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Thomas R, Huntley A, Mann M, Huws D, Paranjothy S, Elwyn G, Purdy S. Specialist clinics for reducing emergency admissions in patients with heart failure: a systematic review and meta-analysis of randomised controlled trials. Heart 2013; 99:233-9. [PMID: 23355639 DOI: 10.1136/heartjnl-2012-302313] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
UNLABELLED Unplanned admissions for heart failure are common and some are considered preventable. OBJECTIVE Undertake a systematic literature review and meta-analysis to evaluate the effectiveness of specialist clinics in reducing unplanned hospital admissions in people with heart failure. DATA SOURCES 18 databases were searched from inception to June 2010. Relevant websites and reference lists of included studies were checked for additional publications. STUDY SELECTION Randomised controlled trials in Organisation for Economic Co-operation and Development countries that evaluated the effectiveness of specialist clinic interventions for heart failure compared with usual care, where unplanned heart failure admissions or readmissions were an outcome. DATA EXTRACTION Data were extracted by one reviewer and checked by a second reviewer. RESULTS 10 of 17 randomised controlled trials met the inclusion criteria. Specialist clinics showed a reduction in unplanned admissions at 12 months (pooled risk ratio (RR) for five studies 0.51 (95% CI 0.33 to 0.76); absolute risk reduction 16 per 100 (95% CI 12 to 20)). Studies with initial frequent (weekly/fortnightly) appointments reducing in frequency over the study duration demonstrated a 58% RR reduction in unplanned admissions (pooled RR for three studies 0.42 (95% CI 0.27 to 0.65); absolute risk reduction 14 per 100 (95% CI 7 to 20)). Clinics conducted on a monthly or 3 monthly basis throughout or tailored to the individual patients did not show an effect. CONCLUSIONS Specialist clinics for patients with heart failure can reduce the risk of unplanned admissions; these were most effective when there was a high intensity of clinic appointments close to the time of discharge which then reduced over the follow-up period.
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Jansink R, Braspenning J, Laurant M, Keizer E, Elwyn G, Weijden TVD, Grol R. Minimal improvement of nurses' motivational interviewing skills in routine diabetes care one year after training: a cluster randomized trial. BMC FAMILY PRACTICE 2013; 14:44. [PMID: 23537327 PMCID: PMC3637576 DOI: 10.1186/1471-2296-14-44] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 03/21/2013] [Indexed: 05/06/2024]
Abstract
BACKGROUND The effectiveness of nurse-led motivational interviewing (MI) in routine diabetes care in general practice is inconclusive. Knowledge about the extent to which nurses apply MI skills and the factors that affect the usage can help to understand the black box of this intervention. The current study compared MI skills of trained versus non-trained general practice nurses in diabetes consultations. The nurses participated in a cluster randomized trial in which a comprehensive program (including MI training) was tested on improving clinical parameters, lifestyle, patients' readiness to change lifestyle, and quality of life. METHODS Fifty-eight general practices were randomly assigned to usual care (35 nurses) or the intervention (30 nurses). The ratings of applying 24 MI skills (primary outcome) were based on five consultation recordings per nurse at baseline and 14 months later. Two judges evaluated independently the MI skills and the consultation characteristics time, amount of nurse communication, amount of lifestyle discussion and patients' readiness to change. The effect of the training on the MI skills was analysed with a multilevel linear regression by comparing baseline and the one-year follow-up between the interventions with usual care group. The overall effect of the consultation characteristics on the MI skills was studied in a multilevel regression analyses. RESULTS At one year follow up, it was demonstrated that the nurses improved on 2 of the 24 MI skills, namely, "inviting the patient to talk about behaviour change" (mean difference=0.39, p=0.009), and "assessing patient's confidence in changing their lifestyle" (mean difference=0.28, p=0.037). Consultation time and the amount of lifestyle discussion as well as the patients' readiness to change health behaviour was associated positively with applying MI skills. CONCLUSIONS The maintenance of the MI skills one year after the training program was minimal. The question is whether the success of MI to change unhealthy behaviour must be doubted, whether the technique is less suitable for patients with a complex chronic disease, such as diabetes mellitus, or that nurses have problems with the acquisition and maintenance of MI skills in daily practice. Overall, performing MI skills during consultation increases, if there is more time, more lifestyle discussion, and the patients show more readiness to change. TRIAL REGISTRATION Current Controlled Trials ISRCTN68707773.
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Couët N, Desroches S, Robitaille H, Vaillancourt H, Leblanc A, Turcotte S, Elwyn G, Légaré F. Assessments of the extent to which health-care providers involve patients in decision making: a systematic review of studies using the OPTION instrument. Health Expect 2013; 18:542-61. [PMID: 23451939 DOI: 10.1111/hex.12054] [Citation(s) in RCA: 321] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2013] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND We have no clear overview of the extent to which health-care providers involve patients in the decision-making process during consultations. The Observing Patient Involvement in Decision Making instrument (OPTION) was designed to assess this. OBJECTIVE To systematically review studies that used the OPTION instrument to observe the extent to which health-care providers involve patients in decision making across a range of clinical contexts, including different health professions and lengths of consultation. SEARCH STRATEGY We conducted online literature searches in multiple databases (2001-12) and gathered further data through networking. INCLUSION CRITERIA (i) OPTION scores as reported outcomes and (ii) health-care providers and patients as study participants. For analysis, we only included studies using the revised scale. DATA EXTRACTION Extracted data included: (i) study and participant characteristics and (ii) OPTION outcomes (scores, statistical associations and reported psychometric results). We also assessed the quality of OPTION outcomes reporting. MAIN RESULTS We found 33 eligible studies, 29 of which used the revised scale. Overall, we found low levels of patient-involving behaviours: in cases where no intervention was used to implement shared decision making (SDM), the mean OPTION score was 23 ± 14 (0-100 scale). When assessed, the variables most consistently associated with higher OPTION scores were interventions to implement SDM (n = 8/9) and duration of consultations (n = 8/15). CONCLUSIONS Whatever the clinical context, few health-care providers consistently attempt to facilitate patient involvement, and even fewer adjust care to patient preferences. However, both SDM interventions and longer consultations could improve this.
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Elwyn G, Lloyd A, Joseph-Williams N, Cording E, Thomson R, Durand MA, Edwards A. Option Grids: shared decision making made easier. PATIENT EDUCATION AND COUNSELING 2013; 90:207-212. [PMID: 22854227 DOI: 10.1016/j.pec.2012.06.036] [Citation(s) in RCA: 205] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 05/29/2012] [Accepted: 06/26/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To describe the exploratory use of short decision support tools for patients, called Option Grids. Option Grids are summary tables, using one side of paper to enable rapid comparisons of options, using questions that patients frequently ask (FAQs) and designed for face-to-face clinical encounters. To date, most evidence about 'patient decision aids' has been based on tools with high content levels, designed for patients to use independently, either before or after visits. METHODS We studied the use of Option Grids in a quality improvement project, collecting field notes and conducting interviews with clinical teams. RESULTS In the 'Making Good Decisions in Collaboration' (MAGIC) program, clinicians found that using Option Grids made it easier to explain the existence of options and reported a 'handover' effect, where patient involvement in decision making was enhanced. CONCLUSION Option Grids made options more visible and clinicians found it easier to undertake shared decision making when these tools were available. Used in a collaborative way, they enhance patients' confidence and voice, increasing their involvement in collaborative dialogs. PRACTICE IMPLICATIONS Further work to confirm these preliminary findings is required, to measure processes and to assess whether these tools have similar impact in other clinical settings.
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Veldhuijzen W, Mogendorff K, Ram P, van der Weijden T, Elwyn G, van der Vleuten C. How doctors move from generic goals to specific communicative behavior in real practice consultations. PATIENT EDUCATION AND COUNSELING 2013; 90:170-176. [PMID: 23218241 DOI: 10.1016/j.pec.2012.10.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Revised: 10/04/2012] [Accepted: 10/07/2012] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To understand how recommendations for communication can be brought into alignment with clinical communication routines, we explored how doctors select communicative actions during consultations. METHODS We conducted stimulated recall interviews with 15 GPs (general practitioners), asking them to comment on recordings of two consultations. The data analysis was based on the principles of grounded theory. RESULTS A model describing how doctors select communicative actions during consultations was developed. This model illustrates how GPs constantly adapt their selection of communicative actions to their evaluation of the situation. These evaluations culminate in the selection of situation-specific goals. These multiple and often dynamic goals require constant revision and adaptation of communication strategies, leading to constant readjustments of the selection of communicative actions. When selecting consultation goals GPs weigh patients' needs and preferences as well as the medical situation and its consequences. CONCLUSIONS GPs' selection of communicative actions during consultations is situational and goal driven. PRACTICE IMPLICATIONS To help doctors develop communicative competence tailored to the specific situation of each consultation, holistic communication training courses, which pay attention to the selection of consultation goals and matching communication strategies besides training specific communication skills, seem preferable to current generic communication skills training.
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Dees MK, Vernooij-Dassen MJ, Dekkers WJ, Elwyn G, Vissers KC, van Weel C. Perspectives of decision-making in requests for euthanasia: a qualitative research among patients, relatives and treating physicians in the Netherlands. Palliat Med 2013; 27:27-37. [PMID: 23104511 DOI: 10.1177/0269216312463259] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Euthanasia has been legally performed in the Netherlands since 2002. Respect for patient's autonomy is the underpinning ethical principal. However, patients have no right to euthanasia, and physicians have no obligation to provide it. Although over 3000 cases are conducted per year in the Netherlands, there is little known about how decision-making occurs and no guidance to support this difficult aspect of clinical practice. AIM To explore the decision-making process in cases where patients request euthanasia and understand the different themes relevant to optimise this decision-making process. DESIGN A qualitative thematic analysis of interviews with patients making explicit requests for euthanasia, most-involved relative(s) and treating physician. PARTICIPANTS/SETTING Thirty-two cases, 31 relatives and 28 treating physicians. Settings were patients' and relatives' homes and physicians' offices. RESULTS Five main themes emerged: (1) initiation of sharing views and values about euthanasia, (2) building relationships as part of the negotiation, (3) fulfilling legal requirements, (4) detailed work of preparing and performing euthanasia and (5) aftercare and closing. CONCLUSIONS A patient's request for euthanasia entails a complex process that demands emotional work by all participants. It is characterised by an intensive period of sharing information, relationship building and negotiation in order to reach agreement. We hypothesise that making decisions about euthanasia demands a proactive approach towards participants' preferences and values regarding end of life, towards the needs of relatives, towards the burden placed on physicians and a careful attention to shared decision-making. Future research should address the communicational skills professionals require for such complex decision-making.
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Adams JR, Elwyn G, Légaré F, Frosch DL. Communicating with physicians about medical decisions: a reluctance to disagree. ACTA ACUST UNITED AC 2012; 172:1184-6. [PMID: 22777319 DOI: 10.1001/archinternmed.2012.2360] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Jansink R, Braspenning J, Keizer E, van der Weijden T, Elwyn G, Grol R. Misperception of patients with type 2 diabetes about diet and physical activity, and its effects on readiness to change. J Diabetes 2012; 4:417-23. [PMID: 22613223 DOI: 10.1111/j.1753-0407.2012.00207.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The aim of the present study was to assess misperceptions about lifestyle among patients with type 2 diabetes and their effects on readiness to change. METHODS Nine hundred and forty patients, with an HbA1c >7% and a body mass index >25 kg/m(2), from 57 general practices participated in a cross-sectional survey. Misperceptions of lifestyle (fruit, vegetable, and fat consumption, as well as physical activity) and readiness to change were determined with validated questionnaires. Logistic regression analysis calculated the association of misperception with readiness to change. RESULTS The response rate was 55.4%. Misperception existed for all lifestyle behaviors (physical activity, 41.5%; consumption of fruit, 40.1%; consumption of vegetables, 69.2%; consumption of fat, 21.6%). Misperception significantly affected readiness to change the relevant lifestyle (odds ratios [95% confidence intervals] ranging from 2.67 [1.68-4.23] to 1.80 [1.16-2.79]), except in the case of fruit consumption. The degree of misperception varied greatly between the different lifestyle behaviors and was somewhat larger (1-10%) than that in the general Dutch population. CONCLUSIONS Patients with type 2 diabetes misperceive their lifestyle behaviors, which hinders lifestyle changes. The variations in misperception and readiness to change show that diversity should be considered in lifestyle counseling for patients with type 2 diabetes.
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Mulley AG, Trimble C, Elwyn G. Stop the silent misdiagnosis: patients' preferences matter. BMJ (CLINICAL RESEARCH ED.) 2012. [PMID: 23137819 DOI: 10.1136/bmj.e6572.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, Cording E, Tomson D, Dodd C, Rollnick S, Edwards A, Barry M. Shared decision making: a model for clinical practice. J Gen Intern Med 2012; 27:1361-7. [PMID: 22618581 PMCID: PMC3445676 DOI: 10.1007/s11606-012-2077-6] [Citation(s) in RCA: 2192] [Impact Index Per Article: 182.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 01/03/2012] [Accepted: 04/03/2012] [Indexed: 02/06/2023]
Abstract
The principles of shared decision making are well documented but there is a lack of guidance about how to accomplish the approach in routine clinical practice. Our aim here is to translate existing conceptual descriptions into a three-step model that is practical, easy to remember, and can act as a guide to skill development. Achieving shared decision making depends on building a good relationship in the clinical encounter so that information is shared and patients are supported to deliberate and express their preferences and views during the decision making process. To accomplish these tasks, we propose a model of how to do shared decision making that is based on choice, option and decision talk. The model has three steps: a) introducing choice, b) describing options, often by integrating the use of patient decision support, and c) helping patients explore preferences and make decisions. This model rests on supporting a process of deliberation, and on understanding that decisions should be influenced by exploring and respecting "what matters most" to patients as individuals, and that this exploration in turn depends on them developing informed preferences.
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Witt J, Elwyn G, Wood F, Brain K. Decision making and coping in healthcare: the Coping in Deliberation (CODE) framework. PATIENT EDUCATION AND COUNSELING 2012; 88:256-261. [PMID: 22465484 DOI: 10.1016/j.pec.2012.03.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Revised: 01/27/2012] [Accepted: 03/03/2012] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To develop a framework of decision making and coping in healthcare that describes the twin processes of appraisal and coping faced by patients making preference-sensitive healthcare decisions. METHODS We briefly review the literature for decision making theories and coping theories applicable to preference-sensitive decisions in healthcare settings. We describe first decision making, then coping and finally attempt to integrate these processes by building on current theory. RESULTS Deliberation in healthcare may be described as a six step process, comprised of the presentation of a health threat, choice, options, preference construction, the decision itself and consolidation post-decision. Coping can be depicted in three stages, beginning with a threat, followed by primary and secondary appraisal and ultimately resulting in a coping effort. CONCLUSIONS Drawing together concepts from prominent decision making theories and coping theories, we propose a multidimensional, interactive framework which integrates both processes and describes coping in deliberation. PRACTICE IMPLICATIONS The proposed framework offers an insight into the complexity of decision making in preference-sensitive healthcare contexts from a patient perspective and may act as theoretical basis for decision support.
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Ruijs WLM, LA Hautvast J, van IJzendoorn G, van Ansem WJC, Elwyn G, van der Velden K, Hulscher MEJL. How healthcare professionals respond to parents with religious objections to vaccination: a qualitative study. BMC Health Serv Res 2012; 12:231. [PMID: 22852838 PMCID: PMC3469371 DOI: 10.1186/1472-6963-12-231] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 07/13/2012] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND In recent years healthcare professionals have faced increasing concerns about the value of childhood vaccination and many find it difficult to deal with parents who object to vaccination. In general, healthcare professionals are advised to listen respectfully to the objections of parents, provide honest information, and attempt to correct any misperceptions regarding vaccination. Religious objections are one of the possible reasons for refusing vaccination. Although religious objections have a long history, little is known about the way healthcare professionals deal with these specific objections. The aim of this study is to gain insight into the responding of healthcare professionals to parents with religious objections to the vaccination of their children. METHODS A qualitative interview study was conducted with health care professionals (HCPs) in the Netherlands who had ample experience with religious objections to vaccination. Purposeful sampling was applied in order to include HCPs with different professional and religious backgrounds. Data saturation was reached after 22 interviews, with 7 child health clinic doctors, 5 child health clinic nurses and 10 general practitioners. The interviews were thematically analyzed. Two analysts coded, reviewed, discussed, and refined the coding of the transcripts until consensus was reached. Emerging concepts were assessed using the constant comparative method from grounded theory. RESULTS Three manners of responding to religious objections to vaccination were identified: providing medical information, discussion of the decision-making process, and adoption of an authoritarian stance. All of the HCPs provided the parents with medical information. In addition, some HCPs discussed the decision-making process. They verified how the decision was made and if possible consequences were realized. Sometimes they also discussed religious considerations. Whether the decision-making process was discussed depended on the willingness of the parents to engage in such a discussion and on the religious background, attitudes, and communication skills of the HCPs. Only in cases of tetanus post-exposure-prophylaxis, general practitioners reported adoption of an authoritarian stance. CONCLUSION Given that the provision of medical information is generally not decisive for parents with religious objections to vaccination, we recommend HCPs to discuss the vaccination decision-making process, rather than to provide them with extra medical information.
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Frosch DL, May SG, Elwyn G. Shared Decision Making: The Authors Reply. Health Aff (Millwood) 2012. [DOI: 10.1377/hlthaff.2012.0715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Sivell S, Edwards A, Manstead ASR, Reed MWR, Caldon L, Collins K, Clements A, Elwyn G. Increasing readiness to decide and strengthening behavioral intentions: evaluating the impact of a web-based patient decision aid for breast cancer treatment options (BresDex: www.bresdex.com). PATIENT EDUCATION AND COUNSELING 2012; 88:209-217. [PMID: 22541508 DOI: 10.1016/j.pec.2012.03.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 01/18/2012] [Accepted: 03/27/2012] [Indexed: 05/31/2023]
Abstract
OBJECTIVES To undertake a quantitative evaluation of a theory-based, interactive online decision aid (BresDex) to support women choosing surgery for early breast cancer (Stage I and II), based on observations of its use in practice. METHODS Observational cohort study. Website log-files collected data on the use of BresDex. Online questionnaires assessed knowledge about breast cancer and treatment options, degree to which women were deliberating about their options, and surgery intentions, pre- and post-BresDex. RESULTS Readiness to make a decision significantly increased after using BresDex (p<.001), although there was no significant improvement in knowledge. Participants that were 'less ready' to make a decision before using BresDex, spent a longer time using BresDex (p<.05). Significant associations between surgery intentions and choices were observed (p<.001), with the majority of participants going on to have BCS. Greater length of time spent on BresDex was associated with stronger intentions to have BCS (p<.05). CONCLUSION The use of BresDex appears to facilitate readiness to make a decision for surgery, helping to strengthen surgery intentions. PRACTICE IMPLICATIONS BresDex may prove a useful adjunct to the support provided by the clinical team for women facing surgery for early breast cancer.
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Elwyn G, Hardisty AR, Peirce SC, May C, Evans R, Robinson DKR, Bolton CE, Yousef Z, Conley EC, Rana OF, Gray WA, Preece AD. Detecting deterioration in patients with chronic disease using telemonitoring: navigating the 'trough of disillusionment'. J Eval Clin Pract 2012; 18:896-903. [PMID: 21848942 DOI: 10.1111/j.1365-2753.2011.01701.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To examine the evidence base for telemonitoring designed for patients who have chronic obstructive pulmonary disease and heart failure, and to assess whether telemonitoring fulfils the principles of monitoring and is ready for implementation into routine settings. DESIGN Qualitative data collection using interviews and participation in a multi-path mapping process. PARTICIPANTS Twenty-six purposively selected informants completed semi-structured interviews and 24 individuals with expertise in the relevant clinical and informatics domains from academia, industry, policy and provider organizations and participated in a multi-path mapping workshop. RESULTS The evidence base for the effectiveness of telemonitoring is weak and inconsistent, with insufficient cost-effectiveness studies. When considered against an accepted definition of monitoring, telemonitoring is found wanting. Telemonitoring has not been able so far to ensure that the technologies fit into the life world of the patient and into the clinical and organizational milieu of health service delivery systems. CONCLUSIONS To develop effective telemonitoring for patients with chronic disease, more attention needs to be given to agreeing the central aim of early detection and, to ensure potential implementation, engaging a wide range of stakeholders in the design process, especially patients and clinicians.
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Street RL, Elwyn G, Epstein RM. Patient preferences and healthcare outcomes: an ecological perspective. Expert Rev Pharmacoecon Outcomes Res 2012; 12:167-80. [PMID: 22458618 DOI: 10.1586/erp.12.3] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
This article examines the nature of patients' preferences for healthcare and whether clinician accommodation of patient preferences influences health outcomes. First, we provide a conceptualization of patient preferences along with their key attributes. Second, we review research on the relationship between health outcomes and patient preferences for treatments and for the process of care (e.g., preferred involvement in decision-making). Third, following a critique of this literature, we present an ecological model of patient preferences that, while acknowledging that patient preferences may emerge from various contexts (e.g., family or media exposure), we focus on the important role that clinical encounters and patients' health-related experiences play in the elicitation and construction of patient preferences. Fourth, we propose two pathways, one behavioral (adherence) and the other psychological (sense of autonomy or satisfaction with decision), through which meeting patient preferences could lead to better health outcomes. Fifth, we discuss how preferences can be elicited and clarified through patient-centered conversations. We conclude with implications for future research and clinical practice.
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Brookes-Howell L, Elwyn G, Hood K, Wood F, Cooper L, Goossens H, Ieven M, Butler CC. 'The body gets used to them': patients' interpretations of antibiotic resistance and the implications for containment strategies. J Gen Intern Med 2012; 27:766-72. [PMID: 22065334 PMCID: PMC3378752 DOI: 10.1007/s11606-011-1916-1] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Revised: 04/25/2011] [Accepted: 09/26/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND Interventions promoting evidence based antibiotic prescribing and use frequently build on the concept of antibiotic resistance but patients and clinicians may not share the same assumptions about its meaning. OBJECTIVE To explore patients' interpretations of 'antibiotic resistance' and to consider the implications for strategies to contain antibiotic resistance. DESIGN Multi country qualitative interview study. PARTICIPANTS One hundred and twenty-one adult patients from primary care research networks based in nine European countries who had recently consulted a primary care clinician with symptoms of Lower Respiratory Tract Infection (LRTI). APPROACH Semi-structured interviews with patients following their consultation and subjected to a five-stage analytic framework approach (familiarization, developing a thematic framework from the interview questions and the themes emerging from the data, indexing, charting, and mapping to search for interpretations in the data), with local network facilitators commenting on preliminary reports. RESULTS The dominant theme was antibiotic resistance as a property of a 'resistant human body', where the barrier to antibiotic effectiveness was individual loss of responsiveness. Less commonly, patients correctly conceptualized antibiotic resistance as a property of bacteria. Nevertheless, the over-use of antibiotics was a strong central concept in almost all patients' explanations, whether they viewed resistance as located in either the body or in bacteria. CONCLUSIONS Most patients were aware of the link between antibiotic use and antibiotic resistance. The identification of the misinterpretation of antibiotic resistance as a property of the human body rather than bacterial cells could inform clearer clinician-patient discussions and public health interventions through emphasising the transferability of resistance, and the societal contribution individuals can make through more appropriate antibiotic prescribing and use.
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van der Weijden T, Boivin A, Burgers J, Schünemann HJ, Elwyn G. Clinical practice guidelines and patient decision aids. An inevitable relationship. J Clin Epidemiol 2012; 65:584-9. [DOI: 10.1016/j.jclinepi.2011.10.007] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2011] [Revised: 08/17/2011] [Accepted: 10/02/2011] [Indexed: 10/14/2022]
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Frosch DL, May SG, Rendle KA, Tietbohl C, Elwyn G. Authoritarian Physicians And Patients’ Fear Of Being Labeled ‘Difficult’ Among Key Obstacles To Shared Decision Making. Health Aff (Millwood) 2012; 31:1030-8. [PMID: 22566443 DOI: 10.1377/hlthaff.2011.0576] [Citation(s) in RCA: 279] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Mcgarrigle H, Lloyd A, Joseph-Williams N, Elwyn G. Making Good Decisions in Collaboration with Patients with Breast Cancer: The role of Decision Quality Measures and in-consultation decision support tools. Eur J Surg Oncol 2012. [DOI: 10.1016/j.ejso.2012.02.117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Brehaut JC, Carroll K, Elwyn G, Saginur R, Kimmelman J, Shojania K, Syrowatka A, Nguyen T, Hoe E, Fergusson D. Informed consent documents do not encourage good-quality decision making. J Clin Epidemiol 2012; 65:708-24. [PMID: 22537428 DOI: 10.1016/j.jclinepi.2012.01.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Revised: 01/17/2012] [Accepted: 01/22/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Informed consent for research has emphasized information provision over support to people making a difficult decision. We assessed the extent to which existing informed consent documents (ICDs) conform to the International Patient Decision Aid Standards for supporting decision making. STUDY DESIGN AND SETTING One hundred thirty-nine ICDs for trials registered with ClinicalTrials.gov were obtained from study investigators. Using a four-point scale, two raters assessed each ICD on 32 items. RESULTS Overall agreement between raters was 95.1% (linear weighted kappa-0.745). For 12 items focused on providing enough information, conformity was above 50% for three, and 0% for another four. For all eight items focused on how to present outcome probabilities, conformity was below 20%. For two items focused on clarifying and expressing values, conformity was below 10%. For two items focused on improving structured guidance, conformity was below 5%. For four items focused on using evidence, one item showed conformity of 74%; all others showed conformity below 5%. For four items focused on transparency, conformity was high (above 60% for two, above 80% for the others). CONCLUSIONS Existing ICDs do not meet most validated standards for encouraging good decision making. These standards make clear predictions about how one might improve ICDs ensure that research participants are fully informed.
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Sivell S, Marsh W, Edwards A, Manstead ASR, Clements A, Elwyn G. Theory-based design and field-testing of an intervention to support women choosing surgery for breast cancer: BresDex. PATIENT EDUCATION AND COUNSELING 2012; 86:179-188. [PMID: 21571485 DOI: 10.1016/j.pec.2011.04.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 03/07/2011] [Accepted: 04/08/2011] [Indexed: 05/30/2023]
Abstract
OBJECTIVE Design and undertake usability and field-testing evaluation of a theory-guided decision aid (BresDex) in supporting women choosing surgery for early breast cancer. METHODS An extended Theory of Planned Behavior (TPB) and the Common Sense Model of Illness Representations (CSM) guided the design of BresDex. BresDex was evaluated and refined across 3 cycles by interviewing 6 women without personal history of breast cancer, 8 women with personal history of breast cancer who had completed treatment and 11 women newly diagnosed with breast cancer. Participants were interviewed for views on content, presentation (usability) and perceived usefulness towards deciding on treatment (utility). Framework analysis was used, guided by the extended TPB and the CSM. RESULTS BresDex was positively received in content and presentation (usability). It appeared an effective support to decision-making and useful source for further information, particularly in clarifying attitudes, social norms and perceived behavioral control, and presenting consequences of decisions (utility). CONCLUSION This study illustrates the potential benefit of the extended TPB and CSM in designing a decision aid to support women choosing breast cancer surgery. PRACTICE IMPLICATIONS BresDex could provide decision-making support and serve as an additional source of information, to complement the care received from the clinical team.
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Stiggelbout AM, Van der Weijden T, De Wit MPT, Frosch D, Légaré F, Montori VM, Trevena L, Elwyn G. Shared decision making: really putting patients at the centre of healthcare. BMJ 2012; 344:e256. [PMID: 22286508 DOI: 10.1136/bmj.e256] [Citation(s) in RCA: 578] [Impact Index Per Article: 48.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Although many clinicians feel they already use shared decision making, research shows a perception-reality gap. A M Stiggelbout and colleagues discuss why it is important and highlight some best practices.
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