Perceptions of Urologists About the Conversational Elements Leading to Treatment Decision-Making Among Newly Diagnosed Prostate Cancer Patients

Widespread adoption and use of the practice of shared decision-making among health-care providers, especially urologists, has been limited. This study explores urologists' perceptions about their conversational practices leading to decision-making by newly diagnosed prostate cancer patients facing treatment. Semi-structured, in-depth interviews were conducted with 12 community and academic urologists practicing in the St. Louis, MO, region. Data were analyzed using a consensus coding approach. Urologists reported spending 30-60 min with newly diagnosed prostate cancer patients when discussing treatment options. They frequently encouraged family members' involvement in discussions about treatment, especially patients' spouses and children. Participants perceived these conversations to be difficult given the emotional burden associated with a cancer diagnosis, and encouraged patients to postpone their decisions or to get a second opinion before finalizing their treatment of choice. Initial discussions included a presentation of treatment options relevant to the patient's condition, side effects, outcome probabilities, and next steps. Urologists seldom used statistics while talking about treatment outcome probabilities and preferred to explain outcomes in terms of the patient's practical, emotional, and social experiences. Their styles to elicit the patient's preferences ranged from explicitly asking questions to making assumptions based on clinical experience and subtle patient cues. In conclusion, urologists' routine conversations included most elements of shared decision-making. However, shared decision-making required urologists to have nuanced discussions and be skilled in elicitation methods and risk discussions which requires further training. Further research is required to explore roles of family and clinical staff as participants in this process.

Becoming a health literate organization: Formative research results from healthcare organizations providing care for undeserved communities

Background Integrating health literacy into primary care institutional policy and practice is critical to effective, patient centered health care. While attributes of health literate organizations have been proposed, approaches for strengthening them in healthcare systems with limited resources have not been fully detailed. Methods We conducted key informant interviews with individuals from 11 low resourced health care organizations serving uninsured, underinsured, and government-insured patients across Missouri. The qualitative inquiry explored concepts of impetus to transform, leadership commitment, engaging staff, alignment to organization wide goals, and integration of health literacy with current practices. Findings Several health care organizations reported carrying out health literacy related activities including implementing patient portals, selecting easy to read patient materials, offering community education and outreach programs, and improving discharge and medication distribution processes. The need for change presented itself through data or anecdotal staff experience. For any change to be undertaken, administrators and medical directors had to be supportive; most often a champion facilitated these changes in the organization. Staff and providers were often resistant to change and worried they would be saddled with additional work. Lack of time and funding were the most common barriers reported for integration and sustainability. To overcome these barriers, managers supported changes by working one on one with staff, seeking external funding, utilizing existing resources, planning for stepwise implementation, including members from all staff levels and clear communication. Conclusion Even though barriers exist, resource scarce clinical settings can successfully plan, implement, and sustain organizational changes to support health literacy.

Prostate Cancer Survivors: Physical, Emotional and Practical Concerns from the LIVESTRONG Survey

Objective

To determine whether a relationship exists between types of treatment received and/or survivorship status of prostate cancer survivors with physical, emotional, and practical concerns that they experience with the hypothesis that no such relationship exists.

Methods

We analyzed data from the 2010 LIVESTRONG survey for cancer survivors which queried their physical, emotional, and practical concerns. This previously tested survey was administered between June 20, 2010 and March 31, 2011 on the LIVESTRONG.org website. Survivorship status was categorized as reported by the respondents: currently on treatment; living with cancer as a chronic condition; finished treatment less than 1 year ago; 1–5 years ago and; more than 5 years ago. Four categories were established for the types of treatment received: surgery, radiation, hormonal, and combination therapies. One-way ANOVA's were conducted to detect differences between groups and descriptive statistics were reported.

Results

Of 2,307 respondents overall, only 281 males were included in this study based on self-reported primary diagnosis of prostate cancer and US residency status. The mean age of respondents was 60 years (SD = 8.54 years) and majority were white (90%). One-way ANOVA detected significant differences between the number of physical (p = 0.02), emotional (p = 0.04), and practical (p = 0.00) concerns for patients receiving different treatments. When compared across the survivorship trajectory, only number of practical concerns (p = 0.00) experienced by prostate cancer survivors were significantly different.

Conclusions

Study findings highlight significant differences in number of concerns experienced by the patients based on their survivorship stage and the type of treatment received. Incorporating strategies to address the differences in physical, emotional, and practical concerns are essential to help physicians and clinical team members provide high quality post treatment survivorship care.

Systematic Review of Decision Aids for Newly Diagnosed Patients with Prostate Cancer Making Treatment Decisions

PURPOSE

Despite established evidence for using patient decision aids, use with newly diagnosed patients with prostate cancer remains limited partly due to variability in aid characteristics. We systematically reviewed decision aids for newly diagnosed patients with prostate cancer.

MATERIALS AND METHODS

Published peer reviewed journal articles, unpublished literature on the Internet and the Ottawa decision aids web repository were searched to identify decision aids designed for patients with prostate cancer facing treatment decisions. A total of 14 aids were included in study. Supplementary materials on aid development and published studies evaluating the aids were also included. We studied aids designed to help patients make specific choices among options and outcomes relevant to health status that were specific to prostate cancer treatment and in English only. Aids were reviewed for IPDAS (International Patient Decision Aid Standards) and additional standards deemed relevant to prostate cancer treatment decisions. They were also reviewed for novel criteria on the potential for implementation. Acceptable interrater reliability was achieved at Krippendorff α = 0.82.

RESULTS

Eight of the 14 decision aids (57.1%) were developed in the United States, 6 (42.8%) were print based, 5 (35.7%) were web or print based and only 4 (28.5%) had been updated since 2013. Ten aids (71.4%) were targeted to prostate cancer stage. All discussed radiation and surgery, 10 (71.4%) discussed active surveillance and/or watchful waiting and 8 (57.1%) discussed hormonal therapy. Of the aids 64.2% presented balanced perspectives on treatment benefits and risks, and/or outcome probabilities associated with each option. Ten aids (71.4%) presented value clarification prompts for patients and steps to make treatment decisions. No aid was tested with physicians and only 4 (28.6%) were tested with patients. Nine aids (64.2%) provided details on data appraisal and 4 (28.6%) commented on the quality of evidence used. Seven of the 8 web or computer based aids (87.5%) provided patients with the opportunity to interact with the aid. All except 1 aid scored above the 9th grade reading level. No evidence on aid implementation in routine practice was available.

CONCLUSIONS

As physicians look to adopt decision aids in practice, they may base the choice of aid on characteristics that correlate with patient socioeconomic and educational status, personal practice style and practice setting.

Clinicians' perceptions of digital vs. paper-based decision support interventions

RATIONALE, AIMS AND OBJECTIVES

Despite extensive evidence on the value of patient decision support interventions (DESIs), there is no consensus on optimal DESI formats. Assessing clinicians' perceptions about DESI formats can help facilitate their adoption. The aim of this study was to assess clinicians' perceptions of DESIs formats and potential use in practice.

METHODS

Semi-structured qualitative interviews were conducted with doctors from diverse practice areas (internal medicine, OB/GYN, surgery, medical oncology, emergency medicine) and elicited perceptions toward patient DESIs formats (digital vs. paper) and timing of administration. Questions also elicited beliefs underlying attitudes, perceived social norms and self-efficacy for using DESIs and the feasibility of doing so. Data analysis was conducted using a thematic analysis approach.

RESULTS

Participants identified strengths of both more comprehensive digital and shorter paper-based tools and thought they could complement each other. Participants consistently expressed the advantages of using DESIs outside the consultation to supplement clinical discussions about cancer decisions given the amount of information to discuss during these emotion-laden conversations. Participants felt that patients with older age and lower socio-economic status were more likely to use a paper-based compared with a digital DESI. Participants also noted challenges related to reliable resources such as computers and Internet in the practice setting, which would be necessary for implementing the digital DESIs on site.

CONCLUSIONS

Clinicians' perceptions and opinions about value of DESIs can vary widely across doctor, patient and clinic characteristics. A one-size-fits-all approach to implementation might not be feasible, suggesting that flexible approaches to providing decision support for patients are needed to drive broader adoption.

Results of an online survey of physical, emotional, and practical concerns for prostate cancer survivors in the United States

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Background: Prostate cancer survivors face numerous health concerns after treatment. The type of treatment received may have a significant impact on the physical, emotional and practical concerns of the patient. Methods: We analyzed self-reported data from the 2010 LIVESTRONG survey for people affected by prostate cancer. Survey questions were divided into 3 sections including physical, emotional, and practical concerns in the survivorship period. Survey was administered online between June 20, 2010 and March 31, 2011 on the LIVESTRONG.org website. Results: Of the 12,307 respondents, 281 males were included in the analysis based on a primary diagnosis of prostate cancer and US residency status. Mean age was 60 years (range, 41-94) and the majority were white men (90%). The 3 most common physical concerns were decrease in sexual function (70%), urinary frequency (54%) and fatigue (35%). The leading emotional concerns were fear of cancer recurrence (61%), grief about death of other cancer patients (52%) and worry about cancer genes in family members (51%). Practical concerns were cost beyond insurance coverage (90%), financial debt (40%), and inability to continue previous work (6%). One way ANOVA was conducted to detect differences in number of physical, emotional and practical concerns across types of treatment received (surgery, radiation, hormonal and combination). Significant differences were seen in number of physical (p=0.02), emotional (p=0.04) and practical (p<0.001) concerns for patients receiving different treatments (Table 1). Patient concerns also varied based on length of follow-up after treatment. Conclusions: Based on treatment type, hormonal patients have the greatest physical and emotional concerns compared to other treatment options, while surgery patients demonstrate the most practical concerns. The results of the survey illuminate the principal physical, emotional and practical concerns of prostate cancer survivors, and can assist in prioritizing and addressing major patient concerns after prostate cancer treatment.