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Kamath CC, Espinoza Suarez NR, Vallejo S, Montori VM, Brito JP, Boehmer KR. Not all cost conversations are the same: An exploration of potential value in cost conversations during Atrial fibrillation treatment decision making. PATIENT EDUCATION AND COUNSELING 2024; 128:108366. [PMID: 39032442 DOI: 10.1016/j.pec.2024.108366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 06/26/2024] [Accepted: 06/27/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVES To explore the cost conversations taking place when patients with atrial fibrillation and their clinicians decide on whether and how to use anticoagulation to prevent strokes. METHODS Secondary qualitative thematic analysis of conversations from 476 clinical encounters in three sites of a multicenter randomized trial comparing usual care with and without a shared decision-making tool. RESULTS We identified three themes with subthemes: (1) What was discussed: conversation content (2) How content was transmitted: communication patterns and (3) Implicit conversation drivers. Due to each patient's unique circumstances, bi-directional conversations focused on relationship- and solution-based content enabled better cost burden discovery. Conversation drivers included affordability, comorbidities, preferences, and uncertainty about future costs. CONCLUSIONS Cost conversations were often initiated by clinicians, and if they did not invite a response, patients passively received information without understanding or weighing cost burden. When clinicians discussed cost information using relational or solution-focused content and bi-directional communication patients were more likely to engage in discussion including their unique situation. PRACTICE IMPLICATIONS Solution-focused cost conversations can reduce financial treatment burden, but require estimates of out-of-pocket costs, insurance coverage, and long-term financial effects of various options. Conversation tools and information on financial resources are valuable to patients and clinicians.
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Affiliation(s)
- Celia C Kamath
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA; Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Nataly R Espinoza Suarez
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; VITAM - Center for Sustainable Health Research, Integrated University Health and Social Services Center of Capitale-Nationale, Quebec City, QC, Canada; Faculty of Nursing, Laval University, Quebec City, QC, Canada
| | | | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Juan P Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kasey R Boehmer
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Health Care Delivery Research, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA.
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Kaplan H, Kostick-Quenet K, Lang B, Volk RJ, Blumenthal-Barby J. Impact of personalized risk scores on shared decision making in left ventricular assist device implantation: Findings from a qualitative study. PATIENT EDUCATION AND COUNSELING 2024; 130:108418. [PMID: 39288559 DOI: 10.1016/j.pec.2024.108418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 08/26/2024] [Accepted: 08/31/2024] [Indexed: 09/19/2024]
Abstract
OBJECTIVE To assess stakeholders' perspectives on integrating personalized risk scores (PRS) into left ventricular assist device (LVAD) implantation decisions and how these perspectives might impact shared decision making (SDM). METHODS We conducted 40 in-depth interviews with physicians, nurse coordinators, patients, and caregivers about integrating PRS into LVAD implantation decisions. A codebook was developed to identify thematic patterns, and quotations were consolidated for analysis. We used Thematic Content Analysis in MAXQDA software to identify themes by abstracting relevant quotes. RESULTS Clinicians had varying preferences regarding PRS integration into LVAD decision making, while patients and caregivers preferred real-time discussions about PRS with their physicians. Physicians voiced concerns about time constraints and suggested delegating PRS discussions to advanced practice providers or nurse coordinators. CONCLUSIONS Integrating PRS information into LVAD decision aids presents both opportunities and challenges for SDM. Given variable preferences among clinicians and patients, clinicians should elicit patients' desired role in the decision-making process. Addressing time constraints and ensuring patient-centered care will be crucial for optimizing SDM. Practice implications Clinicians should elicit patient preferences for PRS information disclosure and address challenges, such as time constraints and delegation of PRS discussions to other team members.
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Affiliation(s)
- Holland Kaplan
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA; Section of General Internal Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Kristin Kostick-Quenet
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Benjamin Lang
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
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Jolliffe L, Christie LJ, Fearn N, Nohrenberg M, Liu R, Williams JF, Parsons MW, Pearce AM. A systematic review of discrete choice experiments in stroke rehabilitation. Top Stroke Rehabil 2024; 31:632-643. [PMID: 38372124 DOI: 10.1080/10749357.2024.2312641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 01/27/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVES Existing research qualitatively explores consumer preferences for stroke rehabilitation interventions. However, it remains unclear which intervention characteristics are most important to consumers, and how these preferences may influence uptake and participation. Discrete choice experiments (DCE) provide a unique way to quantitatively measure preferences for health and health care. This study aims to explore how DCEs have been used in stroke rehabilitation and to identify reported consumer preferences for rehabilitation interventions. MATERIAL AND METHODS A systematic review of published stroke rehabilitation DCEs was completed (PROSPERO registration: CRD42021282578). Six databases (including CINAHL, MEDLINE, EconLIT) were searched from January 2000-March 2023. Data extracted included topic area, sample size, aim, attributes, design process, and preference outcomes. Descriptive and thematic analyses were conducted, and two methodological checklists applied to review quality. RESULTS Of 2,446 studies screened, five were eligible. Studies focused on exercise preference (n = 3), the structure and delivery of community services (n = 1), and self-management programs (n = 1). All had small sample sizes (range 50-146) and were of moderate quality (average score of 77%). Results indicated people have strong preferences for one-to-one therapy (over group-based), light-moderate intensity of exercise, and delivery by qualified therapists (over volunteers). CONCLUSIONS Few DCEs have been conducted in stroke rehabilitation, suggesting consumer preferences could be more rigorously explored. Included studies were narrow in the scope of attributes included, limiting their application to practice and policy. Further research is needed to assess the impact of differing service delivery models on uptake and participation.
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Affiliation(s)
- Laura Jolliffe
- Department of Occupational Therapy, Peninsula Health, Melbourne, Australia
- Department of Occupational Therapy, Monash University, Melbourne, Australia
- National Centre for Healthy Ageing (NCHA), Melbourne, Australia
| | - Lauren J Christie
- Allied Health Research Unit, St Vincent's Health Network Sydney, Darlinghurst, Australia
- Nursing Research Institute, Australian Catholic University, Sydney, Australia
| | - Nicola Fearn
- Allied Health Research Unit, St Vincent's Health Network Sydney, Darlinghurst, Australia
| | - Michael Nohrenberg
- School of Public Health, The University of Sydney, Camperdown, Australia
| | - Rasia Liu
- School of Public Health, The University of Sydney, Camperdown, Australia
| | - Julie F Williams
- Walter McGrath Library, St Vincent's Hospital Sydney, Darlinghurst, Australia
| | - Mark W Parsons
- Department of Neurology, Liverpool Hospital, South Western Sydney Local Health District, Liverpool, Australia
- School of Medicine and Health, UNSW, Sydney, Australia
- Sydney Brain Centre, Ingham Institute of Applied Medical Research, Liverpool, Australia
| | - Alison M Pearce
- School of Public Health, The University of Sydney, Camperdown, Australia
- The Daffodil Centre, a joint venture between Cancer Council NSW and the University of Sydney, The University of Sydney, Sydney, Australia
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Helbach J, Hoffmann F, Hecht N, Heesen C, Thomalla G, Wilfling D, Rahn AC. Information needs of people who have suffered a stroke or TIA and their preferred approaches of receiving health information: A scoping review. Eur Stroke J 2024:23969873241272744. [PMID: 39188106 DOI: 10.1177/23969873241272744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/28/2024] Open
Abstract
PURPOSE We aimed to synthesize the information needs of people with stroke (PwS) in recurrent stroke prevention. METHODS In this scoping review we searched Medline (via PubMed), CINAHL, and PsycINFO from inception to June 5, 2023, to identify all studies describing the information needs of people 18 years and older who have suffered a stroke or transient ischemic attack within the past 5 years. We included qualitative and quantitative studies from developed countries published in German or English. Data analysis was performed following Arksey and O'Malley's methodological framework for scoping reviews. FINDINGS We screened 5822 records for eligibility and included 36 articles published between 1993 and 2023. None of the included studies used a comprehensive framework or defined information needs. Based on statements from PwS and their caregivers, PwS needed information on treatment, etiology, effects of stroke, prognosis, rehabilitation, discharge, life changes, care role, support options, information sources, and hospital procedures. The most frequently expressed needs were information on the treatment (77.8%) and stroke etiology (63.9%). The primary information source was healthcare professionals (85.7%), followed by written information (71.4%), family and friends (42.6%), and the internet (35.7%), with information provided directly by healthcare professionals being preferred. The timing of information transfer is often described as too early. CONCLUSION PwS are primarily interested in clinical information about stroke, for example, treatment and etiology, and less often in information about daily life, for example, rehabilitation, the role of care, or lifestyle changes. PwS prefer to receive information directly from healthcare professionals. Developing a shared understanding of PwS's information needs is crucial to implement suitable strategies and programs for dealing with these needs in clinical practice.
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Affiliation(s)
- Jasmin Helbach
- Department of Health Services Research, School of Medicine and Health Sciences, Carl von Ossietzky Universität Oldenburg, Oldenburg, Germany
| | - Falk Hoffmann
- Department of Health Services Research, School of Medicine and Health Sciences, Carl von Ossietzky Universität Oldenburg, Oldenburg, Germany
| | - Nina Hecht
- Nursing Research Unit, Institute of Social Medicine and Epidemiology, University of Lübeck, Germany
| | - Christoph Heesen
- Institute of Neuroimmunology and Multiple Sclerosis (INIMS), Center for Molecular Neurobiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Denise Wilfling
- Nursing Research Unit, Institute of Social Medicine and Epidemiology, University of Lübeck, Germany
| | - Anne Christin Rahn
- Nursing Research Unit, Institute of Social Medicine and Epidemiology, University of Lübeck, Germany
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Sommers N, Rubenstein JC, Ahmad A, Oujiri J, Kapoor R, Adsit G, Berger M. Implementation of a Patient Decision Aid for Atrial Fibrillation Ablation Improves Patient Procedural Knowledge but Does Not Impact Perceived Involvement With the Shared Decision-Making Process. J Patient Cent Res Rev 2024; 11:74-80. [PMID: 39044856 PMCID: PMC11262844 DOI: 10.17294/2330-0698.2055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024] Open
Abstract
Purpose Shared decision-making (SDM) is a method for a patient and physician to cooperatively consider a diagnostic or therapeutic option, ultimately empowering the patient to make an informed decision. Atrial fibrillation (AF) ablation is a procedure that would benefit from SDM given the risk of serious adverse events, the high rate of arrhythmia recurrence, and alternative treatment options. Implementing a patient decision aid (PDA) may help facilitate AF ablation SDM by succinctly conveying important information to patients. Methods Patients scheduled for initial AF catheter ablation were randomized to a virtual SDM visit utilizing a PDA, which covered procedural risks and benefits, or a virtual control visit with a tool outlining periprocedural processes. Preoperatively, patients completed a questionnaire assessing procedural risk and benefit knowledge, as well as perceived involvement with the decision-making process. Unpaired t-tests were used to compare groups. Results The SDM group scored significantly better overall on knowledge-based questions compared to the control group (69% correct [n=34] vs 53% [n=32]; P=0.00013). In particular, the SDM group was significantly more likely to answer questions correctly about stroke risk (P=0.01), anticoagulation (P=0.01), and potential need for additional procedures (P=0.03 and P=0.03). Perceived involvement in the decision-making process was overall not improved with PDA use (4.7 vs 4.6 out of 5; P=0.72). Conclusions The addition of a PDA for AF ablation significantly improved procedural knowledge but did not impact patients' perceived involvement in the decision-making process compared to traditional preprocedural discussion alone.
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Zeng A, Tang Q, O'Hagan E, McCaffery K, Ijaz K, Quiroz JC, Kocaballi AB, Rezazadegan D, Trivedi R, Siette J, Shaw T, Makeham M, Thiagalingam A, Chow CK, Laranjo L. Use of digital patient decision-support tools for atrial fibrillation treatments: a systematic review and meta-analysis. BMJ Evid Based Med 2024:bmjebm-2023-112820. [PMID: 38950915 DOI: 10.1136/bmjebm-2023-112820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2024] [Indexed: 07/03/2024]
Abstract
OBJECTIVES To assess the effects of digital patient decision-support tools for atrial fibrillation (AF) treatment decisions in adults with AF. STUDY DESIGN Systematic review and meta-analysis. ELIGIBILITY CRITERIA Eligible randomised controlled trials (RCTs) evaluated digital patient decision-support tools for AF treatment decisions in adults with AF. INFORMATION SOURCES We searched MEDLINE, EMBASE and Scopus from 2005 to 2023.Risk-of-bias (RoB) assessment: We assessed RoB using the Cochrane Risk of Bias Tool 2 for RCTs and cluster RCT and the ROBINS-I tool for quasi-experimental studies. SYNTHESIS OF RESULTS We used random effects meta-analysis to synthesise decisional conflict and patient knowledge outcomes reported in RCTs. We performed narrative synthesis for all outcomes. The main outcomes of interest were decisional conflict and patient knowledge. RESULTS 13 articles, reporting on 11 studies (4 RCTs, 1 cluster RCT and 6 quasi-experimental) met the inclusion criteria. There were 2714 participants across all studies (2372 in RCTs), of which 26% were women and the mean age was 71 years. Socioeconomically disadvantaged groups were poorly represented in the included studies. Seven studies (n=2508) focused on non-valvular AF and the mean CHAD2DS2-VASc across studies was 3.2 and for HAS-BLED 1.9. All tools focused on decisions regarding thromboembolic stroke prevention and most enabled calculation of individualised stroke risk. Tools were heterogeneous in features and functions; four tools were patient decision aids. The readability of content was reported in one study. Meta-analyses showed a reduction in decisional conflict (4 RCTs (n=2167); standardised mean difference -0.19; 95% CI -0.30 to -0.08; p=0.001; I2=26.5%; moderate certainty evidence) corresponding to a decrease in 12.4 units on a scale of 0 to 100 (95% CI -19.5 to -5.2) and improvement in patient knowledge (2 RCTs (n=1057); risk difference 0.72, 95% CI 0.68, 0.76, p<0.001; I2=0%; low certainty evidence) favouring digital patient decision-support tools compared with usual care. Four of the 11 tools were publicly available and 3 had been implemented in healthcare delivery. CONCLUSIONS In the context of stroke prevention in AF, digital patient decision-support tools likely reduce decisional conflict and may result in little to no change in patient knowledge, compared with usual care. Future studies should leverage digital capabilities for increased personalisation and interactivity of the tools, with better consideration of health literacy and equity aspects. Additional robust trials and implementation studies are warranted. PROSPERO REGISTRATION NUMBER CRD42020218025.
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Affiliation(s)
- Aileen Zeng
- Westmead Applied Research Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Queenie Tang
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Edel O'Hagan
- Westmead Applied Research Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, School of Public Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Kiran Ijaz
- Affective Interactions lab, School of Architecture, Design and Planning, The University of Sydney, Sydney, New South Wales, Australia
| | - Juan C Quiroz
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Ahmet Baki Kocaballi
- School of Computer Science, Faculty of Engineering & Information Technology, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Dana Rezazadegan
- Department of Computing Technologies, Swinburne University of Technology, Melbourne, Victoria, Australia
| | - Ritu Trivedi
- Westmead Applied Research Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Joyce Siette
- The MARCS Institute for Brain, Behaviour and Development, Western Sydney University, Penrith, New South Wales, Australia
| | - Timothy Shaw
- Westmead Applied Research Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Meredith Makeham
- The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Aravinda Thiagalingam
- Westmead Applied Research Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Clara K Chow
- Westmead Applied Research Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Liliana Laranjo
- Westmead Applied Research Centre, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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Strehlow M, Alvarez A, Blomkalns AL, Caretta-Wyer H, Gharahbaghian L, Imler D, Khan A, Lee M, Lobo V, Newberry JA, Riberia R, Sebok-Syer S, Shen S, Gisondi MA. Precision emergency medicine. Acad Emerg Med 2024. [PMID: 38940478 DOI: 10.1111/acem.14962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/13/2024] [Accepted: 05/23/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Precision health is a burgeoning scientific discipline that aims to incorporate individual variability in biological, behavioral, and social factors to develop personalized health solutions. To date, emergency medicine has not deeply engaged in the precision health movement. However, rapid advances in health technology, data science, and medical informatics offer new opportunities for emergency medicine to realize the promises of precision health. METHODS In this article, we conceptualize precision emergency medicine as an emerging paradigm and identify key drivers of its implementation into current and future clinical practice. We acknowledge important obstacles to the specialty-wide adoption of precision emergency medicine and offer solutions that conceive a successful path forward. RESULTS Precision emergency medicine is defined as the use of information and technology to deliver acute care effectively, efficiently, and authentically to individual patients and their communities. Key drivers and opportunities include leveraging human data, capitalizing on technology and digital tools, providing deliberate access to care, advancing population health, and reimagining provider education and roles. Overcoming challenges in equity, privacy, and cost is essential for success. We close with a call to action to proactively incorporate precision health into the clinical practice of emergency medicine, the training of future emergency physicians, and the research agenda of the specialty. CONCLUSIONS Precision emergency medicine leverages new technology and data-driven artificial intelligence to advance diagnostic testing, individualize patient care plans and therapeutics, and strategically refine the convergence of the health system and the community.
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Affiliation(s)
- Matthew Strehlow
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Al'ai Alvarez
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Andra L Blomkalns
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Holly Caretta-Wyer
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Laleh Gharahbaghian
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Daniel Imler
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Ayesha Khan
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Moon Lee
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Viveta Lobo
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jennifer A Newberry
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Ryan Riberia
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Stefanie Sebok-Syer
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Sam Shen
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Michael A Gisondi
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA
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Jaeken J, Billiouw C, Mertens L, Van Bostraeten P, Bekkering G, Vermandere M, Aertgeerts B, van Mileghem L, Delvaux N. A systematic review of shared decision making training programs for general practitioners. BMC MEDICAL EDUCATION 2024; 24:592. [PMID: 38811922 PMCID: PMC11137915 DOI: 10.1186/s12909-024-05557-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/15/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Shared decision making (SDM) has been presented as the preferred approach for decisions where there is more than one acceptable option and has been identified a priority feature of high-quality patient-centered care. Considering the foundation of trust between general practitioners (GPs) and patients and the variety of diseases in primary care, the primary care context can be viewed as roots of SDM. GPs are requesting training programs to improve their SDM skills leading to a more patient-centered care approach. Because of the high number of training programs available, it is important to overview these training interventions specifically for primary care and to explore how these training programs are evaluated. METHODS This review was reported in accordance with the PRISMA guideline. Eight different databases were used in December 2022 and updated in September 2023. Risk of bias was assessed using ICROMS. Training effectiveness was analyzed using the Kirkpatrick evaluation model and categorized according to training format (online, live or blended learning). RESULTS We identified 29 different SDM training programs for GPs. SDM training has a moderate impact on patient (SMD 0.53 95% CI 0.15-0.90) and observer reported SDM skills (SMD 0.59 95%CI 0.21-0.97). For blended training programs, we found a high impact for quality of life (SMD 1.20 95% CI -0.38-2.78) and patient reported SDM skills (SMD 2.89 95%CI -0.55-6.32). CONCLUSION SDM training improves patient and observer reported SDM skills in GPs. Blended learning as learning format for SDM appears to show better effects on learning outcomes than online or live learning formats. This suggests that teaching facilities designing SDM training may want to prioritize blended learning formats. More homogeneity in SDM measurement scales and evaluation approaches and direct comparisons of different types of educational formats are needed to develop the most appropriate and effective SDM training format. TRIAL REGISTRATION PROSPERO: A systematic review of shared-decision making training programs in a primary care setting. PROSPERO 2023 CRD42023393385 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023393385 .
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Affiliation(s)
- Jasmien Jaeken
- Department of PH&PC, Academic Center for General Practice, KU Leuven, Kapucijnenvoer 7 block h, box 7001, Leuven, 3000, Belgium.
| | - Cathoo Billiouw
- Department of PH&PC, Academic Center for General Practice, KU Leuven, Kapucijnenvoer 7 block h, box 7001, Leuven, 3000, Belgium
| | - Lien Mertens
- Department of PH&PC, Academic Center for General Practice, KU Leuven, Kapucijnenvoer 7 block h, box 7001, Leuven, 3000, Belgium
| | - Pieter Van Bostraeten
- Department of PH&PC, Academic Center for General Practice, KU Leuven, Kapucijnenvoer 7 block h, box 7001, Leuven, 3000, Belgium
| | - Geertruida Bekkering
- Department of PH&PC, Academic Center for General Practice, KU Leuven, Kapucijnenvoer 7 block h, box 7001, Leuven, 3000, Belgium
| | - Mieke Vermandere
- Department of PH&PC, Academic Center for General Practice, KU Leuven, Kapucijnenvoer 7 block h, box 7001, Leuven, 3000, Belgium
| | - Bert Aertgeerts
- Department of PH&PC, Academic Center for General Practice, KU Leuven, Kapucijnenvoer 7 block h, box 7001, Leuven, 3000, Belgium
| | - Laura van Mileghem
- Department of PH&PC, Academic Center for General Practice, KU Leuven, Kapucijnenvoer 7 block h, box 7001, Leuven, 3000, Belgium
| | - Nicolas Delvaux
- Department of PH&PC, Academic Center for General Practice, KU Leuven, Kapucijnenvoer 7 block h, box 7001, Leuven, 3000, Belgium
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Keij SM, Branda ME, Montori VM, Brito JP, Kunneman M, Pieterse AH. Patient Characteristics and the Extent to Which Clinicians Involve Patients in Decision Making: Secondary Analyses of Pooled Data. Med Decis Making 2024; 44:346-356. [PMID: 38563311 PMCID: PMC10988989 DOI: 10.1177/0272989x241231721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 01/22/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The occurrence of shared decision making (SDM) in daily practice remains limited. Various patient characteristics have been suggested to potentially influence the extent to which clinicians involve patients in SDM. OBJECTIVE To assess associations between patient characteristics and the extent to which clinicians involve patients in SDM. METHODS We conducted a secondary analysis of data pooled from 10 studies comparing the care of adult patients with (intervention) or without (control) a within-encounter SDM conversation tool. We included studies with audio(-visual) recordings of clinical encounters in which decisions about starting or reconsidering treatment were discussed. MAIN MEASURES In the original studies, the Observing Patient Involvement in Decision Making 12-items (OPTION12 item) scale was used to code the extent to which clinicians involved patients in SDM in clinical encounters. We conducted multivariable analyses with patient characteristics (age, gender, race, education, marital status, number of daily medications, general health status, health literacy) as independent variables and OPTION12 as a dependent variable. RESULTS We included data from 1,614 patients. The between-arm difference in OPTION12 scores was 7.7 of 100 points (P < 0.001). We found no association between any patient characteristics and the OPTION12 score except for education level (p = 0.030), an association that was very small (2.8 points between the least and most educated), contributed mostly by, and only significant in, control arms (6.5 points). Subanalyses of a stroke prevention trial showed a positive association between age and OPTION12 score (P = 0.033). CONCLUSIONS Most characteristics showed no association with the extent to which clinicians involved patients in SDM. Without an SDM conversation tool, clinicians devoted more efforts to involve patients with higher education, a difference not observed when the tool was used. HIGHLIGHTS Most sociodemographic patient characteristics show no association with the extent to which clinicians involve patients in shared decision making.Clinicians devoted less effort to involve patients with lower education, a difference that was not observed when a shared decision-making conversation tool was used.SDM conversation tools can be useful for clinicians to better involve patients and ensure patients get involved equally regardless of educational background.
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Affiliation(s)
- Sascha M. Keij
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands
| | - Megan E. Branda
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester MN, USA
| | - Victor M. Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester MN, USA
| | - Juan P. Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester MN, USA
| | - Marleen Kunneman
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester MN, USA
| | - Arwen H. Pieterse
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, The Netherlands
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Bakhit M, Fien S, Abukmail E, Jones M, Clark J, Scott AM, Glasziou P, Cardona M. Cardiovascular disease risk communication and prevention: a meta-analysis. Eur Heart J 2024; 45:998-1013. [PMID: 38243824 PMCID: PMC10972690 DOI: 10.1093/eurheartj/ehae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 12/22/2023] [Accepted: 01/03/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND AND AIMS Knowledge of quantifiable cardiovascular disease (CVD) risk may improve health outcomes and trigger behavioural change in patients or clinicians. This review aimed to investigate the impact of CVD risk communication on patient-perceived CVD risk and changes in CVD risk factors. METHODS PubMed, Embase, and PsycINFO databases were searched from inception to 6 June 2023, supplemented by citation analysis. Randomized trials that compared any CVD risk communication strategy versus usual care were included. Paired reviewers independently screened the identified records and extracted the data; disagreements were resolved by a third author. The primary outcome was the accuracy of risk perception. Secondary outcomes were clinician-reported changes in CVD risk, psychological responses, intention to modify lifestyle, and self-reported changes in risk factors and clinician prescribing of preventive medicines. RESULTS Sixty-two trials were included. Accuracy of risk perception was higher among intervention participants (odds ratio = 2.31, 95% confidence interval = 1.63 to 3.27). A statistically significant improvement in overall CVD risk scores was found at 6-12 months (mean difference = -0.27, 95% confidence interval = -0.45 to -0.09). For primary prevention, risk communication significantly increased self-reported dietary modification (odds ratio = 1.50, 95% confidence interval = 1.21 to 1.86) with no increase in intention or actual changes in smoking cessation or physical activity. A significant impact on patients' intention to start preventive medication was found for primary and secondary prevention, with changes at follow-up for the primary prevention group. CONCLUSIONS In this systematic review and meta-analysis, communicating CVD risk information, regardless of the method, reduced the overall risk factors and enhanced patients' self-perceived risk. Communication of CVD risk to patients should be considered in routine consultations.
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Affiliation(s)
- Mina Bakhit
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Samantha Fien
- School of Health, Medical and Applied Sciences, Central Queensland University, Mackay, QLD, Australia
| | - Eman Abukmail
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Mark Jones
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Anna Mae Scott
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Paul Glasziou
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Magnolia Cardona
- Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
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11
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Gunn AH, Warraich HJ, Mentz RJ. Costs of care and financial hardship among patients with heart failure. Am Heart J 2024; 269:94-107. [PMID: 38065330 DOI: 10.1016/j.ahj.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/17/2023] [Accepted: 12/02/2023] [Indexed: 01/09/2024]
Abstract
With the implementation of new therapies, more patients are living with heart failure (HF) as a chronic condition. Alongside these advances, out-of-pocket (OOP) medical costs have increased, and patients experience significant financial burden. Despite increasing interest in understanding and mitigating financial burdens, there is a relative paucity of data specific to HF. Here, we explore financial hardship in HF from the patient perspective, including estimated OOP costs for guideline-directed medical therapy for HF with reduced ejection fraction, hospitalizations, and total direct medical costs, as well as the consequences of high OOP costs. Studies estimate that high OOP costs are common in HF, and a large proportion are related to prescription drugs. Subsequently, the effects on patients can lead to worsening adherence, delayed care, and poor outcomes, leading to a financial toxicity spiral. Further, we summarize patients' cost preferences and outline future research that is needed to develop evidence-based solutions to reduce costs in HF.
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Affiliation(s)
- Alexander H Gunn
- Department of Medicine, Duke University School of Medicine, Durham, NC.
| | - Haider J Warraich
- Department of Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Department of Medicine, Cardiology Section, VA Boston Healthcare System, Boston, MA
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
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12
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Stacey D, Lewis KB, Smith M, Carley M, Volk R, Douglas EE, Pacheco-Brousseau L, Finderup J, Gunderson J, Barry MJ, Bennett CL, Bravo P, Steffensen K, Gogovor A, Graham ID, Kelly SE, Légaré F, Sondergaard H, Thomson R, Trenaman L, Trevena L. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2024; 1:CD001431. [PMID: 38284415 PMCID: PMC10823577 DOI: 10.1002/14651858.cd001431.pub6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
BACKGROUND Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017. OBJECTIVES To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach. SEARCH METHODS We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022. SELECTION CRITERIA We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention. DATA COLLECTION AND ANALYSIS Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence. MAIN RESULTS This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015. AUTHORS' CONCLUSIONS Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, Canada
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | | | - Meg Carley
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robert Volk
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elisa E Douglas
- Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Michael J Barry
- Informed Medical Decisions Program, Massachusetts General Hospital, Boston, MA, USA
| | - Carol L Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Paulina Bravo
- Education and Cancer Prevention, Fundación Arturo López Pérez, Santiago, Chile
| | - Karina Steffensen
- Center for Shared Decision Making, IRS - Lillebælt Hospital, Vejle, Denmark
| | - Amédé Gogovor
- VITAM - Centre de recherche en santé durable, Université Laval, Quebec, Canada
| | - Ian D Graham
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, Canada
| | - Shannon E Kelly
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - France Légaré
- Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Université Laval, Quebec, Canada
| | | | - Richard Thomson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Logan Trenaman
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
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Haider S, Gonzalez-Lopez C, Clark J, Gravholt DL, Breslin M, Boehmer KR, Hartasanchez SA, Sanchez B, Montori VM, Lipska KJ. Feasibility and Acceptability of an Agenda-Setting Kit in the Care of People With Type 2 Diabetes: The QBSAFE ASK Feasibility Study. Clin Diabetes 2024; 42:358-363. [PMID: 39015172 PMCID: PMC11247036 DOI: 10.2337/cd23-0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
This article reports on a study to assess the feasibility of research procedures and acceptability of QBSAFE, a set of conversation cards focused on quality of life, treatment burden, safety, and avoidance of future events in people with type 2 diabetes. The study enrolled 84 patients and 7 clinicians. Of the 58 patients who completed questionnaires, 64% agreed that the QBSAFE agenda-setting kit (ASK) helped them discuss their situation, 78% agreed that others could benefit from it, and 38% said they would use it again. Most clinicians felt confident responding to issues (in 89% of encounters) and said they would use the kit again (78%) and recommend it to colleagues (82%). The QBSAFE ASK can be feasibly implemented and holds promise in facilitating discussion and collaborative problem-solving.
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Affiliation(s)
- Shanzay Haider
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT
| | | | - Jennifer Clark
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester, MN
| | | | | | - Kasey R. Boehmer
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | | | - Brianna Sanchez
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | | | - Kasia J. Lipska
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 286] [Impact Index Per Article: 286.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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15
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 95] [Impact Index Per Article: 95.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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16
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Song K, Fan Z, Chen Y, Fei G, Li X, Wu D. Shared decision-making improving efficacy in diarrhoea-dominant irritable bowel syndrome in Chinese outpatient setting: protocol of a prospective, randomised controlled trial. BMJ Open 2023; 13:e077605. [PMID: 38110380 DOI: 10.1136/bmjopen-2023-077605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
INTRODUCTION Diarrhoea-dominant irritable bowel syndrome (IBS-D) is a disorder with multiple pathogenesis; many people with IBS-D may have psychosocial issues which can make assessment and treatment more difficult. Routine treatment procedure might not always achieve the desired outcome. Therefore, patients may not be satisfied with the conventional experience and would like to be more involved in clinical decision-making. A shared decision-making (SDM) model, that requires patient participation, has been demonstrated to have a powerful effect on the diagnosis and treatment of other diseases, which improves patients' compliance, satisfaction, thus refining the clinical outcome. However, there is no corresponding evidence in IBS-D. Herein, we hope to verify the effect of SDM through clinical studies, and we anticipate that SDM can improve the therapeutic effect in patients with IBS-D. METHODS The study is a prospective, randomised, single-centre trial. 166 IBS-D outpatients who attend Peking Union Medical College Hospital will be allocated into routine treatment group and SDM group. The primary endpoint is the severity of bowel symptoms, measured by the IBS symptom severity scale. Secondary endpoints include impact of disease and quality of life, negative psychology and the evaluation of diagnosis and treatment process. ETHICS AND DISSEMINATION Ethical approval has been obtained from the research ethics committee of Peking Union Medical College Hospital (I-23PJ470). This protocol has been approved by Chinese Clinical Trial Register (ChiCTR2300073681) in July 2023. The results of this trial will be published in an open-access way and disseminated among gastrointestinal physicians. TRIAL REGISTRATION NUMBER Chinese Clinical Trial Register (ChiCTR2300073681).
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Affiliation(s)
- Kai Song
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhengyang Fan
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Chen
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Guijun Fei
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoqing Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Dong Wu
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Siouta E, Olsson U, Waldréus N. Nurses' perceptions of patient involvement in shared decision-making in cardiovascular care. Heliyon 2023; 9:e22890. [PMID: 38144325 PMCID: PMC10746438 DOI: 10.1016/j.heliyon.2023.e22890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 12/26/2023] Open
Abstract
It is important for nurses to involve patients in their own care to enable shared decision-making. This study aimed to explore the perceptions of nurses regarding the degree to which involvement in shared decision-making takes place in clinical settings during consultations. Previous studies have shown that the use of shared decision-making by healthcare professionals can improve their caring practices and the quality of life of their patients. However, studies have also shown little evidence of the existence of shared decision-making in clinical practice. One step forward can be to clarify nurses' perceptions of patient involvement in shared decision-making. Qualitative data were collected from 10 nurses at four Swedish hospitals using a semi-structured, open-ended interview guide. The data were analyzed using inductive latent content analysis. The results showed that the care practices described by the nurses in the study are clearly different from the healthcare policy and scientific vision of shared decision-making. The nurses in the study believe that, with some exceptions, both healthcare professionals and patients prefer to leave decision-making to medical experts. In order to take advantage of the existing potential for improvement of shared decision-making in cardiologic care, healthcare professionals must be given time to seriously listen to and develop an interest in their patients' lifeworlds. Furthermore, the implementation of shared decision-making requires a mutual initiative and development of knowledge about the decision-making process from healthcare professionals and patients.
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Affiliation(s)
| | - Ulf Olsson
- University of Stockholm, Stockholm, Sweden
| | - Nana Waldréus
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden
- Theme Inflammation and Aging, Karolinska University Hospital, Huddinge, Sweden
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18
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Masterson Creber R, Benda N, Dimagli A, Myers A, Niño de Rivera S, Omollo S, Sharma Y, Goyal P, Turchioe MR. Using Patient Decision Aids for Cardiology Care in Diverse Populations. Curr Cardiol Rep 2023; 25:1543-1553. [PMID: 37943426 PMCID: PMC10914300 DOI: 10.1007/s11886-023-01953-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 11/10/2023]
Abstract
PURPOSE OF REVIEW Patient decision aids (PDAs) are tools that help guide treatment decisions and support shared decision-making when there is equipoise between treatment options. This review focuses on decision aids that are available to support cardiac treatment options for underrepresented groups. RECENT FINDINGS PDAs have been developed to support multiple treatment decisions in cardiology related to coronary artery disease, valvular heart disease, cardiac arrhythmias, heart failure, and cholesterol management. By considering the unique needs and preferences of diverse populations, PDAs can enhance patient engagement and promote equitable healthcare delivery in cardiology. In this review, we examine the benefits, challenges, and current trends in implementing PDAs, with a focus on improving decision-making processes and outcomes for patients from underrepresented racial and ethnic groups. In addition, the article highlights key considerations when implementing PDAs and potential future directions in the field.
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Affiliation(s)
- Ruth Masterson Creber
- Columbia University School of Nursing, Columbia University Irving Medical Center, 560 W 168th St, New York, NY, 10032, USA.
| | - Natalie Benda
- Columbia University School of Nursing, Columbia University Irving Medical Center, 560 W 168th St, New York, NY, 10032, USA
| | - Arnaldo Dimagli
- Columbia University School of Nursing, Columbia University Irving Medical Center, 560 W 168th St, New York, NY, 10032, USA
| | - Annie Myers
- Columbia University School of Nursing, Columbia University Irving Medical Center, 560 W 168th St, New York, NY, 10032, USA
| | - Stephanie Niño de Rivera
- Columbia University School of Nursing, Columbia University Irving Medical Center, 560 W 168th St, New York, NY, 10032, USA
| | - Shalom Omollo
- Columbia University School of Nursing, Columbia University Irving Medical Center, 560 W 168th St, New York, NY, 10032, USA
| | - Yashika Sharma
- Columbia University School of Nursing, Columbia University Irving Medical Center, 560 W 168th St, New York, NY, 10032, USA
| | | | - Meghan Reading Turchioe
- Columbia University School of Nursing, Columbia University Irving Medical Center, 560 W 168th St, New York, NY, 10032, USA
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Chiu HH, Chang SL, Cheng HM, Chao TF, Lin YJ, Lo LW, Hu YF, Chung FP, Liao JN, Tuan TC, Lin CY, Chang TY, Kuo L, Liu CM, Tsai YN, Huang YT, Chang YL, Wung JC, Chen SA. Shared decision making for anticoagulation reduces anxiety and improves adherence in patients with atrial fibrillation. BMC Med Inform Decis Mak 2023; 23:163. [PMID: 37608374 PMCID: PMC10463811 DOI: 10.1186/s12911-023-02260-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/07/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Treatment with oral anticoagulants (OACs) could prevent stroke in atrial fibrillation (AF), but side effects developed due to OACs may cause patients anxiety during decision making. This study aimed to investigate whether shared decision making (SDM) reduces anxiety and improves adherence to stroke prevention measures in patients with AF. METHODS A one-group pretest-posttest design using a questionnaire survey was applied at the outpatient cardiology clinic between July 2019 until September 2020. A Patient Decision Aid (PDA) tool was used for the completion of the questionnaire survey after health education and counseling. Ten questions were included for patients' recognition of SDM, and a 5-point scoring method was used, where "very much" was scored as 5 points, and "totally not" was scored as 1 point. RESULTS Fifty-two patients with AF were enrolled. In terms of patients' recognition of SDM, points of more than 4.17 out of 5 were noted, indicating recognition above the level of "very much." The patients' anxiety scores before SDM were 3.56 (1.2), with a decrease of 0.64 points (p < 0.001) to 2.92 (1.3) after SDM. After SDM, the number of patients who decided to take OAC increased from 76.9% to 88.5%, and the 15.4% answering "unclear" decreased to 1.9% (p = 0.006). The patients' anxiety levels after SDM were associated with gender (p = 0.025). CONCLUSIONS The approach using SDM enhanced our understanding of the pros and cons of OAC treatment and, in patients with AF, decreased anxiety about therapeutic decisions and increased willingness to accept treatment options.
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Affiliation(s)
- Hsiao-Hui Chiu
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Shih-Lin Chang
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan.
- Department of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan.
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan.
| | - Hao-Min Cheng
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tze-Fan Chao
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yenn-Jiang Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Li-Wei Lo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Feng Hu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Fa-Po Chung
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jo-Nan Liao
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ta-Chuan Tuan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chin-Yu Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ting-Yung Chang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ling Kuo
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chih-Min Liu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yung-Nan Tsai
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Ting Huang
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yuh-Lih Chang
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Pharmacy, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Pharmacology, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ju-Chieh Wung
- Department of Pharmacy, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Ann Chen
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
- College of Medicine, Chung Hsing University, Taichung, Taiwan
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Zheng H, Zhang D, Xiang W, Wu Y, Peng Z, Gan Y, Chen S. Interventions to Facilitate Shared Decision-Making Using Decision Aids with Coronary Heart Disease Patients: Systematic Review and Meta-Analysis. Rev Cardiovasc Med 2023; 24:246. [PMID: 39076712 PMCID: PMC11266786 DOI: 10.31083/j.rcm2408246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/13/2023] [Accepted: 05/24/2023] [Indexed: 07/31/2024] Open
Abstract
Background Coronary heart disease (CHD) is the leading cause of death in the world. There are some decision-making conflicts in the management of chest pain, treatment methods, stent selection, and other aspects due to the unstable condition of CHD in the treatment stage. Although using decision aids to facilitate shared decision-making (SDM) contributes to high-quality decision-making, it has not been evaluated in the field of CHD. This review systematically assessed the effects of SDM in patients with CHD. Methods We conducted a systematic review and meta-analysis of randomized controlled trials of SDM interventions in patients with CHD from database inception to 1 June 2022 (PROSPERO [Unique identifier: CRD42022338938]). We searched for relevant studies in the PubMed, Embase, Cochrane Library, Web of Science, CNKI, and Wan Fang databases. The primary outcomes were knowledge and decision conflict. The secondary outcomes were satisfaction, patient participation, trust, acceptance, quality of life, and psychological condition. Results A total of 8244 studies were retrieved. After screening, ten studies were included in the analysis. Compared with the control group, SDM intervention with patient decision aids obviously improved patients' knowledge, decision satisfaction, participation, and medical outcomes and reduced decision-making conflict. There was no significant effect of SDM on trust. Conclusions This study showed that SDM intervention in the form of decision aids was beneficial to decision-making quality and treatment outcomes among patients with CHD. The results of SDM interventions need to be evaluated in different environments.
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Affiliation(s)
- Haoyang Zheng
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022 Wuhan, Hubei, China
| | - Duo Zhang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, Hubei, China
| | - Wei Xiang
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022 Wuhan, Hubei, China
| | - Yuxi Wu
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022 Wuhan, Hubei, China
| | - Zesheng Peng
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022 Wuhan, Hubei, China
| | - Yong Gan
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, Hubei, China
| | - Shengcai Chen
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022 Wuhan, Hubei, China
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Zhang D, Zheng H, Zheng Z, Pan Y, Zha Z, Liu J, Zhu L, Wu Q, Hu K, Chen Z, Wang X, Barnabo Nampoukime KP, Zhou Y. The Impact of Shared Decision-Making on the Quality of Decision Making in Aortic Dissection: A before-and-after Comparison Study. Rev Cardiovasc Med 2023; 24:244. [PMID: 39076701 PMCID: PMC11266772 DOI: 10.31083/j.rcm2408244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 02/24/2023] [Accepted: 03/09/2023] [Indexed: 07/31/2024] Open
Abstract
Background Complex surgical plans and consideration of risks and benefits often cause decisional conflicts for decision-makers in aortic dissection (AD) surgery, resulting in decision delay. Shared decision-making (SDM) improves decision readiness and reduces decisional conflicts. The purpose of this study was to investigate the impact of SDM on decision quality in AD. Methods One hundred and sixty AD decision-makers were divided into two groups: control (n = 80) and intervention (n = 80). The surgical plan for the intervention group was determined using patient decision aids. The primary outcome was decisional conflict. Secondary outcomes included decision preparation, decision satisfaction, surgical method, postoperative complications, actual participation role, and duration of consultation. The data were analyzed with SPSS 26.0 (IBM Corp., Chicago, IL, USA). p < 0.05 was considered statistically significant. Results The decisional conflict score was significantly lower in the intervention group than in the control group (p < 0.001). The decision preparation and decision satisfaction scores in the intervention group were significantly higher than those in the control group (p < 0.001). There were more SDM decision-makers in the intervention group (16 [20%] vs. 42 [52.50%]). There was no statistical significance in the choice of surgical, postoperative complications, duration of consultation, and hospital and post-operative intensive care unit stay time (p = 0.267, p = 0.130, p = 0.070, p = 0.397, p = 0.421, respectively). Income, education level, and residence were the influencing factors of decision-making conflict. Conclusions SDM can reduce decisional conflict, improve decision preparation and satisfaction, and help decision-makers actively participate in the medical management of patients with AD without affecting the medical outcome.
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Affiliation(s)
- Duo Zhang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, Hubei, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, Hubei, China
| | - Haoyang Zheng
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430022 Wuhan, Hubei, China
| | - Zhi Zheng
- Division of Cardiothoracic and Vascular Surgery, Sino-Swiss Heart-Lung Transplantation Institute, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, Hubei, China
| | - Youmin Pan
- Division of Cardiothoracic and Vascular Surgery, Sino-Swiss Heart-Lung Transplantation Institute, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, Hubei, China
| | - Zhengbiao Zha
- Division of Cardiothoracic and Vascular Surgery, Sino-Swiss Heart-Lung Transplantation Institute, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, Hubei, China
| | - Juan Liu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, Hubei, China
| | - Lisi Zhu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, Hubei, China
| | - Qiansheng Wu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, Hubei, China
| | - Kaili Hu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, Hubei, China
| | - Zelin Chen
- Department of Virology, Research Institute for Microbial Diseases, Osaka University, 565-0871 Suita, Osaka, Japan
| | - Xiaoxiao Wang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, Hubei, China
| | - Kan-Paatib Barnabo Nampoukime
- Division of Cardiothoracic and Vascular Surgery, Sino-Swiss Heart-Lung Transplantation Institute, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, Hubei, China
| | - Yanrong Zhou
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430030 Wuhan, Hubei, China
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Bajenaru L, Sorici A, Mocanu IG, Florea AM, Antochi FA, Ribigan AC. Shared Decision-Making to Improve Health-Related Outcomes for Adults with Stroke Disease. Healthcare (Basel) 2023; 11:1803. [PMID: 37372920 DOI: 10.3390/healthcare11121803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/02/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023] Open
Abstract
Stroke is one of the leading causes of disability and death worldwide, a severe medical condition for which new solutions for prevention, monitoring, and adequate treatment are needed. This paper proposes a SDM framework for the development of innovative and effective solutions based on artificial intelligence in the rehabilitation of stroke patients by empowering patients to make decisions about the use of devices and applications developed in the European project ALAMEDA. To develop a predictive tool for improving disability in stroke patients, key aspects of stroke patient data collection journeys, monitored health parameters, and specific variables covering motor, physical, emotional, cognitive, and sleep status are presented. The proposed SDM model involved the training and consultation of patients, medical staff, carers, and representatives under the name of the Local Community Group. Consultation with LCG members, consists of 11 representative people, physicians, nurses, patients and caregivers, which led to the definition of a methodological framework to investigate the key aspects of monitoring the patient data collection journey for the stroke pilot, and a specific questionnaire to collect stroke patient requirements and preferences. A set of general and specific guidelines specifying the principles by which patients decide to use wearable sensing devices and specific applications resulted from the analysis of the data collected using the questionnaire. The preferences and recommendations collected from LCG members have already been implemented in this stage of ALAMEDA system design and development.
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Affiliation(s)
- Lidia Bajenaru
- Department of Computer Science, Faculty of Automatic Control and Computers, University Politehnica of Bucharest, 313 Splaiul Independentei, 060042 Bucharest, Romania
| | - Alexandru Sorici
- Department of Computer Science, Faculty of Automatic Control and Computers, University Politehnica of Bucharest, 313 Splaiul Independentei, 060042 Bucharest, Romania
| | - Irina Georgiana Mocanu
- Department of Computer Science, Faculty of Automatic Control and Computers, University Politehnica of Bucharest, 313 Splaiul Independentei, 060042 Bucharest, Romania
| | - Adina Magda Florea
- Department of Computer Science, Faculty of Automatic Control and Computers, University Politehnica of Bucharest, 313 Splaiul Independentei, 060042 Bucharest, Romania
| | - Florina Anca Antochi
- Department of Neurology, University Emergency Hospital Bucharest, 169 Splaiul Independentei, 050098 Bucharest, Romania
| | - Athena Cristina Ribigan
- Department of Neurology, University Emergency Hospital Bucharest, 169 Splaiul Independentei, 050098 Bucharest, Romania
- Department of Neurology, Faculty of Medicine, University of Medicine and Pharmacy "Carol Davila" Bucharest, 37 Dionisie Lupu, 020021 Bucharest, Romania
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Brod C, Groth N, Rudeck M, Artang R, Rioux M, Benziger C. Oral anticoagulation use in non-valvular atrial fibrillation patients in rural setting. AMERICAN JOURNAL OF MEDICINE OPEN 2023; 9:100026. [PMID: 39035056 PMCID: PMC11256238 DOI: 10.1016/j.ajmo.2022.100026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/27/2022] [Accepted: 10/04/2022] [Indexed: 07/23/2024]
Abstract
Background The 2019 ACC/AHA/HRS guidelines established direct oral anticoagulants (DOACs) as first line therapy over warfarin for non-valvular atrial fibrillation (AF). Methods Ambulatory clinic patients with non-valvular AF or atrial flutter seen between 10/1/2019-7/12/2020 included. High-risk AF defined as males CHA2DS2-VASc score ≥2 and females ≥3. Patients were separated into: warfarin, DOAC, or no oral anticoagulation (OAC). ATRIA bleed score calculated. A provider survey assessing knowledge and barriers to anticoagulation completed via REDCap between 3/5-4/16/2020. Results Of 12,014 subjects with AF, 8,032 were high risk (mean age 75.9 ± 9.8 years; 57.5% male). There were 4,619 (57.1%) ≥ 75 years and 63.4% were rural dwelling. There was no significant difference between the number of subjects on anticoagulation before and after the guideline publication (75.6% vs. 75.7%, p = 0.79). Warfarin use decreased 2.3% over 1 year (39.3% to 37.0%), while DOACs increased 2.4% (36.2% to 38.7%, p < 0.001 for both). At 1-year, age, male gender, CHA2DS2-VASc score 4-6, hypertension, stroke and cardiology consult increased prescription of OAC (p<0.05). Vascular disease, high risk ATRIA bleed, renal disease, prior hemorrhage, and left atrial appendage occlusion were associated with decreased OAC use (p < 0.05). Left atrial appendage occlusion device use was low (<1%). In a survey, majority of providers noted bleeding risk (35.1%) and cost (25.0%) to be the biggest barriers to DOAC use. Conclusions The new guidelines caused a slight increase in DOACs over time. Significant barriers to DOAC use exist in rural areas; one in four high risk AF patient remains without OAC therapy.
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Affiliation(s)
- Camille Brod
- University of Minnesota Medical School – Duluth Campus, Duluth, MN, United States
| | - Nicole Groth
- Essentia Institute of Rural Health, Duluth, MN, United States
| | - Macaela Rudeck
- Essentia Institute of Rural Health, Duluth, MN, United States
| | - Ramin Artang
- University of Minnesota Medical School – Duluth Campus, Duluth, MN, United States
- Essentia Health Heart and Vascular Center, 407 East 3rd Street, Duluth, MN 55805, United States
| | - Matthew Rioux
- Essentia Health Anticoagulation Services, Duluth, MN, United States
| | - Catherine Benziger
- University of Minnesota Medical School – Duluth Campus, Duluth, MN, United States
- Essentia Institute of Rural Health, Duluth, MN, United States
- Essentia Health Heart and Vascular Center, 407 East 3rd Street, Duluth, MN 55805, United States
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Sun Y, Zhou W, Zuo S, Chen C, Zhang Q, Chen Y. Factors Influencing Participation in Shared Decision-Making Among Patients with Glaucoma in China: A Cross-Sectional Study. Patient Prefer Adherence 2023; 17:1261-1270. [PMID: 37214556 PMCID: PMC10199703 DOI: 10.2147/ppa.s411274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/03/2023] [Indexed: 05/24/2023] Open
Abstract
Purpose To explore the level of participation in shared decision-making by patients with glaucoma and identify influencing factors, to subsequently provide references to promote shared decision-making in ophthalmology, and achieve patient-centered care. Patients and Methods A questionnaire was completed by 148 patients with glaucoma who had been admitted to a specialized ophthalmic hospital in China, between October 2021 and January 2022. The participants' responses to the nine-item Shared Decision-Making Questionnaire (SDM-Q-9) and a general information survey were analyzed to determine their level of participation in shared decision-making and influencing factors. Multiple linear regression was used to identify factors that influence shared decision-making at the time of clinical practice. Results The mean score of SDM-Q-9 was 71.73±21.27 (n=140). Multiple linear regression analysis showed that patients with negative attitudes towards participation in decision-making (P=0.023) and those who had rural insurance (P=0.017) had significantly lower SDM-Q-9 scores than those with positive attitudes and those with medical insurance. Patients who were more satisfied with their medical service had higher SDM-Q-9 scores (P<0.05). Conclusion Patients with glaucoma presented a high level of shared decision-making. Patients' attitudes towards participating in decision-making, the payment method of medical expenses, and the level of satisfaction with medical services are factors that influence their level of participation in shared decision-making.
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Affiliation(s)
- Yiwen Sun
- School of Ophthalmology and Optometry, Biomedical Engineering, Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
| | - Wenzhe Zhou
- Glaucoma Clinical Center, the Eye Hospital of Wenzhou Medical University, National Clinical Research Center for Ocular Diseases, Wenzhou, Zhejiang, People’s Republic of China
| | - Shushu Zuo
- School of Ophthalmology and Optometry, Biomedical Engineering, Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
| | - Chen Chen
- School of Ophthalmology and Optometry, Biomedical Engineering, Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
| | - Qiqi Zhang
- School of Ophthalmology and Optometry, Biomedical Engineering, Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
| | - Yanyan Chen
- Nursing Department, the Eye Hospital of Wenzhou Medical University, National Clinical Research Center for Ocular Diseases, Wenzhou, Zhejiang, People’s Republic of China
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Go AS, Al-Khatib SM, Desvigne-Nickens P, Bansal N, Bushnell CD, Fang MC, Freeman JV, Gage BF, Hanke T, Hylek EM, Lopes RD, Noseworthy PA, Reddy VY, Singer DE, Thomas KL, Hills MT, Turakhia MP, Zieman SJ, Cooper LS, Benjamin EJ. Research Opportunities in Stroke Prevention for Atrial Fibrillation: A Report From a National Heart, Lung, and Blood Institute Virtual Workshop. Stroke 2023; 54:e75-e85. [PMID: 36848427 PMCID: PMC9995163 DOI: 10.1161/strokeaha.121.038273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/10/2023] [Indexed: 03/01/2023]
Abstract
Atrial fibrillation (AF) is one of the strongest risk factors for ischemic stroke, which is a leading cause of disability and death. Given the aging population, increasing prevalence of AF risk factors, and improved survival in those with cardiovascular disease, the number of individuals affected by AF will continue increasing over time. While multiple proven stroke prevention therapies exist, important questions remain about the optimal approach to stroke prevention at the population and individual patient levels. Our report summarizes the National Heart, Lung, and Blood Institute virtual workshop focused on identifying key research opportunities related to stroke prevention in AF. The workshop reviewed major knowledge gaps and identified targeted research opportunities to advance stroke prevention in AF in the following areas: (1) improving risk stratification tools for stroke and intracranial hemorrhage; (2) addressing challenges with oral anticoagulants; and (3) delineating the optimal roles of percutaneous left atrial appendage occlusion and surgical left atrial appendage closure/excision. This report aims to promote innovative, impactful research that will lead to more personalized, effective use of stroke prevention strategies in people with AF.
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Affiliation(s)
- Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
- Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, CA
| | - Sana M. Al-Khatib
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, NC
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Nisha Bansal
- Division of Nephrology, University of Washington, Seattle, WA
| | | | - Margaret C. Fang
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA
| | - James V. Freeman
- Department of Medicine, Yale University, New Haven, CT
- Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, CT
| | - Brian F. Gage
- Department of Medicine, Washington University, St. Louis, MO
| | - Thorsten Hanke
- Department of Cardiac Surgery, Asklepios Klinikum Harburg-Hamburg, Germany
| | | | - Renato D. Lopes
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, NC
| | | | - Vivek Y. Reddy
- Department of Medicine, Icahn School of Medicine, New York, NY
| | - Daniel E. Singer
- Division of General Internal Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, MA
| | - Kevin L. Thomas
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, NC
| | | | - Mintu P. Turakhia
- Veterans Affairs Palo Alto Health Care System, Palo Alto CA
- Center for Digital Health, Stanford University, Stanford, CA
| | - Susan J. Zieman
- Division of Geriatrics and Clinical Gerontology, National Institute on Aging, National Institutes of Health, Bethesda, MD
| | - Lawton S. Cooper
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Emelia J. Benjamin
- Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
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Wang PJ, Lu Y, Mahaffey KW, Lin A, Morin DP, Sears SF, Chung MK, Russo AM, Lin B, Piccini J, Hills MT, Berube C, Pundi K, Baykaner T, Garay G, Lhamo K, Rice E, Pourshams IA, Shah R, Newswanger P, DeSutter K, Nunes JC, Albert MA, Schulman KA, Heidenreich PA, Bunch TJ, Sanders LM, Turakhia M, Verghese A, Stafford RS. Randomized Clinical Trial to Evaluate an Atrial Fibrillation Stroke Prevention Shared Decision-Making Pathway. J Am Heart Assoc 2023; 12:e028562. [PMID: 36342828 PMCID: PMC9973612 DOI: 10.1161/jaha.122.028562] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
Background Oral anticoagulation reduces stroke and disability in atrial fibrillation (AF) but is underused. We evaluated the effects of a novel patient-clinician shared decision-making (SDM) tool in reducing oral anticoagulation patient's decisional conflict as compared with usual care. Methods and Results We designed and evaluated a new digital decision aid in a multicenter, randomized, comparative effectiveness trial, ENHANCE-AF (Engaging Patients to Help Achieve Increased Patient Choice and Engagement for AF Stroke Prevention). The digital AF shared decision-making toolkit was developed using patient-centered design with clear health communication principles (eg, meaningful images, limited text). Available in English and Spanish, the toolkit included the following: (1) a brief animated video; (2) interactive questions with answers; (3) a quiz to check on understanding; (4) a worksheet to be used by the patient during the encounter; and (5) an online guide for clinicians. The study population included English or Spanish speakers with nonvalvular AF and a CHA2DS2-VASc stroke score ≥1 for men or ≥2 for women. Participants were randomized in a 1:1 ratio to either usual care or the shared decision-making toolkit. The primary end point was the validated 16-item Decision Conflict Scale at 1 month. Secondary outcomes included Decision Conflict Scale at 6 months and the 10-item Decision Regret Scale at 1 and 6 months as well as a weighted average of Mann-Whitney U-statistics for both the Decision Conflict Scale and the Decision Regret Scale. A total of 1001 participants were enrolled and followed at 5 different sites in the United States between December 18, 2019, and August 17, 2022. The mean patient age was 69±10 years (40% women, 16.9% Black, 4.5% Hispanic, 3.6% Asian), and 50% of participants had CHA2DS2-VASc scores ≥3 (men) or ≥4 (women). The primary end point at 1 month showed a clinically meaningful reduction in decisional conflict: a 7-point difference in median scores between the 2 arms (16.4 versus 9.4; Mann-Whitney U-statistics=0.550; P=0.007). For the secondary end point of 1-month Decision Regret Scale, the difference in median scores between arms was 5 points in the direction of less decisional regret (P=0.078). The treatment effects lessened over time: at 6 months the difference in medians was 4.7 points for Decision Conflict Scale (P=0.060) and 0 points for Decision Regret Scale (P=0.35). Conclusions Implementation of a novel shared decision-making toolkit (afibguide.com; afibguide.com/clinician) achieved significantly lower decisional conflict compared with usual care in patients with AF. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096781.
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Affiliation(s)
- Paul J. Wang
- Stanford University Department of MedicinePalo AltoCA
| | - Ying Lu
- Stanford University Department of Biomedical Data ScienceStanfordCA
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | - Amy Lin
- Stanford University Department of Biomedical Data ScienceStanfordCA
| | | | - Samuel F. Sears
- East Carolina University Department of PsychologyGreenvilleNC
| | - Mina K. Chung
- Cleveland Clinic Foundation Department of MedicineClevelandOH
| | | | - Bryant Lin
- Stanford University Department of MedicinePalo AltoCA
| | | | | | | | - Krishna Pundi
- Stanford University Department of MedicinePalo AltoCA
| | - Tina Baykaner
- Stanford University Department of MedicinePalo AltoCA
| | - Gotzone Garay
- Stanford University Department of MedicinePalo AltoCA
| | - Karma Lhamo
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | - Eli Rice
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | | | - Rushil Shah
- Stanford University Department of MedicinePalo AltoCA
| | - Paul Newswanger
- Stanford Center for Clinical Research Stanford University Department of MedicineStanfordCA
| | | | | | - Michelle A. Albert
- University of California San Francisco Department of MedicineSan FranciscoCA
| | | | - Paul A. Heidenreich
- Stanford University Department of MedicinePalo AltoCA
- Palo Alto Veterans Administration Health Care Department of MedicinePalo AltoCA
| | - T. Jared Bunch
- University of Utah Department of MedicineSalt Lake CityUT
| | | | - Mintu Turakhia
- Stanford University Department of MedicinePalo AltoCA
- iRhythm TechnologiesSan FranciscoCA
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Nunes JC, Baykaner T, Pundi K, DeSutter K, True Hills M, Mahaffey KW, Sears SF, Morin DP, Lin B, Wang PJ, Stafford RS. Design and development of a digital shared decision-making tool for stroke prevention in atrial fibrillation. JAMIA Open 2023; 6:ooad003. [PMID: 36751465 PMCID: PMC9893868 DOI: 10.1093/jamiaopen/ooad003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 10/26/2022] [Accepted: 01/07/2023] [Indexed: 02/05/2023] Open
Abstract
Background Shared decision-making (SDM) is an approach in which patients and clinicians act as partners in making medical decisions. Patients receive the information needed to decide and are encouraged to balance risks, benefits, and preferences. Informative materials are vital to SDM. Atrial fibrillation (AF) is the most common cardiac arrhythmia and responsible for 10% of ischemic strokes, however 1/3 of patients are not on appropriate anticoagulation. Decision sharing may facilitate treatment acceptance, improving outcomes. Aims To develop a framework of the components needed to create novel SDM tools and to provide practical examples through a case-study of stroke prevention in AF. Methods We analyze the design values of a web-based SDM tool created to better inform AF patients about anticoagulation. The tool was developed in partnership with patient advocates, multi-disciplinary investigators, and private design firms. It was refined through iterative, recursive testing in patients with AF. Its effectiveness is being evaluated in a multisite clinical trial led by Stanford University and sponsored by the American Heart Association. Findings The main components considered when creating the Stanford AFib tool included: design and software; content identification; information delivery; inclusive communication, user engagement; patient feedback; clinician experience; and anticipation of implementation and dissemination. We also highlight the ethical principles underlying SDM; matters of diversity and inclusion, linguistic variety, accessibility, and health literacy. The Stanford AFib Guide patient tool is available at: https://afibguide.com and the clinician tool at https://afibguide.com/clinician. Conclusion Attention to a range of vital development and design factors can facilitate tool adoption and information acquisition by diverse cultural, educational, and socioeconomic subpopulations. With thoughtful design, digital tools may decrease decision regret and improve treatment outcomes across many decision-making situations in healthcare.
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Affiliation(s)
- Julio C Nunes
- Corresponding Author: Julio C. Nunes, MD, Stanford Center for Clinical Research, Stanford University, 3180 Porter Dr, Palo Alto, CA 94304, USA; ,
| | - Tina Baykaner
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California, USA
| | - Krishna Pundi
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California, USA
| | - Katie DeSutter
- Stanford Center for Clinical Research, Stanford University, Palo Alto, California, USA
| | | | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Stanford University, Palo Alto, California, USA,Division of Cardiovascular Medicine, Stanford University, Palo Alto, California, USA
| | - Samuel F Sears
- Division of Cardiovascular Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Daniel P Morin
- Cardiovascular Research, Ochsner Medical Center, New Orleans, Louisiana, USA
| | - Bryant Lin
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California, USA
| | - Paul J Wang
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California, USA
| | - Randall S Stafford
- Stanford Prevention Research Center, Stanford University, Palo Alto, California, USA
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Veenendaal HV, Chernova G, Bouman CM, Etten-Jamaludin FSV, Dieren SV, Ubbink DT. Shared decision-making and the duration of medical consultations: A systematic review and meta-analysis. PATIENT EDUCATION AND COUNSELING 2023; 107:107561. [PMID: 36434862 DOI: 10.1016/j.pec.2022.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/07/2022] [Accepted: 11/03/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE 1) determine whether increased levels of Shared Decision-Making (SDM) affect consultation duration, 2) investigate the intervention characteristics involved. METHODS MEDLINE, EMBASE, CINAHL and Cochrane library were systematically searched for experimental and cross-sectional studies up to December 2021. A best-evidence synthesis was performed, and interventions characteristics that increased at least one SDM-outcome, were pooled and descriptively analyzed. RESULTS Sixty-three studies were selected: 28 randomized clinical trials, 8 quasi-experimental studies, and 27 cross-sectional studies. Overall, pooling of data was not possible due to substantial heterogeneity. No differences in consultation duration were found more often than increased or decreased durations. . Consultation times (minutes:seconds) were significantly increased only among interventions that: 1) targeted clinicians only (Mean Difference [MD] 1:30, 95% Confidence Interval [CI] 0:24-2:37); 2) were performed in primary care (MD 2:05, 95%CI 0:11-3:59; 3) used a group format (MD 2:25, 95%CI 0:45-4:05); 4) were not theory-based (MD 4:01, 95%CI 0:38-7:23). CONCLUSION Applying SDM does not necessarily require longer consultation durations. Theory-based, multilevel implementation approaches possibly lower the risk of increasing consultation durations. PRACTICE IMPLICATIONS The commonly heard concern that time hinders SDM implementation can be contradicted, but implementation demands multifaceted approaches and space for training and adapting work processes.
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Affiliation(s)
- Haske van Veenendaal
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, the Netherlands.
| | - Genya Chernova
- Amsterdam UMC, location University of Amsterdam, Surgery, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - Carlijn Mb Bouman
- Amsterdam UMC, location University of Amsterdam, Surgery, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - Faridi S van Etten-Jamaludin
- Amsterdam UMC, location University of Amsterdam, Medical Library AMC, Meibergdreef 9, 1105AZ Amsterdam, the Netherlands.
| | - Susan van Dieren
- Amsterdam UMC, location University of Amsterdam, Surgery, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
| | - Dirk T Ubbink
- Amsterdam UMC, location University of Amsterdam, Surgery, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
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Benjamin EJ, Thomas KL, Go AS, Desvigne-Nickens P, Albert CM, Alonso A, Chamberlain AM, Essien UR, Hernandez I, Hills MT, Kershaw KN, Levy PD, Magnani JW, Matlock DD, O'Brien EC, Rodriguez CJ, Russo AM, Soliman EZ, Cooper LS, Al-Khatib SM. Transforming Atrial Fibrillation Research to Integrate Social Determinants of Health: A National Heart, Lung, and Blood Institute Workshop Report. JAMA Cardiol 2023; 8:182-191. [PMID: 36478155 PMCID: PMC10993288 DOI: 10.1001/jamacardio.2022.4091] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Only modest attention has been paid to the contributions of social determinants of health to atrial fibrillation (AF) risk factors, diagnosis, symptoms, management, and outcomes. The diagnosis of AF provides unique challenges exacerbated by the arrhythmia's often paroxysmal nature and individuals' disparate access to health care and technologies that facilitate detection. Social determinants of health affect access to care and management decisions for AF, increasing the likelihood of adverse outcomes among individuals who experience systemic disadvantages. Developing effective approaches to address modifiable social determinants of health requires research to eliminate the substantive inequities in health care delivery and outcomes in AF. Observations The National Heart, Lung, and Blood Institute convened an expert panel to identify major knowledge gaps and research opportunities in the field of social determinants of AF. The workshop addressed the following social determinants: (1) socioeconomic status and access to care; (2) health literacy; (3) race, ethnicity, and racism; (4) sex and gender; (5) shared decision-making in systemically disadvantaged populations; and (6) place, including rurality, neighborhood, and community. Many individuals with AF have multiple adverse social determinants, which may cluster in the individual and in systemically disadvantaged places (eg, rural locations, urban neighborhoods). Cumulative disadvantages may accumulate over the life course and contribute to inequities in the diagnosis, management, and outcomes in AF. Conclusions and Relevance Workshop participants identified multiple critical research questions and approaches to catalyze social determinants of health research that address the distinctive aspects of AF. The long-term aspiration of this work is to eradicate the substantive inequities in AF diagnosis, management, and outcomes across populations.
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Affiliation(s)
- Emelia J Benjamin
- Cardiovascular Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - Kevin L Thomas
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Medicine, Stanford University, Stanford, California
- Department of Medicine, University of California, San Francisco
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Christine M Albert
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Alanna M Chamberlain
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Utibe R Essien
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Inmaculada Hernandez
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego
| | | | - Kiarri N Kershaw
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Phillip D Levy
- Department of Emergency Medicine and Integrated Biosciences Center, Wayne State University, Detroit, Michigan
| | - Jared W Magnani
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daniel D Matlock
- Division of Geriatrics, University of Colorado, Anschutz Medical Campus, Aurora
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Denver
| | - Emily C O'Brien
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Carlos J Rodriguez
- Division of Cardiovascular Medicine and Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York, New York
| | - Andrea M Russo
- Cooper Medical School of Rowan University, Camden, New Jersey
| | - Elsayed Z Soliman
- Section on Cardiovascular Medicine, Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lawton S Cooper
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Sana M Al-Khatib
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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Bhat A, Karthikeyan S, Chen HHL, Gan GCH, Denniss AR, Tan TC. BARRIERS TO GUIDELINE-DIRECTED ANTICOAGULATION IN PATIENTS WITH ATRIAL FIBRILLATION NEW APPROACHES TO AN OLD PROBLEM. Can J Cardiol 2023; 39:625-636. [PMID: 36716858 DOI: 10.1016/j.cjca.2023.01.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 01/22/2023] [Accepted: 01/22/2023] [Indexed: 01/29/2023] Open
Abstract
Optimising guideline-directed anticoagulation in atrial fibrillation remains a perennial problem despite strong evidence for improved health outcomes with use of guideline-directed anticoagulation. Efforts to improve uptake have been hampered by barriers found at the level of the physician, patient, disease and choices of therapy. Clinician judgement is often clouded by factors such as therapeutic inertia, aversion to bleeding risk and implicit bias. For patients, negative pre-conceptions of therapy, impact of therapy on day-to-day life and the nocebo effect pose significant barriers. Both groups are impacted by poor education. Utility of a single pronged approach directed towards clinicians or patients have demonstrated variable success, with the highest impact appreciated in studies employing shared decision models. Further, there is emerging evidence for use of integrated models of care, which have shown improved efficacy in improving patient outcomes, as well as use of digital platforms such as mobile app-based interventions, which can be of aid to the clinician in improving patient adherence to anticoagulation with translated improved outcomes in clinical trials. Our narrative review article aims to investigate the physician and health system, patient, as well as drug therapy and disease barriers to uptake of guideline-directed anticoagulation in treatment of non-valvular atrial fibrillation.
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Affiliation(s)
- Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, NSW 2148, Australia.
| | - Sowmiya Karthikeyan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Henry H L Chen
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia
| | - Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, NSW 2148, Australia
| | - A Robert Denniss
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, NSW 2148, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW 2145, Australia
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, Sydney, New South Wales, Australia; School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia; School of Medicine, Western Sydney University, Sydney, NSW 2148, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW 2145, Australia
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Fanio J, Zeng E, Wang B, Slotwiner DJ, Reading Turchioe M. Designing for patient decision-making: Design challenges generated by patients with atrial fibrillation during evaluation of a decision aid prototype. Front Digit Health 2023; 4:1086652. [PMID: 36685619 PMCID: PMC9854261 DOI: 10.3389/fdgth.2022.1086652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/14/2022] [Indexed: 01/07/2023] Open
Abstract
Shared decision-making (SDM) empowers patients and care teams to determine the best treatment plan in alignment with the patient's preferences and goals. Decision aids are proven tools to support high quality SDM. Patients with atrial fibrillation (AF), the most common cardiac arrhythmia, struggle to identify optimal rhythm and symptom management strategies and could benefit from a decision aid. In this Brief Research Report, we describe the development and preliminary evaluation of an interactive decision-making aid for patients with AF. We employed an iterative, user-centered design method to develop prototypes of the decision aid. Here, we describe multiple iterations of the decision aid, informed by the literature, expert feedback, and mixed-methods design sessions with AF patients. Results highlight unique design requirements for this population, but overall indicate that an interactive decision aid with visualizations has the potential to assist patients in making AF treatment decisions. Future work can build upon these design requirements to create and evaluate a decision aid for AF rhythm and symptom management.
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Affiliation(s)
- Janette Fanio
- Population Health Sciences, Weill Cornell Medical College, New York, NY, United States
| | - Erin Zeng
- Population Health Sciences, Weill Cornell Medical College, New York, NY, United States,Broadmoor Solutions Inc. Sinking Spring, PA, United States
| | - Brian Wang
- Population Health Sciences, Weill Cornell Medical College, New York, NY, United States,Cerner Corporation North Kansas City, MO, United States
| | - David J. Slotwiner
- Population Health Sciences, Weill Cornell Medical College, New York, NY, United States,Department of Cardiology, NewYork-Presbyterian Medical Group Queens, New York, NY, United States
| | - Meghan Reading Turchioe
- Columbia University School of Nursing, New York, NY, United States,Correspondence: Meghan Reading Turchioe
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32
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Goldwater D, Wenger NK. Patient-centered care in geriatric cardiology. Trends Cardiovasc Med 2023; 33:13-20. [PMID: 34758389 DOI: 10.1016/j.tcm.2021.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/21/2021] [Accepted: 11/03/2021] [Indexed: 02/01/2023]
Abstract
Geriatric cardiology involves providing cardiovascular care to older adults in relation to aging. Although cardiovascular diseases are the most common diseases faced by older adults, they often co-occur with numerous aging-related challenges, such as multimorbidity, frailty, polypharmacy, falls, functional and cognitive impairment, which present challenges to implementing standard disease-based treatment strategies. Faced with these complexities, patient-centered care in geriatric cardiology strives to direct all management toward the achievement of an individual's prioritized health and life goals by employing shared decision-making to align treatment with goals, utilizing stated goals to navigate situations of treatment uncertainty, and pro-actively mitigating aging-related risks. This fundamental change in cardiovascular medicine from disease-centered management to patient-centered goal-directed care is necessary to facilitate wellness, independence, and favorable quality of life outcomes in the older adult population.
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Affiliation(s)
| | - Nanette K Wenger
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Jones AE, McCarty MM, Cameron KA, Cavanaugh KL, Steinberg BA, Passman R, Kansal P, Guzman A, Chen E, Zhong L, Fagerlin A, Hargraves I, Montori VM, Brito JP, Noseworthy PA, Ozanne EM. Development of Complementary Encounter and Patient Decision Aids for Shared Decision Making about Stroke Prevention in Atrial Fibrillation. MDM Policy Pract 2023; 8:23814683231178033. [PMID: 38178866 PMCID: PMC10765759 DOI: 10.1177/23814683231178033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/06/2023] [Indexed: 01/06/2024] Open
Abstract
Introduction Decision aids (DAs) are helpful instruments used to support shared decision making (SDM). Patients with atrial fibrillation (AF) face complex decisions regarding stroke prevention strategies. While a few DAs have been made for AF stroke prevention, an encounter DA (EDA) and patient DA (PDA) have not been created to be used in conjunction with each other before. Design Using iterative user-centered design, we developed 2 DAs for anticoagulation choice and stroke prevention in AF. Prototypes were created, and we elicited feedback from patients and experts via observations of encounters, usability testing, and semistructured interviews. Results User testing was done with 33 experts (in AF and SDM) and 51 patients from 6 institutions. The EDA and PDA underwent 1 and 4 major iterations, respectively. Major differences between the DAs included AF pathophysiology and a preparation to meet with the clinician in the PDA as well as different language throughout. Content areas included personalized stroke risk, differences between anticoagulants, and risks of bleeding. Based on user feedback, developers 1) addressed feelings of isolation with AF, 2) improved navigation options, 3) modified content and flow for users new to AF and those experienced with AF, 4) updated stroke risk pictographs, and 5) added structure to the preparation for decision making in the PDA. Limitations These DAs focus only on anticoagulation for stroke prevention and are online, which may limit participation for those less comfortable with technology. Conclusions Designing complementary DAs for use in tandem or separately is a new method to support SDM between patients and clinicians. Extensive user testing is essential to creating high-quality tools that best meet the needs of those using them. Highlights First-time complementary encounter and patient decision aids have been designed to work together or separately.User feedback led to greater structure and different experiences for patients naïve or experienced with anticoagulants in patient decision aids.Online tools allow for easier dissemination, use in telehealth visits, and updating as new evidence comes out.
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Affiliation(s)
- Aubrey E. Jones
- College of Pharmacy, Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
| | - Madeleine M. McCarty
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Kenzie A. Cameron
- Feinberg School of Medicine, Department of Medicine, Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, IL, USA
| | - Kerri L. Cavanaugh
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benjamin A. Steinberg
- School of Medicine, Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, USA
| | - Rod Passman
- Feinberg School of Medicine, Department of Medicine, Division of Cardiology, Northwestern University, Chicago, IL, USA
| | - Preeti Kansal
- Feinberg School of Medicine, Department of Medicine, Division of Cardiology, Northwestern University, Chicago, IL, USA
| | - Adriana Guzman
- Feinberg School of Medicine, Department of Medicine, Division of General Internal Medicine and Geriatrics, Northwestern University, Chicago, IL, USA
| | - Emily Chen
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lingzi Zhong
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Angela Fagerlin
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
- Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT, USA
| | - Ian Hargraves
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Victor M. Montori
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Juan P. Brito
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | - Elissa M. Ozanne
- School of Medicine, Department of Population Health Sciences, University of Utah, Salt Lake City, UT, USA
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Mitropoulou P, Grüner-Hegge N, Reinhold J, Papadopoulou C. Shared decision making in cardiology: a systematic review and meta-analysis. Heart 2022; 109:34-39. [PMID: 36007938 DOI: 10.1136/heartjnl-2022-321050] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/30/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES To evaluate the effectiveness of interventions to improve shared decision making (SDM) in cardiology with particular focus on patient-centred outcomes such as decisional conflict. METHODS We searched Embase (OVID), the Cochrane library, PubMed and Web of Science electronic databases from inception to January 2021 for randomised controlled trials that investigated the effects of interventions to increase SDM in cardiology. The primary outcomes were decisional conflict, decisional anxiety, decisional satisfaction or decisional regret; a secondary outcome was knowledge gained by the patients. RESULTS Eighteen studies which reported on at least one outcome measure were identified, including a total of 4419 patients. Interventions to increase SDM had a significant effect on reducing decisional conflict (standardised mean difference (SMD) -0.211, 95% CI -0.316 to -0.107) and increasing patient knowledge (SMD 0.476, 95% CI 0.351 to 0.600) compared with standard care. CONCLUSIONS Interventions to increase SDM are effective in reducing decisional conflict and increasing patient knowledge in the field of cardiology. Such interventions are helpful in supporting patient-centred healthcare and should be implemented in wider cardiology practice.
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Affiliation(s)
- Panagiota Mitropoulou
- Cardiology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Johannes Reinhold
- Norwich Medical School, University of East Anglia, Norwich, UK .,Department of Cardiology, Norfolk and Norwich University Hospitals, Norwich, UK
| | - Charikleia Papadopoulou
- Department of Cardiology, Royal Papworth Hospital, Cambridge, UK .,Department of Medicine, University of Cambridge, Cambridge, UK
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Patient Education Strategies to Improve Risk of Stroke in Patients with Atrial Fibrillation. CURRENT CARDIOVASCULAR RISK REPORTS 2022. [DOI: 10.1007/s12170-022-00709-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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Spencer-Bonilla G, Branda ME, Kunneman M, Bellolio F, Burnett B, Guyatt G, Montori VM. Encounter-based randomization did not result in contamination in a shared decision-making trial: a secondary analysis. J Clin Epidemiol 2022; 152:185-192. [PMID: 36220625 DOI: 10.1016/j.jclinepi.2022.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 09/07/2022] [Accepted: 09/30/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To estimate the level of contamination in an encounter-randomized trial evaluating a shared decision-making (SDM) tool. STUDY DESIGN AND SETTING We assessed contamination at three levels: (1) tool contamination (whether the tool was physically present in the usual care encounter), (2) functional contamination (whether components of the SDM tool were recreated in the usual care encounters without directly accessing the tool), and (3) learned contamination (whether clinicians "got better at SDM" in the usual care encounters as assessed by the OPTION-12 score). For functional and learned contamination, the interaction with the number of exposures to the tool was assessed. RESULTS We recorded and analyzed 830 of 922 randomized encounters. Of the 411 recorded encounters randomized to usual care, the SDM tool was used in nine (2.2%) encounters. Clinicians discussed at least one patient-important issue in 377 usual care encounters (92%) and the risk of stroke in 214 encounters (52%). We found no significant interaction between number of times the SDM tool was used and subsequent functional or learned contamination. CONCLUSION Despite randomly assigning clinicians to use an SDM tool in some and not other encounters, we found no evidence of contamination in usual care encounters.
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Affiliation(s)
- Gabriela Spencer-Bonilla
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Department of Medicine, Stanford University, Stanford, CA, USA
| | - Megan E Branda
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Marleen Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Fernanda Bellolio
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bruce Burnett
- Thrombosis Clinic and Anticoagulation Services, Park Nicollet Health Services, St Louis Park, MN, USA
| | - Gordon Guyatt
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.
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37
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Golden SE, Disher N, Dieckmann NF, Eden KB, Matlock D, Vranas KC, Slatore CG, Sullivan DR. Show me the roads and give me a road map: Development of a patient conversation tool to improve lung cancer treatment decision-making. PEC INNOVATION 2022; 1:100094. [PMID: 37213736 PMCID: PMC10194168 DOI: 10.1016/j.pecinn.2022.100094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 10/13/2022] [Accepted: 10/19/2022] [Indexed: 05/23/2023]
Abstract
Objective Evidence-based decision support resources do not exist for persons with lung cancer. We sought to develop and refine a treatment decision support, or conversation tool, to improve shared decision-making (SDM). Methods We conducted a multi-site study among patients with stage I-IV non-small cell lung cancer (NSCLC) who completed or had ongoing lung cancer treatment using semi-structured, cognitive qualitative interviews to assess participant understanding of content. We used an integrated approach of deductive and inductive thematic analysis. Results Twenty-seven patients with NSCLC participated. Participants with prior cancer experiences or those with family members with prior cancer experiences reported better preparedness for cancer treatment decision-making. All participants agreed the conversation tool would be helpful to clarify their thinking about values, comparisons, and goals of treatment, and to help patients communicate more effectively with their clinicians. Conclusion Participants reported that the tool may empower them with confidence and agency to actively participate in cancer treatment SDM. The conversation tool was acceptable, comprehensible, and usable. Next steps will test effectiveness on patient-centered and decisional outcomes. Innovation A personalized conversation tool using consequence tables and core SDM components is novel in that it can encourage a tailored, conversational dynamic and includes patient-centered values along with traditional decisional outcomes.
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Affiliation(s)
- Sara E. Golden
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System (VAPORHCS), Portland, OR, USA
- Corresponding author at: 3710 SW US Veterans Hospital Rd. R&D 66, Portland, OR 97239, USA.
| | - Natalie Disher
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System (VAPORHCS), Portland, OR, USA
| | - Nathan F. Dieckmann
- School of Nursing, Oregon Health and Science University (OHSU), Portland, OR, USA
- Division of Psychology, School of Medicine, OHSU, Portland, OR, USA
| | - Karen B. Eden
- Department of Medical Informatics and Clinic Epidemiology, OHSU, Portland, OR, USA
| | - Daniel Matlock
- Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Eastern Colorado Geriatric Research Education and Clinical Center, Denver, CO, USA
| | - Kelly C. Vranas
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System (VAPORHCS), Portland, OR, USA
- Section of Pulmonary and Critical Care Medicine, VAPORHCS, Portland, OR, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, OHSU, Portland, OR, USA
| | - Christopher G. Slatore
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System (VAPORHCS), Portland, OR, USA
- Section of Pulmonary and Critical Care Medicine, VAPORHCS, Portland, OR, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, OHSU, Portland, OR, USA
| | - Donald R. Sullivan
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System (VAPORHCS), Portland, OR, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, OHSU, Portland, OR, USA
- Cancer Prevention and Control Program, Knight Cancer Institute, OHSU, Portland, OR, USA
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Gomez Lumbreras A, Reese TJ, Del Fiol G, Tan MS, Butler JM, Hurwitz JT, Brown M, Kawamoto K, Thiess H, Wright M, Malone DC. Shared Decision-Making for Drug-Drug Interactions: Formative Evaluation of an Anticoagulant Drug Interaction. JMIR Form Res 2022; 6:e40018. [PMID: 36260377 PMCID: PMC9631167 DOI: 10.2196/40018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/21/2022] [Accepted: 09/22/2022] [Indexed: 11/07/2022] Open
Abstract
Background Warnings about drug-drug interactions (DDIs) between warfarin and nonsteroidal anti-inflammatory drugs (NSAIDs) within electronic health records indicate potential harm but fail to account for contextual factors and preferences. We developed a tool called DDInteract to enhance and support shared decision-making (SDM) between patients and physicians when both warfarin and NSAIDs are used concurrently. DDInteract was designed to be integrated into electronic health records using interoperability standards. Objective The purpose of this study was to conduct a formative evaluation of a DDInteract that incorporates patient and product contextual factors to estimate the risk of bleeding. Methods A randomized formative evaluation was conducted to compare DDInteract to usual care (UC) using physician-patient dyads. Using case vignettes, physicians and patients on warfarin participated in simulated virtual clinical encounters where they discussed the use of taking ibuprofen and warfarin concurrently and determined an appropriate therapeutic plan based on the patient’s individualized risk. Dyads were randomized to either DDInteract or UC. Participants completed a postsession interview and survey of the SDM process. This included the 9-item Shared Decision-Making Questionnaire (SDM-Q-9), tool usability and workload National Aeronautics and Space Administration (NASA) Task Load Index, Unified Theory of Acceptance and Use of Technology (UTAUT), Perceived Behavioral Control (PBC) scale, System Usability Scale (SUS), and Decision Conflict Scale (DCS). They also were interviewed after the session to obtain perceptions on DDInteract and UC resources for DDIs. Results Twelve dyad encounters were performed using virtual software. Most (n=11, 91.7%) patients were over 50 years of age, and 9 (75%) had been taking warfarin for more than 2 years (75%). Regarding scores on the SDM-Q-9, participants rated DDInteract higher than UC for questions pertaining to helping patients clarify the decision (P=.03), involving patients in the decision (P=.01), displaying treatment options (P<.001), identifying advantages and disadvantages (P=.01), and facilitating patient understanding (P=.01) and discussion of preferences (P=.01). Five of the 8 UTAUT constructs showed differences between the 2 groups, favoring DDInteract (P<.05). Usability ratings from the SUS were significantly higher (P<.05) for physicians using DDInteract compared to those in the UC group but showed no differences from the patient’s perspective. No differences in patient responses were observed between groups using the DCS. During the session debrief, physicians indicated little concern for the additional time or workload entailed by DDInteract use. Both clinicians and patients indicated that the tool was beneficial in simulated encounters to understand and mitigate the risk of harm from this DDI. Conclusions Overall, DDInteract may improve encounters where there is a risk of bleeding due to a potential drug-drug interaction involving anticoagulants. Participants rated DDInteract as logical and useful for enhancing SDM. They reported that they would be willing to use the tool for an interaction involving warfarin and NSAIDs.
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Affiliation(s)
- Ainhoa Gomez Lumbreras
- Department of Pharmacotherapy, Skaggs College of Pharmacy, University of Utah, Salt Lake City, UT, United States
| | - Thomas J Reese
- Department of Biomedical Informatics, Vanderbilt University, Nashville, TN, United States
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
| | - Malinda S Tan
- Department of Pharmacotherapy, Skaggs College of Pharmacy, University of Utah, Salt Lake City, UT, United States
| | - Jorie M Butler
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
| | - Jason T Hurwitz
- Center for Health Outcomes and Pharmacoeconomic Research, University of Arizona, Tucson, AZ, United States
| | - Mary Brown
- University of Arizona, Tucson, AZ, United States
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
| | | | - Maria Wright
- Department of Pharmacotherapy, Skaggs College of Pharmacy, University of Utah, Salt Lake City, UT, United States
| | - Daniel C Malone
- Department of Pharmacotherapy, Skaggs College of Pharmacy, University of Utah, Salt Lake City, UT, United States
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Baers JH, Adekanye J, Hazlewood G, Davies JM, Caird JK, Wilton SB. Systematic Review of Patient Decision Aids for Stroke Prevention Therapy in Atrial Fibrillation Management. Rev Cardiovasc Med 2022; 23:353. [PMID: 39077149 PMCID: PMC11267376 DOI: 10.31083/j.rcm2310353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 09/22/2022] [Accepted: 09/28/2022] [Indexed: 07/31/2024] Open
Abstract
Background Atrial Fibrillation (AF) is a major cause of stroke. Oral anticoagulation can reduce the risk of AF-associated stroke by 65% but it remains underused. Stroke prevention therapy in patients with AF has been considered a good target for shared decision making with patient decision aids as it is a long-term, preference-sensitive decision with known risk-benefit trade-offs. The aim of this systematic review was to summarize published literature on the effectiveness of patient decision aids on the choice of and adherence to stroke prevention therapy in individuals with AF. Methods We conducted a structured literature search for prospective studies evaluating decision aids for AF stroke prevention therapy in adult patients with nonvalvular AF. We included studies that compared those exposed to a decision aid with a control condition for outcomes including choice of therapy, adherence, decisional conflict and patient knowledge. Quantitative meta-analysis was not feasible due to excessive between-study heterogeneity. Results Eight studies met inclusion and exclusion criteria. Six studies were randomized clinical trials and two were pre-post comparisons. Of the 8 studies, each evaluated a different decision aid, with only three including all contemporary oral anticoagulant drugs. All decision aids improved AF knowledge compared to baseline or control and decision aids reduced decisional conflict in four of six studies. However, there were inconsistent effects of the studied decision aids on initiation of oral anticoagulation. Adherence to initial stroke prevention therapy choice appeared to benefit from decision aid use in 2 studies that addressed this issue. Conclusions Decision aids for stroke prevention increased AF patients' knowledge and decisional confidence but had variable impacts on choice of and adherence to stroke prevention therapy. The results highlight the need for well-designed decision aids that present patients with all contemporary therapeutic options.
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Affiliation(s)
- Justin H. Baers
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Joel Adekanye
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Glen Hazlewood
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 2TP, Canada
| | - Jan M. Davies
- Department of Anesthesiology, Perioperative & Pain Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 2T9, Canada
- Department of Psychology, Faculty of Arts, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Jeff K. Caird
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
- Department of Psychology, Faculty of Arts, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Stephen B. Wilton
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
- Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
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Rao BR, Merchant FM, Abernethy ER, Bethencourt C, Matlock D, Dickert NW. Digging Deeper: Understanding Trajectories and Experiences of Shared Decision-Making for Primary Prevention ICD Implantation. J Card Fail 2022; 28:1437-1444. [PMID: 35550427 PMCID: PMC9580508 DOI: 10.1016/j.cardfail.2022.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Shared decision-making using a decision aid is required for patients undergoing implantation of primary prevention implantable cardioverter-defibrillators (ICD). It is unknown how much this process has impacted patients' experiences or choices. Effective shared decision-making requires an understanding of how patients make ICD decisions. A qualitative key informant study was chosen to capture the breadth of patients' experiences making ICD decisions in the context of required shared decision-making. METHODS AND RESULTS We conducted in-depth interviews with 20 patients referred to electrophysiology clinics for the consideration of primary prevention ICD implantation. Purposeful sampling from a prior survey study evaluating mandated shared decision-making was based on patient characteristics and responses to the initial survey questions. Qualitative descriptive analysis of the interviews was performed using a multilevel coding strategy. Patients' paths to an ICD decision often involved multiple visits with multiple clinicians. However, the decision aid was almost exclusively provided to the patient during electrophysiology clinic visits. Some patients used the numeric data in the decision aid to make an ICD decision based on the risk-benefit profile; others made decisions based on other data or based on trust in clinicians' recommendations. Patients highlighted information related to living with the device as particularly important in helping them to make their ICD decisions. Some patients struggled with the emotional aspects of making an ICD decision. CONCLUSIONS Patients' ICD decision-making paths poses a challenge to episodic shared decision-making and may make tools such as decision aids perfunctory if used solely during the electrophysiology visit. Understanding patients' ICD decision-making paths, especially in the context of encounters with primary cardiologists, can inform the implementation strategies of shared decision-making help to enhance its impact. Components of decision aids focusing on the experience of living with an ICD rather than probabilistic data may also be more impactful, although the nature of their impact will differ.
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Affiliation(s)
- Birju R Rao
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
| | - Faisal M Merchant
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Eli R Abernethy
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Christine Bethencourt
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Dan Matlock
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Neal W Dickert
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia; Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia; and the
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Sivly A, Gorr HS, Gravholt D, Branda ME, Linzer M, Noseworthy P, Hargraves I, Kunneman M, Doubeni CA, Suzuki T, Brito JP, Jackson EA, Burnett B, Wambua M, Montori VM. Enrolling people of color to evaluate a practice intervention: lessons from the shared decision-making for atrial fibrillation (SDM4AFib) trial. BMC Health Serv Res 2022; 22:1032. [PMID: 35962351 PMCID: PMC9375357 DOI: 10.1186/s12913-022-08399-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 06/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Trial recruitment of Black, indigenous, and people of color (BIPOC) is key for interventions that interact with socioeconomic factors and cultural norms, preferences, and values. We report on our experience enrolling BIPOC participants into a multicenter trial of a shared decision-making intervention about anticoagulation to prevent strokes, in patients with atrial fibrillation (AF). METHODS We enrolled patients with AF and their clinicians in 5 healthcare systems (three academic medical centers, an urban/suburban community medical center, and a safety-net inner-city medical center) located in three states (Minnesota, Alabama, and Mississippi) in the United States. Clinical encounters were randomized to usual care with or without a shared decision-making tool about anticoagulation. ANALYSIS We analyzed BIPOC patient enrollment by site, categorized reasons for non-enrollment, and examined how enrollment of BIPOC patients was promoted across sites. RESULTS Of 2247 patients assessed, 922 were enrolled of which 147 (16%) were BIPOC patients. Eligible Black participants were significantly less likely (p < .001) to enroll (102, 11%) than trial-eligible White participants (185, 15%). The enrollment rate of BIPOC patients varied by site. The inclusion and prioritization of clinical practices that care for more BIPOC patients contributed to a higher enrollment rate into the trial. Specific efforts to reach BIPOC clinic attendees and prioritize their enrollment had lower yield. CONCLUSIONS Best practices to optimize the enrollment of BIPOC participants into trials that examined complex and culturally sensitive interventions remain to be developed. This study suggests a high yield from enrolling BIPOC patients from practices that prioritize their care. TRIAL REGISTRATION ClinicalTrials.gov (NCT02905032).
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Affiliation(s)
- Angela Sivly
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Haeshik S Gorr
- Hennepin Healthcare, 730 South 8th Street, Minneapolis, MN, 55415, USA
| | - Derek Gravholt
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Megan E Branda
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Department of Quantitative Health Sciences, Division of Clinical Trials & Biostatistics, Mayo Clinic, Rochester, MN, 55905, USA
| | - Mark Linzer
- Hennepin Healthcare, 730 South 8th Street, Minneapolis, MN, 55415, USA
| | - Peter Noseworthy
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Cardiovascular Diseases, Mayo Clinic, Rochester, MN, 55905, USA
| | - Ian Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Marleen Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Chyke A Doubeni
- Mayo Clinic Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, MN, 55905, USA
| | - Takeki Suzuki
- Indiana University School of Medicine, Indianapolis, IN, 46202, USA
| | - Juan P Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Elizabeth A Jackson
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, 32594, USA
| | - Bruce Burnett
- Health Partners, Park Nicollet, 8170 33rd Ave S, Bloomington, MN, 55425, USA
| | - Mike Wambua
- Hennepin Healthcare, 730 South 8th Street, Minneapolis, MN, 55415, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Sprügel MI, Sembill JA, Kremer S, Gerner ST, Knott M, Hock S, Engelhorn T, Dörfler A, Huttner HB, Schwab S. Evaluation of Functional Recovery Following Thrombectomy in Patients With Large Vessel Occlusion and Prestroke Disability. JAMA Netw Open 2022; 5:e2227139. [PMID: 35972737 PMCID: PMC9382438 DOI: 10.1001/jamanetworkopen.2022.27139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE It is uncertain whether thrombectomy is associated with benefits in patients with prestroke disability. OBJECTIVE To evaluate the use of thrombectomy for patients with large vessel occlusion and prestroke disability. DESIGN, SETTING, AND PARTICIPANTS This cohort study included patients with large vessel occlusion stroke and prestroke disability (modified Rankin Scale score, 3 or 4) admitted to a single tertiary care center between January 1, 2006, and June 30, 2019 (controls: 2006-2015; thrombectomy: 2015-2019). Follow-up was conducted at 90 days. Data analysis was performed from November 1 to December 31, 2021. EXPOSURES Use of thrombectomy vs no thrombectomy. MAIN OUTCOMES AND MEASURES The primary outcome was functional recovery at 90 days defined as clinical recovery to the functional status before stroke onset. Secondary outcomes included functional dependency, mortality, early neurologic improvement, and recanalization. RESULTS Among 205 patients (149 women [72.7%]; median age, 82 years [IQR, 75-87 years]), 102 individuals (49.8%) received thrombectomy and 103 (50.2%) were controls. Thrombectomy was significantly associated with functional recovery (thrombectomy, 20 [19.6%]; controls, 8 [7.8%]; adjusted difference, 9.4%; 95% CI, 2.2% to 16.7%; P = .005). Secondary outcomes showed differences in mortality, early neurologic improvement, and recanalization in favor of thrombectomy treatment. The rate of functional dependency did not differ significantly between the 2 groups (adjusted difference, 8.9%; 95% CI, -2.5% to 20.2%; P = .13). The rate of functional recovery after thrombectomy was 44.0% for patients with early neurologic improvement, 29.4% for patients with small infarct volume (<50 mL), and 7.0% for patients with neither of these parameters. CONCLUSIONS AND RELEVANCE Findings of this study suggest that selected patients with prestroke disability may benefit from thrombectomy. However, the thrombectomy-associated increase in functional recovery was small. Therefore, routine use of thrombectomy may not be beneficial among patients with a large ischemic core and infarct volumes less than 50 mL may be necessary to obtain functional recovery. Patients with higher chances of functional recovery are also at an increased risk of survival with substantial disability, indicating potential harms from the intervention; further studies are needed.
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Affiliation(s)
- Maximilian I. Sprügel
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Jochen A. Sembill
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Svenja Kremer
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan T. Gerner
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Knott
- Department of Neuroradiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan Hock
- Department of Neuroradiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Hagen B. Huttner
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Prick JCM, van Schaik SM, Deijle IA, Dahmen R, Brouwers PJAM, Hilkens PHE, Garvelink MM, Engels N, Ankersmid JW, Keus SHJ, The R, Takahashi A, van Uden-Kraan CF, van der Wees PJ, Van den Berg-Vos RM, van Schaik S, Brouwers P, Hilkens P, van Dijk G, Gons R, Saxena R, Schut E. Development of a patient decision aid for discharge planning of hospitalized patients with stroke. BMC Neurol 2022; 22:245. [PMID: 35790912 PMCID: PMC9254531 DOI: 10.1186/s12883-022-02679-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 04/11/2022] [Indexed: 09/13/2024] Open
Abstract
Abstract
Background
Patient involvement in discharge planning of patients with stroke can be accomplished by providing personalized outcome information and promoting shared decision-making. The aim of this study was to develop a patient decision aid (PtDA) for discharge planning of hospitalized patients with stroke.
Methods
A convergent mixed methods design was used, starting with needs assessments among patients with stroke and health care professionals (HCPs). Results of these assessments were used to develop the PtDA with integrated outcome information in several co-creation sessions. Subsequently, acceptability and usability were tested to optimize the PtDA. Development was guided by the International Patient Decision Aids Standards (IPDAS) criteria.
Results
In total, 74 patients and 111 HCPs participated in this study. A three-component PtDA was developed, consisting of:
1) a printed consultation sheet to introduce the options for discharge destinations, containing information that can be specified for each individual patient;
2) an online information and deliberation tool to support patient education and clarification of patient values, containing an integrated “patients-like-me” model with outcome information about discharge destinations;
3) a summary sheet to support actual decision-making during consultation, containing the patient’s values and preferences concerning discharge planning.
In the acceptability test, all qualifying and certifying IPDAS criteria were fulfilled. The usability test showed that patients and HCPs highly appreciated the PtDA with integrated outcome information.
Conclusions
The developed PtDA was found acceptable and usable by patients and HCPs and is currently under investigation in a clinical trial to determine its effectiveness.
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Kunneman M, Hargraves IG, Sivly AL, Branda ME, LaVecchia CM, Labrie NHM, Brand-McCarthy S, Montori V. Co-creating sensible care plans using shared decision making: Patients' reflections and observations of encounters. PATIENT EDUCATION AND COUNSELING 2022; 105:1539-1544. [PMID: 34711446 DOI: 10.1016/j.pec.2021.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 07/13/2021] [Accepted: 10/05/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To evaluate how the use of a within-encounter SDM tool (compared to usual care in a randomized trial) contributes to care plans that make sense to patients with atrial fibrillation considering anticoagulation. METHODS In a planned subgroup of the trial, 123 patients rated post-encounter how much sense their decided-upon care plan made to them and explained why. We explored how sense ratings related to observed patient involvement (OPTION12), patient's decisional conflict, and adherence to their plan based on pharmacy records. We analyzed patient motives using Burke's pentad. RESULTS Plan sensibility was similarly high in both arms (Usual care n = 62: mean 9.4/10 (SD 1.0) vs SDM tool n = 61: 9.2/10 (SD 1.5); p = .8), significantly and weakly correlated to decisional conflict (rho=-0.28, p = .002), but not to OPTION12 or adherence. Plans made sense to most patients given their known efficacy, safety and what is involved in implementing them. CONCLUSION Adding an effective intervention to promote SDM did not affect how much, or why, care plans made sense to patients receiving usual care, nor patient adherence to them. PRACTICE IMPLICATIONS Evaluating the extent to which care plans make sense can improve SDM assessments, particularly when SDM extends beyond selecting from a menu of options.
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Affiliation(s)
- Marleen Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands.
| | - Ian G Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.
| | - Angela L Sivly
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.
| | - Megan E Branda
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO, USA; Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.
| | - Christina M LaVecchia
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; School of Arts and Sciences, Neumann University, Auston, PA, USA.
| | - Nanon H M Labrie
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | | | - Victor Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA.
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Schoot TS, Perry M, Hilbrands LB, van Marum RJ, Kerckhoffs APM. Kidney transplantation or dialysis in older adults-an interview study on the decision-making process. Age Ageing 2022; 51:6577232. [PMID: 35511744 DOI: 10.1093/ageing/afac111] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In older patients with end-stage kidney disease (ESKD), the choice between kidney transplantation (KT) and dialysis may be more complex than in younger patients because of a higher prevalence of comorbidities and frailty. This study aims to provide greater insight into the current decision-making process by exploring the expectations, experiences and health outcome priorities of all stakeholders. METHODS We performed semi-structured interviews with patients ≥65 years with ESKD (eGFR <15 ml/min/1.73m2, KT recipient or treated with dialysis), patients' relatives and healthcare professionals (nephrologists, nurses and medical social workers). Interviews were conducted until data saturation and thematically analysed. RESULTS We performed 36 interviews (patients n = 18, relatives n = 5, healthcare professionals n = 13). Thematic analysis revealed five themes. Older patients' health outcome priorities were mostly related to quality of life (QOL). Individual older patients showed marked differences in the preferred level of engagement during the decision-making process (varying from 'wants to be in the lead' to 'follows the nephrologist') and in informational needs (varying from evidence-based to experience-based). On the contrary, healthcare professionals were quite unanimous on all aspects. They focused on determining eligibility for KT as start of the decision-making process, on clear and extensive information provision and on classical, medical outcomes. CONCLUSIONS The decision-making process could benefit from early identification of older patients' values, needs and health outcome priorities, in parallel with assessment of KT eligibility and before discussing the treatment options, and the explicit use of this information in further steps of the decision-making process.
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Affiliation(s)
- Tessa S Schoot
- Department of Nephrology, Radboud Institute for Health Sciences, Radboud university medical center , Nijmegen , the Netherlands
- Department of Nephrology, ‘s-Hertogenbosch, Jeroen Bosch Hospital , the Netherlands
| | - Marieke Perry
- Department of Geriatric Medicine, Radboud university medical center , Nijmegen , the Netherlands
| | - Luuk B Hilbrands
- Department of Nephrology, Radboud Institute for Health Sciences, Radboud university medical center , Nijmegen , the Netherlands
| | - Rob J van Marum
- Department of Geriatric Medicine, ‘s-Hertogenbosch, Jeroen Bosch Hospital , the Netherlands
- Department of Clinical Pharmacology, ‘s-Hertogenbosch, Jeroen Bosch Hospital , the Netherlands
- Department of Elderly Care Medicine, Amsterdam University Medical Center , the Netherlands
| | - Angèle P M Kerckhoffs
- Department of Nephrology, ‘s-Hertogenbosch, Jeroen Bosch Hospital , the Netherlands
- Department of Geriatric Medicine, ‘s-Hertogenbosch, Jeroen Bosch Hospital , the Netherlands
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Jones AE, McCarty MM, Brito JP, Noseworthy PA, Cavanaugh KL, Cameron KA, Barnes GD, Steinberg BA, Witt DM, Crossley GH, Passman R, Kansal P, Hargraves I, Schmidt M, Jackson E, Guzman A, Ariotti A, Pershing ML, Herrick J, Montori VM, Fagerlin A, Ozanne EM. Randomized evaluation of decision support interventions for atrial fibrillation: Rationale and design of the RED-AF study. Am Heart J 2022; 248:42-52. [PMID: 35218727 PMCID: PMC11348720 DOI: 10.1016/j.ahj.2022.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 02/11/2022] [Accepted: 02/19/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Shared decision making (SDM) improves the likelihood that patients will receive care in a manner consistent with their priorities. To facilitate SDM, decision aids (DA) are commonly used, both to prepare a patient before their clinician visit, as well as to facilitate discussion during the visit. However, the relative efficacy of patient-focused or encounter-based DAs on SDM and patient outcomes remains largely unknown. We aim to directly estimate the comparative effectiveness of two DA's on SDM observed in encounters to discuss stroke prevention strategies in patients with atrial fibrillation (AF). METHODS The study aims to recruit 1200 adult patients with non-valvular AF who qualify for anticoagulation therapy, and their clinicians who manage stroke prevention strategies, in a 2x2 cluster randomized multi-center trial at six sites. Two DA's were developed as interactive, online, non-linear tools: a patient decision aid (PDA) to be used by patients before the encounter, and an encounter decision aid (EDA) to be used by clinicians with their patients during the encounter. Patients will be randomized to PDA or usual care; clinicians will be randomized to EDA or usual care. RESULTS Primary outcomes are quality of SDM, patient decision making, and patient knowledge. Secondary outcomes include anticoagulation choice, adherence, and clinical events. CONCLUSION This trial is the first randomized, head-to-head comparison of the effects of an EDA versus a PDA on SDM. Our results will help to inform future SDM interventions to improve patients' AF outcomes and experiences with stroke prevention strategies.
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Affiliation(s)
- Aubrey E Jones
- Department of Population Health Sciences, University of Utah School of Medicine, SLC, UT
| | - Madeleine M McCarty
- Department of Population Health Sciences, University of Utah School of Medicine, SLC, UT
| | - Juan P Brito
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN
| | - Peter A Noseworthy
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Kerri L Cavanaugh
- Department of Medicine, Division of Nephrology & Hypertension, Vanderbilt University Medical Center, Nashville, TN
| | - Kenzie A Cameron
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Geoffrey D Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah School of Medicine, SLC, UT
| | - Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT
| | - George H Crossley
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN
| | - Rod Passman
- Department of Medicine, Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Preeti Kansal
- Department of Medicine, Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Ian Hargraves
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN
| | - Monika Schmidt
- Department of Medicine, US Department of Veterans Affairs, Nashville, TN
| | - Elizabeth Jackson
- Division of Cardiovascular Disease, University of Alabama Birmingham, Birmingham, AL
| | - Adriana Guzman
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Anthony Ariotti
- Department of Population Health Sciences, University of Utah School of Medicine, SLC, UT
| | - Mandy L Pershing
- Department of Population Health Sciences, University of Utah School of Medicine, SLC, UT
| | - Jennifer Herrick
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, SLC, UT
| | - Victor M Montori
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, MN
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah School of Medicine, SLC, UT; VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for Innovation, Salt Lake City, UT
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, SLC, UT.
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Baykaner T, Pundi K, Lin B, Lu Y, DeSutter K, Lhamo K, Garay G, Nunes JC, Morin DP, Sears SF, Chung MK, Paasche-Orlow MK, Sanders LM, Bunch TJ, Hills MT, Mahaffey KW, Stafford RS, Wang PJ. The ENHANCE-AF clinical trial to evaluate an atrial fibrillation shared decision-making pathway: Rationale and study design. Am Heart J 2022; 247:68-75. [PMID: 35092723 DOI: 10.1016/j.ahj.2022.01.013] [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: 07/15/2021] [Revised: 01/20/2022] [Accepted: 01/20/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Shared decision making (SDM) may result in treatment plans that best reflect the goals and wishes of patients, increasing patient satisfaction with the decision-making process. There is a knowledge gap to support the use of decision aids in SDM for anticoagulation therapy in patients with atrial fibrillation (AF). We describe the development and testing of a new decision aid, including a multicenter, randomized, controlled, 2-arm, open-label ENHANCE-AF clinical trial (Engaging Patients to Help Achieve Increased Patient Choice and Engagement for AF Stroke Prevention) to evaluate its effectiveness in 1,200 participants. METHODS Participants will be randomized to either usual care or to a SDM pathway incorporating a digital tool designed to simplify the complex concepts surrounding AF in conjunction with a clinician tool and a non-clinician navigator to guide the participants through each step of the tool. The participant-determined primary outcome for this study is the Decisional Conflict Scale, measured at 1 month after the index visit during which a decision was made regarding anticoagulation use. Secondary outcomes at both 1 and 6 months will include other decision making related scales as well as participant and clinician satisfaction, oral anticoagulation adherence, and a composite rate of major bleeding, death, stroke, or transient ischemic attack. The study will be conducted at four sites selected for their ability to enroll participants of varying racial and ethnic backgrounds, health literacy, and language skills. Participants will be followed in the study for 6 months. CONCLUSIONS The results of the ENHANCE-AF trial will determine whether a decision aid facilitates high quality shared decision making in anticoagulation discussions for stroke reduction in AF. An improved shared decision-making experience may allow patients to make decisions better aligned with their personal values and preferences, while improving overall AF care.
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Baggett ND, Schulz K, Buffington A, Marka N, Hanlon BM, Zimmermann C, Tucholka J, Fox D, Clapp JT, Arnold RM, Schwarze ML. Surgeon Use of Shared Decision-making for Older Adults Considering Major Surgery: A Secondary Analysis of a Randomized Clinical Trial. JAMA Surg 2022; 157:406-413. [PMID: 35319737 PMCID: PMC8943640 DOI: 10.1001/jamasurg.2022.0290] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Because major surgery carries significant risks for older adults with comorbid conditions, shared decision-making is recommended to ensure patients receive care consistent with their goals. However, it is unknown how often shared decision-making is used for these patients. Objective To describe the use of shared decision-making during discussions about major surgery with older adults. Design, Setting, and Participants This study is a secondary analysis of conversations audio recorded during a randomized clinical trial of a question prompt list. Data were collected from June 1, 2016, to November 31, 2018, from 43 surgeons and 446 patients 60 years or older with at least 1 comorbidity at outpatient surgical clinics at 5 academic centers. Interventions Patients received a question prompt list brochure that contained questions they could ask a surgeon. Main Outcomes and Measures The 5-domain Observing Patient Involvement in Decision-making (OPTION5) score (range, 0-100, with higher scores indicating greater shared decision-making) was used to measure shared decision-making. Results A total of 378 surgical consultations were analyzed (mean [SD] patient age, 71.9 [7.2] years; 206 [55%] male; 312 [83%] White). The mean (SD) OPTION5 score was 34.7 (20.6) and was not affected by the intervention. The mean (SD) score in the group receiving the question prompt list was 36.7 (21.2); in the control group, the mean (SD) score was 32.9 (19.9) (effect estimate, 3.80; 95% CI, -0.30 to 8.00; P = .07). Individual surgeon use of shared decision-making varied greatly, with a lowest median score of 10 (IQR, 10-20) to a high of 65 (IQR, 55-80). Lower-performing surgeons had little variation in OPTION5 scores, whereas high-performing surgeons had wide variation. Use of shared decision-making increased when surgeons appeared reluctant to operate (effect estimate, 7.40; 95% CI, 2.60-12.20; P = .003). Although longer conversations were associated with slightly higher OPTION5 scores (effect estimate, 0.69; 95% CI, 0.52-0.88; P < .001), 57% of high-scoring transcripts were 26 minutes long or less. On multivariable analysis, patient age and gender, patient education, surgeon age, and surgeon gender were not significantly associated with OPTION5 scores. Conclusions and Relevance These findings suggest that although shared decision-making is important to support the preferences of older adults considering major surgery, surgeon use of shared decision-making is highly variable. Skillful shared decision-making can be done in less than 30 minutes; however, surgeons who engage in high-scoring shared decision-making are more likely to do so when surgical intervention is less obviously beneficial for the patient. Trial Registration ClinicalTrials.gov Identifier: NCT02623335.
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Affiliation(s)
- Nathan D. Baggett
- HealthPartners Institute/Regions Hospital Emergency Medicine, St Paul, Minnesota
| | - Kathryn Schulz
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Nicholas Marka
- Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis
| | - Bret M. Hanlon
- Department of Surgery, University of Wisconsin, Madison
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison
| | | | | | - Dan Fox
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Justin T. Clapp
- Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Robert M. Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Swarup V, Soomro A, Abdulla S, de Wit K. Patient values and preferences in pulmonary embolism testing in the emergency department. Acad Emerg Med 2022; 29:278-285. [PMID: 34661318 DOI: 10.1111/acem.14400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 10/06/2021] [Accepted: 10/13/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Patient-centered care is concordant with patient values and preferences. There is a lack of research on patient values and preferences for pulmonary embolism (PE) testing in the emergency department (ED), and a poor physician understanding of patient-specific goals. Our aim was to map patient-specific values, preferences, and expectations regarding PE testing in the ED. METHOD This qualitative study used constructivist grounded theory to identify patient values and expectations around PE testing in the ED. We conducted semi-structured interviews with ED patients who were being tested for PE in two EDs. Patients who were waiting for PE imaging or D-dimer results were approached and consented to take part in a 30-minute audio-recorded interview. Each interview was transcribed verbatim and analyzed using constant comparative coding. The interview script was modified to maximize information on emerging themes. Major themes and subthemes were derived, each representing an opportunity, barrier, or value to address with patient-centered PE testing. RESULTS From 30 patient interviews, we mapped four major themes: patient satisfaction comes from addressing the patient's primary concern (for example, their pain); patients expect individualized care; patients prefer imaging over clinical examination for PE testing; and patients expect 100% confidence from their emergency physician when given a diagnosis. Subthemes included symptomatic relief, finding a diagnosis, receiving tests, rapid progression through their care, perception of highly accurate CT scans, willingness to seek a second opinion, direct physician communication, and expectation of case-specific testing with cognitive reassurance. CONCLUSION Addressing each of these four themes by realigning ED processes could provide patient-centered PE testing.
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Affiliation(s)
- Vidushi Swarup
- Department of Medicine McMaster University Hamilton Ontario Canada
- Hematology‐Oncology Clinical Research Group St. Michael’s Hospital Toronto Ontario Canada
| | - Asfia Soomro
- Department of Medicine McMaster University Hamilton Ontario Canada
| | - Solen Abdulla
- Department of Medicine McMaster University Hamilton Ontario Canada
- Faculty of Medicine McMaster University Hamilton Ontario Canada
| | - Kerstin de Wit
- Department of Medicine McMaster University Hamilton Ontario Canada
- Department of Emergency Medicine Queens University Canada
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Noseworthy PA, Branda ME, Kunneman M, Hargraves IG, Sivly AL, Brito JP, Burnett B, Zeballos-Palacios C, Linzer M, Suzuki T, Lee AT, Gorr H, Jackson EA, Hess E, Brand-McCarthy SR, Shah ND, Montori VM. Effect of Shared Decision-Making for Stroke Prevention on Treatment Adherence and Safety Outcomes in Patients With Atrial Fibrillation: A Randomized Clinical Trial. J Am Heart Assoc 2022; 11:e023048. [PMID: 35023356 PMCID: PMC9238511 DOI: 10.1161/jaha.121.023048] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Guidelines promote shared decision-making (SDM) for anticoagulation in patients with atrial fibrillation. We recently showed that adding a within-encounter SDM tool to usual care (UC) increases patient involvement in decision-making and clinician satisfaction, without affecting encounter length. We aimed to estimate the extent to which use of an SDM tool changed adherence to the decided care plan and clinical safety end points. Methods and Results We conducted a multicenter, encounter-level, randomized trial assessing the efficacy of UC with versus without an SDM conversation tool for use during the clinical encounter (Anticoagulation Choice) in patients with nonvalvular atrial fibrillation considering starting or reviewing anticoagulation treatment. We conducted a chart and pharmacy review, blinded to randomization status, at 10 months after enrollment to assess primary adherence (proportion of patients who were prescribed an anticoagulant who filled their first prescription) and secondary adherence (estimated using the proportion of days for which treatment was supplied and filled for direct oral anticoagulant, and as time in therapeutic range for warfarin). We also noted any strokes, transient ischemic attacks, major bleeding, or deaths as safety end points. We enrolled 922 evaluable patient encounters (Anticoagulation Choice=463, and UC=459), of which 814 (88%) had pharmacy and clinical follow-up. We found no differences between arms in either primary adherence (78% of patients in the SDM arm filled their first prescription versus 81% in UC arm) or secondary adherence to anticoagulation (percentage days covered of the direct oral anticoagulant was 74.1% in SDM versus 71.6% in UC; time in therapeutic range for warfarin was 66.6% in SDM versus 64.4% in UC). Safety outcomes, mostly bleeds, occurred in 13% of participants in the SDM arm and 14% in the UC arm. Conclusions In this large, randomized trial comparing UC with a tool to promote SDM against UC alone, we found no significant differences between arms in primary or secondary adherence to anticoagulation or in clinical safety outcomes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: clinicaltrials.gov. Identifier: NCT02905032.
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Affiliation(s)
- Peter A Noseworthy
- Knowledge and Evaluation Research Unit Mayo Clinic Rochester MN.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Mayo Clinic Rochester MN.,Heart Rhythm Services Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | - Megan E Branda
- Knowledge and Evaluation Research Unit Mayo Clinic Rochester MN.,Division of Biomedical Statistics and Informatics Department of Health Sciences Research Mayo Clinic Rochester MN.,Department of Biostatistics and Informatics Colorado School of Public Health University of Colorado-Denver Anschutz Medical Campus Aurora CO
| | - Marleen Kunneman
- Knowledge and Evaluation Research Unit Mayo Clinic Rochester MN.,Biomedical Data Sciences Leiden University Medical Center Leiden the Netherlands
| | - Ian G Hargraves
- Knowledge and Evaluation Research Unit Mayo Clinic Rochester MN
| | - Angela L Sivly
- Knowledge and Evaluation Research Unit Mayo Clinic Rochester MN
| | - Juan P Brito
- Knowledge and Evaluation Research Unit Mayo Clinic Rochester MN
| | - Bruce Burnett
- Thrombosis Clinic and Anticoagulation ServicesPark Nicollet Health Services St Louis Park MN
| | | | - Mark Linzer
- Department of Medicine Hennepin Healthcare, and the University of Minnesota Minneapolis MN
| | - Takeki Suzuki
- Department of Medicine Krannert Institute of CardiologyIndiana University Indianapolis IN
| | - Alexander T Lee
- Division of Biomedical Statistics and Informatics Department of Health Sciences Research Mayo Clinic Rochester MN
| | - Haeshik Gorr
- Department of Medicine Hennepin Healthcare, and the University of Minnesota Minneapolis MN
| | - Elizabeth A Jackson
- Division of Cardiovascular Disease Department of Internal Medicine University of Alabama at Birmingham Birmingham AL
| | - Erik Hess
- Department of Emergency Medicine for Vanderbilt University Medical Center Nashville TN
| | - Sarah R Brand-McCarthy
- Knowledge and Evaluation Research Unit Mayo Clinic Rochester MN.,Department of Psychiatry and Psychology Mayo Clinic Rochester MN
| | - Nilay D Shah
- Knowledge and Evaluation Research Unit Mayo Clinic Rochester MN
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