Lane GI, Dupati A, Qi J et al: Factors associated with decision aid use in localized prostate cancer. Urol Pract 2021; 9: 108.

Decision aids have been found to help men with localized prostate cancer (PCa) navigate their choices.¹ PCa decision aids are tools that provide patients information about PCa, the treatment options and their harms and benefits, and help patients clarify preferences for decision making. Several high-quality decision aids exist for PCa, but factors driving decision aid use are unknown.^2,3 In 2018, the Michigan Urological Surgery Improvement Collaborative (MUSIC) implemented the use of the Personal Patient Profile–Prostate (P3P), an efficacious web-based decision aid for PCa (free online version available at p3p4me.org), as a quality improvement initiative. Our recent article, “Factors Associated with Decision Aid Use in Localized Prostate Cancer,” analyzes data from patients within practices that adopted P3P from 2018–2021 to assess influential factors on men’s decision to enroll in P3P.⁴

Over the observation period, data from 15,500 men with localized PCa were entered into the MUSIC registry from 46 practices comprising 252 urologists. Of these men, 2,629 (17%) were seen among the 13 practices that participated in the P3P initiative. In all, 45% (1,174) of men within practices offering P3P registered to use the tool (fig. 1). Surprisingly, multilevel, logistic regression analysis found that 41% of the variation in men’s registration to use P3P was attributable to their grouping under specific urologists, whereas patient-level factors contributed only 1.5% of variation in P3P registration and no clinically meaningful patient factors contributed to whether a man enrolled to use the decision aid. The logistic regression model was used to estimate the adjusted probability of P3P registration among patients of urologists who treated more than 25 men. The resultant caterpillar plot showed significant variation between urologists (fig. 2).

Figure 1. Depiction of sample and sampling frame. A, at practice level, practices that participated in P3P are compared to practices who elected not to participate in P3P initiative. B, among patients seen within P3P participating practices, we assess patient factors associated with registration into P3P while controlling for nesting of patients under specific urologists.

Figure 2. Adjusted probability of registration into PCa decision aid (caterpillar plot). Each point represents a urologist. Data are rank-ordered based on point estimate of adjusted probability; error bars denote standard error. Urologists with fewer than 25 patients in sample were excluded.

These results show that men treated by the same urologist tend to make similar decisions on whether or not to register to use a PCa decision aid, leading to the conclusion that urologists may be key facilitators of patients’ use of decision aids and that engaging urologists may be crucial to their implementation. The data for this study were collected within a urological surgery improvement collaborative in which physicians are generally highly engaged. Despite this, overall engagement of practices in the decision aid was low, suggesting that further research investigating and addressing implementation barriers at the organizational and health system may be needed.

The study also found significant variation in urologists’ effect on men’s use of decision aids, ranging from a very negative effect to a very positive effect (fig. 2) While this study did not explore reasons behind the variation, a recent qualitative study from the same cohort found physician skepticism towards the benefits of decision aids to be an ongoing barrier to their use.⁵ Research aimed at understanding how decision aids impact men’s clinical outcomes and quality of life may help address physician skepticism. For example, in separate work, we found that patients who used P3P had decreased odds of bother from post-prostatectomy erectile dysfunction.⁶ Further research aimed at clarifying the clinical impact of decision aids on men undergoing PCa treatment may help inform urologists’ opinions of decision aids and decrease variation in their use.

In summary, this retrospective study finds that urologists may have a large influence on patients’ use of a PCa decision aid. This influence far outweighs the impact of any of the measured patient factors on men’s decision aid use. In addition to this, there is wide variation in the influence clinicians have on men’s use of a decision aid. This information, paired with findings that decision aid use is associated with decreased bothered from post-prostatectomy adverse effects like erectile dysfunction, suggests that further research into methods to effectively disseminate decision aids in this population is needed.

Acknowledgement: The study described in this article was performed by a collaborative team of researchers including Giulia I. Lane, Ajith Dupati, Ji Qi, Stephanie Ferrante, Rodney L. Dunn, Roshan Paudel, Daniela Wittmann, Lauren Wallner, Donna L. Berry, Chad Ellimoottil, James Montie, and J. Quentin Clemens for the Michigan Urological Surgery Improvement Collaborative.

Funding: NIDDK Grant F32 DK126232, The Michigan Urological Surgery Improvement Collaborative (MUSIC) is funded by Blue Cross Blue Shield of Michigan. The Movember Foundation and True North (TrueNTH) USA provided funding for the P3P initiative.