Measuring patient-centered care: An updated systematic review of how studies define and report concordance between patients' preferences and medical treatments

Discordant Care and Decision Quality: Patients' Reasons for Not Receiving Their Initial Test of Choice in Colorectal Cancer Screening

BACKGROUND

Concordance between a person's values and the test or treatment they ultimately receive is widely considered to be an essential outcome for good decision quality. There is little research, however, on why patients receive "discordant" care. A large, randomized trial of decision aids for colorectal cancer (CRC) screening provided an opportunity to assess why some patients received a different test than the one they preferred at an earlier time point.

METHODS

Of 688 patients who participated in the trial, 43 received a different CRC screening test than the one they selected after viewing a decision aid 6 mo prior. These patients answered 2 brief, open-ended questions about the reasons for this discordance. The research team analyzed their answers using qualitative description.

RESULTS

Patient responses reflected 6 major categories: barriers or risks of initially favored test, benefits of alternative test, costs or health insurance coverage, discussion with family or friends, provider factors or recommendation, and health issues.

CONCLUSIONS

Some of the patients' explanations fit well with the informed concordance approach, which infers poor decision quality from the existence of discordant care, since in these cases it appears that the patient's values and preferences were not adequately respected. Other statements suggest that the patient had an informed rationale for changing their mind about which test to undergo. These cases may reflect high-quality decision making, despite the existence of discordance as measured in the trial. This analysis highlights a major challenge to a popular approach for assessing decision quality, the difficulty of normatively assessing the quality of decision making when apparent discordant care has been provided, and the need to assess patient values and preference over time.

HIGHLIGHTS

Value-choice concordance is an accepted measure for assessing decision quality in decision aid trials, but greater exploration of apparently discordant care challenges key assumptions of this method; this study provides evidence that discordance as typically measured may not always reflect low-quality patient decision making.Researchers evaluating decision aids and assessing decision quality should consider the use of qualitative methods to supplement measures of decision quality and consider assessing patient preferences at multiple time points.

Patient-centered outcomes and outcome measurements for people aged 65 years and older-a scoping review

INTRODUCTION

The aging population is a challenge for the healthcare system that must identify strategies that meet their needs. Practicing patient-centered care has been shown beneficial for this patient-group. The effect of patient-centered care is called patient-centered outcomes and can be appraised using outcomes measurements.

OBJECTIVES

The main aim was to review and map existing knowledge related to patient-centered outcomes and patient-centered outcomes measurements for older people, as well as identify key-concepts and knowledge-gaps. The research questions were: How can patient-centered outcomes for older people be measured, and which patient-centered outcomes matters the most for the older people?

STUDY DESIGN

Scoping review.

METHODS

Search for relevant publications in electronical databases, grey literature databases and websites from year 2000 to 2021. Two reviewers independently screened titles and abstracts, followed by full text review and extraction of data using a data extraction framework.

RESULTS

Eighteen studies were included, of which six with involvement of patients and/or experts in the process on determine the outcomes. Outcomes that matter the most to older people was interpreted as: access to- and experience of care, autonomy and control, cognition, daily living, emotional health, falls, general health, medications, overall survival, pain, participation in decision making, physical function, physical health, place of death, social role function, symptom burden, and time spent in hospital. The most frequently mentioned/used outcomes measurements tools were the Adult Social Care Outcomes Toolkit (ASCOT), EQ-5D, Gait Speed, Katz- ADL index, Patient Health Questionnaire (PHQ9), SF/RAND-36 and 4-Item Screening Zarit Burden Interview.

CONCLUSIONS

Few studies have investigated the older people's opinion of what matters the most to them, which forms a knowledge-gap in the field. Future research should focus on providing older people a stronger voice in what they think matters the most to them.

Incorporating parental values in complex paediatric and perinatal decisions

Incorporating parental values in complex medical decisions for young children is important but challenging. In this Review, we explore what it means to incorporate parental values in complex paediatric and perinatal decisions. We provide a narrative overview of the paediatric, ethics, and medical decision-making literature, focusing on value-based and ethically complex decisions for children who are too young to express their own preferences. We explain key concepts and definitions, discuss paediatric-specific features, reflect on challenges in learning and expressing values for both parents and health-care providers, and provide recommendations for clinical practice. Decisional values are informed by global and external values and could relate to the child, the parents, and the whole family. These values should inform preferences and assure value-congruent choices. Additionally, parents might hold various meta values on the process of decision making itself. Complex decisions for young children are emotionally taxing, ethically difficult, and often surrounded by uncertainty. These contextual factors make it more likely that values and preferences are initially absent or unstable and need to be constructed or stabilised. Health-care professionals and parents should work together to construct and clarify values and incorporate them into personalised decisions for the child. An open communication style, with unbiased and tailored information in a supportive environment, is helpful. Dedicated training in communication and shared decision making could help to improve the incorporation of parental values in complex decisions for young children.

Contextualizing the revised Patient Perception of Patient-Centeredness (PPPC-R) scale in primary healthcare settings: a validity and reliability evaluation study

BACKGROUND

An English version of the Patient Perception of Patient-Centeredness (PPPC) scale was recently revised, and it is necessary to test this instrument in different primary care populations.

AIM

This study aimed to assess the validity and reliability of a Chinese version of the PPPC scale.

DESIGN

A mixed method was used in this study. The Delphi method was used to collect qualitative and quantitative data to address the content validity of the PPPC scale by calculating the Content Validity Index, Content Validity Ratio, the adjusted Kappa, and the Item Impact Score. Confirmatory factor analysis (CFA) and exploratory factor analysis (EFA) were used to assess the construct validity of the PPPC scale through a cross-sectional survey. The internal consistency was also assessed.

SETTING/PARTICIPANTS

In the Delphi consultation, seven experts were consulted through a questionnaire sent by email. The cross-sectional survey interviewed 188 outpatients in Guangzhou city and 108 outpatients in Hohhot City from community health service centers or stations face-to-face.

RESULTS

The 21 items in the scale were relevant to their component. The Item-level Content Validity Index for each item was higher than 0.79, and the average Scale-level content validity index was 0.97 in each evaluation round. The initial proposed 4-factor CFA model did not fit adequately. Still, we found a 3-factor solution based on our EFA model and the validation via the CFA model (model fit: [Formula: see text], P < 0.001, RMSEA = 0.044, CFI = 0.981; factor loadings: 0.553 to 0.888). Cronbach's α also indicated good internal consistency reliability: The overall Cronbach's α was 0.922, and the Cronbach's α for each factor was 0.851, 0.872, and 0.717, respectively.

CONCLUSIONS

The Chinese version of the PPPC scale provides a valuable tool for evaluating patient-centered medical service quality.

Authenticity and the argument from testability: a bottom-up approach : Author

Jesper Ahlin Marceta published an article in this journal in which he formulated his "argument from testability", stating that it is impossible, at least practically, to operationalize procedural authenticity. That is, using procedural accounts of authenticity, one cannot reliably differentiate between authentic and inauthentic desires. There are roughly two ways to respond to the argument from testability: top-down and bottom-up. Several authors have endeavored the top-down approach by trying to show that some conceptions of authenticity might be operationalizable after all. At present, however, the bottom-up approach has not been put to the test. That is, no attempt has been made to use a currently existing assessment tool to guide the development of an account of authenticity. In this paper, I will investigate what it means to develop an account of authenticity bottom-up based on measures of concordance. More specifically, I will investigate the following three research questions. First, how do concordance and authenticity relate at a conceptual level? As crucial similarities exist between these concepts, concordance measures seem to offer a good starting point for the bottom-up approach. Second, how do judgements of concordance differ from judgements of authenticity? Both their scope and the way they are justified will turn out to be different. This suggests novel ways to react to Marceta's argument from testability. Third, should we develop a theory of concordance? The positive answer to this question will point towards a central limitation of the bottom-up approach.

Factors influencing dressing choice in wound care: a discussion

Dressing choice can be challenging for clinicians, with many different product types and makes now available. The cost of wound care products is 93% higher for unhealed wounds than for those that heal, so planning appropriate care is essential. Wound care planning requires wound assessment and identification of the aim of care. In turn, this supports dressing selection. Using an assessment framework can help ensure that this is done in a structured way. Reassessment and review of the care plan at agreed intervals is also recommended. In addition to the aim of care, other factors influence the choice of dressing. These include local formulary requirements and allergies and sensitivities. An extensive range of dressings is available and these can be grouped into 10 types: hydrocolloid; wound contact layer; hydrogel; gelling fibre; alginate; foam; absorbent pads; film; odour absorbent; and antimicrobial. Clinicians should use available resources to support decision making and consider continuity of care when selecting the dressing to be used.

Eliciting preferences for cancer screening tests: Comparison of a discrete choice experiment and the threshold technique

OBJECTIVE

To compare results of three preference elicitation methods for a cancer screening test.

METHODS

Participants (undergraduate students) completed a discrete choice experiment (DCE) and a threshold technique (TT) task. Accuracy (false positives, false negatives), benefits (lives saved), and cost for a cancer screening test were used as attributes in the DCE and branching logic for the TT. Participants were also asked a direct elicitation question regarding a hypothetical screening test for breast (women) or prostate (men) cancer without mortality benefit. Correlations assessed the relationship between DCE and TT thresholds. Thresholds were standardized and ranked for both methods to compare. A logistic regression used the thresholds to predict results of the direct elicitation.

RESULTS

DCE and TT estimates were not meaningfully correlated (max ρ = 0.17). Participant rankings of attributes matched only 20% of the time (58/292). Neither method predicted preference for being screened (ps > 0.21).

CONCLUSIONS

The DCE and TT yielded different preference estimates (and rank orderings) for the same participant. Neither method predicted patients' desires for a screening test.

PRACTICE IMPLICATIONS

Clinicians, patients, policy makers, and researchers should be aware that patient preference results may be sensitive to the method of eliciting preferences.

Racial and ethnic disparities in obstetric anesthesia: a scoping review

PURPOSE

Health disparities continue to affect racial and ethnic marginalized obstetric patients disproportionally with increased risk of Cesarean delivery and pregnancy-related death. Yet, the literature on what influences such disparities in obstetric anesthesia service and its clinical outcomes is less well known. We set out to describe racial and ethnic disparities in obstetric anesthesia during the peripartum period in the USA via a scoping review of the recent literature.

SOURCE

Using the Institute of Medicine's definition of disparities, we searched the National Library of Medicine's PubMed/Medline, Embase, Web of Science, APA PsycINFO, and Google Scholar for articles published between 1 January 2000 and 30 June 2022 to identify literature on racial and ethnic disparities in obstetric anesthesia.

PRINCIPAL FINDINGS

Out of 8,432 articles reviewed, 15 met our inclusion criteria. All but one study was observational. Seven studies were single-institutional while the remaining used multicentre data/databases. All studies compared two or more race and ethnicity classifications. Studies in this review described disparities in the use of labour epidural analgesia, labour epidural request timing, anesthesia for Cesarean deliveries, postpartum pain management, and epidural blood patch for postdural puncture headaches. Several studies reported disparities observed in the unadjusted models becoming no longer significant when adjusted for other covariates.

CONCLUSION

Based on the findings of the present scoping review on racial and ethnic disparities in obstetric anesthesia, we present an evidence map identifying knowledge gaps and propose a future research agenda.

POLST recall, concordance, and decision quality outcomes among nursing home residents and surrogate decision-makers

BACKGROUND

POLST orders are actionable in an emergency, so it is important that the decisions be of high quality and concordant with current preferences. The goal of this study is to determine the relationship between concordance and decision quality outcomes, including decision satisfaction and decisional conflict, among nursing facility residents and surrogates who recall POLST.

METHODS

We completed structured interviews in 29 nursing facilities with 275 participants who had previously signed a POLST form. This included residents who were still making their own medical decisions (n = 123) and surrogate decision-makers for residents without decisional capacity (n = 152). POLST recall was defined as remembering talking about and/or completing the POLST form previously signed by the participant. Concordance was determined by comparing preferences elicited during a standardized interview with the POLST form on file. Decisional conflict, decision satisfaction, and conversation quality were assessed with standardized tools.

RESULTS

Half of participants (50%) remembered talking about or completing the POLST form, but recall was not associated with the length of time since POLST completion or concordance with existing preferences. In multivariable analyses, there was no association between POLST recall, concordance, and decision quality outcomes, though satisfaction was associated with conversation quality.

CONCLUSIONS

Half of the residents and surrogates in this study recalled the POLST they previously signed. Neither the age of the form nor the ability to recall the POLST conversation should be considered indicators of whether existing POLST orders match current preferences. Findings confirm a relationship between POLST conversation quality and satisfaction, underscoring the importance of POLST completion as a communication process.

Watson, autonomy and value flexibility: revisiting the debate

Many ethical concerns have been voiced about Clinical Decision Support Systems (CDSSs). Special attention has been paid to the effect of CDSSs on autonomy, responsibility, fairness and transparency. This journal has featured a discussion between Rosalind McDougall and Ezio Di Nucci that focused on the impact of IBM's Watson for Oncology (Watson) on autonomy. The present article elaborates on this discussion in three ways. First, using Jonathan Pugh's account of rational autonomy we show that how Watson presents its results might impact decisional autonomy, while how Watson produces knowledge might affect practical autonomy. Second, by drawing an analogy with patient decision aids we identify an empirical way of estimating Watson's impact on autonomy (ie, value-congruence). Lastly, McDougall introduced the notion of value-flexible design as a way to account for the diverging preferences patients hold. We will clarify its relation with the established domain of value-sensitive design. In terms of the tripartite methodology of value-sensitive design, we offer a conceptual clarification using Pugh's account of rational autonomy, an empirical tool to evaluate Watson's impact on autonomy and situate a group of technical options to incorporate autonomy in Watson's design.

On the relation between decision quality and autonomy in times of patient-centered care: a case study

It is commonplace that care should be patient-centered. Nevertheless, no universally agreed-upon definition of patient-centered care exists. By consequence, the relation between patient-centered care as such and ethical principles cannot be investigated. However, some research has been performed on the relation between specific models of patient-centered care and ethical principles such as respect for autonomy and beneficence. In this article, I offer a detailed case study on the relationship between specific measures of patient-centered care and the ethical principle of respect for autonomy. Decision Quality Instruments (DQIs) are patient-centered care measures that were developed by Karen Sepucha and colleagues. The model of patient-centered care that guided the development of these DQIs pays special attention to the ethical principle of respect for autonomy. Using Jonathan Pugh's theory of rational autonomy, I will investigate how the DQIs relate to patient autonomy. After outlining Pugh's theory of rational autonomy and framing the DQIs accordingly (Part I), I will investigate whether the methodological choices made while developing these DQIs align with respect for autonomy (Part II). My analysis will indicate several tensions between DQIs and patient autonomy that could result in what I call "structural paternalism." These tensions offer us sufficient reasons, especially given the importance of the ethical principle of respect for autonomy, to initiate a more encompassing debate on the normative validity of Decision Quality Instruments. The aim of the present paper is to highlight the need for, and to offer a roadmap to, this debate.

Person-centred care in primary care: What works for whom, how and in what circumstances?

This rapid realist review aims to explain how and why person-centred care (PCC) in primary care works (or not) among others for people with low health literacy skills and for people with a diverse ethnic and socioeconomic background, and to construct a middle-range programme theory (PT). Peered reviewed- and non-peer-reviewed literature (Jan 2013-Feb 2021) reporting on PCC in primary care was included. Selection and appraisal of documents were based on relevance and rigour according to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) criteria. Data on context, mechanisms and outcomes (CMO) were extracted. Based on the extracted data, CMO configurations were identified per source publication. Configurations containing all three constructs (CMO) were included in the PT. The middle-range PT demonstrates that healthcare professionals (HCPs) should be trained and equipped with the knowledge and skills to communicate effectively (i.e. in easy-to-understand words, emphatically, checking whether the patient understands everything, listening attentively) tailored to the wishes, needs and possibilities of the patient, which may lead to higher satisfaction. This way the patient will be more involved in the care process and in the shared decision-making process, which may result in improved concordance, and an improved treatment approach. A respectful and empathic attitude of the HCP plays an important role in establishing a strong therapeutic relationship and improved health (system) outcomes. Together with a good accessibility of care for patients, setting up a personalised care plan with all involved parties may positively affect the self-management skills of patients. Good collaboration within the team and between different domains is desirable to ensure good care coordination. The coherence of items related to PCC in primary care should be considered to better understand its effectiveness.

Effectiveness of a complex regional advance care planning intervention to improve care consistency with care preferences: study protocol for a multi-center, cluster-randomized controlled trial focusing on nursing home residents (BEVOR trial)

Background

According to recent legislation, facilitated advance care planning (ACP) for nursing home (NH) residents is covered by German sickness funds. However, the effects of ACP on patient-relevant outcomes have not been studied in Germany yet. This study investigates whether implementing a complex regional ACP intervention improves care consistency with care preferences in NH residents.

Methods

This is a parallel-group cluster-randomized controlled trial (cRCT) with 48 NHs (≈ 3840 resident beds) between 09/2019 and 02/2023. The intervention group will receive a complex, regional ACP intervention aiming at sustainable systems redesign at all levels (individual, institutional, regional). The intervention comprises comprehensive training of ACP facilitators, implementation of reliable ACP processes, organizational development in the NH and other relevant institutions of the regional healthcare system, and education of health professionals caring for the residents. Control group NHs will deliver care as usual.

Primary outcome is the hospitalization rate during the 12-months observation period. Secondary outcomes include the rate of residents whose preferences were known and honored in potentially life-threatening events, hospital days, index treatments like resuscitation and artificial ventilation, advance directives, quality of life, psychological burden on bereaved families, and costs of care.

The NHs will provide anonymous, aggregated data of all their residents on the primary outcome and several secondary outcomes (data collection 1). For residents who have given informed consent, we will evaluate care consistency with care preferences and further secondary outcomes, based on chart reviews and short interviews with residents, surrogates, and carers (data collection 2). Process evaluation will aim to explain barriers and facilitators, economic evaluation the cost implications.

Discussion

This study has the potential for high-quality evidence on the effects of a complex regional ACP intervention on NH residents, their families and surrogates, NH staff, and health care utilization in Germany. It is the first cRCT investigating a comprehensive regional ACP intervention that aims at improving patient-relevant clinical outcomes, addressing and educating multiple institutions and health care providers, besides qualification of ACP facilitators. Thereby, it can generate evidence on the potential of ACP to effectively promote patient-centered care in the vulnerable population of frail and often chronically ill elderly.

Trial registration

ClinicalTrials.gov ID NCT04333303. Registered 30 March 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06576-3.

Clarifying Values: An Updated and Expanded Systematic Review and Meta-Analysis

Background

Patient decision aids should help people make evidence-informed decisions aligned with their values. There is limited guidance about how to achieve such alignment.

Purpose

To describe the range of values clarification methods available to patient decision aid developers, synthesize evidence regarding their relative merits, and foster collection of evidence by offering researchers a proposed set of outcomes to report when evaluating the effects of values clarification methods.

Data Sources

MEDLINE, EMBASE, PubMed, Web of Science, the Cochrane Library, and CINAHL.

Study Selection

We included articles that described randomized trials of 1 or more explicit values clarification methods. From 30,648 records screened, we identified 33 articles describing trials of 43 values clarification methods.

Data Extraction

Two independent reviewers extracted details about each values clarification method and its evaluation.

Data Synthesis

Compared to control conditions or to implicit values clarification methods, explicit values clarification methods decreased the frequency of values-incongruent choices (risk difference, –0.04; 95% confidence interval [CI], –0.06 to –0.02; P < 0.001) and decisional conflict (standardized mean difference, –0.20; 95% CI, –0.29 to –0.11; P < 0.001). Multicriteria decision analysis led to more values-congruent decisions than other values clarification methods (χ² = 9.25, P = 0.01). There were no differences between different values clarification methods regarding decisional conflict (χ² = 6.08, P = 0.05).

Limitations

Some meta-analyses had high heterogeneity. We grouped values clarification methods into broad categories.

Conclusions

Current evidence suggests patient decision aids should include an explicit values clarification method. Developers may wish to specifically consider multicriteria decision analysis. Future evaluations of values clarification methods should report their effects on decisional conflict, decisions made, values congruence, and decisional regret.

Reliability Generalization Study of the Person-Centered Care Assessment Tool

The so-called Person-Centered Care (PCC) model identifies three fundamental principles: changing the focus of attention from the disease to the person, individualizing care, and promoting empowerment. The Person-Centered Care Assessment Tool (P-CAT) has gained wide acceptance as a measure of PCC in recent years due to its brevity and simplicity, as well as its ease of application and interpretation. The objective of this study is to carry out a reliability generalization meta-analysis to estimate the internal consistency of the P-CAT and analyze possible factors that may affect it, such as the year of publication, the care context, the application method, and certain sociodemographic properties of the study sample. The mean value of α for the 25 samples of the 23 studies in the meta-analysis was 0.81 (95% CI: 0.79-0.84), with high heterogeneity (squared-I = 85.83%). The only variable that had a statistically significant relationship with the reliability coefficient was the mean age of the sample. The results show that the P-CAT gives acceptably consistent scores when its use is oriented toward the description and investigation of groups, although it may be affected by variables such as the age of participants.

A science of collaborative learning health systems

INTRODUCTION

Improving the U.S. healthcare system and health outcomes is one of the most pressing public health challenges of our time. Previously described Collaborative Learning Health Systems (CLHSs) are a promising approach to outcomes improvement. In order to fully realize this promise, a deeper understanding of this phenomenon is necessary.

METHODS

We drew on our experience over the past decade with CLHSs as well as qualitative literature review to answer three questions: What kind of phenomena are CLHSs? and what is an appropriate scientific approach? How might we frame CLHSs conceptually? What are potential mechanisms of action?

RESULTS

CLHSs are complex adaptive systems in which all stakeholders are able to collaborate, at scale, to create and share resources to satisfy a variety of needs. This is accomplished by providing infrastructure and services that enable stakeholders to act on their inherent motivations. This framing has implications for both research and practice.

CONCLUSION

Articulating this framework and potential mechanisms of action should facilitate research to test and refine hypotheses as well as guide practice to develop and optimize this promising approach to improving healthcare systems.

Radiology departmental policy compliance with Swedish guidelines regarding post-contrast acute kidney injury for examinations with iodinated contrast media

INTRODUCTION

Guidelines concerning intravenous iodinated contrast media (CM) during computed tomography (CT) examinations are important to follow to minimize the risk for post-contrast acute kidney injury (PC-AKI). The purpose of this study was to investigate the radiology departmental policy compliance with Swedish guidelines concerning PC-AKI.

METHODS

In February 2020, an electronic survey was distributed to the responsible radiographer at 41 radiology departments in all university hospitals and medium-sized hospitals in Sweden. The questions focused on routines around renal functional tests, individualized contrast administration and handling of patients with diabetes mellitus taking metformin.

RESULTS

The response rate was 83%. Seventy-six percent (n = 26) of radiology departments calculated estimated glomerular filtration rate (eGFR) from serum creatinine prior to CM administration, but only 24% (n = 8) followed the recommendation to calculate eGFR from both serum creatinine and cystatin C. For acute/inpatients, 55% (n = 18) followed the recommendation that renal functional tests should be performed within 12 h before CM administration. For elective patients, 97% (n = 33) followed the recommendation to have eGFR newer than three months which is acceptable for patients with no history of disease that may have affected renal function. Approximately 80% of the radiology departments followed the recommendation that CM dose always should be individually adjusted to patient eGFR. Seventy-six percent (n = 26) followed the recommendation to continue with metformin at eGFR ≥ 45 ml/min.

CONCLUSION

Compliance with the national guidelines was high regarding routines around renal functional tests, dose adjustment of CM and metformin discontinuation. Improvements can be made in using both cystatin C and serum creatinine for eGFR calculations as well as ensuring renal function tests within 12 h for acute/inpatients with acute disease that may affect renal function.

IMPLICATIONS FOR PRACTICE

This study raises awareness of the importance of adhering to guidelines in healthcare. To have knowledge about the current level of compliance regarding PCI-AKI is important to maintain and develop effective clinical implementation of guidelines. The variation in practice seen in this study emphasizes the need of more effective implementation strategies to ensure adherence with best practice.

Implementing a breast cancer patient decision aid: Process evaluation using medical files and the patients' perspective

Objective

Although patient decision aids (PtDAs) have been shown to improve shared decision‐making, integration into clinical care pathways remains limited. This study investigated, among other outcomes, the uptake of the PtDA by professionals and the uptake as perceived by patients.

Methods

We performed a process evaluation among four breast cancer care teams that had been exposed to a multifaceted implementation strategy. Data were gathered by auditing patient files using a standardised data extraction sheet and conducting telephone interviews with patients using a structured interview guide. We analysed the data by using descriptive statistics.

Results

We found that the implementation strategies, including advice on how and when to present the PtDA to the patient, were followed for 14% of the included patients (N = 84); 92% of the patients reported to have received a login code for the web‐based PtDA, while 67% logged in and used the PtDA at home. An important factor influencing the use was the clinician promoting it when delivering the PtDA (OR 9.95 95% CI 3.03–37.72).

Discussion

The implementation strategies were followed in 14% of the patients, and a high delivery of the PtDA was achieved. Redesigning the care pathway and providing personal instruction on using PtDAs seem crucial.

Effectiveness of a web-based decision aid for patients with generalised anxiety disorder: a protocol for a randomised controlled trial

INTRODUCTION

Patients with generalised anxiety disorder (GAD) have concerns and needs about their health and the healthcare they receive. Patient decision aids (PtDAs) are tools that assist patients in making health decisions, when there is uncertainty about treatment choice, incorporating their personal preferences and values about the available treatment options. PtDAs can improve shared decision-making and lead to better treatment outcomes. The aim of this study is to evaluate the effectiveness of a web-based PtDA for patients with GAD in primary care (PC).

METHODS AND ANALYSIS

The general study design is comprised of two stages: (1) development of a web-based PtDA for patients with GAD, derived from an evidence-based Clinical Practice Guideline and (2) assessment of the effectiveness of the PtDA in a randomised controlled trial (RCT) design, in PC centres in Tenerife (Spain). This RCT will be carried out with 124 patients with GAD, comparing the PtDA to a fact sheet with general information on mental health. Patients will review the PtDA in one session accompanied by a researcher. Post-intervention measures will be administered immediately after the intervention and at 3-month follow-up. The primary outcome will be decisional conflict. Secondary outcomes will include knowledge about GAD and its treatment, treatment preference, concordance between treatment preference and choice, and decision quality (knowledge ≥60% and concordant decision).

ETHICS AND DISSEMINATION

The project received ethics approval from the local committee at Nuestra Señora de la Candelaria (HUNSC) University Hospital in Santa Cruz de Tenerife (code: CHUNSC_2019_58). Informed consent will be obtained from each participant before randomisation. Results from the trial will be submitted for publication in international peer-reviewed scientific journals and will be disseminated through workshops and local and international conferences.

TRIAL REGISTRATION NUMBER

NCT04364958.

To What Extent Do Physician Orders for Life-Sustaining Treatment (POLST) Reflect Patients' Preferences for Care at the End of Life?

OBJECTIVE

To assess whether medical orders within Physician Orders for Life-Sustaining Treatment (POLST) forms reflect patients' preferences for care at the end of life.

DESIGN

This cross-sectional study assessed the agreement between medical orders in POLST forms and the free-form text documentation of an advance care planning conversation performed by an independent researcher during a single episode of hospitalization.

SETTING AND PARTICIPANTS

Inpatients at a single public university hospital, aged 21 years or older, and for whom one of their attending physicians provided a negative answer to the following question: "Would I be surprised if this patient died in the next year?" Data collection occurred between October 2016 and September 2017.

MEASURES

Agreement between medical orders in POLST forms and the free-form text documentation of an advance care planning conversation was measured by kappa statistics.

RESULTS

Sixty-two patients were interviewed. Patients' median (interquartile range) age was 62 (56-70) years, and 21 patients (34%) were women. Overall, in 7 (11%) cases, disagreement in at least 1 medical order for life-sustaining treatment was found between POLST forms and the content of the independent advance care planning conversation. The kappa statistic for cardiopulmonary resuscitation was 0.92 [95% confidence interval (CI): 0.82-1.00]; for level of medical intervention, 0.90 (95% CI: 0.81-0.99); and for artificially administered nutrition, 0.87 (95% CI: 0.75-0.98).

CONCLUSIONS AND IMPLICATIONS

The high level of agreement between medical orders in POLST forms and the documentation in an independent advance care planning conversation offers further support for the POLST paradigm. In addition, the finding that the agreement was not 100% underscores the need to confirm frequently that POLST medical orders accurately reflect patients' current values and preferences of care.

Evaluation of a Video Decision Aid to Reduce Decisional Conflict in Physician Orders for Life-Sustaining Treatment (POLST) Decision-Making

BACKGROUND/OBJECTIVES

Physician Orders for Life-Sustaining Treatment (POLST) is recommended as a preferred practice for advance care planning with seriously ill patients. Decision aids can assist patients in advance care planning, but there are limited studies on their use for POLST decisions. We hypothesized that after viewing a POLST video, decision aid participants would demonstrate increased knowledge and satisfaction and decreased decisional conflict.

DESIGN

Pre-and postintervention with no control group.

SETTING/PARTICIPANTS

Fifty community-dwelling adults aged 65 and older asked to complete a POLST based on a hypothetical condition.

INTERVENTIONS

Video decision aid for Sections A and B of the POLST form.

MEASUREMENTS

Pre- and postintervention participant knowledge, decisional satisfaction, decisional conflict, and acceptability of video decision aid.

RESULTS

Use of the video decision aid increased knowledge scores from 11.24 ± 2.77 to 14.32 ± 2.89, P < .001, improved decisional satisfaction 10.14 ± 3.73 to 8.70 ± 3.00, P = .001, and decreased decisional conflict 12 ± 9.42 to 8.15 ± 9.13, P < .001. All participants reported that they were comfortable using the video decision aid, that they would recommend it to others, and that it clarified POLST decisions.

CONCLUSIONS

Participants endorsed the use of a POLST video decision aid, which increased their knowledge of POLST form options and satisfaction with their decisions, and decreased their decisional conflict in POLST completion. This pilot study provides preliminary support for the use of video decision aids for POLST decision-making. Future research should evaluate a decision aid for the entire POLST form and identify patient preferences for implementing POLST decision aids into clinical practice.

What Helps People Make Values-Congruent Medical Decisions? Eleven Strategies Tested across 6 Studies

Background. High-quality health decisions are often defined as those that are both evidence informed and values congruent. A values-congruent decision aligns with what matters to those most affected by the decision. Values clarification methods are intended to support values-congruent decisions, but their effects on values congruence are rarely evaluated. Methods. We tested 11 strategies, including the 3 most commonly used values clarification methods, across 6 between-subjects online randomized experiments in demographically diverse US populations ( n1 = 1346, n2 = 456, n3 = 840, n4 = 1178, n5 = 841, n6 = 2033) in the same hypothetical decision. Our primary outcome was values congruence. Decisional conflict was a secondary outcome in studies 3 to 6. Results. Two commonly used values clarification methods (pros and cons, rating scales) reduced decisional conflict but did not encourage values-congruent decisions. Strategies using mathematical models to show participants which option aligned with what mattered to them encouraged values-congruent decisions and reduced decisional conflict when assessed. Limitations. A hypothetical decision was necessary for ethical reasons, as we believed some strategies may harm decision quality. Later studies used more outcomes and covariates. Results may not generalize outside US-based adults with online access. We assumed validity and stability of values during the brief experiments. Conclusions. Failing to explicitly support the process of aligning options with values leads to increased proportions of values-incongruent decisions. Methods representing more than half of values clarification methods commonly in use failed to encourage values-congruent decisions. Methods that use models to explicitly show people how options align with their values offer more promise for helping people make decisions aligned with what matters to them. Decisional conflict, while arguably an important outcome in and of itself, is not an appropriate proxy for values congruence.

Conceptualizing and Counting Discretionary Utilization in the Final 100 Days of Life: A Scoping Review

CONTEXT

There has been surprisingly little attention to conceptual and methodological issues that influence the measurement of discretionary utilization at the end of life (DIAL), an indicator of quality care.

OBJECTIVE

The objectives of this study were to examine how DIALs have been operationally defined and identify areas where evidence is biased or inadequate to inform practice.

METHODS

We conducted a scoping review of the English language literature published from 1/1/04 to 6/30/17. Articles were eligible if they reported data on ≥2 DIALs within 100 days of the deaths of adults aged ≥18 years. We explored the influence of research design on how researchers measure DIALs and whether they examine demographic correlates of DIALs. Other potential biases and influences were explored.

RESULTS

We extracted data from 254 articles published in 79 journals covering research conducted in 29 countries, mostly focused on cancer care (69.1%). More than 100 DIALs have been examined. Relatively crude, simple variables (e.g., intensive care unit admissions [56.9% of studies], chemotherapy [50.8%], palliative care [40.0%]) have been studied more frequently than complex variables (e.g., burdensome transitions; 7.3%). We found considerable variation in the assessment of DIALs, illustrating the role of research design, professional norms and disciplinary habit. Variables are typically chosen with little input from the public (including patients or caregivers) and clinicians. Fewer than half of the studies examined age (44.6%), gender (37.3%), race (26.5%), or socioeconomic (18.5%) correlates of DIALs.

CONCLUSION

Unwarranted variation in DIAL assessments raises difficult questions concerning how DIALs are defined, by whom, and why. We recommend several strategies for improving DIAL assessments. Improved metrics could be used by the public, patients, caregivers, clinicians, researchers, hospitals, health systems, payers, governments, and others to evaluate and improve end-of-life care.

Implementing the theory-based advance care planning ACP+ programme for nursing homes: study protocol for a cluster randomised controlled trial and process evaluation

BACKGROUND

Research has highlighted the need for improving the implementation of advance care planning (ACP) in nursing homes. We developed a theory-based multicomponent ACP intervention (the ACP+ programme) aimed at supporting nursing home staff with the implementation of ACP into routine nursing home care. We describe here the protocol of a cluster randomised controlled trial (RCT) that aims to evaluate the effects of ACP+ on nursing home staff and volunteer level outcomes and its underlying processes of change.

METHODS

We will conduct a cluster RCT in Flanders, Belgium. Fourteen eligible nursing homes will be pair-matched and one from each pair will be randomised to either continue care and education as usual or to receive the ACP+ programme (a multicomponent programme which is delivered stepwise over an eight-month period with the help of an external trainer). Primary outcomes are: nursing home care staff's knowledge of, and self-efficacy regarding ACP. Secondary outcomes are: 1) nursing home care staff's attitudes towards ACP and ACP practices; 2) support staff's and volunteer's ACP practices and 3) support staff's and volunteers' self-efficacy. Measurements will be performed at baseline and eight months post-measurement, using structured self-reported questionnaires. A process evaluation will accompany the outcome evaluation in the intervention group, with measurements throughout and post-intervention to assess implementation, mechanisms of impact and context and will be carried out using a mixed-methods design.

DISCUSSION

There is little high-quality evidence regarding the effectiveness and underlying processes of change of ACP in nursing homes. This combined outcome and process evaluation of the ACP+ programme aims to contribute to building the necessary evidence to improve ACP and its uptake for nursing home residents and their family.

TRIAL REGISTRATION

The study is registered at ClinicalTrials.gov (no. NCT03521206). Registration date: May 10, 2018. Inclusion of nursing homes started March, 2018. Hence, the trial was retrospectively registered but before end of data collection and analyses.

Correlates of Patient-Centered Care Practices at U.S. Substance Use Disorder Clinics

OBJECTIVE

Substance use disorder treatment professionals are paying increased attention to implementing patient-centered care. Understanding environmental and organizational factors associated with clinicians' efforts to engage patients in clinical decision-making processes is essential for bringing patient-centered care to the addictions field. This study examined factors associated with patient-centered care practices in substance use disorder treatment.

METHODS

Data were from the 2017 National Drug Abuse Treatment System Survey, a nationally representative survey of U.S substance use disorder treatment clinics (outpatient nonopioid treatment programs, outpatient opioid treatment programs, inpatient clinics, and residential clinics). Multivariate regression analyses examined whether clinics invited patients into clinical decision-making processes and whether clinical supervisors supported and believed in patient-centered care practices.

RESULTS

Of the 657 substance use disorder clinics included in the analysis, about 23% invited patients to participate in clinical decision-making processes. Clinicians were more likely to engage patients in decision-making processes when working in residential clinics (compared with outpatient nonopioid treatment programs) or in clinics serving a smaller proportion of patients with alcohol or opioid use disorder. Clinical supervisors were more likely to value patient-centered care practices if the organization's administrative director perceived less regional competition or relied on professional information sources to understand developments in the substance use disorder treatment field. Clinicians' tendency to engage patients in decision-making processes was positively associated with clinical supervisors' emphasis on patient-centered care.

CONCLUSIONS

A minority of U.S. substance use disorder clinics invited patients into clinical decision-making processes. Therefore, patient-centered care may be unavailable to certain vulnerable patient groups.

Stakeholder perceptions on patient-centered care at primary health care level in rural eastern Uganda: A qualitative inquiry

BACKGROUND

Patient-centered care (PCC) offers opportunities for African health systems to improve quality of care. Nonetheless, PCC continually faces implementation challenges. In 2015, Uganda introduced PCC as a concept in their national quality improvement guidelines. In order to investigate whether and how this is implemented in practice, this study aims to identify relevant stakeholders' views on the current quality of primary health care services and their understanding of PCC. This is an important step in understanding how the concept of PCC can be implemented in a resource constrained, sub-Saharan context like Uganda.

METHODS

This qualitative study was conducted in Uganda at national, district and facility level, with a focus on three public and three private health centres. Data collection consisted of in-depth interviews (n = 49); focus group discussions (n = 7); and feedback meetings (n = 14) across the four main categories of stakeholders identified: patients/communities, health workers, policy makers and academia. Interviews and discussions explored stakeholder perceptions on the interpersonal aspects of quality primary health care and meanings attached to the concept of PCC. A content analysis of Ugandan policy documents mentioning PCC was also conducted. Thematic content analysis was conducted using NVivo 11 to organize and analyze the data.

FINDINGS AND CONCLUSION

While Ugandan stakeholder groups have varying perceptions of PCC, they agree on the following: the need to involve patients in making decisions about their health, the key role of healthcare workers in that endeavor, and the importance of context in designing and implementing solutions. For that purpose, three avenues are recommended: Firstly, fora that include a wide range of stakeholders may offer a powerful opportunity to gain an inclusive vision on PCC in Uganda. Secondly, efforts need to be made to ensure that improved communication and information sharing-important components of PCC-translate to actual shared decision making. Lastly, the Ugandan health system needs to strengthen its engagement of the transformation from a community health worker system to a more comprehensive community health system. Cross-cutting the entire analysis, is the need to address, in a culturally-sensitive way, the many structural barriers in designing and implementing PCC policies. This is essential in ensuring the sustainable and effective implementation of PCC approaches in low- and middle-income contexts.

Impact of Timing on Measurement of Decision Quality and Shared Decision Making: Longitudinal Cohort Study of Breast Cancer Patients

Purpose.The objective of this study was to examine whether scores of shared decision-making measures differ when collected shortly after (1 month) or long after (1 year) breast cancer surgical treatment decisions. Methods. Longitudinal, multisite survey of breast cancer (BC) patients, with measurements at 1 month and 1 year after surgery at 4 cancer centers. Patients completed the BC Surgery Decision Quality Instrument (used to generate a knowledge score, ratings of goals, and concordance with treatment preferences) and Shared Decision Making (SDM) Process survey at both time points. We tested several hypotheses related to the scores over time, including whether the scores discriminated between sites that did and did not offer formal decision support services. Exploratory analyses examined factors associated with large increases and decreases in scores over time. Results. Across the 4 sites, 229 patients completed both assessments. The mean total knowledge scores (69.2% [SD 16.6%] at 1 month and 69.4% [SD 17.7%] at 1 year, P = 0.86), SDM Process scores (2.7 [SD 1.1] 1 month v. 2.7 [SD 1.2] 1 year, P = 0.68), and the percentage of patients receiving their preferred treatment (92% at 1 month and 92% at 1 year, P = 1.0) were not significantly different over time. The site using formal decision support had significantly higher knowledge and SDM Process scores at 1 month, and only the SDM Process scores remained significantly higher at 1 year. A significant percentage of patients had large changes in their individual knowledge and SDM Process scores, with increases balancing out decreases. Conclusion. For population-level assessments, it is reasonable to survey BC patients up to a year after the decision, greatly increasing feasibility of measurement. For those evaluating decision support interventions, shorter follow-up is more likely to detect an impact on knowledge scores.

A Learning Loop Model of Collaborative Decision-Making in Chronic Illness

Shared decision-making is a core attribute of quality health care that has proved challenging to implement and assess in pediatric practice. Current models of shared decision-making are limited, including their capacity to incorporate multiple stakeholders; to integrate downstream effects of subacute or minor decisions; and to account for the context(s) in which such decisions are being made and enacted. Based on a review of literature from organizational psychology, cognitive sciences, business, and medicine, we propose an iterative decision-making model of care planning and identify targets at several levels of influence warranting measurement in future studies. Our learning loop model posits the relationship between pediatric patients, their parents, and their clinicians as central to the collaborative decision-making process in the setting of chronic illness. The model incorporates the evolution of both context and developmental capacity over time. It suggests that "meta-learning" from the experience of and outcomes from iterative decision is a key factor that may influence relationships and thus continued engagement in collaboration by patients, their parents, and their clinicians. We consider the model in light of the needs of children with special health care needs, for whom understanding the ongoing iterative effects of decision making and clinician-parent-child dynamics are likely to be particularly important in influencing outcomes.

Partnerships to Improve Shared Decision Making for Patients with Hypertension - Health Equity Implications

Shared decision making (SDM) has increasingly become appreciated as a method to enhance patient involvement in health care decisions, patient-provider communication, and patient-centered care. Compared with cancer, the literature on SDM for hypertension is more limited. This is notable because hypertension is the leading risk factor for cardiovascular disease and both conditions disproportionately affect certain subgroups of patients. However, SDM holds promise for improving health equity by better engaging patients in their health care. For example, many reasonable options exist for treating uncomplicated stage-1 hypertension. These options include medication and/or lifestyle changes such as healthy eating, physical activity, and weight management. Deciding on "the best" plan of action for hypertension management can be challenging because patients have different goals and preferences for treatment. As hypertension management may be considered a preference-sensitive decision, adherence to treatment plans may be greater if those plans are concordant with patient preferences. SDM can be implemented in a broad array of care contexts, from patient-provider dyads to interprofessional collaborations. In this article, we argue that SDM has the potential to advance health equity and improve clinical care. We also propose a process to evaluate whether SDM has occurred and suggest future directions for research.

Preferences for home- and community-based long-term care services in Germany: a discrete choice experiment

BACKGROUND

Most people prefer to "age in place" and to remain in their homes for as long as possible even in case they require long-term care. While informal care is projected to decrease in Germany, the use of home- and community-based services (HCBS) can be expected to increase in the future. Preference-based data on aspects of HCBS is needed to optimize person-centered care.

OBJECTIVE

To investigate preferences for home- and community-based long-term care services packages.

DESIGN

Discrete choice experiment conducted in mailed survey.

SETTING AND PARTICIPANTS

Randomly selected sample of the general population aged 45-64 years in Germany (n = 1.209).

MAIN VARIABLES STUDIED

Preferences and marginal willingness to pay (WTP) for HCBS were assessed with respect to five HCBS attributes (with 2-4 levels): care time per day, service level of the HCBS provider, quality of care, number of different caregivers per month, co-payment.

RESULTS

Quality of care was the most important attribute to respondents and small teams of regular caregivers (1-2) were preferred over larger teams. Yet, an extended range of services of the HCBS provider was not preferred over a more narrow range. WTP per hour of HCBS was €8.98.

CONCLUSIONS

Our findings on preferences for HCBS in the general population in Germany add to the growing international evidence of preferences for LTC. In light of the great importance of high care quality to respondents, reimbursement for services by HCBS providers could be more strongly linked to the quality of services.

A behavior-theoretic evaluation of values clarification on parental beliefs and intentions toward genomic sequencing for newborns

Decision aids commonly include values clarification exercises to help people consider which aspects of a choice matter most to them, and to help them make decisions that are congruent with their personal values and preferences. Using a randomized online experiment, we examined the influence of values clarification on parental beliefs and intentions about having genomic sequencing for newborns. We recruited 1186 women and men ages 18-44 who were pregnant or whose partner was pregnant or planning to become pregnant in the next two years. Participants (N = 1000) completed one of two versions of an online decision aid developed as part of a larger project examining the technical, clinical, and social aspects of using exome sequencing to screen newborns for rare genetic conditions. The education-only version provided information about using genomic sequencing to screen newborns for medically treatable conditions. The education-plus-values-clarification version included the same information, along with a values clarification exercise in which participants classified as important or unimportant five reasons in support of having and five reasons against having their newborn undergo genomic sequencing. We conducted partial correlations, regression analysis, and MANCOVAs with sex, health literacy, and experience with genetic testing as covariates. Participants who completed the decision aid with the values clarification exercise agreed less strongly with four of the five statements against sequencing compared to participants who viewed the education-only decision aid. The groups did not differ on agreement with reasons in support of sequencing. Agreement with four of five reasons against genomic sequencing was negatively associated with intentions to have their newborn sequenced, whereas agreement with all five reasons in support of sequencing were positively associated with intentions.

Stated preferences for long-term care: a literature review

Person-centred provision of long-term care (LTC) requires information on how individuals value respective LTC services. The literature on LTC preferences has not been comprehensively reviewed, existing summaries are contradictory. An explorative, scoping review was conducted to provide a thorough methodological description and results synthesis of studies that empirically investigated LTC preference outcomes based on respondents’ statements. A wide search strategy, with 18 key terms relating to ‘LTC’ and 31 to ‘preferences’, was developed. Database searches in PubMed, Ovid and ScienceDirect were conducted in February 2016. The 59 studies meeting the inclusion criteria were grouped and methodically described based on preference elicitation techniques and methods. Despite substantial methodological heterogeneity between studies, certain findings consistently emerged for the investigated LTC preference outcomes. The large majority of respondents preferred to receive LTC in their known physical and social environment when care needs were moderate, but residential care when care needs were extensive. Preferences were found to depend on a variety of personal, environmental, social and cultural aspects. Dependent individuals aspired to preserve their personal and social identity, self-image, independence, autonomy, control and dignity, which suggests that LTC preferences are a function of the perceived ability of a specific LTC arrangement to satisfy peoples’ basic physiological and mental/social needs. Research on LTC preferences would greatly profit from a standardisation of respective concepts and methods.

"I don't know exactly what you're referring to": the challenge of values elicitation in decision making for implantable cardioverter-defibrillators

PURPOSE

Patients' values are a key component of patient-centered care and shared decision making in health care organizations. There is limited understanding on how patients' values guide their health related decision making or how patients understand the concept of values during these processes. This study investigated patients' understanding of their values in the context of considering the risks/benefits of receiving an implantable cardioverter-defibrillator (ICD).

PATIENTS AND METHODS

A qualitative substudy was conducted within a feasibility trial with first-time ICD candidates randomized to receive a patient decision aid or usual care prior to specialist consultation. Semi-structured interviews were conducted with participants post-implantation or post-specialist consultation.

RESULTS

Sixteen patients (ten male) aged 47-87 years participated. Of these, ten (62.5%) received the patient decision aid prior to specialist consultation. Findings revealed patients were confused by the word "values" and had difficulty expressing values related to risks/benefits during ICD decision making. When probed, values were conceptualized broadly capturing other factors such as desire to live, good quality of life, family's views, ICD information, control over decision, and medical authority.

CONCLUSION

This study revealed the difficulty patients considering an ICD had with articulating their values in the context of an ICD health decision and highlighted the challenge to effectively elicit patients' values within health decisions overall. It is suggested that there should be a shift away from the use of the word "values" when speaking directly to patients toward language such as "what matters to you the most" or "what is most important to you".

Supporting shared decision-making and people's understanding of medicines: An exploration of the acceptability and comprehensibility of patient information

Background

Patient information may assist in promoting shared decision-making, however it is imperative that the information presented is comprehensible and acceptable to the target audience.

Objective

This study sought to explore the acceptability and comprehensibility of the ' Medicines in Scotland: What's the right treatment for you?' factsheet to the general public.

Methods

Qualitative semi-structured telephone interviews were conducted with members of the public. An interview schedule was developed to explore the acceptability and comprehensibility of the factsheet. Participants were recruited by a researcher who distributed information packs to attendees (n=70) of four community pharmacies. Interviews, (12-24 minutes duration), were audio recorded, transcribed verbatim and analysed using a framework approach.

Results

Nineteen participants returned a consent form (27.1%), twelve were interviewed. Six themes were identified: formatting of the factsheet and interpretation; prior health knowledge and the factsheet; information contained in the factsheet; impact of the factsheet on behaviour; uses for the factsheet; and revisions to the factsheet.

Conclusions

The factsheet was generally perceived as helpful and comprehensive. It was highlighted that reading the leaflet may generate new knowledge and may have a positive impact on behaviour.

Effectiveness of a decision aid for patients with depression: A randomized controlled trial

Background

Shared decision making is an important component of patient‐centred care and decision aids are tools designed to support patients' decision making and help patients with depression to make informed choices.

Objective

The study aim was to assess the effectiveness of a web‐based decision aid for patients with unipolar depression.

Design

Randomized controlled trial.

Setting and participants

Adults diagnosed with a major depressive disorder and recruited in primary care centres were included and randomized to the decision aid (n=68) or usual care (n=79).

Intervention

Patients in the decision aid group reviewed the decision aid accompanied by a researcher.

Outcome measures

Knowledge about treatment options, decisional conflict, treatment intention and preference for participation in decision making. We also developed a pilot measure of concordance between patients' goals and concerns about treatment options and their treatment intention.

Results

Intervention significantly improved knowledge (P<.001) and decisional conflict (P<.001), and no differences were observed in treatment intention, preferences for participation, or concordance. One of the scales developed to measure goals and concerns showed validity issues.

Conclusion

The decision aid “Decision making in depression” is effective improving knowledge of treatment options and reducing decisional conflict of patients with unipolar depression. More research is needed to establish a valid and reliable measure of concordance between patients' goals and concerns regarding pharmacological and psychological treatment, and the choice made.

Patient values informing medical treatment: a pilot community and advance care planning survey

Medicine regards the prevention of death as an important priority. Yet patients may have a range of priorities of equal or greater importance. These other priorities are often not discussed or appreciated by treating doctors.

OBJECTIVES

We sought to identify priorities of care for patients attending an advance care planning (ACP) clinic and among the general population, and to identify factors associated with priorities other than prolonging life.

METHODS

We used a locally developed survey tool 'What Matters Most' to identify values. Choices presented were: maintaining dignity, avoiding pain and suffering, living as long as possible, and remaining independent. Participants rated the importance of each and then selected a main priority for their doctor. Participant groups were a purposive sample of 382 lay people from the general population and 100 attendees at an ACP clinic.

RESULTS

Living as long as possible was considered to be less important than other values for ACP patients and for the general population. Only 4% of ACP patients surveyed and 2.6% of our general population sample selected 'living as long as possible' as their top priority for medical treatment.

CONCLUSIONS

'Living as long as possible' was not the most important value for ACP patients, or for a younger general population. Prioritisation of other goals appeared to be independent of extreme age or illness. When end of life treatment is being discussed with patients, priorities other than merely prolonging life should be considered.

Patient values informing medical treatment: a pilot community and advance care planning survey

Medicine regards the prevention of death as an important priority. Yet patients may have a range of priorities of equal or greater importance. These other priorities are often not discussed or appreciated by treating doctors.

What is a good medical decision? A research agenda guided by perspectives from multiple stakeholders

Informed and shared decision making are critical aspects of patient-centered care, which has contributed to an emphasis on decision support interventions to promote good medical decision making. However, researchers and healthcare providers have not reached a consensus on what defines a good decision, nor how to evaluate it. This position paper, informed by conference sessions featuring diverse stakeholders held at the 2015 Society of Behavioral Medicine and Society for Medical Decision Making annual meetings, describes key concepts that influence the decision making process itself and that may change what it means to make a good decision: interpersonal factors, structural constraints, affective influences, and values clarification methods. This paper also proposes specific research questions within each of these priority areas, with the goal of moving medical decision making research to a more comprehensive definition of a good medical decision, and enhancing the ability to measure and improve the decision making process.

State of the Science: Tools and Measurement for Shared Decision Making

Shared decision making (SDM) has been advocated as an approach to selecting medical tests and treatments for many situations. The goal of SDM is to ensure that patients are well informed, are meaningfully involved in decisions, and receive treatments that meet their goals and preferences. There is considerable evidence about the tools used to promote SDM, called patient decision aids, and many different measures have been developed to assess the impact of SDM. However, fairly little is known about the applicability of the tools and measures in the emergency department (ED) setting. This article builds on insights from two keynote lectures presented at the 2016 Academic Emergency Medicine Consensus Conference discussing the state of the science for measurement of SDM and the design of patient decision aids to promote SDM conversations and highlights some key areas for further research to advance SDM in the ED.

The Quality of Physician Orders for Life-Sustaining Treatment Decisions: A Pilot Study

BACKGROUND

Physician Orders for Life-Sustaining Treatment (POLST) forms are used to document patient treatment preferences as medical orders. Prior research demonstrates that use of POLST alters medical treatments in a way that is consistent with the POLST orders. However, there are minimal data about the quality of POLST decisions, including whether they reflect the current preferences of well-informed patients.

OBJECTIVE

Evaluate the quality of POLST decisions.

DESIGN

Chart abstraction; interviews.

SUBJECTS

Nursing home residents and healthcare agents of incapacitated nursing home residents (n = 28).

MEASUREMENTS

Characteristics of the POLST conversation were assessed. Brief vignettes were used to assess knowledge about how POLST orders guide medical treatment. Current treatment preferences were elicited and compared with the patient's POLST orders to assess discordance.

RESULTS

A majority (59%) of participants recognized the POLST form. Participants were generally accurate in their knowledge of how POLST orders guide treatment concerning cardiopulmonary resuscitation (CPR) (68%), antibiotics (74%), and artificial nutrition (79%), but less so for medical interventions (50%). Current treatment preferences were initially discordant with one or more POLST orders for 64% (18/28) of participants, but half of these discordances were resolved with further discussion (e.g., participant agreed with the existing order). Discordance by treatment decision was as follows: CPR (7%), level of medical intervention (18%), antibiotics (21%), and artificial nutrition (11%).

CONCLUSIONS

Discordance between current preferences and POLST orders is complex. Interventions are needed to support high-quality POLST decisions that are informed and concordant with current preferences.

Care Consistency With Documented Care Preferences: Methodologic Considerations for Implementing the "Measuring What Matters" Quality Indicator

A basic tenet of palliative care is discerning patient treatment preferences and then honoring these preferences, reflected by the inclusion of "Care Consistency With Documented Care Preferences" as one of 10 "Measuring What Matters quality" indicators. Measuring What Matters indicators are intended to serve as a foundation for quality measurement in health care settings. However, there are a number of logistic and practical issues to be considered in the application of this quality indicator to clinical practice. In this brief methodologic report, we describe how care consistency with documented care preferences has been measured in research on patients near the end of life. Furthermore, we outline methodologic challenges in using this indicator in both research and practice, such as documentation, specificity and relevance, preference stability, and measuring nonevents. Recommendations to strengthen the accuracy of measurement of this important quality marker in health care settings include consistent recording of preferences in the medical record, considerations for selection of treatment preferences for tracking, establishing a protocol for review of preferences, and adoption of a consistent measurement approach.

Effects of Design Features of Explicit Values Clarification Methods

Background. Diverse values clarification methods exist. It is important to understand which, if any, of their design features help people clarify values relevant to a health decision. Purpose. To explore the effects of design features of explicit values clarification methods on outcomes including decisional conflict, values congruence, and decisional regret. Data Sources. MEDLINE, all EBM Reviews, CINAHL, EMBASE, Google Scholar, manual search of reference lists, and expert contacts. Study Selection. Articles were included if they described the evaluation of 1 or more explicit values clarification methods. Data Extraction. We extracted details about the evaluation, whether it was conducted in the context of actual or hypothetical decisions, and the results of the evaluation. We combined these data with data from a previous review about each values clarification method’s design features. Data Synthesis. We identified 20 evaluations of values clarification methods within 19 articles. Reported outcomes were heterogeneous. Few studies reported values congruence or postdecision outcomes. The most promising design feature identified was explicitly showing people the implications of their values, for example, by displaying the extent to which each of their decision options aligns with what matters to them. Limitations. Because of the heterogeneity of outcomes, we were unable to perform a meta-analysis. Results should be interpreted with caution. Conclusions. Few values clarification methods have been evaluated experimentally. More research is needed to determine effects of different design features of values clarification methods and to establish best practices in values clarification. When feasible, evaluations should assess values congruence and postdecision measures of longer-term outcomes.

Choosing treatment and screening options congruent with values: Do decision aids help? Sub-analysis of a systematic review

OBJECTIVE

To understand how well patients make value congruent decisions with and without patient decision aids (PtDAs) for screening and treatment options, and identify issues with its measurement and evaluation.

METHODS

A sub-analysis of trials included in the 2014 Cochrane Review of Decision Aids. Eligible trials measured value congruence with chosen option. Two reviewers independently screened 115 trials.

RESULTS

Among 18 included trials, 8 (44%) measured value congruence using the Multidimensional Measure of Informed Choice (MMIC), 7 (39%) used heterogeneous methods, and 3 (17%) used unclear methods. Pooled results of trials that used heterogeneous measures were statistically non-significant (n=3). Results from trials that used the MMIC suggest patients are 48% more likely to make value congruent decisions when exposed to a PtDA for a screening decision (RR 1.48, 95% CI 1.01 to 2.16, n=8).

CONCLUSION

Patients struggle to make value congruent decisions, but PtDAs may help. While the absolute improvement is relatively small it may be underestimated due to sample size issues, definitions, and heterogeneity of measures.

PRACTICE IMPLICATIONS

Current approaches are inadequate to support patients making decisions that are consistent with their values. There is some evidence that PtDAs support patients with achieving values congruent decisions for screening choices.

'Some patients are more equal than others': Patient-centred care differential in two-tier inpatient ward hospitals in Ghana

OBJECTIVE

To examine differences in patient-centred care among private and public inpatients in public hospitals and whether satisfaction with patient-centred care differ between the patient groups.

METHOD

Cross-sectional data collected from inpatients in private wards (n=300) and public wards (n=520) in Ghana, using a structured questionnaire modelled on four dimensions of patient-centred care: respect and dignity, emotional support, interpersonal relations and information sharing.

RESULTS

Patient-centred care differed significantly among private and public patients (p<0.001), with an effect size ranging from medium to large. Private patients rated patient-centred care higher than public patients in all the items of the four dimensions. Satisfaction with patient-centred care discriminated between the patient groups. Satisfaction was significantly high for private patients who are aged 50+ (p<0.001), had high education (p<0.05) and high income (p<0.001) compared to the same category of public patients.

CONCLUSION

Physicians behaviour is stereotyping and less favourable to public patients, suggesting inequitable access to patient-centred care for inpatients from high and low socioeconomic backgrounds.

PRACTICE IMPLICATIONS

Hospitals with private and public wards should be compelled to properly coordinate and regulate the activities of physicians to avoid fragmented care for inpatients.

Process for massage therapy practice and essential assessment

BACKGROUND

Little evidence exists about processes in massage therapy practice. Investigating current frameworks is warranted. This qualitative study is a secondary data analysis using grounded theory to understand how massage therapy experts describe massage therapy practice.

METHODS

31 massage therapy experts were invited to a 2-day symposium to discuss best practices for the profession. Through qualitative analysis, memoing, and discussion, the data were summarized into themes.

RESULTS

Three themes were identified around massage therapy practice: 1) client centered, 2) structure for practice, and 3) influencing factors. Each theme is clarified and expanded.

DISCUSSION

Conceptual models were developed for research and clinical practice and a definition for massage therapy practice was identified. Challenges and limitations are discussed.

CONCLUSION

The goal of providing these models is to give massage therapists tools to deliver the best possible care. The models need testing to see if they help advance the profession.