Cultural challenges to engaging patients in shared decision making

Multiethnic Perspectives of Shared Decision-Making in Hypertension: A Mixed-Methods Study

BACKGROUND

Shared decision-making (SDM) has the potential to improve hypertension care quality and equity. However, research lacks diverse representation and evidence about how race and ethnicity affect SDM. Therefore, this study aims to explore SDM in the context of hypertension management.

METHODS AND RESULTS

Explanatory sequential mixed-methods design was used. Quantitative data were sourced at baseline and 12-month follow up from RICH LIFE (Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone) participants (n=1212) with hypertension. Qualitative data were collected from semistructured individual interviews, at 12-month follow-up, with participants (n=36) selected based on their SDM scores and blood pressure outcome. Patients were cross- categorized based on high or low SDM scores and systolic blood pressure reduction of ≥10 or <10 mm Hg. Multinomial logistic regression analysis showed that predictors of SDM scores and blood pressure outcome were race and ethnicity (relative risk ratio [RRR], 1.64; P=0.029), age (RRR, 1.03; P=0.002), educational level (RRR, 1.87; P=0.016), patient activation (RRR, 0.98; P<0.001; RRR, 0.99; P=0.039), and hypertension knowledge (RRR, 2.2; P<0.001; and RRR, 1.57; P=0.045). Qualitative and mixed-methods findings highlight that provider-patient communication and relationship influenced SDM, being emphasized both as facilitators and barriers. Other facilitators were patients' understanding of hypertension; clinicians' interest in the patient, and clinicians' personality and attitudes; and barriers included perceived lack of compassion, relationship hierarchy, and time constraints.

CONCLUSIONS

Participants with different SDM scores and blood pressure outcomes varied in determinants of decision and descriptions of contextual factors influencing SDM. Results provide actionable information, are novel, and expand our understanding of factors influencing SDM in hypertension.

Reframing the experience of childbirth: Black doula communication strategies and client responses during delivery hospitalization

Doulas, or birth coaches, are said to be "changing the world, one birth at a time." Black doulas have been suggested to mitigate against lack of representation in obstetric care, limited identity acknowledgement and accommodation, and obstetric racism. However, scientific inquiry into the specific communication strategies and messages used by Black doulas to advocate for clients was non-existent in extant literature. Guided by the Agency-Identity Model, we analyzed 20 diary-interviews of nine Black doulas who recently served Black clients. Specifically, we explored Black doulas' communication strategies and whether these strategies had an impact on client agency. We found that Black doulas prepare their clients for patient-provider interactions, including conversations about certain medical treatments and procedures and the risks for Black women and birthing people, the importance of informed consent, how to be heard, and how to resist neglect or abuse. We found that, in turn, most Black clients were able to enact agentic responses. We describe the specific doula messages, and contextualize our findings, considering how these collective interpersonal communication strategies of Black doulas, and their clients' agentic transformations, may index a sociopolitical movement to reframe the experience of childbirth in America.

Understanding perceptions of tumor genomic profile testing in Black/African American cancer patients in a qualitative study: the role of medical mistrust, provider communication, and family support

Tumor genomic profiling (TGP) examines genes and somatic mutations specific to a patient's tumor to identify targets for cancer treatments but can also uncover secondary hereditary (germline) mutations. Most patients are unprepared to make complex decisions related to this information. Black/African American (AA) cancer patients are especially at risk because of lower health literacy, higher levels of medical mistrust, and lower awareness and knowledge of genetic testing. But little is known about their TGP attitudes or preferences. Five in-person focus groups were conducted with Black/AA cancer patients (N = 33) from an NCI-designated cancer center and an affiliated oncology unit in an urban safety-net hospital located in Philadelphia. Focus groups explored participants' understanding of TGP, cultural beliefs about genetics, medical mistrust, and how these perceptions informed decision-making. Participants were mostly female (81.8%), and one-third had some college education; mean age was 57 with a SD of 11.35. Of patients, 33.3% reported never having heard of TGP, and 48.5% were not aware of having had TGP as part of their cancer treatment. Qualitative analysis was guided by the principles of applied thematic analysis and yielded five themes: (1) mistrust of medical institutions spurring independent health-information seeking; (2) genetic testing results as both empowering and overwhelming; (3) how provider-patient communication can obviate medical mistrust; (4) how unsupportive patient-family communication undermines interest in secondary-hereditary risk communication; and (5) importance of developing centralized patient support systems outside of treatment decisions. Results improve understanding of how Black/AA patients perceive of TGP and how interventions can be developed to assist with making informed decisions about secondary hereditary results.

A multi-site cultural and linguistic adaptation of a hypospadias decision aid for Latinx communities

INTRODUCTION

Latinx, Spanish-speaking (LSS) patients are more likely to experience decisional conflict and regret about healthcare decisions than non-Hispanic, white, English-speaking patients.

OBJECTIVE

To adapt the Hypospadias Hub (Hub), a rigorously developed and tested web-based decision aid (DA), for LSS parents.

METHODS

Guided by the Ecological Validity Model (EVM), a heuristic framework was followed to culturally adapt the Hub (see Extended Summary Figure). In stage 1, recommendations were obtained from a focus group with members of the institution's Latinx Community Review Board (Latinx CRB) and semi-structured interviews with pediatricians with Latinx-focused practices. In stage 2, preliminary cultural modifications were made, the Hub was translated into Spanish, and a second focus group with the Latinx CRB was convened to review the revised Hub. In stage 3, semi-structured interviews with LSS parents of healthy boys (i.e., without hypospadias) ≤ 5 years old were conducted to identify any cultural adaptations and/or usability issues regarding the revised Hub. In stage 4, based on parents' feedback, final revisions to the Hub were made. The focus groups and parent interviews were conducted in Spanish; then, the recordings were professionally transcribed in Spanish and translated into English. Interviews with pediatricians were conducted in English; then, the recordings were professionally transcribed. Three coders conducted a qualitative content analysis to identify areas for revision. Changes were applied iteratively.

RESULTS

Participants included 3 Latinx CRB members (2 women, 1 did not disclose gender; mean age = 48.3, SD = 21.2), 3 non-Latinx pediatricians (2 women, 1 man; mean age = 49.6, SD = 9.1), and 5 Latinx mothers (mean age = 34.0, SD = 1.26). Participants recommended: 1) featuring video testimonials from Latinx families or including Spanish voice-overs/subtitles; 2) diversifying racial/ethnic/geographic representation and including extended families in photographs/illustrations; 3) adding information about health insurance coverage and circumcision, 4) reassuring parents that the condition is not their fault, 5) considering cultural values (e.g., reliance on expert advice), and 6) clarifying medical terminology. Feedback related to seven EVM dimensions: concepts, content, context, goals, language, metaphors, and methods.

DISCUSSION

Participants perceived the Hub to be informative in guiding parents' treatment decisions. Revisions were reasonable and acceptable for a linguistic and cultural adaptation for LSS parents.

CONCLUSIONS

We identified and implemented preliminary cultural modifications to the Hub and applied user-centered design methods to test and revise the website. The product is a culturally appropriate DA for LSS parents. Next, English and Spanish-versions of the Hub will be tested in a randomized controlled trial.

Medical Care as Flea Market Bargaining? An International Interdisciplinary Study of Varieties of Shared Decision Making in Physician-Patient Interactions

Phenomenon: Shared decision making (SDM) is a core ideal in the interaction between healthcare providers and patients, but the implementation of the SDM ideal in clinical routines has been a relatively slow process. Approach: In a sociological study, 71 interactions between physicians and simulated patients enacting chronic heart failure were video-recorded in China, Germany, the Netherlands, and Turkey as part of a quasi-experimental research design. Participating physicians varied in specialty and level of experience. The secondary analysis presented in this article used content analysis to study core components of SDM in all of the 71 interactions and a grounded theory approach to observe how physicians responded actively to patients even though they did not actively employ the SDM ideal. Findings: Full realization of the SDM ideal remains an exception, but various aspects of SDM in physician-patient interaction were observed in all four locations. Analyses of longer interactions show dynamic processes of interaction that sometimes surprised both patient and physician. We observed varieties of SDM that differ from the SDM ideal but arguably achieve what the SDM ideal is intended to achieve. Our analysis suggests a need to revisit the SDM ideal-to consider whether varieties of SDM may be acceptable, even valuable, in their own right. Insights: The gap between the SDM ideal and SDM as implemented in clinical practice may in part be explained by the tendency of medicine to define and teach SDM through a narrow lens of checklist evaluations. The authors support the argument that SDM defies a checklist approach. SDM is not uniform, but nuanced, dependent on circumstances and setting. As SDM is co-produced by patients and physicians in a dynamic process of interaction, medical researchers should consider and medical learners should be exposed to varieties of SDM-related practice rather than a single idealized model. Observing and discussing worked examples contributes to the physician's development of realistic expectations and personal professional growth.

Exploring Foreign Domestic Workers' Perceived Contextual Factors That Influence Their Participation in Medical Consultations: An Ecological Lens

Foreign domestic workers have reported various health problems after moving to Hong Kong, which suggests the need for them to seek medical attention. Yet, much uncertainty exists about their perception of healthcare experiences as patients, particularly how they perceive their communication with ethnic-discordant healthcare providers. Drawing on foreign domestic workers' perspectives, we extracted non-interpersonal factors from Street's ecological model and its extension proposed by Head and Bute (2018) and examined how foreign domestic workers perceived these contextual factors affected their communication with healthcare providers. Thematic analysis was conducted on thirty Filipina and Indonesian domestic workers' narratives. Our findings confirmed that the context of digital media (characterized by Internet use and the adoption of a telemedicine approach) and the context of social ties (characterized by employers' involvement and everyday communication with friends and peers) were both potential contextual factors that domestic workers reported accounted for their participation in medical encounters. Theoretical and practical implications are discussed. Future research building on these findings is proposed.

Decision regret of cancer patients after radiotherapy: results from a cross-sectional observational study at a large tertiary cancer center in Germany

PURPOSE

The decision-making process regarding cancer treatment is emotionally challenging for patients and families, harboring the risk of decision regret. We aimed to explore prevalence and determinants of decision regret following radiotherapy.

METHODS

This cross-sectional observational study was conducted at a tertiary cancer center to assess decision regret following radiotherapy. The study employed the German version of the Ottawa Decision Regret Scale (DRS) which was validated in the study population. Decision regret was categorized as absent (0 points), mild (1-25 points), and strong (> 25 points). Various psychosocial outcome measures were collected using validated questionnaires to identify factors that may be associated with decision regret.

RESULTS

Out of 320 eligible patients, 212 participated, with 207 completing the DRS. Median age at start of radiotherapy was 64 years [interquartile range (IQR), 56-72], genders were balanced (105 female, 102 male), and the most common cancer types were breast (n = 84; 41%), prostate (n = 57; 28%), and head-and-neck cancer (n = 19; 9%). Radiotherapy was applied with curative intention in 188 patients (91%). Median time between last radiotherapy fraction and questionnaire completion was 23 months (IQR, 1-38). DRS comprehensibility was rated as good or very good by 98% (196 of 201) of patients. Decision regret was reported by 43% (n = 90) as absent, 38% (n = 78) as mild, and 18% (n = 38) as strong. In the multiple regression analysis, poor Eastern Cooperative Oncology Group performance status, low social support, and dissatisfaction with care were independent risk factors for higher decision regret after radiotherapy.

CONCLUSIONS

The German version of the DRS could be used to assess decision regret in a diverse cohort of cancer patients undergoing radiotherapy. Decision regret was prevalent in a considerable proportion of patients. Further studies are necessary to validate these findings and obtain causal factors associated with decision regret after radiotherapy.

Addressing quality medication use among migrant patients: Establishment of an organization to provide culturally competent medication care

As the global landscape continues to witness an increase in migration, the healthcare community faces an evolving challenge: the provision of quality medication care to migrant patients. Language barriers, cultural differences, and a lack of understanding of the local healthcare system can often impede the effective management of medications and access to healthcare services among migrant populations. Pharmacists, as medication experts, are dignified to make a substantial impact in bridging the gap between migrants and quality healthcare. Their expertise in medication management, accessibility, and counseling positions them as critical healthcare providers for this patient population. Pharmacies and pharmacists can serve as trusted hubs where migrants receive not only essential medications but also culturally sensitive support in navigating the healthcare system. This commentary article highlights the critical importance of culturally competent medication care for migrant patients and the central role that pharmacists can play in this endeavor. By establishing organization dedicated to this cause lead by pharmacists, we can not only address an urgent healthcare concern but also set a precedent for a healthcare system that values inclusivity, cultural competence, and equitable access to quality medication care for all, regardless of their cultural background.

Family-Centered Early Intervention Deaf/Hard of Hearing (FCEI-DHH): Cultural & Global Implications

This article is the third in a series of eight articles that comprise this special issue on family-centered early intervention for children who are deaf or hard of hearing and their families (FCEI-DHH). It highlights the origins of FCEI-DHH in Western contexts and well-resourced locations and emphasizes the role of culture(s) in shaping FCEI-DHH. This article also cautions against the direct application of the 10 FCEI-DHH Principles presented in this issue across the globe without consideration of cultural implications. Cultural perceptions of decision-making processes and persons who can be decision-makers in FCEI-DHH are explored. Deaf culture(s) and the benefits of exposure to DHH adults with diverse backgrounds are introduced. Structural inequities that impact families' access to FCEI-DHH programs/services and systems, within and among nations and regions, are noted. The need to consider the cultural influences on families is emphasized; this applies to all levels of FCEI, including the development of systems through implementation of supports.

Family-Centered Early Intervention Deaf/Hard of Hearing (FCEI-DHH): Support Principles

This article is the sixth in a series of eight articles that comprise a special issue on Family-Centered Early Intervention (FCEI) for children who are deaf or hard of hearing (DHH) and their families, or FCEI-DHH. The Support Principles article is the second of three articles that describe the 10 Principles of FCEI-DHH, preceded by the Foundation Principles, and followed by the Structure Principles, all in this special issue. The Support Principles are composed of four Principles (Principles 3, 4, 5, and 6) that highlight (a) the importance of a variety of supports for families raising children who are DHH; (b) the need to attend to and ensure the well-being of all children who are DHH; (c) the necessity of building the language and communication abilities of children who are DHH and their family members; and (d) the importance of considering the family's strengths, needs, and values in decision-making.

Shared decision-making in pediatric palliative care

Shared decision-making (SDM) with parents and adolescents is normative in pediatric practice in North America. In this article we discuss how it is applicable to the practice of pediatric palliative care (PPC). As PPC itself is exemplary of patient-and-family-centered care, it often uses a SDM approach in clarifying patient and family preferences, goals, and values. This often occurs in an iterative process and across care environments, wherein the patient and family narrative is elaborated. Decisions are then made incorporating both evidence-based medical practice and the unique attributes and considerations of the patient and family.

European Delphi panel to build consensus on tapering and discontinuing thrombopoietin receptor agonists in immune thrombocytopenia

To establish pan-European consensus on tapering and discontinuing thrombopoietin receptor agonists (TPO-RAs) in patients with immune thrombocytopenia (ITP), we applied a three-step Delphi technique consisting of a one-to-one interview round and two online survey rounds. Three healthcare professionals (HCPs) from Italy, Spain, and the United Kingdom formed the Steering Committee (SC), which advised on study design, panelist selection, and survey development. A literature review also informed the development of the consensus statements. Likert scales were used to collect quantitative data on panelists' level of agreement. Twelve hematologists representing nine European countries assessed 121 statements spanning three categories: (1) patient selection; (2) tapering and discontinuation strategies; (3) post-discontinuation management. Consensus was reached on approximately half of the statements in each category (32.2%; 44.6%; 66%). Panelists agreed on patients' main selection criteria, patients' involvement in decision-making, tapering strategies, and follow-up criteria. Areas not reaching consensus were risk factors and predictors of successful discontinuation, monitoring intervals, and rates of successful discontinuation or relapse. This lack of consensus signals knowledge and practice gaps among European countries and suggests the need for the development of clinical practice guidelines that outline a pan-European, evidence-based approach to tapering and discontinuing TPO-RAs.

Cultural Considerations for Patient and Community Education in Global Health: A Qualitative Study in Lesotho

Background: In global health, international nongovernmental organizations (NGOs) frequently hire, train, and partner with host-country clinicians who manage public outreach and patient care. Purpose and Research Design: We conducted a general interpretivist study of Basotho clinicians hired by NGOs and academic affiliates in Lesotho to identify cultural barriers and facilitators to community and patient education. Data Collection and Analysis: We conducted 13 interviews involving 16 participants (one physician, one nutritionist, 14 nurses). Using an inductive and iterative approach, we analyzed interview transcripts through the lens of social cognitive theory and identified 15 themes. Results: Major findings highlighted: 1) patient and community learners may view Basotho clinicians as authority figures; 2) family and community power dynamics affect healthcare access for vulnerable patient groups; and 3) village leaders may refuse community education when excluded from problem-solving and early planning. Conclusions: Although local clinicians and community members may identify with the same cultural group, clinicians can encounter cultural barriers to patient and community education.

Shared decision making: a personal view from two kidney doctors and a patient

Shared decision making (SDM) combines the clinician's expertise in the treatment of disease with the patient's expertise in their lived experience and what is important to them. All decisions made in the care of patients with kidney disease can potentially be explored through SDM. Adoption of SDM in routine kidney care faces numerous institutional and practical barriers. Patients with chronic disease who have become accustomed to paternalistic care may need support to engage in SDM-even though most patients actively want more involvement in decisions about their care. Nephrologists often underestimate the risks and overestimate the benefits of investigations and treatments and often default to recommending burdensome treatments rather than discussing prognosis openly. Guideline bodies continue to issue recommendations written for healthcare professionals without providing patient decision aids. To mitigate health inequalities, care needs to be taken to provide SDM to all patients, not just the highly health-literate patients least likely to need additional support in decision making. Kidney doctors spend much of their time in the consulting room, and it is unjustifiable that so little attention is paid to the teaching, audit and maintenance of consultation skills. Writing letters to the patient to summarise the consultation rather than sending them a copy of a letter between health professionals sets the tone for a consultation in which the patient is an active partner. Adoption of SDM will require nephrologists to relinquish long-established paternalistic models of care and restructure care around the values and preferences of patients.

How culture influences patient preferences for patient-centered care with their doctors

BACKGROUND

Patient-centered care (PCC) is the prevailing model of care globally. However, most research on PCC has been conducted in Westernized countries or has focused on only two facets of PCC: decision-making and information exchange. Our study examined how culture influences patients' preferences for five facets of PCC, including communication, decision-making, empathy, individualized focus, and relationship.

METHODS

Participants (N = 2071) from Hong Kong, the Philippines, Australia, and the U.S.A. completed an online survey assessing their preferences for exchange of information, autonomy in decision-making, expression and validation of their emotions, focus on them as an individual, and the doctor-patient relationship.

RESULTS

Participants from all four countries had similar preferences for empathy and shared decision-making. For other facets of PCC, participants in the Philippines and Australia expressed somewhat similar preferences, as did those in the U.S.A. and Hong Kong, challenging East-West stereotypes. Participants in the Philippines placed greater value on relationships, whereas Australians valued more autonomy. Participants in Hong Kong more commonly preferred doctor-directed care, with less importance placed on the relationship. Responses from U.S.A. participants were surprising, as they ranked the need for individualized care and two-way flow of information as least important.

CONCLUSIONS

Empathy, information exchange, and shared decision-making are values shared across countries, while preferences for how the information is shared, and the importance of the doctor-patient relationship differ.

Enhancing doctor-patient relationships in community health care institutions: the Patient Oriented Four Habits Model (POFHM) trial-a stepped wedge cluster randomized trial protocol

BACKGROUND

The poor relationship between doctors and patients is a long-standing, global problem. However, current interventions tend to focus on the training of physicians, while patient-targeted interventions still need to be improved. Considering that patients play a significant role in outpatient consultations, we developed a protocol to assess the effectiveness of the Patient Oriented Four Habits Model (POFHM) in improving doctor-patient relationships.

METHODS

A cross-sectional incomplete stepped-wedge cluster randomized trial design will be conducted in 8 primary healthcare institutions (PHCs). Following phase I of "usual care" as control measures for each PHC, either a patient- or doctor-only intervention will be implemented in phase II. In phase III, both patients and doctors will be involved in the intervention. This study will be conducted simultaneously in Nanling County and West Lake District. The primary outcomes will be evaluated after patients complete their visit: (1) patient literacy, (2) sense of control and (3) quality of doctor-patient communication. Finally, a mixed-effects model and subgroup analysis will be used to evaluate the effectiveness of the interventions.

DISCUSSION

Fostering good consultation habits for the patient is a potentially effective strategy to improve the quality of doctor-patient communication. This study evaluates the implementation process and develops a rigorous quality control manual using a theoretical domain framework under the collective culture of China. The results of this trial will provide substantial evidence of the effectiveness of patient-oriented interventions. The POFHM can benefit the PHCs and provide a reference for countries and regions where medical resources are scarce and collectivist cultures dominate.

TRIAL REGISTRATION

AsPredicted #107,282 on Sep 18, 2022; https://aspredicted.org/QST_MHW.

Informed Consent and Shared Decision Making in the Perioperative Environment

Informed consent and shared decision making (SDM) are crucial portions of preoperative patient management. Informed consent is a standard for surgery from both a legal and ethical standpoint, involving disclosure of potential risks of a procedure and ensuring patient understanding of these risks. SDM is a process in which a clinician and patients decide between two or more treatment plans, taking into account the patient's goals and values. SDM is a particularly important aspect of patient-centered care when two or more treatment options exist or in situations where an indicated treatment may not align with the patient's long-term goals. This article details aspects of and issues surrounding informed consent and SDM.

Guiding Patients Through Decision-Making in Management of Sporadic Vestibular Schwannoma

Decision-making in management of sporadic vestibular schwannoma aims to identify the most appropriate options based on tumor characteristics, symptoms, health, and goals for each patient. Advances in knowledge of tumor natural history, improvements in radiation techniques, and achievements in neurologic preservation with microsurgery have shifted emphasis toward maximizing quality of life using a personalized approach. To empower patients to make informed decisions, we present a framework to help match patient values and priorities with reasonable expectations from modern management options. Introduced herein are practical examples of communication strategies and decision aids to support shared decision-making in modern practice.

Patient involvement in medical decisions: a survey of shared decision making during physical therapy consultations

INTRODUCTION

Shared decision making (SDM) is widely affirmed as an ethical principle in healthcare; underpinned by both evidence of its positive outcomes among patients and strong inducements for its adoption by health professionals. This study investigated patients' involvement in SDM, determined its association with their personal characteristics and identified factors influencing their participation.

METHOD

A cross-sectional survey was executed among 148 consenting patients, who were recruited using convenience sampling technique and invited to complete self-report questionnaires on SDM. Data were analyzed via descriptive and inferential statistics.

RESULTS

Only 14 patients (9.5%) were involved in SDM whilst most patients (88.5%) had passive roles during consultation. SDM involvement had significant associations with age (p = .006) and educational status (p = .021). Most patients (67.6%) identified 'Doubt towards SDM,' as a factor that could hinder this collaborative process. Similarly, majority of the patients acknowledged the relevance of the influential factors: 'Physiotherapist's support' (83.7%) and 'Adequate health Information' (75%), toward promoting involvement in SDM.

CONCLUSION

Patient involvement in SDM was low in this study. Older and less/uneducated patients exhibited an increased tendency of noninvolvement. Key influential factors that either facilitate or hinder patients' involvement in SDM were revealed. There is a need to curtail drawbacks to SDM and promote its execution in physical therapy as well as general clinical practice.

Patient-Centric Product Development: A Summary of Select Regulatory CMC and Device Considerations

Patient-centric drug development describes the systematic approach to incorporating the patient's perspectives and preferences into the design, assessment, and production of a therapeutic product. While a patient centric approach can be applied at any stage of the drug development lifecycle, an integrated end-to-end strategy is often most effective to create an optimized product for the patient at the earliest possible timepoint. The importance of patient centricity is well recognized by health authorities and biopharmaceutical organizations which have established toolsets, guidances, and methodologies for incorporating patient input during the clinical stage of development. However, in addition to clinical research, there are other significant aspects of product development that profoundly impact the patient experience. Specifically, chemistry, manufacturing, and control (CMC) and device aspects must also be acknowledged and addressed as part of a cohesive patient-centric development strategy. This review explores current applications and regulatory considerations for patient-centric approaches across the product lifecycle, including R&D, early product development, clinical development, device and combination product development, and post-approval change management. Specific topics of discussion include the contributions of product modality, formulation, and devices to the patient experience; usage of the Quality Target Product Profile (QTPP) as a patient-centered design tool; and post-approval product optimization. Future advancements in regulatory data management and information exchange are also explored as potential enablers of patient engagement which support enhanced communication and interconnectivity between stakeholders. Multidisciplinary collaboration between patients, health authorities, health care providers, and the biopharmaceutical industry is ultimately necessary for ensuring that medicinal products, and their corresponding regulatory processes, take on a patient-first mindset that prioritizes patient needs, values, and preferences.

Self-advocacy Behaviors and Needs in Women with Advanced Cancer: Assessment and Differences by Patient Characteristics

BACKGROUND

Self-advocacy skills allow individuals with cancer to overcome challenges related to their health, care, and well-being. Understanding the self-advocacy behaviors and needs of individuals with cancer is critical to addressing the lack of evidence-based self-advocacy interventions. The aims of this study are to describe (1) self-advocacy behaviors and needs of women with advanced cancer and (2) associations between self-advocacy and sociodemographic, cancer, and patient-reported outcomes.

METHODS

We analyzed cross-sectional data from a clinical trial among women within 3 months of a metastatic breast or stage III or IV gynecologic cancer diagnosis. Descriptive and correlational statistics and tests of group difference were calculated for measures of self-advocacy (Female Self-Advocacy in Cancer Survivorship Scale), sociodemographic characteristics, quality of life (FACT-G), symptom burden (M.D. Anderson Symptom Inventory), and mood (Hospital Anxiety and Depression Scale).

RESULTS

Participants (N = 78) reported self-advocacy behaviors including making decisions based on their priorities, asking questions to their healthcare providers, and comparing their experiences to others' experiences. Self-advocacy needs focused on finding health information and talking with healthcare providers. Self-advocacy behaviors and needs did not differ by participants' sociodemographic characteristics or mood. Higher self-advocacy behaviors were associated with higher quality of life (p ≤ .01) and lower symptom severity (p < .05) with a trend for cancer recurrence (p = .05).

CONCLUSIONS

Women with advanced cancer report engaging in self-advocacy behaviors and these are associated with higher quality of life and lower symptom burden. Future research should determine if self-advocacy behaviors and needs change over time and how patient characteristics impact self-advocacy behaviors and needs.

Kidney Failure Patients' Perceptions and Definitions of Health: A Qualitative Study

Rationale & Objective

Patients with kidney failure who have used multiple treatment modalities are a unique source of information for how different options may best fit their values. We aimed to understand how people interpret their health and kidney failure treatment experience to inform providers who facilitate shared decision-making conversations.

Study Design

This qualitative, interpretive phenomenological study explores how patients with kidney failure interpret health throughout their treatment trajectory.

Setting & Participants

We recruited a purposive sample of patients who had used 3 or more kidney failure treatment options, including transplant and dialysis from transplant clinics and online support groups, for semi-structured interviews. Eligible participants were over 18 and spoke English for a total of 7 current transplant, 10 current home dialysis, and 1 current in-center patient.

Analytical Approach

A 6-step iterative process of data analysis occurred concurrently with data collection.

Results

Half of the 18 participants were Black; 67% were women. Three interrelated themes emerged from interviews: ability to engage in meaningful activities; working for balance; and living in context. Participants evaluated health according to their ability to engage in meaningful activities while balancing their emotional and physical needs with their life goals. When their social and treatment environments supported their autonomy, participants also considered themselves healthy.

Limitations

The inclusion of only English-speaking patients limits the transferability of findings. A longitudinal design, repeated interviews, observation, and dyadic interviews would increase the health care providers' understanding and interpretation of health.

Conclusions

The themes demonstrated patients evaluated health based on ability to engage in meaningful activities while maintaining balance. The treatment context, particularly how health care providers responded to patients' physiological experience, autonomy, and power, influenced interpretation of patient treatment experiences. Integrating patient interpretations of health with quantitative measures of treatment effectiveness can help health care providers better partner with patients to provide effective care for kidney failure.

Cochlear Implant Decision Making for Children With Residual Hearing: Perspectives of Practitioners

PURPOSE

Cochlear implants (CIs) are increasingly considered for children with residual hearing who benefit from hearing aids (HAs). However, the decision-making process for families of these children and for practitioners is particularly challenging because there is no clear audiological cut point for CI candidacy. This study aimed to understand Canadian practitioners' perspectives of the CI decision-making process and how they guide families of children with residual hearing.

METHOD

Semistructured interviews were conducted with a total of 17 practitioners through four focus groups and one individual interview. Interviews were transcribed verbatim, and a thematic analysis was carried out.

RESULTS

Data were organized into five broad domains: candidacy issues for children with residual hearing, practitioners' roles in decision support, additional considerations affecting decision making, factors facilitating decision making, and practitioners' needs.

CONCLUSIONS

This study found that practitioners' confidence in determining candidacy and supporting parents has increased due to their experiences with positive outcomes for these children. Practitioners indicated that there was a need for more research to guide the decision-making process.

How patients' psycho-social profiles contribute to decision-making in epilepsy surgery: A prospective study

OBJECTIVE

Identifying factors associated with surgical decision-making is important to understand reasons for underutilization of epilepsy surgery. Neurologists' recommendations for surgery and patients' acceptance of these recommendations depend on clinical epilepsy variables, for example, lateralization and localization of seizure onset zones. Moreover, previous research shows associations with demographic factors, for example, age and sex. Here, we investigate the relevance of patients' psycho-social profile for surgical decision-making.

METHODS

We prospectively studied 296 patients from two large German epilepsy centers. Multiple logistic regression analyses were used to investigate variables linked to neurologists' recommendations for and patients' acceptance of surgery or intracranial video-electroencephalographic monitoring. Patients' psycho-social profiles were assessed via self-reports and controlled for various clinical-demographic variables. Model selection was performed using the Akaike information criterion.

RESULTS

As expected, models for neurologists' surgery recommendations primarily revealed clinical factors such as lateralization and localization of the seizure onset zone, load with antiseizure medication (ASM), and site of the epilepsy-center. For this outcome, employment was the only relevant psycho-social aspect (odds ratio [OR] = .38, 95% confidence interval [CI] = .13-1.11). In contrast, three of the five relevant predictors for patients' acceptance were psycho-social. Higher odds were found for those with more subjective ASM adverse events (OR = 1.04, 95% CI = .99-1.00), more subjective seizure severity (OR = 1.12, 95% CI = 1.01-1.24), and lower subjective cognitive impairment (OR = .98, 95% CI = .96-1.00).

SIGNIFICANCE

We demonstrated the relevance of the patients' psycho-social profile for decision-making in epilepsy surgery, particularly for patients' decisions. Thus, in addition to clinical-demographic variables, patients' individual psycho-social characteristics add to the understanding of surgical decision-making. From a clinical perspective, this calls for individually tailored counseling to assist patients in finding the optimal treatment option.

Consent in Interventional Radiology-How Can We Make It Better?

Informed consent is an important part of the clinician-patient relationship. However, studies suggest consent practices tend to be limited in consistency and completeness. This may be particularly challenging for interventional radiology given more limited public awareness and the often fast-paced, dynamic nature of our practices. This article reviews these challenges as well as ideal consent practices and potential approaches to improve consent in interventional radiology.

Shared Decision Making in Health Care: Theoretical Perspectives for Why It Works and For Whom

Applying both theoretical perspectives and empirical evidence, we address 2 key questions regarding shared decision making (SDM): 1) When should SDM be more patient driven, and when should it be more provider driven? and 2) Should health care providers match their SDM style/strategy to patient needs and preferences? Self-determination theory, for example, posits a distinction between autonomy and independence. A patient may autonomously seek their health care provider's input and guidance, perhaps due to low perceived competence, low coping resources, or high emotional arousal. Given their need state, they may autonomously require nonindependence. In this case, it may be more patient centered and need supportive to provide more provider-driven care. We discuss how other patient characteristics such as personality attributes, motivational state, and the course of illness and other parameters such as time available for an encounter may inform optimal provider decision-making style and strategy. We conclude that for some types of patients and clinical circumstances, a more provider-driven approach to decision making may be more practical, ethical, and efficacious. Thus, while all decision making should be patient centered (i.e., it should consider patient needs and preferences), it does not always have to be patient driven. We propose a flexible model of SDM whereby practitioners are encouraged to tailor their decision making behaviors to patient needs, preferences, and other attributes. Studies are needed to test whether matching decision-making behavior based on patient states and traits (i.e., achieving concordance) is more effective than simply providing all patients with the same type of decision making, which could be tested using matching/mismatching designs.

Laboratory-related outcomes from integrating an accessible delivery model for hereditary cancer risk assessment and genetic testing in populations with barriers to access

PURPOSE

This study aimed to evaluate the laboratory-related outcomes of participants who were offered genomic testing based on cancer family history risk assessment tools.

METHODS

Patients from clinics that serve populations with access barriers, who are screened at risk for a hereditary cancer syndrome based on adapted family history collection tools (the Breast Cancer Genetics Referral Screening Tool and PREMM₅), were offered exome-based panel testing for cancer risk and medically actionable secondary findings. We used descriptive statistics, electronic health record review, and inferential statistics to explore participant characteristics and results, consultations and actions related to pathogenic/likely pathogenic variants identified, and variables predicting category of findings, respectively.

RESULTS

Of all the participants, 87% successfully returned a saliva kit. Overall, 5% had a pathogenic/likely pathogenic cancer risk variant and 1% had a secondary finding. Almost all (14/15, 93%) participants completed recommended consultations with nongenetics providers after an average of 17 months. The recommended actions (eg, breast magnetic resonance imaging) were completed by 17 of 25 participants. Participant personal history of cancer and PREMM₅ score were each associated with the category of findings (history and colon cancer finding, Fisher's exact P = .02; history and breast cancer finding, Fisher's exact P = .01; PREMM₅^TM score; and colon cancer finding, Fisher's exact P < .001).

CONCLUSION

This accessible model of hereditary cancer risk assessment and genetic testing yielded results that were often acted upon by patients and physicians.

Caring for older culturally and linguistically diverse patients with Cancer: Healthcare Providers' perceived barriers to communication

BACKGROUND

Due to various socio-cultural and language related factors, healthcare providers experience barriers when communicating with older culturally and linguistically diverse (CALD) patients with cancer, which can lower the quality of care received by patients and negatively impact healthcare providers. Studies focusing on communication barriers of older CALD patients with cancer and a systematic comparison of those barriers between different healthcare providers have been largely missing.

OBJECTIVES

In order to lay out the healthcare providers' perceived barriers to communication, the present study identified and compared communication barriers among different healthcare providers when caring for older CALD patients with cancer.

METHODS

An online survey was conducted among healthcare providers in the Netherlands who identified as being involved in the care of CALD patients with cancer (N = 191), specifically; GPs (N_GPs = 54), specialists (N_specialists = 29), oncology nurses (N_nurses = 77), and pharmacists (N_pharmacists = 31). Providers assessed twelve pre-specified factors on (i) importance and (ii) frequency of these factors as barriers to communication. A composite score by employing the QUOTE (Quality Of care Through the patients' Eyes) methodology was used to rank, and classify factors as either potential or influential barriers.

RESULTS AND CONCLUSION

Overall, low Dutch language proficiency of older CALD patients with cancer, family interpreters providing inadequate translations, not knowing the extent of patients' informational needs, cultural differences in views about healthcare (i.e., illnesses and treatments) and family members blocking communication were found to be influential communication barriers. Healthcare providers showed several differences in what they perceived to be a potential or an influential barrier: Cultural differences in views about healthcare and patients getting treatment in their home countries were important barriers for GPs, while not knowing the patient's contact person was for pharmacists. Nurses perceived the highest number of influential barriers, while specialists perceived the least. We conclude that specific interventions that address differences in perceived barriers among providers are needed, and we highlight potential interventions that involve digital communication tools, such as the Conversation Starter.

Facilitating Engagement on Family-Centered Rounds for Families With Limited Comfort With English

OBJECTIVE

Conducting family-centered rounds (FCR) for families with limited comfort with English (LCE) presents communication challenges. The objective of this study was to characterize the preferences of Spanish-speaking parents with LCE around interpretation and communication with the medical team during FCR to promote family engagement during rounds.

METHODS

This qualitative study was conducted at a tertiary care children's hospital in New York, New York. Eighteen Spanish-speaking parents of patients admitted to the hospital medicine service participated. Bilingual investigators conducted semistructured interviews over a secure virtual platform. Interview transcriptions were coded and analyzed by using a grounded theory approach and constant comparative method. Parents were recruited until thematic saturation was achieved.

RESULTS

Most participants were mothers (72%) from the Dominican Republic (61%). Responses from participants yielded a conceptual model depicting parents' perspectives on family engagement and bidirectional communication during FCR. Three major themes emerged: (1) importance of interpreter use, (2) understanding of medical information, and (3) participation in FCR. Within each theme, factors that facilitate or impede engagement in FCR were identified. Interpreters facilitated information sharing and parent understanding of medical care, increasing parent appreciation of FCR. Lack of language-concordant care and parents' perceived responsibility for the language barrier limited engagement.

CONCLUSIONS

Families with LCE value involvement during FCR, but face difficulties due to language barriers. Providers can support these families by empowering families' participation and by consistently using an interpreter. Understanding the preferences of families with LCE for participation in FCR will help providers deliver more equitable family-centered care.

The patient as a prosumer of healthcare: insights from a bibliometric-interpretive review

PURPOSE

Healthcare policies around the globe are aimed at achieving patient-centeredness. The patient is understood as a prosumer of healthcare, wherein healthcare service co-production and value co-creation take center stage. The article endeavors to unpack the state of the literature on the innovations promoting the transition toward patient-centeredness, informing policy and management interventions fostering the reconceptualization of the patient as a prosumer of healthcare services.

DESIGN/METHODOLOGY/APPROACH

A hybrid review methodology consisting of a bibliometric-interpretive review following the Scientific Procedures and Rationales for Systematic Literature Reviews (SPAR-4-SLR) protocol is used. The bibliometric component enabled us to objectively map the extant scientific knowledge into research streams, whereas the interpretive component facilitated the critical analysis of research streams.

FINDINGS

Patient-centeredness relies on a bundle of innovations that are enacted through a cycle of patients' activation, empowerment, involvement and engagement, wherein the omission of any steps arrests the transition toward service co-production and value co-creation. Institutional, organizational and cognitive barriers should be overcome to boost the transition of patients from consumers to prosumers in a patient-centered model of healthcare.

ORIGINALITY/VALUE

The article delivers the state of the art of the scientific literature in the field of innovations aimed at sustaining the transition toward patient-centeredness and provides some food for thoughts to scholars and practitioners who wish to push forward service co-production and value co-creation in healthcare.

Ethnic Differences in Health Literacy, Self-Efficacy, and Self-Management in Patients Treated With Maintenance Hemodialysis

Background:

There is a gap in research investigating the potential impact of ethnicity on health literacy, self-efficacy, and self-management in patients treated with maintenance hemodialysis (MHD).

Objective:

To explore (1) the associations between health literacy, self-efficacy, and self-management among outpatients with kidney failure receiving treatment with MHD, and (2) the differences in health literacy and self-efficacy based on characteristics of ethnicity (ie, physical resemblance and proficiency in the language of the host population), known to be associated with health care access and health outcomes.

Design:

Cross-sectional

Setting:

Outpatients receiving MHD at 7 adult hemodialysis centers in Calgary, Alberta from September 2014 to December 2014.

Patients:

Participants were grouped into 2 groups based on a proposed 4-quadrant framework of a multicultural society. Quadrant 1 comprised outpatients with physical resemblance and first language of the host population (ie, white and English as a first language), whereas quadrant 4 participants comprised outpatients with physical resemblance and first language not of the host population (ie, non-white and first language other than English). A total of 78 patients (n_Q1 = 44, n_Q4 = 34) were included.

Measurements:

Heath literacy, self-efficacy, and self-management were measured using the Health Literacy Questionnaire (HLQ), Strategies Used by People to Promote Health (SUPPH), and Patient Activation Measure-13 (PAM-13), respectively.

Methods:

Convenience sampling was used to recruit participants at each of the 7 adult hemodialysis centers. All participants completed a study package, which included a demographic questionnaire, HLQ, SUPPH, and PAM-13. Spearman rho was calculated to identify correlations between patient activation level and HLQ and SUPPH scores. Independent t tests were performed to identify differences in HLQ and SUPPH scores between Q1 and Q4 participants. Stepwise regression was performed in other analyses to identify predictor variables of patient activation level.

Results:

Statistically significant correlations were identified between patient activation level and the health literacy domains of “ability to actively engage with health care providers” (r_HLQ6= .535, P < .001), “ability to find good health information” (r_HLQ8 = .611, P < .001), and “understanding health information well enough to know what to do” (r_HLQ9 = .712, P < .001). There was a statistically significant difference between Q1 and Q4 participants in the health literacy domain of “ability to find good health information” (P = .048). “Understanding health information well enough to know what to do” and “actively managing health” were included in the final stepwise regression model, F(2, 72) = 32.232, P < .001.

Limitations:

The cross-sectional design limits the generalizability of the results. The small sample size limits the power to identify significant associations and differences. Although English was not the first language of Q4 participants, all were proficient in English, meaning potential differences of a key subgroup of Q4 (ie, those who did not speak any English) were not captured.

Conclusion:

The HLQ allowed for the creation of a health literacy profile of patients with end-stage kidney disease receiving treatment with MHD. The findings suggest possible associations between specific domains of health literacy and patient activation. Outpatients’ representative of Q4 receiving treatment with MHD appear to struggle more with finding good health information, which may leave them at a disadvantage in the early phases of their self-management efforts. The findings highlight potential opportunities to better tailor patient care to support patients in their self-management, particularly for patients from ethnic minority backgrounds.

Decision support needs for shared clinical decision-making regarding HPV vaccination among adults 27-45 years of age

OBJECTIVE

Identify HPV information needs and shared clinical decision-making preferences among adults 27-45 and describe differences in needs and preferences among underserved and vulnerable populations.

METHODS

Participants 27-45 years old with no history of HPV vaccination completed a cross-sectional web-based survey between April-May 2020 (N = 702). Preferred role in shared clinical decision making was described across demographic groups and sociodemographic correlates of HPV vaccine information needs.

RESULTS

Most (77.6%) reported a preference to make a medical decision on their own or after consulting with a healthcare provider, while the remaining respondents preferred to make a joint decision (17.0%) or for their doctor to make the decision (5.4%). Over 80% needed more information about safety, effectiveness, personal benefit, provider recommendation, side effects, and risks. Education was the strongest demographic factors associated with higher information needs (p<0.05).

CONCLUSION

The majority of individuals across demographic groups were individually focused with regard to their healthcare decisions and wanted more information about HPV vaccine safety, side effects, and risks, in addition to personalized information about benefits from HPV vaccination.

PRACTICAL IMPLICATIONS

Patient-centered interventions are needed to engage adults in shared decision-making regarding HPV vaccination.

A Systematic Review of Shared Decision-Making Interventions for Service Users With Serious Mental Illnesses: State of the Science and Future Directions

OBJECTIVE

Shared decision making (SDM) is a health communication model that may be particularly appealing to service users with serious mental illnesses, who often want to be involved in making decisions about their mental health care. The purpose of this systematic review was to describe and evaluate participant, intervention, methodological, and outcome characteristics of SDM intervention studies conducted within this population.

METHODS

Systematic searches of the literature through April 2020 were conducted and supplemented by hand searching of reference lists of identified studies. A total of 53 independent studies of SDM interventions that were conducted with service users with serious mental illnesses and that included a quantitative or qualitative measure of the intervention were included in the review. Data were independently extracted by at least two authors.

RESULTS

Most studies were conducted with middle-age, male, White individuals from Western countries. Interventions fell into the following categories: decision support tools only, multicomponent interventions involving decision support tools, multicomponent interventions not involving decision support tools, and shared care planning and preference elicitation interventions. Most studies were randomized controlled trials with sufficient sample sizes. Outcomes assessed were diverse, spanning decision-making constructs, clinical and functional, treatment engagement or adherence, and other constructs.

CONCLUSIONS

Findings suggest important future directions for research, including the need to evaluate the impact of SDM in special populations (e.g., young adults and racial-ethnic minority groups); to expand interventions to a broader array of decisions, users, and contexts; and to establish consensus measures to assess intervention effectiveness.

Update to 2019-2022 ONS Research Agenda: Rapid Review to Address Structural Racism and Health Inequities

PURPOSE

The Oncology Nursing Society (ONS) formed a team to develop a necessary expansion of the 2019-2022 ONS Research Agenda, with a focus on racism and cancer care disparities.

METHODS

A multimethod consensus-building approach was used to develop and refine the research priorities. A panel of oncology nurse scientists and equity scholars with expertise in health disparities conducted a rapid review of the literature, consulted with experts and oncology nurses, and reviewed priorities from funding agencies.

RESULTS

Critical gaps in the literature were identified and used to develop priority areas for oncology nursing research, practice, and workforce development.

SYNTHESIS

This is the first article in a two-part series that discusses structural racism and health inequities within oncology nursing. In this article, three priority areas for oncology nursing research are presented; in the second article, strategies to improve cancer disparities and equity and diversity in the oncology workforce are described.

IMPLICATIONS FOR RESEARCH

Research priorities are presented to inform future research that will provide methods and tools to increase health equity and reduce structural racism in oncology nursing practice, research, education, policy, and advocacy.

Relationships among Antecedents, Processes, and Outcomes for Shared Decision Making: A Cross-Sectional Survey of Patients with Lumbar Degenerative Disease

BACKGROUND

Among musculoskeletal disorders, lumbar degenerative disease (LDD) is the leading cause of total disability-adjusted life years globally. Clinical guidelines for LDD describe multiple treatment options in which shared decision making becomes appropriate.

OBJECTIVES

To explore the relationships among measures of decision antecedents, process, and outcomes in patients with LDD.

METHODS

Patients with LDD were recruited from outpatient clinics in a teaching hospital in Taiwan and administered surveys to collect measures of decision antecedents, processes, and outcomes. Multiple linear regression was conducted to assess the association between decision antecedents and the decision making process. Hierarchical linear regression was conducted to assess the relationships among decision antecedents, the decision making process, and decision outcomes.

RESULTS

A total of 132 patients (mean age, 61 years) completed the survey. After adjustment for personal factors, 2 decision antecedents (namely, decision making self-efficacy and readiness) significantly predicted patients' experiences of engaging in shared decision making (SDM). Decision making readiness and process were associated with fewer decisional conflicts and greater decision satisfaction.

LIMITATIONS

Models derived from cross-sectional surveys cannot establish causal relationships among decision antecedents, decision making processes, and decision outcomes.

CONCLUSIONS

Our results support the SDM framework, which proposes relationships among decision antecedents, the decision making process, and decision outcomes.

Neuropalliative Care in the Inpatient Setting

The palliative care needs of inpatients with neurologic illness are varied, depending on diagnosis, acuity of illness, available treatment options, prognosis, and goals of care. Inpatient neurologists ought to be proficient at providing primary palliative care and effective at determining when palliative care consultants are needed. In the acute setting, palliative care should be integrated with lifesaving treatments using a framework of determining goals of care, thoughtfully prognosticating, and engaging in shared decision-making. This framework remains important when aggressive treatments are not desired or not available, or when patients are admitted to the hospital for conditions related to advanced stages of chronic neurologic disease. Because prognostic uncertainty characterizes much of neurology, inpatient neurologists must develop communication strategies that account for uncertainty while supporting shared decision-making and allowing patients and families to preserve hope. In this article, we illustrate the approach to palliative care in inpatient neurology.

Perception and Experience of Transcultural Care of Stakeholders and Health Service Users with a Migrant Background: A Qualitative Study

INTRODUCTION

While European health policies do frequently take into consideration the ideas and experiences of their users, the voices of minority and marginalized communities are not often heard. European healthcare services must address this issue as the number of healthcare users with an MM background increases.

AIM

To explore the perspectives of key stakeholders and healthcare users with an MM background on transcultural care in four European countries.

DESIGN

Qualitative phenomenological study.

METHODS

Semi-structured, individual interviews were conducted with stakeholders and MM users. Interviews were translated and transcribed verbatim and were carried out from February to May 2021. Descriptive statistics was used to describe the characteristics of the sample; qualitative data were analyzed thematically following Braun and Clarke's phases, resulting in 6 themes and 18 subthemes.

RESULTS

For stakeholders and MM users with long-established residence in their respective countries, cultural differences involve different family and community norms, religious beliefs, lifestyles, and habits. These components are perceived as in tension with healthcare norms and values, and they mediate in two key and related aspects of the relationship between MM users and healthcare providers: accessibility and communication.

CONCLUSIONS

Communication and access to healthcare are key to MM health service users, and they are the most frequent sources of misunderstanding and conflict between them and healthcare professionals.

IMPACT

It is important to extend the investigation of cultural issues in healthcare to stakeholders and MM users. There is no doubt that healthcare professionals should be trained in cultural competence; however, cultural competence training is not the only area for improvement. There should be a change in paradigm in healthcare services across Europe: from individual to organizational integration of culture and diversity.

An Analysis of Individual and Contextual-Level Disparities in Screening, Treatment, and Outcomes for Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver and affects patients of all genders, races, ethnicities, and socioeconomic status. While the causes of HCC are numerous, the primary etiology is cirrhosis from alcohol and non-alcoholic fatty liver disease in the United States and from infectious agents such as Hepatitis B and Hepatitis C in the developing world. In patients at-risk for developing HCC, screening is recommended with ultrasound imaging and alpha fetoprotein laboratory tests. In socioeconomically vulnerable patients, however, individual-level barriers (eg, insurance status) and contextual-level disparities (eg, health facilities) may not be readily available, thus limiting screening. Additional challenges faced by racial/ethnic minorities can further challenge the spectrum of HCC care and lead to inadequate screening, delayed diagnosis, and unequal access to treatment. Efforts to improve these multilevel factors that lead to screening and treatment disparities are critical to overcoming challenges. Providing health insurance to those without access, improving societal challenges that confine patients to a lower socioeconomic status, and reducing challenges to seeking healthcare can decrease the morbidity and mortality of these patients. Additionally, engaging with communities and allowing them to collaborate in their own healthcare can also help to attenuate these inequities. Through collaborative multidisciplinary change, we can make progress in tackling disparities in vulnerable populations to achieve health equity

Role of weight bias and patient-physician communication in the underutilization of bariatric surgery

A growing body of evidence supports the efficacy and safety of bariatric surgery for clinically severe obesity. Despite this empirical support, bariatric surgery remains profoundly underutilized. The reasons for underutilization are likely multifactorial, including health insurance coverage and benefits design, lack of awareness about bariatric surgery by patients, and anecdotal concerns about safety. We believe that there are two other factors-the occurrence of weight stigma and bias and suboptimal communication between patients and providers-that also serve as barriers to greater utilization. The article reviews the existing literature related to these two factors. The review also highlights the science of shared medical decision-making as a potential strategy to promote appropriate conversations between patients and providers, both surgical and nonsurgical, about the efficacy and safety of bariatric surgery. Shared medical decision-making is used in other areas where complex medical decisions are required. We believe that it has great potential to contribute to the increased utilization for the millions of individuals who could benefit from bariatric surgery.

"I think that everybody should be involved": What informs experiences of shared decision-making in supporting people living with schizophrenia spectrum disorders?

OBJECTIVE

To identify facilitators and barriers associated with shared decision-making (SDM) in Australians affected by schizophrenia spectrum disorders.

METHODS

We surveyed 78 participants with lived experience and held 12 in-depth interviews, including seven carers.

RESULTS

A multiple linear regression model identified two independent variables significantly associated with degree of SDM: Personal Wellbeing Index scores (ß = .32, t = 3.3, p = .001) and treatment satisfaction rating (ß =.46, t = 4.7, p < .001), indicating that higher personal wellbeing and higher treatment satisfaction were significantly related to higher degree of SDM. Two key themes were identified through interview data: a complex pathway to SDM and impacts on wellbeing. Sub-themes included: self and carer characteristics, holistic care, education and knowledge, and power balance. Generally, participants reported a desire for SDM, noting that healthcare professionals inconsistently involve them in treatment decisions.

CONCLUSION

SDM is associated with treatment satisfaction and personal wellbeing among people living with schizophrenia spectrum disorders, but can be difficult to implement due to a range of challenges.

PRACTICE IMPLICATIONS

There is a need to improve SDM in this population by decreasing stigma and discrimination, balancing power in consultations, increasing access to holistic treatment, and improving education and knowledge.

A Review and Clinical Practice Guideline for Health Professionals Working With Indigenous and Culturally and Linguistically Diverse (CALD) Populations During COVID-19

Background: As the rates of infection and mortality from COVID-19 have been higher in minority groups, the communication of health information in a way that is understood and accepted is of particular importance.

Aims: To provide health professionals with a clinical practice guideline for clear and culturally sensitive communication of health information about COVID-19 to people of Indigenous and culturally and linguistically diverse (CALD) backgrounds.

Assessment of Guideline Options: The authors conducted a review of the literature on health communication, and the guidelines were developed with particular reference to the SPIKES protocol of “breaking bad news” in oncology and the use of the DSM-5 Cultural Formulation Interview (CFI).

Actionable Recommendations: The guideline combines two approaches, the Cultural Formulation Interview, developed for DSM-5, and the SPIKES protocol used for delivering “bad news” in oncology. The combined CFI-SPIKES protocol is a six-step clinical practice guideline that includes the following: (1) Set up (S) the interview; (2) Determine how the patient perceives the problem (P) using the Cultural Formulation Interview (CFI) to elicit the patient's cultural perception of the problem; (3) Obtain an invitation (I) from the patient to receive a diagnosis; (4) Provide the patient knowledge (K) of diagnosis in a non-technical way; (5) Address the patient's emotional reaction (E) to diagnosis; and (6) Provide the patient a summary (S) of healthcare and treatment.

Conclusions and Relevance: This article presents guidelines for assessing the cultural dimensions of patients' understanding of COVID-19 and delivering diagnostic and treatment recommendations in ways that are culturally safe and responsive, such as: (a) suspending the clinician's own cultural biases to understand the explanatory models and cultural values of their CALD or Indigenous patients; (b) encouraging the use of interpreters or cultural brokers to ensure that that the message is delivered in a way that the patient can understand; and (c) encouraging CALD or Indigenous patient to take an active part in the solution and treatment adherence, to minimize transmission of COVID-19 in CALD and Indigenous communities.

Mixed Methods Study of Nurse Assessment of Patient Preferences for Engagement During Hospitalization

BACKGROUND

Global health care initiatives emphasize the importance of engaging patients in their health care to improve the patient's experience and outcomes. Assessing patient preferences for engagement is critical, as there are many ways patients can engage in their care and preferences vary across individuals.

OBJECTIVE

The primary purpose of this study was to evaluate the effect of implementation of the Patient Preferences for Engagement Tool 13-Item Short Form (PPET13) during hospitalization on patient and nurse experience of engagement. Readmissions and emergency department (ED) usage within 30 days postdischarge was also examined.

METHODS

The mixed methods study was conducted within two medical units in the United States between December 2018 and May 2019. Pre-implementation group patients completed a demographic survey and the Patient Experience of Engagement Survey (PEES) on discharge. Implementation group patients completed the PPET13 within 24 hr of admission with their nurse and the demographic survey and PEES on discharge. A focus group with nurses who implemented the PPET13 was conducted following the implementation period. Data analysis included confirmatory factor analysis, multiple and logistic regression, and qualitative content analysis.

RESULTS

There was significant improvement in PEES during the implementation phase. The PEES score was a significant predictor of ED visits, but not 30-day readmissions. Nurses were not always certain how to best integrate patient preferences for engagement into their care delivery and suggested integrating the PPET13 into the electronic health record to assist with streamlining the assessment and communicating preferences across the care team.

DISCUSSION

Assessing patients' preferences for engagement using the PPET13 was associated with an improved experience of engagement, which was found to mediate the relationship between utilization of PPET13 and ED usage within 30 days postdischarge. Use of a PPET, such as the PPET13, can help inform the delivery of individualized engagement strategies to improve patient and family engagement and outcomes; however, nurses need formalized education on how to tailor their care to meet the individual engagement preferences of their patients.

Perceived involvement in health care decisions among US adults: Sociodemographic and medical condition correlates

OBJECTIVE

To explore factors associated with how often US adults perceived that they were "always" involved in decisions about health care to the degree that they desired.

METHODS

We examined cross-sectional, nationally representative data from the 2018 Health Information National Trends Survey. There were 3504 responses in the full HINTS dataset; 2499 remained after eliminating respondents with missing data for any factor of interest. Sociodemographic factors included age, gender, race/ethnicity, and education. Medical conditions included diabetes, hypertension, heart disease, lung disease, arthritis, cancer, and depression. Participants were asked to think about communication with health professionals during the last 12 months and how often health professionals involved them in decisions about health care.

RESULTS

In univariate analyses, Asian and Hispanic race were associated with lower odds of always being involved in decisions about health care; whereas higher education and a history of cancer were associated with higher odds of "always" being involved in decisions about health care, p < 0.05. In multivariate analyses, race and education both remained significant; however, history of cancer did not.

CONCLUSION

Differences by race/ethnicity and educational attainment exist regarding perceived involvement in decisions about health care.

PRACTICE IMPLICATIONS

Findings may inform future shared decision making interventions.

Shared clinical decision-making experiences in nursing: a qualitative study

Background

Shared decision making (SDM) is a patient-centered nursing concept that emphasizes the autonomy of patients. SDM is a co-operative process that involves information exchange and communication between medical staff and patients for making treatment decisions. In this study, we explored the experiences of clinical nursing staff participating in SDM.

Methods

This study adopted a qualitative research design. Semistructured interviews were conducted with 21 nurses at a medical center in northern Taiwan. All interview recordings were transcribed verbatim. Content analysis was performed to analyze the data.

Results

The findings yielded the following three themes covering seven categories: knowledge regarding SDM, trigger discussion and coordination, and respect of sociocultural factors.

Conclusions

The results of this study describe the experiences of clinical nursing staff participating in SDM and can be used as a reference for nursing education and nursing administrative supervisors wishing to plan and enhance professional nursing SDM in nursing education.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00597-0.

Clinician perspectives on a culturally adapted patient decision aid concerning maintenance therapy for asthma

BACKGROUND AND OBJECTIVE

Patients with persistent asthma often show poor adherence to inhaled corticosteroids (ICS). Shared decision-making can improve adherence rates in this population. Patient decision aids (PDAs) are tools to facilitate shared decision-making. To date, only one PDA, developed in a Canadian French-speaking population, exists for patients considering ICS maintenance therapy. This PDA has been culturally adapted in this study to contextualize to the needs of multi-ethnic Asian patients in Singapore. This study explored the views of local clinicians on the content, design and implementation of this newly-adapted PDA.

METHODS

24 clinicians, who were purposively sampled from polyclinics and a tertiary institution, were interviewed on the content, design and implementation of the PDA. The interviews were audio-recorded, transcribed and analyzed via thematic analysis.

RESULTS

Clinicians generally accepted the design of the PDA. They suggested for the target users to be patients on Step 2 of GINA guidelines and the number of options to be reduced from four to two (do nothing or start inhaled corticosteroids). Moreover, they supported including a list of values for patients to select from given that Asian patients often do not articulate their values readily. The addition of more visual aids, the production of multilingual Asian editions and the involvement of nurses to administer the PDA was also suggested.

CONCLUSION

The PDA was culturally-adapted with local clinicians' perspectives to target multi-ethnic Asian patients with persistent asthma (Step 2 GINA guidelines). The main changes include a list of values and addition of visual aids.

Disparate outcomes in nonsmall cell lung cancer by immigration status

Objective

The purpose of this study was to evaluate overall survival (OS) outcomes by race, stratified by country of origin in patients diagnosed with NSCLC in California.

Methods

We performed a retrospective analysis of nonsmall cell lung cancer (NSCLC) patients diagnosed between 2000 and 2012. Race/ethnicity was defined as White (W), Black (B), Hispanic (H), and Asian (A) and stratified by country of origin (US vs. non‐US [NUS]) creating the following patient cohorts: W‐US, W‐NUS, B‐US, B‐NUS, H‐US, H‐NUS, A‐US, and A‐NUS. Three multivariate models were created: model 1 adjusted for age, gender, stage, year of diagnosis and histology; model 2 included model 1 plus treatment modalities; and model 3 included model 2 with the addition of socioeconomic status, marital status, and insurance.

Results

A total of 68,232 patients were included. Median OS from highest to lowest were: A‐NUS (15 months), W‐NUS (14 months), A‐US (13 months), B‐NUS (13 months), H‐US (11 months), W‐US (11 months), H‐NUS (10 months), and B‐US (10 months) (p < 0.001). In model 1, B‐US had worse OS, whereas A‐US, W‐NUS, B‐NUS, H‐NUS, and A‐NUS had better OS when compared to W‐US. In model 2 after adjusting for receipt of treatment, there was no difference in OS for B‐US when compared to W‐US. After adjusting for all variables (model 3), all race/ethnicity profiles had better OS when compared to W‐US; B‐NUS patients had similar OS to W‐US.

Conclusion

Foreign‐born patients with NSCLC have decreased risk of mortality when compared to native‐born patients in California after accounting for treatments received and socioeconomic differences.

Foreign‐born patients with NSCLC have decreased risk of mortality when compared to native born patients in California after accounting for treatments received and socioeconomic differences.