Nananda F. Col, MD, MPP, MPH, FACPNananda F. Col, MD, MPP, MPH, FACPDirector, Center for Outcomes Research and Director, Center for Outcomes Research and

EvaluationEvaluation Maine Medical CenterMaine Medical Center

Dept of MedicineDept of MedicineColn@MMC.orgColn@MMC.org

Implementing Shared Decision Implementing Shared Decision Making: Making:

Improving Efficiency and Quality of Improving Efficiency and Quality of CareCare

INTRODUCTIONINTRODUCTION

• Most patients want to be more Most patients want to be more involved in decisions about their involved in decisions about their healthhealth

• Shared decisions have better Shared decisions have better outcomesoutcomes

• Despite repeated calls for shared Despite repeated calls for shared decision making, it remains decision making, it remains uncommonuncommon

What is Shared Decision Making?What is Shared Decision Making?

What is Shared Decision Making What is Shared Decision Making (SDM)?(SDM)?

• A recent systematic review identified A recent systematic review identified 161 different conceptual definitions161 different conceptual definitions

• ““A decision-making process jointly A decision-making process jointly shared by patients and their health shared by patients and their health care provider” care provider”

QUESTIONQUESTION

1.1. How often do you engage in How often do you engage in informed decision making with your informed decision making with your patients?patients?

A.A. Most visits Most visits

B.B. OccasionallyOccasionally

C.C. SeldomSeldom

D.D. NeverNever

Elements of Informed Decision Elements of Informed Decision MakingMaking

• Discuss:Discuss:– clinical issue and nature of the decision clinical issue and nature of the decision

to be madeto be made– alternativesalternatives– pros and cons of the alternativespros and cons of the alternatives– uncertainties associated with the uncertainties associated with the

decisiondecision• Assess patient’s understandingAssess patient’s understanding• Ask patient to express preferencesAsk patient to express preferences

Braddock CH, JGIM 1997

QUESTIONQUESTION

2. How often do you discuss the 2. How often do you discuss the uncertainty about risks and benefits uncertainty about risks and benefits of treatment?of treatment?

A.A. Most visits that involve a treatment Most visits that involve a treatment decisiondecision

B.B. OccasionallyOccasionally

C.C. SeldomSeldom

D.D. NeverNever

How common is shared decision How common is shared decision making?making?

Analysis of 1057 clinical encounters by Analysis of 1057 clinical encounters by PCPs and surgeonsPCPs and surgeons

• 16-18% of discussions met minimum 16-18% of discussions met minimum criteria for an informed decisioncriteria for an informed decision

• 1% discussed the uncertainty about 1% discussed the uncertainty about risks and benefits of treatmentrisks and benefits of treatment

Braddock, JAMA 1999

QUESTION QUESTION State of KnowledgeState of Knowledge

3. What percent of all treatments for 3. What percent of all treatments for clinical prevention or treatment are clinical prevention or treatment are of of unknownunknown effectiveness? effectiveness?

A.A. 95%95%

B.B. 75%75%

C.C. 50%50%

D.D. <10%<10%

Clinical Evidence, BMJ

Answer:Answer:

A recent comprehensive summary of A recent comprehensive summary of the state of medical knowledge the state of medical knowledge

• 47%: unknown efficacy47%: unknown efficacy

• 7%: uncertain tradeoff between 7%: uncertain tradeoff between benefits and harmsbenefits and harms

The ChallengeThe Challenge

• More and more people realize that More and more people realize that they are the best judges of their they are the best judges of their values when deliberating over a values when deliberating over a health care decisionhealth care decision

Patient barriers to shared decision Patient barriers to shared decision makingmaking

• Cognitive: complex risk informationCognitive: complex risk information

• Affective: anxiety, fearAffective: anxiety, fear

• Self-efficacy: medical decision Self-efficacy: medical decision makingmaking

• Social/environmental influencesSocial/environmental influences– Locus of control for decision makingLocus of control for decision making

The ProblemThe Problem

• 52% of pts were dissatisfied with the 52% of pts were dissatisfied with the information given (in all aspects) and information given (in all aspects) and reported a desire for more reported a desire for more informationinformation

• The better the match between the The better the match between the information that was desired and the information that was desired and the information received, the better information received, the better patient outcomespatient outcomes

Role of Decision Support ToolsRole of Decision Support Tools

PatientPatient– Educate about risks, treatments, and how to Educate about risks, treatments, and how to

incorporate preferences into the treatment incorporate preferences into the treatment decisiondecision

PCP’sPCP’s– collect relevant pt data (risk factors, medical collect relevant pt data (risk factors, medical

history)history)– understand patient preferences for outcomes understand patient preferences for outcomes

and treatmentsand treatments– Integrate/synthesize risks and preferences to Integrate/synthesize risks and preferences to

make informed decisionsmake informed decisions

Patient Decision AidsPatient Decision Aids Adjuncts to counselling Adjuncts to counselling

1.1. InformInform

2.2. Clarify values Clarify values

3.3. Support Support

1. Inform1. Inform

Provide facts Provide facts Condition, Condition, options, benefits, harmsoptions, benefits, harms

Communicate Communicate probabilitiesprobabilities

2. Clarify values2. Clarify values

Patient experiencePatient experience

Ask which benefits/harms Ask which benefits/harms matters mostmatters most

Facilitate communicationFacilitate communication

3. Support3. Support

Guide in steps of Guide in steps of deliberation, deliberation, communicationcommunication

Worksheets, list of Worksheets, list of questionsquestions

What’s wrong with the status quo?What’s wrong with the status quo?

• Standard counseling is inadequateStandard counseling is inadequate• Clinicians are poor judges of pts’ valuesClinicians are poor judges of pts’ values• Leads to overuse of treatments that patients do Leads to overuse of treatments that patients do

not valuenot value• Preference sensitive surgeries (hip Preference sensitive surgeries (hip

replacements, prostatectomy, mastectomy, replacements, prostatectomy, mastectomy, discectomy, CABG) vary 2-5 folddiscectomy, CABG) vary 2-5 fold

• Informing pts about these procedures Informing pts about these procedures ↓ use 25%↓ use 25%– No adverse impact on pt satisfaction or health No adverse impact on pt satisfaction or health

outcomesoutcomes

Compared to standard care, Compared to standard care, decision aids…decision aids…

Improve decision Improve decision qualityquality 15%15% higher higher

knowledge scoresknowledge scores 70%70% more realistic more realistic

expectations expectations (probabilities)(probabilities)

better match between better match between values & choicesvalues & choices

Reduce decisional Reduce decisional conflict conflict ((9 9 points)points)

Help undecided to decide Help undecided to decide ((50%50%))

Patients Patients 40%40% less passive less passive in decisionsin decisions

Reduce over-useReduce over-use↓↓25%25% surgery; surgery; ↓↓ 20% 20% PSA; PSA; ↓↓

29%29% HRT HRT

Potential to reduce under-Potential to reduce under-use use

O’Connor et al., Cochrane Library, 2007

Are they cost-effective?Are they cost-effective?

• A randomized controlled trial A randomized controlled trial measured economic impact of using measured economic impact of using pt decision aidspt decision aids

• Hysterectomy for heavy menstrual Hysterectomy for heavy menstrual bleeding:bleeding:

Kennedy et al. JAMA 2002; 288: 2701-2708

Growth in trials and PtDAs Registered in Cochrane Growth in trials and PtDAs Registered in Cochrane Collaboration’s InventoryCollaboration’s Inventory

17 24 34 5587

221

523

0

100

200

300

400

500

1999 2001 2002 2006

Year

num

ber

PtDA trials

Other PtDAs inCochrane Inventory

How are decision aids available?How are decision aids available?

• Paper (pamphlet)Paper (pamphlet)

• Game boardsGame boards

• Touch screen monitorsTouch screen monitors

• VideosVideos

• CD ROMsCD ROMs

• Internet Internet

Delivery ModelsDelivery Models

1.1. Internet Internet [8 million in 2006][8 million in 2006]

2.2. Call CenterCall Center

3.3. Practice Centers or Practice Centers or Shared DM CenterShared DM Center

Range of Decision Support ToolsRange of Decision Support Tools

PATIENTDOCTOR

Information: Information: diagnosticdiagnostic teststests::•Where to orderWhere to order•CostsCosts

Tools to Tools to assess riskassess risk

Patient electronic Patient electronic medical record (EMR)medical record (EMR)

Risk self-Risk self-assessmentassessment

Information: Information: cancer, risk cancer, risk factors, diagnostic testsfactors, diagnostic tests

MD-pt interaction

??

Patient Patient portals: portals: TricareTricare

personal personal health journalhealth journal

disease tracking & disease tracking &

management toolsmanagement tools

Clinical Clinical trialstrials

Foundation for Informed Decision Foundation for Informed Decision MakingMaking

• The Informed Health Care Consumer The Informed Health Care Consumer • Treatment Choices for Benign Prostatic HyperplasiaTreatment Choices for Benign Prostatic Hyperplasia• Treatment Choices for Prostate CancerTreatment Choices for Prostate Cancer• Is a PSA Test Right for You? Is a PSA Test Right for You? • Treatment Choices for Abnormal Uterine BleedingTreatment Choices for Abnormal Uterine Bleeding• Treatment Choices for Uterine FibroidsTreatment Choices for Uterine Fibroids• Ovarian Cancer: Reducing Your RisksOvarian Cancer: Reducing Your Risks• Early Breast Cancer: Hormone Therapy and ChemotherapyEarly Breast Cancer: Hormone Therapy and Chemotherapy• Early Stage Breast Cancer: Choosing Your SurgeryEarly Stage Breast Cancer: Choosing Your Surgery• Breast Reconstruction: Is It Right For You? Breast Reconstruction: Is It Right For You? • Living with Metastatic Breast CancerLiving with Metastatic Breast Cancer• Ductal Carcinoma In Situ: Choosing Your TreatmentDuctal Carcinoma In Situ: Choosing Your Treatment• Managing Menopause: Choosing Treatments for Menopause Managing Menopause: Choosing Treatments for Menopause

SymptomsSymptoms

Ottawa Health Research Institute: www.ohri.ca

Fox Chase Cancer Center: http://www.fccc.edu

Decision AidDecision Aid Personal Decision FormPersonal Decision Form

• GP/Physio screens GP/Physio screens for surgical for surgical eligibilityeligibility– Decision AidDecision Aid

• Assess patients’ Assess patients’ informed informed preferencepreference– Patient decision aidPatient decision aid– Decision qualityDecision quality

Dear Dr. Thank you for the referral. Your patient, ___________________, was assessed at the Orthopaedic Intake Clinic at the Riverside campus of the Ottawa Hospital. We used the following standardized assessment:

A. Clinical Assessment of Surgical EligibilityYour patient completed an osteoarthritis specific quality of life measure, the validated WOMAC (Western Ontario McMaster Osteoarthritis Index). Higher scores indicate worse quality of life (threshold for consideration of joint replacement > 39).A physician completed joint replacement assessment tool, HKPT (Hip & Knee Priority Tool) developed and validated for the Western Canada Wait List Project and includes aspects of history, physical examination and X-ray interpretation. Higher scores indicate higher need for joint replacementYour patient self-reported a WOMAC osteoarthritis score of ____/120 and was assigned a HKPT screening score of _______/80. Both forms are attached for your information. Based on this global assessment, your patient meets the criteria for further assessment by an orthopaedic surgeon.

B. Assessment of Patients’ Informed PreferencesYour patient watched an evidence-based, validated video/DVD patient decision aid on total knee replacement surgery. It describes the options, benefits, risks, and their associated probabilities. It also helps them to clarify the personal importance of benefits versus risks.Your patient completed a decision quality measure eliciting: a) their knowledge of options, benefits, and harms; b) the personal importance they place on benefits versus risks; and c) unresolved decisional needs. The form is appended. After viewing a patient decision aid on total knee replacement surgery, your patient prefers non-operative alternatives at this time and did not want to consider surgery. Other non-operative alternatives to consider include: physiotherapy, bracing_______________; intra-articular cortisone injection; viscosupplementation injections; weight lossInformation on these alternatives can be found at www.aaos.org/Research/documents/oainfo_knee.aspThe Ottawa Hospital Orthopaedic Intake Clinic staff would be happy to reassess your patient in 6 months if the condition changes and your patient re-considers having surgery.

Challenges in Counseling Women Challenges in Counseling Women about Menopauseabout Menopause

• HT: complex benefits versus risksHT: complex benefits versus risks• Many other treatments availableMany other treatments available• Long-term vs short-term effectsLong-term vs short-term effects• Importance of individual riskImportance of individual risk• Uncertainty/probabilitiesUncertainty/probabilities• Women often harbor other concernsWomen often harbor other concerns• Quality of menopausal counseling Quality of menopausal counseling

poorpoor

An Interactive WebsiteAn Interactive Website

• Patient-specific decision model translates Patient-specific decision model translates RCT findings to individual patientsRCT findings to individual patients– Applies RR from WHI to individual baseline Applies RR from WHI to individual baseline

risksrisks

• Links decision model to comprehensive Links decision model to comprehensive database of treatmentsdatabase of treatments

• Considers major outcomes affected by HT, Considers major outcomes affected by HT, including relief from menopausal including relief from menopausal symptomssymptoms

Col et al: JAMA, AIM, MDM

Women’s Interactive System for Women’s Interactive System for Decisions on MenopauseDecisions on Menopause

• Purpose: Purpose: – Empower women to make better Empower women to make better

decisions about menopausedecisions about menopause– Help clinicians counsel menopausal Help clinicians counsel menopausal

patientspatients• Designed by multidisciplinary teamDesigned by multidisciplinary team• Funding: AHRQ R01Funding: AHRQ R01

Screen Shots from WISDOMScreen Shots from WISDOM

Treatment Options ChartTreatment Options Chart

Alternative Treatments Alternative Treatments

Drilling Down to Tailor Amount of Drilling Down to Tailor Amount of Information to Information NeedsInformation to Information Needs

Drilling Down: ReferencesDrilling Down: References

Risk AssessmentRisk Assessment

Personalized Risk ReportPersonalized Risk Report

Clinician SummaryClinician Summary

Clinician Summary (cont)Clinician Summary (cont)

How Patients Use WISDOMHow Patients Use WISDOM

• Clinic or doctor refers patient to WISDOM (URL and Clinic or doctor refers patient to WISDOM (URL and password) password) beforebefore her clinic appointment her clinic appointment

• Patient visits WISDOM Patient visits WISDOM – Enters information about her risks, symptoms, and Enters information about her risks, symptoms, and

preferencespreferences– Explores personalized information about menopause, her Explores personalized information about menopause, her

symptoms & risks, & treatmentssymptoms & risks, & treatments

• Patient sends summary report to her doctorPatient sends summary report to her doctor• Clinic appointment to discuss menopauseClinic appointment to discuss menopause• Patient uses website as resource after doctor visitPatient uses website as resource after doctor visit

The Randomized TrialThe Randomized Trial

• Evaluated in multi-site RCT (n=200)Evaluated in multi-site RCT (n=200)

• Intervention: WISDOMIntervention: WISDOM

• Control: standard care Control: standard care

• 4 Clinic sites4 Clinic sites

• Randomization at patient level within Randomization at patient level within each clinicianeach clinician– 6 control/6 intervention patients per 6 control/6 intervention patients per

clinicianclinician

Outcome MeasuresOutcome Measures

• Medication UseMedication Use• Decisional ConflictDecisional Conflict• KnowledgeKnowledge• SatisfactionSatisfaction• Behavioral changeBehavioral change• Quality of counselingQuality of counseling• Risk perceptionRisk perception

Feedback from DoctorsFeedback from DoctorsWISDOM…WISDOM… % of positive

responses

prepared the patient for the visit 70%

improved the quality of the visit 65%

improved the way time was spent during the visit 60%

helped me understand the issues important to my patient 80%

helped my patient understand treatment risks, benefits 75%

helped my patient be as involved in the decision making process as she desired

85%

helped my patient to make a more informed decision 90%

affected the patient-physician relationship 75%

saved time in my clinic visits 50%

improved the efficiency of my patient consultation 55%

improved my counseling session on menopause 70%

SummarySummary

• WISDOM users:WISDOM users:– Decrease use of HT and MTDecrease use of HT and MT– Higher use of other prescription meds Higher use of other prescription meds

• To treat HTN, depression, insomniaTo treat HTN, depression, insomnia– More likely to try exercise/diet/soyMore likely to try exercise/diet/soy

28.6

12.0

28.6

8.0

42.9

80.0

01

02

03

04

05

06

07

08

09

01

00P

erc

ent P

resc

ribe

d

MT HT Other

Fisher's exact p = .038

Prescription Drug Type by Intervention (n = 46)

Control Wisdom

Possible Mechanisms of Action?Possible Mechanisms of Action?

– WISDOM users more knowledgeable about WISDOM users more knowledgeable about risks of HT, impact of HT on other conditionsrisks of HT, impact of HT on other conditions

– WISDOM users more aware of the benefits of WISDOM users more aware of the benefits of lifestyle improvements lifestyle improvements

– Doctors and patients better able to identify Doctors and patients better able to identify and address critical non-menopausal issues and address critical non-menopausal issues

– Doctors and patients are more aware of the Doctors and patients are more aware of the patient’s risks and symptoms & better able patient’s risks and symptoms & better able to prioritizeto prioritize

-0.200

-0.100

0.000

0.100

0.200

0.300

0.400

0.500

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nal

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Un

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nd

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Mea

n C

han

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Control

WISDOM

Impact on Decisional ConflictImpact on Decisional Conflict

Access to WISDOMAccess to WISDOM

• URL: URL: www.medwisdom.orgwww.medwisdom.org

• Currently password protectedCurrently password protected– Username: “guest5” Username: “guest5” – Password: gue5t5 Password: gue5t5

QuestionQuestion

4. Would you be interested in using 4. Would you be interested in using this website if it were free of charge?this website if it were free of charge?A.A. Yes Yes

B.B. No No

C.C. Not sure Not sure

Can Patient-Centered Technology Can Patient-Centered Technology Transform Health Care?Transform Health Care?

• Help identify high-risk patientsHelp identify high-risk patients– Facilitate targeted counseling, risk Facilitate targeted counseling, risk

reductionreduction• Help PCPs counsel patients about treatments Help PCPs counsel patients about treatments • More efficient use of PCP time More efficient use of PCP time

– Shift time consuming tasks to those better Shift time consuming tasks to those better equipped: computers and patientsequipped: computers and patients

– Technology performs data collection, Technology performs data collection, integration, synthesis, mappingintegration, synthesis, mapping

– PCP has more time to address other areasPCP has more time to address other areas– Less error, less biasLess error, less bias

QUESTION: QUESTION: 5. What would most 5. What would most preventprevent you from you from incorporating Shared Decision Making incorporating Shared Decision Making

into your practice?into your practice?A.A. Not enough timeNot enough timeB.B. Don’t believe its applicable to characteristics Don’t believe its applicable to characteristics

of my patientsof my patientsC.C. Don’t believe applicable to clinical situationDon’t believe applicable to clinical situationD.D. Believe it’s not possible to reconcile patient Believe it’s not possible to reconcile patient

preferences with SDMpreferences with SDME.E. Don’t believe in concept of asking patients Don’t believe in concept of asking patients

about their preferencesabout their preferencesF.F. Believe can’t perform SDMBelieve can’t perform SDMG.G. Don’t understand SDM (lack of familiarity)Don’t understand SDM (lack of familiarity)H.H. Difficult to find/access the appropriate Difficult to find/access the appropriate

decision tool at the time when it is neededdecision tool at the time when it is needed

QUESTIONQUESTION Would you use DS to help: Would you use DS to help:

6. 6. Choose the best drug for your patient?Choose the best drug for your patient?A.A. YesYes

B.B. NoNo

C.C. Not sureNot sure

QUESTIONQUESTION Would you use DS to help: Would you use DS to help:

7. 7. Prioritize your patient’s risks for Prioritize your patient’s risks for chronic disease?chronic disease?

A.A. YesYes

B.B. NoNo

C.C. Not sureNot sure

QUESTIONQUESTION Would you use DS to help: Would you use DS to help:

8. Identify patient preferences for 8. Identify patient preferences for treatments?treatments?

A.A. YesYes

B.B. NoNo

C.C. Not sureNot sure

QUESTIONQUESTION Would you use DS to help: Would you use DS to help:

9. Educate patients about disease self-9. Educate patients about disease self-management?management?

A.A. YesYes

B.B. NoNo

C.C. Not sureNot sure

QUESTIONQUESTION Would you use DS to help: Would you use DS to help:

10. Patient identify/prioritize what they want 10. Patient identify/prioritize what they want to talk about during the clinic visit?to talk about during the clinic visit?

A.A. YesYes

B.B. NoNo

C.C. Not sureNot sure

QUESTION: QUESTION:

1111. What attribute of DS is most important for you?

A.A. SaveSave timetimeB.B. Avoid paperworkAvoid paperworkC.C. Prepare patients for visitPrepare patients for visitD.D. Educate patient after the visitEducate patient after the visitE.E. Help set priorities for the clinic visitHelp set priorities for the clinic visitF.F. Reduce liabilityReduce liabilityG.G. Simplify counselingSimplify counseling

QUESTIONQUESTION

12. Would you be interested in training 12. Would you be interested in training in shared decision making?in shared decision making?

A.A. YesYes

B.B. NoNo

C.C. Not sureNot sure

QUESTIONQUESTION

13. If you were aware of your patients 13. If you were aware of your patients top 2-3 health concerns just before top 2-3 health concerns just before they walked in the door, would that they walked in the door, would that help you?help you?

A.A. YesYes

B.B. NoNo

C.C. Not sureNot sure

Legal standard: Legal standard: informed patient informed patient choicechoice

How long before it will be unethical to ask a patient to consent to treatment without using a decision aid? I predict it will not be long—despite the time needed to use aids and the limited availability of good ones. The Ottawa Health Decision Centre is working on this. … it provides a list of decision aids, each scored for quality against an international standard (http://decisionaid.ohri.ca).

Washington State New LegislationWashington State New LegislationBill 5930 (May 2007) An act relating to providing high quality, affordable healthcare Bill 5930 (May 2007) An act relating to providing high quality, affordable healthcare to Washingtonians based on the recommendations of the blue ribbon commission to Washingtonians based on the recommendations of the blue ribbon commission

on health care costs and accesson health care costs and access

• if a patient/delegate signs an acknowledgement of shared decision if a patient/delegate signs an acknowledgement of shared decision making, such acknowledgement shall constitute evidence that the patient making, such acknowledgement shall constitute evidence that the patient gave his or her informed consent to the treatment administeredgave his or her informed consent to the treatment administered

• Acknowledgement of SDM includes:Acknowledgement of SDM includes:– Statement that patient and health care provider have engaged in SDMStatement that patient and health care provider have engaged in SDM– Brief description of the services the patient and provider have jointly have Brief description of the services the patient and provider have jointly have

agreed toagreed to– Brief description of the patient decision aid usedBrief description of the patient decision aid used– Statement that patient understands risks or seriousness of disease, available Statement that patient understands risks or seriousness of disease, available

treatment alternatives (including non-tx), risks, benefits and uncertainties of treatment alternatives (including non-tx), risks, benefits and uncertainties of treatment alternativestreatment alternatives

– Statement that patient had opportunity to ask the provider questions and have Statement that patient had opportunity to ask the provider questions and have questions answered to patients’ satisfactionquestions answered to patients’ satisfaction

• SDM Def’n: process in which the physician or other health care SDM Def’n: process in which the physician or other health care practitioner discusses with the patient or his/her representative the practitioner discusses with the patient or his/her representative the information specified above with the use of a patient decision aid and the information specified above with the use of a patient decision aid and the patient shares with the provider such relevant personal info as might patient shares with the provider such relevant personal info as might make one treatment or side effect more or less tolerable than othersmake one treatment or side effect more or less tolerable than others

QUESTION 14QUESTION 14

ChooseChoose the statement that is most like you the statement that is most like you

A.A. It is easy for me to become emotionally close to others. I am It is easy for me to become emotionally close to others. I am comfortable depending on others and having others depend on me. comfortable depending on others and having others depend on me. I don't worry about being alone or having others not accept me.I don't worry about being alone or having others not accept me.

B.B. I am comfortable without close relationships. It is very important to I am comfortable without close relationships. It is very important to me to feel independent and self-sufficient, and I prefer not to depend me to feel independent and self-sufficient, and I prefer not to depend on others or have others depend on me.on others or have others depend on me.

C.C. I want to be completely emotionally intimate with others, but I often I want to be completely emotionally intimate with others, but I often find that others are reluctant to get as close as I would like. I am find that others are reluctant to get as close as I would like. I am uncomfortable being without close relationships, but I sometimes uncomfortable being without close relationships, but I sometimes worry that others don't value me as much as I value them.worry that others don't value me as much as I value them.

D.D. I am uncomfortable getting close to others. I want emotionally I am uncomfortable getting close to others. I want emotionally close relationships, but I find it difficult to trust others completely, or close relationships, but I find it difficult to trust others completely, or to depend on them. I worry that I will be hurt if I allow myself to to depend on them. I worry that I will be hurt if I allow myself to become too close to others.become too close to others.

THANK YOUTHANK YOU

Design of Randomized TrialDesign of Randomized Trial

1,450 women notified

300 (21%) responded

67 excluded•7 had breast cancer or heart disease•58 returned packet too late•2 failed to participate

233 randomized

WISDOM (117)

107 (91%) returned 2-wk survey

Control (116 )

111 (96%) returned 2-wk survey