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Fattori F, O'Donnell D, Rodríguez-Martín B, Kroll T. Which instruments are used to measure shared, supported and assisted healthcare decision-making between patients who have limited, impaired or fluctuating capacity, their family carers and healthcare professionals? A systematic review protocol. HRB Open Res 2019; 2:19. [DOI: 10.12688/hrbopenres.12932.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Shared decision-making (SDM) is a dialogical relationship where the physician and the patient define the problem, discuss the available options according to the patient’s values and preferences, and co-construct the treatment plan. Undertaking SDM in a clinical setting with patients who have limited, impaired or fluctuating cognitive capacity may prove challenging. Supported (defined “Assisted” in the Irish context) decision-making describes how people with impaired or fluctuating capacity remain in control of their healthcare-related choices through mechanisms which build and maximise capacity. Supported and assisted decision-making (ADM) within healthcare settings is theoretically and practically novel. Therefore, there is a knowledge gap about the validity of psychometric instruments used to assess ADM and its components within clinical settings. This systematic review aims to identify and characterise instruments currently used to assess shared, supported and assisted healthcare decision-making between patients with limited, impaired or fluctuating capacity, their family carers and healthcare professionals. Methods: A systematic review and narrative synthesis will be performed using a search strategy involving the following databases (PubMed, Cinahl, Embase, Web of Science, Scopus and PsycINFO). Quantitative studies published in the last decade and describing psychometric instruments measuring SDM, supported decision-making and ADM with people having limited or fluctuating capacity will be considered eligible for inclusion. Title and abstract screening will be followed by full-text eligibility screening, data extraction, synthesis and analysis. This review will be structured and reported according to the PRISMA checklist. The COSMIN Risk of bias checklist will be used to assess the quality of the instruments. Discussion: The results will inform and be useful to HCPs and policymakers interested in having updated knowledge of the available instruments to assess SDM, supported and assisted healthcare decision-making between patients who have impaired or fluctuating capacity, their family carers and healthcare professionals. Registration: PROSPERO CRD42018105360; registered on 10/08/2018.
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Martin Y, Braun AL, Biller-Andorno N, Bulliard JL, Cornuz J, Selby K, Auer R. Screening Refusal Associated with Choice of Colorectal Cancer Screening Methods. A Cross-sectional Study Among Swiss Primary Care Physicians. J Gen Intern Med 2019; 34:1409-1411. [PMID: 31190255 PMCID: PMC6667528 DOI: 10.1007/s11606-019-05096-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Yonas Martin
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | | | - Nikola Biller-Andorno
- Institute for Biomedical Ethics and History of Medicine (IBME), UZH, Zürich, Switzerland
| | - Jean-Luc Bulliard
- Institute of Social and Preventive Medicine (IUMSP), University of Lausanne, Lausanne, Switzerland
| | - Jacques Cornuz
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
| | - Kevin Selby
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
| | - Reto Auer
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of Ambulatory Care and Community Medicine, University of Lausanne, Lausanne, Switzerland
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153
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Sepucha KR, Langford AT, Belkora JK, Chang Y, Moy B, Partridge AH, Lee CN. Impact of Timing on Measurement of Decision Quality and Shared Decision Making: Longitudinal Cohort Study of Breast Cancer Patients. Med Decis Making 2019; 39:642-650. [PMID: 31354095 DOI: 10.1177/0272989x19862545] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose.The objective of this study was to examine whether scores of shared decision-making measures differ when collected shortly after (1 month) or long after (1 year) breast cancer surgical treatment decisions. Methods. Longitudinal, multisite survey of breast cancer (BC) patients, with measurements at 1 month and 1 year after surgery at 4 cancer centers. Patients completed the BC Surgery Decision Quality Instrument (used to generate a knowledge score, ratings of goals, and concordance with treatment preferences) and Shared Decision Making (SDM) Process survey at both time points. We tested several hypotheses related to the scores over time, including whether the scores discriminated between sites that did and did not offer formal decision support services. Exploratory analyses examined factors associated with large increases and decreases in scores over time. Results. Across the 4 sites, 229 patients completed both assessments. The mean total knowledge scores (69.2% [SD 16.6%] at 1 month and 69.4% [SD 17.7%] at 1 year, P = 0.86), SDM Process scores (2.7 [SD 1.1] 1 month v. 2.7 [SD 1.2] 1 year, P = 0.68), and the percentage of patients receiving their preferred treatment (92% at 1 month and 92% at 1 year, P = 1.0) were not significantly different over time. The site using formal decision support had significantly higher knowledge and SDM Process scores at 1 month, and only the SDM Process scores remained significantly higher at 1 year. A significant percentage of patients had large changes in their individual knowledge and SDM Process scores, with increases balancing out decreases. Conclusion. For population-level assessments, it is reasonable to survey BC patients up to a year after the decision, greatly increasing feasibility of measurement. For those evaluating decision support interventions, shorter follow-up is more likely to detect an impact on knowledge scores.
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Affiliation(s)
- Karen R Sepucha
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aisha T Langford
- Division of Comparative Effectiveness and Decision Science, Department of Population Health, NYU School of Medicine, New York, NY, USA
| | | | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Beverly Moy
- Division of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ann H Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Clara N Lee
- The Ohio State University, Columbus, OH, USA
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Association between person and disease related factors and the planned diabetes care in people who receive person-centered type 2 diabetes care: An implementation study. PLoS One 2019; 14:e0219702. [PMID: 31339929 PMCID: PMC6655662 DOI: 10.1371/journal.pone.0219702] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 06/29/2019] [Indexed: 11/20/2022] Open
Abstract
AIMS To assess the planned diabetes care for the coming year and its associated factors in patients with Type 2 diabetes who have a person-centered annual consultation. METHODS Implementation study of a new consultation model in 47 general practices (primary care) and 6 outpatient clinics (secondary care); 1200 patients from primary and 166 from secondary care participated. Data collection took place between November 2015 and February 2017. Outcomes: preferred monitoring frequency; referral to other health care provider(s); medication change. One measurement at the end of the consultation. We performed logistic regression analyses. Differences between primary and secondary care were analyzed. RESULTS Many patients arranged a monitoring frequency <4 times per year (general practices 19.5%, outpatient clinics 40%, p < .001). Type of provider (physician/nurse, OR 3.83, p < .001), baseline HbA1c (OR 1.02, p = .017), glucose lowering medication; and setting treatment goals (OR .65, p = .048) were associated with the chosen frequency. Independently associated with a referral were age (OR .99, p = .039), baseline glucose lowering medication and patients' goal setting (OR 1.52, p = .016). Medication change was associated with type of provider, baseline HbA1c, blood glucose lowering medication, quality of life (OR .80, p = .037) and setting treatment goals (OR 2.64, p = .001). CONCLUSIONS Not only disease but also person related factors, especially setting treatment goals, are independently associated with planned care use in person-centered diabetes care.
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Bansback N, Chiu JA, Carruthers R, Metcalfe R, Lapointe E, Schabas A, Lenzen M, Lynd LD, Traboulsee A. Development and usability testing of a patient decision aid for newly diagnosed relapsing multiple sclerosis patients. BMC Neurol 2019; 19:173. [PMID: 31325961 PMCID: PMC6642472 DOI: 10.1186/s12883-019-1382-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 06/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multiple sclerosis (MS) patients often struggle with treatment decisions, in part due to the increasing number of approved disease modifying therapies, each with different characteristics, and also since physicians can struggle to identify which of these characteristics matter most to each individual patient. Decision uncertainty can contribute to late treatment initiation and treatment non-adherence-causes of 'undertreatment' in MS. An interactive online patient decision aid that informs patients of their options, considers their individual preferences and goals, and facilitates conversations with their physicians, could improve how patients with relapsing forms of MS make evidence-based treatment decisions. OBJECTIVE To develop and evaluate a prototype patient decision aid (PtDA) for first-line disease modifying therapies for relapsing-remitting multiple sclerosis. METHODS Informed by previous studies and International Patient Decision Aid Standards guidelines, a prototype PtDA was developed for patients with relapsing multiple sclerosis considering first line treatment. Patients with relapsing multiple sclerosis were recruited from the University of British Columbia's Multiple Sclerosis Clinic to participate in either an online survey or a focus group. Online survey participants completed the PtDA, followed by measures of acceptability, usability, and preparedness for decision-making, and provided general feedback. Focus group participants assessed usability of the revised PtDA. The analysis of qualitative and quantitative data led to improvements of the PtDA prototype. RESULTS The prototype PtDA received high ratings for acceptability and usability, and after its use, participants reported high-levels of preparedness for decision-making. Analysis of all qualitative data identified three key themes: the need for credible information; the usefulness of the PtDA; and the importance of normalizing and sharing experiences. Nine content areas were identified for revision. Overall, participants found the PtDA to be a valuable tool for facilitating treatment decisions. CONCLUSIONS This mixed methods study has led to the development of a PtDA that can support patients with RRMS as they make treatment decisions. Future studies will assess the feasibility of implementation and the impact of the PtDA on both the timely treatment initiation and longer-term adherence.
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Affiliation(s)
- Nick Bansback
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, British Columbia V6T 1Z3 Canada
- Centre for Health Evaluation & Outcome Sciences, St. Paul’s Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6 Canada
| | - Judy A. Chiu
- Centre for Health Evaluation & Outcome Sciences, St. Paul’s Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6 Canada
| | - Robert Carruthers
- Division of Neurology, University of British Columbia, Djavad Mowafaghian Center for Brain Health, 2215 Wesbrook Mall, Vancouver, British Columbia V6T 1Z3 Canada
| | - Rebecca Metcalfe
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, British Columbia V6T 1Z3 Canada
- Centre for Health Evaluation & Outcome Sciences, St. Paul’s Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6 Canada
| | - Emmanuelle Lapointe
- Division of Neurology, University of British Columbia, Djavad Mowafaghian Center for Brain Health, 2215 Wesbrook Mall, Vancouver, British Columbia V6T 1Z3 Canada
| | - Alice Schabas
- Division of Neurology, University of British Columbia, Djavad Mowafaghian Center for Brain Health, 2215 Wesbrook Mall, Vancouver, British Columbia V6T 1Z3 Canada
| | | | - Larry D. Lynd
- Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver, British Columbia V6T 1Z3 Canada
- Collaboration for Outcomes Research and Evaluation, 2405 Wesbrook Mall, Vancouver, British Columbia V6T 1Z3 Canada
| | - Anthony Traboulsee
- Division of Neurology, University of British Columbia, Djavad Mowafaghian Center for Brain Health, 2215 Wesbrook Mall, Vancouver, British Columbia V6T 1Z3 Canada
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156
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Coates D, Homer C, Wilson A, Deady L, Mason E, Foureur M, Henry A. Indications for, and timing of, planned caesarean section: A systematic analysis of clinical guidelines. Women Birth 2019; 33:22-34. [PMID: 31253513 DOI: 10.1016/j.wombi.2019.06.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND There has been a worldwide rise in planned caesarean sections over recent decades, with significant variations in practice between hospitals and countries. Guidelines are known to influence clinical decision-making and, potentially, unwarranted clinical variation. The aim of this study was to review guidelines for recommendations in relation to the timing and indications for planned caesarean section as well as recommendations around the process of decision-making. METHOD A systematic search of national and international English-language guidelines published between 2008 and 2018 was undertaken. Guidelines were reviewed, assessed in terms of quality and extracted independently by two reviewers. FINDINGS In total, 49 guidelines of varying quality were included. There was consistency between the guidelines in potential indications for caesarean section, although guidelines vary in terms of the level of detail. There was substantial variation in timing of birth, for example recommended timing of caesarean section for women with uncomplicated placenta praevia is between 36 and 39weeks depending on the guideline. Only 11 guidelines provided detailed guidance on shared decision-making. In general, national-level guidelines from Australia, and overseas, received higher quality ratings than regional guidelines. CONCLUSION The majority of guidelines, regardless of their quality, provide very limited information to guide shared decision-making or the timing of planned caesarean section, two of the most vital aspects of guidance. National guidelines were generally of better quality than regional ones, suggesting these should be used as a template where possible and emphasis placed on improving national guidelines and minimising intra-country, regional, variability of guidelines.
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Affiliation(s)
- Dominiek Coates
- University of Technology Sydney, Faculty of Health, Centre for Midwifery and Child and Family Health, NSW, Australia; Maridulu Budyari Gumal, The Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Australia; School of Women's and Children's Health, UNSW Medicine, UNSW, Australia.
| | - Caroline Homer
- University of Technology Sydney, Faculty of Health, Centre for Midwifery and Child and Family Health, NSW, Australia; Burnet Institute, Victoria, Australia
| | - Alyssa Wilson
- Maridulu Budyari Gumal, The Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Australia
| | - Louise Deady
- South Eastern Sydney Local Health District, District Offices, Sutherland Hospital Locked Bag 21, Taren Point, NSW 2229, Australia.
| | - Elizabeth Mason
- South Eastern Sydney Local Health District, District Offices, Sutherland Hospital Locked Bag 21, Taren Point, NSW 2229, Australia.
| | - Maralyn Foureur
- Hunter New England Nursing and Midwifery Research Centre, Australia; University of Newcastle, Faculty of Health and Medicine, Australia.
| | - Amanda Henry
- School of Women's and Children's Health, UNSW Medicine, UNSW, Australia; Department of Women's and Children's Health, St. George Hospital, Sydney, Australia; The George Institute for Global Health, UNSW Medicine, Australia
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157
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Anderson N, Ozakinci G. "It all needs to be a full jigsaw, not just bits": exploration of healthcare professionals' beliefs towards supported self-management for long-term conditions. BMC Psychol 2019; 7:38. [PMID: 31234924 PMCID: PMC6591939 DOI: 10.1186/s40359-019-0319-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 06/12/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Long-Term Conditions are physical health issues which profoundly impact physical and psychological outcomes and have reached epidemic worldwide levels. An increasing evidence-base has developed for utilizing Supported Self-Management to ensure Health, Social Care & Voluntary staff are knowledgeable, skilled, and experienced to enable patients to have the confidence and capability to self-manage their conditions. However, despite Health Psychology theories underpinning chronic care models demonstrating beliefs are crucially associated with intention and behaviour, staff beliefs towards Supported Self-Management have received little attention. Therefore, the study aimed to explore healthcare professionals' beliefs towards Supported Self-Management for Long-Term Conditions using the Theory of Planned Behaviour. METHODS A mixed-methods approach was conducted within a single UK local government authority region in 2 phases: (1) Qualitative focus group of existing Supported Self-Management project staff (N = 6); (2) Quantitative online questionnaire of general Long-Term Conditions staff (N = 58). RESULTS (1) Eighty two utterances over 20 theme sub-codes demonstrated beliefs that Supported Self-Management improves healthcare outcomes, but requires enhancements to patient and senior stakeholder buy-in, healthcare culture-specific tailoring, and organizational policy and resources; (2) Mean scores indicated moderate-strength beliefs that Supported Self-Management achieves positive healthcare outcomes, but weak-strength intentions to implement Supported Self-Management and beliefs it is socially normative and perceived control over implementing it. Crucially, regression analyses demonstrated intentions to implement Supported Self-Management were only associated with beliefs that important others supported it and perceived control over, or by whether it was socially encouraged. CONCLUSIONS Healthcare professionals demonstrated positive attitudes towards Supported Self-Management improving healthcare outcomes. However, intentions towards implementing this approach were low with staff only slightly believing important others (including patients and clinicians) supported it and that they had control over using it. Future Supported Self-Management projects should seek to enhance intention (and consequently behaviour) through targeting beliefs that important others do indeed actually support this approach and that staff have control over implementing it, as well as enhancing social encouragement.
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Affiliation(s)
- Niall Anderson
- Public Health Department, NHS Borders, Melrose, TD6 9BD UK
- School of Medicine, University of St Andrews, St Andrews, KY16 9TF UK
| | - Gozde Ozakinci
- School of Medicine, University of St Andrews, St Andrews, KY16 9TF UK
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158
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Steffensen KD, Vinter M, Crüger D, Dankl K, Coulter A, Stuart B, Berry LL. Lessons in Integrating Shared Decision-Making Into Cancer Care. J Oncol Pract 2019; 14:229-235. [PMID: 29641952 DOI: 10.1200/jop.18.00019] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The benefits of shared decision-making (SDM) in health care delivery are well documented, but implementing SDM at the institutional level is challenging, particularly when patients have complex illnesses and care needs, as in cancer. Denmark's Lillebaelt Hospital, in creating The Patient's Cancer Hospital in Vejle, has learned key lessons in implementing SDM so that the organization's culture is actually being transformed. In short, SDM is becoming part of the fabric of care, not a mere add-on to it. Specifically, the hospital chose and structured its leadership to ensure that SDM is constantly championed. It organized multiple demonstration projects focused on use of decision aids, patient-reported outcome measures, and better communication tools and practices. It designed programs to train clinicians in the art of doctor-patient communication. It used research evidence to inform development of the decision aids that its clinicians use with their patients. And it rigorously measured SDM performance in an ongoing fashion so that progress could be tracked and refined to ensure continuous improvement. Initial data on the institution's SDM initiatives from the Danish national annual survey of patients' experiences show substantial progress, thereby motivating Lillebaelt to reassert its commitment to the effort, to share what it has learned, and to invite dialogue among all cancer care organizations as they seek to fully integrate SDM in daily clinical practice.
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Affiliation(s)
- Karina Dahl Steffensen
- Lillebaelt Hospital, Vejle; The Danish Cancer Society, Copenhagen; Design School Kolding, Kolding, Denmark; University of Oxford, Oxford, United Kingdom; Coalition to Transform Advanced Care, Washington, DC; Advanced Care Innovation Strategies, Forestville, CA; Texas A&M University, College Station, TX; and Institute for Healthcare Improvement, Cambridge, MA
| | - Mette Vinter
- Lillebaelt Hospital, Vejle; The Danish Cancer Society, Copenhagen; Design School Kolding, Kolding, Denmark; University of Oxford, Oxford, United Kingdom; Coalition to Transform Advanced Care, Washington, DC; Advanced Care Innovation Strategies, Forestville, CA; Texas A&M University, College Station, TX; and Institute for Healthcare Improvement, Cambridge, MA
| | - Dorthe Crüger
- Lillebaelt Hospital, Vejle; The Danish Cancer Society, Copenhagen; Design School Kolding, Kolding, Denmark; University of Oxford, Oxford, United Kingdom; Coalition to Transform Advanced Care, Washington, DC; Advanced Care Innovation Strategies, Forestville, CA; Texas A&M University, College Station, TX; and Institute for Healthcare Improvement, Cambridge, MA
| | - Kathrina Dankl
- Lillebaelt Hospital, Vejle; The Danish Cancer Society, Copenhagen; Design School Kolding, Kolding, Denmark; University of Oxford, Oxford, United Kingdom; Coalition to Transform Advanced Care, Washington, DC; Advanced Care Innovation Strategies, Forestville, CA; Texas A&M University, College Station, TX; and Institute for Healthcare Improvement, Cambridge, MA
| | - Angela Coulter
- Lillebaelt Hospital, Vejle; The Danish Cancer Society, Copenhagen; Design School Kolding, Kolding, Denmark; University of Oxford, Oxford, United Kingdom; Coalition to Transform Advanced Care, Washington, DC; Advanced Care Innovation Strategies, Forestville, CA; Texas A&M University, College Station, TX; and Institute for Healthcare Improvement, Cambridge, MA
| | - Brad Stuart
- Lillebaelt Hospital, Vejle; The Danish Cancer Society, Copenhagen; Design School Kolding, Kolding, Denmark; University of Oxford, Oxford, United Kingdom; Coalition to Transform Advanced Care, Washington, DC; Advanced Care Innovation Strategies, Forestville, CA; Texas A&M University, College Station, TX; and Institute for Healthcare Improvement, Cambridge, MA
| | - Leonard L Berry
- Lillebaelt Hospital, Vejle; The Danish Cancer Society, Copenhagen; Design School Kolding, Kolding, Denmark; University of Oxford, Oxford, United Kingdom; Coalition to Transform Advanced Care, Washington, DC; Advanced Care Innovation Strategies, Forestville, CA; Texas A&M University, College Station, TX; and Institute for Healthcare Improvement, Cambridge, MA
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159
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de Mik SML, Stubenrouch FE, Legemate DA, Balm R, Ubbink DT. Delphi Study to Reach International Consensus Among Vascular Surgeons on Major Arterial Vascular Surgical Complications. World J Surg 2019; 43:2328-2336. [PMID: 31183537 DOI: 10.1007/s00268-019-05038-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The complications discussed with patients by surgeons prior to surgery vary, because no consensus on major complications exists. Such consensus may improve informed consent and shared decision-making. This study aimed to achieve consensus among vascular surgeons on which complications are considered 'major' and which 'minor,' following surgery for abdominal aortic aneurysm (AAA), carotid artery disease (CAD) and peripheral artery disease (PAD). METHODS Complications following vascular surgery were extracted from Cochrane reviews, national guidelines, and reporting standards. Vascular surgeons from Europe and North America rated complications as major or minor on five-point Likert scales via an electronic Delphi method. Consensus was reached if ≥ 80% of participants scored 1 or 2 (minor) or 4 or 5 (major). RESULTS Participants reached consensus on 9-12 major and 6-10 minor complications per disease. Myocardial infarction, stroke, renal failure and allergic reactions were considered to be major complications of all three diseases. All other major complications were treatment specific or dependent on disease severity, e.g., spinal cord ischemia, rupture following AAA repair, stroke for CAD or deep wound infection for PAD. CONCLUSION Vascular surgeons reached international consensus on major and minor complications following AAA, CAD and PAD treatment. This consensus may be helpful in harmonizing the information patients receive and improving standardization of the informed consent procedure. Since major complications differed between diseases, consensus on disease-specific complications to be discussed with patients is necessary.
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Affiliation(s)
- S M L de Mik
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - F E Stubenrouch
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D A Legemate
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R Balm
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D T Ubbink
- Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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160
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Vermunt N, Elwyn G, Westert G, Harmsen M, Olde Rikkert M, Meinders M. Goal setting is insufficiently recognised as an essential part of shared decision-making in the complex care of older patients: a framework analysis. BMC FAMILY PRACTICE 2019; 20:76. [PMID: 31170920 PMCID: PMC6555756 DOI: 10.1186/s12875-019-0966-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 05/17/2019] [Indexed: 02/07/2023]
Abstract
Background Multimorbidity poses a challenge for decision-making processes and requires that more attention is paid to patient goals, preferences and needs; however, goal setting is not yet widely recognised as a core aspect of the shared decision-making (SDM) approach. This study aims to analyse clinician perceptions of the concept of goal setting within the context of SDM with older patients with multimorbidity. Methods Semi-structured interviews with general practitioners (GPs) and clinical geriatricians (CGs) were analysed using a framework analysis. The integrative model of SDM was used to develop a categorisation matrix, including goal setting as an additional component. Results Sixteen of the 33 clinicians mentioned explicit Goal setting as an integrated component of their definition of SDM, which was comparable to the number of clinicians who listed Patient values and preferences (n = 16), Doctor knowledge and recommendations (n = 19) and Make or explicitly defer a decision (n = 19), elements which are commonly considered to be important aspects of SDM. The other 17 clinicians (6 CGs and 11 GPs) did not mention Goal setting as an explicit component of SDM. Our analysis revealed two potential reasons for this observation. Besides the use of other terminology, part of clinicians viewed collaborative goal setting and SDM as separate but related processes. Conclusions Our study on clinician perspectives highlighted goal setting as component of a SDM approach and could therefore be considered supportive of recent theoretical insights that SDM models that lack an explicit goal-setting component appear to be deficient and overlook an important aspect of engaging patients in decision-making, particularly for patients with complex multimorbidities. We therefore call for the further development of a comprehensive SDM approach for older patients with multimorbidity to include explicit and unequivocal goal setting elements to sufficiently meet the expectations and needs of clinicians and their patients. Electronic supplementary material The online version of this article (10.1186/s12875-019-0966-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Neeltje Vermunt
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), PO Box 9101, 6500, HB, Nijmegen, The Netherlands. .,The Dutch Council for Health and Society, (Raad voor Volksgezondheid en Samenleving, RVS), The Hague, the Netherlands.
| | - Glyn Elwyn
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), PO Box 9101, 6500, HB, Nijmegen, The Netherlands.,The Dartmouth Institute for Health Policy & Clinical Practice, Level 5 Williamson Translational Research Building, One Medical Center Drive, Lebanon, NH, 03756, USA.,Cochrane Institute for Primary Care and Public Health, Cardiff University, Cardiff, UK
| | - Gert Westert
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Mirjam Harmsen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Marcel Olde Rikkert
- Radboud university Medical Center, Radboudumc Alzheimer Center, Donders Institute for Brain, Cognition and Behavior, PO Box 9101, 6500, HB, Nijmegen, The Netherlands.,Department of Geriatrics, Radboud University Medical Center, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | - Marjan Meinders
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), PO Box 9101, 6500, HB, Nijmegen, The Netherlands
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161
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Setting goals with patients living with multimorbidity: qualitative analysis of general practice consultations. Br J Gen Pract 2019; 69:e479-e488. [PMID: 31160370 PMCID: PMC6592350 DOI: 10.3399/bjgp19x704129] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 12/24/2019] [Indexed: 01/04/2023] Open
Abstract
Background Establishing patient goals is widely recommended as a way to deliver care that matters to the individual patient with multimorbidity, who may not be well served by single-disease guidelines. Though multimorbidity is now normal in general practice, little is known about how doctors and patients should set goals together. Aim To determine the key components of the goal-setting process in general practice. Design and setting In-depth qualitative analysis of goal-setting consultations in three UK general practices, as part of a larger feasibility trial. Focus groups with participating GPs and patients. The study took place between November 2016 and July 2018. Method Activity analysis was applied to 10 hours of video-recorded doctor–patient interactions to explore key themes relating to how goal setting was attempted and achieved. Core challenges were identified and focus groups were analysed using thematic analysis. Results A total of 22 patients and five GPs participated. Four main themes emerged around the goal-setting process: patient preparedness and engagement; eliciting and legitimising goals; collaborative action planning; and GP engagement. GPs were unanimously positive about their experience of goal setting and viewed it as a collaborative process. Patients liked having time to talk about what was most important to them. Challenges included eliciting goals from unprepared patients, and GPs taking control of the goal rather than working through it with the patient. Conclusion Goal setting required time and energy from both parties. GPs had an important role in listening and bearing witness to their patients’ goals. Goal setting worked best when both GP and patient were prepared in advance.
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ALDERWICK HUGH, GOTTLIEB LAURAM. Meanings and Misunderstandings: A Social Determinants of Health Lexicon for Health Care Systems. Milbank Q 2019; 97:407-419. [PMID: 31069864 PMCID: PMC6554506 DOI: 10.1111/1468-0009.12390] [Citation(s) in RCA: 211] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Policy Points Health care systems and policymakers in the United States increasingly use language related to social determinants of health in their strategies to improve health and control costs, but the terms used are often misunderstood, conflated, and confused. Greater clarity on key terms and the concepts underlying them could advance policies and practices related to social determinants of health-including by defining appropriate roles and limits of the health care sector in this multisector field.
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Affiliation(s)
- HUGH ALDERWICK
- The Health Foundation
- University of CaliforniaSan Francisco
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van Leersum CM, Moser A, van Steenkiste B, Wolf JRLM, van der Weijden T. Getting to grips with the process of decision-making in long-term care. Descriptive cases illustrate the chaotic reality of the construction of preferences. PLoS One 2019; 14:e0217338. [PMID: 31125374 PMCID: PMC6534314 DOI: 10.1371/journal.pone.0217338] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 05/10/2019] [Indexed: 12/01/2022] Open
Abstract
Background Clients facing decision-making for long-term care are in need of support and accessible information. Construction of preferences, including context and calculations, for clients in long-term care is challenging because of the variability in supply and demand. This study considers clients in four different sectors of long-term care: the nursing and care of the elderly, mental health care, care of people with disabilities, and social care. The aim is to understand the construction of preferences in real-life situations. Method Client choices were investigated by qualitative descriptive research. Data were collected from 16 in-depth interviews and 79 client records. Interviews were conducted with clients and relatives or informal caregivers from different care sectors. The original client records were explored, containing texts, letters, and comments of clients and caregivers. All data were analyzed using thematic analysis. Results Four cases showed how preferences were constructed during the decision-making process. Clients discussed a wide range of challenging aspects that have an impact on the construction of preferences, e.g. previous experiences, current treatment or family situation. This study describes two main characteristics of the construction of preferences: context and calculation. Conclusion Clients face diverse challenges during the decision-making process on long-term care and their construction of preferences is variable. A well-designed tool to support the elicitation of preferences seems beneficial.
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Affiliation(s)
- Catharina M. van Leersum
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, The Netherlands
- * E-mail:
| | - Albine Moser
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, The Netherlands
- Research Centre for Autonomy and Participation of Persons with a Chronic Illness, Zuyd University of Applied Sciences, Heerlen, The Netherlands
| | - Ben van Steenkiste
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Judith R. L. M. Wolf
- Impuls–Netherlands Center for Social Care Research, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Trudy van der Weijden
- Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, The Netherlands
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165
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Jacot Sadowski I, Rat C, Selby K, Cornuz J. Arrêt du tabac : comment mieux impliquer le patient dans le choix du traitement. Rev Mal Respir 2019; 36:625-632. [DOI: 10.1016/j.rmr.2018.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 06/28/2018] [Indexed: 11/30/2022]
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Torrens C, Miquel J, Santana F. Do we really allow patient decision-making in rotator cuff surgery? A prospective randomized study. J Orthop Surg Res 2019; 14:116. [PMID: 31036041 PMCID: PMC6489206 DOI: 10.1186/s13018-019-1157-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 04/16/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There is a growing patient interest in being involved in the decision-making process. However, little information is provided on how this information should be structured. Does it make a difference, in patient treatment decision-making, whether information is given based on the benefits or on the side effects in rotator cuff disorders? METHODS It is a prospective randomized study that includes patients diagnosed with rotator cuff tears. Patients were randomly allocated to either group A (benefit-inform) or group B (side effect-inform) and were asked to answer the following questions based on their assigned group: Group A: Your doctor informs you that you have a rotator cuff tear and states that if he/she surgically repairs your cuff tear you will improve and that the cuff remains healed at the 2-year follow-up in 71% of the cases where surgery is done. Would you choose surgery? Yes or No Group B: Your doctor informs you that you have a rotator cuff tear and that if he/she surgically repairs your cuff tear you will improve and that the cuff is torn again at 2-year follow-up in 29% of the cases where surgery is done. Would you choose surgery? Yes or No Age, gender, the shoulder affected and the functional status assessed through the Constant score were also recorded. RESULTS 80 patients were randomized (43 to group A and 37 to group B). The patients assigned to group A (benefit) accepted surgery significantly more frequently than those assigned to group B (complication) (P = 0.000). In group A, 36 of 43 (84%) accepted surgery, compared to 17 of 37 (46%) in group B. CONCLUSIONS The way that information on rotator cuff disorders is provided strongly influences patients' treatment decisions. TRIAL REGISTRATION ClinicalTrials.gov, NCT03205852 . Registered 29 June 2017. Retrospectively registered.
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Affiliation(s)
- Carlos Torrens
- Department of Orthopedics, Hospital del Mar, Passeitg Marítim 25-29, 08003, Barcelona, Spain.
| | - Joan Miquel
- Department of Orthopedics, Hospital d'Igualada, Consorci Sanitari l'Anoia, Barcelona, Spain
| | - Fernando Santana
- Department of Orthopedics, Hospital del Mar, Passeitg Marítim 25-29, 08003, Barcelona, Spain
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Eppler SL, Kakar S, Sheikholeslami N, Sun B, Pennell H, Kamal RN. Defining Quality in Hand Surgery From the Patient's Perspective: A Qualitative Analysis. J Hand Surg Am 2019; 44:311-320.e4. [PMID: 30031599 DOI: 10.1016/j.jhsa.2018.06.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE Quality measures are used to evaluate health care delivery. They are traditionally developed from the physician and health system viewpoint. This approach can lead to quality measures that promote care that may be misaligned with patient values and preferences. We completed an exploratory, qualitative study to identify how patients with hand problems define high-quality care. Our purpose was to develop a better understanding of the surgery and recovery experience of hand surgery patients, specifically focusing on knowledge gaps, experience, and the surgical process. METHODS A steering committee (n = 10) of patients who had previously undergone hand surgery reviewed and revised an open-ended survey. Ninety-nine patients who had undergone hand surgery at 2 tertiary care institutions completed the open-ended, structured questionnaire during their 6- to 8-week postoperative clinic visit. Two reviewers completed a thematic analysis to generate subcodes and codes to identify themes in high-quality care from the patient's perspective. RESULTS We identified 4 themes of high-quality care: (1) Being prepared and informed for the process of surgery, (2) Regaining hand function without pain or complication, (3) Patients and caregivers negotiating the physical and psychological challenges of recovery, and (4) Financial and logistical burdens of undergoing hand surgery. CONCLUSIONS Multiple areas that patients identify as representing high-quality care are not reflected in current quality measures for hand surgery. The patient-derived themes of high-quality care can inform future patient-centered quality measure development. CLINICAL RELEVANCE Efforts to improve health care delivery may have the greatest impact by addressing areas of care that are most valued by patients. Such areas include patient education, system navigation, the recovery process, and cost.
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Affiliation(s)
- Sara L Eppler
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Sanjeev Kakar
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN
| | | | - Beatrice Sun
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Hillary Pennell
- Department of Communication, University of Missouri, Columbia, MO
| | - Robin N Kamal
- Department of Orthopaedic Surgery, Stanford University, Redwood City, CA.
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168
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Bottaro LC, Sampietro L, Pellicano R, Testino G. Health and governance: towards a new management of the medicine of sharing. Minerva Med 2019; 110:188-190. [DOI: 10.23736/s0026-4806.19.06007-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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169
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Sherlock R, Wood F, Joseph-Williams N, Williams D, Hyam J, Sweetland H, McGarrigle H, Edwards A. "What would you recommend doctor?"-Discourse analysis of a moment of dissonance when sharing decisions in clinical consultations. Health Expect 2019; 22:547-554. [PMID: 30916446 PMCID: PMC6543150 DOI: 10.1111/hex.12881] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 01/31/2019] [Accepted: 03/01/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Proven benefits of Shared Decision Making (SDM) include improved patient knowledge, involvement and confidence in making decisions. Although widely advocated in policy, SDM is still not widely implemented in practice. A common patient-reported barrier is feeling that "doctor knows best"; thus, patients often defer decisions to the clinician. OBJECTIVE To examine the nature of the discourse when patients ask clinicians for a treatment recommendation during consultations when treatment decisions are being shared and to examine clinicians' strategies used in response. DESIGN, SETTING AND PARTICIPANTS Theme-orientated discourse analysis was performed on eight audio-recordings of breast cancer diagnostic consultations in which patients or their partners attempted to defer treatment decisions to the clinician. Clinicians were trained in SDM. RESULTS Tension was evident in a number of consultations when treatment recommendations were requested. Clinicians responded to recommendation requests by explaining why the decision was being shared (personal nature of the decision, individual preferences and equivalent survival outcomes of treatment options). There was only one instance where a clinician gave a treatment recommendation. DISCUSSION AND CONCLUSIONS Strategies for clinicians to facilitate SDM when patients seem to defer decisional responsibility include being clear about why the decision is being shared, acknowledging that this is difficult and making patients feel supported. When patients seek guidance, clinicians can provide a recommendation if grounded in an understanding of the patient's values.
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Affiliation(s)
- Rebecca Sherlock
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Fiona Wood
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Denitza Williams
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Joanna Hyam
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | | | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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170
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de Mik SML, Stubenrouch FE, Balm R, Ubbink DT. Correspondence. Br J Surg 2019; 106:508. [PMID: 30811046 DOI: 10.1002/bjs.11104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 12/11/2018] [Indexed: 11/09/2022]
Affiliation(s)
- S M L de Mik
- Department of Surgery, Amsterdam UMC, University of Amsterdam Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - F E Stubenrouch
- Department of Surgery, Amsterdam UMC, University of Amsterdam Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - R Balm
- Department of Surgery, Amsterdam UMC, University of Amsterdam Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - D T Ubbink
- Department of Surgery, Amsterdam UMC, University of Amsterdam Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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171
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Grande SW, Longacre MR, Palmblad K, Montan MV, Berquist RP, Hager A, Kotzbauer G. Empowering Young People Living With Juvenile Idiopathic Arthritis to Better Communicate With Families and Care Teams: Content Analysis of Semistructured Interviews. JMIR Mhealth Uhealth 2019; 7:e10401. [PMID: 30794202 PMCID: PMC6406228 DOI: 10.2196/10401] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 11/02/2018] [Accepted: 11/10/2018] [Indexed: 01/06/2023] Open
Abstract
Background Young people living with juvenile idiopathic arthritis (JIA) face a number of communication barriers for achieving optimal health as they transition from pediatric care into adult care. Despite growing interest in mobile or wireless technologies to support health (mHealth), it is uncertain how these engagement tools might support young people, their families, and care teams to optimize preference-based treatment strategies. Objective This study aims to examine how an mHealth patient support system (mPSS) might foster partnership between young people living with JIA, their families, and care teams. Methods Semistructured interviews with young people (5-15 years old), their families, and JIA care teams were conducted using researcher-developed interviews guides. Transcribed data were qualitatively analyzed using conventional content analysis. Results We conducted semistructured interviews with 15 young people, their parents, and 4 care team members. Content analysis revealed the potential of an mPSS to support productive dialogue between families and care teams. We identified four main themes: (1) young people with JIA face communication challenges, (2) normalizing illness through shared experience may improve adherence, (3) partnership opens windows into illness experiences, and (4) readiness to engage appears critical for clinic implementation. Conclusions A human-centered mPSS design that offers JIA patients the ability to track personally relevant illness concerns and needs can enhance communication, generate consensus-based treatment decisions, and improve efficiency and personalization of care. Technology that supports continuous learning and promotes better understanding of disease management may reduce practice burden while increasing patient engagement and autonomy in fostering lasting treatment decisions and ultimately supporting personalized care and improving outcomes.
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Affiliation(s)
- Stuart W Grande
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Meghan R Longacre
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Karin Palmblad
- Karolinska Institutet, Department of Women and Child Health, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Greg Kotzbauer
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, United States
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Gregersen TA, Birkelund R, Wolderslund M, Netsey‐Afedo ML, Steffensen KD, Ammentorp J. What matters in clinical trial decision‐making: a systematic review of interviews exploring cancer patients’ experiences. Scand J Caring Sci 2019; 33:266-278. [DOI: 10.1111/scs.12637] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 11/13/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Trine A. Gregersen
- Department of Oncology Lillebaelt Hospital Vejle Denmark
- Health Services Research Unit Lillebaelt Hospital Vejle Denmark
- Department of Regional Health Research Faculty of Health Sciences University of Southern Denmark Odense Denmark
| | - Regner Birkelund
- Health Services Research Unit Lillebaelt Hospital Vejle Denmark
- Department of Regional Health Research Faculty of Health Sciences University of Southern Denmark Odense Denmark
| | - Maiken Wolderslund
- Health Services Research Unit Lillebaelt Hospital Vejle Denmark
- Department of Regional Health Research Faculty of Health Sciences University of Southern Denmark Odense Denmark
| | - Mette Løwe Netsey‐Afedo
- Health Services Research Unit Lillebaelt Hospital Vejle Denmark
- Department of Regional Health Research Faculty of Health Sciences University of Southern Denmark Odense Denmark
- Urological Research Center Lillebaelt Hospital Vejle Denmark
| | - Karina Dahl Steffensen
- Department of Oncology Lillebaelt Hospital Vejle Denmark
- Department of Regional Health Research Faculty of Health Sciences University of Southern Denmark Odense Denmark
- Center for Shared Decision Making Lillebaelt Hospital Vejle Denmark
| | - Jette Ammentorp
- Health Services Research Unit Lillebaelt Hospital Vejle Denmark
- Department of Regional Health Research Faculty of Health Sciences University of Southern Denmark Odense Denmark
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Laba TL, Reddel HK, Zwar NJ, Marks GB, Roughead E, Flynn A, Goldman M, Heaney A, Lembke K, Jan S. Does a Patient-Directed Financial Incentive Affect Patient Choices About Controller Medicines for Asthma? A Discrete Choice Experiment and Financial Impact Analysis. PHARMACOECONOMICS 2019; 37:227-238. [PMID: 30367400 DOI: 10.1007/s40273-018-0731-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND In Australia, many patients who are initiated on asthma controller inhalers receive combination inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) despite having asthma of sufficiently low severity that ICS-alone would be equally effective and less costly for the government. METHODS We conducted a discrete choice experiment (DCE) in a nationally representative sample of adults (n = 792) and parents of children (n = 609) with asthma. Mixed multinomial models were estimated and calibrated to reflect the estimated market shares of ICS-alone, ICS/LABA and no controller. We then simulated the impact of varying patient co-payment on demand and the financial impact on government pharmaceutical expenditure. RESULTS Preference for inhaler decreased with increasing costs to the patient or government, increasing chance of a repeat visit to the doctor, and if fewer symptoms were present. Adults preferred high-strength controllers, but parents preferred low-strength inhalers for children (general beneficiaries only). The DCE predicted a higher proportion choosing controller treatment (89%) compared to current levels (57%) at the current co-payment level, with proportionately higher uptake of ICS-alone and a lower average cost per patient [32.73 Australian dollars (AU$) c.f. AU$38.54]. Reducing the co-payment on ICS-alone by 50% would increase its market share to 50%, whilst completely removing the co-payment would only have a small marginal impact on market share, but increased average cost of treatment to the government to AU$41.04 per person. CONCLUSIONS Patient-directed financial incentives are unlikely to encourage much switching of medicines, and current levels of under-treatment are not explained by patient preferences. Interventions directed at prescribers are more likely to promote better use of asthma medicines.
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Affiliation(s)
- Tracey-Lea Laba
- Menzies Centre for Health Policy, Sydney Medical School, School of Public Health, The University of Sydney, Sydney, Australia.
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Nicholas J Zwar
- School of Public Health and Community Medicine, University of New South Wales, Randwick, Sydney, Australia
- School of Medicine, University of Wollongong, Wollongong, Australia
| | - Guy B Marks
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Elizabeth Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Anthony Flynn
- Asthma Foundation Queensland and New South Wales, now part of Asthma Australia Limited, Sydney, Australia
| | - Michele Goldman
- Asthma Foundation Queensland and New South Wales, now part of Asthma Australia Limited, Sydney, Australia
| | | | | | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Feeling Respected as a Person: a Qualitative Analysis of Frail Older People's Experiences on an Acute Geriatric Ward Practicing a Comprehensive Geriatric Assessment. Geriatrics (Basel) 2019; 4:geriatrics4010016. [PMID: 31023984 PMCID: PMC6473756 DOI: 10.3390/geriatrics4010016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/18/2019] [Accepted: 01/24/2019] [Indexed: 12/02/2022] Open
Abstract
Comprehensive geriatric assessment (CGA) practices multidimensional, interdisciplinary, and diagnostic processes as a means to identify care needs, plan care, and improve outcomes of frail older people. Conventional content analysis was used to analyze frail older people’s experiences of receiving CGA. Through a secondary analysis, interviews and transcripts were revisited in an attempt to discover the meaning behind the participants’ implied, ambiguous, and verbalized thoughts that were not illuminated in the primary study. Feeling “respected as a person” is the phenomenon participants described on a CGA acute geriatric ward, achieved by having a reciprocal relationship with the ward staff, enabling their participation in decisions when engaged in communication and understanding. However, when a person was too ill to participate, then care was person-supportive care. CGA, when delivered by staff practicing person-centered care, can keep the frail older person in focus despite them being a patient. If a person-centered care approach does not work because the person is too ill, then person-supportive care is delivered. However, when staff and/or organizational practices do not implement a person-centered care approach, this can hinder patients feeling “respected as a person”.
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175
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Coyle R, Feher M, Jones S, Hamilton M, de Lusignan S. Variation in the diagnosis and control of hypertension is not explained by conventional variables: Cross-sectional database study in English general practice. PLoS One 2019; 14:e0210657. [PMID: 30629703 PMCID: PMC6328229 DOI: 10.1371/journal.pone.0210657] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 12/28/2018] [Indexed: 01/13/2023] Open
Abstract
Background Hypertension is a major cause of preventable disability and death globally and affects more than one in four adults in England. Unwarranted variation is variation in access, quality, outcome or value which is unexplained by differences in the condition or patient characteristics and which reduces quality and efficiency. Distinguishing unwarranted from variation due to clinical, organisational or patient factors can be challenging. We carried out this study to explore inter-practice variation in the diagnosis and management of hypertension in the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network database, a large, representative surveillance database. Methods and finding We carried out a cross-sectional study using primary care data extracted from the electronic health records of 1,271,419 adults registered at RCGP RSC general practices on 31st December 2016. Logistic regression was used to indirectly standardise practice-level hypertension prevalence and control against the RCGP RSC population, adjusted for age, gender, ethnicity, deprivation, co-morbidity, NHS region and practice size. Inter-practice variation was demonstrated using funnel plots with 95% and 99.8% control limits. The prevalence of detected hypertension was 18.4% (95% CI 18.4–18.5), n = 234,165. Uncontrolled hypertension was present in 146,553 of 196,052 individuals, 25.2% (25.1–25.4), in whom blood pressure had been recorded in the previous year. Hypertension management varied markedly between practices with a three-fold difference in prevalence, 13.5–38.4%, and a four-fold difference in the proportion of uncontrolled hypertension, 11.8–47.9%. Despite adjustment for sociodemographic and practice characteristics funnel plots demonstrated marked over-dispersion. Conclusions Substantial variation in the prevalence of diagnosed hypertension and the management of hypertension was only partially explained by characteristics captured within a routine dataset. The over-dispersion suggests variation is not fully explained by these factors and that context, behaviour and processes of care delivery may contribute to variation. Routine data sources in isolation to not provide sufficient contextual data to diagnose the causes of variation.
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Affiliation(s)
- Rachel Coyle
- Department of Clinical & Experimental Medicine, University of Surrey, London, United Kingdom
- * E-mail:
| | - Michael Feher
- Department of Clinical & Experimental Medicine, University of Surrey, London, United Kingdom
| | - Simon Jones
- Department of Population Health, Division of Healthcare Delivery Science, NYU School of Medicine, New York, United States of America
| | - Mark Hamilton
- Director, Surrey Heartlands Clinical Academy, Guildford, United Kingdom
| | - Simon de Lusignan
- Department of Clinical & Experimental Medicine, University of Surrey, London, United Kingdom
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Bracken-Roche D, Shevell M, Racine E. Understanding and addressing barriers to communication in the context of neonatal neurologic injury: Exploring the ouR-HOPE approach. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:511-528. [PMID: 31324327 DOI: 10.1016/b978-0-444-64029-1.00024-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Predicting neurologic outcomes for neonates with acute brain injury is essential for guiding the development of treatment goals and appropriate care plans in collaboration with parents and families. Prognostication helps parents imagine their child's possible future and helps them make ongoing treatment decisions in an informed way. However, great uncertainty surrounds neurologic prognostication for neonates, as well as biases and implicit attitudes that can impact clinicians' prognoses, all of which pose significant challenges to evidence-based prognostication in this context. In order to facilitate greater attention to these challenges and guide their navigation, this chapter explores the practice principles captured in the ouR-HOPE approach. This approach proposes the principles of Reflection, Humility, Open-mindedness, Partnership, and Engagement and related self-assessment questions to encourage clinicians to reflect on their practices and to engage with others in responding to challenges. We explore the meaning of each principle through five clinical cases involving neonatal neurologic injury, decision making, and parent-clinician communication. The ouR-HOPE approach should bring more cohesion to the sometimes disparate concerns reported in the literature and encourage clinicians and teams to consider its principles along with other guidelines and practices they find to be particularly helpful in guiding communication with parents and families.
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Affiliation(s)
- Dearbhail Bracken-Roche
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, QC, Canada
| | - Michael Shevell
- Department of Pediatrics and Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada.
| | - Eric Racine
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, QC, Canada
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Miller YD, Holdaway W. How communication about risk and role affects women's decisions about birth after caesarean. PATIENT EDUCATION AND COUNSELING 2019; 102:68-76. [PMID: 30213641 DOI: 10.1016/j.pec.2017.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 09/05/2017] [Accepted: 09/26/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVE This study investigated how health care provider communication of risk information, and women's role in decision-making, influenced women's preferences for mode of birth after a previous caesarean birth. METHODS Women (N = 669) were randomised to one of eight conditions in a 2 (selectivity of risk information) × 2 (format of risk information) × 2 (role in decision making) experimental design. After exposure to a hypothetical decision scenario that varied information communicated by an obstetrician to a pregnant woman with a previous caesarean birth across the three factors, women were asked to decide their preferred hypothetical childbirth preference. RESULTS Women provided with selective information (incomplete/biased toward repeat caesarean) and relative risk formats (ratio of incidence being compared e.g. 2.5 times higher), perceived lower risk for caesarean and were significantly more likely to prefer repeat caesarean birth than those provided with non-selective information (complete/unbiased) and absolute risk formats (incidence rate e.g. 0.01 per 100). Role in decision-making did not significantly influence childbirth preferences CONCLUSIONS: Modifiable aspects of healthcare provider communication may influence women's decision-making about childbirth preferences PRACTICE IMPLICATIONS: Optimised communication about risks of all options may have an impact on over-use of repeat CS.
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Affiliation(s)
- Yvette D Miller
- School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Victoria Park Road, Kelvin Grove, 4059, Queensland, Australia.
| | - Wendy Holdaway
- School of Psychology and Counselling, Queensland University of Technology, Queensland, Australia.
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Meade MJ, Weston A, Dreyer CW. Valid consent and orthodontic treatment. AUSTRALASIAN ORTHODONTIC JOURNAL 2019. [DOI: 10.21307/aoj-2020-031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Abstract
Valid patient consent is a legal and ethical principle that is fundamental to healthcare provision. Oral health practitioners (OHPs) must understand the principles that need to be addressed to ensure that the consent given by a patient is valid. Failure to obtain consent may result in a negligence claim or a complaint of professional misconduct against the OHP. Orthodontic treatment is mostly elective but is not without risk to the patient. Obtaining and maintaining valid consent for orthodontic treatment presents additional challenges in comparison with other dental procedures as the treatment lasts over a longer time and is most commonly performed in adolescents. In addition, prospective patients need to be informed regarding ‘lifelong’ management in the retention phase to minimise the risk of relapse. The present paper outlines the principles of valid consent with particular regard to orthodontic treatment in the adolescent patient. OHPs must ensure that they are satisfied that the competent patient has the capacity to voluntarily consent. Clinicians must also recognise that valid consent is not a one-off ‘tick the box’ procedural exercise but an ongoing process of effective information sharing in light of changing laws and an ever-changing scientific evidence base within a patient-centred model of healthcare.
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Affiliation(s)
- Maurice J. Meade
- * Orthodontic Unit , School of Dentistry , The University of Adelaide , Adelaide South Australia , Australia
| | | | - Craig W. Dreyer
- * Orthodontic Unit , School of Dentistry , The University of Adelaide , Adelaide South Australia , Australia
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The decision-making process for unplanned admission to hospital unveiled in hospitalised older adults: a qualitative study. BMC Geriatr 2018; 18:318. [PMID: 30577791 PMCID: PMC6303984 DOI: 10.1186/s12877-018-1013-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 12/11/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The hazards of hospitalisation, and the growing demand for goal-oriented care and shared decision making, increasingly question whether hospitalisation always aligns with the preferences and needs of older adults. Although decision models are described comprehensively in the literature, little is understood about how the decision for hospitalisation is made in real life situations, especially under acute conditions. The aim of this qualitative study was to gain insight into how the decision to hospitalise was made from the perspective of the older patient who was unplanned admitted to hospital. METHODS Open interviews were conducted with 21 older hospitalised patients and/or their next of kin about the decision-making process leading to hospitalisation. Data were analysed according to the Constructivist Grounded Theory approach. RESULTS Although a period of complaints preceded the decision to unplanned hospitalisation, ranging from hours to years, the decision to hospitalise was always taken acutely. In all cases, there was an acute moment in which the home as a care environment was no longer considered adequate. This conclusion was based on a combination of factors including factors related to complaints, general practitioner and home environment. Three parties were involved in this assessment: the patient, his next of kin and the general practitioner. At the same time, a very positive value was attributed towards the hospital. Depending on the assessment of the home as care environment by the various parties, there were four routes to hospitalisation: referral, shared, demanding and bypassing. CONCLUSIONS For all participants, the decision to hospitalisation was taken acutely, even if the problems evoking admission were not acute, but present for a longer period. Participants saw admission as inevitable, due to the negative perceptions of the care environment at home at that moment, combined with the positive expectations of hospital care. Advance care planning, nor shared decision making were rarely seen in these interviews. An ethical dilemma occurred when the next of kin consented to hospitalisation against the wishes of the patient. More attention for participation of older adults in decision making and their goals is recommended.
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Abstract
There’s something going on out there
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Affiliation(s)
- Martin Marshall
- Department of Primary Care and Population Health, UCL Medical School, London, UK
| | | | - Alf Collins
- Personalised Care Group, NHS England, London, UK
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181
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Beaulac J, Corace K, Balfour L, Kaluzienski M, Cooper C. Hepatitis C patient communication source and modality preferences in the direct-acting antiviral era. CANADIAN LIVER JOURNAL 2018; 1:240-247. [DOI: 10.3138/canlivj.2018-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/11/2018] [Indexed: 11/20/2022]
Abstract
Background: Although hepatitis C virus (HCV) treatment has improved dramatically, decision making related to treatment continues to be complex and challenging. Little data exists regarding patient information needs and preferences in the direct-acting antiviral (DAA) era. Methods: We evaluated patient-perceived information needs and preferences when making HCV treatment decisions. A cross-sectional survey was conducted at two Ottawa-based sites: a hospital-located outpatient viral hepatitis clinic, and a community-based HCV patient support program. Results: One hundred and seventeen patients completed the survey: the mean age was 52.1 years (range 23 to 78), and 64% were male, 81.5% were White, 48.6% were on disability support or leave, and 60.3% had a high school education or less. Although traditional sources of health information (e.g., direct communication with health care providers) remain preferred by most, a range of preferences were reported including utilization of newer technologies (e.g., emails, text messages). The telephone was rated as the preferred method of contact for medication reminders, with daily or weekly communication reported as most helpful. White participants, those more highly educated, and those with a higher income all indicated a greater acceptability for e-mail and/or text message communication for medication and appointment reminders. Conclusions: There is no single preferred source or method of communicating with patients. These findings indicate that a tailored multi-pronged approach, including newer technologies, is more likely to effectively educate and communicate with the heterogeneous population of individuals living with HCV.
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Affiliation(s)
| | - Kim Corace
- Ottawa Hospital Research Institute, Ottawa, Ontario
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario
| | - Louise Balfour
- Ottawa Hospital Research Institute, Ottawa, Ontario
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario
| | | | - Curtis Cooper
- Ottawa Hospital Research Institute, Ottawa, Ontario
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario
- Division of Infectious Diseases, Department of Medicine, University of Ottawa, Ottawa, Ontario
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Dintsios CM, Chernyak N, Grehl B, Icks A. Quantified patient preferences for lifestyle intervention programs for diabetes prevention-a protocol for a systematic review. Syst Rev 2018; 7:214. [PMID: 30497536 PMCID: PMC6264623 DOI: 10.1186/s13643-018-0884-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 11/14/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The 20-70% participation of diabetes patients in lifestyle interventions (LSI) worldwide seems to be rather sub-optimal, in spite of all intents of such interventions to delay further progress of the disease. Positive effects through LSI are expected in particular for patients who suffer less from diabetes-related limitations or other chronic diseases. Seeing that diabetes prevalence and with it mortality are increasing, LSI have become an inherent part of diabetes treatment standards. Various qualitative studies have been carried out to identify participation barriers for LSI. However, these have not resulted in more detailed knowledge about the relative importance of factors with an inhibiting impact on participation. Since it cannot be assumed that all of the influencing factors have equivalent values, it is necessary to investigate their individual importance with regard to a positive or negative decision about participating. There are no systematic reviews on patient preferences for LSI programs in diabetes prevention. As a result, the main objectives of this systematic review are to (i) identify existing patient preference elicitation studies related to LSI for diabetic patients, (ii) summarize the methods applied and findings, and (iii) appraise the reporting and methodological quality of such studies. METHODS We will perform systematic literature searches to identify suitable studies from 14 electronic databases. Retrieved study records will be included based on predefined eligibility criteria as defined in this protocol. We will run abstract and full-text screenings and then extract data from all selected studies by filling in a predefined data extraction spreadsheet. We will undertake a descriptive, narrative synthesis of findings to address the study objectives, since no pooling for quantified preferences is for methodological reasons implementable. We will pay special attention to aspects of methodological quality of preference elicitation by applying established evaluation criteria of the ISPOR and some own developed criteria for different elicitation techniques. All critical stages within the screening, data extraction, and synthesis processes will be conducted by two pairs of authors. This protocol adheres to PRISMA and PRISMA-P standards. DISCUSSION The proposed systematic review will provide an overview of the methods used and current practice in the elicitation and quantification of patients' preferences for diabetes prevention lifestyle interventions. Furthermore, the methodological quality of the identified studies will be appraised as well. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018086988.
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Affiliation(s)
- Charalabos-Markos Dintsios
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine University Düsseldorf, Moorenstr. 5, 40255 Düsseldorf, Germany
| | - Nadja Chernyak
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine University Düsseldorf, Moorenstr. 5, 40255 Düsseldorf, Germany
| | - Benjamin Grehl
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine University Düsseldorf, Moorenstr. 5, 40255 Düsseldorf, Germany
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Faculty of Medicine, Heinrich-Heine University Düsseldorf, Moorenstr. 5, 40255 Düsseldorf, Germany
- Institute for Health Services Research and Health Economics, German Diabetes Center (DDZ), Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
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183
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Brown SL, Salmon P. Reconciling the theory and reality of shared decision-making: A "matching" approach to practitioner leadership. Health Expect 2018; 22:275-283. [PMID: 30478979 PMCID: PMC6543140 DOI: 10.1111/hex.12853] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 11/07/2018] [Accepted: 11/09/2018] [Indexed: 12/12/2022] Open
Abstract
Shared decision making (SDM) evolved to resolve tension between patients’ entitlement to make health‐care decisions and practitioners’ responsibility to protect patients’ interests. Implicitly assuming that patients are willing and able to make “good” decisions, SDM proponents suggest that patients and practitioners negotiate decisions. In practice, patients often do not wish to participate in decisions, or cannot make good decisions. Consequently, practitioners sometimes lead decision making, but doing so risks the paternalism that SDM is intended to avoid. We argue that practitioners should take leadership when patients cannot make good decisions, but practitioners will need to know: (a) when good decisions are not being made; and (b) how to intervene appropriately and proportionately when patients cannot make good decisions. Regarding (a), patients rarely make decisions using formal decision logic, but rely on informal propositions about risks and benefits. As propositions are idiographic and their meanings context‐dependent, normative standards of decision quality cannot be imposed. Practitioners must assess decision quality by making subjective and contextualized judgements as to the “reasonableness” of the underlying propositions. Regarding (b), matched to judgements of reasonableness, we describe levels of leadership distinguished according to how directively practitioners act; ranging from prompting patients to question unreasonable propositions or consider new propositions, to directive leadership whereby practitioners recommend options or deny requested procedures. In the context of ideas of relational autonomy, the objective of practitioner leadership is to protect patients’ autonomy by supporting good decision making, taking leadership in patients’ interests only when patients are unwilling or unable to make good decisions.
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Affiliation(s)
- Stephen L Brown
- Department of Psychological Sciences, University of Liverpool, Liverpool, UK
| | - Peter Salmon
- Department of Psychological Sciences, University of Liverpool, Liverpool, UK
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184
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Durand MA, DiMilia PR, Song J, Yen RW, Barr PJ. Shared decision making embedded in the undergraduate medical curriculum: A scoping review. PLoS One 2018; 13:e0207012. [PMID: 30427901 PMCID: PMC6235351 DOI: 10.1371/journal.pone.0207012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 10/23/2018] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Shared decision making (SDM) training is shown to be effective and is increasingly embedded in continuing medical education. There is little evidence, however, about undergraduate medical education for SDM. The aim of this scoping review was to identify existing SDM training embedded in the undergraduate medical curriculum and analyze their impact. METHODS The authors systematically searched the extant literature for peer reviewed articles, hand searched key journals and reference lists of key articles, and contacted relevant stakeholders as part of a key informant analysis. RESULTS Included in the qualitative synthesis were 12 studies evaluating 11 SDM courses in medical education across six countries. Most courses integrated SDM training in clinical clerkship and varied in length from one to seven hours. The majority of studies assessed course impact on students' skills in SDM. Most studies suggested that students' skills and confidence in SDM significantly increased post-training, but three studies reported no significant improvement in SDM. Ten courses continue to be taught routinely. CONCLUSION Overall, studies suggested a positive impact on medical students' skills, confidence, and attitudes regarding SDM. Embedding SDM training in undergraduate medical education may be a practical and effective solution for current barriers to the widespread adoption of SDM.
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Affiliation(s)
- Marie-Anne Durand
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, United States of America
| | - Peter R. DiMilia
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, United States of America
| | - Julia Song
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, United States of America
| | - Renata W. Yen
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, United States of America
| | - Paul J. Barr
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Lebanon, United States of America
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185
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Makarov DV, Holmes-Rovner M, Rovner DR, Averch T, Barry MJ, Chrouser K, Gee WF, Goodrich K, Haynes M, Krahn M, Saigal C, Sox HC, Stacey D, Tessier C, Waterhouse RL, Fagerlin A. Quality Improvement Summit 2016: Shared Decision Making and Prostate Cancer Screening. UROLOGY PRACTICE 2018. [DOI: 10.1016/j.urpr.2017.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Danil V. Makarov
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | | | - David R. Rovner
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Timothy Averch
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Michael J. Barry
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Kristin Chrouser
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - William F. Gee
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Kate Goodrich
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Mike Haynes
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Murray Krahn
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Christopher Saigal
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Harold C. Sox
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Dawn Stacey
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Christopher Tessier
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Robert L. Waterhouse
- American Urological Association Education and Research Inc., Linthicum, Maryland
| | - Angela Fagerlin
- American Urological Association Education and Research Inc., Linthicum, Maryland
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186
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Serious Choices: A Protocol for an Environmental Scan of Patient Decision Aids for Seriously Ill People at Risk of Death Facing Choices about Life-Sustaining Treatments. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2018; 11:97-106. [PMID: 28825182 DOI: 10.1007/s40271-017-0268-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Seriously ill people at high risk of death face difficult decisions, especially concerning the extent of medical intervention. Given the inherent difficulty and complexity of these decisions, the care they receive often does not align with their preferences. Patient decision aids that educate individuals about options and help them construct preferences about life-sustaining care may reduce the mismatch between the care people say they want and the care they receive. The quantity and quality of patient decision aids for those at high risk of death, however, are unknown. OBJECTIVE This protocol describes an approach for conducting an environmental scan of life-sustaining treatment patient decision aids for seriously ill patients, identified online and through informant analysis. We intend for the outcome to be an inventory of all life-sustaining treatment patient decision aids for seriously ill patients currently available (either publicly or proprietarily) along with information about their content, quality, and known use. METHODS We will identify patient decision aids in a three-step approach (1) mining previously published systematic reviews; (2) systematically searching online and in two popular app stores; and (3) undertaking a key informant survey. We will screen and assess the quality of each patient decision aid identified using the latest published draft of the U.S. National Quality Forum National Standards for the Certification of Patient Decision Aids. Additionally, we will evaluate readability via readable.io and content via inductive content analysis. We will also use natural language processing to assess the content of the decision aids. DISCUSSION Researchers increasingly recognize the environmental scan as an optimal method for studying real-world interventions, such as patient decision aids. This study will advance our understanding of the availability, quality, and use of decision aids for life-sustaining interventions targeted at seriously ill patients. We also aim to provide patients, their families, and friends, along with their clinicians, a broad set of resources for making life-sustaining treatment decisions. Although we intend to capture all patient decision aids for the seriously ill in our review, we anticipate the possibility that we may miss some decision aids. In addition to publishing our findings in an academic journal, we plan to post our inventory online in an easy-to-read format for public and clinical consumption.
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187
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de Mik SML, Stubenrouch FE, Balm R, Ubbink DT. Systematic review of shared decision-making in surgery. Br J Surg 2018; 105:1721-1730. [PMID: 30357815 PMCID: PMC6282808 DOI: 10.1002/bjs.11009] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/08/2018] [Accepted: 09/05/2018] [Indexed: 12/21/2022]
Abstract
Background Multiple treatment options are generally available for most diseases. Shared decision‐making (SDM) helps patients and physicians choose the treatment option that best fits a patient's preferences. This review aimed to assess the extent to which SDM is applied during surgical consultations, and the metrics used to measure SDM and SDM‐related outcomes. Methods This was a systematic review of observational studies and clinical trials that measured SDM during consultations in which surgery was a treatment option. Embase, MEDLINE and CENTRAL were searched. Study selection, quality assessment and data extraction were conducted by two investigators independently. Results Thirty‐two articles were included. SDM was measured using nine different metrics. Thirty‐six per cent of 13 176 patients and surgeons perceived their consultation as SDM, as opposed to patient‐ or surgeon‐driven. Surgeons more often perceived the decision‐making process as SDM than patients (43·6 versus 29·3 per cent respectively). SDM levels scored objectively using the OPTION and Decision Analysis System for Oncology instruments ranged from 7 to 39 per cent. Subjective SDM levels as perceived by surgeons and patients ranged from 54 to 93 per cent. Patients experienced a higher level of SDM during consultations than surgeons (93 versus 84 per cent). Twenty‐five different SDM‐related outcomes were reported. Conclusion At present, SDM in surgery is still in its infancy, although surgeons and patients both think of it favourably. Future studies should evaluate the effect of new interventions to improve SDM during surgical consultations, and its assessment using available standardized and validated metrics. Heterogeneous data
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Affiliation(s)
- S M L de Mik
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - F E Stubenrouch
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R Balm
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - D T Ubbink
- Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Martínez-González NA, Neuner-Jehle S, Plate A, Rosemann T, Senn O. The effects of shared decision-making compared to usual care for prostate cancer screening decisions: a systematic review and meta-analysis. BMC Cancer 2018; 18:1015. [PMID: 30348120 PMCID: PMC6196568 DOI: 10.1186/s12885-018-4794-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 09/03/2018] [Indexed: 01/22/2023] Open
Abstract
Background Shared decision-making (SDM) is recommended for men facing prostate cancer (PC) screening decisions. We synthesize the evidence on the comparative effectiveness of SDM with usual care. Methods We searched academic and grey literature databases, and other sources for primary randomised controlled trials (RCTs) published in English comparing SDM to usual care and conducted in primary and specialised care. We assessed the individual study risk of bias, and calculated the study-specific and pooled relative risks (RR) or standardised mean differences (SMD) [with 95% confidence intervals (CI)] to perform random-effects meta-analyses for SDM-related and patient outcomes. Results Four RCTs comparing SDM to usual care, involving 1760 men, were included. SDM improved knowledge (SMD 0.23, 95%CI 0.02 to 0.43; 2 RCTs), but was not different to usual care in reducing either patient participation in prostate-specific antigen (PSA) testing (RR 1.03, 95%CI 0.90 to 1.19; 2 RCTs) or decisional conflict (SMD -0.04, 95%CI -0.23 to 0.15; SMD -0.05, 95%CI -0.24 to 0.14; 2 RCTs). Individual trial estimates (46.7%) also suggest that SDM may reduce or neutralise physicians’ tendency for PSA screening, and may improve the accuracy of patients’ perception of lifetime-risks and men’s views towards screening. There was no evidence on the effects of SDM on health outcomes. The studies represent various interventions and outcomes and are prone to risk of bias. Conclusions There is currently insufficient evidence to support a clear association of SDM on patient- and SDM-related outcomes for decisions about PSA testing. Further research needs to assess the clinical effectiveness of SDM using well-defined SDM interventions and outcomes. It should address the absence of evidence, particularly on health outcomes. Electronic supplementary material The online version of this article (10.1186/s12885-018-4794-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nahara Anani Martínez-González
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091, Zurich, Switzerland.
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091, Zurich, Switzerland
| | - Andreas Plate
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091, Zurich, Switzerland
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Köpke S, Solari A, Rahn A, Khan F, Heesen C, Giordano A. Information provision for people with multiple sclerosis. Cochrane Database Syst Rev 2018; 10:CD008757. [PMID: 30317542 PMCID: PMC6517040 DOI: 10.1002/14651858.cd008757.pub3] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND People with multiple sclerosis (MS) are confronted with a number of important uncertainties concerning many aspects of the disease. These include diagnosis, prognosis, disease course, disease-modifying therapies, symptomatic therapies, and non-pharmacological interventions, among others. While people with MS demand adequate information to be able to actively participate in medical decision making and to self manage their disease, it has been shown that patients' disease-related knowledge is poor, therefore guidelines recommend clear and concise high-quality information at all stages of the disease. Several studies have outlined communication and information deficits in the care of people with MS. However, only a few information and decision support programmes have been published. OBJECTIVES The primary objectives of this updated review was to evaluate the effectiveness of information provision interventions for people with MS that aim to promote informed choice and improve patient-relevant outcomes, Further objectives were to evaluate the components and the developmental processes of the complex interventions used, to highlight the quantity and the certainty of the research evidence available, and to set an agenda for future research. SEARCH METHODS For this update, we searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Specialised Register, which contains trials from CENTRAL (the Cochrane Library 2017, Issue 11), MEDLINE, Embase, CINAHL, LILACS, PEDro, and clinical trials registries (29 November 2017) as well as other sources. We also searched reference lists of identified articles and contacted trialists. SELECTION CRITERIA Randomised controlled trials (RCTs), cluster-randomised controlled trials, and quasi-randomised trials comparing information provision for people with MS or suspected MS (intervention groups) with usual care or other types of information provision (control groups) were eligible. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the retrieved articles for relevance and methodological quality and extracted data. Critical appraisal of studies addressed the risk of selection bias, performance bias, attrition bias, and detection bias. We contacted authors of relevant studies for additional information. MAIN RESULTS We identified one new RCT (73 participants), which when added to the 10 previously included RCTs resulted in a total of 11 RCTs that met the inclusion criteria and were analysed (1387 participants overall; mean age, range: 31 to 51; percentage women, range: 63% to 100%; percentage relapsing-remitting MS course, range: 45% to 100%). The interventions addressed a variety of topics using different approaches for information provision in different settings. Topics included disease-modifying therapy, relapse management, self care strategies, fatigue management, family planning, and general health promotion. The active intervention components included decision aids, decision coaching, educational programmes, self care programmes, and personal interviews with physicians. All studies used one or more components, but the number and extent differed markedly between studies. The studies had a variable risk of bias. We did not perform meta-analyses due to marked clinical heterogeneity. All five studies assessing MS-related knowledge (505 participants; moderate-certainty evidence) detected significant differences between groups as a result of the interventions, indicating that information provision may successfully increase participants' knowledge. There were mixed results on decision making (five studies, 793 participants; low-certainty evidence) and quality of life (six studies, 671 participants; low-certainty evidence). No adverse events were detected in the seven studies reporting this outcome. AUTHORS' CONCLUSIONS Information provision for people with MS seems to increase disease-related knowledge, with less clear results on decision making and quality of life. The included studies in this review reported no negative side effects of providing disease-related information to people with MS. Interpretation of study results remains challenging due to the marked heterogeneity of interventions and outcome measures.
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Affiliation(s)
- Sascha Köpke
- University of LübeckNursing Research Group, Institute of Social Medicine and EpidemiologyRatzeburger Allee 160LübeckGermanyD‐23538
| | - Alessandra Solari
- Fondazione I.R.C.C.S. ‐ Neurological Institute Carlo BestaNeuroepidemiology UnitVia Celoria 11MilanItaly20133
| | - Anne Rahn
- University Medical CenterInstitute of Neuroimmunology and Multiple SclerosisMartinistr 52HamburgGermany20246
| | - Fary Khan
- Royal Melbourne Hospital, Royal Park CampusDepartment of Rehabilitation MedicinePoplar RoadParkvilleMelbourneVictoriaAustralia3052
| | - Christoph Heesen
- University Medical CenterInstitute of Neuroimmunology and Multiple SclerosisMartinistr 52HamburgGermany20246
| | - Andrea Giordano
- Fondazione I.R.C.C.S. ‐ Neurological Institute Carlo BestaNeuroepidemiology UnitVia Celoria 11MilanItaly20133
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190
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Martens J, de Jong G, Rovers M, Westert G, Bartels R. Importance and Presence of High-Quality Evidence for Clinical Decisions in Neurosurgery: International Survey of Neurosurgeons. Interact J Med Res 2018; 7:e16. [PMID: 30314961 PMCID: PMC6231869 DOI: 10.2196/ijmr.9617] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 06/03/2018] [Accepted: 06/21/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The publication rate of neurosurgical guidelines has increased tremendously over the past decade; however, only a small proportion of clinical decisions appear to be based on high-quality evidence. OBJECTIVE The aim was to evaluate the evidence available within neurosurgery and its value within clinical practice according to neurosurgeons. METHODS A Web-based survey was sent to 2552 neurosurgeons, who were members of the European Association of Neurosurgical Societies. RESULTS The response rate to the survey was 6.78% (173/2552). According to 48.6% (84/173) of the respondents, neurosurgery clinical practices are based on less evidence than other medical specialties and not enough high-quality evidence is available; however, 84.4% (146/173) of the respondents believed neurosurgery is amenable to evidence. Of the respondents, 59.0% (102/173) considered the neurosurgical guidelines in their hospital to be based on high-quality evidence, most of whom considered their own treatments to be based on high-quality (level I and/or level II) data (84.3%, 86/102; significantly more than for the neurosurgeons who did not consider the hospital guidelines to be based on high-quality evidence: 55%, 12/22; P<.001). Also, more neurosurgeons with formal training believed they could understand, criticize, and interpret statistical outcomes presented in journals than those without formal training (93%, 56/60 and 68%, 57/84 respectively; P<.001). CONCLUSIONS According to the respondents, neurosurgery is based on high-quality evidence less often than other medical specialties. The results of the survey indicate that formal training in evidence-based medicine would enable neurosurgeons to better understand, criticize, and interpret statistical outcomes presented in journals.
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Affiliation(s)
- Jill Martens
- Neurosurgical Center Nijmegen, Department of Neurosurgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Guido de Jong
- Neurosurgical Center Nijmegen, Department of Neurosurgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Maroeska Rovers
- Neurosurgical Center Nijmegen, Department of Neurosurgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Gert Westert
- Neurosurgical Center Nijmegen, Department of Neurosurgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ronald Bartels
- Neurosurgical Center Nijmegen, Department of Neurosurgery, Radboud University Medical Center, Nijmegen, Netherlands
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191
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Kistler CE, Golin C, Sundaram A, Morris C, Dalton AF, Ferrari R, Lewis CL. Individualized Colorectal Cancer Screening Discussions Between Older Adults and Their Primary Care Providers: A Cross-Sectional Study. MDM Policy Pract 2018; 3:2381468318765172. [PMID: 30288441 PMCID: PMC6157429 DOI: 10.1177/2381468318765172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 02/08/2018] [Indexed: 01/08/2023] Open
Abstract
Introduction. Discussions of colorectal cancer (CRC) screening with older adults should be individualized to maximize appropriate screening. Our aim was to describe CRC screening discussions and explore their associations with patient characteristics and screening intentions. Methods. Cross-sectional survey of 422 primary care patients aged ≥70 years and eligible for CRC screening, including open-ended questions about CRC screening discussions. Primary outcomes were the frequency with which CRC screening discussions occurred, who had those discussions, and the domains that emerged from thematic analysis of participants' brief reports of their discussions. We also examined the associations between 1) patient characteristics and whether a screening discussion occurred and 2) the domains discussed and what screening decisions were made. Results. Of 422 participants, 209 reported having discussions and 201 responded to open-ended questions about CRC discussions. In a regression analysis, several factors were associated with increased odds of having a discussion: participants' preference to pursue screening (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.3, 3.9), good health (OR 2.9, 95% CI 1.7, 4.8), and receipt of the decision aid (OR 2.1, 95% CI 1.4, 3.2). Our thematic analysis identified five domains related to discussion content and three related to discussion process. The CRC screening-related information domain was the most commonly discussed content domain, and the timing/frequency domain was associated with increased odds of intent to pursue screening. Decision-making role, the most commonly discussed process domain, was associated with increased odds of the intent to forgo CRC screening. Conclusions and Relevance. CRC screening discussions varied by type of participant and content. Future work is needed to determine if interventions focused on specific domains alters the appropriateness of participants' colorectal cancer screening intentions.
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Affiliation(s)
- Christine E Kistler
- Department of Family Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Carol Golin
- Department of Medicine, and Department of Health Behavior, Gillings School of Global Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anupama Sundaram
- School of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Carolyn Morris
- Department of Family Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Alexandra F Dalton
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Renee Ferrari
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carmen L Lewis
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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192
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Woltz S, Krijnen P, Pieterse AH, Schipper IB. Surgeons' perspective on shared decision making in trauma surgery. A national survey. PATIENT EDUCATION AND COUNSELING 2018; 101:1748-1752. [PMID: 29908865 DOI: 10.1016/j.pec.2018.06.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 05/14/2018] [Accepted: 06/05/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE This study aimed to answer the following research question: What is the knowledge, opinion, and experience of trauma surgeons with respect to shared decision making (SDM)? METHODS An online survey was sent out in September 2016 to all 257 surgeons registered as a trauma surgeon with the Dutch Association of Trauma Surgery, to gather demographic, knowledge, and practice based information regarding their use of SDM. Results were presented according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). RESULTS The questionnaire was filled out by 112 (44%) trauma surgeons. Opinions about what SDM entails differed, but 27% described a process that was clearly discordant with current consensus. Eighty-six percent of trauma surgeons regarded SDM as (very) relevant for providing good care. Sixty-two percent reported to encounter problems in achieving SDM. CONCLUSION AND IMPLICATIONS The general opinion of Dutch trauma surgeons towards SDM is very positive, but many lack the understanding of what SDM really implies and surgeons report SDM to be difficult to accomplish. To improve the occurrence of SDM in trauma surgery, there is an obvious need for education and training in SDM skills for surgeons.
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Affiliation(s)
- Sarah Woltz
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands.
| | - Pieta Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Arwen H Pieterse
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Inger B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
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193
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Schoenfeld EM, Kanzaria HK, Quigley DD, Marie PS, Nayyar N, Sabbagh SH, Gress KL, Probst MA. Patient Preferences Regarding Shared Decision Making in the Emergency Department: Findings From a Multisite Survey. Acad Emerg Med 2018; 25:1118-1128. [PMID: 29897639 PMCID: PMC6185792 DOI: 10.1111/acem.13499] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 06/01/2018] [Accepted: 06/07/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES As shared decision making (SDM) has received increased attention as a method to improve the patient-centeredness of emergency department (ED) care, we sought to determine patients' desired level of involvement in medical decisions and their perceptions of potential barriers and facilitators to SDM in the ED. METHODS We surveyed a cross-sectional sample of adult ED patients at three academic medical centers across the United States. The survey included 32 items regarding patient involvement in medical decisions including a modified Control Preference Scale and questions about barriers and facilitators to SDM in the ED. Items were developed and refined based on prior literature and qualitative interviews with ED patients. Research assistants administered the survey in person. RESULTS Of 797 patients approached, 661 (83%) agreed to participate. Participants were 52% female, 45% white, and 30% Hispanic. The majority of respondents (85%-92%, depending on decision type) expressed a desire for some degree of involvement in decision making in the ED, while 8% to 15% preferred to leave decision making to their physician alone. Ninety-eight percent wanted to be involved with decisions when "something serious is going on." The majority of patients (94%) indicated that self-efficacy was not a barrier to SDM in the ED. However, most patients (55%) reported a tendency to defer to the physician's decision making during an ED visit, with about half reporting they would wait for a physician to ask them to be involved. CONCLUSION We found that the majority of ED patients in our large, diverse sample wanted to be involved in medical decisions, especially in the case of a "serious" medical problem, and felt that they had the ability to do so. Nevertheless, many patients were unlikely to actively seek involvement and defaulted to allowing the physician to make decisions during the ED visit. After fully explaining the consequences of a decision, clinicians should make an effort to explicitly ascertain patients' desired level of involvement in decision making.
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Affiliation(s)
- Elizabeth M Schoenfeld
- Department of Emergency Medicine, Springfield, MA
- Institute for Healthcare Delivery and Population Science, Springfield, MA
| | - Hemal K Kanzaria
- University of California San Francisco, Zuckerberg San Francisco General Hospital, San Francisco, CA
| | | | - Peter St Marie
- Office of Research and the Epidemiology/Biostatistics Research Core, University of Massachusetts Medical School-Baystate, Springfield, MA
| | - Nikita Nayyar
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY
| | - Sarah H Sabbagh
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA
| | - Kyle L Gress
- Georgetown University School of Medicine, Washington, DC
| | - Marc A Probst
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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194
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Factors Associated With Quality of Online Information on Trapeziometacarpal Arthritis. J Hand Surg Am 2018; 43:889-896.e5. [PMID: 30286849 DOI: 10.1016/j.jhsa.2018.08.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 06/03/2018] [Accepted: 08/01/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE People increasingly search the Internet for information about common medical problems such as trapeziometacarpal (TMC) joint arthritis. But this information can be biased, inaccurate, and misleading. Medical professionals should be aware of what patients may be reading about their condition because concepts and beliefs can affect symptoms, limitations, and decision making. This study sought factors associated with the quality of design and content of health information Web sites about TMC arthritis. METHODS Using 3 search engines we entered "thumb arthritis" and measured the quality of design and content of 67 Web sites using the DISCERN and LIDA tools, dominant tones using the IBM Watson Tone Analyzer, and readability, and we recorded Web site characteristics. All but 1 Web site exceeded the recommended sixth-grade reading level. We created 2 backward stepwise regression models to identify independent factors associated with Web site design and content quality. RESULTS In multivariable analysis, the Web site not having a clear preference for treatment was independently associated with greater design and content quality measured by DISCERN. Health On the Net (HON) code certification-a code of conduct for medical Web sites-and nonprofit Web sites had higher LIDA scores. CONCLUSIONS Online information on TMC arthrosis is difficult to read, often biased in favor of a particular treatment and influenced by profit and HONcode. CLINICAL RELEVANCE Hand surgeons should prepare to gently correct misconceptions established or reinforced, in part, by material found on the Internet.
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195
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Blaiss MS, Steven GC, Bender B, Bukstein DA, Meltzer EO, Winders T. Shared decision making for the allergist. Ann Allergy Asthma Immunol 2018; 122:463-470. [PMID: 30201469 DOI: 10.1016/j.anai.2018.08.019] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/21/2018] [Accepted: 08/27/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Shared decision making (SDM) is becoming more commonly appreciated and used in medical practice as a way to empower patients who are facing treatment preference-sensitive conditions, such as allergic rhinitis, atopic dermatitis, food allergy, and persistent asthma. The purpose of this review is to educate the allergy health care provider about how SDM works and provide practical advice and allergist-specific SDM resources. DATA SOURCES PubMed and online patient decision aid resources. STUDY SELECTIONS Studies and reviews relevant to SDM and patient decision aids relevant to the allergy health care provider were selected for discussion. RESULTS There are ethical, practical, economic, and psychological imperatives for the implementation of quality SDM, particularly for chronic diseases. Many benefits and barriers of SDM have been identified and models have been developed to encourage implementation of quality SDM. For the allergy health care provider, SDM for asthma has been shown to improve adherence, outcomes, and patient satisfaction with care. Patient decision aids are useful tools for SDM and have recently been developed for allergen immunotherapy, severe asthma, and atopic dermatitis. CONCLUSION Effective SDM has been shown to improve adherence and lead to better outcomes. SDM should be universally implemented as a key component of patient-centered health care. Allergy health care providers should work with their patients to reach treatment decisions that align with their values and preferences.
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Affiliation(s)
- Michael S Blaiss
- Department of Pediatrics, Medical College of Georgia, Augusta, Georgia.
| | - Gary C Steven
- Allergy, Asthma & Sinus Center, Milwaukee, Wisconsin
| | - Bruce Bender
- National Jewish Health, Denver, and University of Colorado School of Medicine, Aurora, Colorado
| | | | - Eli O Meltzer
- Department of Pediatrics, University of California-San Diego School of Medicine, San Diego, California
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Abstract
EXECUTIVE SUMMARY This study involved an examination of the literature with the goal of establishing innovative leadership initiatives to reduce healthcare costs. To achieve this objective, the author used a qualitative research design based on grounded theory to identify the key drivers of high healthcare costs and examine ways to manage them. The study outcomes show that the key drivers were unnecessary diagnostic procedures such as imaging tests, large numbers of specialty referrals, and hospitalization. The author observed that adoption of patient-centered care results in a significant reduction in hospitalization, unnecessary procedures, and specialty visits. The findings also indicate that an emphasis on primary care reduces hospitalization, unnecessary procedures, and visits to specialists. Further, organizational restructuring had a significant impact on reducing unnecessary diagnostic procedures. The study outcomes suggest that healthcare leaders should promote the active participation of patients in care delivery. Leaders also should develop strategies that enhance primary care as a means of reducing hospitalization and the need for specialty referrals. Finally, the study proposes that leaders should focus on organizational restructuring as a means of limiting unnecessary diagnostic procedures.
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User-centered Development of a Decision Aid for Patients Facing Implantable Cardioverter-Defibrillator Replacement. J Cardiovasc Nurs 2018; 33:481-491. [DOI: 10.1097/jcn.0000000000000477] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sylvain C, Durand MJ, Maillette P. Insurers' Influences on Attending Physicians of Workers Sick-listed for Common Mental Disorders: What Are the Impacts on Physicians' Practices? JOURNAL OF OCCUPATIONAL REHABILITATION 2018; 28:531-540. [PMID: 29192369 DOI: 10.1007/s10926-017-9744-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Purpose In many jurisdictions, general practitioners (GPs) play an important role in the sick-leave and return-to-work (RTW) process of individuals with common mental disorders (CMD). Since it is insurers that decide on workers' eligibility for disability benefits, they can influence physicians' ability to act. The nature of these influences remains little documented to date. The aim of this study was therefore to describe these influences and their impacts from the GPs' perspective. Methods Semi-structured interviews were conducted with GPs having a diversified clientele (n = 13). The interviews were audio-recorded, transcribed verbatim and analyzed according to thematic analysis principles. Results The results indicated that the GPs recognized insurers as influencing their practices with patients on sick leave for CMDs. The documented influences were generally seen as constraints, but sometimes as enablers. The impacts of these influences on the GPs' practices depended on the organizational characteristics of their work context (such as limited consultation time) and other characteristics of their practice setting (such as lack of timely access to consultations with specialists). Conclusion The results brought three major issues to light: the quality of the information sent to insurers by GPs, the respect shown (or not) for workers' care preferences, and the relevance of the specialized services offered to support workers' RTW. These issues in turn reveal potential risks for workers, risks that need to be identified and recognized by all parties concerned if we are to come up with possible solutions.
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Affiliation(s)
- Chantal Sylvain
- School of Rehabilitation, Université de Sherbrooke, Sherbrooke, Canada.
- Centre for Action in Work Disability Prevention and Rehabilitation (CAPRIT), Hôpital Charles-Le Moyne Research Centre, Université de Sherbrooke, Longueuil Campus, 150 Place Charles LeMoyne, Longueuil, QC, J4K 0A8, Canada.
| | - Marie-José Durand
- School of Rehabilitation, Université de Sherbrooke, Sherbrooke, Canada
- Centre for Action in Work Disability Prevention and Rehabilitation (CAPRIT), Hôpital Charles-Le Moyne Research Centre, Université de Sherbrooke, Longueuil Campus, 150 Place Charles LeMoyne, Longueuil, QC, J4K 0A8, Canada
| | - Pascale Maillette
- Centre for Action in Work Disability Prevention and Rehabilitation (CAPRIT), Hôpital Charles-Le Moyne Research Centre, Université de Sherbrooke, Longueuil Campus, 150 Place Charles LeMoyne, Longueuil, QC, J4K 0A8, Canada
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Lynøe N, Helgesson G, Juth N. Value-impregnated factual claims may undermine medical decision-making. CLINICAL ETHICS 2018; 13:151-158. [PMID: 30166945 PMCID: PMC6099986 DOI: 10.1177/1477750918765283] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Clinical decisions are expected to be based on factual evidence and official values derived from healthcare law and soft laws such as regulations and guidelines. But sometimes personal values instead influence clinical decisions. One way in which personal values may influence medical decision-making is by their affecting factual claims or assumptions made by healthcare providers. Such influence, which we call 'value-impregnation,' may be concealed to all concerned stakeholders. We suggest as a hypothesis that healthcare providers' decision making is sometimes affected by value-impregnated factual claims or assumptions. If such claims influence e.g. doctor-patient encounters, this will likely have a negative impact on the provision of correct information to patients and on patients' influence on decision making regarding their own care. In this paper, we explore the idea that value-impregnated factual claims influence healthcare decisions through a series of medical examples. We suggest that more research is needed to further examine whether healthcare staff's personal values influence clinical decision-making.
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Affiliation(s)
- Niels Lynøe
- Centre for healthcare ethics, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
| | - Gert Helgesson
- Centre for healthcare ethics, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
| | - Niklas Juth
- Centre for healthcare ethics, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden
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Incorporating patients' preference diagnosis in implantable cardioverter defibrillator decision-making: a review of recent literature. Curr Opin Cardiol 2018; 33:42-49. [PMID: 29216014 DOI: 10.1097/hco.0000000000000464] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Strong recommendations exist for implantable cardioverter defibrillators (ICD) in appropriately selected patients. Yet, patient preferences are not often incorporated when decisions about ICD therapy are made. Literature published since 2016 was reviewed aiming to discuss current advances and ongoing challenges with ICD decision-making in adults, discuss shared decision-making (SDM) as a strategy to incorporate preference diagnoses, summarize current evidence on effective interventions to facilitate SDM, and identify opportunities for research and practice. RECENT FINDINGS Advances in risk stratification can identify patients who will most and least likely benefit from the ICD. Interventions to support SDM are emerging. These interventions present options, the risks, and the benefits of each option, and elicit patients' values and preferences regarding possible outcomes. SUMMARY Appropriate patient selection for initial or continued ICD therapy is multifactorial. It requires accurate clinical diagnosis using careful risk stratification and accurate preference diagnosis based upon the patient's preferences. SDM aims to unite the elements that constitute these two equally important diagnoses. High-quality decision-making will be difficult to achieve if patients lack or misunderstand information, and if evolving patient preferences are not incorporated when making decisions.
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