Implementing clinical practice guidelines about health promotion and disease prevention through shared decision making

Cost-effectiveness of a multicomponent-adherence intervention in fracture liaison services

BACKGROUND

This study aims to assess the lifetime cost-effectiveness of a multi-component adherence intervention (MCAI), including a patient decision aid and motivational interviewing, compared to usual care in patients with a recent fracture attending fracture liaison services (FLS) and eligible for anti-osteoporosis medication (AOM).

RESEARCH DESIGN AND METHODS

Data on AOM initiation and one-year persistence were collected from a quasi-experimental study conducted between 2019 and 2023 in two Dutch FLS centers. An individual level, state-transition Markov model was used to simulate lifetime costs and quality-adjusted life years (QALYs) with a societal perspective of MCAI vs usual care. One-way and probabilistic sensitivity analyses were conducted including variation in additional FLS and MCAI costs (no MCAI cost in baseline).

RESULTS

MCAI was associated with gain in QALYs (0.0012) and reduction in costs (-€16) and is therefore dominant. At the Dutch willingness-to-pay threshold of €50,000/QALY, MCAI remained cost-effective when increasing costs of the FLS visit or the yearly maintenance cost for MCAI up to +€60. Probabilistic sensitivity analysis demonstrated MCAI to be dominant in 54% of the simulations and cost-effective in 87% with a threshold of €50,000/QALY.

CONCLUSIONS

A MCAI implemented in FLS centers may lead to cost-effective allocation of resources in FLS care, depending on extra costs.

Exploring the Implementation of Shared Decision-Making Involving Health Coaches for Diabetes and Hypertension Self-Management: Qualitative Study

BACKGROUND

An emerging focus on person-centered care has prompted the need to understand how shared decision-making (SDM) and health coaching could support self-management of diabetes and hypertension.

OBJECTIVE

This study aims to explore preferences for the scope of involvement of health coaches and health care professionals (HCPs) in SDM and the factors that may influence optimal implementation of SDM from the perspectives of patients and HCPs.

METHODS

We conducted focus group discussions with 39 patients with diabetes and hypertension and 45 HCPs involved in their care. The main topics discussed included the roles of health coaches and HCPs in self-management, views toward health coaching and SDM, and factors that should be considered for optimal implementation of SDM that involves health coaches. All focus group discussions were audio recorded, transcribed verbatim, and analyzed using thematic analysis.

RESULTS

Participants agreed that the main responsibility of HCPs should be identifying the patient's stage of change and medication education, while health coaches should focus on lifestyle education, monitoring, and motivational conversation. The health coach was seen to be more effective in engaging patients in lifestyle education and designing goal management plans as health coaches have more time available to spend with patients. The importance of a health coach's personal attributes (eg, sufficient knowledge of both medical and psychosocial management of disease conditions) and credentials (eg, openness, patience, and empathy) was commonly emphasized. Participants viewed that addressing the following five elements would be necessary for the optimal implementation of SDM: (1) target population (newly diagnosed and less stable patients), (2) commitment of all stakeholders (discrepancy on targeted times and modality), (3) continuity of care (familiar faces), (4) philosophy of care (person-centered communication), and (5) faces of legitimacy (physician as the ultimate authority).

CONCLUSIONS

The findings shed light on the appropriate roles of health coaches vis-à-vis HCPs in SDM as perceived by patients and HCPs. Findings from this study also contribute to the understanding of SDM on self-management strategies for patients with diabetes and hypertension and highlight potential opportunities for integrating health coaches into the routine care process.

Detailed Analysis of Three Major Breast Reconstructions Using BREAST-Q Responses From 1001 Patients

BACKGROUND

Patient-reported outcomes have become as important as mortality and morbidity in the postoperative evaluation of breast reconstruction surgery. The BREAST-Q is one of the most widely used patient-reported outcomes for breast reconstruction.

OBJECTIVES

A comparative analysis of the scores on each of the BREAST-Q modules could help analyze different reconstruction methods. However, few studies have utilized BREAST-Q for this purpose. The aim of this study was therefore to compare breast reconstruction methods in terms of BREAST-Q module ratings.

METHODS

The authors retrospectively reviewed the data of 1001 patients who had been followed for more than 1 year after breast reconstruction. The 6 BREAST-Q modules were rated on a scale of 0 to 100 and statistically analyzed by multiple regression. In addition, Fisher's exact test was performed after dividing the responses to each question into high- and low-rating groups.

RESULTS

Microvascular abdominal flap reconstruction scored significantly better than implant-based reconstruction on all modules, except psychosocial and sexual well-being. In terms of satisfaction with the breast, latissimus dorsi flap reconstruction was superior to implant-based reconstruction. However, in terms of the reconstruction method, there were no differences in patients' willingness to make the same choice again or whether they regretted having surgery.

CONCLUSIONS

The results highlight the superiority of autologous breast reconstruction. Reconstruction methods should only be performed after a thorough explanation of their characteristics to achieve results that meet patient expectations. The findings are useful for facilitating patient decision-making in breast reconstruction.

LEVEL OF EVIDENCE: 4

A Qualitative Study of Knowledge of Metabolic Syndrome, Attitudes about Lifestyle Modifications, and Preferences for Lifestyle Interventions among Patients with Cancer and Metabolic Syndrome

Background

Nearly 60% of patients with cancer have metabolic syndrome, which increases the risk of mortality, but there is no clear guidance for oncology providers about its management. Here, we report on the qualitative component of a larger mixed methods study that aimed to understand cancer patients' knowledge, attitudes, and preferences regarding metabolic syndrome.

Methods

Adult cancer patients with metabolic syndrome were recruited during 2022-2023 in the MD Anderson General Internal Medicine clinic and participated in semistructured interviews focused on metabolic syndrome and lifestyle interventions. Interviews were audio-recorded and transcribed verbatim. Participants' demographic information was collected. Interviews were analyzed using hybrid thematic analysis and constant comparison involving deductive and inductive coding. Researcher triangulation and debriefing were used to ensure rigor.

Results

There were 19 participants, 12 female and 12 White. Eighteen had solid tumors, including gynecologic (n = 5), genitourinary (n = 4), colorectal (n = 3), and breast (n = 2). Analysis yielded 5 major themes: 1) patients' understanding of metabolic syndrome; 2) attitudes about and approaches to managing metabolic syndrome; 3) capacity and limitations regarding managing metabolic syndrome; 4) patient-led care; and 5) tailored intervention plans. Participants had limited knowledge of metabolic syndrome and its cancer-related consequences; most desired additional education. Many participants reported that their cancer or diabetes diagnosis motivated them to prioritize lifestyle Modifications. Participants expressed strong interest in personalized care plans focused on healthy lifestyle rather than simply weight loss. As part of their tailored intervention plans, participants desired clear communication with their medical team, coordination of care among team members, and collaboration with providers about treatment decisions.

Conclusion

Cancer patients with metabolic syndrome want collaborative, patient-centered care. Shared decision-making based on respect for patients' distinctive needs and preferences is an essential component of the development of such collaborative care. Tailored interventions, practical implementation strategies, and personalized care plans are needed for cancer patients with metabolic syndrome. The study findings contribute to filling the gap in knowledge regarding clear guidance for oncology providers on managing metabolic syndrome and will inform the development of future lifestyle interventions for patients diagnosed with metabolic syndrome.

Mortality Conversations Between Male Veterans and Their Providers Prior to Dysvascular Lower Extremity Amputation

BACKGROUND

Among patients facing lower extremity amputation due to dysvascular disease, the mortality risk is very high. Given this, as well as the importance of a patient-centered approach to medical care, informing patients about their possible risk of dying may be important during preoperative shared decision-making. The goal of this investigation was to gain an understanding of patient and provider experiences discussing mortality within the context of amputation within the Veterans Health Administration.

METHODS

Semistructured interviews were performed with Veterans with peripheral arterial disease and/or diabetes, vascular and podiatric surgeons, and physical medicine and rehabilitation physicians. Interviews were analyzed using team-based content analysis to identify themes related to amputation-level decisions.

RESULTS

We interviewed 22 patients and 21 surgeons and physicians and identified 3 themes related to conversations around mortality: (1) both patients and providers report that mortality conversations are not common prior to amputation; (2) while most providers find value in mortality conversations, some express concerns around engaging in these discussions with patients; and (3) some patients perceive mortality conversations as unnecessary, but many are open to engaging in the conversation.

CONCLUSIONS

Providers may benefit from introducing the topic with patients, including providing the context for why mortality conversations may be valuable, with the understanding that patients can always decline to participate should they not be interested or comfortable discussing this issue.

For which decisions is Shared Decision Making considered appropriate? - A systematic review

OBJECTIVE

To identify decision characteristics for which SDM authors deem SDM appropriate or not, and what arguments are used.

METHODS

We applied two search strategies: we included SDM models from an earlier review (strategy 1) and conducted a new search in eight databases to include papers other than describing an SDM model, such as original research, opinion papers and reviews (strategy 2).

RESULTS

From the 92 included papers, we identified 18 decision characteristics for which authors deemed SDM appropriate, including preference-sensitive, equipoise and decisions where patient commitment is needed in implementing the decision. SDM authors indicated limits to SDM, especially when there are immediate life-saving measures needed. We identified four decision characteristics on which authors of different papers disagreed on whether or not SDM is appropriate.

CONCLUSION

The findings of this review show the broad range of decision characteristics for which authors deem SDM appropriate, the ambiguity of some, and potential limits of SDM.

PRACTICE IMPLICATIONS

The findings can stimulate clinicians to (re)consider pursuing SDM in situations in which they did not before. Additionally, it can inform SDM campaigns and educational programs as it shows for which decision situations SDM might be more or less challenging to practice.

Shared Decision-Making in Cardiovascular Practice

Clinical decisions are optimally made collaboratively, with patients and clinicians working together to review all available information and treatment options. A comprehensive dialogue that identifies and brings into focus individual patient goals within the context of the evidence base is the ideal approach. Shared decision-making (SDM) is essential to making choices about treatment preferences and characterizes the optimal practice of evidence-based medicine and good patient care. By supporting patient autonomy and engagement, the patient and family become partners in their health care. Decisions surrounding whether or not to proceed with diagnostic and therapeutic procedures after fully discussing appropriate alternatives are best made considering both the evidence base and patient goals. The central feature of SDM is that a clinician and a patient engage in a dialogue to jointly make decisions, with reciprocated sharing of information that both find beneficial to reach the best decision. SDM entails much more than patient education or informed consent: there must be bidirectional transfer of knowledge, discussion of patient preference, and a process of deliberation reaching consensus. Patient decision aids have been shown to improve patient understanding of options and risks, enhance the patient's involvement, and focus their comprehension of treatment preferences. Patient decision aids also may be of value in strengthening the physician-patient relationship. The need to emphasize SDM should be integrated into the quality process at every level to make it meaningful, not an apparently arbitrary obstacle that requires discovery of a shrewd work-around. A more patient-oriented consideration of the benefits of symptom relief and improved quality of life, in addition to survival and freedom from adverse events, could only be beneficial.

Impact of Immediate and Delayed Breast Reconstruction on Quality of Life of Breast Cancer Patients

A mastectomy affects the psychological, social, and sexual well-being of patients. Research has confirmed that breast reconstruction is important for improving the quality of life in patients with breast cancer. The aim of this study was to assess the quality of life of patients who underwent a mastectomy followed by immediate or delayed breast reconstruction. This prospective study was conducted from January 2018 to March 2020 at the Clinical Hospital Center Osijek, using the health questionnaire SF-36. The study included 79 patients. The results of the study showed that patients who underwent a mastectomy had the lowest scores in the domain of restriction due to physical difficulties, 18.8 (6.3−31.3), in physical functioning and limitation due to emotional difficulties, 16.7 (8.3−33.3), in mental health. In immediate breast reconstruction, patients rated better physical health (p < 0.001), while patients who underwent delayed breast reconstruction rated their mental health worse (p < 0.001) as measured by the SF-36 questionnaire. Conclusion: The results of this study show that patients without breast reconstruction rated their quality of life worse than patients who underwent immediate and delayed breast reconstruction after mastectomy. There is no difference in the quality of life between patients who underwent immediate and delayed breast reconstruction after mastectomy.

Shared decision making, patient-centered communication and patient satisfaction - A cross-sectional analysis

OBJECTIVES

The integration of shared decision making (SDM) and patient-centered communication (PCC) is needed to actively involve patients in decision making. This study examined the relationship between shared decision making and patient-centered communication.

METHODS

In 82 videotaped hospital outpatient consultations by 41 medical specialists from 18 disciplines, we assessed the extent of shared decision making by the OPTION⁵ score and patient-centered communication by the Four Habits Coding Scheme (4HCS), and analyzed the occurrence of a high versus low degree (above or below median) of SDM and/or PCC, and its relation to patient satisfaction scores.

RESULTS

In comparison to earlier studies, we observed comparable 4HCS scores and relatively low OPTION⁵ scores. The correlation between the two was weak (r = 0.29, p = 0.009). In 38% of consultations, we observed a combination of high SDM and low PCC scores or vice versa. The combination of a high SDM and high PCC, which was observed in 23% of consultations, was associated with significantly higher patient satisfaction scores.

CONCLUSION

Shared decision making and patient-centered communication are not synonymous and do not always co-exist.

PRACTICE IMPLICATIONS

The value of integrated training of shared decision making and patient-centered communication should be further explored.

Stakeholder Research Priorities to Promote Implementation of Shared Decision-Making for Lung Cancer Screening: An American Thoracic Society and Veterans Affairs Health Services Research and Development Statement

Rationale: Shared decision-making (SDM) for lung cancer screening (LCS) is recommended in guidelines and required by Medicare, yet it is seldom achieved in practice. The best approach for implementing SDM for LCS remains unknown, and the 2021 U.S. Preventive Services Task Force calls for implementation research to increase uptake of SDM for LCS. Objectives: To develop a stakeholder-prioritized research agenda and recommended outcomes to advance implementation of SDM for LCS. Methods: The American Thoracic Society and VA Health Services Research and Development Service convened a multistakeholder committee with expertise in SDM, LCS, patient-centered care, and implementation science. During a virtual State of the Art conference, we reviewed evidence and identified research questions to address barriers to implementing SDM for LCS, as well as outcome constructs, which were refined by writing group members. Our committee (n = 34) then ranked research questions and SDM effectiveness outcomes by perceived importance in an online survey. Results: We present our committee's consensus on three topics important to implementing SDM for LCS: 1) foundational principles for the best practice of SDM for LCS; 2) stakeholder rankings of 22 implementation research questions; and 3) recommended outcomes, including Proctor's implementation outcomes and stakeholder rankings of SDM effectiveness outcomes for hybrid implementation-effectiveness studies. Our committee ranked questions that apply innovative implementation approaches to relieve primary care providers of the sole responsibility of SDM for LCS as highest priority. We rated effectiveness constructs that capture the patient experience of SDM as most important. Conclusions: This statement offers a stakeholder-prioritized research agenda and outcomes to advance implementation of SDM for LCS.

Correlation analysis between physicians' evaluations of doctor-patient relationship and their preferences for shared decision-making in China

Shared decision-making (SDM) is a scientific and reasonable decision-making model. However, whether physicians choose SDM is usually influenced by many factors. It is not clear whether the strained doctor-patient relationship will affect physicians' willingness to choose SDM. Through a survey by questionnaire, 304 physicians' evaluations of doctor-patient relationship (DPR) were quantified by the difficult DPR questionnaire-8. Their preferences for SDM and the reasons were also evaluated. The correlation between physicians' evaluations of DPR and their preferences for SDM were analyzed. 84.5% physicians perceived DPR as poor or strained, 53.3% physicians preferred SDM, mainly because of the influences of medical ethics and social desirability bias. Their preferences for SDM were not significantly correlated with their evaluations of DPR (P > 0.05). Physicians with different evaluations of DPR (good, poor, and strained) all had similar preferences for SDM (42.6, 56.4, and 42.9%), with no significant difference (P > 0.05). There was no correlation between physicians' evaluations of DPR and their preferences for SDM. Physicians' evaluations of poor DPR did not affect their preferences for SDM. This may be influenced by the medical ethics and social desirability bias.

Interventions involving own treatment choice for people living with coexisting severe mental illness and type 1 or 2 diabetes: A scoping review

AIM

The objective of this scoping review was to summarize, understand and provide an overview of the empirical literature on interventions involving own treatment choice for people with coexisting diabetes (type 1 and 2) and severe mental illness (SMI).

METHODS

This scoping review undertook a systematic literature assessment. Searches were performed in MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, the Cochrane Library and grey literature (OpenGrey, Google Scholar and Danish Health and Medicine Authority databases). Publications from 2000 to July 2020 were of interest. Studies were included if they involved the users' own choice of treatment.

INCLUDED STUDIES

RCT, intervention, cohort and case-based studies.

RESULTS

A total of 4320 articles were screened, of which nine were included. The review identified eight studies from the United States and one from Canada testing different interventions for people with SMI and diabetes (one diabetes education program, five randomized controlled trials, one retrospective cohort study, one naturalistic intervention program and one case vignette). The interventions described in the nine articles involved service users, the majority incorporated individualized healthcare plans, and all interventions were based on multidisciplinary teamwork.

CONCLUSIONS

Research in the area is limited. Care management interventions tend to focus on a single condition, paradoxically excluding SMI during enrolment. Interventions aimed at people with both conditions often prioritize one condition treatment leading to an unbalanced care.

Impact of a hidradenitis suppurativa patient decision aid on treatment decision making: A randomized controlled trial

Background

Patient decision aids are tools that facilitate shared decision making when clinical evidence and patient values and preferences inform the process. Evidence-based guidelines have been developed for clinicians in hidradenitis suppurativa management. To address treatment decision-making needs of hidradenitis suppurativa patients, we developed a hidradenitis suppurativa patient decision aid.

Objective

To assess the efficacy of the hidradenitis suppurativa patient decision aid during treatment decision making.

Methods

An online, participant-blinded, parallel-group, randomized controlled trial of the hidradenitis suppurativa patient decision aid versus Mayo Clinic hidradenitis suppurativa website content (Mayo) was conducted with hidradenitis suppurativa patients. Outcomes were knowledge, decisional conflict, and preparation for decision making.

Results

Forty participants fulfilled inclusion criteria and were randomized to hidradenitis suppurativa patient decision aid or Mayo. In the hidradenitis suppurativa patient decision aid group, data from 16 and 15 participants were analyzed at phases 1 and 2, respectively. In the Mayo group, data from 15 and 13 participants were analyzed at phases 1 and 2, respectively. Increased knowledge (P < .01) and preparation for decision making (P < .01), as well as reduced decisional conflict (P < .01), were observed in the hidradenitis suppurativa patient decision aid compared with the Mayo group.

Limitations

The online methodology and recruitment from online hidradenitis suppurativa support groups limits generalizability of findings.

Conclusion

A hidradenitis suppurativa patient decision aid increased knowledge and preparation for decision making and reduced decisional conflict.

Application of the Parent Attitudes about Childhood Vaccines (PACV) survey in three national languages in Switzerland: Exploratory factor analysis and Mokken scale analysis

Vaccine hesitancy (VH) is a complex and context-specific phenomenon that is linked to under-immunization and poses challenges to immunization programs. The Parent Attitudes about Childhood Vaccines (PACV) is an instrument developed to measure VH. We translated the PACV into three languages (German, French and Italian) and administered it to 1388 Swiss parents. We used exploratory factor analysis (EFA) to confirm the scale sub-domains, Cronbach's alpha to assess internal consistency reliability, and Mokken scale analysis (MSA), to explore unidimensionality of each language version. We determined to construct validity by linking parental PACV score to children's immunization status for the first dose of measles vaccine. For the 15-item PACV, EFA extracted three sub-domains in German and French and four sub-domains in Italian. Cronbach's alpha was >0.8 across the three languages, and MSA produced a 13-item German, 14-item French, and 11-item Italian PACV. EFA and MSA of the short version PACV extracted a single factor and scale with Cronbach's alpha >0.7 in all three language versions. VH was significantly associated with non-timely receipt of the first dose of measles in all languages (odds ratio of 20.7, 21.3, and 8.3 for German, French, and Italian languages, respectively). The translated and revised PACV-15 versions are valid and reliable instruments for VH measurement. The structure and reliability of the short version of the PACV was as good as the long version. Our results suggest that the PACV can be used to measure parental VH outside the US in the validated languages.

Reframing Clinical Paradigms: Strategies for Improving Patient Care Relationships

This article presents strategies for reframing clinical paradigms to build better therapeutic relationships with patients and the members of their support network from the unique and important lens of a parent and disability researcher. First, a brief history of the evolution of models of care is presented, and implementation of the current biopsychosocial model is discussed. Then, evidence-based practice and the role of the patient perspective is considered. Next, specific examples, tools, techniques, guidelines, and resources to foster the demonstration of patient-informed respect and patient-centered communication in clinical practice are provided. Examples and resources are presented that can be accessed and implemented immediately, without cost to the practitioner and with the vast potential to improve care, therapeutic relationships, and patient outcomes. It is important for health care providers and researchers in all practice areas and across all experience levels to regularly evaluate their psychosocial skills. It is critical that the voices of patients and the members of their support network are central in this process. This can enable health care providers to acknowledge areas for growth and to implement changes effectively and efficiently at the individual level to facilitate changes across the broader spectrum of health care practice.

Impact of Cost Conversation on Decision-Making Outcomes

Objective

To understand the impact of cost conversations on the following decision-making outcomes: patients’ knowledge about their conditions and treatment options, decisional conflict, and patient involvement.

Patients and Methods

In 2020 we performed a secondary analysis of a randomly selected set of 220 video recordings of clinical encounters from trials run between 2007 and 2015. Videos were obtained from eight practice-based randomized trials and one pre–post-prospective study comparing care with and without shared decision-making (SDM) tools.

Results

The majority of trial participants were female (61%) and White (86%), with a mean age of 56, some college education (68%), and an income greater than or equal to $40,000 per year (75%), and who did not participate in an encounter aided by an SDM tool (52%). Cost conversations occurred in 106 encounters (48%). In encounters with SDM tools, having a cost conversation lead to lower uncertainty scores (2.1 vs 2.6, P=.02), and higher knowledge (0.7 vs 0.6, P=.04) and patient involvement scores (20 vs 15.7, P=.009) than in encounters using SDM tools where cost conversations did not occur. In a multivariate model, we found slightly worse decisional conflict scores when patients started cost conversations as opposed to when the clinicians started cost conversations. Furthermore, we found higher levels of knowledge when conversations included indirect versus direct cost issues.

Conclusion

Cost conversations have a minimal but favorable impact on decision-making outcomes in clinical encounters, particularly when they occurred in encounters aided by an SDM tool that raises cost as an issue.

A comparison of patient-reported outcomes between Alloderm and Dermacell in immediate alloplastic breast reconstruction: A randomized control trial

BACKGROUND

Alloderm and Dermacell are the two leading human acellular dermal matrices (ADM) in immediate breast reconstruction (IBR). Despite differences in sterility, consistency, thickness and cost, there are no comparative trials to date to compare patient-reported outcome measures (PROM) between the two products. The purpose of this study was to determine if there was a difference in patient-reported outcomes (as measured by the BREAST-Q) between patients reconstructed with Alloderm and Dermacell.

METHODS

A single center, open-label, randomized control trial of patients undergoing IBR with an implant for breast cancer or breast cancer prophylaxis was performed. Patients were randomized to either Alloderm or Dermacell. Baseline demographic data were compared, and linear mixed models were used to identify associations with BREAST-Q over time.

RESULTS

Between June 2016 and October 2018, 62 patients were randomized into two groups, 31(50%) Alloderm and 31(50%) Dermacell. Of these, 23(74%) patients in the Alloderm group and 27(87%) patients of the Dermacell group filled out BREAST-Q questionnaires. Baseline BREAST-Q scores with respect to satisfaction with breasts, psychosocial well-being, sexual well-being, and physical well-being were similar between groups (p>0.05). At 3 months postoperatively, the Alloderm group had a statistically significant improvement with respect to satisfaction with breasts (67 vs 53, p = 0.03), satisfaction with overall results (85 vs 61, p = 0.003), satisfaction with the surgeon (89 vs 67, p = 0.01), and satisfaction with information provided (74 vs 59, p = 0.02). At 12 months postoperatively, there were no statistically significant differences in PROM between groups (p>0.05).

CONCLUSION

We report the first randomized controlled trial to date comparing patient-reported outcomes of the two most commonly used ADMs in IBR in Canada. Although a short-term analysis favors the use of Alloderm, there does not appear to be any difference in outcomes between the two products in the longer term.

Making shared decisions in relation to planned caesarean sections: What are we up to?

OBJECTIVE

To map the literature in relation to shared decision making (SDM) for planned caesarean section (CS), particularly women's experiences in receiving the information they need to make informed decisions, their knowledge of the risks and benefits of CS, the experiences and attitudes of clinicians in relation to SDM, and interventions that support women to make informed decisions.

METHODS

Using a scoping review methodology, quantitative and qualitative evidence was systematically considered. To identify studies, PubMed, Maternity and Infant Care, MEDLINE, and Web of Science were searched for the period from 2008 to 2018.

RESULTS

34 studies were included, with 9750 women and 3313 clinicians. Overall women reported limited SDM, and many did not have the information required to make informed decisions. Clinicians generally agreed with SDM, while recognising it often does not occur. Decision aids and educational interventions were viewed positively by women.

CONCLUSION

Many women were not actively involved in decision-making. Decision aids show promise as a SDM-enhancing tool. Studies that included clinicians suggest uncertainty regarding SDM, although willingness to engage.

PRACTICE IMPLICATIONS

Moving from clinician-led decision-making to SDM for CS has potential to improve patient experiences, however this will require considerable clinician training, and implementation of SDM interventions.

Training Interventions to Equip Health Care Professionals With Shared Decision-Making Skills: A Systematic Scoping Review

INTRODUCTION

To support the development, implementation, and evaluation of shared decision-making (SDM) training programs, this article maps the relevant evidence in terms of training program design and content as well as evaluation outcomes.

METHOD

A systematic scoping review methodology was used. To identify studies, the databases PubMed, Medline, and CINAHL were searched from 2009 to 2019, and reference lists of included studies were examined. After removal of duplicates, 1367 articles were screened for inclusion. To be included, studies were to be published in peer-reviewed journals, and should not merely be descriptive but report on evaluation outcomes. Articles were reviewed for inclusion by both authors, and data were extracted using a purposely designed data charting form implemented using REDCap.

RESULTS

The review identified 49 studies evaluating 36 unique SDM training programs. There was considerable variation in terms of program design and duration. Most programs included an overview of SDM theories and key competencies, as well as SDM skill development through role plays. Few programs provided training in reflective practice, in identifying and working with patients' individually preferred decision-making style, or in relation to SDM in a context of medical uncertainty or ambiguity. Most programs were evaluated descriptively, mostly using mixed methods, and there were 18 randomized controlled trials, showing that training was feasible, well received, and improved participants' knowledge and skills, but was limited in its impact on patients.

DISCUSSION

Although there is limited capacity to comment on which types of training programs are most effective, overall training was feasible, well received, and improved participants' knowledge and skills.

Effectiveness and cost-effectiveness of a multicomponent intervention to implement a clinical practice guideline for systemic lupus erythematosus: protocol for a cluster-randomized controlled trial

Background

Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease with significant potential morbidity and mortality. Substantial gaps have been documented between the development and dissemination of clinical practice guidelines (CPG) and their implementation in practice. The aim of this study is to assess the effectiveness and cost-effectiveness of a multi-component knowledge transfer intervention to implement a CPG for the management of SLE (CPG-SLE).

Methods

The study is an open, multicentre, controlled trial with random allocation by clusters to intervention or control. Clusters are four public university hospitals of the Canary Islands Health Service where rheumatologists are invited to participate. Patients diagnosed with SLE at least one year prior to recruitment are selected. Rheumatologists in intervention group receive a short educational group programme to both update their knowledge about SLE management according to CPG-SLE recommendations and to acquire knowledge and training on use of the patient-centred approach, a decision support tool embedded in the electronic clinical record and a quarterly feedback report containing information on management of SLE patients. Primary endpoint is change in self-perceived disease activity. Secondary endpoints are adherence of professionals to CPG-SLE recommendations, health-related quality of life, patient perception of their participation in decision making, attitudes of professionals towards shared decision making, knowledge of professionals about SLE and use of healthcare resources. Calculated sample size is 412 patients. Data will be collected from questionnaires and clinical records. Length of follow-up will be 18 months. Multilevel mixed models with repeated time measurements will be used to analyze changes in outcomes over time. Cost-effectiveness, from both social and healthcare services perspectives, will be analyzed by measuring effectiveness in terms of quality-adjusted life years gained. Deterministic and probabilistic sensitivity analyses are planned.

Discussion

Impact of CPGs in clinical practice could be improved by applying proven value interventions to implement them. The results of this ongoing trial are expected to generate important scientifically valid and reproducible information not only on clinical effectiveness but also on cost-effectiveness of a multi-component intervention for implementation of a CPG based on communication technologies for chronic patients in the hospital setting.

Trial registration

ClinicalTrial.gov NCT03537638. Registered on 25 May 2018.

Long-term Patient-Reported Outcomes in Postmastectomy Breast Reconstruction

Importance

Previous outcome studies comparing implant and autologous breast reconstruction techniques have been limited by short-term follow-up, single-center design, and a lack of rigorous patient-reported outcome data. An understanding of the expected satisfaction and breast-related quality of life associated with each type of procedure is central to the decision-making process.

Objective

To determine outcomes reported by patients undergoing postmastectomy breast reconstruction using implant or autologous techniques 2 years after surgery.

Design, Setting, and Participants

Patients were recruited from 11 centers (57 plastic surgeons) across North America for the Mastectomy Reconstruction Outcomes Consortium study, a prospective, multicenter trial, from February 1, 2012, to July 31, 2015. Women undergoing immediate breast reconstruction using implant or autologous tissue reconstruction after mastectomy for cancer treatment or prophylaxis were eligible. Overall, 2013 women (1490 implant and 523 autologous tissue reconstruction) met the inclusion criteria. All patients included in this analysis had 2 years of follow-up.

Exposures

Procedure type (ie, implant vs autologous tissue reconstruction).

Main Outcomes and Measures

The primary outcomes of interest were scores on the BREAST-Q, a validated, condition-specific, patient-reported outcome instrument, which were collected prior to and at 2 years after surgery. The following 4 domains of the BREAST-Q reconstruction module were evaluated: satisfaction with breasts, psychosocial well-being, physical well-being, and sexual well-being. Responses from each scale were summed and transformed on a 0 to 100 scale, with higher numbers representing greater satisfaction or quality of life.

Results

Of the 2013 women in the study (mean [SD] age, 48.1 [10.5] years for the group that underwent implant-based reconstruction and 51.6 [8.7] years for the group that underwent autologous reconstruction), 1217 (60.5%) completed questionnaires at 2 years after reconstruction. After controlling for baseline patient characteristics, patients who underwent autologous reconstruction had greater satisfaction with their breasts (difference, 7.94; 95% CI, 5.68-10.20; P < .001), psychosocial well-being (difference, 3.27; 95% CI, 1.25-5.29; P = .002), and sexual well-being (difference, 5.53; 95% CI, 2.95-8.11; P < .001) at 2 years compared with patients who underwent implant reconstruction.

Conclusions and Relevance

At 2 years, patients who underwent autologous reconstruction were more satisfied with their breasts and had greater psychosocial well-being and sexual well-being than did those who underwent implant reconstruction. These findings can inform patients and their clinicians about expected satisfaction and quality of life outcomes of autologous vs implant-based procedures and further support the adoption of shared decision making in clinical practice.

Healthy lifestyle discussions between healthcare providers and older cancer survivors: Data from 12 cancer centers in the Southeastern United States

Background

Little is known about the prevalence of healthy lifestyle (HLS) discussions between providers and older cancer survivors.

Methods

We utilized cross‐sectional data from older cancer survivors (≥65 years) seen at 12 southeastern cancer centers during 2013‐2015. Data on demographics, time since diagnosis, weight, height, and healthy behaviors were collected. Respondents were asked if providers (oncologists, other physicians, and/or nurses) discussed exercise, healthy diet, weight management, and/or smoking cessation during clinical encounters. Descriptive statistics and bivariate associations between HLS topics and survivor characteristics were calculated.

Results

Among 1460 cancer survivors, mean age was 74 years (SD 6), most were white (81%), and >1 year postdiagnosis (84%). The majority (71%) reported discussing at least one of three HLS topics (exercise 49%, healthy diet 53%, vegetable consumption 28%); 17% received counseling on all three. Weight loss was recommended to 33% of overweight/obese survivors and smoking cessation to 85% of current smokers. Oncologists and nurses discussed HLS less frequently compared to other physicians. Younger survivors (65‐74 years) received recommendations for exercise, weight loss, and tobacco cessation more often than older survivors (≥75 years). Compared to white respondents, minorities reported discussions on all topics more often except for tobacco cessation. Excluding tobacco cessation, survivors with recent cancer diagnoses (<1 year) reported HLS discussions more often than survivors >1 year postdiagnosis.

Conclusion

Despite the American Cancer Society's recommendations, older survivors reported a low prevalence of HLS discussions with their providers, with some variation by demographic groups. Strategies are needed to promote these important discussions in this population.

Israeli E-patients' Informational Needs

BACKGROUND

Online medical information has transformed the way patients obtain information.

PURPOSE

The present study examined patients' informational needs and the patient- Healthcare Provider (HCP) relationship from the perceptions of both patients and HCP.

METHODS

The study was a cross-sectional study; data were collected in Israel from100 HCPs (nurses and physicians) and 184 e-patients.

FINDINGS

E-patients were comfortable sharing e-information with their HCP and expected them to consider the e-information in treatment decision-making. Physicians thought they provided more information than the patients considered that they received from them, while both nurses and patients were in agreement about their interactions. Patients thought that there was a higher concordance between the e-information and the information they received from the physician/nurse as compared to what physicians and nurses reported.

DISCUSSION AND CONCLUSIONS

E-health information does not disrupt the patient-nurse/physician relationship. To promote compliance to treatment, it is important that HCPs consider information presented by patients when preparing the treatment plan.

The relationship between health literacy and perceived shared decision making in patients with breast cancer

OBJECTIVES

We explored the relationship between patient-perceived shared decision making (SDM) and three domains of health literacy (HL) in patients with breast cancer.

METHODS

In this cross-sectional study, we prospectively recruited a convenience sample of 511 breast cancer patients from 3 hospitals in Taiwan. Patients completed questionnaires about HL and perceived SDM in a recent consultation. Sequential regressions, controlling for International Classification of Functioning, Disability and Health (ICF)-related factors) were conducted. Interactions of each HL domain with age or education were also assessed for the relationship with perceived SDM.

RESULTS

Higher scores in the HL domains of healthcare and disease prevention, but lower scores in the health promotion domain, were significantly associated with a higher perceived level of SDM after controlling for ICF-related factors (R² = 33.44%). The association of SDM with two domains of HL varied with age, while the relationship between the 3 HL domains and SDM differed across education levels.

CONCLUSION

Each HL domain was significantly associated with perceived SDM after controlling for the ICF-related factors and across different age- and education-stratifications.

PRACTICE IMPLICATIONS

Clinicians should be cognizant of patients' HL levels and incorporate HL best practices into consultations and interactions with patients with breast cancer to facilitate SDM.

Application of Kern's 6-Step Approach in the Development of a Novel Anesthesiology Curriculum for Perioperative Code Status and Goals of Care Discussions

BACKGROUND

Code status discussions, goals of care discussions, and shared decision-making in the perioperative setting are of great importance. As perioperative physicians, anesthesiologists are uniquely poised to handle these discussions. Yet formal training for anesthesiology residents in how to approach these scenarios is currently lacking.

METHODS

Using Kern's 6-step approach to curriculum development, we describe an innovative curriculum for anesthesiology residents designed to teach the necessary skills to successfully conduct code status and goals of care discussions and to assess its efficacy.

RESULTS

Our curriculum is composed of the following educational components: (1) formal, online learning modules, (2) selected journal articles describing code status and goals of care discussions skills and communication strategies, and (3) 2 objective-structured clinical examination experiences, with 1 occurring prior to and the other occurring after completion of the educational content. The educational content focuses on evidence-based best practices content covering professional guidelines, current literature, shared decision-making, and effective communication strategies. We also describe the potential methodology to evaluate the effectiveness of our proposed educational interventions.

CONCLUSION

Using Kern's framework, we developed a curriculum focusing on code status discussions, goals of care discussions, and shared decision-making in the perioperative setting which provides trainees with the opportunity to practice communication skills and receive feedback from a standardized patient through participation in an objective structured clinical examination.

Guideline Implementation in Standardized Office Workflows and Exam Types

BACKGROUND

Clinical practice guidelines (CPGs) in medicine are recommendations supported by systematic review of evidence to facilitate optimal patient outcomes. Primary care practices are expected to implement more than 200 CPGs, overwhelming many practices. This qualitative study elucidated the perspectives and priorities of family medicine physicians and office managers in grouping CPGs to facilitate implementation.

METHODS

A qualitative study was performed using individual, semistructured interviews. During the interviews the participants completed an open card-sort exercise grouping 20 CPGs. Purposive sampling was used to identify family medicine physicians and office managers practicing in medically underserved zip codes listed in the local medical society directory. Seven physicians and 6 office managers were interviewed. The interviews were transcribed and analyzed using thematic analysis and compared with the card-sort results.

RESULTS

Thematic content analysis identified priorities and perspectives of office managers and physicians when grouping multiple CPGs for implementation: delegation, personalization, triggers, and change management. The card sort exercise revealed grouping by standardized preventive care visit, standardized rooming and discharge processes, and chronic illness. Chronic illness-based groupings and personalization of guidelines were recognized as presenting barriers to delegation of CPGs to the care team. Development of standardized preventive exams, standard rooming and discharge processes and chronic disease management were identified as promoting CPG adherence through team-based care. Standardized workflows provided opportunities for task delegation through predicable roles. Medicalization of CPG implementation relied heavily on the physician alone to remember to adhere to CPGs and inhibited task sharing by not giving office staff clear disease-based protocols to follow.

CONCLUSIONS

This study identified priorities and perspectives of office managers and physicians when grouping multiple CPGs for concomitant implementation: delegation, personalization, triggers, and change management. Successful implementation was perceived to be associated with standardized preventive exams, standard rooming and discharge processes, and chronic disease management.

A Framework and Resources for Shared Decision Making: Opportunities for Improved Physical Therapy Outcomes

Shared decision making (SDM) is a collaborative approach between clinicians and patients, where the best available evidence is integrated with patients' values and preferences for managing their health problems. Shared decision making may enhance patient-centered care and increase patients' satisfaction, engagement, adherence, and ability to self-manage their conditions. Despite its potential benefits, SDM is underutilized by physical therapists, and frequent mismatches between patients' and therapists' rehabilitation goals have been reported. Physical therapists can use evidence-based strategies, tools, and techniques to address these problems. This paper presents a model for SDM and explains its association with improved patient outcomes and relevance to situations commonly encountered in physical therapy. It describes freely available resources, including health literacy universal precautions, teach-back, motivational interviewing, decision aids, and patient-reported outcome measures that can help physical therapists integrate SDM into their clinical practices. This paper also explains SDM facilitators and barriers, suggests a theoretical framework to address them, and highlights the need for SDM promotion within physical therapy practice, education, administration, and research.

The influence of risk labeling on risk perception and willingness to seek help in an experimental simulation of preventive medical examinations

OBJECTIVE

To study the influence of the presentation of results of a preventive medical examination on risk perception and willingness to seek help for work-related fatigue or being overweight.

METHODS

A factorial design experiment was conducted, presenting workers (n = 82) with vignettes including eight scenarios of test results with and without an emphasis on the risk of a current or future health condition or a probe to seek help. Participants rated perceived risk and willingness to seek help (0-100 Visual Analogue Scale) as if these were their own results. Differences were tested with paired-sample t-tests.

RESULTS

In scenarios emphasizing the risk of a current or future disorder, participants perceived higher risk and were more willing to seek help (p-values < .00). Slightly higher willingness to seek help scores was observed in all scenarios that included probes (p < .00).

CONCLUSION

Risk perception and willingness to seek help of workers participating in a preventive medical examination were higher when they were told that the test results indicate a risk of a current or future disorder and after being advised to seek help.

PRACTICE IMPLICATIONS

Healthcare providers should take the potential effects on risk perception and help-seeking into account in preventive settings.

Physicians' perspectives on communication and decision making in clinical encounters for treatment of latent tuberculosis infection

The aim of the study was to explore the views of tuberculosis (TB) physicians on treatment of latent TB infection (LTBI), focusing on decision making and communication in clinical practice.

20 Australian TB physicians participated in a semistructured interview in person or over the telephone. Interviews were recorded, transcribed and analysed thematically.

The study identified challenges that physicians face when discussing treatment for LTBI with patients. These included difficulties explaining the concept of latency (in particular to patients from culturally and linguistically diverse backgrounds) and providing guidance to patients while still framing treatment decisions as a choice. Tailored estimates of the risk of developing TB and the risk of developing an adverse effect from LTBI treatment were considered the most important information for decision making and discussion with patients. Physicians acknowledged that there is a significant amount of unwarranted treatment variation, which they attributed to the lack of evidence about the risk–benefit balance of LTBI treatment in certain scenarios and guidelines that refer to the need for case-by-case decision making in many instances.

In order to successfully implement LTBI treatment at a clinical level, consideration should be given to research on how to best address communication challenges arising in clinical encounters.

Overcoming challenges in clinical encounters is essential for implementation of treatment of latent TB infectionhttp://ow.ly/HEFu30izBUu

Trends in Drug Prescription Rates for Dementia: An Observational Population-Based Study in France, 2006-2014

BACKGROUND

Since the 2011 French guidance updates, cholinesterase inhibitors and memantine are considered optional in the management of dementia and leave physicians free to prescribe based on their clinical expertise.

OBJECTIVES

The aims of this study were to analyze the influence of these recent guidance updates on the prescription rates of these drugs and to quantify the impact of potential changes on healthcare expenditures.

METHODS

Patients over 65 years old from a representative sample of a national administrative claims database, the French national health insurance database, were retrospectively included from 2006 to 2014. Trends of annual prescription rates were tested using adjusted segmented regression analysis. Drug costs with and without prescribers' behavioral changes were estimated.

RESULTS

A total of 119,731 individuals were included and followed during the study period. Among them, 5514 individuals were treated for dementia. According to the unadjusted segmented regression model, there was a significant increase in prescription rates between 2006 and 2010, from 2.23% (95% confidence interval 2.13-2.34) to 2.73% (95% confidence interval 2.62-2.84) of the study population. Since 2011, the trend has reversed with a significant decrease until 2014, from 2.64% (95% confidence interval 2.54-2.75) to 1.92% (95% confidence interval 1.84-2.01). In the multivariate analysis, we also found a gradual decline since 2011, particularly for patients aged 65-69 years and with one or more other chronic diseases. Cost savings associated with prescribers' behavioral changes were estimated at €108 million.

CONCLUSION

Drugs prescribed for dementia are on a declining trend with important cost savings, and this was concomitant with guidance updates that left physicians to rely on their clinical expertise while managing dementia.

Physician perspectives on the burden and management of asthma in six countries: The Global Asthma Physician Survey (GAPS)

Background

Despite recognition of asthma as a growing global issue and development of global guidelines, asthma treatment practices vary between countries. Several studies have reported patients’ perspectives on asthma control. This study presents physicians’ perspectives and strategies for asthma management.

Methods

Physicians seeing ≥4 adult patients with asthma per month in Australia, Canada, China, France, Germany, and Japan were surveyed (N=1809; ≈300 per country). A standardised questionnaire was developed for this study and administered by telephone, online or face-to-face. Statistics were weighted to account for the sampling scheme.

Results

Physicians estimated that 71% of their adult patients received maintenance medication, with adherence monitored by 76–97% of physicians. Perceived major barriers to patient adherence included: patients taking treatment as needed; acceptance of symptoms; and patients not perceiving treatment benefits. Written action plans (37%) and technology (15%) were seldom employed by physicians to aid patients’ asthma management. Physicians rarely (10%) used validated patient-reported questionnaires to monitor asthma control, instead monitoring selected symptoms, exacerbations, and/or lung function measurements. Awareness of single maintenance and reliever therapy (SMART/MART) varied among countries (56–100%); although most physicians (72%) had prescribed SMART/MART, the majority (91%) co-prescribed a short-acting bronchodilator at least some of the time.

Conclusions

These results show that physicians generally do not employ standardised tools to monitor asthma control or to manage its treatment and that despite high awareness of SMART/MART, the strategy appears to be commonly misapplied. Better education for patients and physicians is required to improve asthma management and resulting patient outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12890-017-0492-5) contains supplementary material, which is available to authorized users.

Clinical trainees' responses to parents who question evidence-based recommendations

OBJECTIVE

We examined clinicians' attitudes, beliefs, and behavioral intentions about discussing evidence and eliciting values when patients question recommendations.

METHODS

We randomized trainees to read one of three scenarios about a parent of a one-year-old: 1) overuse (parent requests antibiotics for presumed viral infection); 2) equipoise (tubes for recurrent ear infections); 3) underuse (parent hesitates about vaccination). Participants then answered survey questions. Outcomes included time spent clarifying values (primary), attitudes and beliefs about the parent (secondary).

RESULTS

132 medical students and pediatric residents enrolled; 119 (90%) completed the study. There were no differences in time participants would spend clarifying values (antibiotics 26±12%; equipoise 28±11%; vaccine-hesitancy 22±11%; p=0.058). Participants in the vaccine-hesitancy group (vs. other groups) would spend less time answering questions (p=0.006). Participants in the antibiotics (vs. equipoise) group perceived the parent as difficult (p=0.0002). Those in the vaccine-hesitancy group (vs. other groups) perceived the parent as difficult, saw less value in the conversation, and had lower respect for the parent's views (all ps<0.0001). Most (76%) wanted additional training navigating these discussions.

CONCLUSION

Clinicians' attitudes may impact conversations when patients question evidence-based recommendations.

PRACTICE IMPLICATIONS

Clinicians should consider ways to discuss evidence and clarify patients' values to optimize health without damaging patient-clinician relationships.

Does shared decision making results in better health related outcomes for individuals with painful musculoskeletal disorders? A systematic review

Background: Shared Decision-Making (SDM) is a dynamic process by which the health care professional and the patient influence each other in making health-related choices or decisions. SDM is strongly embedded in today's health care approaches, and is advocated as an ideal model since it renders individuals more control towards the health care they choose to receive, and has been shown to improve patient outcomes. Objectives: The goal of this systematic review was to investigate the added-value of SDM on clinical health-related outcomes in patients with a variety of musculoskeletal conditions. Data sources: PubMed and CINAHL. Study selection: PRISMA guidelines were followed for this review. To be considered for review, the study had to meet all the following criteria: (1) prospective studies that involved treatment decision-making; (2) randomized controlled trial design; (3) involving patients faced with having to make a treatment decision; (4) comparing SDM with a control intervention and (5) including one or more of the following outcome measures: well-being, costs, health-related pain or disability measures, or quality of life. Study appraisal: A priori, we determined to perform methodological quality assessment using the Cochrane Risk of Bias tool for randomized controlled trials. Results: We did not find a single study that looked at the true effect of SDM on patient reported outcomes in a population with musculoskeletal pain. Conclusion: For the management of painful musculoskeletal conditions, in the light of the current evidence (none), we estimate that it would be wise to explore the effectiveness of SDM before forcing its large-scale implementation in rehabilitation.

Mammography Screening: Gaps in Patient's and Physician's Needs for Shared Decision-Making

As shared decision-making increasingly influences screening mammography, understanding similarities and differences between patients and physician perspectives becomes crucially important. This study compares women's and physicians' experiences of mammography shared decision-making. Results reflect the critical gaps which exist between women's expectations and physicians' confidence in shared decision-making regarding screening mammography.

A patient in the clinic; a person in the world. Why shared decision making needs to center on the person rather than the medical encounter

Interest in shared decision making (SDM) has increased and become widely promoted. However, from both practical and measurement perspectives, SDM's origin as an outgrowth of patient autonomy has resulted in narrowly conceptualizing and operationalizing decision making. The narrow focus on individual patient autonomy fails in four main ways: 1) excluding several facets of the roles, actions, and influences of decision partners in decision making; 2) focusing solely on the medical encounter; 3) ignoring the informational environment to which patients have access; and 4) treating each encounter as independent of all others. In addition to creating a research agenda that could answer important outstanding questions about how decisions are made and the consequences thereof, reconceiving SDM as centered on the person rather than the medical encounter has the potential to transform how illness is experienced by patients and families and how clinicians find meaning in their work.

Providing Nutritional Care in the Office Practice: Teams, Tools, and Techniques

Provision of dietary counseling in the office setting is enhanced by using team-based care and electronic tools. Effective provider-patient communication is essential for fostering behavior change: the key component of lifestyle medicine. The principles of communication and behavior change are skill-based and grounded in scientific theories and models. Motivational interviewing and shared decision making, a collaboration process between patients and their providers to reach agreement about a health decision, is an important process in counseling. The stages of change, self-determination, health belief model, social cognitive model, theory of planned behavior, and cognitive behavioral therapy are used in the counseling process.

Eliciting Preferences of Multimorbid Elderly Adults in Family Practice Using an Outcome Prioritization Tool

OBJECTIVES

To explore an outcome prioritization tool (OPT) in eliciting individuals' preferred health outcomes (remaining alive, maintaining independence, reducing pain, reducing other symptoms) in the context of medication review in family practice.

DESIGN

Cross-sectional pilot study with mixed-methods design.

SETTING

Family practice.

PARTICIPANTS

Multimorbid individuals (N = 60; aged ≥69) with polypharmacy (≥5 chronic medications) derived from the practice lists of a purposive sample of 13 family physicians (FPs).

MEASUREMENTS

Participants were asked to prioritize each health outcome according the trade-off principle, and FPs used this prioritization for medication review. The acceptability and practicality were measured using a questionnaire for FPs and participants and semistructured interviews with FPs.

RESULTS

Ninety-two percent of participants found the OPT understandable, and 55% could easily prioritize between health outcomes. Working with the OPT (mean duration 31 minutes) was a new approach for FPs, but they became more adept at using it. For FPs, the OPT provides better understanding of their patients. Participants and FPs thought that there should be a specific reason to discuss preferences, such as (expected) decline in health status.

CONCLUSION

The OPT appears to be promising in eliciting patient preferences but is not suitable for routine medication review at present. Further optimization before actual use is needed (e.g., knowledge in which clinical situations the OPT is useful). More information is needed on how individuals and their families perceive the tool.

Smoking Cessation 1 Year or More: Experiences of Successful Quitters

There is a paucity of research focused on the experience of maintaining cessation for a year or longer, and recidivism rates for smoking cessation are estimated at 50% to 97%. As cigarette smoking is one of the leading causes of death worldwide, there is a critical need for more knowledge about maintaining smoking cessation. Therefore, this study was undertaken to explore the lived experience of maintaining cigarette smoking cessation for a year or more. Using Streubert's nurse-developed descriptive phenomenological method, seven adults who sustained cessation for 1.5 to 18 years, after repeated relapses, were interviewed about their experience of sustaining cessation. Data collection included interviews, field notes, and a reflexive journal. Phenomenological analysis involved dwelling intensely with the data, extracting parts of the transcript, and identifying codes and themes, defined by Streubert as essences, common to all participants' descriptions of the experience of sustained cessation. Through this inductive process, the investigator ascertained relationships among the essences, forming the basis for a formalized, exhaustive description of the experience. Six essences captured participants' experiences of maintaining cigarette smoking cessation: (a) breaking free, (b) developing an olfactory aversion, (c) reframing, (d) learning through relapse, (e) reclaiming acceptance, and (f) self-transformation. The findings suggest that maintaining cessation for a year or more is shaped by biological, psychological, and social conditions, as reflected in the essences. The essences coalesced to a tipping point of motivation and conditions leading to sustained behavior change, allowing participants to maintain cessation.

Evaluating the quality of shared decision making during the patient-carer encounter: a systematic review of tools

BACKGROUND

The concept of shared decision making (SDM) has been developing in many countries since the 1990s. The main challenge of SDM, based on the principles of respect for the person's autonomy, is to improve patients' participation, should they so wish, in decisions concerning their personal health. To our knowledge, there is only one SDM evaluation tool validated in metropolitan French that does not measure the entire SDM construct. The aim of this review was to identify existing and validated SDM measurement tools to determine which of them could be adapted in French to cover all the dimensions of SDM.

METHODS

A systematic literature review was conducted based on articles found in the PubMed and PsycINFO bibliographic databases and published between 2010 and 2014. Studies were included if the main goal of the article was the development and psychometric validation of an SDM measurement tool, not specific to any given disease or situation, in English, French and Spanish. We used the nine essential elements of the Makoul and Clayman's integrative model to describe the different existing tools.

RESULTS

Nineteen studies were included. Seven new tools had been published since Scholl's previous review in 2011. We observed a recent spread of the multi-appraiser approach, which combines points of view of patients, healthcare professionals and sometimes external observers. Several models were used for the development of the seven newly identified tools. None of the identified tools assessed the nine elements of the Makoul's model. Three of these elements, however, were systematically measured in each of the new tools: "defining/explaining the problem", "patient values/preferences", and "checking/clarifying understanding".

CONCLUSIONS

We identified several potentially interesting tools for the French context which could cover the whole elements of Makoul's model. The next step will be the development of a French-language instrument based on these tools.

Modelling and Predicting eHealth Usage in Europe: A Multidimensional Approach From an Online Survey of 13,000 European Union Internet Users

Background

More advanced methods and models are needed to evaluate the participation of patients and citizens in the shared health care model that eHealth proposes.

Objective

The goal of our study was to design and evaluate a predictive multidimensional model of eHealth usage.

Methods

We used 2011 survey data from a sample of 13,000 European citizens aged 16–74 years who had used the Internet in the previous 3 months. We proposed and tested an eHealth usage composite indicator through 2-stage structural equation modelling with latent variables and measurement errors. Logistic regression (odds ratios, ORs) to model the predictors of eHealth usage was calculated using health status and sociodemographic independent variables.

Results

The dimensions with more explanatory power of eHealth usage were health Internet attitudes, information health Internet usage, empowerment of health Internet users, and the usefulness of health Internet usage. Some 52.39% (6811/13,000) of European Internet users’ eHealth usage was more intensive (greater than the mean). Users with long-term health problems or illnesses (OR 1.20, 95% CI 1.12–1.29) or receiving long-term treatment (OR 1.11, 95% CI 1.03–1.20), having family members with long-term health problems or illnesses (OR 1.44, 95% CI 1.34–1.55), or undertaking care activities for other people (OR 1.58, 95% CI 1.40–1.77) had a high propensity toward intensive eHealth usage. Sociodemographic predictors showed that Internet users who were female (OR 1.23, 95% CI 1.14–1.31), aged 25–54 years (OR 1.12, 95% CI 1.05–1.21), living in larger households (3 members: OR 1.25, 95% CI 1.15–1.36; 5 members: OR 1.13, 95% CI 0.97–1.28; ≥6 members: OR 1.31, 95% CI 1.10–1.57), had more children <16 years of age (1 child: OR 1.29, 95% CI 1.18–1.14; 2 children: OR 1.05, 95% CI 0.94–1.17; 4 children: OR 1.35, 95% CI 0.88–2.08), and had more family members >65 years of age (1 member: OR 1.33, 95% CI 1.18–1.50; ≥4 members: OR 1.82, 95% CI 0.54–6.03) had a greater propensity toward intensive eHealth usage. Likewise, users residing in densely populated areas, such as cities and large towns (OR 1.17, 95% CI 1.09–1.25), also had a greater propensity toward intensive eHealth usage. Educational levels presented an inverted U shape in relation to intensive eHealth usage, with greater propensities among those with a secondary education (OR 1.08, 95% CI 1.01–1.16). Finally, occupational categories and net monthly income data suggest a higher propensity among the employed or self-employed (OR 1.07, 95% CI 0.99–1.15) and among the minimum wage stratum, earning ≤€1000 per month (OR 1.66, 95% CI 1.48–1.87).

Conclusions

We provide new evidence of inequalities that explain intensive eHealth usage. The results highlight the need to develop more specific eHealth practices to address different realities.

Cost-Effectiveness of Osteoporosis Screening Strategies for Men

Osteoporosis affects many men, with significant morbidity and mortality. However, the best osteoporosis screening strategies for men are unknown. We developed an individual-level state-transition cost-effectiveness model with a lifetime time horizon to identify the cost-effectiveness of different osteoporosis screening strategies for US men involving various screening tests (dual-energy X-ray absorptiometry [DXA]; the Osteoporosis Self-Assessment Tool [OST]; or a fracture risk assessment strategy using age, femoral neck bone mineral density [BMD], and Vertebral Fracture Assessment [VFA]); screening initiation ages (50, 60, 70, or 80 years); and repeat screening intervals (5 years or 10 years). In base-case analysis, no screening was a less effective option than all other strategies evaluated; furthermore, no screening was more expensive than all strategies that involved screening with DXA or the OST risk assessment instrument, and thus no screening was "dominated" by screening with DXA or OST at all evaluated screening initiation ages and repeat screening intervals. Screening strategies that most frequently appeared as most cost-effective in base-case analyses and one-way sensitivity analyses when assuming willingness-to-pay of $50,000/quality-adjusted life-year (QALY) or $100,000/QALY included screening initiation at age 50 years with the fracture risk assessment strategy and repeat screening every 10 years; screening initiation at age 50 years with fracture risk assessment and repeat screening every 5 years; and screening initiation at age 50 years with DXA and repeat screening every 5 years. In conclusion, expansion of osteoporosis screening for US men to initiate routine screening at age 50 or 60 years would be expected to be effective and of good value for improving health outcomes. A fracture risk assessment strategy using variables of age, femoral neck BMD, and VFA is likely to be the most effective of the evaluated strategies within accepted cost-effectiveness parameters. DXA and OST are also reasonable screening options, albeit likely slightly less effective than the evaluated fracture risk assessment strategy. © 2016 American Society for Bone and Mineral Research.

Community dissemination and genetic research: moving beyond results reporting

The community-based participatory research (CBPR) literature notes that researchers should share study results with communities. In the case of human genetic research, results may be scientifically interesting but lack clinical relevance. The goals of this study were to learn what kinds of information community members want to receive about genetic research and how such information should be conveyed. We conducted eight focus group discussions with Yup'ik Alaska Native people in southwest Alaska (N = 60) and 6 (N = 61) with members of a large health maintenance organization in Seattle, Washington. Participants wanted to receive genetic information they "could do something about" and wanted clinically actionable information to be shared with their healthcare providers; they also wanted researchers to share knowledge about other topics of importance to the community. Although Alaska Native participants were generally less familiar with western scientific terms and less interested in web-based information sources, the main findings were the same in Alaska and Seattle: participants wished for ongoing dialogue, including opportunities for informal, small-group conversations, and receiving information that had local relevance. Effective community dissemination is more than a matter of presenting study results in lay language. Community members should be involved in both defining culturally appropriate communication strategies and in determining which information should be shared. Reframing dissemination as a two-way dialogue, rather than a one-way broadcast, supports the twin aims of advancing scientific knowledge and achieving community benefit.