Preferences for involvement in treatment decision-making generally and in hormone replacement and urinary incontinence treatment decision-making specifically

Desired decision-making role and treatment satisfaction among trans people during medical transition: results from the ENIGI follow-up study

BACKGROUND

Shared decision making (SDM) is particularly important in transition-related medical interventions (TRMIs) given the nature of treatment and history of gatekeeping in transgender health care. Yet few studies have investigated trans people's desired decision-making role within TRMI and factors that influence these desires.

AIMS

The study investigated trans people's desired level of decision making during medical transition as well as possible sociodemographic predictors and correlations between decision-making desires and satisfaction with treatment.

METHODS

Data were collected from a clinical sample from 3 trans health care centers, as part of the larger ENIGI study. The data consisted of 568 trans individuals (60.2% assigned male at birth) 20 to 82 years of age (mean age = 38.58 years) who took part in the study 4 to 6 years after initial clinical contact. Binary logistic regressions were conducted to determine whether independent variables predicted group membership in decision-making role subgroups while a Spearman rank-order correlation was conducted to determine the relationship between desired decision-making involvement and satisfaction with care.

OUTCOMES

Main measures were desired decision-making role, satisfaction with treatment, age, education level, country of residence, treatment status, individual treatment progress score (ITPS), gender identity, and sex assigned at birth.

RESULTS

The vast majority of participants wanted to make medical decisions themselves. Age, education level, country of residence, treatment status, gender identity, and sex assigned at birth showed no significant effects in desired level of decision making, while the ITPS neared significance. Satisfaction with treatment was overall very high. For participants assigned male at birth, desire for a more active role in decision making was negatively correlated with satisfaction of labia surgery.

CLINICAL IMPLICATIONS

A desired decision-making role cannot be predicted based on the trans person's sociodemographic characteristics. More involvement from health professionals addressing medical information and education obligations may be needed when offering surgical construction of labia to individuals assigned male at birth.

STRENGTHS AND LIMITATIONS

This study builds on the few existing analyses of desired levels of decision-making role among trans people during transition. It is the first to investigate the role of education level and treatment status/ITPS on the desire of decision-making role. Gender identity and influence of nonbinary identity were not investigated for treatment satisfaction as these items were presented based on sex assigned at birth.

CONCLUSION

This study highlights that trans people in 3 European trans health care centers during medical transition desire a more active role in decision making. Satisfaction with treatment received was overall very high.

Shared Decision-Making in Patients With Prostate Cancer in Japan: Patient Preferences Versus Physician Perceptions

This article adds the Japanese perspective to our knowledge of shared decision-making (SDM) preferences by surveying patients with prostate cancer (PCA) and physicians in Japan. In 2015, 103 Japanese patients with PCA were asked about their SDM preferences by using an Internet-based 5-point-scale questionnaire. Concurrently, 127 Japanese physicians were surveyed regarding their perceptions of patient preferences on SDM. Drivers of preferences and perceptions were analyzed using univariable ordinal logistic regression and graphing the fitted response probabilities. Although 41% of both patients and physicians expressed and expected a desire for active involvement in treatment decisions (a higher rate than in a similar study for the United States in 2001), almost half the Japanese patients preferred SDM, but only 33% of physicians assumed this was their choice. That is, 29% of Japanese physicians underestimated patients’ preference for involvement in making treatment decisions. Patients with lower health-related quality of life (as measured by the Functional Assessment of Cancer Therapy-Prostate [FACT-P]) expressed a stronger preference for SDM. The study shows that the worse the medical situation, the more patients with PCA prefer to be involved in the treatment decision, yet physicians tend to underestimate the preferences of their patients. Perhaps in contrast to common assumptions, Japanese patients are as interested in being involved in decision making as are patients in the United States.

Preferences Regarding Shared Decision-Making in Japanese Inflammatory Bowel Disease Patients

INTRODUCTION

Recent studies have indicated that patients are showing increased interest in playing a larger role in making decisions regarding their medical treatment. Inflammatory bowel disease (IBD) is a chronic disease that manifests either as Crohn's disease (CD) or ulcerative colitis (UC). IBD treatment is multifaceted and dependent on patient-specific factors. The selection of treatment options is mostly driven by physicians, and it is unclear to what degree patients are involved in shared decision-making (SDM). The objective of the current study is to assess preferences among Japanese patients with IBD in regard to SDM during their treatment for IBD.

METHODS

A nationwide web-based survey was performed in Japan during February 2016. The patients were asked for their basic clinical characteristics, socioeconomic status, medical history, treatment details, and preferences regarding SDM in IBD treatment. Differences were analyzed by chi-square, t tests, a multiple regression analysis, and ordered logistic regression analysis.

RESULTS

In response to the screening survey, a total of 1068 Japanese nationals met the inclusion criteria for this study of being patients diagnosed with IBD who are currently receiving treatment. Of these, 235 had CD and 800 UC; 33 were not specified. Overall, the majority of these patients felt that SDM was very important. Furthermore, interest in SDM was strongly associated with certain disease comorbidities, surgical history, and current treatment, although there were some differences in the results between CD and UC.

CONCLUSION

The present study found that the majority of IBD patients in Japan wanted to have a role in their treatment plan. The results indicate that the patient's preference in regard to SDM was driven by their perception of the severity or progression of their disease.

FUNDING

Janssen Pharmaceuticals.

Theory-based strategies for enhancing the impact and usage of digital health behaviour change interventions: A review

There is growing evidence that digital interventions can successfully effect meaningful changes in health-related behaviour. However, optimisation of digital intervention delivery is challenged by low usage, high attrition and small effect sizes. Whilst a number of conceptual frameworks and models exist to guide intervention planning and development, insufficient attention has been paid to how existing psychological theory could inform the optimal implementation and delivery of the design features commonly used in digital health behaviour change interventions. This paper provides a critical review of psychological theories and models in order to consider their implications for the design of digital interventions. The theories reviewed include theories of: persuasion and attitude change; motivation; volition and self-regulation; patient preferences for participation in medical decision making; and social support. A set of theory-based guidelines is provided to inform the development of future interventions.

Psychiatric patients' preferences and experiences in clinical decision-making: examining concordance and correlates of patients' preferences

OBJECTIVE

To assess the concordance between patients' preferred role in clinical decision-making and the role they usually experience in their psychiatric consultations and to analyze the influence of socio-demographic, clinical and personality characteristics on patients' preferences.

METHODS

677 consecutive psychiatric outpatients were invited to participate in a cross-sectional survey and 507 accepted. Patients completed Control Preference Scale twice consecutively before consultation, one for their preferences of participation and another for the style they usually experienced until then, and locus of control and self-efficacy scales.

RESULTS

Sixty-three percent of psychiatric outpatients preferred a collaborative role in decision-making, 35% preferred a passive role and only a 2% an active one. A low concordance for preferred and experienced participation in medical decision-making was registered, with more than a half of patients wanting a more active role than they actually had. Age and doctors' health locus of control orientation were found to be the best correlates for participation preferences, while age and gender were for experienced. Psychiatric diagnoses registered significant differences in patients' preferences of participation but no concerning experiences.

CONCLUSION

The limited concordance between preferred and experienced roles in psychiatric patients is indicative that clinicians need to raise their sensitivity regarding patient's participation.

PRACTICE IMPLICATIONS

The assessment of patient's attribution style should be useful for psychiatrist to set objectives and priority in the communication with their patients.

Medical decision-making among adolescents with neonatal brachial plexus palsy and their families: a qualitative study

BACKGROUND

Elective surgical management of neonatal brachial plexus palsy is complex, variable, and often individualized. Little is known about the medical decision-making process among adolescents with neonatal brachial plexus palsy and their families when faced with making complex treatment decisions. The experiences of these patients and their parents were analyzed to identify key factors in the decision-making process.

METHODS

Eighteen adolescents with residual neonatal brachial plexus palsy deficits between 10 and 17 years and their parents were included. Qualitative research design was used involving separate, 1-hour, in person, semistructured interviews, which were audio recorded and transcribed. Grounded theory was applied by two members of the research team to identify recurrent themes and create a codebook that was applied to the data.

RESULTS

Medical decision-making among adolescents with neonatal brachial plexus palsy and their families is multifaceted and individualized, composed of both patient- and system-dependent factors. Four codes were identified: (1) knowledge acquisition, (2) multidisciplinary care, (3) adolescent autonomy, and (4) patient expectations and treatment desires. Overall, parental decision-making was heavily influenced by system-dependent factors, whereas adolescents largely based their decisions on individual treatment desires to improve function and/or aesthetics.

CONCLUSIONS

There are many areas for improving the delivery of information and health care organization among adolescents with neonatal brachial plexus palsy and their families. The authors recommend the development of educational interdisciplinary programs and decision aids containing evidence-based management guidelines targeted toward primary care providers and patients. The authors believe that a computer-based learning module may provide the best avenue to achieve maximum penetrance and convenience of information sharing.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Too complex and time-consuming to fit in! Physicians' experiences of elderly patients and their participation in medical decision making: a grounded theory study

OBJECTIVE

To explore physicians' thoughts and considerations of participation in medical decision making by hospitalised elderly patients.

DESIGN

A qualitative study using focus group interviews with physicians interpreted with grounded theory and completed with a questionnaire.

SETTING AND PARTICIPANTS

The setting was three different hospitals in two counties in Sweden. Five focus groups were conducted with physicians (n=30) in medical departments, with experience of care of elderly patients.

RESULTS

Physicians expressed frustration at not being able to give good care to elderly patients with multimorbidity, including letting them participate in medical decision making. Two main categories were found: 'being challenged' by this patient group and 'being a small part of the healthcare production machine'. Both categories were explained by the core category 'lacking in time'. The reasons for the feeling of 'being challenged' were explained by the subcategories 'having a feeling of incompetence', 'having to take relatives into consideration' and 'having to take cognitive decline into account'. The reasons for the feeling of 'being a small part of the healthcare production machine' were explained by the subcategories 'at the mercy of routines' and 'inadequate remuneration system', both of which do not favour elderly patients with multimorbidity.

CONCLUSIONS

Physicians find that elderly patients with multimorbidity lead to frustration by giving them a feeling of professional inadequacy, as they are unable to prioritise this common and rapidly growing patient group and enable them to participate in medical decision making. The reason for this feeling is explained by lack of time, competence, holistic view, appropriate routines and proper remuneration systems for treating these patients.

Measuring decisional control preferences in men newly diagnosed with prostate cancer

The Control Preferences Scale is widely used in decision research to measure patient preferences for participation in treatment decision making with health care providers. Following anecdotal reports of confusion with the scale the authors conducted an exploratory interview study to examine perceptions of the meaning and applicability of the Control Preferences Scale for men with localized prostate cancer seeking treatment in a multidisciplinary urology clinic. The preliminary data suggest potential validity challenges when the Control Preferences Scale is used in a multidisciplinary prostate cancer care setting, including the clinical context of localized prostate cancer and the meaning of shared decision making.

Lifestyle risk management--a qualitative analysis of women's descriptions of taking hormone therapy following surgically induced menopause

AIM

This article is a report of a study that examined how women describe their decisions in relation to the use of menopausal hormone therapy following surgical menopause.

BACKGROUND

Women who have had a surgically induced menopause generally experience more intense menopausal symptoms than natural menopause and are regularly prescribed menopausal hormone therapy. Since 2002 the risks associated with this therapy have been widely reported.

METHOD

This study is a qualitative analysis of semi-structured interviews between March and May 2009 with 30 participants who had experienced surgical menopause and were, or had in the past, taken menopausal hormone therapy. This was a community sample recruited in Christchurch, New Zealand. A risk management theoretical approach underpinned the analysis.

FINDINGS

The womens' descriptions of managing the risks associated with menopausal therapy fell into two main themes: Life has to go on and Waiting for someone to tell me. All these women had either made an active decision to continue on treatment because of the impact of menopausal symptoms or took their doctor's advice to continue. A less dominant theme but one that was also evident was Relying on my body to get me through in which the women had decided to discontinue treatment because they regarded it as unnatural.

CONCLUSION

The study provided insights into how women utilize an experiential reasoning process to manage the health and lifestyle risks associated with taking menopausal hormone therapy. Nurses need to be aware of how this process influences women's reasoning processes when working with women following surgical menopause.

A qualitative study of factors influencing the decision to have an elective amputation

BACKGROUND

Some patients with a functionally impaired lower limb choose to have an elective amputation, whereas others do not. Functional outcomes do not favor either type of treatment, making this a complex decision. The experiences of patients who have chosen elective amputation were analyzed to identify the key factors in this decision-making process.

METHODS

Patients from a tertiary care amputee clinic who had chosen to undergo elective amputation of a functionally impaired lower limb participated in the present study. A qualitative research design involved the use of one-on-one semi-structured interviews, which were audio recorded and transcribed. Narrative analysis was used by three researchers to provide triangulation. Recurrent key themes and patterns were described. Personal factors in the decision-making process were identified.

RESULTS

Factors that had the largest impact on the decision-making process were pain, function, and participation. Body image, self identity, and the opinions of others had little influence. Satisfaction with the surgical outcome was related to how closely the result matched the patient's expectations. Patients who were better informed prior to surgery had more realistic expectations about living with an amputation.

CONCLUSIONS

The severity of pain and the desire for improved function are strong drivers for patients deciding to undergo elective amputation of a functionally impaired lower extremity. While patients do not want others' opinions, information regarding life with an amputation helps to set realistic expectations regarding outcome.

Researching involvement in health care practices: interrupting or reproducing medicalization?

In this paper we reflect upon and problematize the ways in which 'patient involvement' is interpreted in a substantial proportion of the research literature on involvement and shared decision making. Drawing upon an analysis of this literature we raise concerns about the 'medicalization of involvement' embedded in, and reproduced by, some dominant research lenses, suggesting that this medicalization has powerful discursive and material effects. For example, we suggest that it tends to normalize and arguably trivialize intrinsically problematic and contentious concepts such as 'patient preferences' and, at the same time, to obscure the full range of possibilities for reciprocity in the exchanges between the medical world of the professional and the experiential and narrative world of the patient. We argue that richer conceptualizations of collaboration in clinical work are both possible and very much needed, and we indicate some examples of scholarly resources and perspectives that point towards richer and more defensible accounts of involvement. Overall we call for more attention to the idea of 'epistemic involvement' and much greater cross-fertilization between different epistemological paradigms in this area of research.

Are elderly people with co-morbidities involved adequately in medical decision making when hospitalised? A cross-sectional survey

BACKGROUND

Medical decision making has long been in focus, but little is known of the preferences and conditions for elderly people with co-morbidities to participate in medical decision making. The main objective of the present study was to investigate the preferred and the actual degree of control, i.e. the role elderly people with co-morbidities wish to assume and actually had with regard to information and participation in medical decision making during their last stay in hospital.This study was a cross-sectional survey including three Swedish hospitals with acute admittance. The participants were patients aged 75 years and above with three or more diagnoses according to the International Classification of Diseases (ICD-10) and three or more hospitalisations during the last year.

METHODS

We used a questionnaire combined with a telephone interview, using the Control Preference Scale to measure each participant's preferred and actual role in medical decision making during their last stay in hospital. Additional questions were asked about barriers to participation in decision making and preferred information seeking role. The results are presented with descriptive statistics with kappa weights.

RESULTS

Of the 297 elderly patients identified, 52.5% responded (n = 156, 46.5% male). Mean age was 83.1 years. Of the respondents, 42 of 153 patients said that they were not asked for their opinion (i.e. no shared decision making). Among the other 111 patients, 49 had their exact preferred level of participation, 37 had less participation than they would have preferred, and 23 had more responsibility than they would have preferred. Kappa statistics showed a moderate agreement between preferred and actual role (κw = 0.57; 95% CI: 0.45-0.69). Most patients wanted to be given more information without having to ask. There was no correlation between age, gender, or education and preferred role. 35% of the patients agreed that they experienced some of the various barriers to decision making that they were asked about: 1) the severity of their illness, 2) doctors with different treatment strategies, 3) difficulty understanding the medical information, and 4) difficulty understanding doctors who did not speak the patient's own language.

CONCLUSIONS

Physicians are not fully responsive to patient preferences regarding either the degree of communication or the patient's participation in decision making. Barriers to participation can be a problem, and should be taken into account more often when dealing with hospitalised elderly people.

Development of a questionnaire to assess communication preferences of patients with chronic illness

OBJECTIVE

the objectives of the study are to develop a patient-oriented and theory-based questionnaire on the communication preferences of chronically ill patients (KOPRA questionnaire) and to carry out psychometric testing of the instrument.

METHODS

following two preliminary studies (focus groups, cognitive interviews), a total of 472 patients with chronic back pain or chronic ischemic heart disease were surveyed. In the main sample (N=333), communication preferences regarding the physician were assessed; for N=89 (or N=50) patients, preferences regarding nursing staff (or therapists) were analyzed. Psychometric testing was done with respect to unidimensionality, fit to an item response theory (IRT) model, and for reliability. The questionnaire was developed and validated in German.

RESULTS

In the physician version with a total of 32 items, there are four scales ("Patient participation and patient orientation", "Effective and open communication", "Emotionally supportive communication", and "Communication about personal circumstances") that are unidimensional, fulfill the demands for a 1-parameter IRT model, and are reliable (Cronbach's alpha between .80 and .92). The psychometric properties with respect to nursing staff and therapists are slightly worse.

CONCLUSION

the KOPRA questionnaire has good psychometric properties.

PRACTICE IMPLICATIONS

clinical use of the questionnaire appears useful to determine patients' communication preferences.

Treatment decision-making and information-seeking preferences in women with pelvic floor disorders

INTRODUCTION AND HYPOTHESIS

The Autonomy Preference Index (API) and Control Preferences Scale (CPS) measure information-seeking and decision-making preferences. Our objective was to validate these scales in women with pelvic floor disorders (PFDs) and identify variables associated with decision-making preferences.

METHODS

Women seeking care for PFDs completed the API and the CPS. Psychometric properties were determined. Multivariable analyses were used to identify correlates of information-seeking and decision-making preferences.

RESULTS

One hundred ten women were recruited. Both scales demonstrated good psychometric properties (intraclass correlation coefficient = 0.5 to 0.7; Cronbach's alpha = 0.8 for the API, and r = -0.3 between the API and CPS). Based on scores, women had strong preferences to be well informed, but were more neutral in their decision-making preferences. In multivariable analyses, higher education levels were associated with a stronger desire for seeking medical information.

CONCLUSIONS

Women seeking care for PFDs vary in their preferences for participating in treatment decisions.

Clinician and cancer patient views on patient participation in treatment decision-making: a quantitative and qualitative exploration

Patient participation in treatment decision-making is being increasingly advocated, although cancer treatments are often guideline-driven. Trade-offs between benefits and side effects underlying guidelines are made by clinicians. Evidence suggests that clinicians are inaccurate at predicting patient values. The aim was to assess what role oncologists and cancer patients prefer in deciding about treatment, and how they view patient participation in treatment decision-making. Seventy disease-free cancer patients and 60 oncologists (surgical, radiation, and medical) were interviewed about their role preferences using the Control Preferences Scale (CPS) and about their views on patient participation using closed- and open-ended questions. Almost all participants preferred treatment decisions to be the outcome of a shared process. Clinicians viewed participation more often as reaching an agreement, whereas 23% of patients defined participation exclusively as being informed. Of the participants, > or = 81% thought not all patients are able to participate and > or = 74% thought clinicians are not always able to weigh the pros and cons of treatment for patients, especially not quality as compared with length of life. Clinicians seemed reluctant to share probability information on the likely impact of adjuvant treatment. Clinicians should acknowledge the legitimacy of patients' values in treatment decisions. Guidelines should recommend elicitation of patient values at specific decision points.