Applying a deliberation model to the analysis of consultations in haemophilia: Implications for doctor-patient communication

Development of a haemophilia A gene therapy shared decision-making tool for clinicians

INTRODUCTION

As gene therapies are incorporated into clinical practice, shared decision-making (SDM) is recommended for implementation.

AIM

To inform development of a clinician SDM tool for haemophilia A gene therapy.

METHODS

Clinicians at US Hemophilia Treatment Centers completed semi-structured interviews about their experience with SDM and provided feedback on a clinician SDM tool prototype. Interviews were transcribed verbatim for coding and thematic content analysis.

RESULTS

Ten participants enrolled, eight physicians and two haemophilia nurses. All participants care for adults with haemophilia (1-27 years of experience) and 7 have gene therapy trials open at their institution. Confidence in having a clinical discussion about gene therapy included none (N = 1), slight (N = 3), moderate (N = 5) and high (N = 1). All participants reported familiarity with SDM and agreed that the tool would be useful for their clinical practice. Key themes in participant feedback for the tool were (1) language and presentation; (2) content; and (3) implementation. Participants highlighted the importance of providing unbiased information and having companion tools with patient-centric language.

CONCLUSION

These data highlight the need for SDM tools for haemophilia A gene therapy. Key information to include in the tool are safety, efficacy, cost and detailed information on the gene therapy process. Data should be provided in an unbiased format and allow comparison to other treatments. The tool will be evaluated in clinical practice and refined as clinical trial data and real-world experience mature.

Hemophilia treatment in 2021: Choosing the"optimal" treatment using an integrative, patient-oriented approach to shared decision-making between patients and clinicians

The mainstay of hemophilia treatment is to prevent bleeding through regular long-term prophylaxis and to control acute breakthrough bleeds. Various treatment options are currently available for prophylaxis, and treatment decision-making is a challenging and multifaceted process of identifying the most appropriate option for each patient. A multidisciplinary expert panel convened to develop a practical, patient-oriented algorithm to facilitate shared treatment decision-making between clinicians and patients. Key variables were identified, and an algorithm proposed based on five variables: bleeding phenotype, musculoskeletal status, treatment adherence, venous access, and lifestyle. A complementary, patient-focused preference tool was also hypothesized, with the aim of exploring individual patients' priorities, preferences, and goals. It is hoped that the proposed algorithm and the hypothesized patient preference tool will assist in selecting a treatment for each patient that is as efficient as possible in preventing bleeds while also accounting for the patient's expectations and priorities.

Haemo-Adhaesione: A New Measure of Adherence for Adolescent and Adult Patients with Haemophilia

PURPOSE

To build a multidimensional questionnaire of adherence for a patient with hemophilia that includes not only clinical but also psychosocial aspects.

PATIENTS AND METHODS

One hundred and forty-six patients with haemophilia (A and B) were recruited from several Hemophilia Treatment Centers for this study. The recruitment was performed through a personal interview (20-25 mins for each patient). A literature review was carried out (different databases). In the first version (136 items), all items were subjected to an external judgment (experts in hemophilia) and also presented and discussed with a group of patients. It was made a study of content validity and homogeneity index and reliability coefficients of score were calculated with an alpha coefficient. Empirical validation was made with Pearson correlation.

RESULTS

The Haemo-Adhaesione scale was composed of 5 dimensions and 10 questions about basic haemophilia concepts. It was shown to be valid and reliable to assess adherence in the Spanish population. Its internal consistency was good in all dimensions. The Rasch model was used to confirm the multidimensional structure of the scale. Significant and negative correlations were observed with the VERITAS-Pro and VERITAS-PRN scale in all dimensions, and in the total score.

CONCLUSIONS

The Haemo-Adhaesione scale is a good measure of adherence for PWH. Its multidimensional structure favors the inclusion of the objective and subjective aspects implicit in its definition, as well as its dynamic nature. Patients with greater adherence are those who have more awareness of their disease, and as a result, they are more compliant with prescription and their self-care. It also discriminates between patients who follow one treatment or another.

Shared decision making: Does a physician's decision-making style affect patient participation in treatment choices for primary immunodeficiency?

Overall health care spending in the United States is equivalent to more than 15% of GDP, yet outcomes rank below the top 25 in most quality categories when compared with other Organization for Economic Cooperation and Development (OECD) countries. The majority of spending is consumed by small patient populations with chronic diseases. Experts believe increased patient-physician shared decision making (SDM) should result in better overall longitudinal care but understanding the physician's role in facilitating SDM is limited. Structural equation modelling was applied to results of a 2016 questionnaire-based survey of 330 US physicians who treat approximately 55% of primary immune deficiency requiring immune globulin therapy; it tested the relationship between slow/rational vs fast/intuitive decision-making styles and SDM as mediated by patient-centric care and moderated by physician's trust in the patient. The results showed a statistically significant relationship between slow/rational decision making and SDM. The results also suggest differences related to age, gender, education, and race but no differences related to trust.

UK vs US physician decision-making in the treatment of haemophilia

INTRODUCTION

Patient-physician shared decision-making (SDM) has become increasingly seen as having a positive effect on management of chronic diseases. However, little is known of the factors that encourage SDM or how effective it may be at improving health outcomes or how cost-effective it is.

AIM

To investigate the uses and applications of patient physician-SDM in the management of haemophilia and the influence of healthcare systems in the United States and the United Kingdom.

METHODS

This was a qualitative study based on interviews with treatment experts in the United States and United Kingdom. A grounded theory approach was used to analyse the data from the transcribed interviews and themes that emerged as related to the decision influencers. Twelve physicians from each country were interviewed by the author.

RESULTS

Treatment guidelines were viewed as having only limited applicability because of the lack of universal best options in haemophilia. The US physicians in the sample appeared to be more influenced by patient preferences than physicians in the UK, who instead tended to follow policies and standards of care more closely. Physicians in both countries commented that many of their patents had become highly knowledgeable of their bleeding disorder. US physicians were sometimes limited by insurance company policies but also reported that they were often successful in appealing insurance decisions.

CONCLUSION

The research suggests that there are different influences on decision-making between healthcare systems; patients and overarching healthcare systems play a major role in how physicians treat haemophilia.

Measuring therapeutic relationship in the care of patients with haemophilia: A scoping review

OBJECTIVE

We conducted a scoping review of the tools used to measure therapeutic relationship in patients with haemophilia.

BACKGROUND

Haemophilia is an inherited bleeding disorder caused by a deficiency of a clotting factor in the blood. Therapeutic relationship is foundational to the management of patients with chronic diseases like haemophilia. A reliable and valid measurement tool for assessing therapeutic relationship is needed to evaluate the quality of care received by these patients, and to rigorously study the association between therapeutic relationship and the outcomes of treatment.

METHODS

We adopted the Arksey and O'Malley framework for scoping studies. The following electronic databases were searched for studies that measured a construct related to therapeutic relationships in haemophilia care: MEDLINE, EMBASE, CINAHL, PsycINFO and Scopus. We inventoried these studies, identified the measurement tools used, and described each tool by purpose, content, measurement properties and target population. We identified gaps in the current evidence and directions for future research.

RESULTS

There were 253 unique records retrieved in the search, and twenty studies were deemed relevant. Ten measurement tools were identified. None of the tools measured therapeutic relationship as a single entity; however, six tools measured constructs considered part of patient-provider relationship (eg trust, communication, working alliance). There has been little validation testing of these tools in haemophilia patient populations.

CONCLUSIONS

There is a need for a validated tool for measuring therapeutic relationship in the care of patients with haemophilia. This review provides a foundation for future research in this area.

The role of patient and healthcare professionals in the era of new hemophilia treatments in developed and developing countries

Medical decisions in hemophilia care are primarily related to the type of factor replacement and treatment regimen. With the growing number of treatment options for patients with hemophilia, decision making is more complex and requires careful consideration of benefits, risks, and patient goals. Shared decision making and decision-aid tools facilitate patient and healthcare provider communication. In this review, the overall role of shared decision making in medicine is outlined, with special emphasis on models for practical implementation. Examples of shared decision making in hemophilia are outlined, and application to new therapeutics is discussed through a case-based approach.