Shared treatment decision making in a collectively funded health care system: possible conflicts and some potential solutions

National Investment Framework for Revitalizing the R&D Collaborative Ecosystem of Sustainable Smart Agriculture

Demographic, economic, and environmental issues, including climate change events, aging population, growing urban-rural disparity, and the COVID-19 pandemic, contribute to vulnerabilities in agricultural production and food systems. South Korea has designated smart agriculture as a national strategic investment, expanding investment in research and development (R&D) to develop and commercialize convergence technologies, thus extending sustainable smart agriculture and strengthening global competitiveness. Hence, this study probes the status of smart agricultural R&D investment from the perspectives of public funds, research areas, technologies, regions, organizations, and stakeholders. It examines 5646 public R&D projects worth USD 1408.5 million on smart agriculture in 17 regions and eight technology clusters from 2015 to 2021. Further, it proposes a pool of potential collaborative networks via a case study of strawberry, a representative veritable crop inspiring smart agriculture, to demonstrate the study framework’s usefulness in promoting smart agriculture and establishing a sustainable R&D collaboration ecosystem. The proposed framework, accordingly, allows stakeholders to understand and monitor the status of R&D investment from various perspectives. Moreover, given the insight into the tasks belonging to technical areas and regions that require sustainable cooperation in smart agriculture, central and local governments develop policies to reinforce sustainable smart-farming models.

Cancer care at home or in local health centres versus in hospital: Public policy goals and patients' preferences in the Rhône-Alps region in France

In France, cancer treatments are mainly provided in hospitals, which are expensive and crowded. Health decision-makers therefore want to develop alternative structures such as home care and local health centres.

OBJECTIVES

To elicit cancer patients' preferences for home, local health centre, or hospital, and analyze factors affecting these choices: patients' characteristics, experiences of care, expectations and perceptions of cancer management.

METHODS

We developed a decision aid composed of 1) information on the 3 options 2) a questionnaire to measure preferences; 3) a questionnaire on sociodemographics and experiences of care, 386 patients participated in the survey.

RESULTS

hospital was the preferred option for 71 % of the participants, especially for complicated care, followed by home care (24 %) and local health centres (5%). Main reasons for preferring hospital were the wish to separate home life and place of care, wanting to avoid being a burden on their relatives. Reasons influencing a preference for home care were wanting to avoid trips, maintain their lifestyle, and finding hospitals frightening. Neither socio-demographics nor even experience of care seemed to explain preferences.

CONCLUSION

A quarter of patients preferred home care, which is highly disproportionate to the home care currently available. This suggests that hindrances to developing alternatives to hospital do not come from patients' reluctance to make use of them, but rather from healthcare providers' objections.

A 4-Step Framework for Shared Decision-making in Pediatrics

Shared decision-making (SDM) is a well-established component of patient-centered care, and yet, its application in pediatrics is poorly understood. Common features of pediatric decision-making are not completely addressed in current SDM models, such as the fact that the principal SDM participant is the patient's surrogate, who, unlike competent adult patients deciding for themselves, has limitations on decision-making authority. To address this gap and improve the practice of SDM in pediatrics, a practical 4-step framework is presented. In step 1, physicians are posed the following question for any discrete decision: does the decision include >1 medically reasonable option? If the answer is no, SDM is not indicated. If the answer is yes, physicians proceed to step 2 and answer the following question: does 1 option have a favorable medical benefit-burden ratio compared with other options? If yes, physician-guided SDM is appropriate. If no, parent-guided SDM is appropriate. For each SDM approach, the physician proceeds to step 3 and answers the following question: how preference sensitive are the options? This helps to determine the specific SDM approach in step 4, which ranges from a strong or weak version of physician-guided SDM to a strong or weak version of parent-guided SDM. Several decisional characteristics, if present, can also help calibrate the version of SDM used. Additional analyses are needed to consider the inclusion of adolescents into this SDM framework.

Social value and individual choice: The value of a choice-based decision-making process in a collectively funded health system

Evidence about cost-effectiveness is increasingly being used to inform decisions about the funding of new technologies that are usually implemented as guidelines from centralized decision-making bodies. However, there is also an increasing recognition for the role of patients in determining their preferred treatment option. This paper presents a method to estimate the value of implementing a choice-based decision process using the cost-effectiveness analysis toolbox. This value is estimated for 3 alternative scenarios. First, it compares centralized decisions, based on population average cost-effectiveness, against a decision process based on patient choice. Second, it compares centralized decision based on patients' subgroups versus an individual choice-based decision process. Third, it compares a centralized process based on average cost-effectiveness against a choice-based process where patients choose according to a different measure of outcome to that used by the centralized decision maker. The methods are applied to a case study for the management of acute coronary syndrome. It is concluded that implementing a choice-based process of treatment allocation may be an option in collectively funded health systems. However, its value will depend on the specific health problem and the social values considered relevant to the health system.

A definition and ethical evaluation of overdiagnosis

Overdiagnosis is an emerging problem in health policy and practice: we address its definition and ethical implications. We argue that the definition of overdiagnosis should be expressed at the level of populations. Consider a condition prevalent in a population, customarily labelled with diagnosis A. We propose that overdiagnosis is occurring in respect of that condition in that population when (1) the condition is being identified and labelled with diagnosis A in that population (consequent interventions may also be offered); (2) this identification and labelling would be accepted as correct in a relevant professional community; but (3) the resulting label and/or intervention carries an unfavourable balance between benefits and harms. We identify challenges in determining and weighting relevant harms, then propose three central ethical considerations in overdiagnosis: the extent of harm done, whether harm is avoidable and whether the primary goal of the actor/s concerned is to benefit themselves or the patient, citizen or society. This distinguishes predatory (avoidable, self-benefiting), misdirected (avoidable, other-benefiting) and tragic (unavoidable, other-benefiting) overdiagnosis; the degree of harm moderates the justifiability of each type. We end with four normative challenges: (1) methods for adjudicating between professional standards and identifying relevant harms and benefits should be procedurally just; (2) individuals, organisations and states are differently responsible for addressing overdiagnosis; (3) overdiagnosis is a matter for distributive justice: the burdens of both overdiagnosis and its prevention could fall on the least-well-off; and (4) communicating about overdiagnosis risks harming those unaware that they may have been overdiagnosed. These challenges will need to be addressed as the field develops.

Patient preference and satisfaction with their involvement in the selection of an anesthetic method for surgery

This prospective study aimed to evaluate the satisfaction of patients who participated in the decision-making process for selecting an anesthesia method for surgery; the patients' preferred role (active, collaborative or passive) in the decision-making; and the patients' preferred choice of anesthetic method. The study included 257 patients scheduled for simple elective surgeries involving the upper or lower extremities. During the preanesthetic visit, patients were informed regarding two methods of anesthesia for their surgeries, and participated in selecting one option. Of the 257 patients, 69.6% preferred a collaborative role, 18.3% and 12.1% preferred an active and a passive role, respectively. Among patients requiring surgery on an upper extremity and on a lower extremity, 64.3% and 51.3% expressed a preference for general anesthesia over regional anesthesia, respectively. After surgery, the majority of our patients were satisfied (93.4%) and felt respected (97.7%). Furthermore, the patients expressed a change in preference for assuming an active role (49.4%) and a collaborative role (43.6%) in the decision-making process for their future anesthesia needs. This study may help to promote patient centered care in a department of anesthesiology.

Shared decision making: examining key elements and barriers to adoption into routine clinical practice

For many patients, the time spent meeting with their physician-the clinical encounter-is the most opportune moment for them to become engaged in their own health through the process of shared decision making. In the United States shared decision making is being promoted for its potential to improve the health of populations and individual patients, while also helping control care costs. In this overview we describe the three essential elements of shared decision making: recognizing and acknowledging that a decision is required; knowing and understanding the best available evidence; and incorporating the patient's values and preferences into the decision. To achieve the promise of shared decision making, more physicians need training in the approach, and more practices need to be reorganized around the principles of patient engagement. Additional research is also needed to identify the interventions that are most effective.

'They leave at least believing they had a part in the discussion': understanding decision aid use and patient-clinician decision-making through qualitative research

OBJECTIVE

This study explores how patient decision aids (DAs) for antihyperglycemic agents and statins, designed for use during clinical consultations, are embedded into practice, examining how patients and clinicians understand and experience DAs in primary care visits.

METHODS

We conducted semistructured in-depth interviews with patients (n=22) and primary care clinicians (n=19), and videorecorded consultations (n=44). Two researchers coded all transcripts. Inductive analyses guided by grounded theory led to the identification of themes. Video and interview data were compared and organized by themes.

RESULTS

DAs used during consultations became flexible artifacts, incorporated into existing decision making roles for clinicians (experts, authority figures, persuaders, advisors) and patients (drivers of healthcare, learners, partners). DAs were applied to different decision making steps (deliberation, bargaining, convincing, case assessment), and introduced into an existing knowledge context (participants' literacy regarding shared decision-making (SDM) and DAs).

CONCLUSION

DAs' flexible use during consultations effectively provided space for discussion, even when SDM was not achieved. DAs can be used within any decision-making model.

PRACTICE IMPLICATIONS

Clinician training in DA use and SDM practice may be needed to facilitate DA implementation and promote more ideal-type forms of sharing in decision making.

How should we deal with patient heterogeneity in economic evaluation: a systematic review of national pharmacoeconomic guidelines

OBJECTIVE

To review and analyze recommendations from national pharmacoeconomic guidelines with regard to acknowledging patient heterogeneity in economic evaluations.

METHODS

National pharmacoeconomic guidelines were obtained through the ISPOR Web site. Guidance was extracted by using a developed data extraction sheet. Extracted data were divided into subcategories on the basis of consensus meetings.

RESULTS

Of the 26 included guidelines, 20 (77%) advised to identify patient heterogeneity. Most guidelines (77%) provided general methodological advice to acknowledge patient heterogeneity, including justifications for distinguishing subgroups (65%), prespecification of subgroups (42%), or methodology to acknowledge patient heterogeneity (77%). Stratified analysis of cost-effectiveness was most commonly advised (20 guidelines; 77%); however, guidance on the specific application of methods was scarce (9 guidelines; 34%) and generally limited if provided. Guidance to present patient heterogeneity was provided by 15 guidelines (58%), most prominently to describe the definition (31%) and justification (31%) of subgroups.

CONCLUSIONS

The majority of national pharmacoeconomic guidelines provide guidance on acknowledging patient heterogeneity in economic evaluations. However, because guidance is mostly not specific, its usefulness is limited. This may reflect that the importance of acknowledging patient heterogeneity is usually recognized while there is a lack of consensus on specific methods to acknowledge patient heterogeneity. We advise the further development of national pharmacoeconomic guidelines to provide specific guidance on the identification of patient heterogeneity, methods to acknowledge it, and presenting the results. We present a checklist that can assist in formulating these recommendations. This could facilitate the systematic and transparent handling of patient heterogeneity in economic evaluations worldwide.

Acknowledging patient heterogeneity in economic evaluation : a systematic literature review

BACKGROUND AND OBJECTIVE

Patient heterogeneity is the part of variability that can be explained by certain patient characteristics (e.g. age, disease stage). Population reimbursement decisions that acknowledge patient heterogeneity could potentially save money and increase population health. To date, however, economic evaluations pay only limited attention to patient heterogeneity. The objective of the present paper is to provide a comprehensive overview of the current knowledge regarding patient heterogeneity within economic evaluation of healthcare programmes.

METHODS

A systematic literature review was performed to identify methodological papers on the topic of patient heterogeneity in economic evaluation. Data were obtained using a keyword search of the PubMed database and manual searches. Handbooks were also included. Relevant data were extracted regarding potential sources of patient heterogeneity, in which of the input parameters of an economic evaluation these occur, methods to acknowledge patient heterogeneity and specific concerns associated with this acknowledgement.

RESULTS

A total of 20 articles and five handbooks were included. The relevant sources of patient heterogeneity (demographics, preferences and clinical characteristics) and the input parameters where they occurred (baseline risk, treatment effect, health state utility and resource utilization) were combined in a framework. Methods were derived for the design, analysis and presentation phases of an economic evaluation. Concerns related mainly to the danger of false-positive results and equity issues.

CONCLUSION

By systematically reviewing current knowledge regarding patient heterogeneity within economic evaluations of healthcare programmes, we provide guidance for future economic evaluations. Guidance is provided on which sources of patient heterogeneity to consider, how to acknowledge them in economic evaluation and potential concerns. The improved acknowledgement of patient heterogeneity in future economic evaluations may well improve the efficiency of healthcare.

[New strategies to improve accessibility to laboratory tests in cancer patients]

OBJECTIVE

To develop models to improve accessibility of performing laboratory tests on chronic oncology patients, as well as a more flexible choice of sample collection in both primary and specialized care.

MATERIAL AND METHODS

Circuit analysis of cancer patients. Patient survey to study access to laboratory tests. High Resolution Consultation Development Model (MCAR) and Patient Access Analytical Model (MAAP).

RESULTS

The percentage of cancer patients on treatment has increased by 8.76% in the past two years. There was a 32% increased in the use of the MAAP model in the two years of its implementation, and has been the choice of 74% due to greater accessibility, with 8% of the patients having used both models to suit their needs.

CONCLUSIONS

The implementation of optimized and preferred care systems has shown that both models improve accessibility and flexibility of the diagnostic testing laboratory in the patients studied.

Using Argumentation Theory to Identify the Challenges of Shared Decision-Making when the Doctor and the Patient have a Difference of Opinion

This paper aims to identify the challenges in the implementation of shared decision-making (SDM) when the doctor and the patient have a difference of opinion. It analyses the preconditions of the resolution of this difference of opinion by using an analytical and normative framework known in the field of argumentation theory as the ideal model of critical discussion. This analysis highlights the communication skills and attitudes that both doctors and patients must apply in a dispute resolution-oriented communication. Questions arise over the methods of empowerment of doctors and patients in these skills and attitudes as the preconditions of SDM. Overall, the paper highlights aspects in which research is needed to design appropriate programmes of training, education and support in order to equip doctors and patients with the means to successfully engage in shared decision-making.

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

OBJECTIVE

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

DESIGN

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

SETTING AND PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

Le partage des décisions en santé entre patients et médecins

Les nombreuses enquêtes portant sur la population de plusieurs pays industrialisés incluant le Canada indiquent que de plus en plus, dans le contexte des rencontres médecin-patient, les patients désirent participer activement aux décisions portant sur leur santé. Toutefois, ces enquêtes rapportent aussi que ce partage de la décision entre les patients et les médecins n’a pas préséance. Le présent texte donne les raisons expliquant l’intérêt de la population et des décideurs envers la prise de décision partagée. Il introduit les fondements conceptuels de la prise de décision partagée et fait état de quelques travaux empiriques dans ce domaine. À l’aide de données recueillies lors d’une étude descriptive des pratiques médicales en matière de dépistage prénatal du syndrome de Down, il discute la relation médecin-patiente lors de ces rencontres. Enfin, il propose quelques pistes de réflexion pour des recherches futures.

Administrative gatekeeping - a third way between unrestricted patient advocacy and bedside rationing

The inevitable need for rationing of healthcare has apparently presented the medical profession with the dilemma of choosing the lesser of two evils. Physicians appear to be obliged to adopt either an implausible version of traditional professional ethics or an equally problematic ethics of bedside rationing. The former requires unrestricted advocacy of patients but prompts distrust, moral hazard and unfairness. The latter commits physicians to rationing at the bedside; but it is bound to introduce unfair inequalities among patients and lack of political accountability towards citizens. In this paper I shall argue that this dilemma is false, since a third intermediate alternative exists. This alternative, which I term 'administrative gatekeeping', makes it possible for physicians to be involved in rationing while at the same time being genuine advocates of their patients. According to this ideal, physicians are required to follow fair rules of rationing adopted at higher organizational levels within healthcare systems. At the same time, however, they are prohibited from including considerations of cost in their clinical decisions.

Incorporation of process preferences within the QALY framework: a study of alternative methods

OBJECTIVE

This article explores the implications of incorporating process preferences using time tradeoff and standard gamble methods to assess the benefits of health care.

METHODS

Data were derived from 2 sources: a randomized controlled trial of alternative palliative care treatments (plastic stents, thermal ablation, or brachytherapy) for esophageal cancer, and a valuation survey conducted among individuals who had previously undergone curative treatment for such cancer. Costs and quality-adjusted life years (QALYs) associated with different palliative treatments in terms of health outcome values were compared to costs and QALYs based on process values derived from 3 different treatment allocation methods: 1) receipt of most preferred treatment; 2) receipt of least preferred treatment; and 3) mean process values.

RESULTS

Process values produced a different number of QALYs and QALY gains compared to those derived from health outcome values. However, treatment recommendations based on process values corresponded with those based on health outcome values: brachytherapy was identified as the more cost-effective treatment in terms of the incremental cost-per-QALY ratio by both the standard health outcome values approach and methods based on process values. These findings were supported by probabilistic analysis using the net monetary benefit framework.

CONCLUSIONS

Estimation of process preferences provides additional information to policy makers in judgments over the cost-effectiveness of health care programs. These methods offer a promising alternative to standard cost-per-QALY estimation using health outcomes. However, further research examining the role of process preferences in decision making in other clinical applications appears warranted.

Shared decision making in the medical encounter: are we all talking about the same thing?

OBJECTIVE

This article aims to explore 1) whether after all the research done on shared decision making (SDM) in the medical encounter, a clear definition (or definitions) of SDM exists; 2) whether authors provide a definition of SDM when they use the term; 3) and whether authors are consistent, throughout a given paper, with respect to the research described and the definition they propose or cite.

METHODS

The authors searched different databases (Medline, HealthStar, Cinahl, Cancerlit, Sociological Abstracts, and Econlit) from 1997 to December 2004. The keywords used were informed decision making and shared decision making as these are the keywords more often encountered in the literature. The languages selected were English and French.

RESULTS

The 76 reported papers show that 1) several authors clearly define what they mean by SDM or by another closely related phrase, such as informed shared decision making. 2) About a third of the papers reviewed (25/76) cite these authors although 8 of them do not use the term in a manner consistent with the definition cited. 3) Certain authors use the term SDM inconsistently with the definition they propose, and some use the terms informed decision making and SDM as if they were synonymous. 4) Twenty-one papers do not provide or cite any definition, or their use of the term (i.e., SDM) is not consistent with the definition they provide.

CONCLUSION

Although several clear definitions of shared decision making have been proposed, they are cited by only about a third of the papers reviewed. In the other papers, authors refer to the term without specifying or citing a definition or use the term inconsistently with their definition. This is a problem because having a clear definition of the concept and following this definition are essential to guide and focus research. Authors should use the term consistently with the identified definition.

Patient participation in decision making: views of health professionals caring for people with colorectal cancer

AIM

The aim of this study was to explore views on patient participation in decision making, as described by health professionals caring for people with colorectal cancer.

BACKGROUND

Patient participation in health-care decision making is on the policy agenda at an international level. However, many aspects of cancer care and treatment are complex and it is unclear how health professionals view their role as promoters of patient participation.

DESIGN

A qualitative exploratory study.

METHODS

In depth interviews with 35 health professionals in clinical practice. Data were analysed using thematic content analysis, assisted by a computer software package for analysis of qualitative data (N-VIVO).

RESULTS

Choices in relation to surgical treatment were viewed as limited. Although it was perceived that patients could be more involved in decisions related to adjuvant treatment, providing information on various chemotherapy regimes was challenging. It was acknowledged that patients could be involved in treatment choices but there was far less clarity concerning aspects of physical and psychological care. Age was a factor when determining which patients should be offered treatment choices.

CONCLUSION

The availability and presentation of choices to patients is context specific and tailored to the preferences of individuals. If health professionals focus only on aspects of decision making related to treatment, the potential for shared partnerships with patients in relation to choices about physical and psychological care may be lost. This may be particularly pertinent for nurses and allied professions who engage with patients throughout the illness trajectory.

RELEVANCE TO CLINICAL PRACTICE

Policy makers should arguably appreciate that health professionals have an awareness of current thinking on patient participation, but may find policy recommendations challenging to implement in clinical practice when faced with the individual needs and preferences of patients and the complexities and uncertainties of disease management.

Clinical decision-making: physicians' preferences and experiences

Background

Shared decision-making has been advocated; however there are relatively few studies on physician preferences for, and experiences of, different styles of clinical decision-making as most research has focused on patient preferences and experiences. The objectives of this study were to determine 1) physician preferences for different styles of clinical decision-making; 2) styles of clinical decision-making physicians perceive themselves as practicing; and 3) the congruence between preferred and perceived style. In addition we sought to determine physician perceptions of the availability of time in visits, and their role in encouraging patients to look for health information.

Methods

Cross-sectional survey of a nationally representative sample of U.S. physicians.

Results

1,050 (53% response rate) physicians responded to the survey. Of these, 780 (75%) preferred to share decision-making with their patients, 142 (14%) preferred paternalism, and 118 (11%) preferred consumerism. 87% of physicians perceived themselves as practicing their preferred style. Physicians who preferred their patients to play an active role in decision-making were more likely to report encouraging patients to look for information, and to report having enough time in visits.

Conclusion

Physicians tend to perceive themselves as practicing their preferred role in clinical decision-making. The direction of the association cannot be inferred from these data; however, we suggest that interventions aimed at promoting shared decision-making need to target physicians as well as patients.

Patient involvement in clinical decision making: the effect of GP attitude on patient satisfaction

OBJECTIVE

This study investigates general practitioners' (GPs) and patients' attitudes to shared decision making, and how these attitudes affect patient satisfaction.

BACKGROUND

Sharing of information and decisions in the consultation is largely accepted as the ideal in general practice. Studies show that most patients prefer to be involved in decision making and shared decision making is associated with patient satisfaction, although preferences vary. Still we know little about how the interaction of GP and patients' attitudes affects patient satisfaction. One such study was conducted in the USA, but comparative studies are lacking.

DESIGN

Questionnaire survey distributed through GPs.

SETTING AND PARTICIPANTS

The results are based on the combined questionnaires of 41 GPs and 829 of their patients in the urban municipality of Bergen in the western part of Norway. Main variables studied The data were collected using a nine-item survey instrument constructed to measure attitudes towards patient involvement in medical consultations. The patients were also asked to rate their satisfaction with their GP.

RESULTS AND CONCLUSIONS

The patients had a strong preference for shared decision making. The GPs also generally preferred shared decision making, but to a lesser degree than the patients, which is the opposite of the findings of the US study. There was a positive effect of the GP's attitude towards shared decision making on patient satisfaction, but no significant effect of congruence of attitudes between patient and GP on patient satisfaction. The suggested explanation is that GPs that are positive to sharing decisions are more responsive to patients' needs and therefore satisfy patients even when the patient's attitude differs from the GPs' attitude. Hence, although some patients do prefer a passive role, it is important to promote positive attitudes towards patient involvement in medical consultations.

Using preference-based measures to assess quality of life in stuttering

PURPOSE

The purpose of this study was to determine whether standard pharmaco-economic preference methods can be used to assess perceived quality of life in stuttering.

METHOD

Seventy-five nonstuttering adults completed a standardized face-to-face interview that included a rating scale, standard gamble, and time trade-off preference measures for 4 health states (your health and mild, moderate, and severe stuttering) in the context of 2 anchor states (perfect health and death).

RESULTS

Results showed mean utility values between .443 for severe stuttering estimated using the rating scale technique and .982 for respondents' own current health estimated using a standard gamble technique. A two-way repeated measures analysis of variance and post hoc tests showed significant effects for method, health state, and the interaction.

CONCLUSIONS

These results confirm that utility estimates can differentiate between stuttering severity levels and that utility scores for stuttering conform to the known properties of data obtained using these standard measurement techniques. These techniques, therefore, can and should be further investigated as potential contributors to complete measurement protocols for the study and treatment of stuttering.

Incorporating patient preferences into orthopaedic practice: should the orthopaedic encounter change?

The issues concerning treatment decision-making are that often options for treatment lead to uncertain outcomes (benefits and risks) at the individual patient level and that both patients and physicians might value these outcomes differently. There are three main approaches commonly used to describe treatment decision-making including paternalistic, shared and informed decision-making. The challenge and responsibility of physicians is to effectively communicate to patients that they should feel welcome to participate in decision-making through whichever approach seems suitable to them. Changes in laws governing the ethics of medical practice mandate a more comprehensive decision-making tactic requiring a two-way flow of information between patient and physician. The key to information exchange lies in evoking patient preferences by informing the patient of the benefits and risks associated with each treatment option. Decision aids have been developed in a variety of forms to facilitate this transfer of information about available treatment alternatives in as unbiased fashion as possible. We believe that treatment options presented should include not only those available by the particular physicians at that institution but also those available at outside institutions and within other healthcare systems. We discuss barriers for physicians who wish to encourage patient participation such as the power differential that exists between patients and physicians, factors related to health policy, and those unique to surgery. We believe that investigation is necessary to understand how the differences between types of medical practices, or even within a medical field, will influence the importance that patients attach to having their values and preferences considered during treatment decision-making and to evaluate how this importance changes as the severity of adverse events associated with treatment outcomes changes. We feel that it is important for physicians and surgeons to begin to think about these issues and how they might investigate potential resolutions for incorporating patient values and sharing their own preferences for treatment options with their patients during the orthopaedic encounter.

An integrative model of shared decision making in medical encounters

OBJECTIVE

Given the fluidity with which the term shared decision making (SDM) is used in teaching, assessment and research, we conducted a focused and systematic review of articles that specifically address SDM to determine the range of conceptual definitions.

METHODS

In April 2005, we ran a Pubmed (Medline) search to identify articles published through 31 December 2003 with the words shared decision making in the title or abstract. The search yielded 681 citations, 342 of which were about SDM in the context of physician-patient encounters and published in English. We read and reviewed the full text of all 342 articles, and got any non-redundant references to SDM, which yielded an additional 76 articles.

RESULTS

Of the 418 articles examined, 161 (38.5%) had a conceptual definition of SDM. We identified 31 separate concepts used to explicate SDM, but only "patient values/preferences" (67.1%) and "options" (50.9%) appeared in more than half the 161 definitions. Relatively few articles explicitly recognized and integrated previous work.

CONCLUSION

Our review reveals that there is no shared definition of SDM. We propose a definition that integrates the extant literature base and outlines essential elements that must be present for patients and providers to engage in the process of SDM.

PRACTICE IMPLICATIONS

The integrative definition of SDM is intended to provide a useful foundation for describing and operationalizing SDM in further research.

Patient-doctor decision-making about treatment within the consultation--a critical analysis of models

This paper highlights some of the limitations of models of patient involvement in decision-making and explores the reasons for, and implications of, these limitations. Taking the three models of interpretative, shared and informed decision-making as examples, we focus on two limitations of the models: (1) neglect of which decisions the patient should be involved in (the framing problem) and (2) how the patient should be involved in decision-making (the nature of reasoning problem). Although there will inevitably be a gap between models and practice--this much is in the nature of the models--we suggest that these two issues are substantially neglected by the models and yet are fundamental to understanding patient-doctor decision-making. We also suggest that the fundamental problem that lies behind these limitations is insufficient attention to, and explicitness about, the dilemmas of professional ethics, which are played out in the professional-patient relationships that the models are supposed to represent, particularly with respect to the issue of expert and lay accountability.

Patient involvement in general practice care: a pragmatic framework

This paper presents a pragmatic framework to guide decisions on involving people in general practice care. Patient involvement may be defined as: enabling patients to take an active role in deciding about and planning their healthcare. It can be located at different levels of care, including the patient-clinician contact or episode of care, and the patient population served by a care provider, or the regional or national population. The involvement of patients depends on considerations that include the aim of patient involvement, the type of health decision, and the type of patient. With respect to the aims, the fundamental question is whether involvement is seen as desirable in itself, or whether it is expected to result in favourable consequences. We suggest that patients' ability and willingness to be involved should determine the level of involvement. The concept of involving patients is relatively new, and new approaches are required to overcome obstacles for its implementation in healthcare.

How is medical decision-making shared? The case of haemophilia patients and doctors: the aftermath of the infected blood affair in France

OBJECTIVE

This article looks at how users and doctors in France have rethought the question of shared decision-making in the clinical field of haemophilia following a major crisis - that of the infected blood affair.

DESIGN

We did a qualitative survey based on semi-structured interviews in three regions of France.

SETTING AND PARTICIPANTS

The interviews covered 31 clinical doctors of haemophilia and 31 users: 21 adult males with severe haemophilia (21/31), infected (14/21) or not (7/21) with HIV, the infected wife of one of the latter (1/31) and nine parents of young patients with severe haemophilia (9/31), either HIV positive (6/9) or negative (3/9).

RESULTS AND CONCLUSIONS

The results show the infected blood affair to be a major individual and collective ordeal. It has caused users and doctors to rethink their roles within clinical relationships and to develop new ways of sharing medical decision-making. Prior to the crisis, the dominant model was based upon a distinction between the medical aspect, governed by the doctors, and the psychosocial aspect, which involved the patients and their families. Since the crisis, medicoscientific knowledge has been shared between users and doctors. This general trend nevertheless permits the existence of different patient, family and doctor profiles which in turn correspond to different notions of what a clinical decision should be. Some users remain attached to the idea of complementarity between doctors and patients (new partnership model), whilst others put doctors and patients on an equal footing (negotiation model). On the doctors' side, whilst some still prefer the initial model for therapeutic decision-making, the majority have reassessed their perceptions and viewpoints. A certain number believe that decisions should be made by both doctor and patient in accordance with scientific procedures (decision-making controlled by scientific standards) or regulatory procedures (decision-making controlled by legal standards). Yet others feel that multiple points of view are acceptable within the decision-making process (decision-making model as interactivity).

Clinical decision guidelines for NHS cosmetic surgery: analysis of current limitations and recommendations for future development

Because of increasing demand for publicly funded elective cosmetic surgery, clinical decision guidelines have been developed to select those patients who should receive it. The aims of this study were to identify: the main characteristics of such guidelines; whether and how they influence clinical decision making; and ways in which they should be improved. UK health authorities were asked for their current guidelines for elective cosmetic surgery and, in a single plastic surgery unit, we examined the impact of its guidelines by observing consultations and interviewing surgeons and managers. Of 115 authorities approached, 32 reported using guidelines and provided sufficient information for analysis. Guidelines mostly concerned arbitrary sets of cosmetic procedures and lacked reference to an evidence base. They allowed surgery for specified anatomical, functional or symptomatic reasons, but these indications varied between guidelines. Most guidelines also permitted surgery 'exceptionally' for psychological reasons. The guidelines that were studied in detail did not appreciably influence surgeons' decisions, which reflected criteria that were not cited in the guidelines, including cost of the procedure and whether patients sought restoration or improvement of their appearance. Decision guidelines in this area have several limitations. Future guidelines should: include all cosmetic procedures; be informed by a broad range of evidence; and, arguably, include several nonclinical criteria that currently inform surgeons' decision-making.

An economic perspective on evidence-based patient choice in surgery

The aim of the present paper is to provide an economic perspective on current and emerging issues relating to surgical decision-making. The central issue discussed in the paper is choice and how this relates to patient management. The paper explores three factors that may influence the nature of choice; they are--evidence-based medicine, patient involvement in making choices and the role of cost-effectiveness analysis in surgery. Together, these factors are driving a shift from the traditional model of care based on medical beneficence to one based more on individual patient autonomy. This shift has been described as a move towards 'evidence-based patient choice' (EBPC). The concept of EBPC is relatively new and ill defined. Yet it encapsulates what is happening now and what will occur more dramatically in the future; that is, the nature of the relationship between surgeon and patient is changing. We hope that this paper will provoke discussion on the concept of EBPC and cost-effectiveness analysis in surgical decision-making.