Validation of SURE, a four-item clinical checklist for detecting decisional conflict in patients

Med Decis Making. 2014 Jan;34(1):54-62. doi: 10.1177/0272989X13491463. Epub 2013 Jun 17.


Background: We sought to determine the psychometric properties of SURE, a 4-item checklist designed to screen for clinically significant decisional conflict in clinical practice.

Methods: This study was a secondary analysis of a clustered randomized trial assessing the effect of DECISION+2, a 2-hour online tutorial followed by a 2-hour interactive workshop on shared decision making, on decisions to use antibiotics for acute respiratory infections. Patients completed SURE and also the Decisional Conflict Scale (DCS), as the gold standard, after consultation. We evaluated internal consistency of SURE using the Kuder-Richardson 20 coefficient (KR-20). We compared DCS and SURE scores using the Spearman correlation coefficient. We assessed sensitivity and specificity of SURE scores (cut-off score ≤3 out of 4) by identifying patients with and without clinically significant decisional conflict (DCS score >37.5 on a scale of 0-100).

Results: Of the 712 patients recruited during the trial, 654 completed both tools. SURE scores showed adequate internal consistency (KR-20 coefficient of 0.7). There was a significant correlation between DCS and SURE scores (Spearman's ρ = -0.45, P < 0.0001). The prevalence of clinically significant decisional conflict as estimated by the DCS was 5.2% (95% CI 3.7-7.3). Sensitivity and specificity of SURE ≤3 were 94.1% (95% CI 78.9-99.0) and 89.8% (95% CI 87.1-92.0), respectively.

Conclusions: SURE shows adequate psychometric properties in a primary care population with a low prevalence of clinically significant decisional conflict. SURE has the potential to be a useful screening tool for practitioners, responding to the growing need for detecting clinically significant decisional conflict in patients.

Keywords: SURE; clinical checklist; decisional conflict; sensitivity and specificity; shared decision making.

Publication types

  • Validation Study

MeSH terms

  • Acute Disease
  • Adult
  • Anti-Bacterial Agents / therapeutic use
  • Checklist*
  • Child, Preschool
  • Conflict, Psychological*
  • Decision Making*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Patient Participation*
  • Psychometrics
  • Respiratory Tract Infections / drug therapy


  • Anti-Bacterial Agents