Development of a patient decision aid regarding aspects of oral health in a home care context

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Older adults receiving home care are at high risk of poor oral health and often have limited opportunities to participate in decisions affecting their oral health, despite strong links between oral health, autonomy and quality of life. While shared decision-making (SDM) is increasingly emphasised in health care, patient decision aids (PtDAs) addressing oral health decisions in home-care settings are lacking. This study aimed to describe the iterative development of a PtDA designed to support oral health decision-making among older adults receiving home care. Methods Guided by the International Patient Decision Aid Standards (IPDAS) development model, the PtDA was developed through three phases: understanding users, developing and refining the tool, and assessment. A co-design approach was applied throughout. Data were collected through interviews, living labs and workshops involving older adults, municipal home-care staff, dental professionals, leaders, and system developers. Results A PtDA was developed to facilitate SDM regarding oral health in home care contexts. The tool was informed by the Ottawa Decision Support Framework (ODSF) and IPDAS principles. Four key decisional needs were identified: holistic information, clarity of roles, support for, and preservation of existing routines. Living labs revealed two recurrent decision points during cross-organisational oral assessments: decisions regarding dental care (type, location, or deferral) and decisions regarding support for daily oral hygiene. These insights informed a PtDA integrating subjective oral health assessments, Revised Oral Assessment Guide (ROAG) findings, values clarification, and structured deliberation guidance. The PtDA fulfilled all IPDAS qualifying and essential criteria. Conclusions The study presents the development of an evidence-informed, co-designed PtDA for oral health in a home-care context. Embedded within a digital, cross-organisational oral-health platform, the PtDA supports older adults’ involvement in oral health decisions, enhances communication across care providers, and aligns with established standards for SDM. Co-design Dental Care Home care Older adults Shared decision-making Figures Figure 1 Introduction Oral health is a key component of healthy ageing and overall quality of life ( 1 , 2 ). As increasing numbers of older adults retain their natural teeth into later life, oral health needs have become more complex ( 3 ). At the same time, older adults living with frailty often lose regular contact with dental services ( 4 ). Poor oral health is associated with a range of adverse health outcomes, including respiratory diseases, cardiovascular disease, malnutrition, and type 2 diabetes ( 5 – 8 ). Nevertheless, oral care is frequently deprioritized in home care settings, partly due to fragmented responsibilities and limited professional knowledge ( 9 – 11 ). Oral health decisions are closely linked to autonomy, everyday habits, and personal preferences ( 12 ). Despite the central role of oral health in healthy ageing, current home-care assessment models rarely include structured mechanisms to support shared decision-making (SDM), limiting older adults’ opportunities to participate actively in decisions regarding their oral health. This gap appears particularly pronounced in situations characterised by cognitive, functional, and organisational complexity. Older adults receiving home care have repeatedly expressed a desire to be more involved in decisions concerning their oral health ( 13 ). However, few tools are available to support SDM in this context ( 14 ). Shared decision-making is a collaborative process in which patients and clinicians work together to make health decisions based on the best available evidence and the patient’s values and preferences ( 15 ). Existing patient decision aids (PtDAs) in oral health care primarily focus on specific clinical procedures and do not address the needs of older adults receiving home care ( 16 – 18 ). To address this gap, we developed a PtDA as part of a broader Swedish research initiative aimed at strengthening oral health among older adults receiving home care ( 19 ). The development followed the International Patient Decision Aid Standards (IPDAS) model ( 20 ) and was informed by the Ottawa Decision Support Framework (ODSF) ( 15 ) ensuring an evidence-based and person-centred approach to decision-making. The aim of this article is to describe the iterative development of a PtDA for oral health in a home care context. Methods Design The study followed the three overarching phases of the IPDAS developmental model: 1) understanding users, 2) developing and refining the PtDA, and 3) assessment ( 20 ). A co-design approach guided all stages of the process ( 21 ). The ODSF ( 15 ) and the Ottawa Patient Decision Guide (OPDG) ( 22 ) informed the theoretical framework, with a focus identifying decisional needs, supporting informed and value-based choices, and reducing decision conflict. The developmental process followed a user-centred design methodology, that integrating evidence synthesis, iterative prototyping, and multi-stakeholder engagement to ensure that empirical findings were systematically translated into PtDA features. Setting This study was conducted in western Sweden through collaboration between municipal home care service and the Public Dental Service ( 23 ). Figure 1 illustrates the overarching organisational decision-making processes within municipal home care and the Public Dental Service. Although care processes are fragmented from a cross-organisational perspective, oral health assessments for older adults with extensive care needs are routinely conducted jointly by nursing assistants and dental hygienists ( 24 ). The existing nationally used paper-based oral care card for cross-organisational recording was identified as insufficient to support person-centred decision-making, which prompted the development of a digital platform incorporating a paper-based PtDA for older adults and potential significant others. Data collection Interviews Between 2021 and 2022, 27 semi-structured individual and group interviews were conducted with 60 participants, including nursing assistants, dental hygienists, municipal leaders, and significant others. The interviews explored experiences of oral health assessments, communication needs, and expectations regarding decision support. Findings from these interviews have been reported in previous studies ( 26 – 28 ). Living labs In 2022, the first PtDA prototype was tested in 24 living labs ( 29 ) across seven municipalities. Participants included 24 older adults, eight home healthcare nurses, and seven dental hygienists. Each living lab consisted of an in-home oral assessment followed by an interview. The aim was to explore usability, communication patterns, and decision points emerging during assessments ( 13 , 30 ). Workshops Workshops conducted in 2024 and 2025 involved older adults, nursing assistants, home healthcare nurses, dental hygienists, and system developers. These workshops focused on refining the content, structure, and integration of the PtDA within the broader digital platform. Prototype development Insights from interviews and living labs informed iterative revisions of the PtDA prototype. The digital platform was designed to integrate objective clinical assessments using the validated Revised Oral Assessment Guide (ROAG) ( 31 ) with subjective self-reported oral health data. In 2025, the prototype for the PtDA was reviewed against core IPDAS criteria ( 20 ), including balanced information, values clarification, guidance in deliberation, structured decision steps, and citation of evidence, and aligned with the OPDG ( 22 ). Planned assessment The PtDA will undergo pilot testing in late 2025, followed by a cluster-randomised controlled trial in spring 2026 ( 15 ). Results User needs informing the PtDA Analysis of interview data ( 26 – 28 ) revealed four overarching decisional needs: Holistic information: Nursing assistants and dental hygienists expressed a need for assessment that encompass general health, functional ability, autonomy, and personal preferences, rather than focusing solely on oral status. Clarity of roles: Leaders and practitioners highlighted fragmented responsibilities across organisations and emphasised the need for a tool that supports role clarity and reciprocal learning between professions. Support for older adults’ autonomy: Older adults and significant others stressed the importance of clear, accessible communication and meaningful involvement in decisions regarding oral health. Preservation of existing routines: Participants emphasised that new tools should build on existing workflows rather than replace them entirely. Prototype performance in living labs Living labs revealed two recurrent decision points during in-home oral assessments ( 29 ): Whether the older adults wished to receive dental care, and in what form (clinic-based care, home-based visits, or no contact). Whether the older adult desired support with daily oral hygiene, and what type of support is acceptable. Despite the presence of oral disease or elevated risk, most older adults were generally unfamiliar with SDM processes in relation to oral health. Several expressed a preference for in-home dental care rather than clinic visits. Some were willing to accept preventive or supportive measures, such as fluoride applications, while declining daily assistance with toothbrushing. Professional highlighted the need for enhanced digital communication tools and expanded models for in-home dental service. The findings also underscored the importance of a clear implementation strategy and an interprofessional work model to support the PtDA in practice. Final PtDA structure The final PtDA integrates: Subjective measures of oral health and autonomy Objective clinical findings based on ROAG ( 31 ) Values clarification prompts Evidence-based descriptions of available options Structured guidance for deliberation, inspired by the OPDG ( 22 ) Consideration of short- and long-term outcomes, such as scheduled dental care contact (short-term) and daily oral hygiene support needs (long-term) Discrepancies between subjective and objective assessments trigger exploration of potential decisional conflict, in accordance with ODSF ( 15 ) and IPDAS ( 20 ) recommendations. In supplementary files Table 3 pictures the IPDAS criterias in relation to the newly developed PtDA. Discussion This study describes the development of a novel PtDA aimed at strengthening oral health decision-making for older adults receiving home care. As frailty, multimorbidity, and cognitive variability increase with age, oral health becomes both clinically and organisationally complex, particularly when regular contact with dental services is lost ( 9 – 11 ). Despite older adults expressed desire for autonomy ( 12 ), research indicates that oral health decisions are often made without their active involvement ( 13 ). The PtDA responds to a clear gap in existing PtDAs. To our knowledge, no previously PtDA has focused on oral health in home care settings or addressed cross-organisational decision-making involving both municipal and dental services. Grounded in IPDAS ( 20 ) and the ODSF ( 15 ), the PtDA supports clarity, neutrality, alignment with personal values, and structured deliberation, core components of high-quality decision support. From a public-health and community-dentistry perspective, the PtDA functions as a meso-level tool linking individual decision-making with system-level responsibilities. Oral health inequities among older adults receiving home care are well documented, with frail individuals and those dependent on municipal services facing elevated risk of preventable oral disease and limited access to dental care ( 9 – 11 , 32 – 34 ). By embedding structured decisionsupport within shared digital platform across organisations, the PtDA has the potential to strengthen equity, continuity and preventive oral health at scale. The development process identified four central decisional needs: holistic information, clarity of roles, support for autonomy, and preservation of existing routines. These needs align with previous research demonstrating that oral health among frail older adults is deeply intertwined with general health, everyday functioning, and reliance on formal and informal caregivers ( 1 – 3 , 11 , 12 , 33 , 34 ). By integrating ROAG findings, subjective experiences, and value clarification into a coherent structure, the PtDA reframes oral health as a shared deliberation process rather than a purely technical assessment. Overall, the findings demonstrate that SDM for oral health in home care requires more than information provision. It requires tools that fit existing workflows, validate older adults’ perspectives and create a shared language among older adults, significant others, municipal care staff and dental professionals. The PtDA developed addresses these requirements by combining clinical assessment with subjective experiences, and value clarification in a format suitable for routine care. Living labs revealed two recurrent decision points ( 35 ): decisions regarding dental care and decisions regarding daily oral hygiene support, that reflect common dilemmas in gerodontology and community dentistry ( 4 , 9 – 11 , 32 , 33 ). By structuring these decisions and explicitly presenting structured options, benefits and trade-offs, the PtDA makes everyday complexities visible and discussable. Preferences for in-home dental care and selective acceptance of preventive measures highlight the importance of nuanced, person-centred decision support. Although the challenges addressed in this study are situated within Swedish context, similar issues have been reported internationally ( 3 , 32 , 33 ). ( 32 , 33 ). The PtDA therefore contributes to emerging international efforts to integrate oral health into primary and community care. While adaptation to local contexts will be necessary, the underlying principles, integrating clinical and subjective data, clarifying decision points, and embedding SDM in routine workflows are likely transferable ( 34 ) This study represents early-phase design research conducted within a single national context, which may limit transferability. Although a wide range of stakeholders were involved, the number of older adults participating in living labs was limited, and individuals with severe cognitive impairment were underrepresented. The PtDA is embedded in a digital platform, requiring a level of digital infrastructure and inter-organisational collaboration that may not yet be present in all settings. Finally, the article focuses on development; the impact of the PtDA on decision quality, oral health outcomes, service utilisation, and equity will be evaluated in forthcoming pilot and cluster-randomised studies ( 19 , 36 ). Conclusion We developed an evidence-informed, co-designed PtDA embedded within a digital oral health platform for home care. The PtDA supports older adults’ involvement in oral health decisions, strengthens cross-organisational communication, and aligns with IPDAS and ODSF principles for high-quality decision support. Declarations Ethics approval and consent to participate The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Swedish Ethics Review Authority (Dnr. 2020–04603; 2022-03928-01; 2025-03612-01). All participants have given their informed consent to participate, both orally and in writing. Consent for publication Not applicable Competing interest The authors declare no competing interests. Funding This research was funded by the Health Promotion Research Funding (VGFOUREG-937918, VGFOUREG-966932), Region Västra Götaland, Sweden and the Local Research and Development Board of Göteborg and Södra Bohuslän (VGFOUGSB-942302), Region Västra Götaland, Sweden. Author Contribution JPK, SB and JF contributed to the conception and design of this study and JPK drafted the first manuscript. JF, SB and BK reviewed the article and provided critical feedback to improve and structure the manuscript. All the authors agreed and approved the final manuscript. 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Global strategy and action plan on oral health 2023–2030 [Internet]. Geneva: World Health Organization. 2024 [cited 2025 Nov 24]. Available from: https://www.who.int/publications/i/item/9789240090538 Persson Kylén J, Björns S, Hägglin C, Grönbeck-Lindén I, Piper L, Wårdh I. Decisional needs for older adults, home health care nurses and dental hygienists during team-based oral health assessments in ordinary home settings—a qualitative study. BMC Geriatr. 2024;24(1):779. Persson Kylén J, Björns S, Adolfsson A, Torstensson S, Lindmark U, Hägglin C, Almståhl A, Lundegard M, Söder E, Karlén K, Imberg H, Baar A-C, Persson Kylén S, Bogren A, Fjällman C, Klinge B, Edlund J, Wijk H. Protocol for the GAPA@Home Dental Care Intervention: A Substudy within a Cluster Randomised Controlled Trial in Swedish Home Care. Submitted 2026. Additional Declarations No competing interests reported. Supplementary Files Supplementarytables.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 18 Feb, 2026 Reviewers agreed at journal 09 Feb, 2026 Reviewers invited by journal 05 Feb, 2026 Editor invited by journal 08 Jan, 2026 Editor assigned by journal 05 Jan, 2026 Submission checks completed at journal 05 Jan, 2026 First submitted to journal 05 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8480681","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":587491166,"identity":"e92aa903-f92b-41bb-af6a-d1cade08dccf","order_by":0,"name":"Jessica Persson Kylén","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABNElEQVRIie2QP0vDQBTAXzhIlgs6Xgm0XyElkNJB/So5ApmyuAUM9KSQLNG5BalfIVPnyEGy5AM4CDYE2rXFpeLi1T9U8LIL3m+4ezzej/cHQKH4g2hMPN7PDAEkcpEnKe5WDrm6W/nNh6Il3QpK03a7is9hZNy0u330BL0ZvW4vF8HALoxmJRssq13ilT6Ms8q1cL0Gi9CpM1+Gw7zAji1TZqEOlCGwHwMdaQmfLAhNLHMZaULRiUy537RbyiZgP6/R7jXh0Cc0fTPvoou8MDZ7aRewCWVcdNGBmEIRgyXIZCHNC3Bl62tZeNilwuMs0MUuHHpZM7VwGfhzjh3ZYMO0EoeKr/ojo0TiYhxI5T+84Ng/u63SZitT2OePj7c59b4CJBsLYPAdHJWTQl6qUCgU/5Z39EplgobX3IAAAAAASUVORK5CYII=","orcid":"","institution":"Karlstad University","correspondingAuthor":true,"prefix":"","firstName":"Jessica","middleName":"Persson","lastName":"Kylén","suffix":""},{"id":587491167,"identity":"7f46612c-1876-4707-850e-46ee7cfdd515","order_by":1,"name":"Sara Björns","email":"","orcid":"","institution":"Region Västra Götaland","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Björns","suffix":""},{"id":587491168,"identity":"4fd8e3b5-72a9-4205-ae2a-f5b980126a6f","order_by":2,"name":"Björn Klinge","email":"","orcid":"","institution":"Malmö University","correspondingAuthor":false,"prefix":"","firstName":"Björn","middleName":"","lastName":"Klinge","suffix":""},{"id":587491170,"identity":"2d80a6a9-eecd-4dc3-9f30-dbd75465f5a1","order_by":3,"name":"Jeanette Finderup","email":"","orcid":"","institution":"Aarhus University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jeanette","middleName":"","lastName":"Finderup","suffix":""}],"badges":[],"createdAt":"2025-12-30 11:23:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8480681/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8480681/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102462754,"identity":"9a6608b5-5815-421d-81d1-f7365de14c8c","added_by":"auto","created_at":"2026-02-12 01:11:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":473099,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic representation of overarching organisational decision-making processes for municipal home care and the Public Dental Service in Sweden (25).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8480681/v1/d8bd128481db15fcffce03a0.png"},{"id":102745613,"identity":"c07e7dd5-e572-4f3f-9e83-bbb7da72792e","added_by":"auto","created_at":"2026-02-16 08:52:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":869406,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8480681/v1/f35b75cc-7fa1-47c4-98b3-4bbe1b83be10.pdf"},{"id":102462751,"identity":"fa791116-1d2c-498f-8163-3a85b905b967","added_by":"auto","created_at":"2026-02-12 01:11:18","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24824,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarytables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8480681/v1/52662c6ec624b4f482f53dcc.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development of a patient decision aid regarding aspects of oral health in a home care context","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOral health is a key component of healthy ageing and overall quality of life (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). As increasing numbers of older adults retain their natural teeth into later life, oral health needs have become more complex (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). At the same time, older adults living with frailty often lose regular contact with dental services (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Poor oral health is associated with a range of adverse health outcomes, including respiratory diseases, cardiovascular disease, malnutrition, and type 2 diabetes (\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Nevertheless, oral care is frequently deprioritized in home care settings, partly due to fragmented responsibilities and limited professional knowledge (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOral health decisions are closely linked to autonomy, everyday habits, and personal preferences (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Despite the central role of oral health in healthy ageing, current home-care assessment models rarely include structured mechanisms to support shared decision-making (SDM), limiting older adults\u0026rsquo; opportunities to participate actively in decisions regarding their oral health. This gap appears particularly pronounced in situations characterised by cognitive, functional, and organisational complexity.\u003c/p\u003e \u003cp\u003eOlder adults receiving home care have repeatedly expressed a desire to be more involved in decisions concerning their oral health (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, few tools are available to support SDM in this context (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Shared decision-making is a collaborative process in which patients and clinicians work together to make health decisions based on the best available evidence and the patient\u0026rsquo;s values and preferences (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Existing patient decision aids (PtDAs) in oral health care primarily focus on specific clinical procedures and do not address the needs of older adults receiving home care (\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTo address this gap, we developed a PtDA as part of a broader Swedish research initiative aimed at strengthening oral health among older adults receiving home care (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The development followed the International Patient Decision Aid Standards (IPDAS) model (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and was informed by the Ottawa Decision Support Framework (ODSF) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) ensuring an evidence-based and person-centred approach to decision-making. The aim of this article is to describe the iterative development of a PtDA for oral health in a home care context.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign\u003c/h2\u003e \u003cp\u003eThe study followed the three overarching phases of the IPDAS developmental model: 1) understanding users, 2) developing and refining the PtDA, and 3) assessment (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). A co-design approach guided all stages of the process (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The ODSF (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) and the Ottawa Patient Decision Guide (OPDG) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) informed the theoretical framework, with a focus identifying decisional needs, supporting informed and value-based choices, and reducing decision conflict. The developmental process followed a user-centred design methodology, that integrating evidence synthesis, iterative prototyping, and multi-stakeholder engagement to ensure that empirical findings were systematically translated into PtDA features.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting\u003c/h3\u003e\n\u003cp\u003eThis study was conducted in western Sweden through collaboration between municipal home care service and the Public Dental Service (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the overarching organisational decision-making processes within municipal home care and the Public Dental Service. Although care processes are fragmented from a cross-organisational perspective, oral health assessments for older adults with extensive care needs are routinely conducted jointly by nursing assistants and dental hygienists (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The existing nationally used paper-based oral care card for cross-organisational recording was identified as insufficient to support person-centred decision-making, which prompted the development of a digital platform incorporating a paper-based PtDA for older adults and potential significant others.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eInterviews\u003c/h2\u003e \u003cp\u003e Between 2021 and 2022, 27 semi-structured individual and group interviews were conducted with 60 participants, including nursing assistants, dental hygienists, municipal leaders, and significant others. The interviews explored experiences of oral health assessments, communication needs, and expectations regarding decision support. Findings from these interviews have been reported in previous studies (\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eLiving labs\u003c/h3\u003e\n\u003cp\u003eIn 2022, the first PtDA prototype was tested in 24 living labs (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) across seven municipalities. Participants included 24 older adults, eight home healthcare nurses, and seven dental hygienists. Each living lab consisted of an in-home oral assessment followed by an interview. The aim was to explore usability, communication patterns, and decision points emerging during assessments (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eWorkshops\u003c/h2\u003e \u003cp\u003eWorkshops conducted in 2024 and 2025 involved older adults, nursing assistants, home healthcare nurses, dental hygienists, and system developers. These workshops focused on refining the content, structure, and integration of the PtDA within the broader digital platform.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePrototype development\u003c/h3\u003e\n\u003cp\u003eInsights from interviews and living labs informed iterative revisions of the PtDA prototype. The digital platform was designed to integrate objective clinical assessments using the validated Revised Oral Assessment Guide (ROAG) (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) with subjective self-reported oral health data. In 2025, the prototype for the PtDA was reviewed against core IPDAS criteria (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), including balanced information, values clarification, guidance in deliberation, structured decision steps, and citation of evidence, and aligned with the OPDG (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003ePlanned assessment\u003c/h3\u003e\n\u003cp\u003eThe PtDA will undergo pilot testing in late 2025, followed by a cluster-randomised controlled trial in spring 2026 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eUser needs informing the PtDA\u003c/p\u003e \u003cp\u003eAnalysis of interview data (\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) revealed four overarching decisional needs:\u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e Holistic information: Nursing assistants and dental hygienists expressed a need for assessment that encompass general health, functional ability, autonomy, and personal preferences, rather than focusing solely on oral status.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eClarity of roles: Leaders and practitioners highlighted fragmented responsibilities across organisations and emphasised the need for a tool that supports role clarity and reciprocal learning between professions.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e Support for older adults\u0026rsquo; autonomy: Older adults and significant others stressed the importance of clear, accessible communication and meaningful involvement in decisions regarding oral health.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003ePreservation of existing routines: Participants emphasised that new tools should build on existing workflows rather than replace them entirely.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e \u003cp\u003ePrototype performance in living labs\u003c/p\u003e \u003cp\u003eLiving labs revealed two recurrent decision points during in-home oral assessments (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e):\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhether the older adults wished to receive dental care, and in what form (clinic-based care, home-based visits, or no contact).\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhether the older adult desired support with daily oral hygiene, and what type of support is acceptable.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eDespite the presence of oral disease or elevated risk, most older adults were generally unfamiliar with SDM processes in relation to oral health. Several expressed a preference for in-home dental care rather than clinic visits. Some were willing to accept preventive or supportive measures, such as fluoride applications, while declining daily assistance with toothbrushing.\u003c/p\u003e \u003cp\u003eProfessional highlighted the need for enhanced digital communication tools and expanded models for in-home dental service. The findings also underscored the importance of a clear implementation strategy and an interprofessional work model to support the PtDA in practice.\u003c/p\u003e \u003cp\u003eFinal PtDA structure\u003c/p\u003e \u003cp\u003eThe final PtDA integrates:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSubjective measures of oral health and autonomy\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eObjective clinical findings based on ROAG (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eValues clarification prompts\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEvidence-based descriptions of available options\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eStructured guidance for deliberation, inspired by the OPDG (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eConsideration of short- and long-term outcomes, such as scheduled dental care contact (short-term) and daily oral hygiene support needs (long-term)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eDiscrepancies between subjective and objective assessments trigger exploration of potential decisional conflict, in accordance with ODSF (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) and IPDAS (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) recommendations. In supplementary files Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e pictures the IPDAS criterias in relation to the newly developed PtDA.\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eThis study describes the development of a novel PtDA aimed at strengthening oral health decision-making for older adults receiving home care. As frailty, multimorbidity, and cognitive variability increase with age, oral health becomes both clinically and organisationally complex, particularly when regular contact with dental services is lost (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Despite older adults expressed desire for autonomy (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), research indicates that oral health decisions are often made without their active involvement (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe PtDA responds to a clear gap in existing PtDAs. To our knowledge, no previously PtDA has focused on oral health in home care settings or addressed cross-organisational decision-making involving both municipal and dental services. Grounded in IPDAS (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and the ODSF (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), the PtDA supports clarity, neutrality, alignment with personal values, and structured deliberation, core components of high-quality decision support. From a public-health and community-dentistry perspective, the PtDA functions as a meso-level tool linking individual decision-making with system-level responsibilities. Oral health inequities among older adults receiving home care are well documented, with frail individuals and those dependent on municipal services facing elevated risk of preventable oral disease and limited access to dental care (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). By embedding structured decisionsupport within shared digital platform across organisations, the PtDA has the potential to strengthen equity, continuity and preventive oral health at scale.\u003c/p\u003e \u003cp\u003eThe development process identified four central decisional needs: holistic information, clarity of roles, support for autonomy, and preservation of existing routines. These needs align with previous research demonstrating that oral health among frail older adults is deeply intertwined with general health, everyday functioning, and reliance on formal and informal caregivers (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). By integrating ROAG findings, subjective experiences, and value clarification into a coherent structure, the PtDA reframes oral health as a shared deliberation process rather than a purely technical assessment.\u003c/p\u003e \u003cp\u003eOverall, the findings demonstrate that SDM for oral health in home care requires more than information provision. It requires tools that fit existing workflows, validate older adults\u0026rsquo; perspectives and create a shared language among older adults, significant others, municipal care staff and dental professionals. The PtDA developed addresses these requirements by combining clinical assessment with subjective experiences, and value clarification in a format suitable for routine care.\u003c/p\u003e \u003cp\u003eLiving labs revealed two recurrent decision points (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e): decisions regarding dental care and decisions regarding daily oral hygiene support, that reflect common dilemmas in gerodontology and community dentistry (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). By structuring these decisions and explicitly presenting structured options, benefits and trade-offs, the PtDA makes everyday complexities visible and discussable. Preferences for in-home dental care and selective acceptance of preventive measures highlight the importance of nuanced, person-centred decision support.\u003c/p\u003e \u003cp\u003eAlthough the challenges addressed in this study are situated within Swedish context, similar issues have been reported internationally (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). The PtDA therefore contributes to emerging international efforts to integrate oral health into primary and community care. While adaptation to local contexts will be necessary, the underlying principles, integrating clinical and subjective data, clarifying decision points, and embedding SDM in routine workflows are likely transferable (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThis study represents early-phase design research conducted within a single national context, which may limit transferability. Although a wide range of stakeholders were involved, the number of older adults participating in living labs was limited, and individuals with severe cognitive impairment were underrepresented. The PtDA is embedded in a digital platform, requiring a level of digital infrastructure and inter-organisational collaboration that may not yet be present in all settings. Finally, the article focuses on development; the impact of the PtDA on decision quality, oral health outcomes, service utilisation, and equity will be evaluated in forthcoming pilot and cluster-randomised studies (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe developed an evidence-informed, co-designed PtDA embedded within a digital oral health platform for home care. The PtDA supports older adults\u0026rsquo; involvement in oral health decisions, strengthens cross-organisational communication, and aligns with IPDAS and ODSF principles for high-quality decision support.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003e The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Swedish Ethics Review Authority (Dnr. 2020\u0026ndash;04603; 2022-03928-01; 2025-03612-01). All participants have given their informed consent to participate, both orally and in writing.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interest\u003c/strong\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003e This research was funded by the Health Promotion Research Funding (VGFOUREG-937918, VGFOUREG-966932), Region V\u0026auml;stra G\u0026ouml;taland, Sweden and the Local Research and Development Board of G\u0026ouml;teborg and S\u0026ouml;dra Bohusl\u0026auml;n (VGFOUGSB-942302), Region V\u0026auml;stra G\u0026ouml;taland, Sweden.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJPK, SB and JF contributed to the conception and design of this study and JPK drafted the first manuscript. JF, SB and BK reviewed the article and provided critical feedback to improve and structure the manuscript. All the authors agreed and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors acknowledge all participants in the development of the PtDA.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data used to support the findings of this study are available from the corresponding author upon resonable requests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLindmark U, Ernsth Bravell M, Johansson L, Finkel D. Oral health is essential for quality of life in older adults: A Swedish national quality register study. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/9789240090538\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/9789240090538\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePersson Kyl\u0026eacute;n J, Bj\u0026ouml;rns S, H\u0026auml;gglin C, Gr\u0026ouml;nbeck-Lind\u0026eacute;n I, Piper L, W\u0026aring;rdh I. Decisional needs for older adults, home health care nurses and dental hygienists during team-based oral health assessments in ordinary home settings\u0026mdash;a qualitative study. BMC Geriatr. 2024;24(1):779.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePersson Kyl\u0026eacute;n J, Bj\u0026ouml;rns S, Adolfsson A, Torstensson S, Lindmark U, H\u0026auml;gglin C, Almst\u0026aring;hl A, Lundegard M, S\u0026ouml;der E, Karl\u0026eacute;n K, Imberg H, Baar A-C, Persson Kyl\u0026eacute;n S, Bogren A, Fj\u0026auml;llman C, Klinge B, Edlund J, Wijk H. Protocol for the GAPA@Home Dental Care Intervention: A Substudy within a Cluster Randomised Controlled Trial in Swedish Home Care. Submitted 2026.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-informatics-and-decision-making","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"midm","sideBox":"Learn more about [BMC Medical Informatics and Decision Making](http://bmcmedinformdecismak.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/midm/default.aspx","title":"BMC Medical Informatics and Decision Making","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Co-design, Dental Care, Home care, Older adults, Shared decision-making","lastPublishedDoi":"10.21203/rs.3.rs-8480681/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8480681/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eOral health is a fundamental component of healthy ageing. Older adults receiving home care are at high risk of poor oral health and often have limited opportunities to participate in decisions affecting their oral health, despite strong links between oral health, autonomy and quality of life. While shared decision-making (SDM) is increasingly emphasised in health care, patient decision aids (PtDAs) addressing oral health decisions in home-care settings are lacking. This study aimed to describe the iterative development of a PtDA designed to support oral health decision-making among older adults receiving home care.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eGuided by the International Patient Decision Aid Standards (IPDAS) development model, the PtDA was developed through three phases: understanding users, developing and refining the tool, and assessment. A co-design approach was applied throughout. Data were collected through interviews, living labs and workshops involving older adults, municipal home-care staff, dental professionals, leaders, and system developers.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e A PtDA was developed to facilitate SDM regarding oral health in home care contexts. The tool was informed by the Ottawa Decision Support Framework (ODSF) and IPDAS principles. Four key decisional needs were identified: holistic information, clarity of roles, support for, and preservation of existing routines. Living labs revealed two recurrent decision points during cross-organisational oral assessments: decisions regarding dental care (type, location, or deferral) and decisions regarding support for daily oral hygiene. These insights informed a PtDA integrating subjective oral health assessments, Revised Oral Assessment Guide (ROAG) findings, values clarification, and structured deliberation guidance. The PtDA fulfilled all IPDAS qualifying and essential criteria.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e The study presents the development of an evidence-informed, co-designed PtDA for oral health in a home-care context. Embedded within a digital, cross-organisational oral-health platform, the PtDA supports older adults\u0026rsquo; involvement in oral health decisions, enhances communication across care providers, and aligns with established standards for SDM.\u003c/p\u003e","manuscriptTitle":"Development of a patient decision aid regarding aspects of oral health in a home care context","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-12 01:11:09","doi":"10.21203/rs.3.rs-8480681/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-19T00:46:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"235645856986776937292373835215875302903","date":"2026-02-10T00:05:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-05T06:58:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-09T03:55:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-05T11:19:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-05T10:47:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Informatics and Decision Making","date":"2026-01-05T10:32:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-informatics-and-decision-making","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"midm","sideBox":"Learn more about [BMC Medical Informatics and Decision Making](http://bmcmedinformdecismak.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/midm/default.aspx","title":"BMC Medical Informatics and Decision Making","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9eb1dd97-e3d9-4bd3-bcb3-ab101e7ecdb4","owner":[],"postedDate":"February 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-12T01:11:09+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-12 01:11:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8480681","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8480681","identity":"rs-8480681","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}