Information Communicated with Patients in Decision Making about their Abdominal Aortic Aneurysm

Barriers and Stimulus in Shared Decision Making Among Aesthetic Dermatologists in China: Findings from a Cross-Sectional Study

Introduction

Shared decision making (SDM) is a collaborative process involving both healthcare providers and patients in making medical decisions, which gains increasing prominence in healthcare practice. But evidence on the level of SDM in medical practice and barriers as well as stimulus during the SDM implementation among aesthetic dermatologists is limited in China.

Methods

From July to August 2023, 1938 dermatologists were recruited online in China. Data were collected through an electronic questionnaire covering: (1) demographic features; (2) SDM questionnaire physician version (SDM-Q-Doc); and (3) stimulus and barriers in SDM implementation. Logistic regression was applied to explore factors associated with SDM practice, barriers, and stimulus of SDM implementation, respectively.

Results

The 1938 dermatologists included 1329 females (68.6%), with an average age of 35 years. The total SDM score ranged from 0 to 45, with a median value of 40 (IQR: 35-44), and the median stimulus score and barriers scores were 28 (IQR: 24-32) and 19 (IQR: 13-26), respectively. The prevalence of good SDM was 27.2%, logistic regression indicated that female dermatologists (odds ratio, OR=1.21, 95% confidence interval, CI: 0.96-1.51), and dermatologists with more years of aesthetic practice had a higher proportion of good SDM practice (OR was 1.44 for 5-9 years, 1.58 for 10-15 years and 1.77 for over 15 years). Moreover, female dermatologists and dermatologists with higher education level and serviced in private settings had lower barrier scores; female dermatologists and dermatologists with more years of aesthetic practice had higher stimulus scores.

Conclusion

Chinese aesthetic dermatologists appear to implement SDM at an active level, with more stimulus and less barriers in SDM implementation. The integration of SDM into clinical practice among dermatologists is beneficial both for patients and dermatologists. Moreover, SDM practice should be strongly promoted and enhanced during medical aesthetics, especially among male dermatologists, dermatologists with less working experience, and those who work at public institutions.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Surgeon's steering behaviour towards patients to participate in a cluster randomised trial on active surveillance for oesophageal cancer: A qualitative study

INTRODUCTION

Few studies have been conducted into how physicians use steering behaviour that may persuade patients to choose for a particular treatment, let alone to participate in a randomised trial. The aim of this study is to assess if and how surgeons use steering behaviour in their information provision to patients in their choice to participate in a stepped-wedge cluster randomised trial investigating an organ sparing treatment in (curable) oesophageal cancer (SANO trial).

MATERIALS AND METHODS

A qualitative study was performed. Thematic content analysis was applied to audiotaped and transcribed consultations of twenty patients with eight different oncological surgeons in three Dutch hospitals. Patients could choose to participate in a clinical trial in which an experimental treatment of 'active surveillance' (AS) was offered. Patients who did not want to participate underwent standard treatment: neoadjuvant chemoradiotherapy followed by oesophagectomy.

RESULTS

Surgeons used various techniques to steer patients towards one of the two options, mostly towards AS. The presentation of pros and cons of treatment options was imbalanced: positive framing of AS was used to steer patients towards the choice for AS, and negative framing of AS to make the choice for surgery more attractive. Further, steering language, i.e. suggestive language, was used, and surgeons seemed to use the timing of the introduction of the different treatment options, to put more focus on one of the treatment options.

CONCLUSION

Awareness of steering behaviour can help to guide physicians in more objectively informing patients on participation in future clinical trials.

Shared Decision Making and the Management of Intact Abdominal Aortic Aneurysm: A Scoping Review of the Literature

OBJECTIVE

The aim of this study was to summarise the current knowledge of shared decision making (SDM) in patients facing a treatment decision about an intact abdominal aortic aneurysm (AAA), and to identify where further evidence is needed.

DATA SOURCES

MEDLINE, Embase, and the Cochrane Library were searched on 18 July 2021. An updated search was run on 31 May 2022 for relevant studies published from 1 January 2000 to 31 May 2022.

REVIEW METHODS

This scoping review was undertaken in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines following a pre-defined protocol, retrieving studies reporting on aspects of SDM in those with intact AAAs. Qualitative synthesis of the articles was performed, and the results grouped according to theme.

RESULTS

Fifteen articles reporting on a total of 1 344 participants (age range 62-74 years) from hospital vascular surgery clinics with intact AAAs were included. Studies were observational (n = 9), non-randomised studies of an intervention (n = 3), and randomised clinical trials (n = 3). The first theme was the preferences and practice of SDM. The proportion of patients preferring SDM ranged from 58% to 95% (three studies), although objective rating of SDM practice was consistently < 50% (three studies). Clinician training improved SDM practice. The second theme was poor provision of information. Fewer than half of patients (0 - 46%) surveyed were informed about all available treatment options (three studies). Publicly available information sources were rated as poor. The third theme concerned the utility of decision making support tools (DSTs). Two randomised trials demonstrated that the provision of DSTs improves patient knowledge and agreement between patient preference and repair type received but not objective measures of SDM for patients with AAAs.

CONCLUSION

SDM for patients with an intact AAA appears to be in its infancy. Most patients with an AAA want SDM, but this is not commonly applied. Most patients with an AAA do not receive adequate information for SDM, although the use of bespoke DSTs leaves patients better informed to facilitate SDM.

Improving shared decision-making in vascular surgery: a stepped-wedge cluster-randomised trial

BACKGROUND

For various vascular surgical disorders different treatment options are available and feasible. Hence, vascular surgery seems an area par excellence for shared decision-making (SDM), in which clinicians incorporate patients' preferences into the final treatment decision. However, current SDM-levels in vascular surgical outpatient clinics is below expectations. To improve this, different decision support tools (DSTs) were developed: online patient decision aids, consultation cards and decision cards.

METHODS

This stepped-wedge cluster-randomised trial was conducted in 13 Dutch hospitals. Besides the developed DSTs, a training on how to apply SDM during the clinician-patient encounter was used in this study. Data were obtained via questionnaires and audio-recordings. Primary outcome was the OPTION-5 score, an objective tool to assess the level of SDM, expressed as a percentage of exemplary performance. Main secondary outcomes were: patients' disease-specific knowledge, consultation duration, and treatment choice. Factors influencing OPTION-5 scores were studied using linear regression analysis.

RESULTS

We included 342 patients with an abdominal aortic aneurysm (AAA); n=87, intermittent claudication (IC); n=143, or varicose veins (VV); n=112. Audiotapes of 395 consultations were analysed. Overall mean OPTION-5 score significantly improved from 28.7% to 37.8% (mean difference 9.1%, 95%CI: 6.5-11.8%) after implementation of the DSTs. Also patient knowledge increased significantly (median increase: 13%, effect size: 0.13, p=.025). The number of patients choosing non-surgical treatment choices increased with 21.4% to 28.8% for AAA-patients and doubled (16.0% to 32.0%) among IC-patients. For surgeons, the SDM-training and for patients the decision aid significantly and independently increased OPTION-5 scores (p<.001 and p=.047, respectively).

CONCLUSION

Introducing DSTs improves the level of shared decision-making in vascular surgery, improves patient knowledge, and shifts their preference towards more non-surgical treatments. The SDM-training for clinicians and the decision aid for patients appeared the most effective means for improving SDM.

TRIAL REGISTRATION

NTR6487.

Shared decision-making between older people with multimorbidity and GPs: focus group study

Background

Shared decision making (SDM), utilising the expertise of both patient and clinician, is a key feature of good-quality patient care. Multimorbidity can complicate SDM, yet few studies have explored this dynamic for older patients with multimorbidity in general practice.

Aim

To explore factors influencing SDM from the perspectives of older patients with multimorbidity and GPs, to inform improvements in personalised care.

Design and setting

Qualitative study. General practices (rural and urban) in Devon, England.

Method

Four focus groups: two with patients (aged ≥65 years with multimorbidity) and two with GPs. Data were coded inductively by applying thematic analysis.

Results

Patient acknowledgement of clinician medicolegal vulnerability in the context of multimorbidity, and their recognition of this as a barrier to SDM, is a new finding. Medicolegal vulnerability was a unifying theme for other reported barriers to SDM. These included expectations for GPs to follow clinical guidelines, challenges encountered in applying guidelines and in communicating clinical uncertainty, and limited clinician self-efficacy for SDM. Increasing consultation duration and improving continuity were viewed as facilitators.

Conclusion

Clinician perceptions of medicolegal vulnerability are recognised by both patients and GPs as a barrier to SDM and should be addressed to optimise delivery of personalised care. Greater awareness of multimorbidity guidelines is needed. Educating clinicians in the communication of uncertainty should be a core component of SDM training. The incorrect perception that most clinicians already effectively facilitate SDM should be addressed to improve the uptake of personalised care interventions.

Shared decision making in cancer treatment: A Dutch national survey on patients' preferences and perceptions

Objective

Shared decision making (SDM) for cancer treatment yields positive results. However, it appears that discussing essential topics for SDM is not fully integrated into treatment decision making yet. Therefore, we aim to explore to what extent discussion of therapy options, treatment consequences, and personal priorities is preferred and perceived by (former) cancer patients.

Methods

An online questionnaire was distributed by the Dutch Federation of Cancer Patient Organisations among (former) cancer patients in 2018.

Results

Among 3785 (former) cancer patients, 3254 patients (86%) had discussed treatments with their health care provider (HCP) and were included for analysis. Mean age was 62.1 ± 11.5; 55% were female. Discussing the option to choose no (further) treatment was rated by 2751 (84.5%) as very important (median score 9/10—IQR 8–10). Its occurrence was perceived by 28% (N = 899), and short‐ and long‐term treatment consequences were discussed in 81% (N = 2626) and 53% (N = 1727), respectively. An unmet wish to discuss short‐ and long‐term consequences was reported by 22% and 26%, respectively. Less than half of the (former) cancer patients perceived that personal priorities (44%) and future plans (34%) were discussed.

Conclusion

In the perception of (former) cancer patients, several essential elements for effective SDM are insufficiently discussed during cancer treatment decision making.

Improving shared decision-making in vascular surgery by implementing decision support tools: study protocol for the stepped-wedge cluster-randomised OVIDIUS trial

Background

Shared decision-making improves the quality of patient care. Unfortunately, shared decision-making is not yet common practice among vascular surgeons. Thus, decision support tools were developed to assist vascular surgeons and their patients in using shared decision-making. This trial aims to evaluate the effectiveness and implementation of decision support tools to improve shared decision-making during vascular surgical consultations in which a treatment decision is to be made.

Methods

The study design is a multicentre stepped-wedge cluster-randomised trial. Eligible patients are adult patients, visiting the outpatient clinic of a participating medical centre for whom several treatment options are feasible and who face a primary treatment decision for their abdominal aortic aneurysm, carotid artery disease, intermittent claudication, or varicose veins. Patients and vascular surgeons in the intervention group receive decision support tools that may help them adopt shared decision-making when making the final treatment decision. These decision support tools are decision aids, consultation cards, decision cards, and a practical training. Decision aids are informative websites that help patients become more aware of the pros and cons of the treatment options and their preferences regarding the treatment choice. Consultation cards with text or decision cards with images are used by vascular surgeons during consultation to determine which aspect of a treatment is most important to their patient. In the training vascular surgeons can practice shared decision-making with a patient actor, guided by a medical psychologist. This trial aims to include 502 vascular surgical patients to achieve a clinically relevant improvement in shared decision-making of 10 out of 100 points, using the 5-item OPTION instrument to score the audio-recordings of consultations.

Discussion

In the OVIDIUS trial the available decision support tools for vascular surgical patients are implemented in clinical practice. We will evaluate whether these tools actually improve shared decision-making in the consultation room. The stepped-wedge cluster-randomised study design will ensure that at the end of the study all participating centres have implemented at least some of the decision support tools and thereby a certain level of shared decision-making.

Trial registration

Netherlands Trial Registry, NTR6487. Registered 7 June 2017. URL: http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6487

Best-Worst Scaling Study to Identify Complications Patients Want to Be Informed About Prior to Abdominal Aortic Aneurysm Surgery

Background

Surgeons must discuss the most severe surgical complications with their patients while making a treatment decision. However, it is unclear which complications patients deem most severe. This study aimed to have patients classify potential complications following abdominal aortic aneurysm surgery based on severity using best–worst scaling.

Methods

Dutch patients with an abdominal aortic aneurysm, either under surveillance or following surgery, received a survey with 33 potential surgical complications. The survey presented these complications in sets of three. Patients had to classify one of three complications as most severe and one as least severe. After all participants had completed the survey, the number of times a complication was classified as most severe was subtracted from the number of times that the complication was classified as least severe, thus resulting in a best–worse scaling score. Complications with the lowest scores were ranked as more severe.

Results

Fifty out of 79 participating patients completed the survey in full. Patients classified the following ten complications as most severe: Below-ankle amputation, aneurysm rupture, stroke, renal failure, type 1 endoleak, spinal cord ischaemia, peripheral bypass surgery, bowel lesion, myocardial infarction and heart failure. Haematoma was ranked as the least severe complication.

Conclusion

This best–worst scaling study enabled patients to classify complications following abdominal aortic aneurysm surgery based on severity. Vascular surgeons should discuss the ten complications deemed most severe with their patients and help their patients to effectively weigh the benefits of surgery against the harms patients themselves deem important, thereby improving shared decision making.

Electronic supplementary material

The online version of this article (10.1007/s40271-020-00438-3) contains supplementary material, which is available to authorized users.

Risks following surgery that are discussed with patients prior to surgery often differ per surgeon. By law, surgeons are required to discuss the most common and most severe complications that may occur following surgery with their patients. But what do patients actually consider to be the most severe complications? In this study, we have asked this question to 50 patients with a widened abdominal aorta. These patients were approached via the Dutch patient organisation for people with cardiovascular diseases (Harteraad) and the Amsterdam University Medical Centres. From previous research, we collected 33 complications that may occur following surgery of the abdominal aorta. Using a survey, participating patients were shown three complications at a time. Of these three complications, they had to indicate which complication they considered the most severe complication and which the least severe complication. After all participants had completed their survey, we looked at how often a complication was deemed most severe and least severe. The ten most severe complications according to the participating patients were forefoot amputation, rupture of the widened abdominal aorta, stroke, kidney failure, leakage of blood along the aortic prosthesis, not enough blood supply to the spinal cord or bowels, a narrowing of the arteries in the leg, a heart attack and heart failure. We recommend that vascular surgeons discuss these ten severe complications with their patient, when a decision must be made about whether or not that patient should undergo surgery for their widened abdominal aorta. This will allow patients to weigh the benefits of the surgery against the risks they themselves deem important.

Systematic Review of Preoperative Risk Discussion in Practice

BACKGROUND

Informed consent is an ethical imperative of surgical practice. This requires effective communication of procedural risks to patients and is learned during residency. No systematic review has yet examined current risk disclosure. This systematic review aims to use existing published information to assess preoperative provision of risk information by surgeons.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses as a guide, a standardized search in Ovid MEDLINE, Embase, CINHAL, and PubMed was performed. Three reviewers performed the study screening, with 2-reviewer consensus required at each stage. Studies containing objective information concerning preoperative risk provision in adult surgical patients were selected for inclusion. Studies exclusively addressing interventions for pediatric patients or trauma were excluded, as were studies addressing risks of anesthesia.

RESULTS

The initial search returned 12,988 papers after deduplication, 33 of which met inclusion criteria. These studies primarily evaluated consent through surveys of providers, record reviews and consent recordings. The most ubiquitous finding of all study types was high levels of intra-surgeon variation in what risk information is provided to patients preoperatively. Studies recording consents found the lowest rates of risk disclosure. Studies using multiple forms of investigation corroborated this, finding disparity between verbally provided information vs chart documentation.

CONCLUSIONS

The wide variance in what information is provided to patients preoperatively inhibits the realization of the ethical and practical components of informed consent. The findings of this review indicate that significant opportunities exist for practice improvement. Future development of surgical communication tools and techniques should emphasize standardizing what risks are shared with patients.

YouTube as a source of patient information for abdominal aortic aneurysms

OBJECTIVE

Patients are increasingly referring to the Internet after a diagnosis of vascular disease. This study was performed to quantitatively define the accuracy and reliability of information on YouTube regarding abdominal aortic aneurysms (AAA).

METHODS

A systematic search of YouTube was conducted using multiple AAA-specific keywords. The default YouTube search setting of "relevance" was used to replicate an average search attempt, and the first 50 results from each keyword search were reviewed and analyzed by two independent reviewers. Descriptive characteristics, Journal of the American Medical Association Score, modified DISCERN score, Video Power Index, and a novel scoring system for the management of AAAs, the AAA-Specific Score (AAASS), were used to record data. Inter-rater agreement was analyzed using intraclass correlation coefficient estimates and the Kruskal-Wallis test was used for intergroup comparisons.

RESULTS

Fifty-one videos were included for analysis. The mean Journal of the American Medical Association Score, DISCERN, and AAASS values among videos were 1.74/4.00 (standard deviation [SD], 0.84), 2.37/5.00 (SD, 0.97), and 6.63/20.00 (SD, 3.23), respectively. Of all the included videos, 78% were educational in nature, 14% were patient testimonials, and 8% were news programs. Based on the AAASS, the majority of analyzed videos fell into the poor category (41%), followed next by the very poor (31%), moderately useful (25%), very useful (2%), and exceptional (0%) categories. Videos by nonphysicians were significantly more popular (P < .05) than vascular surgeon sources.

CONCLUSIONS

Although variable in source and content, the completeness and reliability of information offered on YouTube for AAA diagnosis and treatment is poor. Patients watching YouTube for information on their AAA diagnosis are receiving an incomplete and perhaps misleading picture of available diagnostic and treatment options. Given that vascular surgeons are likely to be affected by unrealistic treatment expectations from patients accessing online materials regarding AAA, it is important to acknowledge the nature of content on these platforms.

Delphi Study to Reach International Consensus Among Vascular Surgeons on Major Arterial Vascular Surgical Complications

BACKGROUND

The complications discussed with patients by surgeons prior to surgery vary, because no consensus on major complications exists. Such consensus may improve informed consent and shared decision-making. This study aimed to achieve consensus among vascular surgeons on which complications are considered 'major' and which 'minor,' following surgery for abdominal aortic aneurysm (AAA), carotid artery disease (CAD) and peripheral artery disease (PAD).

METHODS

Complications following vascular surgery were extracted from Cochrane reviews, national guidelines, and reporting standards. Vascular surgeons from Europe and North America rated complications as major or minor on five-point Likert scales via an electronic Delphi method. Consensus was reached if ≥ 80% of participants scored 1 or 2 (minor) or 4 or 5 (major).

RESULTS

Participants reached consensus on 9-12 major and 6-10 minor complications per disease. Myocardial infarction, stroke, renal failure and allergic reactions were considered to be major complications of all three diseases. All other major complications were treatment specific or dependent on disease severity, e.g., spinal cord ischemia, rupture following AAA repair, stroke for CAD or deep wound infection for PAD.

CONCLUSION

Vascular surgeons reached international consensus on major and minor complications following AAA, CAD and PAD treatment. This consensus may be helpful in harmonizing the information patients receive and improving standardization of the informed consent procedure. Since major complications differed between diseases, consensus on disease-specific complications to be discussed with patients is necessary.

Insight in Information Provision Prior to Obtaining Surgical Informed Consent-by Audiotaping Outpatient Consultations

BACKGROUND

Literature suggests that patient-informing process prior to obtaining surgical informed consent (SIC) does not function well. This study aimed to provide insight into the current practice of SIC in the Netherlands.

METHODS

This is a prospective, observational, and multicenter study, conducted in one academic and two non-academic teaching hospitals in the Netherlands. Audio recordings were made during outpatient consultations with patients presenting with Dupuytren Disease. The recorded informing process was scored according to a checklist. Written documentation of the SIC process in the patient's chart was compared to these scored checklists. Time spent on SIC during the consultations was also recorded.

RESULTS

A total of 41 outpatient consultations were included in the study. Consultations were conducted by 25 plastic surgeons and their residents. Average time spent on SIC was 55.6% of the total consultation time. Considerable variation was observed concerning the amount and type of information given and discussed. In 59% of the consultations, discrepancies were observed between written documentation of consultations and audio recordings. Information on treatment risks, the postoperative period, and the operating surgeon was addressed the least.

CONCLUSION

Despite a relatively large part of the consultation time being spent on SIC, patients received scarce information concerning treatment risks, postoperative period, and who their operating surgeon would be. Discrepancies were observed between the written documentation of SIC and information recorded on the audio recordings. This occurred predominantly in one hospital that used a pre-made list of 'discussed information' in its digital patient chart.

Treatment of varicose veins, international consensus on which major complications to discuss with the patient: A Delphi study

Objective

To reach consensus on which complications of varicose vein treatments physicians consider major or minor, in order to standardize the informed consent procedure and improve shared decision-making.

Methods

Using the e-Delphi method, expert physicians from 10 countries were asked to rate complications as “major” or “minor” on a 5-point Likert scale. Reference articles from a Cochrane review on varicose veins were used to compose the list of complications.

Results

Participating experts reached consensus on 12 major complications: allergic reaction, cellulitis requiring intravenous antibiotics/intensive care, wound infection requiring debridement, hemorrhage requiring blood transfusion/surgical intervention, pulmonary embolism, skin necrosis requiring surgery, arteriovenous fistula requiring repair, deep venous thrombosis, lymphocele, thermal injury, transient ischemic attack/stroke, and permanent discoloration.

Conclusion

An international consensus was reached about what physicians consider to be major complications of varicose vein treatments. This consensus may assist in standardizing the information physicians discuss with patients prior to varicose vein treatment.

The current level of shared decision-making in anesthesiology: an exploratory study

BACKGROUND

Shared decision-making (SDM) seeks to involve both patients and clinicians in decision-making about possible health management strategies, using patients' preferences and best available evidence. SDM seems readily applicable in anesthesiology. We aimed to determine the current level of SDM among preoperative patients and anesthesiology clinicians.

METHODS

We invited 115 consecutive preoperative patients, visiting the pre-assessment outpatient clinic of the department of Anesthesiology at the Academic Medical Center of Amsterdam. Inclusion criteria were patients who needed surgery in the arms, lower abdomen or legs, and in whom three anesthesia techniques were feasible. The SDM-level of the consultation was scored objectively by independent observers who judged audio-recordings of the consultation using the OPTION⁵-scale, ranging from 0% (no SDM) to 100% (optimum SDM), as well as subjectively by patients (using the SDM-Q-9 and CollaboRATE questionnaires) and clinicians (SDM-Q-Doc questionnaire). Objective and subjective SDM-levels were assessed on five-point and six-point Likert scales, respectively. Both scores were expressed as percentages.

RESULTS

Data of 80 patients could be analysed. Objective SDM-scores were low (30.5%). Subjective scores of the SDM-Q-9 and CollaboRATE were high among patients (91.7% and 96.3%, respectively) and among clinicians (SDM-Q-Doc; 84.3%). Apparently, they appreciated satisfaction rather than SDM, being poorly aware of what SDM entails.

CONCLUSION

The level of SDM in an outpatient anesthesiology clinic where preoperative patients receive information about various possible anesthesia options, was found to be low. Thus, there is room for improving the level of SDM. Some suggestions are given how this can be achieved.

A clinical and ethical review on late results and benefits after EVAR

Introduction

The aim of this review is to assess if late mortality after endovascular repair (EVAR) of abdominal aortic aneurysms (AAA) is a real problem, and whether it could be an issue in the case of medical litigation.

Material and methods

A review of all English language literature was performed on PubMed web-site, looking for all papers reporting EVAR long-term mortality rate. EVAR performances were reviewed also from an ethical and medico-legal point of view, based on current Italian laws.

Results

Mono-centric studies, and international registers suggest that today EVAR offers similar (if not better) results than open repair (OR) in the treatment of AAAs with standard and complex anatomies, even if performed outside the devices-specific instructions for use. In contrast, large randomized trials, and consequently current guidelines, suggest that EVAR still has an ancillary role compared to OR, only to be used for highly selected patients.

Recently, specific litigation cases on surgical options related to the treatment of aortic aneurysms has developed. The informed consent process needs to include not only mortality and major complications related to the procedure but also the chance of patients' outcomes. For those reasons, the generic nature of informed consent has been criticized.

Conclusions

No conclusive data is currently available to assess the initial question of late mortality after EVAR but results are still improving. In the meantime, widespread use of EVAR as first choice for treating AAA may only be acceptable in high-volume centres validating their results by a strict follow up protocol.

•

The long-term results after endovascular repair (EVAR) for abdominal aortic aneurysms (AAA) are still considered one of the main limitations of this treatment option.

•

This paper is a comprehensive review of the current literature on long-term mortality after EVAR procedures.

•

An analysis on informed consent for EVAR from a non-surgical point of view is reported for the very first time.

What are the decision-making preferences of patients in vascular surgery? A mixed-methods study

OBJECTIVES

Shared decision-making (SDM) has been advocated as the preferred method of choosing a suitable treatment option. However, patient involvement in treatment decision-making is not yet common practice in the field of vascular surgery. The aim of this mixed-methods study was to explore patients' decision-making preferences and to investigate which facilitators and barriers patients perceive as important for the application of SDM in vascular surgery.

DESIGN AND SETTING

Patients were invited to participate after visiting the vascular surgical outpatient clinic of an Academic Medical Center in the Netherlands. A treatment decision was made during the consultation for an abdominal aortic aneurysm or peripheral arterial occlusive disease. Patients filled in a number of questionnaires (quantitative part) and a random subgroup of patients participated in an in-depth interview (qualitative part).

RESULTS

A total of 67 patients participated in this study. 58 per cent of them (n=39) indicated that they preferred a shared role in decision-making. In more than half of the patients (55%; n=37) their preferred role was in disagreement with what they had experienced. 31 per cent of the patients (n=21) preferred a more active role in the decision-making process than they had experienced. Patients indicated a good patient-doctor relationship as an important facilitator for the application of SDM.

CONCLUSIONS

The vast majority of vascular surgical patients preferred, but did not experience a shared role in the decision-making process, although the concept of SDM was insufficiently clear to some patients. This emphasises the importance of explaining the concept of SDM and implementing it in the clinical encounter.

Shared Decision-Making in Cosmetic Medicine and Aesthetic Surgery

Shared decision-making (SDM) invokes the bidirectional communication between physicians and patients required to involve the patient's preference in the eventual treatment choice. This paper will explain what SDM is, why it is important, and how it is performed in clinical practice. It is an essential part of evidence-based medicine, as it helps determine whether the available evidence on the possible benefits and harms of treatment options match the patient's characteristics and preferences. Cosmetic medicine and aesthetic surgery seem to be obvious fields of medicine in which SDM should be applied to achieve high-quality care.

Shared decision making: Concepts, evidence, and practice

OBJECTIVE

Shared decision-making (SDM) is advocated as the model for decision-making in preference-sensitive decisions. In this paper we sketch the history of the concept of SDM, evidence on the occurrence of the steps in daily practice, and provide a clinical audience with communication strategies to support the steps involved. Finally, we discuss ways to improve the implementation of SDM.

RESULTS

The plea for SDM originated almost simultaneously in medical ethics and health services research. Four steps can be distinguished: (1) the professional informs the patient that a decision is to be made and that the patient's opinion is important; (2) the professional explains the options and their pros and cons; (3) the professional and the patient discuss the patient's preferences and the professional supports the patient in deliberation; (4) the professional and patient discuss the patient's wish to make the decision, they make or defer the decision, and discuss follow-up. In practice these steps are seen to occur to a limited extent.

DISCUSSION

Knowledge and awareness among both professionals and patients as well as tools and skills training are needed for SDM to become widely implemented.

PRACTICE IMPLICATIONS

Professionals may use the steps and accompanying communication strategies to implement SDM.

The Attitude of Physicians toward the Use of Patient Decision Aids in Iran as a Developing Country

Background:

The patient decision aids (PDAs), which can facilitate the decision-making process when choosing the optimal method of treatment, are a challenge to patients. This study tried to determine the attitude of physicians on the barriers of using PDAs in the way of prioritizing and proposing solutions to them.

Methods:

This study was a cross-sectional research carried out on 150 clinical faculty members of research centers and scientific associations affiliated with Tehran University of Medical Sciences. The participants were chosen using the convenience sampling method. The attitude of physicians toward the application of PDAs was interviewed using a self-made questionnaire composed of 23 questions. The association between physicians’ attitude to the use of PDAs and their characteristics was examined using the t-test, analysis of variance, and correlation test.

Results:

The mean score of physicians’ attitude was 76.2 (standard deviation =11.9) and the range was 33–107. There was a significant and direct association between the attitude toward the use of PDA and the respondents’ age (r = 0.237, P = 0.007), years of experience (r = 0.205, P = 0.02), being male (P = 0.04), and working in the private sector (P = 0.009). The attitude score of instructors was significantly lower than that of professors (P = 0.02).

Conclusions:

The general attitude of physicians toward the use of PDAs was positive. However, apparently as a result of problems mentioned in this study for the developing countries such as Iran, it is much easier to employ these tools in centers run by the private sector. Usage of such tools in public centers necessitates systemic infrastructure as well as credits and budgets required for the training of patients and physicians.

Preoperative risk information and patient involvement in surgical treatment for rectal and sigmoid cancer

AIM

Surgery for rectal and sigmoid cancer is a model setting for investigating preoperative information provision and shared decision making (SDM), as the decision consists of a trade-off between the pros and cons of different treatment options. The aim of this study was to explore surgeons' opinion on the preoperative information that should be given to rectal and sigmoid cancer patients and to evaluate what is actually communicated. In addition, we assessed surgeons' attitudes towards SDM and compared these with patient involvement.

METHOD

A questionnaire was sent to Dutch surgeons with an interest in gastroenterology. Preoperative consultations were recorded. A checklist was used to code the information that surgeons communicated to the patients. The OPTION-scale was used to measure patient involvement.

RESULTS

Questionnaires were sent to 240 surgeons, and 103 (43%) responded. They stated that information on anastomotic leakage and its consequences, the benefits and risks of a defunctioning stoma and the impact of a stoma on quality of life were necessary preoperative information. In practice, patients were inconsistently informed of these items. Most participants agreed to using SDM in their consultations. However, in practice, most patients were offered only one treatment option and little SDM was seen. The mean OPTION-score was low (7/100).

CONCLUSION

Insufficient information is given to patients with rectal and sigmoid cancer to guide them on their preferred surgical option. Information should be given on all treatment options, together with their complications and outcome, before any decision is made.

Research methodologies in informed consent studies involving surgical and invasive procedures: time to re-examine?

OBJECTIVE

We conducted a review of informed consent studies involving surgical and invasive procedures and report the degree to which current research targets a broader scope of patient outcomes beyond comprehension.

METHODS

Using PubMed, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medical Database, we identified 97 articles for review. Six members coded articles and generated scores of study design quality.

RESULTS

The mean quality score (10.7 out of a total score of 20) was low. Most studies were single institution-based, relying on one-time data collections. Randomly assigning subjects to study conditions, using power analysis to determine subject numbers, and reporting psychometric evidence, such as reliability and validity, were not widely reported. Most frequently targeted patient outcomes were knowledge, understanding and satisfaction. Core informed consent outcomes (e.g. capacity, voluntariness, decision making) and emotional factors (e.g. anxiety) were not extensively addressed.

CONCLUSION

Informed consent research may benefit from applying qualitative methods to more directly tap into patients' beliefs and decisions by eliciting in patients' own words their emotions and reasoning around processing informed consent content.

PRACTICE IMPLICATIONS

Research that addresses patient perspectives toward surgical interventions should tap into underexplored ethical and emotional factors that shape decision making.

Decision aids for patients facing a surgical treatment decision: a systematic review and meta-analysis

OBJECTIVE

To summarize the evidence available on the effects of decision aids in surgery.

BACKGROUND

When consenting to treatment, few patients adequately understand their treatment options. To help patients make deliberate treatment choices, decision aids provide evidence-based information on the disease, treatment options, and their associated benefits and harms. Although decision aids are not designed to direct patients toward a particular treatment option, it is possible that their introduction will change the proportion of patients that opt for surgery.

METHODS

We searched electronic databases for studies that evaluated a decision aid in patients offered both surgery and alternative treatment options, regarding the effect on the actual treatment choices made. In addition, we documented effects on knowledge, decisional conflict, anxiety, quality of life, patient involvement, satisfaction, mortality, morbidity, and costs.

RESULTS

Seventeen studies were included. Overall, methodological study quality was good. Patients in the decision aid group less often chose to undergo invasive treatment [risk ratio = 0.80; 95% confidence interval, 0.67-0.95), had more knowledge about treatment options [mean difference = 8.99; 95% confidence interval, 3.20-14.78), and experienced less decisional conflict (mean difference = -5.04; 95% confidence interval, -7.10 to -2.99). Levels of anxiety and quality of life were similar.

CONCLUSIONS

Offering a decision aid increases the number of patients who prefer conservative or less invasive treatment options. As decision aids improve patient knowledge and lower decisional conflict without raising anxiety levels, they have a place in surgery to help surgeons and patients achieve well-considered and shared treatment decisions.

A survey of the current practice of the informed consent process in general surgery in the Netherlands

Additional non-English language abstract (in Dutch)

BACKGROUND

A properly conducted surgical informed consent process (SIC) allows patients to authorize an invasive procedure with full comprehension of relevant information including involved risks. Current practice of SIC may differ from the ideal situation. The aim of this study is to evaluate whether SIC practiced by Dutch general surgeons and residents is adequate with involvement of all required elements.

METHODS

All members of the Dutch Society of Surgery received an online multiple choice questionnaire evaluating various aspects of SIC.

RESULTS

A total of 453 questionnaires obtained from surgeons and residents representing >95% of all Dutch hospitals were eligible for analysis (response rate 30%). Knowledge on SIC was limited as only 55% was familiar with all three basic elements ('assessment of preconditions', 'provision of information' and 'stage of consent'). Residents performance was inferior compared to surgeons regarding most aspects of daily practice of SIC. One in 6 surgeons (17%) had faced a SIC-related complaint in the previous five years possibly illustrating suboptimal SIC implementation in daily surgical practice.

CONCLUSIONS

The quality of the current SIC process is far from optimal in the Netherlands. Surgical residents require training aimed at improving awareness and skills. The SIC process is ideally supported using modern tools including web-based interactive programs. Improvement of the SIC process may enhance patient satisfaction and may possibly reduce the number of complaints.

ACHTERGROND

Het doel van het preoperatieve informed consent proces (surgical informed consent, SIC) is om patiënten een weloverwogen en welgeïnformeerde keuze te laten maken over hun operatieve ingreep. De hedendaagse praktijk betreffende SIC staat mogelijk ver van de ideale situatie af. Doel van deze studie is om de dagelijkse praktijk van chirurgen en chirurgen in opleiding betreffende SIC te evalueren en te zien of deze voldoet aan de daarvoor gestelde eisen. METHODE: Alle chirurgen en andere leden van de Nederlandse Vereniging voor Heelkunde ontvingen een online multiple-choice vragenlijst betreffende de belangrijkste aspecten van SIC. RESULTATEN: In totaal waren er 453 bruikbare reacties uit meer dan 95% van alle Nederlandse ziekenhuizen (respons 30%). De kennis over SIC blijkt zeer beperkt. Slechts 55% van de chirurgen bleek bekend met de drie basiselementen van SIC ('beoordelen van de competentie van een patiënt', 'verstrekken van informatie' and 'adequaat vastleggen van de toestemming van de patiënt'). De dagelijkse praktijk liet behoorlijke verschillen tussen alle respondenten zien, maar chirurgen in opleiding scoorden significant slechter vergeleken met chirurgen. 17% van alle chirurgen kreeg de afgelopen vijf jaar te maken met een klacht betreffende SIC, wat zou kunnen wijzen op een suboptimale implementatie van SIC in de dagelijkse praktijk.

CONCLUSIE

De kwaliteit van het preoperatieve informed consent proces is in Nederland verre van goed. Chirurgen in opleiding scoorden minder goed dan chirurgen en dienen beter geschoold te worden. Het hele SIC proces zou geformaliseerd moeten worden in protocollen. Moderne hulpmiddelen zoals interactieve softwareprogramma's kunnen hierbij mogelijk helpen. Door het verbeteren van het SIC proces kan de patiëntentevredenheid verhoogd worden terwijl het aantal klachten mogelijk wordt verminderd.

Shared decision making in the Netherlands, is the time ripe for nationwide, structural implementation?

WHAT ABOUT POLICY REGARDING SDM? The Dutch health care system has been reformed in 2006 to make it more patient-oriented and demand-driven. We shortly describe four strategies of this health care reform. Although research projects are now fully spread over the country, a coordinated research agenda on SDM is lacking. WHAT ABOUT TOOLS - DECISION SUPPORT FOR PATIENTS? The Dutch governmental healthcare internet portal for patients hosts 16 patient decision aids. WHAT ABOUT PROFESSIONAL INTEREST AND IMPLEMENTATION? There is quite a strong patient participation movement in the Netherlands, on macro and meso level. Limited effort, related to the local research projects has been put into training professionals in SDM skills. WHAT DOES THE FUTURE LOOK LIKE? We need concerted action on the level of educating health care professionals, empowering patients, making patient decision aids easily accessible, supporting the professionals in this new task, and measuring the process of SDM in performance indicators used in quality assurance. The Dutch Platform for SDM that will be launched in Maastricht in June 2011 is therefore a timely and relevant initiative.