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

Project Management and Critical Path Essay

What is project management, and what are its main objectives? What is the relationship between tasks and events, or milestones? What is a work breakdown structure? How do you create one? What are task patterns, and how can you recognize them? Compare the advantages and disadvantages of Gantt and PERT/CPM charts. Define the following terms: best-case estimate, probable-case estimate, and worst- case estimate, and describe how project managers use these concepts. How does a project manager calculate start and finish times? What is a critical path, and why is it important to project managers? How do you identify the critical path? What are some project reporting and communication techniques? What is risk management, and why is it important? In Poor Richard’s Almanac, Benjamin Franklin penned the familiar lines: â€Å"For the want of a nail the shoe was lost, for the want of a shoe the horse was lost, for the want of a horse the rider was lost, for the want of a rider the battle was lost, for the want of a battle the kingdom was lost — and all for the want of a horseshoe nail.† Looking at the outcome in hindsight, could project management concepts have avoided the loss of the kingdom? Explain your answers. At Countywide Construction, you are trying to convince your boss that he should consider modern project management techniques to manage a complex project. Your boss says that he doesn’t need anything fancy, and that he can guess the total time by the seat of his pants. To prove your point, you decide to use a very simple example of a commercial con- struction project, with eight tasks. You create a hypothetical work breakdown struc- ture, as follows: Prepare the foundation (10 days). Then assemble the building (4 days). When the building is assembled, start two tasks at once: Finish the interior work (4 days) and set up an appointment for the final building inspection (30 days). When the interior work is done, start two more tasks at once: landscaping (5 days) and driveway paving (2 days). When the landscaping and driveway are done, do the painting (5 days). Finally, when the painting is done and the final inspection has occurred, arrange the sale (3 days). Now you ask your boss to estimate the total time and write his answer on a piece of paper. You look at the paper and see that his guess is wrong. 1. What is the correct answer? 2. What is the critical path? 3. Create a Gantt chart that shows the WBS. 4. Create a PERT/CPM chart. ————- What are the five questions typically used in fact-finding? What additional question can be asked during this process? What is a systems requirement, and how are systems requirements classified? What are JAD and RAD, and how do they differ from traditional fact-finding methods? What are their pros and cons? What is total cost of ownership (TCO), and why is it important? Provide examples of closed-ended, open-ended, and range-of-response questions. What are three types of sampling, and why would you use them? What is the Hawthorne Effect? Why is it significant? What is a functional decomposition diagram (FDD) and why would you use one? Explain how to create an FDD. What are agile methods, and what are some pros and cons of this approach? To what three different audiences might you have to give a presentation? How would the presentation differ for each? ——– A group meeting sometimes is suggested as a useful compromise between interviews and questionnaires. In such a group meeting, one systems analyst meets with and asks questions of a number of users at one time. Discuss the advantages and disad- vantages of such a group meeting. ——- Elmwood College Situation: The school is considering a new system that will speed up the registration process. As a systems analyst, you are asked to develop a plan for fact-finding. 1. List all the possible techniques that you might use. 2. Describe an advantage for each technique. 3. Suppose the development budget is tight. How might that affect the fact-finding process? 4. What are five important questions to use during fact-finding?

Bloodlines Chapter Twelve

WHEN WE LEFT on our group date or family outing or whatever it was, Lee couldn't stop apologizing for his father. â€Å"I'm sorry,† he said, slumping miserably in the backseat of Latte. â€Å"There's no reasoning with him anymore. We tried to tell him that Tamara was killed by Strigoi, but he won't believe it. He doesn't want to. He can't take revenge on a Strigoi. They're immortal. Invincible. But some human vampire hunter? Somehow, in his head, that's something he can go after. And if he can't, then he can focus his energy on how the guardians won't go after these nonexistent vampire hunters.† I just barely heard Eddie mutter, â€Å"Strigoi aren't that invincible.† In the rearview mirror, I saw Jill's face filled with compassion. She was seated between Lee and Eddie. â€Å"Even if it's a fantasy, maybe it's better this way,† she suggested. â€Å"It gives him comfort. I mean, kind of. Having something tangible to hate is what gets him through. Otherwise he'd just give in to despair. He's not hurting anyone with his theories. I think he's sweet.† She caught her breath in that way she did when she'd said a whole lot all at once. My eyes were back on the road, but I could swear Lee was smiling. â€Å"That's nice of you,† he told her. â€Å"I know he likes having you around. Turn right up here.† That was to me. Lee had been giving me directions ever since we left Clarence's. We were just outside of Palm Springs proper, nearing the very impressive-looking Desert Gods Golf Course and Resort. Further guidance from him led us to the Mega-Fun Mini-Golf Center, which was adjacent to the resort. I searched for a parking spot and heard Jill gasp when she caught sight of the golf course's crowning glory. There, in the center of a cluster of gaudily decorated putting greens, was a huge fake mountain with an artificial waterfall spouting from its top. â€Å"A waterfall!† she exclaimed. â€Å"It's amazing.† â€Å"Well,† said Lee, â€Å"I wouldn't go that far. It's made of water that's been pumped over and over and has God only knows what in it. I mean, I wouldn't try to drink or swim in it.† Before I even had the car to a stop, Adrian was out the door, lighting a cigarette. We'd gotten in an argument on the way over, despite me telling him three times that Latte was a strictly no-smoking car. The rest of us soon got out as well, and I wondered what I'd signed up for here as we strolled toward the entrance. â€Å"I've actually never been mini-golfing,† I remarked. Lee came to a halt and stared. â€Å"Never?† â€Å"Never.† â€Å"How does that happen?† asked Adrian. â€Å"How is it possible that you've never played mini-golf?† â€Å"I had kind of an unusual childhood,† I said at last. Even Eddie looked incredulous. â€Å"You? I was practically raised at an isolated school in the middle of nowhere Montana, and even I've played mini-golf.† Saying I was homeschooled was no excuse this time, so I just let it go. Really, it just came down to having a childhood more focused on chemical equations than on fun and recreation. Once we started playing, I soon got the hang of it. My first few attempts were pretty bad, but I soon understood the weight of the club and how the angles on each course could be maneuvered. From there, it was pretty simple to calculate distance and force to make accurate shots. â€Å"Unbelievable. If you'd been playing since you were a child, you'd be a pro by now,† Eddie told me as I knocked my ball into a gaping dragon's mouth. The ball rolled out the back, down a tube, bounced off a wall, and into the hole. â€Å"How'd you do that?† I shrugged. â€Å"It's simple geometry. You're not that bad either,† I pointed out, watching him make his shot. â€Å"How do you do it?† â€Å"I just line it up and putt.† â€Å"Very scientific.† â€Å"I just rely on natural talent,† said Adrian, strolling up to the start of the Dragon's Lair. â€Å"When you have such a wealth of it to draw from, the danger comes from having too much.† â€Å"That makes no sense whatsoever,† said Eddie. Adrian's response was to pause and take out a silver flask from his inner coat pocket. He unscrewed it and took a quick drink before leaning in to line up his shot. â€Å"What was that?† I exclaimed. â€Å"You can't have alcohol out here.† â€Å"You heard Jailbait earlier,† he countered. â€Å"It's the weekend.† He lined up his ball and shot. The ball went directly for the dragon's eye, bounced off it, and shot back toward Adrian. It rolled and came to a stop at his feet, nearly where it had started. â€Å"Natural talent, huh?† asked Eddie. I leaned forward. â€Å"I think you broke the dragon's eye.† â€Å"Just like Keith,† said Adrian. â€Å"I figured you'd appreciate that, Sage.† I gave him a sharp look, wondering if there was any hidden meaning behind that. Mostly, Adrian seemed amused by his own wit. Eddie mistook my expression. â€Å"That was inappropriate,† he told Adrian. â€Å"Sorry, Dad.† Adrian shot again and managed not to maim any statues this time. A couple more shots, and he sank the ball. â€Å"There we go. Three.† â€Å"Four,† said Eddie and I in unison. Adrian looked at us incredulously. â€Å"It was three.† â€Å"You're forgetting about your first one,† I said. â€Å"The one where you blinded the dragon.† â€Å"That was just the warm-up,† Adrian argued. He put on a smile I think he hoped would charm me. â€Å"Come on, Sage. You understand how my mind works. You said I was brilliant, remember?† Eddie glanced at me in surprise. â€Å"You did?† â€Å"No! I never said that.† Adrian's smile was infuriating. â€Å"Stop telling people that.† Since I was in charge of the scorecard, his play was logged as four, despite his many further protests. I started to move forward, but Eddie held out a hand to stop me, his hazel eyes gazing over my shoulder. â€Å"Hold up,† he said. â€Å"We need to wait for Jill and Lee.† I followed his gaze. The two of them had been in deep conversation since we arrived, so much so that they'd slowed and lagged behind the rest of us. Even during his bantering with Adrian and me, Eddie had continually checked on her – and our surroundings. It was kind of amazing the way he could multitask. Thus far, Jill and Lee had only been one hole behind us. Now it was nearly two, and that was too far for Eddie to keep her in his sight. So, we waited while the oblivious couple meandered their way toward the Dragon's Lair. Adrian took another drink from his flask and shook his head in awe. â€Å"You had nothing to worry about, Sage. She went right for him.† â€Å"No thanks to you,† I snapped. â€Å"I can't believe you told her every detail of my visit that night. She was so mad at me for interfering behind her back with you, Lee, and Micah.† â€Å"I hardly told her anything,† argued Adrian. â€Å"I just told her to stay away from that human guy.† Eddie glanced between our faces. â€Å"Micah?† I shifted uncomfortably. Eddie didn't know about how I'd gone proactive. â€Å"Remember when I wanted you to say something to him? And you wouldn't?† I proceeded to tell him how I'd then sought out Adrian's help and found out about Lee's interest in Jill. Eddie was aghast. â€Å"How could you not tell me any of this?† he demanded. â€Å"Well,† I said, wondering if everything I did was going to result in the wrath of a Moroi or dhampir, â€Å"it didn't involve you.† â€Å"Jill's safety does! If some guy likes her, I need to know.† Adrian chuckled. â€Å"Should Sage have passed you a note in class?† â€Å"Lee's fine,† I said. â€Å"He obviously adores her, and it's not like she'll ever be alone with him.† â€Å"We don't know for sure that he's fine,† said Eddie. â€Å"Whereas Micah's a hundred percent okay? Did you do a background check or something?† I asked. â€Å"No,† said Eddie, looking embarrassed. â€Å"I just know. It's a feeling I get about him. There's no problem with him spending time with Jill.† â€Å"Except that he's human.† â€Å"They wouldn't have gotten serious.† â€Å"You don't know that.† â€Å"Enough, you two,† interrupted Adrian. Jill and Lee had finally reached the start of the Dragon's Lair, meaning we could move on. Adrian lowered his voice. â€Å"Your argument's useless. I mean, look at them. That human boy doesn't enter into it.† I looked. Adrian was right. Jill and Lee were clearly enthralled with each other. Some guilty part of me wondered if I should be a doing a better job of looking out for Jill. I was so relieved that she was interested in a Moroi that I hadn't stopped to wonder if she should even be dating anyone. Was fifteen old enough? I hadn't dated at fifteen. I'd actually, well, never dated. â€Å"There is an age difference between them,† I admitted, more to myself. Adrian scoffed. â€Å"Believe me, I've seen age differences. Theirs is nothing.† He walked off, and a few moments later, Eddie and I went to join him. Eddie maintained his simultaneous vigil of Jill, but this time, I got the impression the danger he was watching out for was right beside her. Adrian's laughter rang out ahead of us. â€Å"Sage!† he called. â€Å"You have got to see this.† Eddie and I reached the next green and stared in astonishment. Then I burst out laughing. We had reached Dracula's Castle. A huge, multi-towered black castle guarded the hole some distance away. A tunnel was cut out through the center of it with a narrow bridge meant for the ball to go over. If the ball fell off the sides before getting through the castle, it was returned back to the starting point. An animatronic Count Dracula stood off to the castle's side. He was pure white, with red eyes, pointed ears, and slicked-back hair. He jerkily kept raising his arms to show off a batlike cape. Nearby, a speaker blasted eerie organ music. I couldn't stop laughing. Adrian and Eddie looked at me as though they'd never seen me before. â€Å"I don't think I've ever heard her laugh,† Eddie told him. â€Å"Certainly not the reaction I was expecting,† mused Adrian. â€Å"I'd been counting on abject terror, judging from past Alchemist behavior. I didn't think you liked vampires.† Still grinning, I watched Dracula raise his cape up and down. â€Å"This isn't a vampire. Not a real one. And that's what makes it so funny. It's pure Hollywood camp. Real vampires are terrifying and unnatural. This? This is hilarious.† It was clear from their expressions that neither really understood why this would appeal to my sense of humor so much. Adrian did, however, offer to take a picture with my cell phone when I asked him. I posed by Dracula and put on a big smile. Adrian managed to snap the shot just as Dracula was raising his cape. When I viewed the picture, I was pleased to see it had come out perfectly. Even my hair looked good. Adrian gave the picture a nod of approval before handing me the phone. â€Å"Okay, even I can admit that's pretty cute.† I found myself overanalyzing the comment. What had he meant in saying even he could admit it? That I was cute for a human? Or that I had just met some kind of Adrian hot-girl criteria? Moments later, I had to forcibly stop thinking about it. Let it go, Sydney. It's a compliment. Accept it. We played through the rest of the course, finally finishing off with the waterfall itself. That was a particularly challenging hole, and I took my time lining up the shot – not that I needed to. I was beating everyone pretty handily. Eddie was the only one who came close. It was clear Jill and Lee didn't even have their attention on the game, and as for Adrian and his natural talent†¦ well, they were very solidly in last place. Eddie, Adrian, and I were still ahead of the other two, so we waited for them by the waterfall. Jill practically ran to it when she had the chance, gazing up at it with enchanted eyes. â€Å"Oh,† she breathed. â€Å"This is wonderful. I haven't seen this much water in days.† â€Å"Remember what I said about the toxicity,† teased Lee. But it was clear he found her reaction endearing. As I glanced at the other two guys, I saw that they shared the same feelings. Well, not exactly the same. Adrian's affection was clearly brotherly. Eddie's? It was hard to read, kind of a mix of the other two. Maybe it was a kind of guardian fondness. Jill made a gesture to the waterfall, and suddenly, part of it broke off from the tumbling cascade. The chunk of water shaped itself into a braid, then twisted high into the air, making spirals before shattering into a million drops that misted over us all. I had been staring wide-eyed and frozen, but those drops hitting me shocked me awake. â€Å"Jill,† I said in a voice I barely recognized as my own. â€Å"Don't do that again.† Jill, eyes bright, barely spared me a glance as she made another piece of water dance in the air. â€Å"No one's around to see, Sydney.† That wasn't what had me so upset. That wasn't what filled me with so much panic that I could barely breathe. The world was doing that thing where it started to spin, and I worried I was going to faint. Stark, cold fear ran through me, fear at the unknown. The unnatural. The laws of my world had just been broken. This was vampire magic, something foreign and inaccessible to humans – inaccessible because it was forbidden, something no mortal was meant to delve into. I had only once seen magic used, when two spirit users had turned on each other, and I never wanted to see it again. One had forced the plants of the earth to do her bidding while the other telekinetically hurled objects meant to kill. It had been terrifying, and even though I hadn't been the target, I'd felt trapped and overwhelmed in the face of such otherworldly power. It was a reminder that these weren't fun, easy people to hang out with. These were creatures wholly different from me. â€Å"Stop it,† I said, feeling the panic rise. I was afraid of the magic, afraid it would touch me, afraid of what it might do to me. â€Å"Don't do it anymore!† Jill didn't even hear me. She grinned at Lee. â€Å"You're air, right? Can you create fog over the water?† Lee stuffed his hands in his pockets and looked away. â€Å"Ah, well, it's probably not a good idea. I mean, we're in public†¦Ã¢â‚¬  â€Å"Come on,† she pleaded. â€Å"It won't take any effort for you at all.† He actually appeared nervous. â€Å"Nah, not right now.† â€Å"Not you too.† She laughed. Above her and in front of her, that demon water was still spinning, spinning, spinning†¦ â€Å"Jill,† said Adrian, a harsher note in his voice than I'd ever heard before. In fact, I couldn't recall him ever addressing her by her actual name. â€Å"Stop.† It was all he said, but it was like a wave of something went through Jill. She flinched, and the water spirals disappeared, falling away in droplets. â€Å"Fine,† she said, looking confused. There was a moment of awkwardness, and then Eddie said, â€Å"We should hurry. We're going to be pushing curfew.† Lee and Jill set out to make their shots and soon were laughing and flirting again. Eddie continued watching them in his concerned way. Only Adrian paid any attention to me. He was the only one who really understood what had happened, I realized. His green eyes studied me, with no trace of their usual bitter humor. I wasn't fooled, though. I knew there had to be some witty quip coming, mocking my reaction. â€Å"Are you okay?† he asked quietly. â€Å"I'm fine,† I said, turning from him. I didn't want him to see my face. He'd already seen too much, seen my fear. I didn't want any of them to know how afraid of them I was. I heard him take a few steps toward me. â€Å"Sage – â€Å" â€Å"Leave me alone,† I snapped back. I hurried off toward the course's exit, certain he wouldn't follow me. I was right. I waited for them to finish the game, using the alone time to calm myself down. By the time they caught up to me, I was fairly certain I had wiped most of the emotions from my face. Adrian still watched me with concern, which I didn't like, but at least he didn't say anything else about my breakdown. Surprising to no one, the final score showed that I had won and Adrian had lost. Lee had come in third, which seemed to trouble him. â€Å"I used to be a lot better,† he muttered, frowning. â€Å"I used to be perfect at this game.† Considering he'd spent most of the time paying attention to Jill, I thought third was a pretty respectable performance. I dropped him and Adrian off first and then just barely got Eddie, Jill, and me back to Amberwood on time. I was more or less back to normal by then, not that anyone would've noticed. Jill was floating on a cloud as we went into our dorm room, talking nonstop about Lee. â€Å"I had no idea he'd traveled so much! He's maybe been more places than you, Sydney. He keeps telling me that he'll take me to all of them, that we'll spend the rest of our lives traveling and doing whatever we want. And he's taking all sorts of classes in college because he's not sure what he wants to major in. Well, not all sorts this semester. He's got a light schedule so that he can spend more time with his father. And that's good for me. For us, I mean.† I stifled a yawn and nodded wearily. â€Å"That's great.† She paused from where she'd been searching her dresser for pajamas. â€Å"I'm sorry, by the way.† I froze. I didn't want an apology for the magic. I didn't even want to remember it had happened. â€Å"For yelling at you the other night,† she continued. â€Å"You didn't set me up with Lee. I should never have accused you of interfering. He really has liked me all along, and, well†¦ he's really great.† I let out the breath I'd been holding and attempted a weak smile. â€Å"I'm glad you're happy.† She returned cheerfully to her tasks and to talking about Lee until I left to go down to the bathroom. Before brushing my teeth, I stood in front of the sink and washed my hands and arms over and over, scrubbing as hard as I could to wash away the magical drops of water I swore I could still feel on my skin.

100 Years of Solitude - Essay Assignment Example | Topics and Well Written Essays - 750 words

100 Years of Solitude - Essay - Assignment Example The conditions of that region are depicted by the use of various facts of life; revolution and war, youth and old age, poverty and prosperity, love and lust – all themes are found dispersed throughout this work. People belonging to a variety of cultures reside in the South American land and it is for this reason that the influence of these cultures is evident in everyday life of the people of Macondo – the imaginary village. The story of the novel takes into account the history of almost five generations of the Buendia family and there are various points in the story where the author points towards the multicultural nature of the residents of the region. The author has at various points pointed towards the uncertainties that prevail in the South American region. Of note is the way in which the political realities of the region are presented in the novel. The novel clearly depicts how the influential classes of the South American society used assassination as a tool to control the lives of common people. The number of people who lose their lives in the process is astounding; yet the thirst of blood of the power-hungry politically influential class is never satisfied. They way in which the influential class of the society uses the slogan of ‘patriotism’ to provoke the innocents of the society, is clearly a reflection of the negative ways that are utilized to achieve political gains using the strength of masses. The picture portrayed by the author clearly demonstrates the uncertainty regarding life; people are provoked and then punished, but justice is hardly ever served. An interesting metaphor used by the author of this work is ‘ice’. Although regarded as the ‘greatest invention’ of this time by the author, ice holds symbolic significance that is beyond ordinary. Ice and its fate have been associated with the history of Macondo.

Financial crisis Term Paper Example | Topics and Well Written Essays - 2000 words

Financial crisis - Term Paper Example In such a situation, the entity would face liquidity problems, have cash flow problems, and see the net worth decreasing. If it happens to a market or a bank, then there would be panic selling that further brings the prices of stocks down. There would be a run on the banks with a large number of people attempting to withdraw cash. Assets would lose their valuation. Depending on the severity of the crisis, the market would recover in a few days or the ill effects would persist for a few years. A financial crisis is followed by recession and a general slowdown of the market. Financial crisis can even happen to individuals and businesses and such entities cannot pay their bills, they cannot pay their employees and their business would be repossessed. Recession is said to follow financial crisis and when the GDP becomes negative for two quarters, then the nation is said to be in recession (World Bank, 28 June 2012). This paper examines the subject of financial crisis and discuses various types, causes and method of preventing such a crisis. 2) Types of Financial Crisis Financial crisis usually results in a notional and ‘on paper’ wealth of a firm. If the firm has retained its assets and other infrastructure then after the crisis is over, it can regain its previous position in the market. Financial crises usually occur in a free and liberal market economy that is not subject to protection and where market forces are free to act on the economy. As an example, UK, USA and many other nations have a free and open economy hence financial crisis occur in these markets. However, in the former Soviet Russia, nation such as North Korea and even China where the market is regulated, market forces are not allowed to act freely. Types of financial crisis are broadly classified as international and domestic crisis (Cipriani and Guarino, 2008). These again have sub types and these are discussed as below. A) International Financial Crisis International financial crisis occur at two levels and mechanisms. One is where turmoil in the global stock markets causes a global market crash that precipitates a financial crisis. Another type is the currency crisis that can lead to sovereign default. These terms are explained as below. 1) Global Crisis Global crises can begin in one corner of the world and then if the causes and money involved is high, the crisis can spread to other stock exchanges and nations quickly. One of the reasons is due to the inter connectedness of the stock markets and financial markets across the world. Hence, if the London Stock Market Index crashes and it cannot recover, it will cause the Japan Nikkei index and the US based Dow and NYSE index also to crash. This can create a financial crisis when there is no liquidity in the market and funds, loans, cash is not available. As a result, banks cannot clear the payments, customers and depositors cannot withdraw crash and business also cannot pay their vendors and employees. When thi s cash shortage is long lasting and it affects all the nations, then it becomes a global crisis (Banerjee, 2008). 2) Currencies One of the worst forms of financial crisis is the currency crisis and sovereign default. When a nation that has a fixed exchange rate faces a speculative attack on its currency, then it is forced to devalue the currency. This devaluation is done when the currency appreciates excessively against the global reserve currency, the USD.

Walt Disney Company Essay Example | Topics and Well Written Essays - 1000 words

Walt Disney Company - Essay Example In general the team had pretty good track record of delivering the assigned tasks on time with exception of some minor incidents. The team had strengths and weaknesses that affected the performance of the group. One of the strengths of the team was that it did not waste any time in choosing a topic for the project. This enabled the team to quickly start working on the topic. Another strength of the team was its communication process. The team often utilized emails to communicate with each other. The use of emails was very effective because it allowed the members of the team to exchange information instantly. The members of the team communicated well during meetings. The organization of the team was also very good. Everybody was assigned their own part so we would not have any incidents. The teammate that worked the hardest in the team was Jay. He did more work because every one emailed their part to him and he had to connect and correct all of them before making the final paper. He d eserves a lot of credit for his tremendous work efforts. The weaknesses of the team can be best described by evaluating the work behavior of the members. Shane did a pretty good job, but one time he submitted his part late. Despite his mistake the team was not hurt. The weakest link on the team was Alana. Alana was a problematic teammate that often acted unprofessionally with her antics. Alana contributed fairly to the topic, but it seemed like she always choose the easy part to do. My assessment of Alana is that sometimes she did not take the work seriously. She often laughed at all times about any topic whether it was good or bad. She did not seem to realize that her antics were annoying to the group. She also had the bad habit of nail biting. Another thing is she acted like a child when she kept knocking her pen on the table nonstop during the class and group meeting time. My role in the group was to bring up ideas and make some suggestions at the time we choose topic. I also sub mitted my work on time despite the fact that I had a hard time due to personal problems. I had to come back to my country due to an emergency to resolve a problem. If the team had to work together again next semester I would make changes by establishing ground rules to follow during the team’s initial meeting. I would also increase the amount of meetings during the project to improve the planning and the communication process. The team achieved a coordinated effort. This was accomplished by meeting regularly and by each member being accountable for their actions. The leadership function of the team was not clearly defined, but the team member that showed the most leadership was Jay. I also informally provided leadership to my team by leading through example. I always supported my teammates during the project. I helped my teammates by giving them ideas on how to proceed with their assigned tasks. I was able to build a sense of trust with most of my teammates except with Alana. Her childish behavior made me think she would be an irresponsible teammate. In the end she actually delivered her assigned tasks and performed a fair job. Since leadership roles were not clearly defined by the team I can honesty say that the team exercise did not help me that much in building my leadership abilities. I did not feel compromised by the team because the work was evenly distributed. The team did not experience any major conflicts that would have compromised the project deliverables. The tasks performed by the group were

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Intellectual Property Rights Infringement of TV Productions - Essay Example The UK law does not require copyright to be registered as trademarks, designs and patents. A copyright in UK is created automatically with the creation of the work. Therefore, it can be enforced in case of infringement without prior registration in UK. Conversely, the other member countries of the Berne Convention require that copyright should be registered to create evidence of original author of the work and the time of creation. This way it assists the courts in deciding copyright infringement cases. In UK, there is no such mandatory requirement to register for enforcement of copyrights in the courts. Likewise, the symbol  © is not required by law in UK to be used on the literary, artistic, musical, cinematographic, records and related rights either. It is understood that these works are copyrighted and protected under CDPA, 1988. On the other hand, there are countries and people in UK who still use symbol  © on their works to show that these are copyrighted works and in case of infringement can be fully enforced against the infringer. The law of copyright protection provides the exclusive protection to the author to make copies of the work, sell or license it and use it for any purpose whatsoever. It provides protection to the broadcasters and singers in the shape of exclusive rights to their broadcasted work to ensure that others do not infringe upon their rights. The law recognizes 50 years of protection to films and cinematographic works from the date of the manufacturing of the work (Copyright Service 2012). Likewise, the copyrights in the broadcast last for 50 years, starting from the end of the calendar year in which the broadcast was first made. The copyright in the work arises automatically... This essay discusses the copyright law of UK and intellectual property rights, that constitute transforming ideas into tangible products and services. The diversity in the ideas that give rise to products and services today, requires that there are different protections available for every different aspect of a product or service. Likewise, the concept of protection of these products and services was highlighted in 1886 and a treaty came into existence titled Berne Convention for the Protection of Copyrights and Artistic Works. It was realized that the intellectual property in the form of literary, musical and artistic works requires protection globally, and all countries which are members of the World Trade Organization shall become members of the Berne Convention. The UK law does not require copyright to be registered as trademarks, designs and patents. A copyright in UK is created automatically with the creation of the work. Therefore, it can be enforced in case of infringement wi thout prior registration in UK. The copyright in the work arises automatically as it is created with the work. It is not mandatory to register a copyright for a work. However, if registered, it can be easily proved in the courts of law in case any instance of infringement has occurred. According to the UK law on copyrights and related rights, the film and TV productions can be entirely covered under copyright protection. The copyright holder can either sell the rights in the film and TV production or license it to others to broadcast it.

Lord of War and New Thought of Crime Movie Review

Lord of War and New Thought of Crime - Movie Review Example No one takes into account millions of human lives killed by the arms, which is sold to different countries by such guys, as Orlov. There is no fear and emotions, there is only money. A group of people, such as Orlov, do not have moral norms and their deviant behavior is poignant and devastating for the modern society. Cruel and soulless money-gaining machines! Still, if to consider that modern governments chose military ways of doing their business, then â€Å"the Orlovs† are just dummies in their games. Therefore, the modern world is rather controversial and makes people look for different means to keep their head above the water. For the contemporaries, crime has turned into the means to survive and it is not surprising at all. Sometimes people have no other choice but to commit crime, small or big simply in order to stay alive. The globalized world is cruel and there is a need to shift the accents of survival: different means of earning money have all just resulted in a str ong desire to survive. The main prototype of Orlov is the Russian man Victor Bout, who lives unhindered in Moscow, but he is sought by different agencies all over the world. It is a controversial mentality of post-Soviet countries. An enormous quantity of military hardware is â€Å"ranging from bullets and tanks to nuclear warheads† (Viktor Bout Arms Traders and Lord of War). ... Thus, Victor Bout, a prototype of Orlov, was named as the core element of military conflicts. Actually, the main conflict was in the desire of the governments to survive in the cruel modern world, full of military conflicts and political challenges. Different wars in different times were connected with the name of this trader. The military conflict in Afghanistan's and his further help to Taliban. The main character has no soul; he sells weapon for killing innocent people as if he sells hotdogs or vacuum cleaners. It is claimed in the film that people gain profits from vast arms sales and from the taxes paid by the arms manufacturers and the millions of money they employ (Smoking Guns, 2005). The sources of arms trafficking are intimidating the world, and in spite of drugs trafficking, these sources are often neglected. There are shallow relationships between arms traders, governments and arms manufacturers. This is terra incognita. This is a fertile ground for gaining huge profits, a strong and powerful means to survive in the hostile and turbulent modern world (Smoking Guns, 2005). These guys, like Orlov, supply the governments with huge amounts of money and they are often released. These guys have no fear and there is a little bit of Orlov in every of us. This claim can be supported in the following way: it is appropriate in the modern society to survive by any means. There is no need to refer to moral norms or standardized principles of behavior (Smoking Guns, 2005). It is much easier to break up rules and remain safe, to create our own reality, to set up individuals norms and to gain money hand over fist and laugh at the victims of your game. This is the way Orlov acted. This claim can be

Anayse how language is used in a couple of texts( opening pages of Essay

Anayse how language is used in a couple of texts( opening pages of Gone with the wind and Romeo and Juliet - Essay Example These elements include phonology, lexis, punctuation, syntax, semantics and pragmatics. By comparing the usage of these elements between two classic texts, such as William Shakespeare’s Romeo and Juliet and Margaret Mitchell’s Gone With the Wind, evidence can be found in each element of language that demonstrate how the usage of language changes over time and place as well as through dominant format of the communication goals. Shakespeare wrote Romeo and Juliet in 1597 reflecting the Elizabethan values and traditions of England while focusing on the story of a young couple in Verona. In this way, he also incorporates some of the values that were understood in his time to have been important to people of an even earlier time. Mitchell wrote Gone With the Wind in 1936 America reflecting the struggles of the Great Depression and capturing some of the major issues that faced people living in the Civil War south. Like Shakespeare, although she didn’t live during that time period, she incorporates many of the values that were understood in her generation to have been important issues a generation or so earlier. In each case, there is a strong sense of identity reflected in every aspect of the language used. While each novel is written in the same general English language, each illustrates the ideas of love coming to bitter conclusions and each struggles to portray a period of time prior to that in which the author lived, each does so in such a unique way as to make it seem as if they were each written in separate languages all together, which can be teased out by examining the various aspects of language used to tell the story. In Romeo and Juliet, Shakespeare establishes early on a formal and literary tone within the lexis of his text. For example, in the Prologue, he indicates the scene of his play is in â€Å"fair Verona†, a use of the word ‘fair’ that falls within the formal lexicon, especially

495 disc Assignment Example | Topics and Well Written Essays - 250 words

495 disc - Assignment Example The ability to choose your roommate and have access to television and DVD player is very enticing. Interns like having fun and accessing such facilities together with the freedom is great. Availability of the house cleaner give interns more time to focus on the productivity of the company. In line with the week’s readings, Qualcomm incorporated Maslow hierarchy of needs theory as an employee motivational and retention tool. It tries to meet the need s of the interns in order to make the motivated and have interest in working for the company in future (Montana & Charnov, 2008). Through the payment, the company accomplishes the physiological and security need of its interns. Offering the interns the opportunity to choose their roommates in the fully furnished houses help them meet their social needs. The strategies adopted by Qualcomm make the interns comfortable. Chances of requesting retention to work for the company are

Economic Growth in Nigeria Essay Example for Free

Economic Growth in Nigeria Essay The agriculture sector was the focus of intense development interest during the 1990s, with food self-sufficiency the goal. In 1990, agriculture was the subject of a separate three-year development plan involving public and private spending targets concentrating on the family farmer. The program  included price stabilization plans and schemes to revitalize the palm oil, cocoa, and rubber subsectors. The Agricultural Development Projects continued through the decade, but implementation of goals was difficult. The country still imports most of its wheat from the United States. An integrated petrochemical industry was also a priority. Using the output of the nations refineries, Nigeria produced benzene, carbon black, and polypropylene. The development of liquid natural gas facilities was expected to lead to the production of methanol, fertilizer, and domestic gas. Nigerias refineries operated at less than optimal rates throughout the 1990s. In the manufacturing sector, the government was backing a policy of local sourcing whereby locally produced raw materials were converted into finished products. By 1999, manufacturing accounted for less than 1% of gross domestic product (GDP). By the beginning of the 2000s, the government was more concerned about halting corruption and reigning in the state budget than economic development. Nevertheless, the Niger Delta Development Commission (NDDC) was created to coordinate economic and social development in the oil-producing region. Nigerias foreign debt stood at around $28.5 billion in 2001, a large portion of which was interest and payment arrears. The Obasanjo administration in the early 2000s was supporting private-sector-led, market-oriented economic growth, and had begun economic reform programs. Privatization of state-owned enterprises continued. A Stand-By Arrangement with the International Monetary Fund (IMF), approved in 2000, lapsed in 2001 as the governments economic reform program went off track. There were indications a new IMF program for the country would be negotiated in 2003–04. Read more: http://www.nationsencyclopedia.com/Africa/Nigeria-ECONOMIC-DEVELOPMENT.html#ixzz2HUrqN4ZB

Post Civil War South Essay Example for Free

Post Civil War South Essay After the war, the South was devastated and it was going to take a lot of money and a lot of rebuilding for it to be self-sufficient again. It financially and architecturally succeeded in reinventing itself and in the thirty five years following the war, Southern iron, steel and textile industries emerged, with Railroads leading the South’s industrial expansion. The Southern economy grew and prospered, although it could never quite compete with the North in innovations or wages. Now that there were almost 4 million freed slaves living in the South and a huge population of poor white people, there was plenty of cheap labor and business owners took full advantage of the fact. What kept the South from a strong Industrial development was the inability of the White men to work alongside the freed slaves. Attitudes toward the freed slaves had not changed and were getting progressively worse. Black Southerners were barred from working in industrial jobs and only a small percentage of White Southerners were employed in these jobs, therefore expansion could not take place. The South started on the right course and for a period of time it looked like the New South had risen but hatred towards the Black Southerners was the industrial development downfall with The South still strongly depending on agriculture as the economy stabilizer. Supposedly, the New South was based on rich natural resources, economic opportunity and increased racial equality, but after the North removed military control in the South in 1877, the Southern White Democrats went to work at changing their states constitutions and establishing legal barriers that kept the Black Southerners from voting. By 1913 new laws had been enacted, known as the Jim Crow laws, the made it unlawful for Black Southerners to comingle with White Southerners everywhere. Violence and Intimidation was the face of the New South now as Black Southerners and White Southerners competed for the same jobs. Lynching’s, beatings, false imprisonment and raping of the Black Southern women was all the freed slaves had to look forward to now, some of the same treatment many had to endure as slaves. Racial Segregation was fully embraced by the White Southerners and lthough the slaves had been freed, the South had completely failed in their quest for racial equality being a sign of the New South. http://www. civilwaracademy. com/reconstruction. html How did the culture of the Plains Indians, specifically the Lakota Sioux, change in the late 19th century? The Lakota Tribe first acquired horses in the 1700’s and it changed their way of life as they knew it. Over the next 200 years, they saw even more significant changes, but none of them good. Their original warfare between other tribes was never to acquire lands or control people but to obtain more horses, as the Lakota directly equated honor with the number of horses they had. Their warfare strategy changed as the white man encroached on their territory, threatened their buffalo and pushed them out of their lands. To them, their way of life was changing and the attitude became that of â€Å"kill or â€Å"be killed†, protecting family and possessions at any cost. Buffalo was a major source of food, shelter and material items that the Lakota relied heavily on to sustain them. As the White man encroached on the Lakota Territory, they felt that if they eradicated the Buffalo, the Lakota Tribe would be easier to manage and beat down. With the Government policy in the mid 1860’s being that of confining all Indians to reservations, the Establishment of the Great Sioux Reservation through the 1868 Fort Laramie Treaty was proposed. This would drastically change their way of life and make them dependent upon the government to survive. The treaty proposed the following: * Set aside a 25 million acre tract of land for the Lakota and Dakota encompassing all the land in South Dakota west of the Missouri River, to be known as the Great Sioux Reservation; * Permit the Dakota and Lakota to hunt in areas of Nebraska, Wyoming, Montana, and North Dakota until the buffalo were gone; * Provide for an agency, grist mill, and schools to be located on the Great Sioux Reservation; * Provide for land allotments to be made to individual Indians; and provide clothing, blankets, and rations of food to be distributed to all Dakotas and Lakota’s living within the bounds of the Great Sioux Reservation. The majority of the Lakota males did not sign this treaty and since the government did not keep their end of the bargain and broke treaty many times as it suited them, numerous battles were fought while they tried to keep their independence. Eventually the Lakota tried to live on the reservation and by the government’s guidelines, but without horses or guns, they could not hunt and the rations promised to them were either always late or didn’t show up at all. The Lakota were encouraged towards self-sufficiency by imposed farming, and the government did everything it could to â€Å"civilize† the Tribe by making them dress in American traditional clothing and outlawing their rituals and ceremonies.