Person Centered Care and Personalized Medicine: Irreconcilable Opposites or Potential Companions?

An Egalitarian Perspective on Information Sharing: The Example of Health Care Priorities

In health care, the provision of pertinent information to patients is not just a moral imperative but also a legal obligation, often articulated through the lens of obtaining informed consent. Codes of medical ethics and many national laws mandate the disclosure of basic information about diagnosis, prognosis, and treatment alternatives. However, within publicly funded health care systems, other kinds of information might also be important to patients, such as insights into the health care priorities that underlie treatment offers made. While conventional perspectives do not take this as an obligatory part of the information to be shared with patients, perhaps through viewing it as clinically "non-actionable," we advocate for a paradigm shift. Our proposition diverges from the traditional emphasis on actionability. We contend that honoring patients as equal moral agents necessitates, among other principles, a commitment to honesty. Withholding specific categories of information pertinent to patients' comprehension of their situation is inherently incompatible with this principle. In this article, we advocate for a recalibration of the burden of proof. Rather than requiring special justifications for adding to the standard set of information items, we suggest that physicians should be able to justify excluding relevant facts about the patient's situation and the underlying considerations shaping health care professionals' choices. This perspective prioritizes transparency and empowers patients with a comprehensive understanding, aligning with the ethos of respect for the patient as person.

Perceptions and Attitudes Toward Genetic Counselors and Genetic Testing Among Certified Professional Midwives in Vermont: A Modified Grounded Theory Study

Increasingly, pregnant people in the United States are choosing to give at birth at home, and certified professional midwives (CPMs) often attend these births. Care by midwives, including home birth midwives, has the potential to decrease unnecessary medical interventions and their associated health care costs, as well as to improve maternal satisfaction with care. However, lack of integration into the health care system affects the ability of CPMs to access standard medications and testing for their clients, including prenatal screening. Genetics and genomics are now a routine part of prenatal screening, and genetic testing can contribute to identifying candidates for planned home birth. However, research on genetics and midwifery care has not, to date, included the subset of midwives who attend the majority of planned home births, CPMs. The purpose of this study was to examine CPMs' access to, and perspectives on, one aspect of prenatal care, genetic counselors and genetic counseling services. Using semi-structured interviews and a modified grounded theory approach to narrative analysis, we identified three key themes: (1) systems-level issues with accessing information about genetic counseling and genetic testing; (2) practice-level patterns in information delivery and self-awareness about knowledge limitations; and (3) client-level concerns about the value of genetic testing relative to difficulties with access and stress caused by the information. The results of this study can be used to develop decision aids that include information about genetic testing and genetic counseling access for pregnant people intending home births in the United States.

Recommendations for Improving Chronic Care in Times of a Pandemic Based on Patient Experiences

OBJECTIVES

The COVID-19 pandemic had a profound and pervasive impact on the health of chronic care patients and disrupted care systems worldwide. Our research aimed to assess the impact of the pandemic on chronic care provision and provide recommendations for improving care provision, based on patient experiences.

DESIGN

Qualitative semi-structured interviews were held among patients with chronic obstructive pulmonary disease (COPD) or heart failure.

SETTING AND PARTICIPANTS

Using stratified sampling, 23 patients with COPD, heart failure, or both were recruited to participate in semi-structured interviews. In the summer of 2021, online interviews were conducted.

METHODS

An iterative process was adopted to analyze the data. Going back and forth through the data and our analytical structure, we first coded the data, and subsequently developed categories, themes, and aggregate dimensions. The data were synthesized in a data structure and a data table, which were analyzed using an interpretative approach.

RESULTS

We found 3 dimensions through which care might be improved: (1) proactive and adaptive health care organization and use of innovative technologies, (2) assistance in maintaining patient resilience and coping strategies, and (3) health care built on outreaching and person-centered care enabling identification of individual patient needs. Experiences of impaired accessibility to care, altered and unmet care demands and patient needs, and the negative impact of national containment strategies on patient resilience support the need for improvement in these dimensions.

CONCLUSIONS AND IMPLICATIONS

The in-depth insight gained on the impact of the pandemic on chronic care provision was used to propose recommendations for improving care, supported by not only the what and how but also the why developments require additional efforts made by policymakers and change agents, augmented by structural use and development of innovations. Health care organizations should be enabled to rapidly respond to changing internal and external environments, develop and implement innovations, and match care to patient needs.

Three-dimensional microanalysis of tooth movement during the first 6 months of orthodontic double retention

INTRODUCTION

This study performed a 3-dimensional analysis of tooth movement during orthodontic retention to assess the effectiveness of double retention (fixed and removable) in preventing undesired tooth movement.

METHODS

One hundred randomly selected patients were included at the initiation of double orthodontic retention with fixed retainers and vacuum-formed splints (recommended to be worn 22 h/d) in both arches. Intraoral scans were performed directly (T0), 1 month (n = 88), 3 months (T2) (n = 78), and 6 months (T3) (n = 66) after retainer bonding. Nine reference points were marked on each tooth in every patient. Subsequent scans were superimposed, and point displacement was calculated. Statistical analysis was performed using the R statistical software (version 4.2.2; R Core Team, Vienna, Austria).

RESULTS

Sample size calculation determined at least 55 patients were needed. The total dropout between T0 and T3 was 34 patients (did not show up for appointment). The median absolute displacement value of a single point between T0 and T3 was 0.015 mm. The most stable teeth were mandibular central incisors, whereas the least stable were mandibular molars. Most tooth displacements occurred between T0 and T2, then slowed down significantly.

CONCLUSIONS

Double orthodontic retention prevents major tooth displacements in most patients during the first 6 months of retention; however, larger, unpredictable single-tooth displacement may occur in individual patients.

A rapid realist review of clinical neuropsychology rehabilitation programmes to improve psychological wellbeing and quality of life for people with acquired brain injuries

Approximately 20% of acquired brain injury (ABI) survivors experience reduced psychological wellbeing (PWB). Neuropsychological rehabilitation (NPR) is one approach supporting people with ABI to participate meaningfully in activities despite challenges. Although literature supports NPR effectiveness, little is known about change mechanisms. This systematic realist review identifies what NPR programmes have been designed, delivered, and evaluated for people with ABI to improve PWB and/or quality of life (QOL), as well as providing a context-relevant understanding of what NPR includes and how NPR might lead to positive outcomes. A rapid realist review was conducted in three phases: (1) structured retrieval and evidence extraction; (2) stakeholder consultation; (3) analysis and synthesis. Searches were completed, and findings from 35 publications and one stakeholder consultation were synthesized into a refined logic model. Six context-mechanism-outcome chains (CMOCs) were identified. Participants' relationships to internal experiences, and feelings of self-worth, mastery, and connection appeared to be mechanisms that led to improved PWB and QOL. Adaptation and individualized programmes were also key mechanisms to explain successful NPR. Embedding CMOCs into NPR could improve PWB and/or QOL for people with ABI. The logic model will inform ongoing development of a new online, group-based, NPR programme.

Electronic patient-reported outcomes in clinical kidney practice (ePRO Kidney): a process evaluation of educational support for clinicians

Background

Patient-reported outcomes (PROs) are increasingly mandated in kidney care to incorporate patients' perspectives.

Objectives

We assessed whether educational support for clinicians using electronic (e)PROs could enhance person-centered care.

Design

A process evaluation, using a mixed methods longitudinal comparative concurrent design was undertaken of educational support to clinicians on routine use of ePROs. In two urban home dialysis clinics in Alberta, Canada, patients completed ePROs. At the implementation site, clinicians were provided with ePROs and clinician-oriented education via voluntary workshops. At the non-implementation site, neither were provided. Person-centered care was measured using the Patient Assessment of Chronic Illness Care-20 (PACIC-20).

Methods

Longitudinal structural equation models (SEMs) compared change in overall PACIC scores. The interpretive description approach, using thematic analysis of qualitative data, further evaluated processes of implementation.

Results

Data were collected from questionnaires completed by 543 patients, 4 workshops, 15 focus groups, and 37 interviews. There was no overall difference in person-centered care throughout the study, including after delivery of workshops. The longitudinal SEMs revealed substantial individual-level variability in overall PACIC trajectories. However, there was no improvement at the implementation site and no difference between the sites during both the pre- and post-workshop periods. Similar results were obtained for each PACIC domain. Qualitative analysis provided insights into why there was no substantial difference between sites: (1) clinicians wanted to see kidney symptoms, not quality of life, (2) workshops were tailored to clinicians' educational needs, not patients' needs, and (3) variable use of ePRO data by clinicians.

Conclusion

Training clinicians on use of ePROs is complex and likely only part of what is required to enhance person-centered care.

Registration

NCT03149328. https://clinicaltrials.gov/ct2/show/NCT03149328.

Motivations of patients and their care partners for visiting a memory clinic. A qualitative study

OBJECTIVE

We investigated motivations of patients and care partners for their memory clinic visit, and whether these are expressed in consultations.

METHODS

We included data from 115 patients (age 71 ± 11, 49% Female) and their care partners (N = 93), who completed questionnaires after their first consultation with a clinician. Audio-recordings of these consultations were available from 105 patients. Motivations for visiting the clinic were content-coded as reported by patients in the questionnaire, and expressed by patients and care partners in consultations.

RESULTS

Most patients reported seeking a cause for symptoms (61%) or to confirm/exclude a (dementia) diagnosis (16%), yet 19% reported another motivation: (more) information, care access, or treatment/advice. In the first consultation, about half of patients (52%) and care partners (62%) did not express their motivation(s). When both expressed a motivation, these differed in about half of dyads. A quarter of patients (23%) expressed a different/complementary motivation in the consultation, then reported in the questionnaire.

CONCLUSION

Motivations for visiting a memory clinic can be specific and multifaceted, yet are often not addressed during consultations.

PRACTICE IMPLICATIONS

We should encourage clinicians, patients, and care partners to talk about motivations for visiting the memory clinic, as a starting point to personalize (diagnostic) care.

The validation of inherited retinal disease-specific patient-reported outcome measures in adolescent patients

PURPOSE

To determine the validity of the validate the adult patient-reported outcome measure tools, the Michigan Retinal Degeneration Questionnaire (MRDQ) and Michigan Vision-Related Anxiety Questionnaire (MVAQ), in adolescent patients with inherited retinal diseases (IRDs).

METHODS

Ninety-one adolescent patients diagnosed with IRDs were recruited at the Hospital for Sick Children (University of Toronto) and the Kellogg Eye Center (University of Michigan). The patients were administered the MRDQ, MVAQ, and Patient Health Questionnaire-4 (PHQ-4). Test-retest variability was assessed in eighteen patients within 14 days of the initial administration. Adolescent responses were analyzed for validity and reliability. As a further validation step, comparisons were made to adult data from the original MRDQ and MVAQ studies to ensure consistency in response ranges.

RESULTS

The existing MRDQ and MVAQ content and format could accurately detect the impact of IRD on activities of daily living in adolescents with IRDs. No floor/ceiling effects were identified, test-retest reliability was established (r = 0.73-0.86), and no items were excluded after differential item functioning analysis. Domain and trait associations with visual acuity and IRD phenotypes were similar between adolescents and adults.

CONCLUSIONS

The MRDQ and MVAQ are psychometrically validated questionnaires for which we have shown validity for use in adolescent patients with IRDs.

Needs and preferences of patients regarding atopic dermatitis care in the era of new therapeutic options: a qualitative study

To optimally tailor atopic dermatitis (AD) care to patients' needs, especially considering the many emerging therapeutic options, insight into patients' needs and preferences regarding AD care is needed. To explore patients' needs and preferences regarding AD care, a qualitative study consisting of three focus groups with a total of 20 adult AD patients was conducted. All sessions were transcribed verbatim and inductively analyzed using several phases of coding to create an overview of patients' needs and preferences. AD patients emphasized the need for a patient-tailored approach in all identified aspects of AD care. With regard to consultations, patients stressed the need for a personal approach and increased recognition of the disease impact, which should mainly be determined by patients. With regard to the organization of AD care, the need for psychosocial and medical supportive care as well as quick access to health-care providers during disease flares was emphasized. Within the decision-making process, patients indicated that the provided information, the role of the patient and physician, whether or not treatment goals should be set, and decisive factors for indication and feasibility of novel therapies should be patient dependent. AD care should be patient tailored with increased attention for the psychosocial burden, as well as better access to health care during disease flares. To provide patient-tailored care, the personal situation, needs, and preferences of the patient should be taken into account in the therapeutic decision-making process, with respect for the autonomy of the patient.

Shared Decision Making in Psychiatry: Dissolving the Responsibility Problem

Person centered care (PCC) invites ideas of shared responsibility as a direct result of its shared decision making (SDM) process. The intersection of PCC and psychiatric contexts brings about what I refer to as the responsibility problem, which seemingly arises when SDM is applied in psychiatric settings due to (1) patients’ potentially diminished capacities for responsibility, (2) tension prompted by professional reasons for and against sharing responsibility with patients, as well as (3) the responsibility/blame dilemma. This paper aims to do away with the responsibility problem through arguing for a functional approach to mental illness, a blameless responsibility ascription to the person with mental illness, as well as a nuanced understanding of SDM as part of an emancipation-oriented PCC model.

Representations of personalised medicine in family medicine: a qualitative analysis

Background

The promise of personalised medicine (PM) to transform healthcare has sparked great enthusiasm in the last years. Yet, its lack of consensus around the nature and scope of the concept has ended in terminological confusion amongst the users in primary care. We aimed to investigate the perceptions of doctors and their patients in response to this evolving concept. This present article focuses on the general understanding of personalised medicine, underlining the confusion over the concept.

Methods

Semi-structured comprehensive interviews were conducted with 10 general practitioners (GPs) and 10 of their patients. The purposive sampling took into account the doctor’s age, sex, and place of practice (rural/urban); each doctor recruited one patient of the same age and sex. Each interview began with the same open-ended question about the participant’s knowledge of the topic, after which a working definition was provided to continue the discussion. Using the grounded theory method, the analysis consisted of open coding, axial coding and selective coding.

Results

From our present analysis focusing on the general understanding of PM, three main themes representing the concept emerged. The first two representations being “centred on the person as a whole” and “focused on alternative and complementary methods”, in which the therapeutic relationship was stated as key. The third theme “medicine open to innovation” involved the few participants who had a good understanding of the concept and could associate personalised medicine with genomics. For those who value therapeutic relationship, the risks of accepting innovation could result in “fast-food” medicine and interpersonal barriers.

Discussion

PM is predominantly unfamiliar in family medicine. It is misinterpreted as a holistic or integrative type of medicine. This semantic confusion probably lies in the choice of the label “personalised” or from the lack of a uniform definition for the term.

Unifying and universalizing Personalised Care? An analysis of a national curriculum with implications for policy and education relating to person-centred care

OBJECTIVE

To examine the Curriculum of England's Personalised Care Institute as a national initiative to promote person-centred practice.

METHOD

Analysis of Curriculum content and discourse RESULTS: The Curriculum describes an educational framework which aspires to unify approaches and universalize provision of Personalised Care. It presents 8 "models and approaches" and 6 "components" within the "whole" of Personalised Care. It locates their unity in an underlying common core repertoire of professional capabilities and values and an anchoring belief in people's strengths, resourcefulness and ability to develop their own solutions with appropriate support. The Curriculum indicates some complexity in the provision of Personalised Care but leaves unanswered questions about the theoretical coherence of the concept. It also neglects some important aspects of person-centredness (especially values beyond empowerment and choice); the implications of entrenched social inequalities and systemic prejudices; and other practical-ethical implementation challenges that can be difficult for health professionals.

CONCLUSION

The Curriculum signals a national commitment to person-centred practice, but its practical potential is limited by its neglect of the value tensions and diverse situational challenges involved.

PRACTICE IMPLICATIONS

The Curriculum and similar policy-education initiatives could be strengthened by more explicit attention to the normative complexities of person-centred practice.

Application of Machine Learning to Improve Appropriateness of Treatment in an Orthopaedic Setting of Personalized Medicine

The rise of personalized medicine and its remarkable advancements have revealed new requirements for the availability of appropriate medical decision-making models. Computer science is an area that plays an essential role in the field of personalized medicine, where one of the goals is to provide algorithms and tools to extrapolate knowledge and improve the decision-support process. The minimum clinically important difference (MCID) is the smallest change in PROM scores that patients perceive as meaningful. Treatment that does not achieve the minimum level of improvement is considered inappropriate as well as a potential waste of resources. Using the MCID threshold to identify patients who fail to achieve the minimum change in PROM that results in a meaningful outcome may aid in pre-surgical shared decision-making. The decision tree algorithm is a method for extracting valuable information and providing further meaningful information to the domain expert that supports the decision-making. In the present study, different tools based on machine learning were developed. On the one hand, we compared three XGBoost models to predict the non-achievement of the MCID at six months post-operation in the SF-12 physical score. The prediction score threshold was set to 0.75 to provide three decision-making areas on the basis of the high confidence (HC) intervals; the minority class was re-balanced by weighting the positive class to penalize the loss function (XGBoost cost-sensitive), oversampling the minority class (XGBoost with SMOTE), and re-sampling the negative class (XGBoost with undersampling). On the other hand, we modeled the data through a decision tree (assessment tree), based on different complexity levels, to identify the hidden pattern and to provide a new way to understand possible relationships between the gathered features and the several outcomes. The results showed that all the proposed models were effective as binary classifiers, as they showed moderate predictive performance both regarding the minority or positive class (i.e., our targeted patients, those who will not benefit from surgery) and the negative class. The decision tree visualization can be exploited during the patient assessment status to better understand if those patients will benefit or not from the medical intervention. Both of these tools can come in handy for increasing knowledge about the patient’s psychophysical state and for creating an increasingly specialized assessment of the individual patient.

Caregiver perspectives on patient capacities and institutional pathways to person centered forensic psychiatric care

The ethical discourse surrounding patients’ agential capacities, vis-à-vis their active participation in shared decision-making (SDM) in forensic psychiatric (FP) contexts, is an unexplored area of inquiry. The aim of this paper is to explore caregivers’ perceptions of patient agential capacities and institutional pathways and barriers to person centered care (PCC) in the context of FP. Following an exploratory qualitative design, we conducted eight semi-structured interviews with hands-on caregivers at an in-patient FP facility in Sweden. A deductive framework method of analysis was employed, and four themes emerged: “Fundamental Variability in Patient Capacity”, “Patient Participation: Narration or Compliance?”, “Antagonism Rooted in Power Struggles”, and “System Structure Thwarts Patient Release”. While the results generally paint a bleak picture for the possibility of a person-centered FP care, we describe a constrained version of PCC with high-level SDM dynamics which promotes a certain degree of patient empowerment while allowing care strategies, within set restrictions, to promote patient adherence and treatment progress.

The making of a professional digital caregiver: personalisation and friendliness as practices of humanisation

The aim of this paper is to explore how a digital caregiver, developed within a Swedish interdisciplinary research project, is humanised through health-enhancing practices of personalisation and friendliness. The digital caregiver is developed for being used in older patients' homes to enhance their health. The paper explores how the participants (researchers and user study participants) of the research project navigate through the humanisation of technology in relation to practices of personalisation and friendliness. The participants were involved in a balancing act between making the digital caregiver person-like and friend-like enough to ensure the health of the patient. Simultaneously, trying to make the patients feel like as if they were interacting with someone rather than something-while at the same time not making the digital caregiver seem like a real person or a real friend. This illustrates the participants' discursive negotiations of the degree of humanisation the digital caregiver needs in order to promote the health of the patient. A discursive conflict was identified between a patient discourse of self-determination versus a healthcare professional discourse of authority and medical responsibility: whether the digital caregiver should follow the patient's health-related preferences or follow the healthcare professionals' health rules. Hence, a possible conflict between the patient and the digital caregiver might arise due to different understandings of friendliness and health; between friendliness (humanisation) as a health-enhancing practice governed by the patient or by the healthcare professionals (healthcare professionalism).

Scandinavian Nurses’ Use of Social Media during the COVID-19 Pandemic—A Berger and Luckman Inspired Analysis of a Qualitative Interview Study

There is a knowledge gap about nurses’ use of social media in relation to and during the COVID-19 pandemic, which demands the upholding of a physical distance to other people, including patients and their relatives. The study aims to explore how nurses in the Scandinavian countries used social media for professional purposes in relation to the first 15 months of the COVID-19 pandemic. Qualitative, semi-structured interviews with 30 nurses in three Scandinavian countries (Denmark, Norway, and Sweden) were conducted. Thematic analyses were made, methodically inspired by Braun and Clarke, and theoretically inspired by Berger and Luckmann’s theory about the construction of social reality. The Standards for Reporting Qualitative Research (SRQR) checklist was used. The results showed that social media was a socialisation tool for establishing new routines in clinical practice. Virtual meeting places supported collective understandings of a specific COVID-19 ‘reality’ and ‘knowledge’ amongst nurses, with the pandemic bringing to the fore the issue of e-professionalism among nurses relating to their clinical practice. However, social media and virtual education were not commonly used in patient contacts. Further, nurses attempted a re-socialisation of the public to proper COVID-19 behaviour through social media. Moreover, blurred boundaries between acting as a private individual and a professional nurse were identified, where ethics of the nursing profession extended to nurses’ private lives.

Patients' Experiences of Participation in High-Security, Forensic Psychiatric Care

The role of patient participation in forensic psychiatric care is unclear, but has been emphasised as important in recent research. This study aims to describe patients' lived experiences of participation in high-security, forensic psychiatric settings. Sixteen patient interviews were performed in this phenomenological study and analysed with a Reflective Lifeworld Research approach (RLR). Results show that participation must be understood in relation to its opposite construct, non-participation. Participation can thus be explained as situations where non-participation is less visible. Actions to develop the training of patient-staff interactions for forensic psychiatric staff to promote patient participation are called for.

Health literacy in medication communication during hospital discharge: a qualitative study at an internal medicines ward in Norway

OBJECTIVE

When discharged from hospital patients are often assumed to have sufficient health literacy (HL) to participate in their medical treatment and manage medical self-care after discharge. However, limited HL is a widespread concern and patient participation during discharge is lacking. In this study, we explore how HL influences medication communication during hospital discharge.

DESIGN

A qualitative case study, comprising unstructured observations of patient-healthcare personnel (HCP) encounters followed by semistructured interviews. Data were analysed using content analysis.

SETTING

An internal medicines ward at a university hospital in Norway.

PARTICIPANT

Fifteen patients aged 40-89 years were included close to the day of discharge.

RESULTS

The following themes describing dimensions of HL emerged: (1) access, (2) understand, (3) appraise and (4) apply. Most patients sought access to medication information from HCP, while some felt dependent on HCP to provide it. However, their abilities to understand, evaluate and make informed decisions were challenged, partly because HCPs' ability to adapt their communication to the patient's knowledgebase varied.

CONCLUSION

The results give a broader understanding of how HL influences medication communication during hospital discharge. To consider central dimensions of HL is important to achieve optimal medication communication, as the communication only can be exercised within the frames of the patient's HL. The findings in this study support that HL should be described as a shared responsibility between the patients and HCP. Attention should be focused to the HCP's responsibility to adapt the communication to the patient's knowledgebase.

Rehabilitation Workforce Challenges to Implement Person-Centered Care

There is an increasing emphasis on developing person-centered care in rehabilitation settings. However, this care practice has not been fully implemented due to several factors. This study explores rehabilitation workforce perspectives on the barriers and facilitators to implementing person-centered care (PCC). This was a quantitative descriptive study, which was developed based on interviews with 12 healthcare professionals from a private institution in the region of Lisbon and Tagus Valley in Portugal. The recruitment was made in October 2020. Braun, Clarke, Hayfield, and Terry’s content analysis was applied to the transcripts, and these were transcribed verbatim. The consolidated criteria for reporting qualitative research (COREQ) checklist were applied to this study. Participants described barriers such as an unsupportive organization and leadership, staff constraints, heavy workload, and resistance to change. Unique to this study, a patient’s clinical characteristics were identified as barriers to person-centered care. As facilitators, they described leadership, staff satisfaction, a positive physical environment, training and education, and shared decision-making. It is essential to understand the perceptions of the rehabilitation workforce, as they play an integral role in providing PCC. This study serves as a guide to facilitate person-centered care, as it provides an understanding of key barriers and facilitators for its implementation in rehabilitation settings.

Effectiveness of Written Dietary Advice for Improving Blood Lipids in Primary Care Adults-A Pragmatic Randomized Controlled Trial (MYDICLIN)

Lifestyle management is the first line of treatment for moderately elevated blood lipids in healthy individuals. We investigated the effectiveness of providing food-based written advice for lowering low-density lipoprotein (LDL) cholesterol (intervention) or triglycerides (control) in a pragmatic randomized controlled trial with two parallel arms from 2018-2019 at a rural primary health care center. We sent feedback letters after 3 weeks and 6 months. Out of the 113 adult primary care patients randomized, 112 completed the study. There were no differences between the intervention and control groups for changes in LDL cholesterol after 3 weeks (mean ± standard deviation -0.21 ± 0.38 vs. -0.11 ± 0.34 mmol/L, p = 0.45) or 6 months (-0.05 ± 0.47 vs. 0.02 ± 0.41 mmol/L, p = 0.70) (primary outcome). Following the advice to consume plant sterols and turmeric was associated with a reduction in LDL cholesterol after 3 weeks. Following the advice to consume less carbohydrates was associated with reduced triglycerides. In the intervention arm, 14 individuals (25%) reduced their LDL cholesterol by ≥10% after three weeks. Their reduction was attenuated but maintained after six months (-7.1 ± 9.2% or -0.31 ± 0.38 mmol/L, p = 0.01 compared with baseline). They differed only in higher adherence to the advice regarding turmeric. In conclusion, this undemanding intervention had little effect on blood lipids for most individuals.

Success Factors and Barriers in Combining Personalized Medicine and Patient Centered Care in Breast Cancer. Results from a Systematic Review and Proposal of Conceptual Framework

Breast Cancer (BC) is the leading cause of death due to cancer in women. Ensuring equitable, quality-assured and effective care has increased the complexity of BC management. This systematic review reports on the state-of-the art of available literature investigating the enactment of personalized treatment and patient-centered care models in BC clinical practice, building a framework for the delivery of personalized BC care within a Patient-Centered model. Databases were searched for articles (from the inception to December 2020) reporting on Patient-Centered or Personalized Medicine BC management models, assessing success factors or limits. Out of 1885 records, 25 studies were included in our analysis. The main success factors include clearly defined roles and responsibilities within a multi-professional collaboration, appropriate training programs and adequate communication strategies and adopting a universal genomic language to improve patients' involvement in the decision-making process. Among detected barriers, delays in the use of genetic testing were linked to the lack of public reimbursement schemes and of clear indications in timing and appropriateness. Overall, both care approaches are complementary and necessary to effectively improve BC patient management. Our framework attempts to bridge the gap in assigning a central role played by shared decision-making, still scarcely investigated in literature.

Empowering the patient? Medication communication during hospital discharge: a qualitative study at an internal medicines ward in Norway

OBJECTIVE

Effective communication and patient empowerment before hospital discharge are important steps to ensure medication safety. Patients discharged from hospitals are often expected to assume self-management, frequently without healthcare personnel (HCP) having ensured patients' knowledge, motivation and/or skills. In this substudy of a larger study, we explore how patients experience medication communication during encounters with HCPs and how they are empowered at hospital discharge.

DESIGN

This is a qualitative case study. Data collection was done through qualitative observations of patient-HCP encounters, semistructured interviews with patients and drug reconciliation. Data were analysed using content analysis.

SETTING

An internal medicines ward at a university hospital in Norway.

PARTICIPANTS

Nine patients aged 49-90 years were included close to the day of discharge.

RESULTS

The analysis revealed the following themes: (1) patient-centred care (PCC), which included 'understanding and involvement in the patient-as-person', 'establishment of a therapeutic alliance', and 'sharing power and responsibility'; and (2) biomedical (conventional) care, including the subthemes 'HCPs in power and control' and 'optimising medical outcomes, following guidelines'. Even though the elements of PCC were observed in several encounters, overall communication was not sufficiently fostering patient empowerment. Spending time with patients and building relations based on mutual trust seemed undervalued.

CONCLUSIONS

The results provide a broader understanding of how patients experience medication communication at hospital discharge. Both the patients and the HCPs appear to be inculcated with biomedical traditions and are uncertain about the roles and opportunities associated with PCC. Attention should be paid to patient preferences and to the core elements of the PCC model from admission to discharge to empower patients in medication self-management.

An Evidence-Based Theory About PRO Use in Kidney Care: A Realist Synthesis

BACKGROUND

There is international interest on the use of patient-reported outcomes (PROs) in nephrology.

OBJECTIVES

Our objectives were to develop a kidney-specific program theory about use of PROs in nephrology that may enhance person-centered care, both at individual and aggregated levels of care, and to test and refine this theory through a systematic review of the empirical literature. Together, these objectives articulate what works or does not work, for whom, and why.

METHODS

Realist synthesis methodology guided the electronic database and gray literature searches (in January 2017 and October 2018), screening, and extraction conducted independently by three reviewers. Sources included all nephrology patients and/or practitioners. Through a process of extraction and synthesis, each included source was examined to assess how contexts may trigger mechanisms to influence specific outcomes.

RESULTS

After screening 19,961 references, 84 theoretical and 34 empirical sources were used. PROs are proposed to be useful for providing nephrology care through three types of use. The first type is use of individual-level PRO data at point of care, receiving the majority of theoretical and empirical explorations. Clinician use to support person-centered care, and patient use to support patient engagement, are purported to improve satisfaction, health, and quality of life. Contextual factors specific to the kidney care setting that may influence the use of PRO data include the complexity of kidney disease symptom burden, symptoms that may be stigmatized, comorbidities, and time or administrative constraints in dialysis settings. Electronic collection of PROs may facilitate PRO use given these contexts. The second type is use of aggregated PRO data at point of care, including public reporting of PROs to inform decisions at point of care and improve quality of care, and use of PROs for treatment decisions. The third type is use of aggregated PRO data by organizations, including publicly available PRO data to compare centers. In single-payer systems, regular collection of PROs by dialysis centers can be achieved through economic incentives. Both the second and third types of PRO use include pressures that may trigger quality improvement processes.

CONCLUSION

The current state of the evidence is primarily theoretical. There is pressing need for empirical research to improve the evidence-base of PRO use at individual and aggregated levels of nephrology care.

Orthodontic retention: what's on the horizon?

Orthodontic retention remains one of the great challenges in orthodontics. In this article, we discuss what is on the horizon to help address this challenge, including biological approaches to reduce relapse, treating patients without using retainers, technological developments, personalised medicine and the impact of COVID-19 on approaches to orthodontic retention.

Patient-Centered Medicine: A Necessary Condition for the Management of Functional Somatic Syndromes and Bodily Distress

This paper argues that “functional,” “medically unexplained,” or “somatoform” symptoms and disorders necessarily require a patient-centered approach from the clinicians. In the first part, I address the multiple causes of the patients' suffering and I analyze the unease of the doctors faced with these disorders. I emphasize the iatrogenic role of medical investigations and the frequent failure in attempting to reassure the patients. I stress the difficulties in finding the right terms and concepts, despite overabundant nosological categories, to give a full account of psychosomatic complexity. Finally, I discuss the moral dimension attached to assigning a symptom, at times arbitrarily, to a psychogenic origin. The following part presents a brief reminder of the patient-centered approach (PCA) in medicine. In the last part, I aim to explain why and how patient-centered medicine should be applied in the context of functional disorders. First, because PCA focuses on the patients' experience of illness rather than the disease from the medical point of view, which is, indeed, absent. Second, because PCA is the only way to avoid sterile attribution conflicts. Last, because PCA allows doctors and patients to collaboratively create plausible and non-stigmatizing explanations for the symptoms, which paves the way toward effective management.

The evolution of personalized healthcare and the pivotal role of European regions in its implementation

Personalized medicine (PM) moves at the same pace of data and technology and calls for important changes in healthcare. New players are participating, providing impulse to PM. We review the conceptual foundations for PM and personalized healthcare and their evolution through scientific publications where a clear definition and the features of the different formulations are identifiable. We then examined PM policy documents of the International Consortium for Personalised Medicine and related initiatives to understand how PM stakeholders have been changing. Regional authorities and stakeholders have joined the race to deliver personalized care and are driving toward what could be termed as the next personalized healthcare. Their role as a key stakeholder in PM is expected to be pivotal.

The ethics of resource allocation in translational genomic medicine

Two basic models of the rationale of translational genomic medicine (TGM)-the "Lab Assisting Clinic" (LAC) and the "Clinic Assisting Lab" (CAL) models-are distinguished, in order to address the ethics of allocating resources for TGM. The basic challenge of justifying such allocation is for TGM to demonstrate sufficient benefits to justify the opportunity cost of lost benefits in other areas of medicine or research. While suggested ethics frameworks for translational medicine build on clearly distinguishing these models, actual TGM typically blurs them. Due to lack of and difficulty in collecting evidence, prospects for justifying the LAC model currently seem poor, but this difficulty might be overcome by more research that tests the very concept of TGM. The CAL model aims to thus advance science, but is ridden by ethical hazard, undermining attempts at justification. This leaves the notion of running bona fide controlled trials of entire TGM concepts that have been justified from the perspective of clinical and research ethics (and approved by IRBs). It remains, however, an open question if the outcomes of such trials will demonstrate benefits that can justify the investment in TGM. To advance the prospect of such justification further, charting of the cost-benefit profile of TGM compared to alternative health investments would be helpful.

Patients' perceptions of medicines information received at hospital discharge in Norway: a qualitative interview study

Background Insufficient transfer of medicines information is a common challenge at discharge from hospital. Following discharge, home dwelling patients are expected to manage their medicines themselves and adequate counselling is an important prerequisite for patient empowerment and self-efficacy for medicines management. Objective The aim was to identify patients' needs for medicines information after discharge from hospital, including the patients' perception and appraisal of the information they received at discharge. Setting The study enrolled patients discharged from three medical wards at a secondary care hospital in Oslo, Norway. Method Patients were included at the hospital, at or close to the day of discharge and qualitative, semi-structured interviews were performed during the first 2 weeks after discharge. Eligible patients were receiving medicines treatment on admission and after discharge, were handling the medicines themselves, and discharged to their own home. Data were collected in 2017. Interviews were analysed with thematic analysis inspired by Systematic Text Condensation. Main outcome measure Patients' perceptions of medicines information. Results In total, 12 patients were interviewed. They were discharged in equal numbers from the three wards, representing both sexes and a broad age range. Patients perceive medicines information as a continuum and not limited to specific encounters, like the discharge conversation. They gain information in several ways; by receiving information from health care professionals, through observations, and by seeking it themselves. Some thought they could have been better informed about adverse reactions and how to manage life while being a medicines user. Others felt they did not want or need more information. Patients employ various strategies for coping with their use of medicines, influencing their self-efficacy towards medicine management. Conclusion Medicines information should focus on empowering the patients throughout the hospital stay and not solely at discharge, taking into account the individual patient's needs for information, preferences and prior knowledge.

The bigger, the better? When multicenter clinical trials and meta-analyses do not work

Courtesy of the development of the Internet, bursts of information technology, and globalization, huge multicenter studies along with meta-analyses have been introduced to the medical sciences society. Meta-analyses and multicenter studies revolutionized modern medicine and drug development, and empowered evidence based medicine by providing extremely high levels of evidence. Nevertheless, there are occasions that while results of local multi/single center studies showed efficacy of a new treatment, larger multicenter studies or meta-analyses failed to show efficacy, and vice versa. Generally, bigger studies are more powerful and we rely on their results in clinical decision making. Nevertheless, we should keep in mind that in certain circumstances, single center studies are of great importance, and are preferred to multicenter studies and meta-analyses. In order to have a better understanding of why and when multicenter studies along with meta-analyses might not be the best options, we have discussed three different scenarios.

Personalized and Patient-Centered Strategies to Improve Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), a common sleep disorder characterized by repeated pauses in breathing during sleep, is effectively treated with positive airway pressure (PAP) therapy. The magnitude of improvements in daily functioning and reduced negative health risks are dependent on maintaining PAP adherence, which is a significant challenge. Evidence-based interventions to improve PAP use are not easily translated to clinical practice because they are labor-intensive and require specialty expertise. Further, to date, individualized care, inclusive of personalized medicine and patient- and person-centered care have been marginally incorporated in the field's understanding of OSA and PAP adherence. This integrative review describes current PAP adherence assessment processes, interventions to improve adherence, and outlines future opportunities to advance the field, particularly as it relates to individualizing care and the use of implementation science to apply evidence to practice.

Nursing Interventions to Prevent Delirium in Critically Ill Patients in the Intensive Care Unit during the COVID19 Pandemic-Narrative Overview

It has become a standard measure in recent years to utilise evidence-based practice, which is associated with a greater need to implement and use advanced, reliable methods of summarising the achievements of various scientific disciplines, including such highly specialised approaches as personalised medicine. The aim of this paper was to discuss the current state of knowledge related to improvements in "nursing" involving management of delirium in intensive care units during the SARS-CoV-2 pandemic. This narrative review summarises the current knowledge concerning the challenges associated with assessment of delirium in patients with COVID-19 by ICU nurses, and the role and tasks in the personalised approach to patients with COVID-19.

Distressed doctors: a narrative and historical study of work-related mental discomfort among practising physicians

This article explores the complexity of mental distress among physicians, as portrayed in two literary narratives: John Berger and Jean Mohr's A Fortunate Man: The Story of a Country Doctor (1967) and Pia Dellson's Väggen: En utbränd psykiaters noteringar (2015, 'The Wall: Notes by a Burnt-Out Psychiatrist'). Departing from a historical understanding of medical practice, the article seeks to discuss whether some of the noted similarities and differences in the two narratives could be related to changes appearing over time in the role model of the medical encounter. As the two narratives provide illustrative descriptions of the difficulties experienced by doctors suffering from mental discomfort, they also call for a greater awareness among medical practitioners of the sociological terms of doctoring. Practising a person-centred, rather than patient-centred, care might be part of such awareness and is discussed as a possible protective strategy for physicians at risk of work-related mental distress.

Predictors of patient-centered care provision among nurses in acute care setting

AIM

The study was conducted to assess the predictors of patient-centred care provision among nurses working in an acute care setting. We hypothesized that higher structural empowerment and compassion satisfaction and lower burnout would predict the provision of patient-centred care.

BACKGROUND

Patient-centred care is a crucial aspect of quality health care and the heart of nursing care. Although previous studies have highlighted some determinants of patient-centred care provision among nurses, there remains a gap in understanding the factors that predict the provision of patient-centred care.

METHODS

A cross-sectional predictive design was used. Through random sampling, 255 nurses were recruited from five hospitals providing acute care services in Saudi Arabia.

RESULTS

Multiple linear regression revealed that compassion satisfaction (β = 0.260 [95% CI: 0.201-0.645]), burnout (β = -0.266 [95% CI: -0.998 to -0.403]) and structural empowerment (β = 0.273 [95% CI: 0.462-1.427]) jointly explained significant variance (27.5%) in the provision of patient-centred care by nurses.

CONCLUSIONS

The study findings reveal that lower burnout, higher compassion satisfaction and structural empowerment increase nurses' provision of patient-centred care.

IMPLICATIONS FOR NURSING MANAGEMENT

Leadership and managerial strategies that not only address compassion satisfaction and burnout but also empower nurses are crucial for the provision of patient-centred care by nurses.

Young People's Response to Six Smartphone Apps for Anxiety and Depression: Focus Group Study

BACKGROUND

Suicide is one of the most frequent causes of death in young people worldwide. Depression lies at the root of this issue, a condition that has a significant negative impact on the lives of those who experience it and on society more generally. However, 80% of affected young people do not obtain professional help for depression and other mental health issues. Therefore, a key challenge is to find innovative and appealing ways to engage young people in learning to manage their mental health. Research suggests that young people prefer to access anonymous Web-based programs rather than get face-to-face help, which has led to the development of numerous smartphone apps. However, the evidence indicates that not all of these apps are effective in engaging the interest of young people who are most in need of help.

OBJECTIVE

The study aimed to investigate young people's response to six currently available smartphone apps for mental health and to identify features that young people like and dislike in such apps.

METHODS

Focus groups were conducted with 23 young people aged 13 to 25 years in which they viewed and used six smartphone apps for mental health. A general inductive approach following a realist paradigm guided data analysis.

RESULTS

The results revealed that young people value autonomy and the opportunity to personalize experiences with these apps above other things. Finding a balance between simplicity and informativeness is also an important factor.

CONCLUSIONS

App developers need to consider using participant-design frameworks to ensure that smartphone apps are providing what young people want in a mental health app. Solutions to the need for personalization and increasing user engagement are also crucially needed.

Smart tattoo: technology for monitoring blood glucose in the future

New ways of measuring blood glucose bring hope of easing the burden of diabetes management for patients living with the conditions. The smart tattoo is an innovation that represents a nascent nanotechnology, which is designed to be implanted within the skin to provide continuous and reliable glucose detection for individuals diagnosed with diabetes. The potential benefits of the smart tattoo are compelling not only due to the potential of these nanodevices to prevent diabetic complications and decrease the related social costs, but also due to ease of use and relative user comfort. However, despite the advantages of the smart tattoo, it is important that health professionals, in embracing nanotechnology, understand the ethical implications of using these innovative devices.

Unraveling the Black Box: Exploring Usage Patterns of a Blended Treatment for Depression in a Multicenter Study

BACKGROUND

Blended treatments, combining digital components with face-to-face (FTF) therapy, are starting to find their way into mental health care. Knowledge on how blended treatments should be set up is, however, still limited. To further explore and optimize blended treatment protocols, it is important to obtain a full picture of what actually happens during treatments when applied in routine mental health care.

OBJECTIVE

The aims of this study were to gain insight into the usage of the different components of a blended cognitive behavioral therapy (bCBT) for depression and reflect on actual engagement as compared with intended application, compare bCBT usage between primary and specialized care, and explore different usage patterns.

METHODS

Data used were collected from participants of the European Comparative Effectiveness Research on Internet-Based Depression Treatment project, a European multisite randomized controlled trial comparing bCBT with regular care for depression. Patients were recruited in primary and specialized routine mental health care settings between February 2015 and December 2017. Analyses were performed on the group of participants allocated to the bCBT condition who made use of the Moodbuster platform and for whom data from all blended components were available (n=200). Included patients were from Germany, Poland, the Netherlands, and France; 64.5% (129/200) were female and the average age was 42 years (range 18-74 years).

RESULTS

Overall, there was a large variability in the usage of the blended treatment. A clear distinction between care settings was observed, with longer treatment duration and more FTF sessions in specialized care and a more active and intensive usage of the Web-based component by the patients in primary care. Of the patients who started the bCBT, 89.5% (179/200) also continued with this treatment format. Treatment preference, educational level, and the number of comorbid disorders were associated with bCBT engagement.

CONCLUSIONS

Blended treatments can be applied to a group of patients being treated for depression in routine mental health care. Rather than striving for an optimal blend, a more personalized blended care approach seems to be the most suitable. The next step is to gain more insight into the clinical and cost-effectiveness of blended treatments and to further facilitate uptake in routine mental health care.

Norwegian drug information centres strongly promote person-centred and personalised medicine: a brief report on the achievements and strategy

The Norwegian network of drug information centres (RELIS) has achievements in person-centred and personalised medicine. RELIS receive questions from physicians, pharmacists, nurses and other health professionals and provide decision support in all aspects of pharmacotherapy. Questions associated with person-centred medicine often include problems with unrealistic risk perception and poor adherence among patients. Questions associated with personalised medicine frequently concern comorbidity, biomarkers and pharmacogenetics. The questions frequently include a mix of problems related to health and disease care. The RELIS staff addresses each question in a problem-oriented approach with expertise in pharmacology and skills in searching and critical evaluation of the literature. A written answer can describe decision support concerning patient empowerment, further diagnostics and preferences in pharmacotherapy including advice with regard to choice of drug and dose to a patient. Links to online resources and attached references for further reading are often included in the answers. The question-answer service is documented in a full-text, searchable question-answer database. Additional drug information activities towards clinicians and patients, and a multi-professional staff with pharmacists and clinical pharmacologists, are important elements in RELIS drug information strategy, and it is essentially relevant to predictive, preventive and personalised medicine (PPPM).

Woman-centered care 2.0: Bringing the concept into focus

INTRODUCTION

Woman-centered care has become a midwifery concept with implied meaning. In this paper we aim to provide a clear conceptual foundation of woman-centered care for midwifery science and practice.

METHODS

An advanced concept analysis was undertaken. At the outset, a systematic search of the literature was conducted in PubMed, OVID and EBSCO. This was followed by an assessment of maturity of the retrieved data. Principle-based evaluation was done to reveal epistemological, pragmatic, linguistic and logic principles, that attribute to the concept. Summative conclusions of each respective component and a detailed analysis of conceptual components (antecedents, attributes, outcomes, boundaries) resulted in a definition of woman-centered care.

RESULTS

Eight studies were selected for analyses. In midwifery, woman-centered care has both a philosophical and a pragmatic meaning. There is strong emphasis on the woman-midwife relationship during the childbearing period. The concept demonstrates a dual and equal focus on physical parameters of pregnancy and birth, and on humanistic dimensions in an interpersonal context. The concept is epistemological, dynamic and multidimensional. The results reveal the concept’s boundaries and fluctuations regarding equity and control. The role of the unborn child is not incorporated in the concept.

CONCLUSION

An in-depth understanding and a broad conceptual foundation of womancentered care has evolved. Now, the concept is ready for research and educational purposes as well as for practical utility.