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Carlisle JB. To operate or not? Uncertainty, regret and the art of conversation. Anaesthesia 2023; 78:155-158. [PMID: 36196780 DOI: 10.1111/anae.15875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 01/11/2023]
Affiliation(s)
- J B Carlisle
- Department of Peri-operative Medicine, Anaesthesia and Intensive Care, Torbay Hospital, Torquay, Devon, UK
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van der Weijden T, van der Kraan J, Brand PLP, van Veenendaal H, Drenthen T, Schoon Y, Tuyn E, van der Weele G, Stalmeier P, Damman OC, Stiggelbout A. Shared decision-making in the Netherlands: Progress is made, but not for all. Time to become inclusive to patients. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2022; 171:98-104. [PMID: 35613990 DOI: 10.1016/j.zefq.2022.04.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/20/2022] [Accepted: 04/27/2022] [Indexed: 06/15/2023]
Abstract
Dutch initiatives targeting shared decision-making (SDM) are still growing, supported by the government, the Federation of Patients' Organisations, professional bodies and healthcare insurers. The large majority of patients prefers the SDM model. The Dutch are working hard to realise improvement in the application of SDM in daily clinical practice, resulting in glimpses of success with objectified improvement on observed behavior. Nevertheless, the culture shift is still ongoing. Large-scale uptake of SDM behavior is still a challenge. We haven't yet fully reached the patients' needs, given disappointing research data on patients' experiences and professional behavior. In all Dutch implementation projects, early adopters, believers or higher-educated persons have been overrepresented, while patients with limited health literacy have been underrepresented. This is a huge problem as 25% of the Dutch adult population have limited health literacy. To further enhance SDM there are issues to be addressed: We need to make physicians conscious about their limited application of SDM in daily practice, especially regarding preference and decision talk. We need to reward clinicians for the extra work that comes with SDM. We need to be inclusive to patients with limited health literacy, who are less often actually involved in decision-making and at the same time more likely to regret their chosen treatment compared to patients with higher health literacy.
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Affiliation(s)
- Trudy van der Weijden
- Department of Family Medicine, School for Public Health and Primary Care CAPHRI, Maastricht University, Maastricht, The Netherlands.
| | | | - Paul L P Brand
- Isala Women's and Children's Hospital, Zwolle, and UMCG Postgraduate School of Medicine, University Medical Centre and University of Groningen, Groningen, The Netherlands
| | - Haske van Veenendaal
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Ton Drenthen
- Dutch College of General Practitioners, Utrecht, The Netherlands
| | - Yvonne Schoon
- Department of Geriatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eline Tuyn
- Program manager health care innovation, CZ Health Care Insurance, Tilburg, The Netherlands
| | | | - Peep Stalmeier
- Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Olga C Damman
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Public and Occupational Health and Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Anne Stiggelbout
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam and Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Centre, The Netherlands
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Simons M, Rapport F, Zurynski Y, Stoodley M, Cullis J, Davidson AS. Links between evidence-based medicine and shared decision-making in courses for doctors in training: a scoping review. BMJ Open 2022; 12:e057335. [PMID: 35470193 PMCID: PMC9039384 DOI: 10.1136/bmjopen-2021-057335] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES This scoping review aims to synthesise the current evidence on the inclusion and effectiveness of integrating evidence-based medicine (EBM) and shared decision-making (SDM) into training courses for doctors in training to enhance patient care. Both EBM and SDM appear to be taught separately and their combined role in providing high-quality patient care has not yet been explored. DESIGN Scoping review of literature from January 2017 to June 2021. SETTING Any setting where doctors in training could undertake EBM and/or SDM courses (hospitals, universities, clinics and online). PARTICIPANTS Doctors in training (also known as junior doctors, residents, registrars, trainees, fellows) defined as medical graduates undertaking further training to establish a career pathway. METHODS Searches were conducted in the databases Medline, Embase, Scopus and Cochrane Library. Bibliographies of included articles and their cited references were hand searched and assessed for inclusion. Included studies described training and outcomes of either EBM, SDM or both. Reported outcomes included EBM knowledge and skill tests, attitude surveys, SDM checklists and surveys and patient and doctor experience data obtained from surveys, focus groups and interviews. RESULTS Of the 26 included studies, 15 described EBM training courses, 10 described SDM training courses and 1 course combined both EBM and SDM. Courses were heterogeneous in their content and outcomes, making comparisons difficult. EBM courses prioritised quantitative outcome assessments and linked knowledge and skills, such as critical appraisal, but overlooked other key elements of patient-centred care including SDM. CONCLUSIONS SDM and EBM are taught separately in most training courses. The inclusion of SDM, evaluated by qualitative assessments, is currently omitted, yet could provide a more person-centred care focus in EBM courses and should be investigated to increase our knowledge of the effectiveness of such courses and their role in improving doctors' skills and patient care. PROTOCOL A protocol for this review has been published and contains further details of the methodology.
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Affiliation(s)
- Mary Simons
- Library, Macquarie University, Sydney, New South Wales, Australia
| | - Frances Rapport
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Yvonne Zurynski
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Marcus Stoodley
- Macquarie Neurosurgery & Spine, Macquarie University Faculty of Medicine Health and Human Sciences, Sydney, New South Wales, Australia
| | - Jeremy Cullis
- Library, Macquarie University, Sydney, New South Wales, Australia
| | - Andrew S Davidson
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Neurosurgery, The Royal Melbourne Hospital City Campus, Parkville, Victoria, Australia
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Patient, Nurse, Medical Assistant, and Surgeon Perspectives Inform the Development of a Decision Support Tool for Inguinal Hernia Surgery: A Qualitative Analysis. Am J Surg 2021; 222:272-280. [DOI: 10.1016/j.amjsurg.2021.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/14/2020] [Accepted: 01/05/2021] [Indexed: 11/19/2022]
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Evaluation of a shared decision-making strategy with online decision aids in surgical and orthopaedic practice: study protocol for the E-valuAID, a multicentre study with a stepped-wedge design. BMC Med Inform Decis Mak 2021; 21:110. [PMID: 33781253 PMCID: PMC8008649 DOI: 10.1186/s12911-021-01467-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/10/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Inguinal hernia repair, gallbladder removal, and knee- and hip replacements are the most commonly performed surgical procedures, but all are subject to practice variation and variable patient-reported outcomes. Shared decision-making (SDM) has the potential to reduce surgery rates and increase patient satisfaction. This study aims to evaluate the effectiveness of an SDM strategy with online decision aids for surgical and orthopaedic practice in terms of impact on surgery rates, patient-reported outcomes, and cost-effectiveness. METHODS The E-valuAID-study is designed as a multicentre, non-randomized stepped-wedge study in patients with an inguinal hernia, gallstones, knee or hip osteoarthritis in six surgical and six orthopaedic departments. The primary outcome is the surgery rate before and after implementation of the SDM strategy. Secondary outcomes are patient-reported outcomes and cost-effectiveness. Patients in the usual care cluster prior to implementation of the SDM strategy will be treated in accordance with the best available clinical evidence, physician's knowledge and preference and the patient's preference. The intervention consists of the implementation of the SDM strategy and provision of disease-specific online decision aids. Decision aids will be provided to the patients before the consultation in which treatment decision is made. During this consultation, treatment preferences are discussed, and the final treatment decision is confirmed. Surgery rates will be extracted from hospital files. Secondary outcomes will be evaluated using questionnaires, at baseline, 3 and 6 months. DISCUSSION The E-valuAID-study will examine the cost-effectiveness of an SDM strategy with online decision aids in patients with an inguinal hernia, gallstones, knee or hip osteoarthritis. This study will show whether decision aids reduce operation rates while improving patient-reported outcomes. We hypothesize that the SDM strategy will lead to lower surgery rates, better patient-reported outcomes, and be cost-effective. TRIAL REGISTRATION The Netherlands Trial Register, Trial NL8318, registered 22 January 2020. URL: https://www.trialregister.nl/trial/8318 .
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Latenstein CSS, Thunnissen FM, Harker M, Groenewoud S, Noordenbos MW, Atsma F, de Reuver PR. Variation in practice and outcomes after inguinal hernia repair: a nationwide observational study. BMC Surg 2021; 21:45. [PMID: 33472620 PMCID: PMC7816298 DOI: 10.1186/s12893-020-01030-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/22/2020] [Indexed: 11/11/2022] Open
Abstract
Background Inguinal hernia repair has often been used as a showcase to illustrate practice variation in surgery. This study determined the degree of hospital variation in proportion of patients with an inguinal hernia undergoing operative repair and the effect of this variation on clinical outcomes. Methods A nationwide, longitudinal, database study was performed in all hospitals in the Netherlands between 2013 and 2015. Patients with inguinal hernias were collected from the Diagnosis-Related-Group (DRG) database. The case-mix adjusted operation rate in patients with a new DRG determines the observed variation. Hospital variation in case-mix adjusted inguinal hernia repair-rates was calculated per year. Clinical outcomes after surgery were compared between hospitals with high and low adjusted operation-rates. Results In total, 95,637 patients were included. The overall operation rate was 71.6%. In 2013–2015, the case-mix adjusted performance of inguinal hernia repairs in hospitals with high rates was 1.6–1.9 times higher than in hospitals with low rates. Moreover, in hospitals with high adjusted rates of inguinal hernia repair the time to surgery was shorter, more laparoscopic procedures were performed, less emergency department visits were recorded post-operatively, while more emergency department visits were recorded when patients were treated conservatively compared to hospitals with low adjusted operation rates. Conclusion Hospital variation in inguinal hernia repair in the Netherlands is modest, operation-rates vary by less than two-fold, and variation is stable over time. Hernia repair in hospitals with high adjusted rates of inguinal hernia repair are associated with improved outcomes.
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Affiliation(s)
- Carmen S S Latenstein
- Department of Surgery, Radboud University Medical Centre Nijmegen, Geert Grooteplein 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Floris M Thunnissen
- Department of Surgery, Radboud University Medical Centre Nijmegen, Geert Grooteplein 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Mitchell Harker
- Department of Surgery, Radboud University Medical Centre Nijmegen, Geert Grooteplein 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Stef Groenewoud
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Mark W Noordenbos
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Femke Atsma
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Philip R de Reuver
- Department of Surgery, Radboud University Medical Centre Nijmegen, Geert Grooteplein 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
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Latenstein CSS, Thunnissen FM, Thomeer BJM, van Wely BJ, Meinders MJ, Elwyn G, de Reuver PR. The association between patients' preferred treatment after the use of a patient decision aid and their choice of eventual treatment. Health Expect 2020; 23:651-658. [PMID: 32167653 PMCID: PMC7321744 DOI: 10.1111/hex.13045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 02/02/2020] [Accepted: 02/11/2020] [Indexed: 12/16/2022] Open
Abstract
Objective To investigate the association between patients' preferred treatment and eventual treatment. Second, to compare patients with surgical treatment to watchful waiting in order to identify predictive factors for surgery. Methods A single‐centre retrospective study was performed between December 2015 and August 2018. Patients (≥18 years) who used a patient decision aid (PDA) for gallstones or inguinal hernia were included. After their first surgical consultation, patients received access to an online PDA. The patients' preferred treatment after the PDA was compared with their choice of eventual treatment. Multivariable regression analyses were performed for predictive factors for surgery. Results In total, 567 patients with gallstones and 585 patients with an inguinal hernia were included. Of the patients with gallstones, 121 (21%) preferred watchful waiting, 367 (65%) preferred surgery, and 79 (14%) were not sure. The patients' preferred treatment was performed in 85.9%. Frequent pain attacks (OR 2.1, 95% CI 1.1‐3.9, P = .020) and preference for surgery (OR 4.4, 95% CI 1.9‐10.1, P = .001) independently predicted surgery. Of the patients with an inguinal hernia, 77 (13.2%) preferred watchful waiting, 452 (78.8%) preferred surgery, and 56 (9.6%) were not sure. The patients' preferred treatment was performed in 86.0%. The preference for surgery (OR 5.2, 95% CI 2.5‐10.6, P < .001) independently predicted surgery and worry about complications predicted avoidance of surgery (OR 0.5, 95% CI 0.2‐1.0, P = .037). Conclusion This study, reflecting current clinical care, shows that patients' preferred treatment after using a PDA matches their eventual treatment choice in 86% of patients with gallstones or an inguinal hernia. In these patients, symptoms and patients' preference for surgery independently predicts eventual choice of surgery.
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Affiliation(s)
| | - Floris M Thunnissen
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | - Marjan J Meinders
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Glyn Elwyn
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, Nijmegen, The Netherlands.,The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA
| | - Philip R de Reuver
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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