n.d.)Most significant fact about culture of a group of people is that it is most often unique from another culture of another group of people. Culture will influence people to behave in a certain way which affects immensely in a business context. Because if the product or service which the business produces are against the cultural values, the demand of the product or service in the subject culture will tend to decrease. In order to be a successful business in a new culture, the business should be able to adapt to the new culture. The movie Outsourced which was directed by John Jeffcoat depicts the challenges faced by the character Todd (Josh Hamilton) when he runs the operations of a call-centre in a foreign culture.The cultures of India and USA differ from one another. Indian cultural values are a lot similar to most of the Asian countries like; Sri Lanka, Pakistan, and Bangladesh etc. They tend to have a collectivist and masculine cultures. On the other hand, American cultural values are more individualistic but also a masculine culture. Both of the countries are driven by success and competition. Hence, they are masculine. The differences between the cultures of India and America have made the character Todd falls down in cultural shock. The term cultural shock could be defined as a state of anxiety and frustration resulting from the immersion in a culture distinctly different from ones own.The term basically means the feeling of confusion and distress experienced by a person who is exposed to a foreign culture. This was shown mentally as well as physically from Todd from the moment he stepped on to India. Everything about India was new to Todd. From the moment, he first stepped in to India, he had difficulties. The language, transportation, food etc. This was mainly because of the cultural shock and that made Todd feel stressed, disoriented and discouraged. First, how the pick-up driver misspelled his name has led him to hire a taxi for himself and get to his destination, Gharapuri. Next, being invited by many taxi drivers and facing an uncomfortable situation. However, when he chooses the taxi, it turns out not to be taxi that he wanted to get in has also increased the shock and the confusion hes facing in this foreign culture. Finally, the moment where Todd had to chase the train and jumped in to the train and he was offered a seat by a little boy but the little boy then sat on Todds leg makes him more uncomfortable. The above-mentioned situations reflect the cultural shock that Todd was facing when he came to India. When Todd started the operations on the call centre at Gharapuri, he faced a lot challenges because of the cultural differences of the employees that had to work with. Main issue he had to face was the accent of these employees which was a lot different to the American accent. Since American citizens were against the concept of outsourcing Todd had to ask these employees to deceive the customers by saying the call centre is situated in Chicago. For this, he had to make the accents of these employees to be more like the accents of the American customers. Todd advised them to listen carefully how the customers pronounce words and learn from them to learn about America. Todd had small sessions after work for the employees to improve their accents to be more alike the American accent. Even though, majority of the employees didnt have a problem with this situation the character Asha was against of deceiving the customers by lying to them about the location. This was another additional challenge that Todd had to face in the call centre.The main target Todd was given is to reduce the average talk time per customer to 6 minutes. When Todd started the operations, the average time was more than 12 minutes, he had to achieve the objective of reducing it into 6 minutes in order to go back to his home country, USA. Todd was pretty upset about how the operations were going since the average time was more than 12 minutes. He yelled at Purohit (Puro) about the operations. But what Todd didnt know was it was 14 minutes before Todd had arrived. Todd didnt appreciate what Puro had done but instead he just yelled at him for whats happening currently. This would de-motivate the employee but as a solution what Todd implied was, he pushed Puro to achieve the target by mentioning his life goals that he wanted to achieve by getting the new job as the manager of the call center.Since the cultural differences of these two countries, Todd had to explain some of these items that they are selling. As a manager which supervises employees of a different country, its very important for the manager to be well aware of the culture of the employees. However, in this situation Todd was not aware of the cultural values of this foreign country, he only had the idea that it was completely different from his home culture. So, when he was explaining some of these products that they are selling it shocked some of the employees. Cow is considered to be a sacred animal in India because they believe that cow is the gods animal. Todd had to explain a product that they were selling which is been used to stamp the owners name into the cow. It is hard for an employee to promote and sell products that are against your personal and cultural values. In this case, Todd wasnt aware of the cultural values of the country and it was suggested to Todd by Asha that he should be aware of the cultural values of the country.This movie could be further analyzed according to the cultural dimensions which were introduced by the scholar Hofstede. Hofstede described cultural dimensions in mainly four contexts, which are power distance, uncertainty avoidance, individualism/collectivism and masculinity/femininity.First, the masculinity and femininity dimension focuses on how extent to which society stress achievement or nurture. As mentioned above, both India and USA have masculine cultures. Both the countries prefer men in leadership roles and women as inferior. CITATION Wor16 l 1033 (WordPress, 2016) However, it should be mentioned that comparatively Indian women are treated more inferior than the American women. Women in western countries most often encourage the women to get education and work later in their lives. It is not the same with Indian women. They are expected to wives that look after their children and household work, they are expected not to work nor to get education. This was depicted in the movie where Todd was given Asha responsibility to carry on the operations and Puro was doubting that Asha could do it CITATION Joh06 l 1033 m Joh06 (Outsourced, 2006) . It depicts that Indian culture often believe that its mens role to be the leader and not women.Individualism and collectivism is another dimension Hofstede explained which could relate to this movie. This dimension basically could be described as the degree of interdependence a society maintains among its members. CITATION Wor16 l 1033 (WordPress, 2016) America is a country which is more towards individualism. For an example, the superiors of Todds company were not concerned about the loss of worker jobs their main focus was to maximize their profits by shifting the call center to a place where it would cost them the least. On the other hand, India is more of a collective culture. One of the most interesting part was how Todd learnt to give the leftover food to the disadvantaged Indian families on the other side of the wall. This depicts interdependency as well as the how the collective culture is comparatively morally better.Power distance represents the degree of power each person exerts or can exert over other persons. CITATION Wor16 l 1033 (WordPress, 2016) The term power can be basically defined as a persons ability to influence another persons ideas and behavior. From the start, the power distance dimension was depicted since its a movie mainly related to a work place. Authorities that was possessed by the superiors use them to influence the employees in a work place context. For an example when Todds manager first asked Todd to take operations in India he did not want to move, he was trying to negotiate with the manager. However, with the power the manager possessed he forced Todd to move there and take control over the operations.Uncertainty avoidance is the extent to which people feel threatened by ambiguous situations and have created beliefs and institutions that try to avoid such situations. This was directly depicted in the movie when Todd announced the Indian employees that their jobs were going to outsourced to China. CITATION Joh06 l 1033 (Outsourced, 2006) Surprisingly, after hearing the bad news employees were not upset but happy because of the extra pay and the vacation they got. The employees believed that the god had brought an end in order to create room for a new beginning. The movie depicts the belief system that this foreign culture used as the mechanism to cope up with these uncertainties they face.From the day Todd stepped into India he faced lots of challenges but the main challenge he got was to reduce the average talk time per customer to under 6 minutes. By the time he first visited the call center, it was an impossible task. It was more than 12 minutes at the beginning. Todd wanted results in order to get back to his home country. Todd tried to teach new words to the employees, tried to improve their accents but nothing seemed to work until the suggestion was brought to him by Asha. Asha taught Todd a very valuable lesson of how to make the operations of the call center more efficient by giving help for those who needed and also making the employees feel part of the team. In order to achieve these objectives, Todd followed several steps. One is, he admitted to the staff that he was wrong by trying to the operations like an American company. As a good leader, he got suggestions from the employees to make their workday more positive experience. Allowing to wear any clothes that they want, allowing to bring them anything that they want to keep with them at work hours (allowing Sanjeev to bring his family pictures to keep on his desk) are some of the steps Todd took. From a question arose while these suggestions were brought up, Todd realized that he found a new market for the products that their company is selli ng. Employee motivation is crucial for the success of a business organization. Mainly because if the employees of an organization are demotivated or dissatisfied with their work itll directly affect the success of the subject organization. After discovering the high demand for the products that the company sells, Todd informed the employees that whoever improves their average talk time per customer in a given day the employee gets the chance to pick a product from the most popular products in their catalog. This depicts how Todd had the presence of mind and how he got the advantage of the discovery.Todd was able to get results in a quick time by letting them feel more comfortable in their workplace. But average time was yet to be reduced by more than 1 minute. Todd further had sessions to the operators and taught them the little tricks that would help them to reduce the talk times. For an example, Todd taught about the reductions which the Americans use in their sentences. Also, he was much more aware of the culture than before. In one of those sessions, Todd even danced into an Indian song. He was able to maintain a closer relationship with their employees which would help Todd to reach his final objective.Finally, after taking all the actions Todd was able to reduce the average talk time to 6 minutes. However, when Todds manager visited the office was filled with water and operations was paused and the talk time has again gone to more than 12 minutes. Todd didnt stop, he suggested to carry on the operations on the roof stop. Todds manager thought it was an impossible task. But it should be mentioned that it would seem difficult for the manager because of the cultural differences of the two countries. Indian collective culture would assist this kind of a scenario better than the American individualistic culture. To be well aware of that difference depicts how Todd has improved his knowledge about this foreign culture has helped him to get the maximum advantage from the knowledge. References BIBLIOGRAPHY Campbell, n.d. [Online] Available at: http://writingpad. org/?tag=culture-defined-by-various-authorsHofstede, G., n.d. [Online] Available at: http://writingpad.org/?tag=culture-defined-by-various-authorsOberg, K., n.d. [Online].Outsourced. 2006. [Film] Directed by John Jeffcoat. s.l.: s. n.WordPress, 2016. [Online] Available at: https://h00251921.wordpress.com/2016/03/12/culture-clash-2/

Antisocial Networking

Nervous System.

Nervous System. The Nervous System is the body's information gatherer, storage center and control system. Its overall function is to collect information about the external conditions in relation to the body's internal state, to analyze this information, and to initiate appropriate responses to satisfy certain needs.Neurons.The cells that make up the nervous system arecalled neurons. Long, stringy neurons are perfect forcarrying the electrical messages that are the "language"of the nervous system.Brain.The brain is the command center of your entire body. The brain is the body's main information center. It is made of billions of neurons. The brain helps the body respond to the information it receives from the senses. The brain also processes thoughts.Spinal Cord.The spinal cord is a tube of neurons that runs up the spine and attaches to the brain stem. Information from nerves that branch out to the rest of the body goes to the spinal cord.Some messages are processed by the spinal cord but most informa tion is sent on to the brain.A Neuron consists of THREE MAIN PARTS:A. CELL BODY - The largest part, contains the nucleus and much of the cytoplasm (area between the nucleus and the cell membrane), most of the metabolic activity of the cell,B. DENDRITES - Short branch extensions spreading out from the cell body. Dendrites Receive STIMULUS (Action Potentials) and carry IMPULSES from the ENVIRONMENT or from other NEURONS AND CARRY THEM TOWARD THE CELL BODY.C. AXON - A Long fiber that CARRIES IMPULSES AWAY FROM THE CELL BODY. Each neuron has only ONE AXON. The Axon Ends in a series of small swellings called AXON TERMINALS.The CENTRAL NERVOUS SYSTEM serves as the CONTROL CENTER of the body. The Central Nervous System consists of the BRAIN and SPINAL...

Emergency Services Management - Advanced Interactions of Hazardous Essay

Emergency Services Management - Advanced Interactions of Hazardous Materials - - Essay Example According to Spellman (2007), risk mitigation involves plans to curb hazards from occurring or to prevent them from developing into unmanageable disasters in case they occur. More importantly, it focuses on long-lasting solutions aimed at reducing or eliminating risks. Besides mitigation, there are standardized instructions for untrained first respondent on how to carry out an emergency operation. As one of the resourceful tool of information, Emergency Response Guidebook (ERG) provides guidance to the HAZMAT personnel on how to manage accidents involving hazardous materials such as chlorine explosion during road or rail transport. Therefore, this discussion explores how reliable is the ERG in dealing with a hazardous substance release on an accident scene. However, other sources of information such as Safety Data Sheets (SDS) and submitted Tier II information can also be used. ERG provides explicit instructions on how to approach the scene of the incident. For instance, the response team should approach the scene from upstream and upwind since the wind blows away gases and fumes. Such kind of approach, therefore, enables them to move close enough before coming in direct contact with the released substance. On getting to the scene, they are required to make an assessment and look out for any signs of fire, leakage, or any person in danger. It will enable them to determine if there is a need for evacuation, as well as the resources needed for the entire operation. The response team would then secure the location and isolate it so as to restrict entry and reduce exposure to the hazards. Identifying the name and nature of the hazardous material is necessary so that you know what to expect and the protective measures to be taken. Shipping name of the material can be found in the shipping documents that are available in the cab of the vehicle or possession of a train crew member. Identification number of the substance can be

An investigation into the use of Six Sigma within the Irish Dissertation

An investigation into the use of Six Sigma within the Irish construction industry - Dissertation Example .8 Ethical Considerations 40 3.9 Method of Data Analysis 41 3.10 Conclusion 41 Chapter 4: Results and Discussion 42 4.1 Introduction 42 4.2 Results 42 4.3 Discussion 71 Chapter 5: Conclusions and Recommendations 77 5.1 Conclusions 77 5.2 Recommendations 79 References 82 Appendix A – Survey Questionnaire 87 List of Tables Table 1. Frequencies: Intent of the company to adopt Six Sigma in the near future. 43 Table 2. Frequencies: Number of years of existence of the company within the industry 43 Table 3. Frequencies: Company size in terms of number of employees. 44 Table 4. Descriptive statistics: Improvement of company metrics: Financial Aspect. 44 Table 5. Descriptive statistics: Improvement of company metrics: Customer Aspect. 45 Table 6. Descriptive statistics: Improvement of company metrics: Operations Aspect. 46 Table 7. Descriptive statistics: Assessment of leadership ability. 48 Table 8. Descriptive statistics: Assessment of leaders’ passion. 49 Table 9. Descriptiv e statistics: Management interest in quality improvement. 50 Table 10. Descriptive statistics: Customer focus. 51 Table 11. Descriptive statistics: Management of information. 53 Table 12. Descriptive statistics: Strategic management. 54 Table 13. Descriptive statistics: Assessment of the leader’s capacity to execute strategy. 55 Table 14. Descriptive statistics: Assessment of process management competence. 58 Table 15. Descriptive statistics: System of measurement. 59 Table 16. Descriptive statistics: Problem solving capacity. 60 Table 17. Descriptive statistics: Assessment of infrastructure, management system and resources. 61 Table 18. Descriptive statistics: Independent and dependent variables overall. 63 Table 19. Coefficient of determination: Predictors of Six Sigma adoption and use. 64 Table... The objective of the study aims to establish if key / top management ability influences the readiness of adoption and use of Six Sigma in the said industry. This factor was found to positively and significantly predict the readiness for adoption and use of Six Sigma within the Irish construction industry. The next objective is meant to establish if organisational ability influences the readiness of adoption and use of Six Sigma in the said industry. This variable did not significantly predict the dependent variable. Given the Six Sigma scheme’s propensity for facilitating business processes, it is applicable in a whole host of industries besides the manufacturing industry, the construction sector included. While traditional quality improvement initiatives focus heavily on detecting errors and then correcting them, a company operating under the Six Sigma scheme would be able to ensure that such errors never occur in the first place by establishing and then strictly adhering to a set of standards. The construction sector is the largest labour-intensive industry that makes significant contributions to the Irish economy (Duffy, Graham, and Thomas 2007). The process of planning in Ireland has brought about numerous regulations that emphasize the design, manufacturing and construction of buildings, particularly the need to adhere to quality standards and ensure that the expectations of owners or occupiers are met.

Immigration Term Paper Example | Topics and Well Written Essays - 1750 words

Immigration - Term Paper Example Immigration law is a complicated process and there are exceptions when enforcing these laws, especially when acts of a criminal nature are committed. Most immigrants are not aware of the potential risks involved, (especially those with a temporary or non-secure status) when they commit a criminal offense. Additionally, the terrorists’ acts of 911 have directly impacted immigration laws. When the United States national security is violated at point of entry by criminals who enter unnoticed it becomes a spiraling effect on its citizens. The numbers of immigrants that enter the United States borders (land, sea and air) every year are in the millions. It is virtually impossible to have a profile on every single individual. Some of these immigrants have criminal backgrounds and are on the run from their own country or they may possess no criminal record but have a high potential to become first time offenders in the United States. The citizens of the United States expect that immig ration law will protect them on a national level from potential criminals at the point of entry. However, many criminals have become very adept at disguising themselves in order to enter the United States. Sadly, they are not found until something disastrous occurs. These individuals put a strain on the infrastructure and services within our local communities. The costs for retaining immigrant criminals and processing them through our system are exorbitant spiraling into the millions. While local governments and law enforcement agencies face the direct burdens of immigrant criminals the costs spills over at the state and federal levels as well. Based on the severity of the crime most individuals will be deported after serving their time. An example of how a criminal act can affect immigration law is the case of â€Å"Padilla versus Kentucky†, (October 13, 2009 – March 31, 2010) whereby Mr. Padilla who lived in the United States for over 40 years and was a lawful perman ent resident, faced mandatory deportation after pleading guilty to drug distribution in the state of Kentucky. At his post conviction hearing he stated that his lawyer not only did not advise him that he could be deported but also told him that since he lived in America for such a long time there was no chance of him being deported. Well, there is no excuse for ignorance or misinformation in the court of law. There was a time when judges were very lax in deporting immigrants for criminal offenses but this was more than 90 years ago. Federal law now imposes strict guidelines for deportation of criminal offenses whether or not the individual has a status of lawful permanent resident. This case showed how immigration law and criminal law became intertwined. Mr. Padilla committed a criminal offense which was punishable under federal immigration laws. After the devastating attack of September 11, the immigration problem in the United States took a major turn. Terrorism was the new crime on the horizon. This was a downward turn in America’s economy. Military personnel had to be increased; diplomatic relations and initiatives with other countries had to be look at with scrutiny. The security at airports and several public places had to be increased. As a result changes in immigration and border patrol were directly affected. Nineteen of the terrorists apprehended from that major event were foreign citizens who entered the United States legally. The terrorists

Purpose of Economics and Price Mechanisms

Purpose of Economics and Price Mechanisms Task 1 Describe ‘economics’, the purpose of its activities and identify economic problem. Economic system is a system aim for producing, distributing and consuming goods and services. It includes the combination of the various institutions, agencies, consumers, entities that comprise the economic structure of a given society or community. Furthermore, it also includes how these agencies and institutions are related to each other, how information flows between them and the social relations within the system which including property rights and the structure of management. The mode of production will be the related concept. Every economic system provides solutions to four questions: what goods and services will be produced; how they will be produced; for whom they will be produced; and how they will be allocated between consumption (for present use) and investment (for future use). In a devolved economic system, these questions are resolved. This lead to economic coordination to achieved through the price mechanism(Elton, 2014). The basic economic problem is about scarcity and choice since there are only a limited amount of resources available to produce the unlimited amount of goods and services which human, people wants and needs. Because of scarcity, various economic decisions must be made to allocate resources efficiently. Resources A resource is a means of support also can be regarded as any feature of our environment that helps to support our well being. There are three main types of resource: The first Physical or natural resource – such as oil, climate, water, minerals, forests and fisheries. The second human resource – peoples and their various skills. The third man made resources – e.g. machines, equipments. Scarcity Scarcity can be broken down into four key ingredients of factors of production: Land – Land includes all natural resources. Labour – Labour includes all physical and mental effort. Capital – Capital includes machinery and other items that go into further production. Enterprise – enterprise is the art of combining the other three factors in the production process. Scarce goods and services As notes above, if did not exist, all goods and services would be free. A good is considered scarce if it has a non-zero cost to consume costs something and is scarce. By consuming one good, another good is foregone. Therefore decisions and trade-offs to be made.(T.Ming, 2014,) The cost of a food is a signal of its scarcity. One good maybe more scare than another, either because of limited resources or higher want (demand) for that good. Choice Because resources are scarce and most of our wants are extensive, a choice has to be made about how to use scare resources in the best way. Based on the choice, the highest-value option will be forgone and this is called ‘opportunity cost’. This rule applies to organisations, society as a whole, and to individuals. Choice and opportunity cost Choice and opportunity cost are two fundamental concepts in economics. Given that resources are limited, producers and consumers have to make choices between competing alternatives. All economic decisions involve making choices. Individuals must choose how best to use their skill and effort, firms must choose how best to use their workers and machinery, and governments must choose how to use taxpayer’s money. Making an economic choice creates a sacrifice because alternatives must be given up, which results in the loss of benefit that the alternative would have provided. Similarly, land and other resources, which have been used to build a new school could have been used to build a new factory. The loss of thenext bestoption represents the real sacrifice and is referred to asopportunity cost. The opportunity cost of choosing the school is the loss of the factory, and what could have been produced. It is necessary to appreciate that opportunity cost relates to the loss of the next best alternative, and not just any alternative. The true cost of any decision is always the closest option not chosen. (Bong, 2014) Define the theory of ‘price mechanism’ by Adam Smith and illustrate by examples(s) to supports yours answer with relevant issues. Adam Smith is one of the Founding Fathers of economics described the â€Å"invisible hand of the price mechanism† in which the hidden-hand of the market operating in a competitive market through the pursuit of self-interest allocated resources in society’s best interest. It was the notion of the invisible hand that enabled Adam Smith to develop the first comprehensive theory of the economy as an interrelated social system. (Tay, 2014) In common, the concept is composed of three logical steps: The first is the observation that human action often leads to consequences that were unintended and unforeseen by the actors. The second step is the argument that the sum of these unintended consequences over a large number of individuals or over a long period of time may, given the right circumstances, result in an order that is understandable to the human mind and appears as if it were the product of some intelligent planner. The third and final step is the judgments that the overall order is beneficial to the participants in the order in ways that they did not intend but nevertheless find desirable. The price mechanism performs three main functions: Rationing The aim is to ration scare resources when demand in market outstrips supply. When there is a shortage of a good, the price is bid up, leaving only those with the willingness and ability to pay to purchase the product. This can causes supply and demand to reach equilibrium of demand and supply. Signaling function They adjust to demonstrate where resources are required or not, via a change in demand. For example, the price of goods which are scarce will increase. This increase in price should provide an incentive for producers to increase production of the good so that can meet the demand. Transmission of preferences Consumers are able to alert producers to changes the nature in wants and needs through their choices so that the market provides the right amount of the right goods. When demand is weaker, then the supply will contracts as the producers cut back on output. Task 2 Identify factors affecting the economics of an organization. There are few types of competition in business. They are perfect competition, imperfect competition, and monopolistic competition. Perfect competition It is a low barrier to entry, many choices by consumers, and no business has supremacy. It means that many companies competing and nobody has a substantial lead. For examples, restaurants, grocery stores, barbers shop, shopping mall, professional services such as dentist, doctor, contractor and others. It is a theoretical state in which not only single buyer or seller has influence over the any products sold in the market. Sellers are free to enter the market to sell any product and buyers are free to purchase any product wanted. A large number of producers and sellers operate in the perfect competitive market, and the products sold by one producer are easily replaced by a similar product from another producer. Prices for goods or services would be established by the rate in majority of consumers are willing to pay and producers will adjusting the productivity to balance with the price. (ReemHeakal, 2014) Imperfect competition It describes a market where many firms offer variations of the same product or multiple products are offered with differences. The difference may be differs in quality, preference, durability, price or utility. However, firm will be forced to departure the market if their products are not purchase by consumers. For example, a hair style cutting may be assisted by more than numbers of barber shops which all differing in style, price and environment. Consumers are bound only by personal preference and affordability in choosing a barber shop. (Hans, 2014) Monopolistic competition The sellers feel they do have some competition. There is one big company dominating the market with a few medium or smaller sized companies. Identify source of finance. Source of finance Some sources of finance areshort termand must be paid back within a year. Other sources of finance arelong termand can be paid back over many years. Venture capital provides long-term, dedicated share capital to help unquoted companies grow and succeed. Obtaining venture capital is significantly different from raising debt or a loan from a lender. The lenders have a legal right to interest on a loan and repayment of the capital depends on the business weather success or failure. Venture capital is the money put into an enterprise which may all be lost if the enterprise fails. A businessman starting up a new business will invest venture capital of his own, but he will probably need extra funding from other source, and can be very successful if he gets very high profits and a substantial return on the investment. However, there must be a very high risk of losing the investment and it will take some times to get the return and profits. A venture capitalist will require a high expected rate of return on investments, to recompense for the high risk. Internal sourcesof finance are funds found inside the business. For example, profits can be kept back to finance expansion. Alternatively the business can sell assets that are no longer really needed to free up cash. Internal Sources of finance and growth It defined as organic growth which is the growth generated through the development and expansion of the business itself. An organic growth can be achieved through generating increasing sales which increase income to influence on overall profit levels. Besides that, it can be used of retained profit which used to reinvest in the business. Other than that, the company also can sale their asset which can be a double edged sword so that it can reduce the capacity. External sourcesof finance are found outside the business, eg fromcreditorsor banks. External Sources of finance and growth This can be categorizing into 3 groups which are long term, short term, and inorganic growth. Long term may be paid back after many years or not to be paid. Short term is used to cover variations in cash flow. The growth which generated by gaining is used to define inorganic growth. In long term, there are shares and loans can be practice. Long term There are few types of shares in long term shares which are ordinary shares, preference shares, new share issues, rights issue and bonus or scrip issue. Ordinary shares (Equities) Ordinary shareholders have the voting to rights in making any decision for company’s benefits. The dividend can be differing according to their contribution and share capital. Last to be paid back in event of collapse. They share the price varies with trade on stock exchange. Preference share The shareholders will be paid before ordinary shareholders. They have the fixed in return. It is cumulative preference shareholders which have the right to dividend carried over to next year in event of non-payment. Rights issue The present shareholders are given discount on buying new shares.Bonus or scrip issue- It is the change to the share structure which increase number of shares and reduces value but market capitalization will remain the same.There are few types of loan in long term loan which are Debentures, bank loans and mortgages, merchant or investment banks, and government. Debentures It has the fixed in rate of return which first to be paid.Bank loans and mortgages- It is suitable for small to medium sized of corporation where property or some other asset acts as security for the loan. Merchant or Investment Banks It act depends on clients to organize and underwrite raising finance. Short term There are some categories in 5 groups including bank loans, overdraft facilities, trade credit, factoring and leasing. Bank loans It has the necessity of paying interest on the payment. The periods of payment is generally from one year then not longer than ten years. Overdraft facilities It is the right to be able to withdraw funds that do not currently have. It provides flexibility for a firm. The interest only paid on the amount been overdrawn. There is an overdraft limit which is the maximum amount allowed to be drawn. Trade credit It can help the ease of cash flow which commonly can be paid within 90 days. Factoring It is about the sale of debt to a specialist firm who secures payment and charges a commission for the services. Leasing The used of capital can be secure without the ownership. It is effectively a hire agreement. Inorganic growth It is about achievement. The components to gain the external finance of inorganic growth are merger and also takeover. Merger The Company agrees to join together which both can remain some of the identity form. Takeover The firm will be secure control by the other, the firm taken over most probability will lose its identity. Task 3 Identify and describe types of financing sources which available for the said projects. On my opinion, this company should base on medium and long terms sources of finance. Medium term sources are usually repaid between 1 – 5 years. Some sources of finance areshort termand must be paid back within a year. Short term sources are repaid within one tear. Other sources of finance arelong termand can be paid back over many years. Long term sources are usually repaid between 5 – 20 years. Medium term Hire purchase:It involves purchasing an asset paying for it over a period of time. Usually a percentage of the price is paid as down payment and the rest is paid in installments for the period of time agreed upon. The business has to pay an interest on these installments. Leasing:Leasing involves using an asset, but the ownership does not pass to the user. Business can lease a building or machinery and a periodic payment is made as rent, till the time the business uses the assets. The business does not need to purchase the asset. Advantage Disadvantage The business can benefit from the asset without purchasing it. Usually the maintenance of the asset is done by the leasing firm. The total cost of leasing may end up higher than the purchasing of asset Medium term loans:The business borrows an agreed amount, which is advanced at the start of the loan. A repayment schedule between one and five years is agreed. Interest is charged in line with general interest rates and the category of the borrower is taken into consideration. The business will normally have to provide security for the loan but, with the cash raised, they can avail of cash discounts when buying assets. Leasing:This form of finance allows a business to use an asset without having to raise the full price. In essence, the business rents the asset from a financial institution. The advantage to the business is that it allows the business claim a tax deduction for the full leasing payments over the life of the lease. The downside is that the asset is not owned unless the business decides to buy out the lease. Leasing is appropriate for IT equipment, which may have to be changed every two to three years Long term Ordinary sharesmay be issued to finance a major expansion such as the building of a factory overseas. The board of directors must convince the existing shareholders or attract investors to subscribe to the new issue. The shareholders will expect a dividend and a capital gain on their investment. The proposed expansion must therefore be profitable or else the investors will be disappointed. Retained earningsare profits, which are ploughed back into the business to create growth. This form of finance is suitable for organic growth as the pace of the expansion can be matched to the funds available. The shareholders have to give up some or all of their dividends but, if growth is a success, the value of their shares will increase. Long-term loansare borrowed from financial institutions and must be repaid with interest within five to twenty years. If repayments can be met, borrowing allows the business to grow without introducing any new owners who would have a share of all future profits. Dunes Stores, one of Irelands leading retail chains, remains a private company and does not look for shareholder funds when expanding. Instead it uses borrowings and retained earnings. This means that a small family group retain absolute control of the business. Venture capitala special type of financial institution has been formed to help firms grow. Venture capital companies provide money for a limited period of time, usually in the form of a minority equity stake. It is hoped that at the end of this time the company will have grown large enough to achieve a stock exchange quotation. This allows the venture capital company to sell its shares for a large profit. Propose a financing source which is suitable for given project. Justify the reason of the chosen option. Some sources of finance are medium term and must be paid back within 5 – 10 years. Other sources of finance arelong termand can be paid back over many years. Long term sources are usually repaid between 5 – 20 years. Long term The term venture capital is more specifically associated with putting money, usually in return for an equity stake, into a new business, a management buy-out or a major expansion scheme. The institution that puts in the money recognizes the gamble inherent in the funding. There is a serious risk of losing the entire investment, and it might take a long time before any profits and returns materialize. But there is also the prospect of very high profits and a substantial return on the investment. A venture capitalist will require a high expected rate of return on investments, to compensate for the high risk. A venture capital organization will not want to retain its investment in a business indefinitely, and when it considers putting money into a business venture, it will also consider its exit, that is, how it will be able to pull out of the business eventually and realize its profits. Examples of venture capital organizations are: Merchant Bank of Central Africa Ltd and Anglo American Corporation Services Ltd. When a companys directors look for help from a venture capital institution, they must recognize that: The institution will want an equity stake in the company. It will need convincing that the company can be successful. It may want to have a representative appointed to the companys board, to look after its interests. The directors of the company must then contact venture capital organisations, to try and find one or more which would be willing to offer finance. A venture capital organisation will only give funds to a company that it believes can succeed, and before it will make any definite offer, it will want from the company management: A business plan Details of how much finance is needed and how it will be used The most recent trading figures of the company, a balance sheet, a cash flowforecast A profit forecast Details of the management team, with evidence of a wide range of management skills Details of major shareholders Details of the companys current banking arrangements and any other sources of finance Any sales literature or publicity material that the company has issued. A high percentage of requests for venture capital are rejected on an initial screening, and only a small percentage of all requests survive both this screening and further investigation and result in actual investments. 1

Ethics and Accounting :: Finance Business Accountant Accountancy

Ethics and Accounting What's ethics got to do with accounting? Everything! Believe me, everything. When the word ethics is mentioned, what readily comes to mind is the question of deciding between doing what is right and doing what is wrong. But doing what is right versus doing what is wrong within what context? The idealist will say that decisions of ethics should not be conditional. But it is not as simple as it sounds, for what constitutes "right" to one person, may be "wrong" to another person. What bridges the gap, guides, and clearly distinguishes the line between right and wrong in political, economic and social systems are traditions, culture, laws and regulations. Even then, what is unethical may not necessarily be illegal, even though there exists a close relationship between the two. These dynamics apply to almost every legal profession, accounting not exempted. This paper examines the issues of ethics in accounting. It also looks at the differences and similarities between financial accounting to managerial accounting. Introduction According to Marshall et al, (What the numbers mean, 2003) accounting involves "identifying, measuring, and communicating economic information about an organization for the purpose of making decisions and informed judgments." This definition clearly shows that there are stakeholders in the information generated by accountants. These include managers, shareholders, oversight and law enforcement agencies, and the general public. Since these entities rely on the reports generated by accountants for critical decision making, it is important that the information be reliable, objective, and presented in an easy to understand format. Ignoring or circumventing these values renders the information generated unreliable. It can lead to devastating consequences as evidenced by events which led to recent legislation such as the Sarbanes-Oxley Act which seeks to make top management of organizations accountable for the financial statement produced by their organizations through the internal controls they develop and enhance, and to oversee auditors who hitherto could have business interests other than auditing in the organizations they were responsible for auditing. Financial versus Managerial accounting Managerial accounting refers to the management of company resources while applying management accounting principles in decision making. One important characteristic of management accounting is that, it is internal to the organization even though external information such as financial accounting reports will have some amount of influence. Financial accounting refers to the identification, recording, computation, and reporting of financial information to users who may have a stake in the information reported. An important characteristic of this information is that it is geared towards users external to the company. A financial accountant generates information for external consumption. These products include the income statement, the balance sheet, the statement

Why a Safe but Challenging Environment Is Important

Medical Decision Making http://mdm. sagepub. com/ Do Patient Decision Aids Meet Effectiveness Criteria of the International Patient Decision Aid Standards Collaboration? A Systematic Review and Meta-analysis Annette M. O'Connor, Carol Bennett, Dawn Stacey, Michael J. Barry, Nananda F. Col, Karen B. Eden, Vikki Entwistle, Valerie Fiset, Margaret Holmes-Rovner, Sara Khangura, Hilary Llewellyn-Thomas and David Rovner Med Decis Making published online 14 September 2007 DOI: 10. 1177/0272989X07307319.   A more recent version of this article was published on – Oct 5, 2007 Published by: http://www. sagepublications. com On behalf of: Society for Medical Decision Making Additional services and information for Medical Decision Making can be found at: Email Alerts: http://mdm. sagepub. com/cgi/alerts Subscriptions: http://mdm. sagepub. com/subscriptions Reprints: http://www. sagepub. com/journalsReprints. nav Permissions: http://www. sagepub. com/journalsPermissions. nav Version of Re cord – Oct 5, 2007 ;; OnlineFirst Version of Record – Sep 14, 2007 What is This? Downloaded from mdm. sagepub. com by guest on July 22, 2012 Med Decis Making OnlineFirst, published on September 14, 2007 as doi:10. 1177/0272989X07307319 Do Patient Decision Aids Meet Effectiveness Criteria of the International Patient Decision Aid Standards Collaboration? A Systematic Review and Meta-analysis Annette M. O’Connor, RN, PhD, Carol Bennett, MSc, Dawn Stacey, RN, PhD, Michael J. Barry, MD, Nananda F. Col, MD, MPH, MPP, Karen B. Eden, PhD, Vikki Entwistle, PhD, Valerie Fiset, MScN, Margaret Holmes-Rovner, PhD, Sara Khangura, Hilary Llewellyn-Thomas, PhD, David Rovner, MD Objective. Related article: Explain the Post 16 Options 2017 To describe the extent to which patient decision aids (PtDAs) meet effectiveness standards of the International Patient Decision Aids Collaboration (IPDAS). Data sources. Five electronic databases (to July 2006) and personal contacts (to December 2006). Results. Among 55 randomized controlled trials, 38 (69%) used at least 1 measure that mapped onto an IPDAS effectiveness criterion. Measures of decision quality were knowledge scores (27 trials), accurate risk perceptions (12 trials), and value congruence with the chosen option (3 trials). PtDAs improved knowledge scores relative to usual care (weighted mean difference [WMD] = 15. %, 95% confidence interval [CI] = 11. 7 to 18. 7); detailed PtDAs were somewhat more effective than simpler PtDAs (WMD = 4. 6%, 95% CI = 3. 0 to 6. 2). PtDAs with probabilities improved accurate risk perceptions relative to those without probabilities (relative risk = 1. 6, 95% CI = 1. 4 to 1. 9). Relative to simpler PtDAs, detailed PtDAs improved value cong ruence with the chosen option. Only 2 of 6 IPDAS decision process criteria were measured: feeling informed (15 trials) and feeling clear about values (13 trials). PtDAs improved these process measures relative to usual care (feeling uninformed WMD = –8. , 95% CI = –11. 9 to –4. 8; unclear values WMD = –6. 3, 95% CI = –10. 0 to –2. 7). There was no difference in process measures when detailed and simple PtDAs were compared. Conclusions. PtDAs improve decision quality and the decision process’s measures of feeling informed and clear about values; however, the size of the effect varies across studies. Several IPDAS decision process measures have not been used. Future trials need to use a minimum data set of IPDAS evaluation measures. The degree of detail PtDAs require for positive effects on IPDAS criteria should be explored. Key words: decision support techniques; patient education; patient participation; randomized controlled trials. (Med Decis Making 2007;XX:xx–xx) Received 23 July 2007 from the Ottawa Health Research Institute, Canada (AMO, SK, CB); University of Ottawa, Canada (AMO, DS); Massachusetts General Hospital, Boston (MJB); Maine Medical Center, Portland, Maine (NFC); Oregon Health and Science University, Portland (KBE); Social Dimensions of Health Institute, Dundee, UK (VE); Algonquin College, Ottawa, Canada (VF); Michigan State University, East Lansing (MH-R, DR); and Dartmouth Medical School, Hanover, New Hampshire (HL-T). Financial support for this study was provided by a group grant of the Canadian Institutes of Health Research. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, and writing and publishing the report. Address correspondence to Annette M. O’Connor, RN, PhD, University of Ottawa, Ottawa Health Research Institute, 1053 Carling Avenue, ASB, Ottawa, Ontario, Canada K1Y 4E9; e-mail: [email  protected] ca. DOI: 10. 1177/0272989X07307319 P atient decision aids (PtDAs) are adjuncts to counseling that explain options, clarify personal values for the benefits versus harms, and guide patients in deliberation and communication. With the rapid proliferation of these tools, the International Patient Decision Aids Collaboration (IPDAS) has reached agreement on criteria for judging the quality of PtDAs. 1 IPDAS is a network of more than 100 researchers, practitioners, patients, and policy makers from 14 countries. These collaborators developed a checklist of criteria that payers, patients, practitioners, developers, and researchers can use to assess PtDAs they encounter. The criteria address 3 domains of quality: clinical content, the development process, and effectiveness. 554 †¢ MEDICAL DECISION MAKING/MON–MON 2007 Downloaded from mdm. sagepub. com by guest on July 22, 2012 Copyright 2007 by Society for Medical Decision Making.DECISION AIDS â€Å"EFFECTIVENESS CRITERIA OF DECISION AIDS†This article addresses the 3rd domain, the evaluation of PtDAs’ effectiveness in fostering a high-quality decision process and a high-quality choice. Over the past decade, there has been considerable debate about the definition of a good decision when there is no single best therapeutic action and choices depend on how patients value benefits versus harms. 2–6 To select criteria for decision quality, IPDAS participants were asked to identify â€Å"the things that you would nee d to observe in order to say that after using a patient decision aid, the way the decision was made was good and the choice that was made was good. IPDAS endorsed the following criteria for establishing that a decision aid is effective: †¢ Decision quality: The PtDA improves the match between the chosen option and the features that matter most to the informed patient. †¢ Decision processes leading to decision quality: The PtDA helps patients to recognize that a decision needs to be made, know options and their features, understand that values affect the decision, be clear about the option features that matter most, discuss values with their practitioner, and become involved in preferred ways. Our study objectives were 1) to describe the number and types of measures used in randomized controlled trials (RCTs) that correspond to IPDAS criteria for effectiveness and 2) to determine the extent to which RCTs of PtDAs meet these new IPDAS criteria for effectiveness. METHODS We have been updating the Cochrane Review of decision aids since the late 1990s. 7–9 This review differed from previous reviews by focusing on the new IPDAS criteria. Moreover, we used a new systematic review software, TrialStat SRS, to manage the search and data extraction; therefore, our search, screen, and data extraction were redone completely. Data sources included 1) electronic databases to July 2006 (MEDLINE, PsycINFO, CINAHL, and EMBASE), 2) Cochrane Controlled Trials Register (2006, issue 2), and 3) contact with known developers and evaluators to December 2006. The search strategy is described in the appendix. The search was not restricted on the basis of language. PtDAs were defined as interventions designed to help people make specific, deliberated choices among options (including the status quo) by providing information about the options and outcomes (e. . , benefits, DECISION AIDS: PAST, PRESENT, AND FUTURE harms) in sufficient detail that an individual could judge their value implicitly. Patient decision aids may also include information about the clinical condition, outcome probabilities tailored to personal risk factors, an explicit values clarification exercise (e. g. , a relevance chart, utility assessments of probable outcome states, a weigh scale), descriptions of others’ experiences, and guidance in the steps of decision making and communicating with others. This definition excludes interventions focused solely on lifestyle changes, hypothetical situations, clinical trial entry, or general advanced directives; education programs not geared to a specific decision; and interventions designed to promote adherence to a recommended option or to elicit passive informed consent. In the current review, we also excluded studies whose PtDAs were not available for inspection to catalogue their elements according to the new IPDAS domains. As a consequence, a few studies reported in the previous reviews were not included. We included published RCTs comparing 1) PtDAs to usual-care controls or 2) detailed PtDAs to simpler ones (which may not have the level of detail or may not contain all of the IPDAS elements). Participants were deciding about screening or treatment options for themselves, for a child, or for an incapacitated significant other. Two reviewers independently screened each study (CB, SK, DS, AMO, VF), extracted data (CB, SK), and assessed study quality (C. B. , S. K. ) using standardized forms, including the Jadad scale. 0 Inconsistencies were resolved by consensus. Trial results were described individually. Metaanalysis was used for decision quality and for decision process measures because these effects were expected to be independent of the type of decision. Meta-analysis was performed only on those outcomes with similar types of measures. Review Manager 4. 211 was used to estimate a weighted treatment effect (with 95% confidence intervals [CIs]), defined as weighted mean differences ( WMDs) for continuous measures and pooled relative risks (RRs) for dichotomous outcomes. The data used in each meta-analysis can be viewed in the online supplement available at http://mdm. sagepub. com/cgi/ content/full/Volume/Issue/Page#/DC1. All data were analyzed with a DerSimonian and Laird12 random effects model because of the diverse nature of the trials. Forest plots were used to assess and display potential heterogeneity, and funnel plots were used to explore publication bias. Because of statistically significant heterogeneity for most of the outcomes, we performed post hoc subanalyses to explore the potential causes of heterogeneity. Heterogeneity was explored according 555 Downloaded from mdm. sagepub. com by guest on July 22, 2012 O’CONNOR AND OTHERS to the following factors: type of decision (treatment versus screening), type of media of decision aid (video/ computer versus audio booklet/pamphlet), and a possible ceiling effect based on good usual-care scores (removal of studies with lower knowledge and realistic risk perception scores; removal of studies with higher decisional conflict scores for subscales feeling uninformed and unclear values). We analyzed the effects of removing the biggest outlier(s) defined by visual inspection of the forest plots. In addition, a post hoc analysis was performed to examine the effect of 1) excluding trials of low methodological quality and 2) excluding trials that were outliers and contributed to heterogeneity.RESULTSOf the 22,778 unique citations obtained in the review, we identified 1293 as relevant by title and then screened those abstracts (see Figure 1). Of these, 130 citations were retrieved for full-text review. Sixty-four studies were excluded for the following reasons: the study was not focused on making a choice (n = 33), the study was not an RCT (n = 14), the decision support intervention did not meet the definition of a PtDA (n = 8), the study involved a hypothetical situation (n = 6), and no outcome data were provided (n = 3). In all, 55 eligible trials (66 references) were found for duplicate data extraction and analysis. The 55 published RCTs evaluating individual PtDAs13–78 used 51 different PtDAs that focused on 23 different screening or treatment topics (see Table 1). Among the 51 different PtDAs, the elements most frequently included were information about the options and outcomes in sufficient detail to judge their value implicitly (100% by definition), information about the clinical condition (98%), outcome probabilities (84%), examples of others’ experiences (59%), explicit values clarification exercises (55%), and guidance in the steps of decision making (47%). Quality ratings in the trials ranged from 0/5 to 3/5. All studies lost 2 points because patients or practitioners could not be blinded to the intervention. As shown in Table 2, 38 of the 55 trials (69%) reported at least 1 outcome that could be mapped onto an IPDAS criterion for effectiveness; 33 (60%) measured some aspect of decision quality, and 15 (27%) measured a decision process leading to decision quality. Decision Quality As noted above, the definition of decision quality has 2 elements: the extent to which decisions are 556 †¢ MEDICAL DECISION MAKING/MON–MON 2007 informed and based on personal values. Trials used 3 measures corresponding to this definition: knowledge test results, accuracy of risk perceptions, and value congruence with chosen option. Knowledge. Twenty-seven of the 55 studies examined the effects of PtDAs on knowledge; 18 of these compared PtDAs to usual care, and 9 compared PtDAs with more or less detail. The studies’ knowledge tests were based on information contained in the PtDA, thereby establishing content validity. The proportion of accurate responses was transformed to a percentage scale ranging from 0% (no correct responses) to 100% (perfectly accurate responses). In the comparison of PtDAs to usual care15,16,18,26,28,29, 31,36,39,41,43,48,50,64,65,69,73,78 (Figure 2), PtDAs had higher average knowledge scores (WMD = 15. 2%, 95% CI = 11. 7, 18. 7). The 9 studies comparing detailed with simpler PtDAs22,24,30,35,54,60,61,63,66 (Figure 3) showed a smaller effect (WMD = 4. 6%, 95% CI = 3. 0, 6. 2). Accurate risk perceptions. Eleven of 55 studies examined the effects of including probabilities of PtDAs on the accuracy of patients’ perceived probabilities of outcomes. 4,28,41,43–45,54,63,73,74,77 Eight studies measured perceived probabilities as percentages,24,28,43–45,54,73,74 and 3 gauged probabilities in words. 41,63. 77 Perceived outcome probabilities were classified as accurate according to the percentage of individuals whose judgments corresponded to the scientific evidence about the chances of an outcome for similar people. In 4 of 5 studies that elicited perceived probabilities for multiple outcomes,24,44,54,60 the propo rtion of realistic expectations was averaged; in the remaining study,43 the most conservative result was chosen for meta-analysis. People who received a detailed PtDA with descriptions of outcomes and probabilities were more likely to have accurate risk perceptions than those who did not receive this information; the pooled RR of having accurate risk perceptions was 1. 6 (95% CI = 1. 4, 1. 9; Figure 4). The pooled relative risk for probabilities described in words was 1. 3 (95% CI = 1. 1, 1. 5). The pooled relative risk for probabilities described as numbers was 1. 8 (95% CI = 1. 4, 2. 3). Value congruence with chosen option. Four of 55 studies measured value congruence with the chosen option; however, Lerman and others41 did not calculate differences between interventions. The 3 trials comparing interventions were similar in that they 1) focused on the decision to take menopausal hormone replacement therapy (HRT) and 2) compared 2 active interventions. However, these trials used different measures of value (text continued on p 565) Downloaded from mdm. sagepub. com by guest on July 22, 2012 DECISION AIDS â€Å"EFFECTIVENESS CRITERIA OF DECISION AIDS† 2,778 unique citations identified for initial screening (screening based on review of the title) 1,293 potentially relevant citations identified and screened (based on review of the abastract) for retrieval 130 citations retrieved for full-text review 64 excluded: study not focused on making a choice (n = 33); study was not RCT (n = 14); decision support intervention did not meet the definition of a PtDA (n = 8); study involved a hypothetical situatio n (n = 6); no outcome data provided (n = 2); protocol only (n = 1) 5 eligible trials (66 references) for duplicate data extraction Data entry & RCT meta- analysis Figure 1 Flowchart of the procedural steps in the systematic review. RCT = randomized controlled trial; PtDA = patient decision aid. DECISION AIDS: PAST, PRESENT, AND FUTURE Downloaded from mdm. sagepub. com by guest on July 22, 2012 557 Table 1 Elements in DAs Characteristics of 55 Trials Included in the Systematic Review of Patient Decision Aids 558 Number of Enrollees in Intervention + Comparison: Options Considered Quality Rating (Jadad) Others’ Experiences Comparison of Most and Least Intensive Intervention Options and Clinical Outcomes Problem Explicit Outcome Values Probability Clarification Guidance in Steps of DM Source, Year, Location Auvinen and others13,14 2004, Finland 3/5 1/5 2/5 3/5 2/5 2/5 — X — X X X — — X X X — — X — X X — — X X — — X — X — — — X — — X X X — X — — — X — — — — — X — — — X — — — X — — — — — — — — X — — Barry and others15 1997, United States Bekker and others,16,17 2004, United Kingdom Bernstein and others18 1998, United States Pamphlet PtDA Standard care by clinical guideline Interactive videodisc PtDA Usual care Decision analysis plus consultation Usual care Video PtDA Usual care Clancy and others19 1988, United States 30 + 30 men: prostate cancer treatment 67 + 61 women: HRT 1/5 — X X X X X X X X X — X X X X X 103 + 100 men: prostate cancer treatment 104 + 123 men: benign prostate hypertrophy treatment 59 + 58 women: prenatal diagnostic screening for Down syndrome 65 + 53 patients: ischemic heart disease treatment 753 + 263 physicians: hepatitis B vaccine Davison and Degner20 1997, Canada Deschamps and others21 2004, Canada 3/5 — X X X — X — X — X — — — X — X — X — X — X — — — X — — — X — X Downloaded from mdm. sagepub. com by guest on July 22, 2012 Deyo and others22 2000; Phelan and others23 2001, United States 2/5 Dodin and others24 2001, Canada 50 + 47 adults: colon cancer screening 3/5 2/5 3/5 143 + 144 parents: infant polio vaccine schedules 112 + 114 men: PSA testing 190 + 203 patients: herniated disc or spinal stenosis treatment 52 + 49 women: HRT Pamphlet + decision analysis PtDA Usual care Written materials, PtDA, and audiotape of consultation Usual care Audiotape and booklet Pharmacist consultation Interactive videodisc PtDA Simple PtDA pamphlet Audiotape booklet PtDA Simple PtDA pamphlet Dolan and Frisina25 2002, United States Dunn and others26 1998, United States Frosch and others27 2003, United States — X — X X X X X X X — X — X X — — — — — — X — X X — — — — — Computer: analytic hierarchy process and pamphlet PtDA Usual care Video and pamphlet PtDA Usual care Video PtDA Internet presentation mirroring content of video continued) Gattellari and Ward28 2003, Australia 3/5 3/5 3/5 X X — X — X — X X — X X — X — X X — — X — — — — — X X — — — X — — X — — — X — X â⠂¬â€ X — X — X X X X X X — X — X — X — — — — — X — — — — — X — X — X — X — X — X — — — — — 140 + 140 men: PSA testing 86 + 50 women: breast cancer surgery 1/5 126 + 122 men: PSA testing Gattellari and Ward29 2005, Australia Goel and others30 2001, Canada Green and others31 2001, United States 3/5 CD-ROM PtDA plus counseling Genetic counseling Pamphlet PtDA Usual care Pamphlet PtDA General information leaflet Pamphlet PtDA General information leaflet Audiotape and booklet PtDA Simple PtDA pamphlet CD-ROM PtDA plus counseling Usual care Green and others32,33 2004, United States 0/5 2/5 Herrera and others34 1983, United States Hunter and others35 2005, Canada 3/5 3/5 2/5 3/5 Audiotape and booklet PtDA Usual care Audiotape and booklet Individual genetic counseling Decision board PtDA Usual care Video plus booklet PtDA Usual care Booklet PtDA Personal risk profile X — X — X — X — X X X — 2/5 X X X — X — X X X — X X X — X X 9 + 14 higher risk women: breast cancer genetic testing 106 + 105 higher risk women: breast cancer genetic testing 56 + 47 parent(s): circumcision of male newborns 116 + 126 women: prenatal diagnostic testing X — X — X X X — X X X — X X — — X — X — X — X — X — — — Downloaded from m dm. sagepub. com by guest on July 22, 2012 Johnson and others36 2006, United States Kennedy and others37 2002, United Kingdom Lalonde and others38 2006, Canada — — X — X — X — X — X — — — — — X — X — X — X — X — X — (continued) Laupacis and others39 2006, Canada 2/5 Legare and others40 2003, Canada 122 + 164 women: breast cancer genetic testing 100 + 101 women: prenatal diagnostic testing 1/5 32 + 35 patients: dental surgery 300 + 298 women: menorrhagia treatment 13 + 13 patients: cardiovascular health treatment 60 + 60 patients: preoperative autologous blood donation 97 + 87 women: HRT erman and others41 1997, United States Leung and others42 2004, China Audiotape booklet PtDA Simple pamphlet PtDA Discussion PtDA and counseling Usual care wait list control Interactive multimedia PtDA Video and pamphlet 559 Table 1 Elements in DAs continued) 560 Number of Enrollees in Intervention + Comparison: Options Considered Quality Rating (Jadad) Others’ Experiences Comparison of Most and Least Intensive Intervention Options and Clinical Outcomes Problem Explicit Outcome Values Probability Clarification Guidance in Steps of DM Source, Year, Location Man-Son-Hing and others43 1999, Canada — X X X X — — — 3/5 1/5 2/5 X X X X X X — X — X — X — X — X — X — X — X — X — X — — — X — X 3/5 Audiotape and booklet PtDA Usual care X X X X X — X — X — — — — — — X — X — X — — — — — — McAlister and others44 2005, Canada McBride and others45,46 2002, United States Miller and others47 2005, United States 139 + 148 aspirin users in atrial fibrillation trial: move to warfarin 219 + 215 patients: antithrombotic therapy 289 + 292 women: HRT 279 women: BRCA1 BRCA2 gene testing Montgomery and others48,49 2003, United Kingdom 52 + 55 + 51 + 59 adults: hypertension treatment 3/5 Downloaded from mdm. sagepub. com by guest on July 22, 2012 Morgan and others50 2000, Canada 3/5 3/5 — X — X — X — X X — X — X — X — X X — X — X — X — — — — — — — — — — X — — X — X — X — — — — — — — — — — X — Murray and others51 2001, United Kingdom 3/5 2/5 Murray and others52 2001, United Kingdom Myers and others53 2005, United States 121 + 121 men: PSA testing 120 + 120 patients: ischemic heart disease treatment 57 + 55 men: benign prostate hypertrophy treatment 102 + 102 women: HRT Audiotape and booklet PtDA Usual care Pamphlet PtDA Usual care Discussion PtDA and general information pamphlets General information pamphlets Decision analysis PtDA Video and booklet PtDA Decision analysis, video and booklet PtDA Standard care Interactive videodisc PtDA Usual care Interactive videodisc PtDA Usual care O’Connor and others54 1998, Canada 81 + 84 women: HRT 1/5 X X X X X — X — X — X — Interactive videodisc PtDA Usual care Discussion PtDA and general information pamphlet General information pamphlet Audiotape and booklet PtDA Simple PtDA pamphlet O’Connor and others55 1999, Canada 3/5 X X X X X X 1/5 3/5 0/5 — X — X — X — X — X — — — — — — — X — — X X X X X X — X X X X X — — — X 16 + 17 women: osteoporosis treatment 384 + 384 men: PSA testing 37 + 37 patients: dental orthognathic surgery 3/5 3/5 X X X — X — X — X — — — — — — — — X — X 101 +100 women: HRT Oakley and Walley56 2006, United Kingdom Partin and others57 2004, Canada Phillips and others58 1995, United States Pignone and others59 2000, United States Audiotape and booklet PtDA DA without explicit values clarification Audiotape and booklet PtDA Usual care Video PtDA Usual care Video imaging of facial reconstruction PtDA Usual care Video PtDA Usual care — — — X Rostom and others60 2002, Canada X X X X X X — X X X X X X X X X — X — — — 125 + 124 adults: colon cancer screening 25 + 26 women: HRT X X X X — — — — — — — — — — X X — — — — — 83 + 89 women: HRT 1/5 Computer PtDA with testing + feedback regarding knowledge Audiotape with booklet Lecture with personal decision exercise PtDA Simple PtDA pamphlet Booklet PtDA Simple PtDA pamphlet Booklet PtDA Usual care Rothert and others61 1997; Holmes-Rovner and others62 1999, United States Schapira63 2000, United States 1/5 2/5 Downloaded from mdm. sagepub. com by guest on July 22, 2012 Schwartz and others64 2001, United States 2/5 Booklet PtDA Usual care Shorten and others65 2005, Australia X — X — X — X — — — X — Street and others66 1995, United States 1/5 22 + 135 men: prostate cancer screening 191 + 190 Ashkenazi Jewish women: breast cancer genetic testing 85 + 84 pregnant women: birthing options after previous cesarean delivery 30 + 30 women: breast cancer surgery Interactive multimedia PtDA Simple PtDA X X X X — — — — X — X — (continued) 561 562 Table 1 Elements in DAs (continued) Source, Year, Locat ion Number of Enrollees in Intervention + Comparison: Options Considered Quality Rating (Jadad) Comparison of Most and Least Intensive Intervention Options and Clinical Outcomes Problem Explicit Outcome Values Probability Clarification Others’ Experiences Guidance in Steps of DM VanRoosmalen and others67,68 2004, the Netherlands X X — X — X — X — X — X — X — X X — — X — X — X — — X — — X — X — X — X — X — X — X X X X — — — — — — — — — — — — — X — 44 + 44 women with BRCA1/2 mutation: prophylactic surgery 3/5 X X X X — — X — — — — — — — X — — — — — X X — — — — — — — — — — — — — — Volk and others69,70 1999, United States 3/5 3/5 3/5 80 + 80 men: prostate cancer screening Vuorma and others71,72 2003, Finland Video and brochure PtDA with decision analysis Same video and brochure PtDA pamphlet Video with pam phlet PtDA Usual care Booklet PtDA Usual care Whelan and others73 2003, Canada 3/5 2/5 184 + 179 women: menorrhagia treatment 82 + 93 women: breast cancer chemotherapy Downloaded from mdm. sagepub. com by guest on July 22, 2012 Whelan and others74 2004, Canada Wolf and others75,76 1996, United States 1/5 2/5 Script PtDA Usual care Pamphlet PtDA Usual care 94 + 107 women: breast cancer surgery 103 + 102 men: prostate cancer screening Decision board PtDA and booklet Usual care with booklet Decision board PtDA Usual care Script PtDA Usual care Wolf and Schorling77 2000, United States Wong and others78 2006, United States 266 + 133 seniors: colon cancer screening 162 + 164 women: pregnancy termination Note: DM = decision making; PtDA = patient decision aid; HRT = hormone replacement therapy; PSA = prostate-specific antigen. Table 2 Cumulative Studies Still in 2007 Review Reporting Outcome in Each Cochrane Review Update Year % n/N Lead Author 15 50 18 Trials Measuring Outcomes That Map onto the International Patient Decision Aid Standards (IPDAS) Criteria Outcome Decision quality 2007 1999 2003 15 27 2/13 8/30 49 27/55 Knowledge scores 999 2003 54 57 7/13 17/30 Realistic expectations, accurate risk perceptions Barry, Morgan, Bernstein, Lerman,41 Rothert,61 O’Connor,54 Street66 As above plus Schwartz,64 Man-Son-Hing,43 Volk,69 Dunn,26 Green,31 Goel,30 Shapira,63 Rostom,60 Phelan,23 Dodin24 As above plus Bekker,16 Gattellari,28 Johnson,36 Whelan,73 Shorten,65 Montgomery,48 Gattellari,29 Laupacis,39 Wong,78 Hunter35 OConnor,54 Lerman41 As above plus Wolf,77 McB ride,45 Man-Son-Hing,43 Rostom,60 Shapira,63 Dodin24 As above plus Whelan,74 Whelan,73 McAlister,44 Gattellari28 Value congruence with chosen option Decisional Conflict Scale (DCS) 2007 1999 2003 2007 1999 2003 2007 80 2007 1999 2003 2007 1999 2003 57 15 30 27 15 33 24 15/55 2/13 10/30 13/55 2/13 9/30 17/30 Downloaded from mdm. sagepub. com by guest on July 22, 2012 22 0 10 5 15 30 12/55 0/13 3/30 3/55 2/13 9/30 Decision process leading to decision quality Feeling informed, subscale of the DCS Feeling clear about values, subscale of DCS O’Connor,55 Holmes-Rovner,62 Dodin24 As above OConnor,54 Morgan50 As above plus Murray,51 Murray,52 Dolan,25 Man-Son-Hing,43 Dodin,24 Goel,30 OConnor55 As above plus Montgomery,48 Shorten,65 Laupacis,39 Whelan,74 McAlister,44 Lalonde,38 Legare,40 Hunter35 O’Connor,54 Morgan50 As above plus Murray,51 Murray,52 Dolan,25 Man-Son-Hing,43 Dodin,24 Goel,30 OConnor55 As above plus Montgomery,48 Laupacis,39 McAlister,44 Wong,78 Bekker,16 Lalonde38 O’Connor,54 Morgan50 As above plus Murray,51 Murray,52 Dolan,25 Man-Son-Hing,43 Dodin,24 Goel,30 OConnor55 As above plus Montgomery,48 Laupacis,39 McAlister,44 Lalonde38 Note: Trials included in 1999 and 2003 but not in 2007 are Davison and others (measuring feeling informed, clear values); Maisels and others,81 Michie and others82 (measuring knowledge scores), and Thornton and others. 83 These authors were eliminated because we were unable to verify what was in their decision aid to meet the IPDAS definition of a decision aid. 563 O’CONNOR AND OTHERS Study or subcategory y Bekker 2004 Gattellari 2003 Johnson 2006 Whelan 2003 Schwartz 2001 Man-Son-Hing 1999 Morgan 2000 Shorten 2005 Montgomery 2003 Gattellari 2005 Laupacis 2006 Volk 1999 Lerman 1997 Barry 1997 Wong 2006 Bernstein 1998 Dunn 1998 Green 2001 N Decision Aid Mean (SD) 74. 00(14. 50) 50. 00(18. 40) 92. 60(11. 00) 80. 20(14. 40) 65. 71(14. 29) 75. 91(15. 72) 76. 00(32. 04) 75. 33(15. 00) 75. 00(17. 00) 57. 20(21. 30) 83. 00(19. 50) 48. 00(22. 40) 68. 90(19. 00) 75. 00(45. 00) 85. 00(26. 70) 83. 00(16. 00) 83. 67(23. 13) 95. 00(7. 00) N Usual Care Mean (SD) 71. 50(16. 00) 45. 00(15. 90) 85. 20(15. 60) 71. 70(13. 30) 57. 14(15. 71) 66. 46(16. 07) 62. 00(32. 04) 60. 53(17. 07) 60. 00(18. 00) 42. 20(16. 70) 67. 40(17. 00) 31. 00(18. 30) 49. 00(21. 70) 54. 00(45. 00) 60. 00(21. 70) 58. 00(16. 00) 55. 53(22. 80) 65. 00(21. 00) W MD (random) 95% CI W eight % 5. 68 6. 3 5. 49 6. 16 6. 41 6. 24 4. 61 6. 04 5. 43 6. 03 5. 32 5. 50 6. 00 3. 84 5. 81 5. 61 5. 83 3. 97 100. 00 W MD (random) 95% CI 2. 50 [-3. 31, 8. 31] 5. 00 [0. 39, 9. 61] 7. 40 [0. 98, 13. 82] 8. 50 [4. 37, 12. 63] 8. 57 [5. 55, 11. 59] 9. 45 [5. 68, 13. 22] 14. 00 [4. 81, 23. 19] 14. 80 [10. 23, 19. 37] 15. 00 [8. 39, 21. 61] 15. 00 [10. 40, 19. 60] 15. 60 [8. 64, 22. 56 ] 17. 00 [10. 61, 23. 39] 19. 90 [15. 17, 24. 63] 21. 00 [9. 25, 32. 75] 25. 00 [19. 60, 30. 40] 25. 00 [18. 95, 31. 05] 28. 14 [22. 83, 33. 45] 30. 00 [18. 71, 41. 29] 15. 22 [11. 71, 18. 73] 50 106 32 82 191 137 90 99 50 131 53 78 122 104 154 61 143 29 6 108 35 93 190 136 97 92 58 136 53 80 164 123 159 48 144 14 Total (95% CI) 1712 1786 Test for heterogeneity: ? 2 = 130. 32, df = 17 (P ; 0 . 00001), I? = 87. 0% Test for overall effect: Z = 8. 50 (P ; 0. 00001) -50 Favors Usual Care 0 50 Favors Decision Aid Figure 2 Effect of patient decision aids on patients’ mean scores on knowledge tests: decision aid versus usual care. WMD = weighted mean difference; CI = confidence interval. Study N Goel 2001 Rothert / H-Rovner O'Connor 1998-RCT Hunter 2005 Schapira 2000 Street 1995 Rostom 2002 Deyo / Phelan Dodin 2001 Total 77 83 81 116 122 30 25 41 52 627 Detailed DA Mean (SD) 81. 67(11. 1) 86. 79(11. 34) 75. 00(20. 00) 64. 53(19. 61) 83. 33(12. 78) 82. 60(11. 60) 93. 80(9. 00) 71. 76 (17. 06) 71. 04(15. 45) N Simple DA Mean (SD) 80. 00(12. 22) 83. 75(11. 54) 71. 00(21. 00) 60. 13(19. 00) 78. 33(15. 00) 76. 40(13. 80) 87. 10(11. 80) 62. 35(23. 53) 61. 20(17. 90) WMD (random) 95% CI Weight % 14. 31 21. 90 6. 62 10. 92 22. 45 6. 23 7. 85 3. 67 6. 06 100. 00 WMD (random) 95% CI 1. 67 [-2. 59, 5. 93] 3. 04 [-0. 40, 6. 48] 4. 00 [-2. 26, 10. 26] 4. 40 [-0. 47, 9. 27] 5. 00 [1. 60, 8. 40] 6. 20 [-0. 25, 12. 65] 6. 70 [0. 95, 12. 45] 9. 41 [1. 00, 17. 82] 9. 84 [3. 30, 16. 38] 4. 63 [3. 02, 6. 24] 48 87 84 126 135 30 26 49 49 634 Test for heterogeneity: ? 2 = 7. 18, df = 8 (P = 0. 52 ), I? = 0% Test for overall effect: Z = 5. 63 (P < 0. 00001) -50 Favours Simple 0 50 Favours Detailed Figure 3 Effect of patient decision aids (DAs) on patients’ mean scores on knowledge tests: detailed versus simple decision aids. WMD = weighted mean difference; CI = confidence interval. 564 †¢ MEDICAL DECISION MAKING/SEP–OCT 2007 Downloaded from mdm. sagepub. com by guest on July 22, 2012 DECISION AIDS â€Å"EFFECTIVENESS CRITERIA OF DECISION AIDS† Study or subcategory y Decision Aid n/N 90/122 189/266 73/94 109/265 82/122 33/52 58/81 47/82 70/187 88/139 57/106 1516 Usual Care n/N 108/164 72/133 62/107 82/274 62/135 21/49 39/84 34/92 27/165 40/148 11/108 1459 RR (random) 95% CI W eight % 11. 11 10. 83 10. 55 10. 01 10. 16 7. 66 9. 45 8. 54 7. 54 9. 04 5. 12 100. 00 RR (random) 95% CI 1. 12 [0. 96, 1. 31] 1. 31 [1. 10, 1. 56] 1. 34 [1. 10, 1. 63] 1. 37 [1. 09, 1. 73] 1. 46 [1. 17, 1. 83] 1. 48 [1. 01, 2. 17] 1. 54 [1. 18, 2. 02] 1. 55 [1. 12, 2. 15] 2. 29 [1. 55, 3. 38] 2. 34 [1. 75, 3. 14] 5. 28 [2. 93, 9. 50] 1. 61 [1. 35, 1. 92] Lerman 1997 Wolf 2000 Whelan 2004 McBride 2002 Schapira 2000 Dodin 2001 O'Connor 1998-RCT Whelan 2003 McAlister 2005 Man-Son-Hing 1999 Gattellari 2003 Total (95% CI) Total events: 896 (Decision Aid), 558 (Usual Care) Test for heterogeneity: ? 2 = 52. 06, df = 10 (P ; 0. 00001), I? = 80. 8% Test for overall effect: Z = 5. 34 (P ; 0. 00001) 0. 1 0. 2 0. 5 1 Favours Usual Care 2 5 10 Favours Decision Aid Figure 4 Effect of patient decision aids on the proportion of patients classified as having accurate risk perceptions. RR = relative risk; CI = confidence interval. congruence. Holmes-Rovner and others62 measured the correlation between the subjective expected value of hormones and women’s likelihood of taking HRT, converted here to the percentage of variance in likelihood explained by alues. Dodin and others24 measured the percentage of variance in decisions explained by values. O’Connor and others55 used logistic regression to estimate the percentage agreement between values and choice. PtDAs improved value congruence with the chosen option in 2 of 3 studies. In the trial by Dodin and others,24 24% of the variance in HRT decisions wa s explained by personal values when a detailed PtDA with explicit values clarification was used; in contrast, 14% of the variance in decisions was explained when a simpler PtDA was used (P = 0. 003). In the study by Holmes-Rovner and others,62 the percentage of variance in the likelihood of choosing HRT that was explained by women’s expected values was greater when a more detailed PtDA was used (13%–14%) than when a simpler PtDA was used (0. 09%–2%). O’Connor and others55 found that the addition of an explicit values clarification exercise in a PtDA did not improve agreement between values and the chosen option. However, in the subgroup of women who chose HRT, women who used the PtDA with explicit values clarification DECISION AIDS: PAST, PRESENT, AND FUTURE ad a trend toward better agreement (40%) than did those who used an identical PtDA without explicit values clarification (0%, P = 0. 06). Decision Processes Leading to Decision Quality There were no trials evaluating the extent to which PtDAs helped patients to recognize that a decision needs to be made, understand that values affect the decision, and discuss values with their practitioner. Althoug h 8 trials evaluated effects on patient participation, none focused on helping patients become involved in preferred ways. Some studies measured patients’ self-reports about feeling informed and clear about personal values. The measures used to evaluate these 2 criteria were 2 subscales of the Decisional Conflict Scale (DCS). The DCS is reliable, discriminates between those who make or delay decisions, is sensitive to change, and discriminates between different decision support interventions. 54,79 The scores are standardized to range from 0 (no decisional conflict) to 100 points (extreme decisional conflict). Scores of 25 or lower are associated with follow through with decisions, whereas scores that exceed 38 are associated with delay in decision making. 54 When PtDAs are compared with usual care, 565 Downloaded from mdm. agepub. com by guest on July 22, 2012 O’CONNOR AND OTHERS Study or subcategory y Decision Aid N Mean (SD) 22. 17(9. 47) 27. 56(10. 51) 16. 25(13. 75) 29. 93(17. 26) 15. 75(13. 00) 20. 00(21. 50) 15. 75(13. 25) 15. 00(12. 50) 21. 67(15. 83) 32. 50(15. 00) Usual Care N Mean (SD) 58 45 54 93 37 94 148 215 159 56 959 49. 14(25. 40) 38. 88(20. 02) 27. 25(15. 00) 38. 89(22. 53) 24. 50(21. 25) 27. 50(21. 50) 21. 00(14. 75) 20. 00(15. 00) 25. 83(19. 17) 31. 67(14. 17) WMD (random) 95% CI Weight % 8. 64 9. 09 10. 03 9. 73 7. 93 9. 28 11. 82 12. 25 11. 33 9. 90 100. 00 WMD (random) 95% CI -26. 97 [-34. 1, -19. 93] -11. 32 [-17. 83, -4. 81] -11. 00 [-16. 43, -5. 57] -8. 96 [-14. 73, -3. 19] -8. 75 [-16. 67, -0. 83] -7. 50 [-13. 79, -1. 21] -5. 25 [-8. 49, -2. 01] -5. 00 [-7. 60, -2. 40] -4. 16 [-8. 05, -0. 27] 0. 83 [-4. 74, 6. 40] -8. 35 [-11. 89, -4. 80] 02 Uninformed Subscale Montgomery 2003 50 Murray BPH 2001 52 Laupacis 2006 54 Murray HRT 2001 93 Dolan 2002 41 Morgan 2000 86 Man-Son-Hing 1999 139 McAlister 2005 219 Wong 2006 154 Bekker 2004 50 Subtotal (95% CI) 938 Test for heterogeneity: 48. 12, df = 9 (P ; 0. 00001), I? = 81. 3% Test for overall effect: Z = 4. 61 (P ; 0. 0001) -50 0 Favours Decision Aid 50 Favours Usual Care ?2 = Figure 5 Effect of patient decision aids on patients’ scores on the Uninformed subscale of the Decisional Conflict Scale: d ecision aid versus usual care. WMD = weighted mean difference; CI = confidence interval. Study or subcategory y Detailed DA N Mean (SD) 22. 50(17. 50) 17. 50(12. 50) 20. 75(10. 75) 22. 50(17. 50) 38. 25(12. 00) Simple DA N Mean (SD) 84 49 45 100 12 27. 50(20. 00) 22. 25(14. 75) 24. 00(16. 00) 20. 00(17. 50) 31. 25(10. 75) W MD (random) 95% CI W eight % 20. 52 21. 72 22. 00 23. 42 12. 34 100. 00 W MD (random) 95% CI -5. 0 [-10. 73, 0. 73] -4. 75 [-10. 10, 0. 60] -3. 25 [-8. 51, 2. 01] 2. 50 [-2. 34, 7. 34] 7. 00 [-2. 12, 16. 12] -1. 32 [-5. 27, 2. 62] 02 Uninformed Subscale O'Connor 1998-RCT 81 Dodin 2001 52 Goel 2001 76 O'Connor Wells 1999 101 Lalonde 2006 12 Subtotal (95% CI) 322 290 Test for heterogeneity: ? 2 = 9. 24, df = 4 (P = 0. 06), I? = 56. 7% Test for overall effect: Z = 0. 66 (P = 0. 51) -50 0 Favours Detailed DA 50 Favours Simple DA Figure 6 Effect of patient decision aids on patients’ scores on the Uninformed subscale of the Decisional Conflict Scale: detailed ve rsus simple decision aid (DA). WMD = weighted mean difference; CI = confidence interval. a negative score indicates a reduction in decisional conflict, which is in favor of the PtDA. In our review, 15 trials used the DCS subscale for feeling informed and 13 trials used the DCS subscale for feeling clear about values. Because this DCS subscale measures self-reported comfort with knowledge and not actual knowledge, we elected to consider it a process measure and to reserve the gold standard of objective knowledge tests in assessing decision quality. The WMD in feeling uninformed about options, benefits, and harms was –8. (95% CI = –11. 9 to –4. 8) in the 10 trials16,25,39,43,44,48,50–52,78 that compared the PtDAs to usual care (Figure 5). The 5 trials that compared detailed with simpler PtDAs24,30,38,54,55 had a WMD in feeling uninformed of –1. 3 (95% CI = –5. 3 to 2. 6; Figure 6). Eight trials comparing PtDA to usual care25,39,43,44,48,50–52 had a WMD of –6. 3 (95% CI = –10. 0, –2. 7) for feeling clear about values (Figure 7). Five trials compared detailed to simpler PtDAs. 24,30,38,54,55 For these trials, the WMD in feeling clear about values was –1. 1 (95% CI = –4. 8 to 2. ; Figure 8). 566 †¢ MEDICAL DECISION MAKING/MON–MON 2007 Downloaded from mdm. sagepub. com by guest on July 22, 2012 DECISION AIDS â€Å"EFFECTIVENESS CRITERIA OF DECISION AIDS† Study or sub-category Decision Aid N Mean (SD) 50 54 41 82 53 139 219 86 724 28. 50(12. 50) 18. 75(16. 50) 19. 75(15. 75) 37. 50(15. 00) 35. 38(12. 33) 16. 25(12. 50) 15. 00(12. 50) 30. 00(3. 25) Usual Care N Mean (SD) 58 55 37 84 45 148 215 94 736 51. 29(25. 73) 30. 00(17. 00) 29. 25(24. 00) 42. 85(16. 57) 40. 56(16. 44) 19. 00(14. 75) 17. 50(15. 00) 30. 00(3. 25) WMD (random) 95% CI Weight % 9. 8 11. 11 8. 15 12. 88 11. 64 14. 75 15. 30 16. 40 100. 00 WMD (random) 95% CI -22. 79 [-30. 26, -15. 32] -11. 25 [-17. 54, -4. 96] -9. 50 [-18. 61, -0. 39] -5. 35 [-10. 16, -0. 54] -5. 18 [-11. 02, 0. 66] -2. 75 [-5. 91, 0. 41] -2. 50 [-5. 10, 0. 10] 0. 00 [-0. 95, 0. 95] -6. 33 [-9. 98, -2. 69] 03 Unclear Values Subscale Montgomery 2003 Laupacis 2006 Dolan 2002 Murray HRT 2001 Murray BPH 2001 Man-Son-Hing 1999 McAlister 2005 Morgan 2000 Subtotal (95% CI) Test for heterogeneity: 57. 71, df = 7 (P ; 0. 0 0001), I? = 87. 9% Test for overall effect: Z = 3. 40 (P = 0. 007) -50 Favours Decision Aid 0 50 Favours Usual Care ?2 = Figure 7 Effect of patient decision aids on patients’ scores on the Unclear Values subscale of the Decisional Conflict Scale: decision aid versus usual care. WMD = weighted mean difference; CI = confidence interval. Study or sub-category y Detailed DA N Mean (SD) 81 77 52 12 97 25. 00(17. 50) 24. 00(12. 50) 25. 00(13. 75) 39. 50(10. 75) 22. 50(15. 00) N 84 45 49 12 100 Simple DA Mean (SD) 32. 50(17. 50) 25. 75(15. 75) 24. 75(13. 50) 37. 50(13. 00) 20. 00(15. 00) W MD (random) 95% CI W eight % 21. 23 21. 09 21. 32 10. 94 25. 42 100. 0 W MD (random) 95% CI -7. 50 [-12. 84, -2. 16] -1. 75 [-7. 13, 3. 63] 0. 25 [-5. 07, 5. 57] 2. 00 [-7. 54, 11. 54] 2. 50 [-1. 69, 6. 69] -1. 05 [-4. 81, 2. 70] O'Connor 1998-RCT Goel 2001 Dodin 2001 Lalonde 2006 O'Connor Wells 1999 Subtotal (95% CI) 319 290 Test for heterogeneity: ? 2 = 9. 02, df = 4 (P = 0. 06 ), I? = 55. 7% Test for overall effect: Z = 0. 55 (P = 0. 58) -50 0 Favours Detailed DA 50 Favours Simple DA Figure 8 Effect of patient decision aids on patients’ scores on the Unclear Values subscale of the Decisional Conflict Scale: detailed versus simple decision aid (DA). WMD = weighted mean difference; CI = confidence interval. Post hoc Analysis Effects of study quality. To examine the effect of possible bias from including trials of low methodological quality, the 13 trials15,21,31,34. 41,45,54,56,58,61,63,66,77 with Jadad scores of 0 or 1 were excluded from the analysis. Overall, the results remained the same. There was a significant improvement in knowledge scores for the comparison of PtDAs to usual-care controls (WMD = 14. 0%, 95% CI = 2. 4, 8. 6) and for the comparison of detailed to simpler PtDAs (WMD = 5. 5%, 95% CI = 2. 4, 8. 6). The proportion of patients having accurate risk perceptions was greater for patients receiving PtDAs with information on outcome probabilities (RR = 2. 0, 95% CI = 1. 4, 2. 8). Publication bias. There were too few studies to explore potential publication bias for all of the outcomes, with the exception of knowledge for the comparison of PtDAs to usual care. The funnel plot for this outcome (Figure 9) points to the absence of smaller negative studies. DECISION AIDS: PAST, PRESENT, AND FUTURE Downloaded from mdm. sagepub. com by guest on July 22, 2012 567 O’CONNOR AND OTHERS Comparison: 01 Decision Aids versus Usual Care Outcome: 0 07 Knowledge: Decision Aids vs Usual Care SE(WMD) 2 4 6 8 -100 -50 0 50 100 WMD (fixed) Figure 9 Funnel plot of all 18 randomized controlled trials comparing patient decision aids to usual care (knowledge). WMD = weighted mean difference. Heterogeneity. There was statistically significant heterogeneity when PtDAs were compared with usual care for 4 outcomes: knowledge test scores, realistic risk perceptions, feeling uninformed, and feeling unclear regarding personal values (Table 3). It should be noted that the heterogeneity of the effect was not in the direction but in the size. When we explored the potential factors contributing to heterogeneity (Table 3), we found that none of the factors eliminated heterogeneity for the outcomes of knowledge scores. When grouped into treatment and screening decisions, the WMD for knowledge scores was slightly higher for the treatment group (16. 6% v. 13. 1%), but there was still statistically significant heterogeneity. For the outcomes of accurate risk perceptions, heterogeneity was not significant when we removed 3 studies with lower accurate risk perception scores in the usual-care control group (P = 0. ). 28,43,44 For the outcome of feeling uninformed, heterogeneity was no longer significant with 1) removal of 3 studies with higher uninformed scores in the usual-care control group (P = 0. 11), 2) inclusion of only audio booklet/ pamphlet decision aids (P = 0. 06), and 3) removal of an outlier48 (P = 0. 06). None of the factors eliminated heterogeneity for the outcomes of unclear values scores. DISCUSSION The majority o f trials report on at least 1 IPDAS effectiveness measure, predominately knowledge test scores. Of those reporting IPDAS measures, we found that PtDAs were superior to usual practices in 568 †¢ MEDICAL DECISION MAKING/SEP–OCT 2007 meeting the new IPDAS standards 1) for decision quality and 2) for 2 process measures (feeling informed and feeling clear about personal values). Detailed PtDAs had superior effects over simpler PtDAs on value congruence with the chosen option and on accurate risk perceptions but not on knowledge test scores or on self-reports about feeling informed and feeling clear about values. We also identified the gaps in the use of measures of effectiveness endorsed by IPDAS, notably, value congruence with the chosen option and most of the decision process measures. There are some study limitations. Study quality ratings of all trials included in the review were low because they all lost 2 points for lack of blinding. Although not an a priori exclusion criterion for this review, in the future, we may consider using study quality ratings for the selection of included trials. The conclusions of this review are limited by 1) inadequate power to detect important differences in effectiveness in subgroups and 2) the wide variability in the decision contexts, the elements within the PtDAs, the type of comparison interventions, the targeted outcomes, and the evaluation procedures. This article focuses solely on measures of effectiveness, not harms. The small number of studies for most outcomes did not allow for analysis of publication bias because of the failure to publish negative studies. Moreover, there may have been publication bias because of failure to report all negative findings in a published study. Lastly, several of the outcomes demonstrated statistically significant heterogeneity. It reflects differences across clinically diverse studies; therefore, the pooled effect size and CI should be interpreted as a range across conditions, which may not be applicable to a specific condition. There are several implications for future research. Studies are needed to evaluate the effects of PtDAs on congruence between values and chosen options. Moreover, the methods for quantifying value congruence should be explored. The IPDAS decision processes criteria leading to decision quality should also be measured. It would be helpful to develop a standardized approach to measurement. With the addition of more trials to the database, it may be possible to tease out the reason for heterogeneity of results, including variability in 1) study quality, 2) comparison intervention, 3) elements within PtDAs, 4) decision type, and 5) format of decision aid (e. g. , video, Internet, booklet). The degree of detail in PtDAs that is required for positive effects on IPDAS criteria should also be explored. Downloaded from mdm. sagepub. com by guest on July 22, 2012 Table 3 Exploration of Potential Factors Affecting Heterogeneity Outcome Overall Effect Treatment Decision Screening Decision Video/Computer Decision Aid Audio/Pamphlet Decision Aid Baseline Risk in Usual-Care Groupa Removal of Outliers Knowledge 1. 6 (1. 4, 1. 9) –3. 5 (–12. 9, 5. 8) 1. 6 (1. 1, 2. 3) No data 15. 2 (11. 7, 18. 7) 16. 6 (12. 0, 21. 2) 13. 1 ( 7. 7, 18. 5) 21. 4 (16. 5, 26. 2) 11. 9 (8. 3, 15. 6) 1. 6 (1. 4, 1. 9) 15. 6 (11. 3, 19. 9) 1. 3 (1. 2,1. 5)* 1. 6 (1. 4, 1. 9) 17. 316,28,36 (13. 7, 20. 9) 1. 528 (1. 3, 1. 7) –8. 4 (–11. 9, –4. 8) –9. 4 (–13. 3 –5. 5) 12. 6 (–19. 5, –5. 8) –4. 9 (–7. 6, –2. 3)*** –5. 4 (–7. 7, –3. 2)** –6. 248 (–8. 4, –4. 1)*** –8. 0 (–15. 1, –1. 0) –4. 5 (–8. 4, –0. 6) –3. 6 (–6. 8, –0. 5) –4. 0 r48 (–6. 7, –1. 3) Downloaded from mdm. s agepub. com by guest on July 22, 2012 Accurate risk perceptions Uninformed Subscale of the Decisional Conflict Scale Unclear values subscale of the Decisional Conflict Scale –6. 0 (–9. 8, –2. 3) Insufficient data –6. 3 (–10. 0, –2. 7) Note: Values are presented as the weighted mean treatment effect (95% confidence interval). Chi-square heterogeneity test P value