An environmental scan of advance care planning decision AIDS for patients undergoing major surgery: a study protocol

Reporting of patient involvement: a mixed-methods analysis of current practice in health research publications using a targeted search strategy

OBJECTIVES

To evaluate the extent and quality of patient involvement reporting in examples of current practice in health research.

DESIGN

Mixed-methods study. We used a targeted search strategy across three cohorts to identify health research publications that reported patient involvement: original research articles published in 2019 in the British Medical Journal (BMJ), articles listed in the Patient-Centered Outcomes Research Institute (PCORI) database (2019), and articles citing the GRIPP2 (Guidance for Reporting Involvement of Patients and Public) reporting checklist for patient involvement or a critical appraisal guideline for user involvement. Publications were coded according to three coding schemes: 'phase of involvement', the GRIPP2-Short Form (GRIPP2-SF) reporting checklist and the critical appraisal guideline.

OUTCOME MEASURES

The phase of the study in which patients were actively involved. For the BMJ sample, the proportion of publications that reported patient involvement. The quality of reporting based on the GRIPP2-SF reporting guideline. The quality of patient involvement based on the critical appraisal guideline. Quantitative and qualitative results are reported.

RESULTS

We included 86 publications that reported patient involvement. Patients were most frequently involved in study design (90% of publications, n=77), followed by study conduct (71%, n=61) and dissemination (42%, n=36). Reporting of patient involvement was often incomplete, for example, only 40% of publications (n=34) reported the aim of patient involvement. While the methods (57%, n=49) and results (59%, n=51) of involvement were reported more frequently, reporting was often unspecific and the influence of patients' input remained vague. Therefore, a systematic assessment of the quality and impact of patient involvement according to the critical appraisal guideline was not feasible across samples.

CONCLUSIONS

As patient involvement is increasingly seen as an integral part of the research process and requested by funding bodies, it is essential that researchers receive specific guidance on how to report patient involvement activities. Complete reporting builds the foundation for assessing the quality of patient involvement and its impact on research.

Online Decision Aids for Knee Arthroplasty: An Environmental Scan

BACKGROUND

Knee arthroplasty is a high-risk, resource-intensive procedure that should be reserved for patients in whom the benefit will outweigh the risks. The provision of high-quality, publicly available decision aids can help patients to balance the benefits against the harms of treatments and to assist informed decision-making. The aim of this study was to identify and evaluate the content and readability of freely available knee arthroplasty decision aids.

METHODS

A systematic search using an environmental scan methodology of publicly available online materials was performed in December 2018. Included materials were assessed for quality using the International Patient Decision Aid Standards instrument (IPDASi), understandability and actionability from a patient's perspective using the Patient Education Materials Assessment Tool (PEMAT), and readability grade level using the Flesch-Kincaid Grade Level and the Gunning Fog Index.

RESULTS

Of 761 online materials screened, 26 decision aids were identified. Only 18 (69%) may be considered to meet criteria to be defined as a decision aid and 4 (15%) met criteria suggesting that the material did not introduce potential harmful bias according to the IPDASi. The mean score (and standard deviation) for all decision aids was 74% ± 12% for understandability and 44% ± 19% for actionability using the PEMAT. Readability indices indicated a mean minimum reading level of Grade 10 (10.8 ± 2.5). No decision aid included a wait-and-see option.

CONCLUSIONS

Few high-quality decision aids exist for patients considering knee arthroplasty and none include a wait-and-see option. Many do not provide actionable options and are pitched at above-average reading levels. Developers need to address these issues to encourage high-quality decision-making, especially for those with low health literacy.

Literacy assessment of preimplantation genetic patient education materials exceed national reading levels

PURPOSE

In vitro fertilization with preimplantation genetic testing (IVF+PGT-M) reduces the risk of having a child affected by a heritable condition, yet only one-third of eligible patients are aware of this reproductive option. Access to education materials written at appropriate literacy levels could raise patients' awareness, but there is a mismatch between patient reading ability and the literacy demand of most materials. This study aimed to systematically identify written education materials on IVF+PGT-M and evaluate their literacy levels. We hypothesized that materials would fail to meet standards set by the Joint Commission and Centers for Disease Control and Prevention (CDC).

METHODS

To identify patient education materials about IVF+PGT-M from academic databases and public-facing sources, an environmental scan was performed. Materials were analyzed using three validated scales: Simple Measure of Gobbledygook, Patient Education Materials Assessment Tool, and Clear Communication Index.

RESULTS

Seventeen patient education materials about IVF+PGT-M were identified from patient education databases, a consumer search engine, and professional organizations. The median reading level was 14.5 grade, median understandability was 74.2%, and median comprehensibility was 73.3%.

CONCLUSIONS

For most American adults, materials about IVF+PGT-M are not readable, understandable, or clear. The Joint Commission requires patient education materials be written at or below 5th grade reading level and the CDC recommends a 90% minimum score for comprehensibility. No evaluated material met these guidelines. Patient education materials that exceed average American literacy skills may perpetuate disparities in the utilization of IVF+PGT-M. Materials that communicate this complicated subject at an understandable level are needed.

The use of the environmental scan in health services delivery research: a scoping review protocol

INTRODUCTION

The environmental scan has been described as an important tool to inform decision-making on policy, planning and programme development in the healthcare sector. Despite the wide adoption of environmental scans, there is no consensus on a working definition within the health services delivery context and methodological guidance on the design and implementation of this approach is lacking in the literature. The objectives of this study are to map the extent, range and nature of evidence that describe the definitions, characteristics, conceptualisations, theoretical underpinnings, study limitations and other features of the environmental scan in the health services delivery literature and to propose a working definition specific to this context.

METHODS AND ANALYSIS

This protocol describes a scoping review based on the methodology outlined by Khalil and colleagues. A comprehensive search strategy was developed by experienced health science librarians in consultation with the research team. A Peer Review of Electronic Search Strategies (PRESS) was completed. Two reviewers will independently screen titles, abstracts and full-text articles and select studies meeting the inclusion criteria from seven electronic databases: Academic Search Premier, Canadian Business & Current Affairs (CBCA), CINAHL, ERIC, Embase, MEDLINE and PsycINFO. The grey literature and reference lists of included articles will also be searched. The data will be analysed and presented in tabular format, and will include a descriptive numerical summary as well as a qualitative thematic analysis.

ETHICS AND DISSEMINATION

This protocol provides an audit trail for a scoping review that will advance understanding about the environmental scan and its application in the health services delivery context. The review will propose a working definition and will inform future research to explore the development of a conceptual framework in this context. Findings will be disseminated through a peer-reviewed journal and conference presentations. The scoping review does not require ethics approval.

A Multicenter, Randomized Controlled Trial of Perioperative Palliative Care Surrounding Cancer Surgery for Patients and Their Family Members (PERIOP-PC)

Background: Despite positive outcomes associated with specialist palliative care (PC) in diverse medical populations, little research has investigated specialist PC in surgical ones. Although cancer surgery is predominantly safe, operations can be extensive and unpredictable perioperative morbidity and mortality persist, particularly for patients with upper gastrointestinal (GI) cancers. Objectives and Hypotheses: Our objective is to complete a multicenter, randomized controlled trial comparing surgeon-PC co-management with surgeon-alone management among patients pursuing curative-intent surgery for upper GI cancers. We hypothesize that perioperative PC will improve patient postsurgical quality of life. This study and design are based on >8 years of engagement and research with patients, family members, and clinicians surrounding major cancer surgery and advance care planning/PC for surgical patients. Methods: Randomized controlled superiority trial with two study arms (surgeon-PC team co-management and surgeon-alone management) and five data collection points over six months. The principal investigator and analysts are blinded to randomization. Setting: Four, geographically diverse, academic tertiary care hospitals. Data collection began December 20, 2018 and continues to December 2020. Participants: Patients recruited from surgical oncology clinics who are undergoing curative-intent surgery for an upper GI cancer. Interventions: In the intervention arm, patients receive care from both their surgical team and a specialist PC team; the PC is provided before surgery, immediately after surgery, and at least monthly until three months postsurgery. Patients randomized to the usual care arm receive care from only the surgical team. Main Outcomes and Measures: Primary outcome: patient quality of life. Secondary outcomes: patient: symptom experience, spiritual distress, prognostic awareness, health care utilization, and mortality. Caregiver: quality of life, caregiver burden, spiritual distress, and prognostic awareness. Intent-to-treat analysis will be used. Ethics and Dissemination: This study has been approved by the institutional review boards of all study sites and is registered on clinicaltrials.gov (NCT03611309, First received: August 2, 2018).

Availability and readability of patient education materials for deprescribing: An environmental scan

AIMS

To identify and evaluate content and readability of freely available online deprescribing patient education materials (PEMs).

METHODS

Systematic review of PEMs using MEDLINE, Embase, CINAHL, PsycINFO and The Cochrane Library of Systematic Reviews from inception to 25 September 2017 to identify PEMs. Additionally, deprescribing researchers and health professionals were surveyed to identify additional materials. Known repositories of materials were searched followed by a systematic Google search (22-28 January 2018). Materials were evaluated using an approach informed by the Patient Education Material Assessment Tool and the International Patient Decision Aids Standards Inventory. Readability of text-based materials was assessed using the US-based Gunning-Fog Index and Flesch-Kincaid Grade level.

RESULTS

Forty-eight PEMs were identified. PEMs addressing deprescribing of medications for symptom control (81%) were most common. Preventative medications were rarely addressed and material (39%) focused on older people. Only 37% of PEMs provided information about both potential benefits (e.g. reducing risk of side effects) and harms (e.g. withdrawal symptoms, increased risk of disease) of deprescribing, while 40% focussed on benefits only. Readability indices indicated an average minimum reading level of Grade 12. Option Grids and Decision Aids (mean reading level below Grade 10) were most suitable for people with average literacy levels.

CONCLUSIONS

Over 1/3 of deprescribing PEMs present potential benefits and harms of deprescribing indicating most of the freely available materials are not balanced. Most PEMs are pitched above average reading levels making them inaccessible for low health literacy populations.

Online Decision Aids for Knee Osteoarthritis and Low Back Pain: An Environmental Scan and Evaluation

Background. Musculoskeletal conditions are leading causes of disability. Management options are plentiful, but the current evidence base suggests many are ineffective or unproven. Online decision aids can help support patients make informed health care choices. However, there are little data on the quality of online decision aids for common musculoskeletal conditions such as knee or low back pain. Purpose. To identify all publicly available online decision aids for knee osteoarthritis and low back pain and evaluate them against the International Patient Decision Aids Standards Inventory (IPDASi). Data Sources. Google Australia. Study selection. Two reviewers independently screened websites for inclusion and assessed the quality of included online decision aids between April and May 2018. Included online decision aids were free, provided information about knee osteoarthritis or low back pain, and written in English. Online decision aids that required payment, targeted health professionals, addressed rheumatoid arthritis, or addressed a screening decision were excluded. Data Extraction. IPDASi Version 4. Data Synthesis. Twenty-five online decision aids were identified: 15 knee osteoarthritis and 10 low back pain. Only 3 online decision aids (12%) provided a “wait-and-see” option. Nineteen (75%) met IPDASi criteria to be considered a decision aid and 3 (12%) met IPDASi criteria to state that the online decision aid was unbiased. Limitations. Dynamic nature of Google searches may not be replicable easily. Conclusions. Few good-quality online decision aids are available for people with knee osteoarthritis or low back pain. Most online decision aids failed to explicitly provide a wait-and-see option, suggesting a bias toward intervention. These online decision aids would benefit from explicitly highlighting a wait-and-see option to support informed choice.

Integrating Advance Care Planning Videos into Surgical Oncologic Care: A Randomized Clinical Trial

Background: Preoperative advance care planning (ACP) may benefit patients undergoing major surgery. Objective: To evaluate feasibility, safety, and early effectiveness of video-based ACP in a surgical population. Design: Randomized controlled trial with two study arms. Setting: Single, academic, inner-city tertiary care hospital. Subjects: Patients undergoing major cancer surgery were recruited from nine surgical clinics. Of 106 consecutive potential participants, 103 were eligible and 92 enrolled. Interventions: In the intervention arm, patients viewed an ACP video developed by patients, surgeons, palliative care clinicians, and other stakeholders. In the control arm, patients viewed an informational video about the hospital's surgical program. Measurements: Primary Outcomes-ACP content and patient-centeredness in patient-surgeon preoperative conversation. Secondary outcomes-patient Hospital Anxiety and Depression Scale (HADS) score; patient goals of care; patient and surgeon satisfaction; video helpfulness; and medical decision maker designation. Results: Ninety-two patients (target enrollment: 90) were enrolled. The ACP video was successfully integrated with no harm noted. Patient-centeredness was unchanged (incidence rate ratio [IRR] = 1.06, confidence interval [0.87-1.3], p = 0.545), although there were more ACP discussions in the intervention arm (23% intervention vs. 10% control, p = 0.18). While slightly underpowered, study results did not signal that further enrollment would have yielded statistical significance. There were no differences in secondary outcomes other than the intervention video was more helpful (p = 0.007). Conclusions: The ACP video was successfully integrated into surgical care without harm and was thought to be helpful, although video content did not significantly change the ACP content or patient-surgeon communication. Future studies could increase the ACP dose through modifying video content and/or who presents ACP. Trial Registration: clinicaltrials.gov Identifier NCT02489799.

Favourable understandability, but poor actionability: An evaluation of online type 2 diabetes risk calculators

OBJECTIVE

The study aim was to identify all freely available online diabetes risk calculators and to evaluate their suitability for patients with low health literacy.

METHODS

Online diabetes risk calculators were identified by an environmental scan. The Patient Education Material Assessment Tool for Printable Materials was used to determine understandability and actionability scores. A high-risk profile was used to compare the risk results obtained with each calculator.

RESULTS

Thirty-five risk calculators were identified; 51% had no described model, 23% reported absolute risk and 31% used visual aids. The estimated risk for the same profile ranged from low to very high. The mean understandability score was 79% (SD = 19%) and the mean actionability score was 42% (SD = 30%).

CONCLUSIONS

Online diabetes risk calculators are generally understandable, but not very actionable, and may not be completely suitable for use by patients with low health literacy. The estimated risk is highly variable depending on the underlying model used for the calculation.

PRACTICE IMPLICATIONS

Patients and healthcare providers need to exercise caution when selecting a diabetes risk calculator.

Serious Choices: A Protocol for an Environmental Scan of Patient Decision Aids for Seriously Ill People at Risk of Death Facing Choices about Life-Sustaining Treatments

BACKGROUND

Seriously ill people at high risk of death face difficult decisions, especially concerning the extent of medical intervention. Given the inherent difficulty and complexity of these decisions, the care they receive often does not align with their preferences. Patient decision aids that educate individuals about options and help them construct preferences about life-sustaining care may reduce the mismatch between the care people say they want and the care they receive. The quantity and quality of patient decision aids for those at high risk of death, however, are unknown.

OBJECTIVE

This protocol describes an approach for conducting an environmental scan of life-sustaining treatment patient decision aids for seriously ill patients, identified online and through informant analysis. We intend for the outcome to be an inventory of all life-sustaining treatment patient decision aids for seriously ill patients currently available (either publicly or proprietarily) along with information about their content, quality, and known use.

METHODS

We will identify patient decision aids in a three-step approach (1) mining previously published systematic reviews; (2) systematically searching online and in two popular app stores; and (3) undertaking a key informant survey. We will screen and assess the quality of each patient decision aid identified using the latest published draft of the U.S. National Quality Forum National Standards for the Certification of Patient Decision Aids. Additionally, we will evaluate readability via readable.io and content via inductive content analysis. We will also use natural language processing to assess the content of the decision aids.

DISCUSSION

Researchers increasingly recognize the environmental scan as an optimal method for studying real-world interventions, such as patient decision aids. This study will advance our understanding of the availability, quality, and use of decision aids for life-sustaining interventions targeted at seriously ill patients. We also aim to provide patients, their families, and friends, along with their clinicians, a broad set of resources for making life-sustaining treatment decisions. Although we intend to capture all patient decision aids for the seriously ill in our review, we anticipate the possibility that we may miss some decision aids. In addition to publishing our findings in an academic journal, we plan to post our inventory online in an easy-to-read format for public and clinical consumption.

A review of paper-based advance care planning aids

Background

Advance care planning (ACP) aids can help prepare patients, family members, and physicians for in-the-moment medical decision-making. We wished to describe the content and approach of paper-based ACP aids in order to characterize existing aids and inform the development of a new ACP aid.

Methods

Paper-based ACP aids were identified through an environmental scan and screened for eligibility. ACP conceptual frameworks and data were gathered via stakeholder engagement and used to inform the coding framework that two investigators used to independently code each aid. A directed content analysis was conducted on these eligible aids. Aids were categorized through a deliberative process with an investigator abstracting general information for each aid.

Results

Fifteen aids met the eligibility criteria. They ranged in length from 6 to 78 pages with the average aid written at an eighth-grade reading level. The content analysis revealed that many aids encouraged choosing a surrogate decision maker and informed users about legal medical documents. Fewer than half of the aids facilitated patient clarification of values regarding quality of life issues. The authors identified and termed the following three categories of aids: informative; semi-action oriented; and action-oriented. It was often unclear whether patients contributed to the development or testing of the ACP aids reviewed.

Conclusions

Most existing paper-based ACP aids address legal matters such as completing an advance directive. Only a minority elicited patient values and it was unclear whether any were developed in partnership with patients. Future development of ACP aids should account for patient preferences with a goal of supporting in-the-moment medical decision-making.

An advance care plan decision support video before major surgery: a patient- and family-centred approach

OBJECTIVE

Video-based advanc care planning (ACP) tools have been studied in varied medical contexts; however, none have been developed for patients undergoing major surgery. Using a patient- and family-centredness approach, our objective was to implement human-centred design (HCD) to develop an ACP decision support video for patients and their family members when preparing for major surgery.

DESIGN AND METHODS

The study investigators partnered with surgical patients and their family members, surgeons and other health professionals to design an ACP decision support video using key HCD principles. Adapting Maguire's HCD stages from computer science to the surgical context, while also incorporating Elwyn et al's specifications for patient-oriented decision support tool development, we used a six-stage HCD process to develop the video: (1) plan HCD process; (2) specify where video will be used; (3) specify user and organisational requirements; (4) produce and test prototypes; (5) carry out user-based assessment; (6) field test with end users.

RESULTS

Over 450 stakeholders were engaged in the development process contributing to setting objectives, applying for funding, providing feedback on the storyboard and iterations of the decision tool video. Throughout the HCD process, stakeholders' opinions were compiled and conflicting approaches negotiated resulting in a tool that addressed stakeholders' concerns.

CONCLUSIONS

Our patient- and family-centred approach using HCD facilitated discussion and the ability to elicit and balance sometimes competing viewpoints. The early engagement of users and stakeholders throughout the development process may help to ensure tools address the stated needs of these individuals.

TRIAL REGISTRATION NUMBER

NCT02489799.

A patient and community-centered approach selecting endpoints for a randomized trial of a novel advance care planning tool

BACKGROUND

Despite a movement toward patient-centered outcomes, best practices on how to gather and refine patients' perspectives on research endpoints are limited. Advanced care planning (ACP) is inherently patient centered and would benefit from patient prioritization of endpoints for ACP-related tools and studies.

OBJECTIVE

This investigation sought to prioritize patient-centered endpoints for the content and evaluation of an ACP video being developed for patients undergoing major surgery. We also sought to highlight an approach using complementary engagement and research strategies to document priorities and preferences of patients and other stakeholders.

MATERIALS AND METHODS

Endpoints identified from a previously published environmental scan were operationalized following rating by a caregiver co-investigator, refinement by a patient co-investigator, review by a stakeholder committee, and validation by patients and family members. Finalized endpoints were taken to a state fair where members of the public who indicated that they or a loved one had undergone major surgery prioritized their most relevant endpoints and provided comments.

RESULTS

Of the initial 50 ACP endpoints identified from the review, 12 endpoints were selected for public prioritization. At the state fair, 359 individuals prioritized the endpoints, the highest ranking of which was having a meaningful conversation with a physician before surgery (57%).

CONCLUSION

Using a novel combination of engagement and research techniques provided the opportunity to understand which endpoints were most important to patients and families and fostered framework development clarifying the differential contributions of engagement and research. Results from this study ultimately changed the content and evaluation of the ACP video.

Environmental Scan of Breastfeeding Resources in Canadian NICUs

We conducted an environmental scan using a mixed methods approach to determine the types and frequencies of breastfeeding resources available to mothers of infants in Canadian NICUs. Through interviews with key informants from 29 Level 3 NICUs, we identified six categories of resources: breastfeeding-friendly layout, breastfeeding support personnel, breastfeeding education for mothers, breast pump-related resources, coordination of postdischarge breastfeeding support, and breastfeeding-related policies. Findings from this national study indicate that a wide range of breastfeeding resources were reportedly available in Canadian Level 3 NICUs. NICU professionals are encouraged to connect with other units across Canada to facilitate the exchange of breastfeeding resources and best practices.

Hospice, She Yelped: Examining the Quantity and Quality of Decision Support Available to Patient and Families Considering Hospice

CONTEXT

Whether to engage hospice is one of the most difficult medical decisions patients and families make. Meanwhile, misperceptions about hospice persist. Within this context, the breadth and depth of patient decision support materials for hospice are unknown.

OBJECTIVES

The objective of this study was to identify available patient decision aids (PtDAs) relating information about hospice care and compare that information with the informational needs expressed by real-world health care consumers.

METHODS

First, the research team conducted an environmental scan of available PtDAs that included hospice as a treatment option and met six basic criteria defined by the International Patient Decision Aid Standards. Second, laypersons conducted an organic Web search for information regarding hospice, followed by a semi-structured interview eliciting perceptions of the available information. The setting was the University of Colorado Health Care System. Participants included 20 laypersons aged 18 years or older.

RESULTS

The environmental scan identified 7PtDAs that included hospice. No PtDAs were designed primarily around hospice; rather, hospice was referenced under the umbrella of another treatment option. The layperson search identified information distinct from the scan; no participant accessed any of the above 7PtDAs. Many participants found the available online material confusing and biased, while failing to provide clear information on cost and lacking desired patient and caregiver testimonials.

CONCLUSION

We found no formal PtDA designed primarily to help patients/families contemplating hospice. Furthermore, accessible online information about hospice does not appear to meet patient and caregiver decisional needs. These findings support the development and dissemination of high-quality decision support materials for hospice.

Developing the Storyline for an Advance Care Planning Video for Surgery Patients: Patient-Centered Outcomes Research Engagement from Stakeholder Summit to State Fair

BACKGROUND

Patient-centered outcomes research (PCOR) methods and social learning theory (SLT) require intensive interaction between researchers and stakeholders. Advance care planning (ACP) is valuable before major surgery, but a systematic review found no extant perioperative ACP tools. Consequently, PCOR methods and SLT can inform the development of an ACP educational video for patients and families preparing for major surgery.

OBJECTIVE

The objective is to develop and test acceptability of an ACP video storyline.

DESIGN

The design is a stakeholder-guided development of the ACP video storyline. Design-thinking methods explored and prioritized stakeholder perspectives. Patients and family members evaluated storyboards containing the proposed storyline.

SETTING/SUBJECTS

The study was conducted at hospital outpatient surgical clinics, in-person stakeholder summit, and the 2014 Maryland State Fair.

MEASUREMENTS

Measurements are done through stakeholder engagement and deidentified survey.

RESULTS

Stakeholders evaluated and prioritized evidence from an environmental scan. A surgeon, family member, and palliative care physician team iteratively developed a script featuring 12 core themes and worked with a medical graphic designer to translate the script into storyboards. For 10 days, 359 attendees of the 2014 Maryland State Fair evaluated the storyboards and 87% noted that they would be "very comfortable" or "comfortable" seeing the storyboard before major surgery, 89% considered the storyboards "very helpful" or "helpful," and 89% would "definitely recommend" or "recommend" this story to others preparing for major surgery.

CONCLUSIONS

Through an iterative process utilizing diverse PCOR engagement methods and informed by SLT, storyboards were developed for an ACP video. Field testing revealed the storyline to be highly meaningful for surgery patients and family members.

Utilising advance care planning videos to empower perioperative cancer patients and families: a study protocol of a randomised controlled trial

INTRODUCTION

Despite positive health outcomes associated with advance care planning (ACP), little research has investigated the impact of ACP in surgical populations. Our goal is to evaluate how an ACP intervention video impacts the patient centredness and ACP of the patient-surgeon conversation during the presurgical consent visit. We hypothesise that patients who view the intervention will engage in a more patient-centred communication with their surgeons compared with patients who view a control video.

METHODS AND ANALYSIS

Randomised controlled superiority trial of an ACP video with two study arms (intervention ACP video and control video) and four visits (baseline, presurgical consent, postoperative 1 week and postoperative 1 month). Surgeons, patients, principal investigator and analysts are blinded to the randomisation assignment.

SETTING

Single, academic, inner city and tertiary care hospital. Data collection began July 16, 2015 and continues to March 2017.

PARTICIPANTS

Patients recruited from nine surgical oncology clinics who are undergoing major cancer surgery.

INTERVENTIONS

In the intervention arm, patients view a patient preparedness video developed through extensive engagement with patients, surgeons and other stakeholders. Patients randomised to the control arm viewed an informational video about the hospital surgical programme.

MAIN OUTCOMES AND MEASURES

Primary Outcome: Patient centredness and ACP of patient-surgeon conversations during the presurgical consent visit as measured through the Roter Interaction Analysis System.

SECONDARY OUTCOMES

patient Hospital Anxiety and Depression Scale score; patient goals of care; patient, companion and surgeon satisfaction; video helpfulness; medical decision maker designation; and the frequency patients watch the video. Intent-to-treat analysis will be used to assess the impact of video assignment on outcomes. Sensitivity analyses will assess whether there are differential effects contingent on patient or surgeon characteristics.

ETHICS AND DISSEMINATION

This study has been approved by the Johns Hopkins School of Medicine institutional review board and is registered on clinicaltrials.gov (NCT02489799, First received: July 1, 2015).

TRIAL REGISTRATION NUMBER

clinicaltrials.gov, NCT02489799.

Promoting perioperative advance care planning: a systematic review of advance care planning decision aids

This systematic review identifies possible decision aids that promote perioperative advance care planning (ACP) and synthesizes the available evidence regarding their use. Using PubMed, EMBASE, Cochrane, SCOPUS, Web of Science, CINAHL, PsycINFO and Sociological Abstracts, researchers identified and screened articles for eligibility. Data were abstracted and risk of bias assessed for included articles. Thirty-nine of 5327 articles satisfied the eligibility criteria. Primarily completed in outpatient ambulatory populations, studies evaluated a variety of ACP decision aids. None were evaluated in a perioperative population. Fifty unique outcomes were reported with no head-to-head comparisons conducted. Findings are likely generalizable to a perioperative population and can inform development of a perioperative ACP decision aid. Future studies should compare the effectiveness of ACP decision aids.

Why don't end-of-life conversations go viral? A review of videos on YouTube

OBJECTIVE

To identify videos on YouTube concerning advance care planning (ACP) and synthesise existing video content and style elements.

METHODS

Informed by stakeholder engagement, two researchers searched YouTube for ACP videos using predefined search terms and snowballing techniques. Videos identified were reviewed and deemed ineligible for analysis if they: targeted healthcare professionals; contained irrelevant content; focused on viewers under the age of 18; were longer than 7 min in duration; received fewer than 150 views; were in a language other than English; or were a duplicate version. For each video, two investigators independently extracted general information as well as video content and stylistic characteristics.

RESULTS

The YouTube search identified 23 100 videos with 213 retrieved for assessment and 42 meeting eligibility criteria. The majority of videos had been posted to YouTube since 2010 and produced by organisations in the USA (71%). Viewership ranged from 171 to 10 642. Most videos used a documentary style and featured healthcare providers (60%) rather than patients (19%) or families (45%). A minority of videos (29%) used upbeat or hopeful music. The videos frequently focused on completing legal medical documents (86%).

CONCLUSIONS

None of the ACP videos on YouTube went viral and a relatively small number of them contained elements endorsed by stakeholders. In emphasising the completion of legal medical documents, videos may have failed to support more meaningful ACP. Further research is needed to understand the features of videos that will engage patients and the wider community with ACP and palliative and end-of-life care conversations.

Medical versus surgical methods of early abortion: protocol for a systematic review and environmental scan of patient decision aids

INTRODUCTION

Currently, we lack understanding of the content, quality and impact of patient decision aids to support decision-making between medical and surgical methods of early abortion. We plan to undertake a systematic review of peer-reviewed literature to identify, appraise and describe the impact of early abortion method decision aids evaluated quantitatively (Part I), and an environmental scan to identify and appraise other early abortion method decision aids developed in the US (Part II).

METHODS AND ANALYSIS

For the systematic review, we will search PubMed, Cochrane Library, CINAHL, EMBASE and PsycINFO databases for articles describing experimental and observational studies evaluating the impact of an early abortion method decision aid on women's decision-making processes and outcomes. For the environmental scan, we will identify decision aids by supplementing the systematic review search with Internet-based searches and key informant consultation. The primary reviewer will assess all studies and decision aids for eligibility, and a second reviewer will also assess a subset of these. Both reviewers will independently assess risk of bias in the studies and abstract data using a piloted form. Finally, both reviewers will assess decision aid quality using the International Patient Decision Aid Standards criteria, ease of readability using Flesch/Flesch-Kincaid tests, and informational content using directed content analysis.

ETHICS AND DISSEMINATION

As this study does not involve human subjects, ethical approval will not be sought. We aim to disseminate the findings in a scientific journal, via academic and/or professional conferences and among the broader community to contribute knowledge about current early abortion method decision-making support.

TRIAL REGISTRATION NUMBER

This protocol is registered in the International Prospective Register of Systematic Reviews (CRD42015016717).

Creating an advance-care-planning decision aid for high-risk surgery: a qualitative study

BACKGROUND

High-risk surgery patients may lose decision-making capacity as a result of surgical complications. Advance care planning prior to surgery may be beneficial, but remains controversial and is hindered by a lack of appropriate decision aids. This study sought to examine stakeholders' views on the appropriateness of using decision aids, in general, to support advance care planning among high-risk surgery populations and the design of such a decision aid.

METHODS

Key informants were recruited through purposive and snowball sampling. Semi-structured interviews were conducted by phone until data collected reached theoretical saturation. Key informants were asked to discuss their thoughts about advance care planning and interventions to support advance care planning, particularly for this population. Researchers took de-identified notes that were analyzed for emerging concordant, discordant, and recurrent themes using interpretative phenomenological analysis.

RESULTS

Key informants described the importance of initiating advance care planning preoperatively, despite potential challenges present in surgical settings. In general, decision aids were viewed as an appropriate approach to support advance care planning for this population. A recipe emerged from the data that outlines tools, ingredients, and tips for success that are needed to design an advance care planning decision aid for high-risk surgical settings.

CONCLUSIONS

Stakeholders supported incorporating advance care planning in high-risk surgical settings and endorsed the appropriateness of using decision aids to do so. Findings will inform the next stages of developing the first advance care planning decision aid for high-risk surgery patients.