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Can Fam Physician. 2010 Aug;56(8):e308-14.

Are you SURE?: Assessing patient decisional conflict with a 4-item screening test.

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Department of Family Medicine at Laval University in Quebec city, Que.



To assess the reliability and validity of the 4-item SURE (Sure of myself; Understand information; Risk-benefit ratio; Encouragement) screening test for decisional conflict in patients.


Cross-sectional study.


Four family medicine groups in Quebec and 1 rural academic medical centre in New Hampshire.


One hundred twenty-three French-speaking pregnant women considering prenatal screening for Down syndrome and 1474 English-speaking patients referred to watch condition-specific video decision aids.


Cronbach alpha was used to assess the reliability of SURE. A factorial analysis was performed to assess its unidimensionality. The Pearson correlation coefficient was computed between SURE and the Decisional Conflict Scale to assess concurrent validation. A t test procedure comparing the SURE scores of patients who had made decisions with the scores of those who had not was used to assess construct validation.


Among the 123 French-speaking pregnant women, 105 (85%) scored 4 out of 4 (no decisional conflict); 10 (8%) scored 3 (<or= 3 indicates decisional conflict); 7 (6%) scored 2; and 1 (1%) scored 1. Among the 1474 English-speaking treatment-option patients, 981 (67%) scored 4 out of 4; 272 (18%) scored 3; 147 (10%) scored 2; 54 (4%) scored 1; and 20 (1%) scored 0. The reliability of SURE was moderate (Cronbach alpha of 0.54 in French-speaking pregnant women and 0.65 in treatment-option patients). In the group of pregnant women, 2 factors accounted for 72% of the variance. In the treatment-option group, 1 factor accounted for 49% of the variance. In the group of pregnant women, SURE correlated negatively with the Decisional Conflict Scale (r = -0.46; P < .0001); and in the group of treatment-option patients, it discriminated between those who had made a choice for a treatment and those who had not (P < .0001).


The SURE screening test shows promise for screening for decisional conflict in both French- and English-speaking patients; however, future studies should assess its performance in a broader group of patients.

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