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

Afghanistan State Building

Afghanistan State Building Introduction Since its independence from British in 1919, Afghanistan has had a turbulence history characterized by foreign invasions, sectarian wars and poor governance. From the 1980s the Taliban, which began as a resistance group fighting against the Soviet invasion of Afghanistan, has played a key role in the affairs of Afghanistan.Advertising We will write a custom essay sample on Afghanistan State Building specifically for you for only $16.05 $11/page Learn More Following the US led invasion of Afghanistan, the Taliban lost the almost absolute control it held in the country.  This led to Afghanistan being classified as a failing state by the international community. After the US invasion of Afghanistan in 2001, there was need for state-building; a term which is defined as constructing a functional state. The US has therefore been at the forefront of rebuilding Afghanistan with a huge military presence being established in the region.  Even so, inci dents of insecurity continue to be high in Afghanistan. This paper shall argue that Afghanistans security is best served by the withdrawal of Americas troops on Afghan soils. A Case for Continued US Presence Failing and failed states provide safe havens for terrorist organizations some of which operate internationally. Pauly (2010) specifically cautions that nations on the brink of failure are ideal bases for terrorist groups. Afghanistan served as the safe haven for Al-Qaida it was only after the invasion of the country by US led troops and the establishment of a functional government that the country stopped serving as a hub for terrorists. Paris and Sisk (2009) assert that international efforts were essential for the state-building efforts in post-Taliban Afghanistan. The Afghan government was installed through efforts of the US and currently, the military security and national budget of Afghanistan depends heavily on foreign funding. For a nation to function favorably, it has to have a functional justice system. This is because a nation’s justice system has a direct bearing on the perceived legitimacy of a government by its people. Hains (2008) states that the reason for this is that the nations citizens are more likely to cooperate with the security apparatus if they perceive that the justice system is effective and fair. Afghanistan’s justice system is primarily aided by the US. Should the US move out of Afghanistan, it can be assumed that the justice system would collapse therefore throwing Afghanistan into further turmoil.Advertising Looking for essay on government? Let's see if we can help you! Get your first paper with 15% OFF Learn More Failure of US Efforts While US led efforts to stability Afghanistan and bring about peace have been massive, they have not worked. This has mostly been because of the huge foreign military presence in Afghanistan. The presence of US military installations in Afghanistan has resul ted in the radicalization of sections of the population. The Taliban have in particular used the presence of foreign troops as recruitment tools with great success (Paris and Sisk, 2010). As a result of the increased US presence in Afghanistan, the Afghan government has been forced to demonstrate its accountability to the US instead of its citizens. This visible political intrusion has been as a result of the huge financial aid that the US gives to Afghanistan. By being accountable to its donors rather than its own people, the Afghan government has lost legitimacy in the eyes of Afghans which has resulted in increased attacks on government installations. While the 2001 Afghanistan invasion by the US let military force may have been largely welcomed by the general Afghan public, the ensuing breakdown of security and reemergence of sectarian war largely undermined the efforts of the new government and its international backers (Ayub, Kouvo Wareham, 2009). A decade after the dramatic fall of the Taliban, the country is full of violence, drug-related crimes and other abusive behavior that have cast a dark cloud over Afghanistan. Conclusion This paper has argued that the presence of the US in Afghanistan is detrimental to the security of the region. It has been shown that some of the violence that is currently perpetrated in the region is in retaliation to US presence. This paper has demonstrated that US forces help strengthen Taliban and increase sectarian wars. It can therefore be proposed that Afghanistans security is better served by American withdrawal from the region. Reference Ayub, F., Kouvo, S. Wareham, R. (2009). â€Å"Security Sector Reform in Afghanistan.† International Center for Transitional Justice. Web. Hains, C. M. et al. (2008). Breaking the Failed-State Cycle. RAND Corporation. Paris, R. Sisk, T.D. (2009). The Dilemmas of State Building: Confronting the Contradictions of Postwar Peace Operations. Taylor Francis.Advertising We w ill write a custom essay sample on Afghanistan State Building specifically for you for only $16.05 $11/page Learn More Pauly, J. R. (2010). The Ashgate Research Companion to US Foreign Policy. Ashgate Publishing, Ltd.

The influence of modern technology on Society Essays

The influence of modern technology on Society Essays The influence of modern technology on Society Essay The influence of modern technology on Society Essay 1. Introduction While engineering is frequently described as the most of import influence upon society ( ref ) , it remains a topic which deserves further survey. This state of affairs is by and large accepted, with politicians, sociologists, industrialists and educationists likewise recognizing that engineering lies at the very bosom of society ( Chandler, 1996 ) . The critical function that engineering dramas in the development of society, exciting non merely the economic system but society’s socio-cultural values, instead than being simply a tool of society, nevertheless, is referred to as ‘technological determinism’ ( Underwood, 2009 ) . It is this facet of how engineering drives modern society that this essay addresses. Social advancement has come to be equated with proficient advancement, peculiarly since the Industrial Revolution ( Beniger, 1989 ) . This advancement has non ever been acknowledged at the clip it was happening ; so, as Beniger farther notes, ‘human society seems instead to germinate mostly through alterations so gradual as to be all but unperceivable, at least compared to the generational rhythms of the persons through whose lives they unfold’ ( 1989, p. 2 ) . Possibly because of this ‘historical myopia’ , the value of the alteration may non be evaluated until the alterations has already passed ( Beniger, 1989, p. 2 ) . Critics such as Henry David Thoreau, for case, suggested that betterments in society’s proficient agencies are no warrant of improved terminals, and that they may alternatively take to a mechanistic and fatalistic mentality, situating that we do non sit upon the railway ; it rides upon us ( 1845, p. 308 ) . Therefore, engineering its elf becomes an overruling preoccupation, for it neer stops still. Technological promotion seems of import at the clip to different ages in different societies, psychologically if non practically ; in a assortment of modern societies, for illustration, immature people soon feel a heightened empathy with the digital age ( Bennett and Maton, 2010 ) . However, non all sectors of the community will be straight involved with, portion an apprehension, or even see the relevancy, of the latest technological innovations. However, as de Tocqueville ( 1990, p. twenty-two ) noted in 1840, ‘this societal revolution, which I believe to be irresistible†¦ is already accomplished or about to be so’ , and therefore acknowledgment of it is acknowledgment of the past every bit much as the present. The current revolution in engineering, known diversely as the ‘Information Age’ or ‘Age of Technology’ , likewise is grim: the older individual who is loath to utilize a computing machine has a life shaped by others’ usage of computing machines and may even accept a basic Mobile telephone, one time considered a glamorous accoutrement ( Coeckelbergh, 2012 ) . As globalization becomes an progressively important factor in countries’ economic success, technological competency is going an indispensable tool for lasting and booming non merely in society, but in its component parts, such as employment, instruction, agribusiness, and industry. 2. Advantages and disadvantages of modern technological advancement The younger coevals today, like many old coevalss, seeks to alter the universe and do it a better and more comfy topographic point in which to populate ( Griswold, 2012 ) . They want to be subscribers to peace, economic reforms, the betterment of public services and many other facets of the society. For them, the best manner to lend to these alterations is through modern engineering. ( Weiser and Brown, 1997 ) . This does non needfully intend that young person wants to do a immense alteration on the position of the universe where they grew up, or that they merely want to divide off from the norms of society. Alternatively, they believe that the progresss in communicating, through technological agencies, will ease societal alteration as no old coevals has had the chance to larn so much, so genuinely, from one another ( Griswold, 2012 ) . The ability for real-time conversations, forums, information exchange, visual image of other civilizations, and greater societal equality across the universe has developed more in the last 20-25 old ages than at any other clip in history. This has allowed commentary on state of affairss as they develop, instead than strictly through the position of written media. For illustration, the function of societal media during the ‘Arab Spring’ , non merely through Twitter but Facebook and other societal media platforms, provided contextualisation for the media studies at a clip when media bias is progressively critically examined ( Khondker, 2011 ) . Therefore, this coevals is able to corroborate journalists’ reading of an event, even in movie, with those who are take parting on both sides of the event, every bit good as insouciant perceivers. This is alone in history. The grade to which unchained entree to sentiment, counter-opinion, coverage, and propaganda will truly reshape the universe is yet to be determined. The Habermasian reading of the development of the populace sphere holds some analogies, as the democratization of critical analysis unfolded in fin-de-siecle Viennese java houses ( Habermas, 1989 ) . Harmonizing to di Maggioet Al.( 2001 ) extensive societal effects , both optimistic and pessimistic, have been claimed for many communications engineerings before our current computer-based age of information engineering. The alleged I.T. revolution ( which tends to be presented as the ‘final’ communications revolution ) can be seen as holding been preceded by the ‘writing revolution’ and ‘the print revolution’ , and merely the latest stage of an ‘electronics revolution’ which began with telegraphy and telephone. Winston ( 1998 ) criticises technological determinism and alternatively develops his theory of cultural determinism. In this theory, Winston considers non how engineering shapes society, but instead that the development of engineering, which is non inactive, is mediated and manipulated by society. Therefore, as a consequence of these tactics, the ‘radical potential’ of a specific engineering is stifled ; socie ty therefore merely accepts that which it believes itself to be in a place to accept ( Winston, 1998 ) . Systems and machines like computing machines, nomadic phones and runing systems, which merely involve one chink on the computing machine, replace the things which used to takes hours or even yearss. Almost every place has a computing machine and telephone, and persons within those places frequently each have a nomadic phone ( Bennett and Maton, 2010 ) . For some people, the application of engineering is the lone technique for them to develop forbearance, as even the boring concern of waiting can be ameliorated by maintaining busy with a nomadic phone, particularly for young person. One of the most of import advantages of modern engineering is globalization, which has allowed the universe to experience ‘closer’ , and permitted the universe s economic system to go a individual, mutualist system ( Barrell and Fic, 2014 ) . This means that people can non merely portion information rapidly and expeditiously, but can besides convey down barriers of lingual and geographic boundaries. Zhong ( 2007 ) observes that, in today s stock markets, fiscal substructure, planetary intelligence administrations, powerful armed forcess, strong authoritiess and large corporations, instantaneous communicating is an plus society can non afford to lose. The cyberspace allows interconnectedness and promotes globalization and information sharing. The decrease in the cost of instantaneous communicating over the last 20 old ages have well expanded its possible, by doing it accessible to developing every bit good as developed economic systems. However, modern engineering does non convey advantages but some disadvantages every bit good. The similarity of life styles, whereby communicating channels homogeneousness, can hold hurtful effects ( Griswold, 2012 ) . Before the rise of movie, telecasting, and the cyberspace, people had different civilizations and traditions that were reflected in the manner they wear apparels or design edifices. Now, in a signifier of crawling conformance, people tend to construct the same theoretical accounts of house and wear the same manners. The new, modern engineering is first-class in many ways, but its philosophical, physiological, and psychological effects remain unknown in a period when technological interaction and unrecorded communicating through computing machine usage, cyberspace confab, nomadic phones, and SMS texts are portion of the mundane life of -teenagers and the young person of today. This non merely includes issues such as the argument on whether nomadic telephones increase the likeliness of encephalon tumors, but the behavioral responses of kids to ‘instant’ satisfaction, or whether nomadic phone dependence will go a important disablement ( di Maggioet al. ,2001 ) . These are issues which remain unsolved ; their declaration will non be immediate. 3. The vision of adolescents in this twenty-four hours and age With the growing of engineerings as the cyberspace and computing machines, adolescents and immature people are going more disjointed from society ( Griswold, 2012 ) . Isolation is one signifier of this job. The Nipponese phenomenon ofhikikomori,whereby immature people ( normally, males, and more progressively, grownups ) sequester themselves, utilizing merely engineering to maintain in touch with society, is believed to impact about two million people worldwide ( Longo, 2010 ) . Social interaction consequences in degrees of emphasis and hurt to the grade that persons can non get by, and seek safety alternatively in an environment which they feel is to the full within their control. Additionally, instruction is being transformed by engineering. Stimulating pupils is non a affair of doing a great address or a dominant lesson any longer ; pedagogues need to be brought down to a adolescent s degree of understanding ( Weiser and Brown, 1997 ) . The demand and wants of modern young person are really different from those of their parents, as can be seen inhikikomori( Longo, 2010 ) . The most inspiring tool for teens and their life style is the cyberspace, nomadic engineerings, and computing machines ( Griswold, 2012. Adolescents and immature people besides have changed in comparing with teens in the yesteryear, taking into history eating wonts, an active manner of life, passing free clip, and the importance of music and manner. The affordability of many of these factors has changed well since, for illustration, the post-war coevals ( Bennett and Maton, 2010 ) . The most of import alteration, nevertheless, is that they are a engineering coevals. For teens in today s universe, nomadic phones, cyberspace, music, films, telecasting and picture games are really of import. Most adolescents prefer watching telecasting and playing computing machine games to reading books. They dislike reading because watching telecasting or playing on-line role-playing games is easier and they do non hold to utilize their ain imaginativeness ( Davies and Eynon, 2013 ) . Computer games have the capacity to supply learning chances but they are besides harmful to wellness ( Longo, 2010 ) . Teenagers prefer to pass free clip in forepart of a computing machine instead than to walk, play football, go to a swimming pool, or merely merely run into a friend in the park and have a confab. The long term effects of these alterations are non likely to be apparent for at least three more coevalss. Harmonizing to di Maggioet Al.( 2001 ) , the cyberspace expands day-to-day and reaches more and more people globally. As a society, betterments in literacy may lift due to the growing of the cyberspace. The immature coevals can non conceive of their day’s prep without the support of the one of most of import modern technological developments, the cyberspace. The cyberspace is really utile and an of import tool for surveies, as there they are able to see the latest studies and articles, discovery and practise exercisings which are relevant to their surveies, every bit good as submit assignments and other work. Further, a adolescent s societal life becomes inextricably linked to societal networking, particularly through unrecorded confab and Facebook. They would instead state that this is the easiest manner to pass on with each other, every bit good as larning new things and holding merriment ( Davies and Eynon, 2013 ) . Many things can be done through the cyberspace. Young people can download music and other files and play on-line games with their existent or practical friends. In this manner, hence, the cyberspace influences the adolescent position to the universe and its hereafter. It besides gives them an chance to interact with other teens and discuss relevant issues. One of import facet of teens utilizing cyberspace is their freedom to post unfavorable judgment of authorities leaders. Young persons have limited abilities to pass on meaningfully with authorities as they can non vote ; the cyberspace permits them to give their beliefs about what is incorrect and what is right from their point of position, ( Davies and Eynon, 2013 ) . On societal web sites young persons can hold dealingss and communicating with their friends or merely person who is far off from their places and around the universe, chew the fating on the worldwide web, e-mailing or merely playing games. This has been extended well with the coming of smart phones ( Bennett and Maton, 2010 ) . Using the cyberspace adolescents can travel shopping with their friends utilizing the same web site, usage mikes or cameras to movie themselves, about in the same manner as they would travel out together for existent shopping. Therefore, the populace sphere – through recreational confab every bit good as more complex interactions – is extended in the mode kindred to that described by Habermas ( 1989 ) . However, this alteration to ‘life online’ agencies that, necessarily, many existent universe jobs manifest themselves in the cyberspace, and so hold a farther existent universe effect. This can be seen in the phenomenon of cyber intimidation. Cyber strong-arming marks the gender, physical attraction and friendly relationships of kids and adolescents ( Davies and Eynon, 2013 ) . Victims do non cognize what to make or where to turn. Cyber toughs harass victims anonymously. The psychological harm is hideous because the victim s ain equals have turned on them and there is nowhere for them to travel, with teenage self-destructions and attempted self-destructions reported in the yesteryear ( Griswold, 2013 ) . A ‘dis-connect’ from human reactions could lend to cyber intimidation. Peoples learn to pass on largely through text messages or online, and do non larn of import facets of human interaction, such as noticing and accepting non-verbal signals ( Griswold, 2013 ) . Without these signals and features it is easy to be misunderstood and for the victim to be dehumanised ( di Maggioet al. ,2001 ) . This is besides true of online dating ( Winston, 1998 ) . Peoples are usually cognizant of what person is stating or non stating, through gesticulations and voice tones. Without these cues, it is hard to appreciate how the other individual is experiencing and whether there is genuinely a connexion. Young person can get down to experience as if who they are is non recognised, that they are reviled or that cipher wants them, when for illustration the text message or electronic mail was merely non received. Young people have created and developed a communicating civilization that incorporates many particular characteristics, such as a rise in the usage of text-based communicating channels ( Davies and Eynon, 2013 ) . Teenagers intersecting and selective usage of communicating channels has been shaped by multimedia communicating ( Weiser and Brown, 1997 ) . Therefore, their public domain utilises a wider scope of platforms than antecedently ; however, it is still simply an extension of the populace sphere, merely as telecasting and newspapers were ( Habermas, 1989 ) . Regardless of their signifier, the media landscapes created by adolescents serve to joint their personal infinite, every bit good as enabling their presentation of ego and specifying their relationships to others ) . This can be seen in immature people s relationship to the nomadic phone and other signifiers of synergistic engineering, which is consistent with their general ingestion manners. An habit-forming usage of the phone has been related to trendy and unprompted ingestion manners prevalent among females ( Davies and Eynon, 2013 ) . Technology enthusiasm and trend-consciousness was linked to unprompted ingestion and difficult values more prevailing among males ( di Maggioet al. ,2001 ) . In contrast, a economical Mobile phone usage was non related to gender but to environmentalism and thrifty ingestion in general. The traditional gender division in nomadic phone usage manners that could be observed is interesting in the visible radiation of speculations that genders are going more likewise in their usage of new engineering. The increasing tendency towards ‘instant gratification’ that has been fed by high rates of recognition over the last 30 old ages is exacerbated by a n restlessness facilitated by devices such as smart phones ( Griswold, 2012 ) . The net consequence of several of several coevalss for whom this is true has non yet been realised. 4. Decision Technology is one of a figure of interceding factors in human behavior and societal alteration, which both Acts of the Apostless on and is acted upon by other phenomena. Bing critical of technological determinism is non to dismiss the importance of the fact that the proficient characteristics of different communicating engineerings facilitate different sorts of usage, though the possible applications of engineerings are non needfully realised. Enthusiasm for technological progress typically involves technological determinism. As Potter and Sarre ( 1974, p. 485 ) , cautiousness that, in reaction to the alterations taking topographic points amongst today’s youth, there is obviously an unmistakable tone of moral disapproval directed against cultural interval – that is, oppositions to structural and normative versions occasioned by invention . This is non new. Every coevals expresses concern for the gait and nature of alteration, and inquiries whether alteration is driving society or society desires the alterations wrought. In the interim, the technological revolution will enable people’s lives to be easier, in ways such as societal interaction, instruction, fabrication, and so on. Withdrawing from the grade to which engineering has shaped society will be really hard, and probably to take to large-scale economic pandemonium ( Barrell and Fic, 2013 ) . The rise in costs, for illustration, through slower communications or manual fabrication methods, would ensue in an overwhelming, if impermanent drain on the economic system ; nevertheless, given the lessening in fossil fuel handiness, this may be a hereafter that society needs to see. Worlds are extremely adaptable, as the integrating of alteration antecedently has demonstrated. There may be a societal cost in this, as Thoreau ( 1854 ) speculated, but this flexibleness has permitted societies of many different signifiers to boom for millenary. The autonomy for people discuss alteration, as Habermas ( 1989 ) has described, has expanded in the last t hree hundred old ages. However, minds such as Thoreau and Habermas are prepared to oppugn non merely technological advancement but alteration in its most simple signifier. This is what will continue humanity from suicidal alteration. Many people may experience that adolescents are inadvertently ‘walking into’ suicidal alteration through their eager credence of engineering in every facet of their lives ( di Maggioet al. ,2001 ) . Whilst this may be a legitimate concern, it should besides be borne in head that adolescents are non simply being controlled by devices but are utilizing devices to ease alteration – through societal media. This was evident during the ‘Arab Spring’ ( Khondker, 2011 ) , and was widely welcomed. Enthusiasm for technological progress typically involves technological determinism. As Potter and Sarre ( 1974, p. 485 ) , cautiousness that, in reaction to the alterations taking topographic points amongst today’s young person, ‘there is obviously an unmistakable tone of moral disapproval directed against cultural interval – that is, oppositions to structural and normative versions occasioned by invention . This is non new. Every coevals expresses concern for the gait and nature of alteration, and inquiries whether alteration is driving society or society desires the alterations wrought. The human willingness to utilize alteration meaningfully and self-reflect, it is hoped, will protect society from itself. 5. Mentions Barrell, R. and Fic, T. ( 2013 ) . Integration, globalization, engineering and trade forms in the EU8.Research in Economics and Business: Central and Eastern Europe, 2 ( 1 ) , pp. 1-13. Beniger, J. ( 1989 ) .The control revolution: Technological and economic beginnings of the information society. Cambridge, MA: Harvard University Press. 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