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Online decision aids for primary cardiovascular disease prevention: systematic search, evaluation of quality and suitability for low health literacy patients
  1. Carissa Bonner1,2,
  2. Pinika Patel1,2,
  3. Michael Anthony Fajardo1,2,
  4. Ruixuan Zhuang1,
  5. Lyndal Trevena1,2
  1. 1 School of Public Health, The University of Sydney, Camperdown, New South Wales, Australia
  2. 2 Ask, Share, Know: Rapid Evidence for General Practice Decisions Centre for Research Excellence, The University of Sydney, Camperdown, New South Wales, Australia
  1. Correspondence to Dr Carissa Bonner; carissa.bonner{at}


Objectives Recent guideline changes for cardiovascular disease (CVD) prevention medication have resulted in calls to implement shared decision-making rather than arbitrary treatment thresholds. Less attention has been paid to existing tools that could facilitate this. Decision aids are well-established tools that enable shared decision-making and have been shown to improve CVD prevention adherence. However, it is unknown how many CVD decision aids are publicly available for patients online, what their quality is like and whether they are suitable for patients with lower health literacy, for whom the burden of CVD is greatest. This study aimed to identify and evaluate all English language, publicly available online CVD prevention decision aids.

Design Systematic review of public websites in August to November 2016 using an environmental scan methodology, with updated evaluation in April 2018. The decision aids were evaluated based on: (1) suitability for low health literacy populations (understandability, actionability and readability); and (2) International Patient Decision Aids Standards (IPDAS).

Primary outcome measures Understandability and actionability using the validated Patient Education Materials Assessment Tool for Printed Materials (PEMAT-P scale), readability using Gunning–Fog and Flesch–Kincaid indices and quality using IPDAS V.3 and V.4.

Results A total of 25 unique decision aids were identified. On the PEMAT-P scale, the decision aids scored well on understandability (mean 87%) but not on actionability (mean 61%). Readability was also higher than recommended levels (mean Gunning–Fog index=10.1; suitable for grade 10 students). Four decision aids met criteria to be considered a decision aid (ie, met IPDAS qualifying criteria) and one sufficiently minimised major bias (ie, met IPDAS certification criteria).

Conclusions Publicly available CVD prevention decision aids are not suitable for low literacy populations and only one met international standards for certification. Given that patients with lower health literacy are at increased risk of CVD, this urgently needs to be addressed.

  • cardiovascular disease
  • decision support
  • decision aid
  • prevention
  • shared decision making
  • health literacy

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  • Contributors CB contributed to the conceptualisation, methodology, data analysis and interpretation and drafting the manuscript. PP and RZ contributed to the methodology, data collection and revising the manuscript. MAF contributed to the data analysis and revising the manuscript. LT contributed to the conceptualisation, methodology and revising the manuscript.

  • Funding The study was supported by grants from the National Heart Foundation of Australia (Vanguard Grant 101326), the Royal Australian College of General Practitioners and Therapeutic Guidelines (TGL/RACGP Research Grant TGL16b).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Website URLs containing the CVD Decision Aids are available in Supplementary Files. Descriptive and evaluative data are also available within Supplementary Files.

  • Patient consent for publication Not required.

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